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 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 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. 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 that denied line should be reported. Denied line items of an adjudicated claim aid with cost analysis. Should claims that are paid a ‘global payment’, or ‘capitated payment’ thus zero paid, be reported in this file. Yes. Any medical 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.
MC 7 Insured Group or Policy Number 6/24/10 Text ID Group Group / Policy Number Report the number that defines the insured group or policy. Do not report the number that uniquely identifies the subscriber or member. All 95% C 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 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 value that defines the Patient's relationship to the Subscriber. EXAMPLE: 20 = Self / Employee All 98% B Value Description Spouse Grandfather or Grandmother Grandson or Granddaughter 07 Nephew or 10 Foster Child 06 08
U Unknown MC 14 Member Date of Birth 6/24/10 Full Date - Integer Century Year Month 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 15 Member City Name 6/24/10 Text Address City Member City name of the Member/Patient Report the city name of the member / patient. Used to validate Unique Member ID. All 98% B MC 16 Member State 11/8/12 External Code Source 2 - Text Address State External Code Source 2 - States char[2] / 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 98% B MC 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 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 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 Day - CCYYMMDD int[8] Inpatient Admit Date Report the date of admit to a facility in CCYYMMDD Format. Only applies to facility claims where Type of Bill = an inpatient setting. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 98% A1
MC 20 Filler 10/30/14 Filler Filler char[4] Filler The MA APCD reserves this field for future use. Do not populate with any data. All 0% Z MC 21 Admission Type 11/8/12 External Code Source 14 - Integer External Code Source 14 - Admission Type int[1] Admission Type Code Report Admit Type as it applies to facility claims where Type of Bill = an inpatient setting. This code indicates the type of admission into an inpatient setting. Also known as Admission Priority. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 98% A1 MC 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 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 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. All 97% C 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 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 Required when = 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 Table - Integer int[1] Provider Name Suffix Report the individuals name-suffix when applicable here. Used to capture the generation of the individual clinician (e.g., Jr. Sr., III). Do not report degree acronyms here. EXAMPLE: 0 = Unknown / Not Applicable Required when MC027 = 1 2% Z Value Description 1 I. 2 II. 3 III. 4 Jr. 5 Sr. 0 Unknown / Not Applicable MC 33 Service Provider Taxonomy 11/8/12 External Code Source 5 - Text External Code Source 5 - Taxonomy Taxonomy Code Report the standard code that defines this provider for this line of service. Taxonomy values allow for the reporting of nurses, assistants and laboratory technicians, where applicable, as well as Physicians, Medical Groups, Facilities, etc. All 98% A2
MC 34 Service Provider City Name 6/24/10 Text Address City Provider City Name of the Provider Report the city name of provider - preferably practice location. Do not report any value if not available. All 98% B MC 35 Service Provider State 11/8/12 External Code Source 2 - Text Address 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. 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] 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
22 Reversal of previous payment 23 Not our forwarded to additional payer(s) 25 Predetermination Pricing Only - no payment MC 40 Admitting Diagnosis 11/8/12 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] Admitting Diagnosis Code Report the diagnostic code assigned by provider that supported admission into the inpatient setting. Required when 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 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 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 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 Other Diagnosis - 2 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 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code ICD Diagnosis Code - 3. If not applicable do not report any value here. All 13% C MC 46 Other Diagnosis - 4 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code ICD Diagnosis Code - 4. If not applicable do not report any value here. All 7% C MC 47 Other Diagnosis - 5 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 Diagnosis - 6 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. All 3% C MC 49 Other Diagnosis - 7 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 Other Diagnosis - 8 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 8. If not applicable do not report any value here. All 2% C
MC 51 Other Diagnosis - 9 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 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code ICD Diagnosis Code - 10. If not applicable do not report any value here. All 1% C MC 53 Other Diagnosis - 11 External Code Source 8 - Text External Codes 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 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other 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 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] / 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 Codes 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 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 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 69 Patient Control Number 10/30/14 Text ID Claim Number Patient Control Number Report the provider assigned Encounter / Visit number to identify patient treatment. Also known as the Patient Account Number. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 98% A2 MC 70 Discharge Date 11/8/12 Full Date - Integer Century Year 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 = 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 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 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 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 = 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 10/30/14 External Codes Source 8 - Text External Code Source 8 - ICDCM Procedure Codes varchar[7] ICD Secondary Procedure Code Report the subsequent ICD CM procedure code when applicable. Repeat this code on all lines of the inpatient claim. Do not code decimal point. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 1% C MC 85 Other ICD-CM Procedure Code - 2 10/30/14 External Source 8 - Text External Code Source 8 - ICDCM Procedure Codes varchar[7] ICD Other Procedure Code Report the 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 Procedure Code - 3 10/30/14 External Codes Source 8 - Text External Code Source 8 - ICDCM Procedure Codes varchar[7] ICD Other Procedure Code Report the fourth ICD procedure code when applicable. The Integer point is not coded. The ICD procedure must be repeated for all lines of the claim if necessary. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 1% C MC 87 Procedure Code - 4 10/30/14 External Codes Source 8 - Text External Code Source 8 - ICDCM Procedure Codes varchar[7] ICD Other Procedure Code Report the fifth ICD procedure code when applicable. The Integer point is not coded. The ICD procedure must be repeated for all lines of the claim if necessary. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 1% C
MC 91 LOINC Code 11/8/12 External Code Source 11 - Text External Code Source 11 - LOINC varchar[7] Logical Observation Identifiers, 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 MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 98% B MC 93 Covered Days 10/30/14 Quantity - Integer Days Covered Covered Inpatient Days Report the number of covered days the patient incurred during this admission. Report 0 if days were Noncovered or partially covered under Coinsurance Days. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 98% B
MC 97 Other Insurance Paid Amount 11/8/12 Integer Currency Amount paid by a Primary Carrier Report the amount that a prior payer has paid for this claim line. Indicates the submitting Payer is 'secondary' to the prior payer. Only report 0 if the Prior Payer paid 0 towards this claim line, 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 Required when MC038 = 2, 3, 20, or 21 98% A2 MC 98 Medicare Paid Amount 11/8/12 Integer Currency Amount Medicare paid on claim Report the amount Medicare paid towards this claim line. Only report 0 here if Medicare paid 0. If Medicare did not pay towards this claim line 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 Required when MC115 = 1 98% A2 MC 99 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 does not = 4, 22, or 23 99% A2
MC Subscriber Middle Initial 10/15/10 Text Name Middle Subscriber char[1] Middle initial of Subscriber Report the Subscriber's middle initial here. Used to validate Unique Member ID. All 2% C MC Member Last Name 6/24/10 Text Name Last Member Last name of Member/Patient 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. 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 Member First Name 6/24/10 Text Name First Member First name of Member/Patient 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 98% B MC Member Middle Initial 6/24/10 Text Name Middle Member char[1] Middle initial of Member/Patient Report the middle initial of the patient / member when available. Used to validate Unique Member ID. All 2% C
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 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] / CPT Code Modifier Report a valid Procedure modifier when a modifier clarifies / improves the reporting accuracy of the associated procedure code (MC055). All 0% C MC Claim Processed Date 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Claim Processed Date Report the date the 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 Filler 10/30/14 Filler Filler int[1] Filler The MA APCD reserves this field for future use. Do not populate. All 0% Z MC Referral Indicator 11/8/12 Lookup Table - Integer int[1] Indicator - Referral Needed Report the value that defines the element. EXAMPLE: 1 = Yes service was preceded by a referral. All 100% A0 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable MC PCP Indicator 11/8/12 Lookup Table - Integer int[1] Indicator - PCP Rendered Service Report the that defines the element. EXAMPLE: 1 = Yes service was performed by members PCP. All 100% A2 Description 1 Yes 2 No 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 18
MC Patient Total Out of Pocket Amount 11/8/12 Integer Currency Total amount patient/member must pay Report the total amount patient / member is responsible to pay to the provider as part of their costs for services. Report 0 if there are no Out of Pocket expenses. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 All 100% A2 MC Global Payment Flag 11/8/12 Lookup - Integer int[1] Indicator - Global Payment Report the 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 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 5 Not Applicable
MC Denial Reason 11/8/12 Carrier Defined Table - OR - External Code Source 16 - Text External Code Source 16 - Denial Reason OR Carrier-Defined lookup Denial Reason Code Report the code that defines the reason for denial of the line. Carrier must submit denial reason codes in separate table to the MA APCD. Required when MC123 = 1 98% A2 MC Attending Provider 10/30/14 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 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 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable MC Family Planning Indicator 11/8/12 Lookup Table - Integer int[1] Service is related to Family Planning Report the value that defines if family planning services were provided. EXAMPLE: 0 = Unknown / Not Applicable All 98% A2 Value Description 1 Family planning services provided
2 HCPCS Level II Code 3 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 Carrier Defined Table - Text Carrier Defined Table - MCO Service Class char[] 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 MC094 = 001 or 002 100% A2
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 Claim 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 Member Street Address 2 11/8/12 Text Address 2 Member Secondary Street Address of the Member/Patient 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 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 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. All 1% C
MC Diagnosis - 14 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 14. If not applicable do not report any value here. All 1% C MC Other Diagnosis - 15 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 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 16. If not applicable do not report any value here. All 1% C MC Diagnosis - 17 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 17. If not applicable do not report any value here. All 1% C MC Other Diagnosis - External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code ICD Diagnosis Code - 18. If not applicable do not report any value here. All 1% C MC Other Diagnosis - 19 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code ICD Diagnosis Code - 19. If not applicable do not report any value here. All 1% C
MC Other Diagnosis - 20 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. All 1% C MC Other Diagnosis - 21 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. All 1% C MC Other Diagnosis - 22 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code Other ICD Diagnosis Code - 22. If not applicable do not report any value here. All 1% C MC Other Diagnosis - 23 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 - 24 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD 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 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Principal Diagnosis Report the appropriate from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC041 is populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 02 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 1 Report the appropriate from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when = 002, MC039 and MC042 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 03 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 2 Report the appropriate from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC043 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2
MC Present on Admission Code (POA) - 04 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 3 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when = 002, MC039 and MC044 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 05 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 4 Report the appropriate 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 MC045 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 06 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 5 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC046 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2
MC Present on Admission Code (POA) - 07 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 6 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC047 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 08 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for 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 = 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 = 002, MC039 and MC051 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 12 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Diagnosis - 11 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC052 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2
MC Present on Admission Code (POA) - 19 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Diagnosis - 18 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 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 Other 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 = 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 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 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 - 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 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 char[2] Condition Code Report the appropriate value that defines a condition of the claim or patient. If not applicable do not report any value here. All 1% B
MC Value Amount - 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 Value Amount - 3 11/8/12 Integer Currency Amount that corresponds to Value Code - 3 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 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 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] 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 - 5 11/8/12 Integer Currency Amount that corresponds to Value Code - 5 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 MC199 is populated 100% B MC Code - 6 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 - 6 11/8/12 Integer Currency Amount that corresponds to Value Code - 6 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 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 Amount - 7 11/8/12 Integer Currency Amount that corresponds to Value Code - 7 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 MC203 is populated 100% B MC 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 Value Amount - 8 11/8/12 Integer Currency Amount that corresponds to 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 MC205 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 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 MC207 is populated 100% B MC Value Code - 10 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 - 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 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 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 Code - 12 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 Amount - 12 11/8/12 Integer Currency Amount that corresponds to Value Code - 12 Report the appropriate amount that corresponds to the code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when MC213 is populated 100% B MC Code - 1 11/8/12 External Code Source 14 - Text External Code Source 14 - Occurrence Codes char[2] Occurrence Code Report the appropriate value that defines an occurrence category for the claim or patient. If not applicable do not report any value here. All 1% B MC Date - 1 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Date that corresponds to Occurrence Code - 1 Report the appropriate date that corresponds to the occurrence code in CCYYMMDD Format. Required when MC215 is populated 100% B MC Code - 2 11/8/12 External Code Source 14 - Text External Code Source 14 - Occurrence Codes char[2] Occurrence Code Report the appropriate value that defines an occurrence category for the claim or patient. If not applicable do not report any value here. All 1% B MC Date - 2 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Date that corresponds to Occurrence Code - 2 Report the appropriate date that corresponds to the occurrence code in CCYYMMDD Format. Required when MC217 is populated 100% B
MC Span Code - 5 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Occurrence Span Code Report the appropriate code that defines an occurrence span category of the claim or patient. If not applicable do not report any value here. All 1% B MC Span Start Date - 5 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Start Date that corresponds to Occurrence Span Code - 5 Report the appropriate start date that corresponds to the occurrence code in CCYYMMDD Format. Required when MC237 is populated 100% B MC Span End Date - 5 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] End Date that corresponds to Occurrence Span Code - 5 Report the appropriate start date that corresponds to the occurrence code in CCYYMMDD Format. Required when MC238 is populated 100% B MC 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 MC241 = 3 100% A0 MC APCD ID Code 10/30/14 Lookup - Integer int[1] Member Enrollment Type Report the value that describes the member's / subscriber's enrollment into one of the predefined categories; aligns enrollment to appropriate editing and thresholds. EXAMPLE: 1 = FIG - Fully Insured Commercial Group Enrollee. All 100% A2 Value Description 1 FIG - Fully-Insured Commercial Group Enrollee 2 SIG - Self-Insured Group Enrollee 3 GIC - Insurance Commission Enrollee 4 MCO - MassHealth Managed Care Organization Enrollee 5 Supplemental Policy Enrollee 6 ICO - Integrated Care Organization or SCO – Senior Care Option
Value Description 1 General Acute Care Facility 2 Skilled Nursing Facility/Long Term Care Facility 3 Intermediate Care Facility 4 Hospice Facility 5 Designated Cancer Center 6 Designated Inpatient Children’s Hospital 7 Inpatient Rehabilitation Facility 8 Inpatient Pyschiatric Hospital 9 Critical Access Hospital 70 Other Type of Facility MC Type 10/30/14 specific type code Text Char[1] MassHealth Claim Type Indicator Report the value that defines the element Required when submitter is 100% A2 Value Description A INPATIENT PART A CROSSOVER UB92
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 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 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 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 6 Period Ending Date 6/24/10 Date Period - Integer Century Year Month - CCYYMM int[6] Trailer Period Ending Date Report the Year and Month of the reporting submission period in CCYYMM format. This date period must match the date period reported in TR005 and HD005 and HD006. Mandatory 100% TM 7 Date Processed 6/24/10 Full Date - Integer Century Year 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