Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 590 - MAINE HEALTH DATA ORGANIZATION › Chapter 243 - UNIFORM REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS › Appendix 590-243-D-2 - Maine Health Data Organization Medical Claims File Mapping to National Standards

Current through 2024-29, July 17, 2024
Data Element
								#
Data Element Name
UB-04 Form
								Locator
CMS 1500 #
HIPAA Reference ASC
								X12N/005010A1 Transaction Set/Loop/Segment ID/Code Value/Reference
								Designator
MC001
Submitter
N/A
N/A
N/A
MC002
Payor
N/A
N/A
N/A
MC003
Insurance Type/Product Code
N/A
N/A
835/2100/CLP/06
MC004
Payor Claim Control Number
N/A
N/A
835/2100/CLP/07
MC005
Line Counter
N/A
N/A
837/2400/LX/01
MC005A
Version Number
N/A
N/A
N/A
MC006
Insured Group or Policy Number
62 (A-C)
11
837/2000B/SBR/03
MC007
Subscriber Social Security Number
N/A
N/A
835/2100/NM1/MI/09
MC008
Plan Specific Contract Number
60 (A-C)
1a
835/2100/NM1/MI/09
MC009
Member Suffix or Sequence Number
N/A
N/A
N/A
MC010
Member Identification Code
N/A
N/A
835/2100/NM1/34/09
MC011
Individual Relationship Code
59 (A-C)
6
837/2000B/SBR/02, 837/2000C/PAT/01
MC012
Member Gender
11
3
837/2010BA/DMG/03, 837/2010CA/DMG/03
MC013
Member Date of Birth
10
3
837/2010BA/DMG/D8/02,
								837/2010CA/DMG/D8/02
MC014
Member City Name
9b
5
837/2010BA/N4/01, 837/2010CA/N4/01
MC015
Member State or Province
9c
5
837/2010BA/N4/02, 837/2010CA/N4/02
MC016
Member ZIP Code
9d
5
837/2010BA/N4/03, 837/2010CA/N4/03
MC017
Date Service Approved
N/A
N/A
835/Header Financial Information/BPR/16
MC018
Admission Date
12
18
837/2300/DTP/435/03
MC019
Admission Hour
13
N/A
837/2300/DTP/435/03
MC020
Priority (Type) of Admission or
								Visit
14
N/A
837/2300/CL1/01
MC021
Point of Origin for Admission or
								Visit
15
N/A
837/2300/CL1/02
MC022
Discharge Hour
16
N/A
837/2300/DTP/096/03
MC023
Patient Discharge Status
17
N/A
837/2300/CL1/03
MC024
Rendering Provider Number
57
N/A
835/2100/REF/1A/02, 835/2100/REF/1B/02,
835/2100/REF/1C/02, 835/2100/REF/1D/02,
835/2100/REF/G2/02, 835/2100/NM1/BD/09,
835/2100/NM1/BS/09, 835/2100/NM1/MC/09,
835/2100/NM1/PC/09
MC025
Rendering Provider Tax ID Number
5
25 (only if EIN)
835/2100/NM1/FI/09
MC026
National Provider ID - Rendering
								Provider
56
24J
professional:
837/2420A/NM1/XX/09; 837/2310B/NM1/XX/09;
institutional:
837/2010AA/NM1/XX/09
MC027
Rendering Provider Entity Type
								Qualifier
N/A
N/A
professional:
837/2420A/NM1/82/02; 837/2310B/NM1/82/02;
institutional:
837/2010AA/NM1/85/02
MC028
Rendering Provider First Name
N/A
31
professional:
837/2420A/NM1/82/04; 837/2310B/NM1/82/04;
institutional:
N/A
MC029
Rendering Provider Middle Name
N/A
31
professional:
837/2420A/NM1/82/05; 837/2310B/NM1/82/05;
								institutional:
N/A
MC030
Rendering Provider Last Name or Organization
								Name
1
31
professional:
837/2420A/NM1/82/1/03;
								837/2310B/NM1/82/1/03;
institutional:
837/2010AA/NM1/85/2/03
MC031
Rendering Provider Suffix
N/A
31
professional:
837/2420A/NM1/82/07; 837/2310B/NM1/82/07;
institutional:
N/A
MC032
Rendering Provider Specialty
N/A
N/A
professional:
837/2420A/PRV/PXC/03;
837/2310B/PRV/PXC/03;
institutional:
837/2000A/PRV/PXC/03
MC033
Placeholder
N/A
N/A
N/A
MC034
Placeholder
N/A
N/A
N/A
MC035
Placeholder
N/A
N/A
N/A
MC036
Type of Bill - Institutional
4
N/A
837/2300/CLM/05-1
MC037
Place of Service - Professional
N/A
24B
837/2300/CLM/05-1
MC038
Claim Status
N/A
N/A
835/2100/CLP/02
MC039
Placeholder
N/A
N/A
N/A
MC040
Placeholder
N/A
N/A
N/A
MC041
Placeholder
N/A
N/A
N/A
MC042
Placeholder
N/A
N/A
N/A
MC043
Placeholder
N/A
N/A
N/A
MC044
Placeholder
N/A
N/A
N/A
MC045
Placeholder
N/A
N/A
N/A
MC046
Placeholder
N/A
N/A
N/A
MC047
Placeholder
N/A
N/A
N/A
MC048
Placeholder
N/A
N/A
N/A
MC049
Placeholder
N/A
N/A
N/A
MC050
Placeholder
N/A
N/A
N/A
MC051
Placeholder
N/A
N/A
N/A
MC052
Placeholder
N/A
N/A
N/A
MC053
Placeholder
N/A
N/A
N/A
MC054
Revenue Code
42
N/A
835/2110/SVC/NU/01-2,
835/2110/SVC/04
MC055
Procedure Code
44
24D
835/2110/SVC/HC/01-2,
								835/2110/SVC/HP/01-2
MC056
Procedure Modifier - 1
44
24D
835/2110/SVC/HC/01-3
MC057
Procedure Modifier - 2
44
24D
835/2110/SVC/HC/01-4
MC057A
Procedure Modifier - 3
44
24D
835/2110/SVC/HC/01-5
MC057B
Procedure Modifier - 4
44
24D
835/2110/SVC/HC/01-6
MC058
Placeholder
N/A
N/A
N/A
MC059
Claim Date - From
6
N/A
837/2300/DTP/434/D8
MC060
Claim Date - Thru
6
N/A
837/2300/DTP/434/D8
MC061
Quantity
46
24G
835/2110/SVC/05
MC062
Charge Amount
47
24F
835/2110/SVC/02
MC063
Paid Amount
N/A
N/A
835/2110/SVC/03
MC064
Placeholder
N/A
N/A
N/A
MC065
Co-pay Amount
N/A
N/A
835/2110/CAS/PR/3-03
MC066
Coinsurance Amount
N/A
N/A
835/2110/CAS/PR/2-03
MC067
Deductible Amount
N/A
N/A
835/2110/CAS/PR/1-03
MC068
Patient Account/Control Number
3a
26
837/2300/CLM/01
MC069
Discharge Date
6
18
837/2300/DTP/434/03
MC070
Placeholder
N/A
N/A
N/A
MC071
Placeholder
N/A
N/A
N/A
MC072
Placeholder
N/A
N/A
N/A
MC073
Placeholder
N/A
N/A
N/A
MC074
Placeholder
N/A
N/A
N/A
MC075
Drug Code
N/A
N/A
837/2410/LIN/N4/03
MC076
Billing Provider Number
57
33b
837/2010BB/REF/G2/02
MC077
National Provider ID - Billing
								Provider
56
33a
837/2010AA/NM1/85/ /XX/09
MC078
Billing Provider Last Name
1
33
837/2010AA/NM1/85/ /03
MC079
Billing Provider Tax ID Number
NA
NA
837/2010AA/REF/EI/02
MC080
Billing Provider Address Line 1
1
33
837/2010AA/N3/01
MC081
Billing Provider Address Line 2
1
33
837/2010AA/N3/02
MC082
Billing Provider City Name
1
33
837/2010AA/N4/01
MC083
Billing Provider State or Province
1
33
837/2010AA/N4/02
MC084
Billing Provider Zip Code
1
33
837/2010AA/N4/03
MC085
Service Facility Location Name
1
32
professional:
837/2310C/NM1/77/2/03;
institutional:
837/2310E/NM1/77/2/03
MC086
National Provider ID - Service
								Facility
56
32a
professional:
837/2310C/NM1/77/2/XX/09;
institutional:
837/2310E/NM1/77/2/XX/09
MC087
Service Facility Location Address Line
								1
1
32
professional:
837/2310C/N3/01;
institutional:
837/2310E/N3/01
MC088
Service Facility Location Address Line
								2
1
32
professional:
837/2310C/N3/02;
institutional:
837/2310E/N3/02
MC089
Service Facility Location City Name
1
32
professional: 837/
2310C/N4/01;
institutional:
837/2310E/N4/01
MC090
Service Facility Location Address State or
								Province
1
32
professional:
837/2310C/N4/02;
institutional:
837/2310E/N4/02
MC091
Service Facility Location Address Zip
								Code
1
32
professional:
837/2310C/N4/03;
institutional:
837/2310E/N4/03
MC092
Service Facility Number
57
32b
professional:
837/2310C/REF/G2/02;
institutional:
837/2310E /REF/G2/02
MC093
Service Facility Location Country
								Code
(1)
(32)
professional:
837/2310C/N4/04;
institutional:
837/2310E/N4/04
MC094
Billing Provider Country Code
(1)
(33)
837/2010AA/N4/04
MC101
Subscriber Last Name
58(A-C)
4
837/2010BA/NM1/ /03
MC102
Subscriber First Name
58(A-C)
4
837/2010BA/NM1/ /04
MC103
Subscriber Middle Name
N/A
4
837/2010BA/NM1/ /05
MC104
Member Last Name
8b
2
837/2010CA/NM1/ /03, 837/2010BA/NM1/
								/03
MC105
Member First Name
8b
2
837/2010CA/NM1/ /04, 837/2010BA/NM1/
								/04
MC106
Member Middle Name
8b
2
837/2010CA/NM1/ /05, 837/2010BA/NM1/
								/05
MC107
Attending Provider Number
N/A
N/A
professional: N/A
institutional:
837/2310A/REF/G2/02
MC108
National Provider ID - Attending
								Provider
76
N/A
837/2310A/NM1/71/1/XX/09
MC109
Attending Provider First Name
76
N/A
837/2310A/NM1/71/1/04
MC110
Attending Provider Middle Name
N/A
N/A
837/2310A/NM1/71/1/05
MC111
Attending Provider Last Name
76
N/A
837/2310A/NM1/71/1/03
MC112
Attending Provider Suffix
N/A
N/A
837/2310A/NM1/71/1/07
MC113
Attending Provider Specialty
N/A
N/A
837/2310A/PRV/AT/PXC/03
MC114
Operating Provider Number
N/A
N/A
professional:
N/A institutional:
837/2310B/REF/G2/02;
								837/2420A/REF/G2/02
MC115
National Provider ID - Operating
								Provider
77
N/A
professional:
N/A institutional:
837/2420A/NM1/72/1/XX/09;
837/2420A/NM1/72/1/XX/09
MC116
Operating Provider First Name
77
N/A
professional: N/A institutional:
837/2420A/NM1/72/1/04;
								837/2420A/NM1/72/1/04
MC117
Operating Provider Middle Name
N/A
N/A
professional: N/A institutional:
837/2420A/NM1/72/1/05;
837/2420A/NM1/72/1/05
MC118
Operating Provider Last Name
77
N/A
professional: N/A
institutional:
837/2420A/NM1/72/1/03;
								837/2420A/NM1/72/1/03
MC119
Operating Provider Suffix
N/A
N/A
professional: N/A
institutional:
837/2420A/NM1/72/1/07;
								837/2420A/NM1/72/1/07
MC120
Referring Provider Number
N/A
N/A
professional:
837/2310A/REF/G2/02; 837/2420F/REF/G2/02
institutional:
837/2310F/REF/G2/02;
								837/2420D/REF/G2/02
MC121
National Provider ID - Referring
								Provider
78 or 79
17b
professional:
837/2310A/NM1/DN/1/XX/09;
837/2420F/NM1/DN/1/XX/09
institutional:
837/2310F/NM1/DN/1/XX/09;
837/2420D/NM1/DN/1/XX/09
MC122
Referring Provider First Name
78 or 79
17
professional:
837/2310A/NM1/DN/1/04; 837/2420F/NM1/DN/1/04
institutional:
837/2310F/NM1/DN/1/04;
								837/2420D/NM1/DN/1/04
MC123
Referring Provider Middle Name
N/A
17
professional:
837/2310A/NM1/DN/1/05; 837/2420F/NM1/DN/1/05
institutional:
837/2310F/NM1/DN/1/05;
								837/2420D/NM1/DN/1/05
MC124
Referring Provider Last Name
78 or 79
17
professional:
837/2310A/NM1/DN/1/03; 837/2420F/NM1/DN/1/03
institutional:
837/2310F/NM1/DN/1/03;
								837/2420D/NM1/DN/1/03
MC125
Referring Provider Suffix
N/A
17
professional:
837/2310A/NM1/DN/1/07; 837/2420F/NM1/DN/1/07
institutional:
837/2310F/NM1/DN/1/07;
								837/2420D/NM1/DN/1/07
MC200
Principal Diagnosis
67
N/A
837/2300/HI/ABK/01-2
MC201
Present On Admission Indicator
67 (pos 8)
N/A
837/2300/HI/01-9
MC202
Admitting Diagnosis
69
N/A
837/2300/HI/ABJ/01-2
MC203
Reason for Visit Diagnosis - 1
70A
N/A
837/2300/HI/APR/01-2
MC204
Reason for Visit Diagnosis - 2
70B
N/A
837/2300/HI/APR/02-2
MC205
Reason for Visit Diagnosis - 3
70C
N/A
837/2300/HI/APR/03-2
MC206
External Cause of Injury - 1
72A
N/A
837/2300/HI/ABN/01-2
MC207
Present On Admission Indicator - 1
72A (pos 8)
N/A
837/2300/HI/01-9
MC208
External Cause of Injury - 2
72B
N/A
837/2300/HI/ABN/02-2
MC209
Present On Admission Indicator - 2
72B (pos 8)
N/A
837/2300/HI/02-9
MC210
External Cause of Injury - 3
72C
N/A
837/2300/HI/ABN/03-2
MC211
Present On Admission Indicator - 3
72C (pos 8)
N/A
837/2300/HI/03-9
MC212
External Cause of Injury - 4
N/A
N/A
837/2300/HI/ABN/04-2
MC213
Present On Admission Indicator - 4
N/A
N/A
837/2300/HI/04-9
MC214
External Cause of Injury - 5
N/A
N/A
837/2300/HI/ABN/05-2
MC215
Present On Admission Indicator - 5
N/A
N/A
837/2300/HI/05-9
MC216
External Cause of Injury - 6
N/A
N/A
837/2300/HI/ABN/06-2
MC217
Present On Admission Indicator - 6
N/A
N/A
837/2300/HI/06-9
MC218
External Cause of Injury - 7
N/A
N/A
837/2300/HI/ABN/07-2
MC219
Present On Admission Indicator - 7
N/A
N/A
837/2300/HI/07-9
MC220
External Cause of Injury - 8
N/A
N/A
837/2300/HI/ABN/08-2
MC221
Present On Admission Indicator - 8
N/A
N/A
837/2300/HI/08-9
MC222
External Cause of Injury - 9
N/A
N/A
837/2300/HI/ABN/09-2
MC223
Present On Admission Indicator - 9
N/A
N/A
837/2300/HI/09-9
MC224
External Cause of Injury - 10
N/A
N/A
837/2300/HI/ABN/10-2
MC225
Present On Admission Indicator - 10
N/A
N/A
837/2300/HI/10-9
MC226
External Cause of Injury - 11
N/A
N/A
837/2300/HI/ABN/11-2
MC227
Present On Admission Indicator - 11
N/A
N/A
837/2300/HI/11-9
MC228
External Cause of Injury - 12
N/A
N/A
837/2300/HI/ABN/12-2
MC229
Present On Admission Indicator - 12
N/A
N/A
837/2300/HI/12-9
MC230
External Cause of Injury - 13
N/A
N/A
837/2300/HI/ABN/01-2
MC231
Present On Admission Indicator - 13
N/A
N/A
837/2300/HI/01-9
MC232
External Cause of Injury - 14
N/A
N/A
837/2300/HI/ABN/02-2
MC233
Present On Admission Indicator - 14
N/A
N/A
837/2300/HI/02-9
MC234
External Cause of Injury - 15
N/A
N/A
837/2300/HI/ABN/03-2
MC235
Present On Admission Indicator - 15
N/A
N/A
837/2300/HI/03-9
MC236
External Cause of Injury - 16
N/A
N/A
837/2300/HI/ABN/04-2
MC237
Present On Admission Indicator - 16
N/A
N/A
837/2300/HI/04-9
MC238
External Cause of Injury - 17
N/A
N/A
837/2300/HI/ABN/05-2
MC239
Present On Admission Indicator - 17
N/A
N/A
837/2300/HI/05-9
MC240
External Cause of Injury - 18
N/A
N/A
837/2300/HI/ABN/06-2
MC241
Present On Admission Indicator - 18
N/A
N/A
837/2300/HI/06-9
MC242
External Cause of Injury - 19
N/A
N/A
837/2300/HI/ABN/07-2
MC243
Present On Admission Indicator - 19
N/A
N/A
837/2300/HI/07-9
MC244
External Cause of Injury - 20
N/A
N/A
837/2300/HI/ABN/08-2
MC245
Present On Admission Indicator - 20
N/A
N/A
837/2300/HI/08-9
MC246
External Cause of Injury - 21
N/A
N/A
837/2300/HI/ABN/09-2
MC247
Present On Admission Indicator - 21
N/A
N/A
837/2300/HI/09-9
MC248
External Cause of Injury - 22
N/A
N/A
837/2300/HI/ABN/10-2
MC249
Present On Admission Indicator - 22
N/A
N/A
837/2300/HI/10-9
MC250
External Cause of Injury - 23
N/A
N/A
837/2300/HI/ABN/11-2
MC251
Present On Admission Indicator - 23
N/A
N/A
837/2300/HI/11-9
MC252
External Cause of Injury - 24
N/A
N/A
837/2300/HI/ABN/12-2
MC253
Present On Admission Indicator - 24
N/A
N/A
837/2300/HI/12-9
MC254
Other Diagnosis - 1
67A
21A
837/2300/HI/ABF/01-2
MC255
Present On Admission Indicator - 1
67A (pos 8)
N/A
837/2300/HI/01-9
MC256
Other Diagnosis - 2
67B
21B
837/2300/HI/ABF/02-2
MC257
Present On Admission Indicator - 2
67B (pos 8)
N/A
837/2300/HI/02-9
MC258
Other Diagnosis - 3
67C
21C
837/2300/HI/ABF/03-2
MC259
Present On Admission Indicator - 3
67C (pos 8)
N/A
837/2300/HI/03-9
MC260
Other Diagnosis - 4
67D
21D
837/2300/HI/ABF/04-2
MC261
Present On Admission Indicator - 4
67D (pos 8)
N/A
837/2300/HI/04-9
MC262
Other Diagnosis - 5
67E
21E
837/2300/HI/ABF/05-2
MC263
Present On Admission Indicator - 5
67E (pos 8)
N/A
837/2300/HI/05-9
MC264
Other Diagnosis - 6
67F
21F
837/2300/HI/ABF/06-2
MC265
Present On Admission Indicator - 6
67F (pos 8)
N/A
837/2300/HI/06-9
MC266
Other Diagnosis - 7
67G
21G
837/2300/HI/ABF/07-2
MC267
Present On Admission Indicator - 7
67G (pos 8)
N/A
837/2300/HI/07-9
MC268
Other Diagnosis - 8
67H
21H
837/2300/HI/ABF/08-2
MC269
Present On Admission Indicator - 8
67H (pos 8)
N/A
837/2300/HI/08-9
MC270
Other Diagnosis - 9
67I
21I
837/2300/HI/ABF/09-2
MC271
Present On Admission Indicator - 9
67I (pos 8)
N/A
837/2300/HI/09-9
MC272
Other Diagnosis - 10
67J
21J
837/2300/HI/ABF/10-2
MC273
Present On Admission Indicator - 10
67J (pos 8)
N/A
837/2300/HI/10-9
MC274
Other Diagnosis - 11
67K
21K
837/2300/HI/ABF/11-2
MC275
Present On Admission Indicator - 11
67K (pos 8)
N/A
837/2300/HI/11-9
MC276
Other Diagnosis - 12
67L
21L
837/2300/HI/ABF/12-2
MC277
Present On Admission Indicator - 12
67L (pos 8)
N/A
837/2300/HI/12-9
MC278
Other Diagnosis - 13
N/A
N/A
837/2300/HI/ABF/01-2
MC279
Present On Admission Indicator - 13
N/A
N/A
837/2300/HI/01-9
MC280
Other Diagnosis - 14
N/A
N/A
837/2300/HI/ABF/02-2
MC281
Present On Admission Indicator - 14
N/A
N/A
837/2300/HI/02-9
MC282
Other Diagnosis - 15
N/A
N/A
837/2300/HI/ABF/03-2
MC283
Present On Admission Indicator - 15
N/A
N/A
837/2300/HI/03-9
MC284
Other Diagnosis - 16
N/A
N/A
837/2300/HI/ABF/04-2
MC285
Present On Admission Indicator - 16
N/A
N/A
837/2300/HI/04-9
MC286
Other Diagnosis - 17
N/A
N/A
837/2300/HI/ABF/05-2
MC287
Present On Admission Indicator - 17
N/A
N/A
837/2300/HI/05-9
MC288
Other Diagnosis - 18
N/A
N/A
837/2300/HI/ABF/06-2
MC289
Present On Admission Indicator - 18
N/A
N/A
837/2300/HI/06-9
MC290
Other Diagnosis - 19
N/A
N/A
837/2300/HI/ABF/07-2
MC291
Present On Admission Indicator - 19
N/A
N/A
837/2300/HI/07-9
MC292
Other Diagnosis - 20
N/A
N/A
837/2300/HI/ABF/08-2
MC293
Present On Admission Indicator - 20
N/A
N/A
837/2300/HI/08-9
MC294
Other Diagnosis - 21
N/A
N/A
837/2300/HI/ABF/09-2
MC295
Present On Admission Indicator - 21
N/A
N/A
837/2300/HI/09-9
MC296
Other Diagnosis - 22
N/A
N/A
837/2300/HI/ABF/10-2
MC297
Present On Admission Indicator - 22
N/A
N/A
837/2300/HI/10-9
MC298
Other Diagnosis - 23
N/A
N/A
837/2300/HI/ABF/11-2
MC299
Present On Admission Indicator - 23
N/A
N/A
837/2300/HI/11-9
MC300
Other Diagnosis - 24
N/A
N/A
837/2300/HI/ABF/12-2
MC301
Present On Admission Indicator - 24
N/A
N/A
837/2300/HI/12-9
MC302
Principal Procedure Code
74
N/A
837/2300/HI/BBR/01-2
MC303
Other Procedure Code - 1
74A
N/A
837/2300/HI/BBQ/01-2
MC304
Other Procedure Code - 2
74B
N/A
837/2300/HI/BBQ/02-2
MC305
Other Procedure Code - 3
74C
N/A
837/2300/HI/BBQ/03-2
MC306
Other Procedure Code - 4
74D
N/A
837/2300/HI/BBQ/04-2
MC307
Other Procedure Code - 5
74E
N/A
837/2300/HI/BBQ/05-2
MC308
Other Procedure Code - 6
N/A
N/A
837/2300/HI/BBQ/06-2
MC309
Other Procedure Code - 7
N/A
N/A
837/2300/HI/BBQ/07-2
MC310
Other Procedure Code - 8
N/A
N/A
837/2300/HI/BBQ/08-2
MC311
Other Procedure Code - 9
N/A
N/A
837/2300/HI/BBQ/09-2
MC312
Other Procedure Code - 10
N/A
N/A
837/2300/HI/BBQ/10-2
MC313
Other Procedure Code - 11
N/A
N/A
837/2300/HI/BBQ/11-2
MC314
Other Procedure Code - 12
N/A
N/A
837/2300/HI/BBQ/12-2
MC315
Other Procedure Code - 13
N/A
N/A
837/2300/HI/BBQ/01-2
MC316
Other Procedure Code - 14
N/A
N/A
837/2300/HI/BBQ/02-2
MC317
Other Procedure Code - 15
N/A
N/A
837/2300/HI/BBQ/03-2
MC318
Other Procedure Code - 16
N/A
N/A
837/2300/HI/BBQ/04-2
MC319
Other Procedure Code - 17
N/A
N/A
837/2300/HI/BBQ/05-2
MC320
Other Procedure Code - 18
N/A
N/A
837/2300/HI/BBQ/06-2
MC321
Other Procedure Code - 19
N/A
N/A
837/2300/HI/BBQ/07-2
MC322
Other Procedure Code - 20
N/A
N/A
837/2300/HI/BBQ/08-2
MC323
Other Procedure Code - 21
N/A
N/A
837/2300/HI/BBQ/09-2
MC324
Other Procedure Code - 22
N/A
N/A
837/2300/HI/BBQ/10-2
MC325
Other Procedure Code - 23
N/A
N/A
837/2300/HI/BBQ/11-2
MC326
Other Procedure Code - 24
N/A
N/A
837/2300/HI/BBQ/12-2
MC327
Member Address Line 1
9a
5
837/2010BA/N3/01, 837/2010CA/N3/01
MC328
Member Address Line 2
9a
5
837/2010BA/N3/02, 837/2010CA/N3/02
MC329
Member Country Code
9e
N/A
837/2010BA/N4/04, 837/2010CA/N4/04
MC330
In-Plan Network Indicator
N/A
N/A
N/A
MC331
Payment Arrangement Type Indicator
N/A
N/A
N/A
MC332
Member Age
N/A
N/A
N/A
MC333
Substance Use Disorder (SUD)
								Indicator
N/A
N/A
N/A
MC334
Service Line Date - From
FL45
24A
837/2400/DTP/472/D8
MC335
Service Line Date - Thru
FL45
24A
837/2400/DTP/472/D8
MC336
Carrier Specific Unique Member (CSUM)
								ID
N/A
N/A
N/A
MC899
Record Type
N/A
N/A
N/A