Revision History Date Version Description Author 12/1/2012 3.0 Administrative Bulletin 12-01; issued 11/8/2012 M. Prettenhofer 1/25/2013 3.1 Removed ‘Non-Massachusetts Resident’ section Increased length of ICD-CM Procedure Code fields to varchar(7) MC241 (APCD Id Code): Added option 6) ICO – Integrated Care Organization Payment Arrangement: Added option for MassHealth H. Hines 5/31/13 3.1 Updated HD009 to reflect reporting period change H. Hines 5/31/13 3.1 Updated Condition on Charge Amount, MC107 ICD Indicator Updated element submission guideline for Delegated Benefit Adminstrator OrganizationID Updated code source on Procedure Code (MC055) K. Hines 10/2014 4.0 Administrative Bulletin 14-08 K. 2/2016 5.0 Administrative Bulletin 16-03 K. 2/2016 5.0 Update APCD Version Number – HD009 – to 5.0 K. Hines 2/2016 5.0 change Format/Length from 2 to 3 K. Hines 2/2016 5.0 MC245 update for VNA/Home Care K. Hines 2/2016 5.0 Add clarifying language to fields K. 2/2016 5.0 Update Cover Sheet, CHIA website and address K. Hines 2/2016 5.0 Added Enhanced Ambulatory Patient Grouping (EAPG) (MassHealth) to MC113 Payment Arrangement Type K. Hines 2/2017 6.0 Initial Version 6.0 updates K. Hines Table of Contents
services performed and billed on a claim, each of those services will be uniquely identified and reported on a line. understand how services are perceived and adjudicated by different carriers. Won’t reporting claim lines create redundancy? Yes, certain data elements of claim level data will be repeated in every row in order to report unique line item processing. The repeated claim level data will be de-duplicated at CHIA. Claim-line level data is required to capture accurate details of claims and encounters. Are denied claims to be reported? No. Wholly denied claims should not be reported at this time. However, if a single procedure is denied within a paid claim that denied line should be reported. Denied line items of an adjudicated claim aid with cost analysis. Should claims that are paid under a ‘global payment’, or ‘capitated payment’ thus zero paid, be reported in this file? Yes. Any medical claim that is considered ‘paid’ by the carrier should appear in this filing. Paid amount should be reported as 0 and the corresponding Allowed, Contractual, Deductible Amounts should be calculated accordingly. The reporting of Zero Paid Medical Claims is required to accurately capture encounters and to further understand contractual arrangements. Should previously paid but now Voided Claims 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 to each are included; however only those elements that apply to the claim type 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.
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;No longer valid as of August 2017 6.0 Version 6.0; required for reporting periods October 2013 onward as of August 2017 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 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 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. 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 which this patient's claim line was processed. EXAMPLE: HM = HMO All 98% A2 Code Description 09 Self-pay 10 Central Certification 11 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 01 02
17 Dental Maintenance Organization (DMO) AM Automobile Medical BL Blue Cross / 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 V VA Veterans Administration Plan WC Workers' Compensation ZZ Other 4 Payer Claim Control Number 6/24/10 Text ID Claim Number Payer 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
O Other U Unknown MC 14 Member Date of Birth 2/2017 Year Month - Integer Century Year - CCYYMM int[6] Member/Patient's month and year of birth Report the month/year the member / patient was born in CCYYMM Format. Used to validate Unique Member ID. All 99% A0 MC 15 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 MC 16 Member State 2/2017 External Code Source 2 - Text Address 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 99% A0 MC 17 Member ZIP Code 2/2017 External Code Source 2 - Text Address Zip External Code Source 2 - Zip Codes varchar[5] Zip Code of the Member / Patient Report the 5 digit Zip Code as defined by the United States Postal Service. Must not report the digit zip code. All 99% A0 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 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 22 Admission Source 11/8/12 External Code Source 14 - Text External Code Source 14 - Admission Source char[1] Admission Source Code Report the code that applies to facility claims where Type of Bill = an inpatient setting. This code indicates how the patient was referred into an inpatient setting at the facility. Required when = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 98% A1 MC 23 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 24 Discharge Status 11/8/12 External Code Source 14 - Numeric External Code Source 14 - Discharge Status char[2] Inpatient Discharge Status Code Report the appropriate Discharge Status Code of the patient as defined by External Code Source Required when MC094 = 002 and MC069 is populated 98% A1 MC 25 Service Provider Number 6/24/10 Text ID Link to PV002 Service Provider Identification Number Report the carrier / submitter assigned service 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% A1 MC 26 Service Provider Tax ID Number 11/8/12 Numeric ID Tax char[9] Service Provider's Tax ID number Report the Federal Tax ID of the Service Provider here. Do not use hyphen or alpha prefix.Reminder: Must not be an SSN. All 97% C 24
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 Description 1 Person 2 Non-person entity MC 29 Service Provider First 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 MC027 = 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. MC027 determines if this is an Organization or Individual Name reported here. All 94% A2 MC 32 Service Provider Suffix 10/30/14 Lookup - 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.
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 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 Codes 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 MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86, or 89 98% A1 MC 41 External 11/8/12 External Code Source 8 - Text External Cause Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnostic External Injury Code Report the external cause 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 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 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 Diagnosis Code Other ICD Diagnosis Code - 4. If not applicable do not report any value here. Do not code decimal point. 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 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 valid 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 valid 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 62 Quantity 11/8/12 Quantity - Integer Counter Claim line units of service Report the count of services / units performed. All 98% A1 MC 63 Charge Amount 11/8/12 Integer Currency Amount of provider charges for the claim line Report the charge amount for this claim line. 0 dollar charges allowed only when the procedure code indicates a Category II procedure code vs. a service code. When reporting Total Charges for facilities for the entire claim use 001 (the generally accepted Total Charge Revenue Code) in MC054 (Revenue Code). 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 MC062 must be greater than zero when MC0130 is not 6. 99% A0 MC 64 Paid Amount 10/30/14 Integer Currency Amount paid by the carrier for the claim line Report the amount paid for the claim line. Report 0 if line is paid as part of another procedure / claim line. Do not report any value if the line is denied. 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 = 1, 2, 3, 19, 20 or 21 99% A0 MC 65 Prepaid Amount 11/8/12 Integer Currency Amount carrier has prepaid towards the claim line Report the prepaid amount for this claim line. Report the Fee for Service equivalent amount for Capitated services. Report 0 when there is no Prepaid 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 All 100% A2
MC 66 Amount 6/24/10 Integer Currency Amount of Copay 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 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 73 DRG Version 11/8/12 External Code Source 15 - Text External Code Source 15 - DRG char[2] Diagnostic Related Group 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 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 field 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 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 Other 5 Not Applicable MC 83 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0
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 Codes Source 8 - Text External Code Source 8 - ICDCM Procedure Codes varchar[7] ICD Other 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 Codes Source 8 - Text External Code Source 8 - ICDCM Procedure Codes varchar[7] ICD Procedure Code Report the fourth ICD procedure code when applicable. The Integer 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 88 Other ICD-CM Procedure Code - 5 10/30/14 External Codes Source 8 - Text External Code Source 8 - ICDCM Procedure Codes varchar[7] ICD Procedure Code Report the sixth 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 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 1% C MC 89 Other ICD-CM Procedure Code - 6 10/30/14 External Codes Source 8 - Text External Code Source 8 - Procedure Codes varchar[7] ICD Other Procedure Code Report the seventh 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 90 Paid Date 11/8/12 Full Date - Integer Century Year Day - CCYYMMDD int[8] Paid date of the claim line Report the date that appears on the check and/or remit and/or explanation of benefits and corresponds to any and all types of payment in CCYYMMDD Format. This can be the same date as Processed Date. EXAMPLE: Claims paid in full, partial or zero paid must have a date reported here. Required when MC038 = 1, 2, 3, 19, 20, or 21 98% A0
MC 91 Code 11/8/12 External Code Source 11 - Text External Code Source 11 - LOINC varchar[7] Logical Observation Identifiers, Names 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 = 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 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 98% B
MC Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 MC Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 MC Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 MC ICD Indicator 2/2017 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 MC094 = 001 or 002 and any of the following MC039 thru MC053, MC058, MC083 thru MC088, MC142 thru MC153 is populated 100% A2 Value Description 9 ICD-9 0 ICD-10 07
3 Unknown 4 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 claim 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 for future use. Do not populate. All 0% Z MC Referral Indicator 11/8/12 Lookup - 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 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 used for severity adjustment when applicable. Required when MC071 is populated 80% B MC Patient 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 Table - Integer int[1] Indicator - Global Payment Report the value 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 that defines the element. EXAMPLE: 1 = Yes, Claim Line was denied. Required when = 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 claim 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 value 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
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 State 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 Table - Text Carrier Defined Table - 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 Carrier Specific Unique Member ID 11/8/12 Text ID Link to ME107 Member's Unique ID Report the identifier the carrier / submitter uses internally to uniquely identify the member. Used to validate Unique Member ID and link back to Member Eligibility (ME107). All 100% A0 MC Claim Line Type 11/8/12 Lookup Table - Text char[1] Claim Line Activity Type Code Report the code that defines the claim line status in terms of adjudication. EXAMPLE: O = Original All 98% A2 Code Description O Original V Void R Replacement B Back Out A Amendment MC Former Claim Number 12/1/10 Text ID Number Previous Claim Number Report the Claim Control Number (MC004) that was originally sent in a prior filing that this line corresponds to. When reported, this data cannot equal its own MC004. Use of “Former Claim Number” to version claims can only be used if approved by the MA APCD. Contact the MA APCD for conditions of use. All 0% B MC Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 MC Carrier Specific Unique Subscriber ID 11/8/12 Text ID Link to Subscriber's Unique ID Report the identifier the carrier / submitter uses internally to uniquely identify the subscriber. Used to validate Unique Member ID and link back to Member Eligibility (ME117). All 100% A0
MC Other Diagnosis - 13 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code ICD Diagnosis Code - 13. If not applicable do not report any value here. Do not code decimal point. All 1% C MC Other Diagnosis - 14 2/2016 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Other 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 Codes Source 8 - International Classification of Diseases varchar[7] ICD Other 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 Diagnosis - 16 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code ICD Diagnosis Code - 16. If not applicable do not report any value here. Do not code decimal point. 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 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 Other Diagnosis - 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code Other 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 Other Diagnosis - 20 2/2016 External Code Source 8 - Text External Codes 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 Other 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 point. All 1% C MC Diagnosis - 23 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD 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 Other Diagnosis - 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 - 24. If not applicable do not report any value here. Do not code decimal point. All 1% C
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 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 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 Diagnosis - 4 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 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 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 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 Other 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 MC094 = 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 MC094 = 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 MC094 = 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 Other 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 = 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 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 MC094 = 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 = 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 = 002, MC039 and MC149 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 Diagnosis - 24 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 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 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 - 4 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 - 5 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 - 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 that defines a condition of the claim or patient. If not applicable do not report any value here. All 1% B
MC Condition Code - 8 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 - 9 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 - 10 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 - 11 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 - 12 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 Code - 1 11/8/12 External Code Source 14 - Text External Code Source 14 - Codes char[2] Code Report the appropriate value that defines a value category of the claim. If not applicable do not report any value here. All 1% B MC Amount - 1 11/8/12 Integer Currency Amount that corresponds to Code - 1 Report the appropriate amount that corresponds to the value 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 MC191 is populated 100% B MC Code - 2 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 - 2 11/8/12 Integer Currency Amount that corresponds to Value Code - 2 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 MC193 is populated 100% B MC Value Code - 3 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Value Code Report the appropriate value that defines a value category of the claim. If not applicable do not report any value here. All 1% B MC Value Amount - 3 11/8/12 Integer Currency Amount that corresponds to Value Code - 3 Report the appropriate amount that corresponds to the value 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 MC195 is populated 100% B MC Value Code - 4 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Value Code Report the appropriate value that defines a value category of the claim. If not applicable do not report any value here. All 1% B MC Value Amount - 4 11/8/12 Integer Currency Amount that corresponds to Value Code - 4 Report the appropriate amount that corresponds to the value 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 MC197 is populated 100% B MC Value Code - 5 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Value Code Report the appropriate value that defines a value category of the claim. If not applicable do not report any value here. All 1% B
MC Value Amount - 5 11/8/12 Integer Currency Amount that corresponds to Value Code - 5 Report the appropriate amount that corresponds to the value 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 MC199 is populated 100% B MC Code - 6 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Value Code Report the appropriate value that defines a value category of the claim. If not applicable do not report any value here. All 1% B MC Value Amount - 6 11/8/12 Integer Currency Amount that corresponds to Value Code - 6 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 MC201 is populated 100% B MC Value Code - 7 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Value Code Report the appropriate value that defines a value category of the claim. If not applicable do not report any value here. All 1% B MC Value Amount - 7 11/8/12 Integer Currency Amount that corresponds to Code - 7 Report the appropriate amount that corresponds to the value 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 MC203 is populated 100% B MC Value Code - 8 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Value Code Report the appropriate value that defines a value category of the claim. If not applicable do not report any value here. All 1% B
MC Amount - 8 11/8/12 Integer Currency Amount that corresponds to Value Code - 8 Report the appropriate amount that corresponds to the value 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 - 9 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Value Code Report the appropriate value that defines a value category of the claim. If not applicable do not report any value here. All 1% B MC Value Amount - 9 11/8/12 Integer Currency Amount that corresponds to Value Code - 9 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 MC207 is populated 100% B MC Value Code - 10 11/8/12 External Code Source 14 - Text External Code Source 14 - Codes char[2] Value Code Report the appropriate value that defines a value category of the claim. If not applicable do not report any value here. All 1% B MC Value Amount - 10 11/8/12 Integer Currency Amount that corresponds to Value Code - 10 Report the appropriate amount that corresponds to the value 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 - 11 11/8/12 External Code Source 14 - Text External Code Source 14 - Codes char[2] Value Code Report the appropriate value that defines a value category of the claim. 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 value 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 MC211 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 Value Code - 12 Report the appropriate amount that corresponds to the value 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 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 is populated 100% B
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 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 - Integer int[1] Claim Line Paid Indicator Report the value that defines the element. EXAMPLE: 1 = Yes, Claim Line was paid. Required 100% B Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable MC Type of Facility 10/30/14 Lookup Table - Integer int[2] Type of Facility Indicator Report the value that defines the type of facility setting for this claim. Required 98% B
B PROFESSIONAL PART B CROSSOVER C OUTPATIENT PART B CROSSOVER UB-04 D DENTAL H HOME HEALTH AND COMMUNITY HEALTH I HOSPITAL INPATIENT L LONG TERM CARE M PHYSICIAN O HOSPITAL OUTPATIENT P PHARMACY Q COMPOUND DRUG CLAIMS MC Rate Code 10/30/14 Rate code Text varchar[3] MassHealth Rate Code Indicator Report the value that defines the element. Required when submitter is and = 002 and MC246 = I or A 100% A2 MC Record Type 6/24/10 Text ID File char[2] File Type Identifier Report MC here. This validates the type of file and the data contained within the file. This must match HD004. All 100% A0 1 Record Type 6/24/10 Text ID Record char[2] Trailer Record Identifier Report TR here. Indicates the end of the data file. Mandatory 100% TM
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 HD004. 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 - 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 Month 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