Revision History Date Version Description Author 12/1/2012 3.0 Administrative Bulletin 12-01; issued 11/8/2012 M. Prettenhofer 1/25/2013 3.1 Removed ‘Non-Massachusetts Resident’ section Increased length of ICD-CM Procedure Code fields to varchar(7) MC241 (APCD Id Code): Added option 6) ICO – Integrated Care Organization MC113 Payment Arrangement: Added option for MassHealth H. Hines 5/31/13 3.1 Updated HD009 to reflect reporting period change H. Hines 5/31/13 3.1 Updated Condition on MC062 Charge Amount, MC107 ICD Indicator Updated element submission guideline for Delegated Benefit Adminstrator OrganizationID (MC100) Updated code source on Procedure Code K. Hines 10/2014 4.0 Administrative Bulletin 14-08 K. Hines 2/2016 5.0 Administrative Bulletin 16-03 K. Hines 2/2016 5.0 Update APCD Version Number – HD009 – to 5.0 K. Hines 2/2016 5.0 MC132 change Format/Length from 2 to 3 K. Hines 2/2016 5.0 MC245 update for VNA/Home Care K. 2/2016 5.0 Add clarifying language to fields K. Hines 2/2016 5.0 Update Cover Sheet, CHIA website and address K. Hines 2/2016 5.0 Enhanced Ambulatory Patient Grouping (EAPG) (MassHealth) to MC113 Payment Arrangement Type K. Hines Table of Contents
data essential for the continued monitoring of health care cost trends, minimize the duplication of data submissions by payers to state entities, and promote administrative simplification among state entities in Massachusetts. 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 957 CMR 5.00. 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’ Claims Database NPI – National Provider Identifier 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
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 - CCYYMM int[6] Header Period Ending Date Report the Year and 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 2/2016 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 = Version 3.0 Mandatory 100% HM Code Description 2.1 Prior Version; valid only for reporting periods prior to October 2013 3.0 Version 3.0; required for reporting periods as of October 2013; No Longer Valid as of May 2015 MC MC MC - MC MC - - 9
4.0 Version 4.0; required for reporting periods October 2013 onward; No longer valid as of August 2016 5.0 Version 5.0; required for reporting periods October 2013 onward as of August 2016 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 match the Submitter ID reported in HD002. All 100% A0 2 National Plan ID 11/8/12 Integer ID Nat'l PlanID int[10] CMS National Plan Identification Number (PlanID) Do not report any value here until National PlanID is fully implemented. This is a unique identifier as outlined by Centers for Medicare and Medicaid Services (CMS) for Plans or Sub plans. All 0% Z 3 Insurance Type 10/30/14 Lookup Table Text char[2] Type / Product Identification Code Report the code that defines the type of insurance under which this patient's claim line was processed. EXAMPLE: HM = HMO All 98% A2 Code Description 09 Self-pay 10 Central Certification 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization (DMO) AM Automobile Medical BL Blue Cross / Blue Shield 01
Code Description F Female M Male O Other 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] State / Province of the Patient Report the of the patient as defined by the US Postal Service. Report Province when Country Code does not = USA. All 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 digit 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 Month Day - CCYYMMDD int[8] Inpatient Admit Date Report the date of admit to a facility in CCYYMMDD Format. Only applies to facility claims where Type of Bill = an inpatient setting. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 98% A1 MC 20 Filler 10/30/14 Filler Filler char[4] Filler The MA APCD reserves this 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
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 External Code Source 2 - States char[2] 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 Codes varchar[9] Zip Code of the Service Provider 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 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 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 = 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
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 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Primary Diagnosis Code Report the Primary ICD Diagnosis Code here. Do not code decimal point. All 99% A0
MC 43 Other Diagnosis - 1 2/2016 External Code Source 8 - Text External 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. Do not code decimal All 70% B MC 44 Other Diagnosis - 2 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code Other ICD Diagnosis Code - 2. If not applicable do not report any value here. Do not code decimal point. All 24% B MC 45 Other Diagnosis - 3 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 3. If not applicable do not report any value here. Do not code decimal point. All 13% C MC 46 Other Diagnosis - 4 2/2016 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code Other ICD Diagnosis Code - 4. If not applicable do not report any value here. Do not code decimal point. All 7% C MC 47 Other Diagnosis - 5 2/2016 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 5. If not applicable do not report any value here. Do not code decimal point. All 4% C MC 48 Other Diagnosis - 6 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 6. If not applicable do not report any value here. Do not code decimal point. All 3% C
MC 49 Other Diagnosis - 7 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 7. If not applicable do not report any value here. Do not code decimal All 3% C MC 50 Other Diagnosis - 8 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code Other ICD Diagnosis Code - 8. If not applicable do not report any value here. Do not code decimal point. All 2% C MC 51 Other Diagnosis - 9 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 9. If not applicable do not report any value here. Do not code decimal point. All 1% C MC 52 Other Diagnosis - 10 2/2016 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. Do not code decimal point. All 1% C MC 53 Other Diagnosis - 11 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 11. If not applicable do not report any value here. Do not code decimal point. All 1% C MC 54 Other Diagnosis - 12 2/2016 External Code Source 8 - Text External 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. Do not code decimal point. 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 HCPCS / CPT Code Report a valid Procedure code for the claim line as defined by MC130. All 98% A1 MC 57 Procedure Modifier - 1 11/8/12 External Code Source 9 - Text External Code Source 9 - Modifiers char[2] HCPCS / CPT Code Modifier Report a valid Procedure modifier when a modifier clarifies / improves the reporting accuracy of the associated procedure code (MC055). All 20% B MC 58 Procedure Modifier - 2 11/8/12 External Code Source 9 - Text External Code Source 9 - Modifiers char[2] HCPCS / CPT Code Modifier Report a valid Procedure modifier when a modifier clarifies / improves the reporting accuracy of the associated procedure code (MC055). All 3% B MC 59 ICD-CM Primary Procedure Code 10/30/14 External 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 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 55% A2 MC 60 Date of Service - From 6/24/10 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Date of Service Report the date of service for the 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 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 Month Day - CCYYMMDD int[8] Discharge Date Report the date the member was discharged from the facility in CCYYMMDD Format. If patient is 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 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 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 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 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 Codes Source 8 - Text External Code Source 8 - ICDCM Procedure Codes varchar[7] ICD Procedure Code Report the third ICD procedure code when applicable. The Integer point is not coded. The ICD procedure must be repeated for all lines of the claim if necessary. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 1% C
MC 86 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 is not coded. The ICD procedure must be repeated for all lines of the claim if necessary. Required when = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 1% C MC 87 Other ICD-CM Procedure Code - 4 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 88 Other ICD-CM Procedure Code - 5 10/30/14 External Codes Source 8 - Text External Code Source 8 - ICDCM Procedure Codes varchar[7] ICD Other Procedure Code Report the sixth ICD procedure code when applicable. The Integer point is not coded. The ICD procedure must be repeated for all lines of the claim if necessary. Required when 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 89 Other ICD-CM Procedure Code - 6 10/30/14 External Codes Source 8 - Text External Code Source 8 - ICDCM Procedure Codes varchar[7] ICD Other Procedure Code Report the seventh ICD procedure code when applicable. The Integer point is not coded. The ICD procedure must be repeated for all lines of the claim if necessary. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 1% C MC 90 Paid Date 11/8/12 Full Date - Integer Century Year 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 must have a date reported here. Required when MC038 = 1, 2, 3, 19, 20, or 21 98% A0
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 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 94 Non Covered Days 10/30/14 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 MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 87% B MC 95 Type of Claim 11/8/12 Lookup - Text char[3] Type of Claim Indicator Report the value that defines the type of claim submitted for payment. EXAMPLE: 001 = Professional Claim Line All 100% A0 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 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 10/30/14 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. 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 02
MC ICD Indicator 11/8/12 Lookup Table - Integer tlkpICDIndicator int[1] International Classification of Diseases version Report the 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 valid 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 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 Day - CCYYMMDD int[8] Processed Date Report the date the 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 Diagnostic Pointer 10/30/14 Integer ID Diagnosis varchar[4] Diagnostic Pointer Number Report the placement number of the diagnosis(es) a procedure is related to for a professional claim. Can report up to four diagnostic positions within the first nine diagnoses that can be reported. Do not separate multiple mappings with spaces, zeros or special characters. Do not zero fill. EXAMPLE: Procedure related to diagnoses 1, 4 and 5 = 145 or ADE Required when MC094 = 001 98% B MC Referring Provider ID 11/8/12 Text ID Link to PV002 Referring Provider ID Report the identifier of the provider that submitted the referral for the service or ordered the test that is on the claim (if applicable). The value in this field must have a corresponding Provider ID (PV002) on the provider file. Required when MC118 = 1 98% A2 MC 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: = Fee for Service All 98% A0 Value Description 01 Capitation 02 Fee for Service Percent of Charges 04 DRG 05 Pay for Performance 06 Global Payment Other 08 Bundled Payment 09 Payment Amount Per Episode (PAPE) (MassHealth) ( 09 Valid for HD002 = MassHealth orgid ONLY )
10 Enhanced Ambulatory Patient Grouping (EAPG) (MassHealth) ( 10 Valid for HD002 = MassHealth orgid ONLY ) MC Excluded Expenses 11/8/12 Integer Currency Amount not covered at the claim line due to benefit/plan limitation Report the amount that the patient has incurred towards covered but over-utilized services. Scenario: Physical Therapy units that are authorized for 15 visits at $50 a visit but utilized 20. The amount reported here would be 25000 to state by $250.00. Report 0 if there are no Excluded 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 98% A2 MC Medicare Indicator 11/8/12 Lookup Table - Integer int[1] Indicator - Medicare Payment Applied Report the that defines the element. EXAMPLE: 1 = Yes, Medicare paid for part or all of services. All 100% A0 Value Description 1 Yes 2 No 3 Unknown 4 5 Not Applicable
MC Withhold Amount 11/8/12 Integer Currency Amount to be paid to the provider upon guarantee of performance Report the amount paid to the provider for this claim line if the provider qualified / met performance guarantees. Report 0 if the provider has the agreement but did not satisfy the measure, else do not report any value here. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 All 98% A2 MC Filler 10/30/14 Filler Filler int[1] Filler The MA APCD reserves this 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 - Integer int[1] Indicator - PCP Rendered Service Report the value that defines the element. EXAMPLE: 1 = Yes service was performed by members PCP. All 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable 18
MC DRG Level 11/8/12 External Code Source 15 - Integer External Code Source 15 - DRG int[1] Diagnostic Related Code Severity Level Report the used for severity adjustment when applicable. Required when is populated 80% B 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 Claim Line Indicator Report the 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 - OR - External Code Source 16 - Text External Code Source 16 - Denial Reason OR Carrier-Defined lookup Denial Reason Code Report the code that defines the reason for denial of the claim line. Carrier must submit denial reason codes in separate table to the MA APCD. Required when MC123 = 1 98% A2 MC Attending Provider 10/30/14 Text ID Link to PV002 Attending Provider ID Report the ID that reflects the provider that provided general oversight of the patient's care. This individual may or may not be the Servicing or Rendering provider. This needs to be found in field PV002 on the Provider File. This field may or may not be NPI based on the carrier’s identifier system. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 98% A1 MC Accident Indicator 11/8/12 Lookup Table - Integer int[1] Indicator - Accident Related Report the value that defines the element. EXAMPLE: 1 = Yes, Claim Line is Accident related. All 100% A2 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 CPT or HCPCS Level 1 Code 2 HCPCS Level II Code 3 HCPCS Level III Code (State Medicare code). 4 American Dental Association (ADA) Procedure Code (Also referred to as CDT code.) 5 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 5 Not Applicable MC Service Class 2/2016 Carrier Defined Table - Text Carrier Defined Table - MCO Service Class char[3] Service Class Code Report the code that defines the service class for Medicaid PCC members receiving behavioral health services (values based on MassHealth encounter table). Required when Submitter is identified as a / MCO Submitter 10% C MC 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 Other Diagnosis - 14 2/2016 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. Do not code decimal point. All 1% C MC Diagnosis - 15 2/2016 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code ICD Diagnosis Code - 15. If not applicable do not report any value here. Do not code decimal point. All 1% C MC Diagnosis - 16 2/2016 External Code Source 8 - Text External 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. Do not code decimal point. All 1% C MC Diagnosis - 17 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 17. If not applicable do not report any value here. Do not code decimal point. All 1% C MC Other Diagnosis - 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code ICD Diagnosis Code - 18. If not applicable do not report any value here. Do not code decimal point. All 1% C MC Other Diagnosis - 19 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 19. If not applicable do not report any value here. Do not code decimal point. All 1% C
MC Other Diagnosis - 20 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code ICD Diagnosis Code - 20. If not applicable do not report any value here. Do not code decimal All 1% C MC Diagnosis - 21 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code ICD Diagnosis Code - 21. If not applicable do not report any value here. Do not code decimal All 1% C MC Other Diagnosis - 22 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code Other ICD Diagnosis Code - 22. If not applicable do not report any value here. Do not code decimal point. All 1% C MC Other Diagnosis - 23 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 23. If not applicable do not report any value here. Do not code decimal point. All 1% C MC Other Diagnosis - 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code ICD Diagnosis Code - 24. If not applicable do not report any value here. Do not code decimal point. All 1% C
MC Present on Admission Code (POA) - 04 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 3 Report the appropriate 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 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 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 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 06 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Diagnosis - 5 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC046 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2
MC Present on Admission Code (POA) - 07 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for 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 Other Diagnosis - 7 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC048 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 09 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Diagnosis - 8 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC049 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2
MC Present on Admission Code (POA) - 10 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 9 Report the appropriate 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 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 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 12 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 11 Report the appropriate 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) - 16 10/30/14 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 = 002, MC039 and MC144 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 17 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 16 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 MC145 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 18 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 17 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 MC146 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 MC094 = 002, MC039 and MC149 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2
MC Present on Admission Code (POA) - 22 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Diagnosis - 21 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 MC150 is populated and MC245 are not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 23 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Diagnosis - 22 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 MC151 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 24 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 23 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 MC152 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 MC094 = 002, MC039 and MC153 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Condition Code - 1 11/8/12 External Code Source 14 - Text External Code Source 14 - Condition Codes char[2] Condition Code Report the appropriate value that defines a condition of the claim or patient. If not applicable do not report any value here. All 1% B MC Condition Code - 2 11/8/12 External Code Source 14 - Text External Code Source 14 - Condition Codes char[2] Condition Code Report the appropriate value that defines a condition of the claim or patient. If not applicable do not report any value here. All 1% B MC Condition Code - 3 11/8/12 External Code Source 14 - Text External Code Source 14 - Condition char[2] Condition Code Report the appropriate value that defines a condition of the claim or patient. If not applicable do not report any value here. All 1% B MC Condition Code - 4 11/8/12 External Code Source 14 - Text External Code Source 14 - Condition char[2] Condition Code Report the appropriate value that defines a condition of the claim or patient. If not applicable do not report any value here. All 1% B MC Condition Code - 5 11/8/12 External Code Source 14 - Text External Code Source 14 - Condition Codes char[2] Condition Code Report the appropriate value that defines a condition of the claim or patient. If not applicable do not report any value here. All 1% B MC Condition Code - 6 11/8/12 External Code Source 14 - Text External Code Source 14 - Condition Codes char[2] Condition Code Report the appropriate value that defines a condition of the claim or patient. If not applicable do not report any value here. All 1% B MC Condition Code - 7 11/8/12 External Code Source 14 - Text External Code Source 14 - Condition Codes char[2] Condition Code Report the appropriate 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 value that defines a condition of the claim or patient. If not applicable do not report any value here. All 1% B MC Condition Code - 10 11/8/12 External Code Source 14 - Text External Code Source 14 - Condition 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] 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 - 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 - 5 11/8/12 Integer Currency Amount that corresponds to Code - 5 Report the appropriate amount that corresponds to the value code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when MC199 is populated 100% B MC Value Code - 6 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Value Code Report the appropriate value that defines a value category of the claim. If not applicable do not report any value here. All 1% B MC 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 Code - 7 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Value Code Report the appropriate value that defines a value category of the claim. If not applicable do not report any value here. All 1% B MC Value Amount - 7 11/8/12 Integer Currency Amount that corresponds to Value Code - 7 Report the appropriate amount that corresponds to the value code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when MC203 is populated 100% B MC Value Code - 8 11/8/12 External Code Source 14 - Text External Code Source 14 - 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 - 8 11/8/12 Integer Currency Amount that corresponds to Code - 8 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 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 value that defines a value category of the claim. If not applicable do not report any value here. All 1% B MC Value Amount - 10 11/8/12 Integer Currency Amount that corresponds to 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 code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when MC211 is populated 100% B MC Value Code - 12 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Value Code Report the appropriate that defines a value category of the claim. If not applicable do not report any value here. All 1% B MC Value Amount - 12 11/8/12 Integer Currency Amount that corresponds to Value Code - 12 Report the appropriate amount that corresponds to the value code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when MC213 is populated 100% B MC Code - 1 11/8/12 External Code Source 14 - Text External Code Source 14 - Occurrence Codes char[2] Occurrence Code Report the appropriate value that defines an occurrence category for the claim or patient. If not applicable do not report any value here. All 1% B MC Date - 1 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Date that corresponds to Occurrence Code - 1 Report the appropriate date that corresponds to the occurrence code in CCYYMMDD Format. Required when MC215 is populated 100% B MC Code - 2 11/8/12 External Code Source 14 - Text External Code Source 14 - Occurrence Codes char[2] Occurrence Code Report the appropriate 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
0 Unknown / Not Applicable MC National Provider ID – Plan Rendering 10/30/14 External Code Source 3 – Integer External Code Source 3 – National Provider ID Int[10] National Provider Indentification (NPI) of the Plan Rendering Provider Report the Primary National Provider ID (NPI) of the Plan Rendering Provider in MC134. This ID should be found on the Provider File in the NPI Field (PV039) All 98% A2 MC Benefit Plan Contract ID 10/30/14 Text Benefit Plan ID Identifier for the benefit plan the member is enrolled in that covers this claim The Benefit Plan Contract ID is the issuer-generated unique ID number for the benefit plan which provides coverage for this claim. Report the carrier/submitter-assigned identifier as it appears in BP001 in the Benefit Plan File. This element is used to understand Benefit Plan, Eligibility and Claim attributes of the member / subscriber as applied to this record for the Massachusetts Alternative Risk Adjustment Methodology. Required when Carrier is BP submitter and claim is subject to Risk Adjustment 100% A2 MC Claim Line Paid Flag 10/30/14 Lookup Table - Integer int[1] Claim Line Paid Indicator Report the value that defines the element. EXAMPLE: 1 = Yes, Claim Line was paid. Required 100% B Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable MC Type of Facility 10/30/14 Lookup Table - Integer int[2] Type of Facility Indicator Report the value that defines the type of facility setting for this claim. Required 98% B
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 the Submitter ID reported in HD002. Mandatory 100% TM 3 National Plan ID 11/8/12 Integer ID Nat'l PlanID int[10] CMS National Plan Identification Number (PlanID) Do not report any value here until National PlanID is fully implemented. This is a unique identifier as outlined by Centers for Medicare and Medicaid Services (CMS) for Plans or Sub plans. Situational 0% TS 4 Type of File 6/24/10 Text ID File char[2] Validates the file type defined in HD004. Report MC here. This must 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 Date Report the Year and of the reported submission period in CCYYMM format. This date period must match the date period reported in HD005 and HD006. Mandatory 100% TM 6 Period Ending Date 6/24/10 Date Period - Integer Century Year - CCYYMM int[6] Trailer Period Ending Date Report the Year and Month of the reporting submission period in CCYYMM format. This date period must match the date period reported in TR005 and HD005 and HD006. Mandatory 100% TM 7 Date Processed 6/24/10 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Trailer Processed Date Report the full date that the submission was compiled by the submitter in CCYYMMDD Format. Mandatory 100% TM Appendix – External Code Sources 1. Countries American National Standards Institute
MC070 2. States, Zip Codes and Other Areas of the US U.S. Postal Service MC015 MC016 MC034 MC035 3. National Provider Identifiers National Plan & Provider Enumeration System MC077 5. Health Care Provider Taxonomy Washington Publishing Company MC032 8. International Classification of Diseases 9 & 10 American Medical Association MC039 MC040 MC041 MC042 MC044 MC045 MC047 MC048 MC050 MC049 MC051 MC052 MC053 MC058 MC084 MC086 MC087 MC136 MC143 MC144 MC145 MC146 MC148 MC149 MC150 MC151 MC152 MC153