What each row in the file represents Each row represents a claim line. If there are multiple services performed and billed on a claim, each of those services will be uniquely identified and reported on a line. It is necessary to obtain line item data to understand how services are utilized and adjudicated by different submitters. Won’t reporting claim lines create redundant data? Yes, 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. It is necessary to maintain the link between line item processing and claim level data. 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 analysis in the MA APCD in terms of covered benefits and/or eligibility. Should claims that are paid under a ‘global payment’, thus zero paid, be reported in this file. Yes. Any dental 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 and reported accordingly. The reporting of Zero Paid Dental Claims aids with the analysis of services utilized, Member Eligibility and deductibles applied. 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 Submitter should be reported in the next file. See DC060 below. The reporting of Voided Claims maintains logic integrity between services utilized and deductibles applied. 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.
5 Period 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 11/8/12 Integer Counter varchar[10] 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 varchar[80] 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 Decimal - Numeric ID Version char[3] Submission Guide Version Report the version number as presented on the APCD Dental 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 4.0 1 Submitter 11/8/12 Integer ID OrgID 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 DC - DC DC DC DC - -
2 National Plan ID 11/8/12 Text 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 Type Code / Product 11/8/12 Lookup 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: 17 = Dental Maintenance Organization 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 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 MC Medicaid OF Other Federal Program TF HSN Trust Fund TV Title V VA Veterans Administration Plan WC Workers' Compensation ZZ Other 4 Payer Claim Control Number 6/24/10 Text ID Number varchar[35] Payer Claim Control Identification Report the Unique identifier within the payer's system that applies to the entire claim. All 100% A0 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 6 Version Number 7/6/10 Integer Counter varchar[4] Claim Service Line Version Number Report the version number of this claim 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 7 Insured Group or Policy Number 11/8/12 Text ID Group varchar[30] 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 98% C DC 8 SSN 11/8/12 Numeric ID Tax char[9] Subscriber's Social Security Number Report the Subscriber's SSN here; used to validate Unique Member ID; will not be passed into analytic file. Do not use hyphen. If not available do not report any value here. All 70% B
DC 9 Plan Specific Contract Number 6/24/10 Text ID Contract varchar[30] Contract Number Report the Plan assigned contract number. Do not include values in this element 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 70% C DC 10 Member Suffix or Number 6/24/10 Text ID Sequence varchar[20] Contract Sequence Number Report the unique number / identifier of the member / patient within the contract All 98% B DC 11 Member SSN 11/8/12 Numeric ID Tax char[9] Social Security Number Report the patient's social security number here; used to validate Unique Member ID; will not be passed into analytic file. Do not use hyphen. If not available do not report any value here All 70% B DC 12 Individual Code 6/24/10 Lookup Numeric varchar[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 1 Spouse 4 Grandfather or Grandmother 5 Grandson or Granddaughter 7 Nephew or Niece 10 Foster Child 15 Ward 17 Stepson or Stepdaughter 19 Child 20 Self/Employee 21 Unknown 22 Handicapped Dependent 23 Sponsored Dependent
1 Person 2 Non-person entity DC 23 Service Provider First Name 11/8/12 Text Name First Provider varchar[25] First name of Service Provider Report the individual's first name here. If provider is a facility or organization , do not report any value here All 98% C DC 24 Service Provider Middle Name 11/8/12 Text Name Middle Provider varchar[25] Middle initial of Service Provider Report the individual's middle name here. If provider is a facility or organization , do not report any value here All 2% C DC 25 Service Provider Last Name or Name 6/24/10 Text Name Last / Org Provider varchar[60] Last name or Organization Name of Service Provider Report the name of the organization or last name of the individual provider. DC021 determines if this is an Organization or Individual Name reported here. All 98% B DC 26 Benefit ID 11/8/12 Integer ID Link to OrgID varchar[6] CHIA defined and maintained Org ID for linking across submitters Riskholders report the OrgID of the DBA here. DBAs report the OrgID of the insurance carrier here. This element contains the CHIA assigned organization ID for the DBA or carrier. Contact the MA APCD for the appropriate value. If no DBA is affiliated with this claim line do not report any value here: i.e., do not repeat the OrgID from DC001 All 98% A2 DC 27 Service Provider 11/8/12 External Code Source 5 - Text External Code Source 5 – Taxonomy varchar[10] Taxonomy Code Report the standard code that defines this provider for this line of service. Taxonomy values allow for the reporting of hygienists, assistants and laboratory technicians, where applicable, as well as Dentists, Orthodontists, etc. All 98% A2 DC 28 Service Provider City Name 6/24/10 Text Address City Provider varchar[30] City name of the Provider Report the Providers practice city location All 98% B
DC 29 Service Provider State 11/8/12 External Code Source 2 - Text Address State External Code Source 2 – States char[2] State of the Service Provider Report the state of the service providers as defined by the US Postal Service All 98% B DC 30 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 9 digit Zip Code as defined by the US Postal Service. When submitting the 9-digit Zip Code do not include hyphen. All 98% B DC 31 Facility Type - 11/8/12 External Code Source 13 - Numeric External Code Source 13 - Place of Service char[2] Place of Service Code Report the code the defines the location code where services were performed by the provider referenced on the claim All 80% B DC 32 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 payer(s) 20 Processed as secondary, forwarded to additional 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
DC 46 Paid Date 6/24/10 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. All 98% A0 DC 47 Allowed Amount 11/8/12 Integer Currency Allowed Amount Report the maximum amount contractually allowed, and that a carrier will pay to a provider for a particular procedure or service. This will vary by provider contract and most often it is less than or equal to the fee charged by the provider. Report 0 when the claim 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 DC031 does not = 4, 22, or 23 99% A2 DC 48 Tooth 10/30/14 External Code Source 10 - Text External Code Source 10 - Tooth Numbering varchar[2] Tooth Number or Letter Identification Report the tooth identifier(s) when DC032 is within the given range Required when DC032 = D2000 thru D2999 100% A2 DC 49 Dental Quadrant 10/30/14 External Code Source 10 - Numeric External Code Source 10 - Dental Quadrants char[2] Dental Quadrant Report the standard quadrant identifier from the External Code Source here. Provides further detail on procedure(s). Required when reports Dental Code 100% B DC 50 Tooth Surface 10/30/14 External Code Source 10 - Text External Code Source 10 - Tooth Surfaces varchar[5] Tooth Service Identification Report the tooth surface(s) that this service relates to. Provides further detail on procedure. Required when 100% A2
DC 62 Code 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code Report the ICD Diagnosis Code when applicable Required when DC032 is within the ranges of or D9220 or D9221 1% B DC 63 ICD Indicator 11/8/12 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 is populated 100% B Value Description 9 ICD-9 0 ICD-10 DC 64 Denied Flag 11/8/12 Lookup - Integer int[1] Denied Line Indicator Report the value that defines the element. EXAMPLE: 1 = Yes, Claim Line was denied. Required when DC031 = 04 100% A0 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable DC 65 Denial Reason 11/8/12 Carrier Defined Table - OR - External Code Source 16 External Code Source 16 - Reason Codes OR – Carrier Defined Table - varchar[20] 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 APCD. Required when DC063 = 1 98% A2