Health care data and information submitted by Health Care Payers to CHIA is not a public record. No public disclosure of any health plan information or data shall be made unless specifically authorized under 114.5 CMR 21.00 or 114.5 CMR 22.00. Acronyms Frequently Used APCD – All-Payer Claims Database CHIA – Center for Health Information and Analysis CSO – Computer Services Organization DBA – Delegated Benefit Administrator DBM – Dental Benefit Manager DOI – Division of Insurance GIC – Group Insurance Commission ID – Identification; Identifier MA APCD – Massachusetts’ All-Payer Claims Database PBM – Pharmacy Benefit Manager QA – Quality Assurance RA – Risk Adjustment; Risk Adjuster TME / RP – Total Medical Expense / Relative Pricing TPA – Third Party Administrator The File Types: DC – Dental Claims MC – Medical Claims ME – Member Eligibility PC – Pharmacy Claims PR – Product File PV – Provider File BP – Benefit Plan Control Total File
The APCD Monthly Medical Claims File As part of the MA APCD, submitters are required to submit a Medical Claims File. CHIA, in an effort to decrease any programming burden, has maintained the file layout previously used. There are minor changes to this layout so that it will connect appropriately across other required filings for the MA APCD and a few added elements to aid with line of business identification for better-directed editing of the data. Below we have provided details on business rules, data definitions and the potential uses of this data. Specification Question Clarification Rationale Frequency of submission Medical claim files are to be submitted monthly CHIA requires this frequency to maintain a current dataset for analysis. What is the format of the file Each submission must be a variable field length asterisk delimited file An asterisk cannot be used within an element in lieu of another character. Example: if the file includes “Smith*Jones” in the Last Name, the system will read an incorrect number of elements and drop the file. 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 better understand how services are perceived and adjudicated by different carriers. Won’t reporting 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.
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 This must match the File Type reported in TR004. Mandatory 100% HM 5 Period Beginning Date 11/8/12 Date Period Integer Century Year 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 11/8/12 Decimal - Numeric ID Version char[3] Submission 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 = Newest Version Mandatory 100% HM Code Description 2.1 Prior Version; valid only for reporting periods prior to October 2013 3.0 Current Version; required for reporting periods as of October 2013 MC MC - 9 - -
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 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 MC 3 Insurance Type 11/8/12 Lookup 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 92% C 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. 02 03
MC 8 Subscriber 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 79% B MC 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% C 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% B MC 11 Member SSN 11/8/12 Numeric ID Tax char[9] Member/Patient's 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 73% B MC 12 Individual Code 6/24/10 Lookup Table Text char[2] Patient to Subscriber Relationship Code Report the that defines the Patient's relationship to the Subscriber. EXAMPLE: 20 = Self / Employee All 98% B Value Description 01 Spouse Grandfather or Grandmother 05 Grandson or Granddaughter 07 Nephew or 10 Foster Child 15 Ward 17 Stepson or Stepdaughter 19 Child 08
20 Self/Employee 21 Unknown 22 Handicapped Dependent 23 Sponsored Dependent 24 Dependent of a Dependent 29 Significant Other 32 Mother 33 Father 36 Emancipated Minor 39 Organ 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 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 6/24/10 Full Date - Integer Century Year Day - CCYYMMDD int[8] Member/Patient's date of birth Report the date the member / patient was born in CCYYMMDD Format. Used to validate Unique Member ID. All 98% B
MC 28 Service Provider Entity Type Qualifier 11/8/12 Lookup - 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 First Name 11/8/12 Text Name Provider 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 92% C MC 30 Service Provider Middle Initial 11/8/12 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 All 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 10/15/10 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 All 2% Z 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 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 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. 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 varchar[9] Zip Code of the Service Provider Report the 5 or 9 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 payer(s) 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 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 E-Code 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 injury code for patient when appropriate to the claim. All 3% C MC 42 Principal Diagnosis 11/8/12 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. All 99% A0
MC 43 Other Diagnosis - 1 11/8/12 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. All 70% B MC 44 Diagnosis - 2 11/8/12 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. All 24% B MC 45 Other Diagnosis - 3 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code Other ICD Diagnosis Code - 3. If not applicable do not report any value here. All 13% C MC 46 Other Diagnosis - 4 11/8/12 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. All 7% C MC 47 Other Diagnosis - 5 11/8/12 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. All 4% C MC 48 Other Diagnosis - 6 11/8/12 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. All 3% C
MC 49 Other Diagnosis - 7 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 7. If not applicable do not report any value here. All 3% C MC 50 Diagnosis - 8 11/8/12 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code ICD Diagnosis Code - 8. If not applicable do not report any value here. All 2% C MC 51 Other Diagnosis - 9 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 9. If not applicable do not report any value here. All 1% C MC 52 Other Diagnosis - 10 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code ICD Diagnosis Code - 10. If not applicable do not report any value here. All 1% C MC 53 Other Diagnosis - 11 11/8/12 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 11. If not applicable do not report any value here. All 1% C MC 54 Other Diagnosis - 12 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code Other ICD Diagnosis Code - 12. If not applicable do not report any value here. All 1% C MC 55 Revenue Code 11/8/12 External Code Source 14 - Numeric External Code Source 14 - Revenue Code char[4] Revenue Code Report the valid National Uniform Billing Committee Revenue Code here. Code using leading zeroes, and four digits. Required when MC094 = 002 98% A0
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 must be greater than zero when MC0130 is not 6. 99% A0 MC 64 Paid Amount 10/3/10 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 All 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 Copay Amount 6/24/10 Integer Currency Amount of Copay member/patient is responsible to pay Report the amount that defines a preset, 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 11/8/12 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 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 Group Version Number Report the version of the grouper used. Required when MC071 is populated 20% B MC 74 APC 11/8/12 External Code Source 15 - Text External Code Source 15 - DRG char[4] Ambulatory Payment Classification Number Report the APC number applied to this claim line, with the leading zero(s) when applicable. Code using the CMS methodology. Required when MC094 = 002 and MC039 is null 20% C MC 75 APC Version 11/8/12 External Code Source 15 - Text External Code Source 15 - DRG char[2] Ambulatory Payment Classification Version Report the version of the grouper used. Required when MC073 is populated 20% C
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 Table 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 Member Street Address 11/8/12 Text Address 1 Member Street address of the Member/Patient Report the patient / member's address. Used to validate Unique Member ID. All 90% B MC 84 Other ICD-CM Procedure Code - 1 4/5/13 External 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 MC039 is populated 1% C MC 85 Procedure Code - 2 4/5/13 External Codes Source 8 - Text External Code Source 8 - 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 MC039 is populated 1% C
MC 92 Days 11/8/12 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 MC039 is populated 98% B MC 93 Covered Days 11/8/12 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 under Coinsurance Days. Required when MC094 = 002 and MC039 is populated 98% B MC 94 Non Covered Days 11/8/12 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 = 002 and MC039 is populated 87% B MC 95 Type of Claim 11/8/12 Lookup - 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 after 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 Amount 11/8/12 Integer Currency Amount of claim line charge not covered Report the amount that was charged on a claim that is not reimbursable due to eligibility limitations or provider requirements. Report 0 if all charges are covered or fall into other categories. 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 Delegated Benefit ID 11/8/12 Integer ID Link to OrgID varchar[6] CHIA defined and maintained Org ID for linking across submitters Risk holders 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. Contact the 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 MC001 All 98% A2 MC Subscriber Last Name 10/15/10 Text Name Last Subscriber Last name of Subscriber Report the last name of the subscriber. Used to validate Unique Member ID. Last name should exclude all punctuation, including hyphens and apostrophes, and be reported in case. Name should be contracted where punctuation is removed, do not report spaces. EXAMPLE: O'Brien becomes OBRIEN; Carlton-Smythe becomes CARLTONSMYTHE All 98% B MC Subscriber First Name 10/15/10 Text Name First Subscriber First name of Subscriber Report the first name of the subscriber here. Used to validate Unique Member ID. Exclude all punctuation, including hyphens and apostrophes. Name should be contracted where punctuation is removed, do not report spaces. EXAMPLE: Anne-Marie becomes ANNEMARIE All 98% B
MC 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 MC094 = 001 or 002 and any of the following MC039 thru MC053, MC058, MC083 thru MC088, MC142 thru MC153 is populated 100% B Value Description 9 ICD-9 0 ICD-10 MC Procedure Modifier - 3 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 0% C MC Procedure Modifier - 4 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 0% C MC Claim Processed Date 11/8/12 Full Date - Integer Century Year Day - CCYYMMDD int[8] Claim Processed Date Report the date the claim 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 07
MC DRG 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 Total Out of Pocket Amount 11/8/12 Integer Currency 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 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 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 claim line. Carrier must submit denial reason codes in separate table to the APCD. Required when = 1 98% A2 MC Attending Provider 11/8/12 Text ID Link to 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 = 002 and MC039 is populated 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 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 EPSDT 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 11/8/12 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 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 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 6/24/10 Carrier Defined Table - Text Carrier Defined Table - MCO Service Class char[2] 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 Bill Frequency Code 11/8/12 External Code Source 14 - Text External Code Source 14 - Type of Bill char[1] Bill Frequency Report the valid frequency code of the claim to indicate version, credit/debit activity and/or settling of claim. Required when = 001 or 002 100% A2 MC Plan Rendering Provider Identifier 11/8/12 Text ID Link to PV002 Plan Rendering Number Report the unique code which identifies for the carrier / submitter who or which individual provider cared for the patient for the claim line in question. This code must be able to link to the Provider File. Any value in this field must also show up as a value in field PV002 (Provider ID) on the Provider File. All 100% A0
MC Provider Location 11/8/12 Text ID Link to PV002 Location of Provider Report the unique code which identifies the location / site of the service provided by the plan rendering provider identified in MC134. The code should link to a provider record in field PV002 (Provider ID) and indicate that the service was performed at a specific location; e.g.: Dr. Jones Pediatrics, 123 Main St, Boston, MA, or Pediatric Associates, or Mass General Hospital, etc. Only the code is needed in this field, and the link to the Provider ID in the field PV002 (Provider ID) will allow the physical address and other identifying information about the service location to be captured. Type of location is an incorrect value. All 98% A2 MC Discharge Diagnosis 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Discharge Diagnosis Code Report the ICD diagnosis code as applied to the patient upon discharge. This may or may not be the same as the primary diagnosis or admitting diagnosis. Required when MC069 is populated 80% B 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 - Text char[1] Claim Line Activity Type Code Report the code that defines the 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 APCD. Contact the APCD for conditions of use. All 0% B MC Member Street Address 2 11/8/12 Text Address 2 Member Secondary Street Address of the Member/Patient Report the address of member may include apartment number or suite, or other secondary information besides the street. Used to validate Unique Member ID. All 1% B MC Carrier Specific Unique Subscriber ID 11/8/12 Text ID Link to ME117 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 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 13. If not applicable do not report any value here. All 1% C MC Other Diagnosis - 14 11/8/12 External Code Source 8 - Text External Codes 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. All 1% C MC Diagnosis - 15 11/8/12 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. All 1% C
MC Other Diagnosis - 16 11/8/12 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. All 1% C MC Other Diagnosis - 17 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code ICD Diagnosis Code - 17. If not applicable do not report any value here. All 1% C MC Other Diagnosis - 11/8/12 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. All 1% C MC Diagnosis - 19 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code ICD Diagnosis Code - 19. If not applicable do not report any value here. All 1% C MC Diagnosis - 20 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 20. If not applicable do not report any value here. All 1% C MC Diagnosis - 21 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code Other ICD Diagnosis Code - 21. If not applicable do not report any value here. All 1% C
MC Other Diagnosis - 22 11/8/12 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. All 1% C MC Other Diagnosis - 23 11/8/12 External Code Source 8 - Text External Codes 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. All 1% C MC Other Diagnosis - 11/8/12 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. All 1% C MC Present on Admission Code (POA) - 01 11/8/12 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 100% A2 MC Present on Admission Code (POA) - 02 11/8/12 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 is populated 100% A2
MC Present on Admission Code (POA) - 03 11/8/12 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 is populated 100% A2 MC Present on Admission Code (POA) - 04 11/8/12 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for 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 is populated 100% A2 MC Present on Admission Code (POA) - 05 11/8/12 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 is populated 100% A2 MC Present on Admission Code (POA) - 06 11/8/12 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 5 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 MC046 is populated 100% A2 MC Present on Admission Code (POA) - 11/8/12 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 is populated 100% A2
MC Present on Admission Code (POA) - 08 11/8/12 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 is populated 100% A2 MC Present on Admission Code (POA) - 09 11/8/12 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 8 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 MC049 is populated 100% A2 MC Present on Admission Code (POA) - 10 11/8/12 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 9 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 MC050 is populated 100% A2 MC Present on Admission Code (POA) - 11 11/8/12 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 10 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 MC051 is populated 100% A2 MC Present on Admission Code (POA) - 12 11/8/12 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 11 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 MC052 is populated 100% A2
MC Present on Admission Code (POA) - 13 11/8/12 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 is populated 100% A2 MC Present on Admission Code (POA) - 14 11/8/12 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Diagnosis - 13 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 MC142 is populated 100% A2 MC Present on Admission Code (POA) - 15 11/8/12 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 = 002, MC039 and MC143 is populated 100% A2 MC Present on Admission Code (POA) - 16 11/8/12 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 15 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 MC144 is populated 100% A2 MC Present on Admission Code (POA) - 17 11/8/12 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 16 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 MC145 is populated 100% A2
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 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 - 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 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 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 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 - Value 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 Value Amount - 1 11/8/12 Integer Currency Amount that corresponds to Value 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 Value Code - 2 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 - 2 11/8/12 Integer Currency Amount that corresponds to Value Code - 2 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 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 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] 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 - 10 11/8/12 Integer Currency Amount that corresponds to Value Code - 10 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 MC209 is populated 100% B MC Value Code - 11 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 - 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 Amount - 12 11/8/12 Integer Currency Amount that corresponds to 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
1 FIG - Fully-Insured Commercial Group Enrollee 2 SIG - Self-Insured Group Enrollee 3 GIC - Insurance Commission Enrollee 4 MCO - MassHealth Managed Care Organization Enrollee 5 Supplemental Policy Enrollee 6 ICO - Integrated Care Organization 0 Unknown / Not Applicable 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 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 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 Month of the reported submission period in CCYYMM format. This date period must match the date period reported in HD005 and HD006. Mandatory 100% TM