Should previously paid but now Voided be reported? Yes. Claims that were paid and reported in one period and voided by either the Provider or the Carrier in a subsequent period should be reported in the subsequent file. See MC139 below. The reporting of Voided Claims maintains logic integrity related to medical costs and utilization. What types of claims are to be included? The Medical Claims file is used to report both institutional and professional claims. The unique elements that apply to each are included; however only those elements that apply to the claim type should be submitted. Example: Diagnostic Pointer is a Professional Claim element and would not be a required element on an Institutional Claim record. See MC094 below for claim type ID. CHIA has adopted the most widely used specification at this time. It is important to note that adhering to claim rules for each specific type will provide cleaner analysis. The word ‘Member’ is used in the specification. Are ‘Member’ and ‘Patient’ used synonymously? Yes. Member and Patient are to be used in the same manner in this specification Member is used in the claim specification to strengthen the reporting bond between Member Eligibility and the claims attached to a Member. If claims are processed by a third-party administrator, who is responsible for submitting the data and how should the data be submitted? In instances where more than one entity administers a health plan, the health care carrier and third-party administrators are responsible for submitting data according to the specifications and format defined in the Submission Guides. CHIA expects each party to report the Organization ID of the other party in the Delegated Benefit Organization ID (MC100) field to assist in CHIA’s objective is to create a comprehensive All-Payer database which must include data from all health care carriers and all their third-party administrators (TPAs, PBMs, DBAs, CSOs, etc.).
4 Type of File 11/8/12 Text ID File char[2] Defines the file type and data expected. Report MC here. Indicates that the data within this file is expected to be MEDICAL CLAIM-based. This must match the File Type reported in TR004. Mandatory 100% HM 5 Period Beginning Date 11/8/12 Date Period Integer Century Year Month CCYYMM int[6] Header Period Start Date Report the Year and Month of the reported submission period in CCYYMM format. This date period must be repeated in HD006, TR005 and TR006. This same date must be selected in the upload application for successful transfer. Mandatory 100% HM 6 Period Ending Date 11/8/12 Date Period - Integer Century Year Month - CCYYMM int[6] Header Period Ending Date Report the Year and Month of the reporting submission period in CCYYMM format. This date period must match the date period reported in HD005 and be repeated in TR005 and TR006. Mandatory 100% HM 7 Record Count 11/8/12 Integer Counter Header Record Count Report the total number of records submitted within this file. Do not report leading zeros, space fill, decimals, or any special characters. Mandatory 100% HM 8 11/8/12 Text Free Text Field Header Carrier Comments May be used to document the submission by assigning a filename, system source, compile identifier, etc. Optional 0% HO 9 APCD Version Number 2/201 Decimal - Numeric ID Version char[3] Submission Guide Version Report the version number as presented on the APCD Medical Claim File Submission Guide in 0.0 Format. Sets the intake control for editing elements. Version must be accurate else file will drop. EXAMPLE: 3.0 = Version 3.0 Mandatory 100% HM Code Description 2.1 Prior Version; valid only for reporting periods prior to October 2013 3.0 Version 3.0; required for reporting periods as of October 2013; No Longer Valid as of May 2015 MC MC MC - MC MC - - 9
4.0 Version 4.0; required for reporting periods October 2013 onward; No longer valid as of August 2016 5.0 Version 5.0; required for reporting periods October 2013 onward as of August 2016 1 Submitter 11/8/12 Integer ID Submitter varchar[6] CHIA defined and maintained unique identifier Report the Unique Submitter ID as defined by CHIA here. This must match the Submitter ID reported in HD002. All 100% A0 2 National Plan ID 11/8/12 Integer ID Nat'l PlanID int[10] CMS National Plan Identification Number (PlanID) Do not report any here until National PlanID is fully implemented. This is a unique identifier as outlined by Centers for Medicare and Medicaid Services (CMS) for Plans or Sub plans. All 0% Z 3 Insurance Type 10/30/14 Lookup Table Text char[2] Type / Product Identification Code Report the code that defines the type of insurance under which this patient's claim line was processed. EXAMPLE: HM = HMO All 98% A2 Code Description 09 Self-pay 10 Central Certification 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization (DMO) AM Automobile Medical 01 02 03
BL Blue / Blue Shield CC Commonwealth Care CE Commonwealth Choice CH Champus CI Commercial Insurance Co. DS Disability HM Health Maintenance Organization LI Liability LM Liability Medical MA Medicare Part A MB Medicare Part B Medicaid OF Other Federal Program TF HSN Trust Fund TV Title V VA Veterans Administration Plan WC Workers' Compensation ZZ 4 Payer Claim Control Number 6/24/10 Text ID Number Claim Control Identification Report the Unique identifier within the payer's system that applies to the entire claim. All 100% A0 MC 5 Line Counter 11/8/12 Integer ID Count varchar[4] Incremental Line Counter Report the line number for this service within the claim. Start with 1 and increment by 1 for each additional line. Do not start with 0, include alphas or special characters. All 100% A0 04 05
MC 6 Version Number 6/24/10 Integer Counter varchar[4] Service Line Version Number Report the version number of this service line. The version number begins with 0 and is incremented by 1 for each subsequent version of that service line. No alpha or special characters. All 100% A0 MC 7 Insured Group or Policy Number 6/24/10 Text ID Group Group / Policy Number Report the number that defines the insured group or policy. Do not report the number that uniquely identifies the subscriber or member. All 9% MC 8 All % MC 9 Plan Specific Contract Number 6/24/10 Text ID Contract Contract Number Report the Plan assigned contract number. Do not include values in this field that will distinguish one member of the family from another. This should be the contract or certificate number for the subscriber and all of the dependents. All 98% MC 10 Member Suffix or Sequence Number 6/24/10 Text ID Sequence Member/Patient's Contract Sequence Number Report the unique number / identifier of the member / patient within the contract. All 98% MC 11 MC 12 Individual Code 6/24/10 Lookup Table Text char[2] Patient to Subscriber Relationship Code Report the value that defines the Patient's relationship to the Subscriber. EXAMPLE: 20 = Self / Employee All 98% B Description Spouse Grandfather or Grandmother Grandson or Granddaughter 07 Nephew or Niece 06 08
10 Foster Child 15 Ward 17 Stepson or Stepdaughter 19 Child 20 Self/Employee 21 Unknown 22 Handicapped Dependent 23 Sponsored Dependent 24 Dependent of a Minor Dependent 29 Significant Other 32 Mother 33 Father 36 Emancipated 39 Donor 40 Cadaver Donor 41 Injured Plaintiff 43 Child Where Insured Has No Financial Responsibility 53 Life Partner 76 Dependent MC 13 Member Gender 6/24/10 Lookup Table Text tlkpGender char[1] Patient's Gender Report patient gender as found on the claim in alpha format. Used to validate clinical services when applicable and Unique Member ID. EXAMPLE: F = Female All 98% B Code Description F Female M Male
O Other U Unknown MC 14 Member Date of Birth - Integer Century Year Month - CCYYMM int[] Member/Patient's of Report the the member / patient was born in CCYYMM Format. Used to validate Unique Member ID. All % MC 15 MC 16 Member State External Code Source 2 - Text Address State External Code Source 2 - States char[2] State / Province of the Patient Report the of the patient as defined by the US Postal Service. Report Province when Country Code does not = USA. All MC 17 Member ZIP Code External Code Source 2 - Text Address Zip External Code Source 2 - Zip Codes varchar[] Zip Code of the Member / Patient Report the 5 digit Zip Code as defined by the United States Postal Service. All % MC 18 Date Service Approved (AP Date) 6/24/10 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Date Service Approved by Payer Report the date that the payer approved this claim line for payment in CCYYMMDD Format. This element was designed to capture date other than the Paid date. If Approved Date and Paid Date are the same, then the date here should match Paid Date. All 93% C
MC 19 Admission Date 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Inpatient Admit Date Report the date of admit to a facility in CCYYMMDD Format. Only applies to facility claims where Type of Bill = an inpatient setting. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 98% A1 MC 20 Filler 10/30/14 Filler Filler char[4] Filler The MA APCD reserves this field for future use. Do not populate with any data. All 0% Z MC 21 Admission Type 11/8/12 External Code Source 14 - Integer External Code Source 14 - Admission Type int[1] Admission Type Code Report Admit Type as it applies to facility claims where Type of Bill = an inpatient setting. This code indicates the type of admission into an inpatient setting. Also known as Admission Priority. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 98% A1
MC 27 National Provider ID - Service 10/30/14 External Code Source 3 - Integer External Code Source 3 - National Provider ID int[10] National Provider Identification (NPI) of the Service Provider Report the Primary National Provider ID (NPI) of the Service Provider in MC024. This ID should be found on the Provider File in the NPI Field (PV039) All 98% A2 MC 28 Service Provider Entity Type Qualifier 11/8/12 Lookup Table - integer int[1] Service Provider Entity Identifier Code Report the value that defines the Service Provider entity type. Only individuals should be identified with a 1. Facilities, professional groups and clinic sites should all be identified with a 2. EXAMPLE: 1 = Person All 98% A0 Value Description 1 Person 2 Non-person entity MC 29 Service Provider Name 10/30/14 Text Name First Provider name of Service Provider Report the individual's first name here. If provider is a facility or organization , do not report any value here Required when MC027 = 1 92% C MC 30 Service Provider Middle Initial 10/30/14 Text Name Middle Provider Middle initial of Service Provider Report the individual's middle initial here. If provider is a facility or organization , do not report any value here Required when = 1 2% C MC 31 Servicing Provider Last Name or Name 6/24/10 Text Name Last / Org Provider Last name or Organization Name of Service Provider Report the name of the organization or last name of the individual provider. determines if this is an Organization or Individual Name reported here. All 94% A2 MC 32 Service Provider Suffix 10/30/14 Lookup Table - Integer int[1] Provider Name Suffix Report the individuals name-suffix when applicable here. Used to capture the generation of the individual clinician (e.g., Jr. Sr., III). Do not report degree acronyms here. EXAMPLE: 0 = Unknown / Not Applicable Required when MC027 = 1 2% Z Value Description 1 I.
2 II. 3 III. 4 Jr. 5 Sr. 0 Unknown / Not Applicable MC 33 Service Provider Taxonomy 11/8/12 External Code Source 5 - Text External Code Source 5 - Taxonomy Taxonomy Code Report the standard code that defines this provider for this line of service. Taxonomy values allow for the reporting of nurses, assistants and laboratory technicians, where applicable, as well as Physicians, Medical Groups, Facilities, etc. All 98% A2 MC 34 Service Provider City Name 6/24/10 Text Address City Provider City Name of the Provider Report the city name of provider - preferably practice location. Do not report any value if not available. All 98% B MC 35 Service Provider State 11/8/12 External Code Source 2 - Text Address External Code Source 2 - States char[2] State of the Service Provider Report the of the service providers as defined by the US Postal Service. Do not report any value if not available. All 98% B MC 36 Service Provider ZIP Code 11/8/12 External Code Source 2 - Text Address Zip External Code Source 2 - Zip Codes varchar[9] Zip Code of the Service Provider Report the 5 or Zip Code as defined by the United States Postal Service. When submitting the 9-digit Zip Code do not include hyphen. All 98% B MC 37 Type of Bill - on Facility Claims 11/8/12 External Code Source 14 - Integer External Code Source 14 - Type of Bill int[2] Type of Bill Report the two-digit value that defines the Type of Bill on an institutional claim. Do not report leading zero Required when MC094 = 002 98% A0 MC 38 Site of Service - on NSF/CMS 1500 Claims 11/8/12 External Code Source 13 - Numeric External Code Source 13 - Place of Service char[2] Place of Service Code Report the two-digit value that defines the Place of Service on professional claim Required when MC094 = 001 100% A0 MC 39 Claim Status 11/8/12 Lookup Table - Numeric tlkpClaimStatus varchar[2] Claim Line Status Report the value that defines the payment status of this claim line All 98% A0
Value Description 1 Processed as primary 2 Processed as secondary 3 Processed as tertiary 4 Denied 19 Processed as primary, forwarded to additional 20 Processed as secondary, forwarded to additional payer(s) 21 Processed as tertiary, forwarded to additional payer(s) 22 Reversal of previous payment 23 Not our claim, forwarded to additional payer(s) 25 Predetermination Pricing Only - no payment MC 40 Admitting Diagnosis 11/8/12 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] Admitting Diagnosis Code Report the diagnostic code assigned by provider that supported admission into the inpatient setting. Required when = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86, or 89 98% A1 MC 41 ECode 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnostic External Injury Code Report the external code for patient when appropriate to the claim. All 3% C MC 42 Principal Diagnosis 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Primary Diagnosis Code Report the Primary ICD Diagnosis Code here. Do not code decimal point. All 99% A0
MC 43 Other Diagnosis - 1 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Secondary Diagnosis Code Report the Secondary ICD Diagnosis Code here. If not applicable do not report any value here. Do not code decimal point. All 70% B MC 44 Other Diagnosis - 2 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 2. If not applicable do not report any value here. Do not code decimal point. All 24% B MC 45 Other Diagnosis - 3 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 3. If not applicable do not report any value here. Do not code decimal point. All 13% C MC 46 Other Diagnosis - 4 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 4. If not applicable do not report any value here. Do not code decimal All 7% C MC 47 Other Diagnosis - 5 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 5. If not applicable do not report any value here. Do not code decimal point. All 4% C MC 48 Other Diagnosis - 6 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 6. If not applicable do not report any value here. Do not code decimal point. All 3% C
MC 56 Procedure Code 11/8/12 External Code Source 9 - Text External Code Source 9 - CPTs & HCPCS / CPT Code Report a Procedure code for the claim line as defined by MC130. All 98% A1 MC 57 Procedure Modifier - 1 11/8/12 External Code Source 9 - Text External Code Source 9 - Modifiers char[2] HCPCS / CPT Code Modifier Report a valid Procedure modifier when a modifier clarifies / improves the reporting accuracy of the associated procedure code (MC055). All 20% B MC 58 Procedure Modifier - 2 11/8/12 External Code Source 9 - Text External Code Source 9 - Modifiers char[2] HCPCS / CPT Code Modifier Report a Procedure modifier when a modifier clarifies / improves the reporting accuracy of the associated procedure code (MC055). All 3% B MC 59 ICD-CM Primary Procedure Code 10/30/14 External Source 8 - Text External Code Source 8 - ICDCM Procedure Codes varchar[7] ICD Primary Procedure Code Report the primary ICD CM procedure code when appropriate. Repeat this code on all lines of the inpatient claim. Do not code decimal point. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 55% A2 MC 60 Date of Service - From 6/24/10 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Date of Service Report the date of service for the claim line in CCYYMMDD Format. All 98% A0 MC 61 Date of Service - To 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Date of Service Report the end service date for the claim line in CCYYMMDD Format. For inpatient claims, the room and board line may or may not be equal to the discharge date. Procedures delivered during a visit should indicate which date they occurred. All 98% A0
MC 66 Copay Amount 6/24/10 Integer Currency Amount of member/patient is responsible to pay Report the amount that defines a preset, fixed amount for this claim line service that the patient is responsible to pay. Report 0 if no Copay applies. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 All 99% A1 MC 67 Amount 6/24/10 Integer Currency Amount of coinsurance member/patient is responsible to pay Report the amount that defines a calculated percentage amount for this claim line service that the patient is responsible to pay. Report 0 if no Coinsurance applies. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 All 99% A1 MC 68 Deductible Amount 6/24/10 Integer Currency Amount of deductible member/patient is responsible to pay on the claim line Report the amount that defines a preset, fixed amount for this claim line service that the patient is responsible to pay. Report 0 if no Deductible applies to service. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 All 99% A1
MC 69 Patient Control Number 10/30/14 Text ID Claim Number Patient Control Number Report the provider assigned Encounter / Visit number to identify patient treatment. Also known as the Patient Account Number. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 98% A2 MC 70 Discharge Date 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Discharge Date Report the date the member was discharged from the facility in CCYYMMDD Format. If patient is still in-house and claim represents interim billing for interim payment, report the interim through date. Required when MC094 = 002 and MC039 is populated 98% A2 MC 71 Service Provider Country Code 12/1/10 External Code Source 1 - Text Address Country External Code Source 1 - Countries char[3] Country name of the Service Provider Report the three-character country code as defined by ISO 3166-1, Alpha 3 All 98% C MC 72 DRG 11/8/12 External Code Source 15 - Text External Code Source 15 - DRG varchar[7] Diagnostic Related Group Code Report the DRG number applied to this claim on every line to which it’s applicable. Insurers and health care claims processors shall code using the CMS methodology when available. When the CMS methodology for DRGs is not available, but the All Payer DRG system is used, the insurer shall format the DRG and the complexity level within the same element with the prefix of "A" and with a hyphen separating the AP DRG from the complexity level (e.g. AXXX-XX) Required when MC094 = 002 and MC069 is populated 98% B
MC 73 DRG Version 11/8/12 External Code Source 15 - Text External Code Source 15 - DRG char[2] Diagnostic Related Version Number Report the version of the grouper used. Required when MC071 is populated 20% B MC 74 Filler 10/30/14 Filler Filler char[4] Filler The MA APCD reserves this field for future use. Do not populate with any data. All 0% Z MC 75 Filler 10/30/14 Filler Filler char[2] Filler The MA APCD reserves this for future use. Do not populate with any data. All 0% Z MC 76 Drug Code 6/24/10 External Code Source 12 - Text External Code Source 12 - National Drug char[11] National Drug Code (NDC) Report the NDC code used only when a medication is paid for as part of a medical claim or when a DME device has an NDC code. J codes should be submitted under procedure code (MC055), and have a procedure code type of 'HCPCS'. Drug Code as defined by the FDA in 11 digit format (5-4-2) without hyphenation. All 1% B MC 77 Billing Provider Number 6/24/10 Text ID Link to PV002 Billing Provider Number Report the carrier / submitter assigned billing provider number. This number should be the identifier used for internal identification purposes, and does not routinely change. The value in this field must match a record in the provider file in PV002. All 99% B MC 78 National Provider ID - Billing 10/30/14 External Code Source 3 - Integer External Code Source 3 - National Provider ID int[10] National Provider Identification (NPI) of the Billing Provider Report the Primary National Provider ID (NPI) here. This ID should be found on the Provider File in the NPI field (PV039). All 99% A2 MC 79 Billing Provider Last Name or Name 6/24/10 Text Name Last / Org Provider Last name or Organization Name of Billing Provider Report the name of the organization or last name of the individual provider. All 99% B
MC 80 Product ID Number 11/8/12 Text ID Link to PR001 Product Identification Report the submitter-assigned identifier as it appears in PR001 in the Product File. This element is used to understand Product and Eligibility attributes of the member / subscriber as applied to this record. All 100% A0 MC 81 Payment Reason 11/8/12 Carrier Defined Table - OR - External Code Source 16 - Text External Code Source 16 - Claim Adjustment Reasons- OR – Carrier Defined Payment Reason Code Report the value that describes how the claim line was paid, either using a standard code set or a proprietary list pre-sent by submitter. Required when MC038 = 1, 2, 3, 19, 20, or 21 100% A0 MC 82 Capitated Encounter Flag 11/8/12 Lookup Table - Integer int[1] Indicator - Capitation Payment Report the value that defines the element. EXAMPLE: 1 = Yes payment for this service is covered under a capitated arrangement. All 100% A0 Value Description 1 Yes 2 No 3 Unknown 4 5 Not Applicable MC 83
MC 84 Other ICD-CM Procedure Code - 1 10/30/14 External Codes Source 8 - Text External Code Source 8 - ICDCM Procedure Codes varchar[7] ICD Secondary Procedure Code Report the subsequent ICD CM procedure code when applicable. Repeat this code on all lines of the inpatient claim. Do not code decimal point. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 1% C MC 85 Other ICD-CM Procedure Code - 2 10/30/14 External Source 8 - Text External Code Source 8 - Procedure Codes varchar[7] ICD Procedure Code Report the third ICD procedure code when applicable. The Integer point is not coded. The ICD procedure must be repeated for all lines of the claim if necessary. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 1% C
MC 86 Other ICD-CM Procedure Code - 3 10/30/14 External Source 8 - Text External Code Source 8 - Procedure Codes varchar[7] ICD Other Procedure Code Report the fourth ICD procedure code when applicable. The Integer point is not coded. The ICD procedure must be repeated for all lines of the claim if necessary. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 1% C MC 87 Other ICD-CM Procedure Code - 4 10/30/14 External Codes Source 8 - Text External Code Source 8 - ICDCM Procedure Codes varchar[7] ICD Other Procedure Code Report the fifth ICD procedure code when applicable. The Integer point is not coded. The ICD procedure must be repeated for all lines of the claim if necessary. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 1% C
MC 91 LOINC Code 11/8/12 External Code Source 11 - Text External Code Source 11 - LOINC varchar[7] Logical Observation Identifiers, and Codes (LOINC) Report the LOINC here, a standardized test code (lab work) when applicable and available. Do not report any value if not applicable. All 0% B MC 92 Days 10/30/14 Quantity - Integer Days Partially Covered Covered Coinsurance Days Report the number of partially covered days the patient incurred during this admission. Report 0 if all days were covered and/or Noncovered days. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 98% B MC 93 Covered Days 10/30/14 Quantity - Integer Days Covered Covered Inpatient Days Report the number of covered days the patient incurred during this admission. Report 0 if days were Noncovered or partially covered Coinsurance Days. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 98% B
MC 94 Non Covered Days 10/30/14 Quantity - Integer Days Noncovered Noncovered Inpatient Days Report the number of Noncovered days the patient incurred during this admission. Report 0 if all days were covered. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 87% B MC 95 Type of Claim 11/8/12 Lookup Table - Text char[3] Type of Claim Indicator Report the that defines the type of claim submitted for payment. EXAMPLE: 001 = Professional Claim Line All 100% A0 Value Description 001 Professional 002 Facility 003 Reimbursement Form MC 96 of Liability Amount 11/8/12 Integer Currency Amount due from a Secondary Carrier when known Report the amount that another carrier / insurer is liable for submitting payer has processed this claim line. Report 0 if there is no COB / TPL amount. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when MC038 = 19, 20 or 21 98% A2
MC MC MC MC ICD Indicator Lookup Table - Integer tlkpICDIndicator int[1] International Classification of Diseases version Report the value that defines whether the diagnoses on claim are ICD9 or ICD10. EXAMPLE: 9 = ICD9 Required when = 001 or 002 and any of the following MC039 thru MC053, MC058, MC083 thru MC088, MC142 thru MC153 is populated 100% Value Description 9 ICD-9 0 ICD-10 07
MC Procedure Modifier - 3 11/8/12 External Code Source 9 - Text External Code Source 9 - Modifiers char[2] / CPT Code Modifier Report a Procedure modifier when a modifier clarifies / improves the reporting accuracy of the associated procedure code (MC055). All 0% C MC Procedure Modifier - 4 11/8/12 External Code Source 9 - Text External Code Source 9 - Modifiers char[2] / CPT Code Modifier Report a valid Procedure modifier when a modifier clarifies / improves the reporting accuracy of the associated procedure code (MC055). All 0% C MC Claim Processed Date 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Claim Processed Date Report the date the was processed by the carrier / submitter in CCYYMMDD Format. This date can be equal to Paid Date, but cannot be after Paid Date. All 98% A2 MC Diagnostic Pointer 10/30/14 Integer ID Diagnosis varchar[4] Diagnostic Pointer Number Report the placement number of the diagnosis(es) a procedure is related to for a professional Can report up to four diagnostic positions within the first nine diagnoses that can be reported. Do not separate multiple mappings with spaces, zeros or special characters. Do not zero fill. EXAMPLE: Procedure related to diagnoses 1, 4 and 5 = 145 or ADE Required when MC094 = 001 98% B MC Referring Provider ID 11/8/12 Text ID Link to PV002 Referring Provider ID Report the identifier of the provider that submitted the referral for the service or ordered the test that is on the claim (if applicable). The value in this field must have a corresponding Provider ID (PV002) on the provider file. Required when MC118 = 1 98% A2 MC Payment Type 11/8/12 Lookup Table - Numeric char[2] Payment Arrangement Type Value Report the value that defines the contracted payment methodology for this claim line. EXAMPLE: = Fee for Service All 98% A0 Value Description 01 Capitation 02 Fee for Service Percent of Charges
04 DRG 05 Pay for Performance Global Payment Other Bundled Payment 09 Payment Amount Per Episode (PAPE) (MassHealth) ( 09 Valid for HD002 = MassHealth orgid ONLY ) 10 Enhanced Ambulatory Patient Grouping (EAPG) (MassHealth) ( 10 Valid for HD002 = MassHealth orgid ONLY ) MC Excluded Expenses 11/8/12 Integer Currency Amount not covered at the line due to benefit/plan limitation Report the amount that the patient has incurred towards covered but over-utilized services. Scenario: Physical Therapy units that are authorized for 15 visits at $50 a visit but utilized 20. The amount reported here would be 25000 to state by $250.00. Report 0 if there are no Excluded Expenses. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 All 98% A2 MC Medicare Indicator 11/8/12 Lookup Table - Integer int[1] Indicator - Medicare Payment Applied Report the value that defines the element. EXAMPLE: 1 = Yes, Medicare paid for part or all of services. All 100% A0 Value Description 1 Yes 2 No
3 Unknown 4 Other 5 Not Applicable MC Withhold Amount 11/8/12 Integer Currency Amount to be paid to the provider upon guarantee of performance Report the amount paid to the provider for this line if the provider qualified / met performance guarantees. Report 0 if the provider has the agreement but did not satisfy the measure, else do not report any value here. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 All 98% A2 MC Filler 10/30/14 Filler Filler int[1] Filler The MA APCD reserves this field for future use. Do not populate. All 0% Z MC Referral Indicator 11/8/12 Lookup Table - Integer int[1] Indicator - Referral Needed Report the value that defines the element. EXAMPLE: 1 = Yes service was preceded by a referral. All 100% A0 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable MC PCP Indicator 11/8/12 Lookup Table - Integer int[1] Indicator - PCP Rendered Service Report the value that defines the element. EXAMPLE: 1 = Yes service was performed by members PCP. All 100% A2 Value Description 1 Yes 2 No 18
3 Unknown 4 Other 5 Not Applicable MC DRG Level 11/8/12 External Code Source 15 - Integer External Code Source 15 - DRG int[1] Diagnostic Related Group Code Severity Level Report the level used for severity adjustment when applicable. Required when is populated 80% B MC Patient Total Out of Pocket Amount 11/8/12 Integer Currency Total amount patient/member must pay Report the total amount patient / member is responsible to pay to the provider as part of their costs for services. Report 0 if there are no Out of Pocket expenses. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 All 100% A2 MC Global Payment Flag 11/8/12 Lookup - Integer int[1] Indicator - Global Payment Report the that defines the element. EXAMPLE: 1 = Yes the claim line was paid under a global payment arrangement. All 100% A0 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable MC Denied Flag 11/8/12 Lookup Table - Integer int[1] Denied Claim Line Indicator Report the value that defines the element. EXAMPLE: 1 = Yes, Claim Line was denied. Required when MC038 = 4 100% A0 Value Description 1 Yes 2 No
3 Unknown 4 Other 5 Not Applicable MC Denial Reason 11/8/12 Carrier Defined Table - OR - External Code Source 16 - Text External Code Source 16 - Denial Reason OR Carrier-Defined lookup Denial Reason Code Report the code that defines the reason for denial of the line. Carrier must submit denial reason codes in separate table to the MA APCD. Required when = 1 98% A2 MC Attending Provider 10/30/14 Text ID Link to PV002 Attending Provider ID Report the ID that reflects the provider that provided general oversight of the patient's care. This individual may or may not be the Servicing or Rendering provider. This value needs to be found in field PV002 on the Provider File. This field may or may not be NPI based on the carrier’s identifier system. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 98% A1 MC Accident Indicator 11/8/12 Lookup Table - Integer int[1] Indicator - Accident Related Report the that defines the element. EXAMPLE: 1 = Yes, Claim Line is Accident related. All 100% A2 Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable
MC Family Planning Indicator 11/8/12 Lookup Table - Integer int[1] Service is related to Family Planning Report the value that defines if family planning services were provided. EXAMPLE: 0 = Unknown / Not Applicable All 98% A2 Value Description 1 Family planning services provided 2 Abortion services provided 3 Sterilization services provided 4 No family planning services provided 0 Unknown / Not Applicable / Not Avail MC Related Indicator 11/8/12 Lookup Table - Integer int[1] Indicator - Accident Related Report the value that defines the element. EXAMPLE: 1 = Yes, Claim Line was related to employment accident. All 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable MC Indicator 11/8/12 Lookup Table - Integer int[1] Service related to Early Periodic Screening, Diagnosis and Treatment (EPSDT) Report the value that defines if service was related to EPSDT and the type of EPSDT service, such as 'screening', 'treatment' or ‘referral’. EXAMPLE: 0 = Unknown / Not Applicable All 98% B Value Description 1 EPSDT Screen 2 EPSDT Treatment 3 EPSDT Referral
0 Unknown / Not Applicable / Not Available MC Procedure Code Type 10/30/14 Lookup Table - Integer int[1] Claim line Procedure Code Type Identifier Report the value that defines the type of Procedure Code expected in MC055. All 98% A1 Description 1 CPT or HCPCS Level 1 Code 2 HCPCS Level II Code 3 HCPCS Level III Code (State Medicare code). 4 American Dental Association (ADA) Procedure Code (Also referred to as CDT code.) 5 defined Procedure Code 6 CPT Category II 7 CPTCategory III Code MC InNetwork Indicator 11/8/12 Lookup Table - Integer int[1] Indicator - Network Rate Applied Report the value that defines the element. EXAMPLE: 1 = Yes claim line was paid at an InNetwork rate. All 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable MC Service Class 2/2016 Carrier Defined - Text Carrier Defined - MCO Service Class char[3] Service Class Code Report the code that defines the service class for Medicaid PCC members receiving behavioral health services (values based on MassHealth encounter table). Required when Submitter is identified as a / MCO Submitter 10% C
MC Other Diagnosis - 13 2/2016 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code Other ICD Diagnosis Code - 13. If not applicable do not report any value here. Do not code decimal All 1% C MC Other Diagnosis - 14 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code ICD Diagnosis Code - 14. If not applicable do not report any value here. Do not code decimal point. All 1% C MC Diagnosis - 15 2/2016 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code Other ICD Diagnosis Code - 15. If not applicable do not report any value here. Do not code decimal point. All 1% C MC Other Diagnosis - 16 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 16. If not applicable do not report any value here. Do not code decimal All 1% C MC Other Diagnosis - 17 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 17. If not applicable do not report any value here. Do not code decimal point. All 1% C MC Diagnosis - 2/2016 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code ICD Diagnosis Code - 18. If not applicable do not report any value here. Do not code decimal point. All 1% C
MC Other Diagnosis - 19 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 19. If not applicable do not report any value here. Do not code decimal point. All 1% C MC Diagnosis - 20 2/2016 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code Other ICD Diagnosis Code - 20. If not applicable do not report any value here. Do not code decimal point. All 1% C MC Other Diagnosis - 21 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code ICD Diagnosis Code - 21. If not applicable do not report any value here. Do not code decimal All 1% C MC Other Diagnosis - 22 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 22. If not applicable do not report any value here. Do not code decimal All 1% C MC Diagnosis - 23 2/2016 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 23. If not applicable do not report any value here. Do not code decimal point. All 1% C MC Diagnosis - 2/2016 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 24. If not applicable do not report any value here. Do not code decimal point. All 1% C
MC Present on Admission Code (POA) - 01 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Principal Diagnosis Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC041 is populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 02 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 1 Report the appropriate from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC042 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 03 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 2 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC043 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2
MC Present on Admission Code (POA) - 04 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 3 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC044 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 05 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 4 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC045 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 06 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 5 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC046 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2
MC Present on Admission Code (POA) - 07 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 6 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC047 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 08 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 7 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC048 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 09 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Diagnosis - 8 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when = 002, MC039 and MC049 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2
MC Present on Admission Code (POA) - 10 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 9 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when = 002, MC039 and MC050 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 11 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 10 Report the appropriate from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when = 002, MC039 and MC051 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 12 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Diagnosis - 11 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC052 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2
MC Present on Admission Code (POA) - 13 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 12 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC053 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 14 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 13 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when = 002, MC039 and MC142 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 15 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 14 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC143 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2
MC Present on Admission Code (POA) - 19 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 18 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC147 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 20 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 19 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC148 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 21 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 20 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC149 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2
MC Present on Admission Code (POA) - 22 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 21 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC150 is populated and MC245 are not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 23 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Diagnosis - 22 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC151 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 24 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 23 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when = 002, MC039 and MC152 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2
MC Present on Admission Code (POA) - 25 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 24 Report the appropriate from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC153 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Condition Code - 1 11/8/12 External Code Source 14 - Text External Code Source 14 - Condition Codes char[2] Condition Code Report the appropriate value that defines a condition of the claim or patient. If not applicable do not report any value here. All 1% B MC Condition Code - 2 11/8/12 External Code Source 14 - Text External Code Source 14 - Condition Codes char[2] Condition Code Report the appropriate value that defines a condition of the claim or patient. If not applicable do not report any value here. All 1% B MC Condition Code - 3 11/8/12 External Code Source 14 - Text External Code Source 14 - Condition char[2] Condition Code Report the appropriate that defines a condition of the claim or patient. If not applicable do not report any value here. All 1% B MC Condition Code - 4 11/8/12 External Code Source 14 - Text External Code Source 14 - Condition Codes char[2] Condition Code Report the appropriate that defines a condition of the claim or patient. If not applicable do not report any value here. All 1% B MC Condition Code - 5 11/8/12 External Code Source 14 - Text External Code Source 14 - Condition Codes char[2] Condition Code Report the appropriate that defines a condition of the claim or patient. If not applicable do not report any value here. All 1% B MC Condition Code - 6 11/8/12 External Code Source 14 - Text External Code Source 14 - Condition Codes char[2] Condition Code Report the appropriate value that defines a condition of the claim or patient. If not applicable do not report any value here. All 1% B MC Condition Code - 7 11/8/12 External Code Source 14 - Text External Code Source 14 - Condition Codes char[2] Condition Code Report the appropriate value that defines a condition of the claim or patient. If not applicable do not report any value here. All 1% B
MC Value Amount - 11 11/8/12 Integer Currency Amount that corresponds to Value Code - 11 Report the appropriate amount that corresponds to the code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when is populated 100% B MC Value Code - 12 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Value Code Report the appropriate that defines a value category of the claim. If not applicable do not report any value here. All 1% B MC Value Amount - 12 11/8/12 Integer Currency Amount that corresponds to Code - 12 Report the appropriate amount that corresponds to the code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when MC213 is populated 100% B MC Code - 1 11/8/12 External Code Source 14 - Text External Code Source 14 - Occurrence Codes char[2] Occurrence Code Report the appropriate value that defines an occurrence category for the claim or patient. If not applicable do not report any value here. All 1% B MC Date - 1 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Date that corresponds to Occurrence Code - 1 Report the appropriate date that corresponds to the occurrence code in CCYYMMDD Format. Required when MC215 is populated 100% B MC Code - 2 11/8/12 External Code Source 14 - Text External Code Source 14 - Occurrence Codes char[2] Occurrence Code Report the appropriate value that defines an occurrence category for the claim or patient. If not applicable do not report any value here. All 1% B MC Date - 2 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Date that corresponds to Occurrence Code - 2 Report the appropriate date that corresponds to the occurrence code in CCYYMMDD Format. Required when MC217 is populated 100% B
MC Span Code - 5 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Occurrence Span Code Report the appropriate code that defines an occurrence span category of the claim or patient. If not applicable do not report any value here. All 1% B MC Span Start Date - 5 11/8/12 Full Date - Integer Century Year Day - CCYYMMDD int[8] Start Date that corresponds to Occurrence Span Code - 5 Report the appropriate start date that corresponds to the occurrence code in CCYYMMDD Format. Required when MC237 is populated 100% B MC Span End Date - 5 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] End Date that corresponds to Occurrence Span Code - 5 Report the appropriate date that corresponds to the occurrence code in CCYYMMDD Format. Required when is populated 100% B MC MC APCD ID Code 10/30/14 Lookup Table - Integer int[1] Member Enrollment Type Report the value that describes the member's / subscriber's enrollment into one of the predefined categories; aligns enrollment to appropriate editing and thresholds. EXAMPLE: 1 = FIG - Fully Insured Commercial Group Enrollee. All 100% A2 Value Description 1 FIG - Fully-Insured Commercial Group Enrollee 2 SIG - Self-Insured Group Enrollee 3 GIC - Group Insurance Commission Enrollee 4 MCO - MassHealth Managed Care Organization Enrollee 5 Supplemental Policy Enrollee 6 ICO - Integrated Care Organization or SCO – Senior Care Option 0 Unknown / Not Applicable
MC National Provider ID – Plan Rendering 10/30/14 External Code Source 3 – Integer External Code Source 3 – National Provider ID Int[10] National Provider Indentification (NPI) of the Plan Rendering Provider Report the Primary National Provider ID (NPI) of the Plan Rendering Provider in MC134. This ID should be found on the Provider File in the NPI Field (PV039) All 98% A2 MC Benefit Plan Contract ID 10/30/14 Text Benefit Plan ID Identifier for the benefit plan the member is enrolled in that covers this claim The Benefit Plan Contract ID is the issuer-generated unique ID number for the benefit plan which provides coverage for this claim. Report the carrier/submitter-assigned identifier as it appears in BP001 in the Benefit Plan File. This element is used to understand Benefit Plan, Eligibility and Claim attributes of the member / subscriber as applied to this record for the Massachusetts Alternative Risk Adjustment Methodology. Required when Carrier is BP submitter and claim is subject to Risk Adjustment 100% A2 MC Claim Line Paid Flag 10/30/14 Lookup Table - Integer int[1] Claim Line Paid Indicator Report the that defines the element. EXAMPLE: 1 = Yes, Claim Line was paid. Required 100% B Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable MC Type of Facility 10/30/14 Lookup - Integer int[2] Type of Facility Indicator Report the value that defines the type of facility setting for this claim. Required 98% B
2 Submitter 11/8/12 Integer ID Submitter varchar[6] Trailer Submitter / Carrier ID defined by CHIA Report the Unique Submitter ID as defined by CHIA here. This must match the Submitter ID reported in HD002. Mandatory 100% TM 3 National Plan ID 11/8/12 Integer ID Nat'l PlanID int[10] CMS National Plan Identification Number (PlanID) Do not report any value here until National PlanID is fully implemented. This is a unique identifier as outlined by Centers for Medicare and Medicaid Services (CMS) for Plans or Sub plans. Situational 0% TS 4 Type of File 6/24/10 Text ID File char[2] Validates the file type defined in Report MC here. This must match the File Type reported in HD004. Mandatory 100% TM 5 Period Beginning Date 6/24/10 Date Period - Integer Century Year Month - CCYYMM int[6] Trailer Period Start Date Report the Year and of the reported submission period in CCYYMM format. This date period must match the date period reported in HD005 and HD006. Mandatory 100% TM 6 Period Ending Date 6/24/10 Date Period - Integer Century Year Month - CCYYMM int[6] Trailer Period Ending Date Report the Year and Month of the reporting submission period in CCYYMM format. This date period must match the date period reported in TR005 and HD005 and HD006. Mandatory 100% TM 7 Date Processed 6/24/10 Full Date - Integer Century Year Day - CCYYMMDD int[8] Trailer Processed Date Report the full date that the submission was compiled by the submitter in CCYYMMDD Format. Mandatory 100% TM Appendix – External Code Sources 1. Countries American National Standards Institute