Revision History Date Version Description Author 12/1/2012 3.0 Administrative Bulletin 12-01; issued 11/8/2012 M. Prettenhofer 1/28/2013 3.1 Updated ‘Non-Massachusetts Resident’ section DC067 (APCD ID Code): Added option (6) ICO - Integrated Care Organization H. Hines 5/31/2013 3.1 Updated DC043 and DC058 – Street Address – to a length of 50 Updated HD009 to reflect reporting period change Updated element submission guideline for Delegated Benefit Adminstrator OrganizationID (DC025). K. Hines of Contents
PV – Provider File BP – Benefit Plan Control Total File The APCD Monthly Dental Claims File As part of the MA APCD, submitters with dental lines of business will be required to submit a Dental Claims File. CHIA, in an effort to decrease any programming burden, is maintaining its adopted file layout but adjusting some of the elements to insure quality, linkage to other files and continuity of the data set. 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 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 Dental 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 length asterisk delimited file An asterisk cannot be used within an element in lieu of another character. Example: if the file includes 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 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.
OF Other Federal Program TF HSN Trust Fund TV Title V VA Veterans Administration Plan WC Workers' Compensation ZZ Other DC 4 Payer Claim Control Number 6/24/10 Text ID Claim 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 DC 5 Line Counter 11/8/12 Integer ID Count varchar[4] Incremental Line Counter Report the line number for this service within the Start with 1 and increment by 1 for each additional line. Do not start with 0, include alphas or special characters. All 100% A0 DC 6 Version Number 7/6/10 Integer Counter varchar[4] Claim Service Line Version Number Report the version number of this service line. The version number begins with 0 and is incremented by 1 for each subsequent version of that service line. No alpha or special characters. All 100% A0 DC 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
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 DC 13 Member Gender 6/24/10 Lookup Table Text tlkpGender char[1] Patient's Gender Report patient gender as found on the claim in alpha format. Used to validate clinical services when applicable and Unique Member ID. EXAMPLE: F = Female All 100% B Code Description F Female M Male O Other U Unknown DC 14 Member Date of Birth 6/24/10 Full Date - Integer Century Year Month Day – CCYYMMDD int[8] date of birth Report the date the member / patient was born in CCYYMMDD Format. Used to validate Unique Member ID. All 99% B DC 15 Member City Name 6/24/10 Text Address City Member varchar[50] City name of the Report the city name of the member / patient. Used to validate Unique Member ID All 99% B DC 16 Member State 11/8/12 External Code Source 2 - Text Address State External Code Source 2 – States char[2] State / Province of the Patient Report the state of the patient as defined by the US Postal Service. Report Province when Country Code does not = USA All 99% B DC 17 Member ZIP Code 11/8/12 External Code Source 2 - Text Address Zip External Code Source 2 - Zip Codes varchar[9] Zip Code of the Member / Patient Report the 5 or 9 digit Zip Code as defined by the United States Postal Service. When submitting the 9-digit Zip Code do not include hyphen. All 99% B
DC 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 98% C DC 19 Service Provider Number 6/24/10 Text ID Link to PV002 varchar[30] 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 in this element must match a record in the provider file in PV002. All 100% A1 DC 20 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. All 99% C DC 21 National Provider ID - Service 11/8/12 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) here. This ID should be found on the Provider File in the NPI element (PV039) All 98% C DC 22 Service Provider Entity Type Qualifier 11/8/12 Lookup Table - integer int[1] Service Provider Entity Identifier Code Report the value that defines the 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 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 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 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 services were performed by the provider referenced on the claim All 80% B DC 32 Claim Status 11/8/12 Lookup - Numeric tlkpClaimStatus varchar[2] Claim Line Status Report the that defines the payment status of this claim line All 98% A0 Description 1 Processed as primary 2 Processed as secondary 3 Processed as tertiary 4 Denied 19 Processed as primary, forwarded to additional 20 Processed as secondary, forwarded to additional payer(s) 21 Processed as tertiary, forwarded to additional payer(s) 22 Reversal of previous payment 23 Not our claim, forwarded to additional payer(s) 25 Predetermination Pricing Only - no payment DC 33 CDT Code 11/8/12 External Code Source 10 - Text External Code Source 10 - Current Dental Terminology char[5] / CDT Code Report the Common Dental Terminology code here All 99% A2 DC 34 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 (DC032). All 0% C DC 35 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 (DC032). All 0% C
DC 42 Amount 6/24/10 Integer Currency Amount of deductible is responsible to pay on the claim line Report the amount that defines a preset, 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 DC 43 Product ID Number 11/8/12 Text ID Link to PR001 varchar[30] 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 DC 44 Member Street Address 11/8/12 Text Address 1 Member varchar[50] Street address of the Report the patient / member's address. Used to validate Unique Member ID. All 90% B DC 45 Billing Provider Tax ID Number 11/8/12 Numeric ID Tax char[9] The Billing Provider's Federal Tax Identification Number (FTIN) Report the Federal Tax ID of the Billing Provider here. Do not use hyphen or alpha prefix. All 90% C DC 46 Paid Date 6/24/10 Full Date - Integer Century Year Month 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 54 Member Last Name 6/24/10 Text Name Last Member varchar[60] Last name of Report the last name of the patient / member here. Used to validate Unique Member ID. Last name should exclude all punctuation, including hyphens and apostrophes, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces. EXAMPLE: O'Brien becomes OBRIEN; Carlton-Smythe becomes CARLTONSMYTHE All 100% B DC 55 Member First Name 6/24/10 Text Name First Member varchar[25] First name of Report the first name of the patient / member 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 100% B DC 56 Member Middle Initial 6/24/10 Text Name Middle Member char[1] Middle initial of the Report the middle initial of the patient / member when available. Used to validate Unique Member ID. All 2% C DC 57 Carrier Specific Unique Member ID 11/8/12 Text ID Link to ME107 varchar[50] 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 DC 58 Carrier Specific Unique ID 11/8/12 Text ID Link to ME117 varchar[50] 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 DC 59 Member Street Address 2 11/8/12 Text Address 2 Member varchar[50] Secondary Street Address of the Report the address of member which may include apartment number or suite, or other secondary information besides the street. Used to validate Unique Member ID. All 2% B DC 60 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 DC 61 Former Number 12/1/10 Text ID Claim Number varchar[35] Previous Claim Number Report the Control Number (DC004) that was originally sent in a prior filing that this line corresponds to. When reported, this data cannot equal its own DC004. 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 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 - 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 DC061 is populated 100% B Value Description 9 ICD-9 0 ICD-10 DC 64 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 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 - 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 DC 66 Payment Type 11/8/12 Lookup Table - Numeric char[2] Payment Arrangement Type Value Report the value that defines the contracted payment methodology for this claim line. EXAMPLE: 02 = Fee for Service All 98% A0 Value Description 01 Capitation 02 Fee for Service 03 Percent of Charges 04 DRG 05 Pay for Performance 06 Global Payment 07 Other 08 Bundled Payment 09 Payment Amount Per Episode (PAPE) (MassHealth) (Valid for MassHealth ONLY) DC 67 GIC ID 11/8/12 Text ID GIC varchar[9] GIC Member ID Report the GIC Member Identification number as provided to GIC Plan Submitters. If not applicable do not report any value here Required when DC067 = 3 100% A0
DC 68 APCD ID Code 11/8/12 Lookup Table - Integer int[1] Member Enrollment Type Report the that describes the member's / subscriber's enrollment into one of the predefined categories; aligns enrollment to appropriate editing and thresholds. EXAMPLE: 1 = FIG - Fully Insured Commercial Group Enrollee. All 100% A2 Value Description 1 FIG - Fully-Insured Commercial Group Enrollee 2 SIG - Self-Insured Group Enrollee 3 GIC - Group Insurance Commission Enrollee 4 MCO - MassHealth Managed Care Organization Enrollee 5 Supplemental Policy Enrollee 6 ICO - Integrated Care Organization 0 Unknown / Not Applicable DC 69 Record Type 11/8/12 Text ID File char[2] File Type Identifier Report DC 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