Revision History Date Version Description Author 12/1/2012 3.0 Administrative Bulletin 12-01; issued 11/8/2012 M. Prettenhofer 1/28/2013 3.1 Updated ‘Non-Massachusetts Resident’ section DC067 (APCD ID Code): Added option (6) ICO - Integrated Care Organization H. 5/31/2013 3.1 Updated DC043 and DC058 – Street Address – to a length of 50 Updated HD009 to reflect reporting period change Updated element submission guideline for Delegated Benefit Adminstrator OrganizationID (DC025). K. Hines 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 Cover Sheet, CHIA website and address K. Hines 2/2016 5.0 Update APCD Version Number – HD009 – to 5.0 K. Hines Table of Contents
To facilitate communication and collaboration, CHIA maintains a MA APCD website (http://www.chiamass.gov/apcd-information-for-data-submitters/ ) with resources that currently include the submission and release regulations, Administrative Bulletins, the technical submission guide with examples, and support documentation. These resources periodically updated with materials and CHIA staff to work with all submitters to ensure full compliance with the regulation. While CHIA is committed to establishing and maintaining an APCD that promotes transparency, improves health care quality, and mitigates health care costs, we welcome your ongoing suggestions for revising reporting requirements that facilitate our shared goal of administrative simplification. If you have any questions regarding the regulations or technical specifications we encourage you to utilize the online resources and reach out to our staff for any further questions. Thank you for your partnership with CHIA on the all payer claims database. 957 CMR 8.00: APCD and Case Mix Data Submission 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
DS Disability HM Health Maintenance Organization LI Liability LM Liability Medical MA Medicare Part A MB Medicare Part B MC Medicaid OF Federal Program TF HSN Trust Fund TV Title V VA Veterans Administration Plan WC Workers' Compensation ZZ Other 4 Claim Control Number 6/24/10 Text ID Claim Number varchar[35] Claim Control Identification Report the Unique identifier within the payer's system that applies to the entire claim. All 100% A0 5 Line Counter 11/8/12 Integer ID varchar[4] Incremental Line Counter Report the line number for this service within the Start with 1 and increment by 1 for each additional line. Do not start with 0, include alphas or special characters. All 100% A0 6 Version Number 7/6/10 Integer Counter varchar[4] Claim Service Line Version Number Report the version number of this claim service line. The version number begins with 0 and is incremented by 1 for each subsequent version of that service line. No alpha or special characters. All 100% A0 7 Insured Group or Policy Number 11/8/12 Text ID Group varchar[30] Group / Policy Number Report the number that defines the insured group or policy. Do not report the number that uniquely identifies the subscriber or member. All 98%
DC 8 All DC 9 Plan Specific Contract Number 6/24/10 Text ID Contract varchar[30] Contract Number Report the Planassigned contract number. Do not include values in this element that will distinguish one member of the family from another. This should be the contract or certificate number for the subscriber and all of the dependents. All 70% DC 10 Member Suffix or Number 6/24/10 Text ID Sequence varchar[20] Contract Sequence Number Report the unique number / identifier of the member / patient within the contract All 98% DC 11 DC 12 Individual Code 6/24/10 Lookup Table Numeric varchar[2] Patient to Subscriber Relationship Code Report the that defines the Patient's relationship to the Subscriber. EXAMPLE: 20 = Self / Employee All 98% B Value Description 1 Spouse 4 Grandfather or Grandmother 5 Grandson or Granddaughter 7 Nephew or 10 Foster 15 Ward 17 Stepson or Stepdaughter 19 Child 20 Self/Employee 21 Unknown
1 Person 2 Non-person entity DC 23 Service Provider First Name 11/8/12 Text Name Provider varchar[25] First name of Service Provider Report the individual's first name here. If provider is a facility or organization , do not report any value here All 98% C DC 24 Service Provider Middle Name 11/8/12 Text Name Middle Provider varchar[25] Middle initial of Service Provider Report the individual's middle name here. If provider is a facility or organization , do not report any value here All 2% C DC 25 Service Provider Last Name or Name 6/24/10 Text Name Last / Org Provider varchar[60] Last name or Organization Name of Service Provider Report the name of the organization or last name of the individual provider. determines if this is an Organization or Individual Name reported here. All 98% B DC 26 Benefit ID 11/8/12 Integer ID Link to varchar[6] CHIA defined and maintained Org ID for linking across submitters Riskholders report the OrgID of the DBA here. DBAs report the OrgID of the insurance carrier here. This element contains the CHIA assigned organization ID for the DBA or carrier. Contact the MA APCD for the appropriate value. If no DBA is affiliated with this claim line do not report any value here: i.e., do not repeat the OrgID from DC001 All 98% A2 DC 27 Service Provider 11/8/12 External Code Source 5 - Text External Code Source 5 – Taxonomy varchar[10] Taxonomy Code Report the standard code that defines this provider for this line of service. Taxonomy values for the reporting of hygienists, assistants and laboratory technicians, where applicable, as well as Dentists, Orthodontists, etc. All 98% A2 DC 28 Service Provider City Name 6/24/10 Text Address City Provider varchar[30] City name of the Provider Report the Providers practice city location All 98% B
DC 29 Service Provider State 11/8/12 External Code Source 2 - Text Address External Code Source 2 – States char[2] State of the Service Provider Report the state of the service providers as defined by the US Postal Service All 98% B DC 30 Service Provider ZIP Code 11/8/12 External Code Source 2 - Text Address Zip External Code Source 2 - Zip Codes varchar[9] Zip Code of the Service Provider Report the 5 or 9 digit Zip Code as defined by the US Postal Service. When submitting the 9-digit Zip Code do not include hyphen. All 98% B DC 31 Facility Type - 11/8/12 External Code Source 13 - Numeric External Code Source 13 - Place of Service char[2] Place of Service Code Report the code the defines the location code where services were performed by the provider referenced on the claim All 80% B DC 32 Claim Status 11/8/12 Lookup Table - Numeric tlkpClaimStatus varchar[2] Claim Line Status Report the value that defines the payment status of this claim line All 98% A0 Value Description 1 Processed as primary 2 Processed as secondary 3 Processed as tertiary 4 Denied 19 Processed as primary, forwarded to additional payer(s) 20 Processed as secondary, forwarded to additional payer(s) 21 Processed as tertiary, forwarded to additional payer(s) 22 Reversal of previous payment 23 Not our claim, forwarded to additional payer(s) 25 Predetermination Pricing Only - no payment
DC 33 CDT Code 11/8/12 External Code Source 10 - Text External Code Source 10 - Current Dental Terminology char[5] HCPCS / CDT Code Report the Dental Terminology code here All 99% A2 DC 34 Modifier - 1 11/8/12 External Code Source 9 - Text External Code Source 9 - Modifiers char[2] HCPCS / CPT Code Modifier Report a valid Procedure modifier when a modifier clarifies / improves the reporting accuracy of the associated procedure code (DC032). All 0% C DC 35 Modifier - 2 11/8/12 External Code Source 9 - Text External Code Source 9 - Modifiers char[2] HCPCS / CPT Code Modifier Report a Procedure modifier when a modifier clarifies / improves the reporting accuracy of the associated procedure code (DC032). All 0% C DC 36 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 this claim line in CCYYMMDD Format. All 99% A0 DC 37 Date of Service - Thru 6/24/10 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Last date of service for this service line. Report the end service date for the claim line in CCYYMMDD Format; it can equal DC035 when a single date of service is being reported. All 0% B DC 38 Charge Amount 6/24/10 Integer Currency Amount of provider charges for the claim line Report the amount the provider billed the insurance carrier for this claim line service. Report 0 for services rendered in conjunction with other services on the claim. Do not code decimal or round up / down to whole dollars code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 All 99% A0 DC 39 Paid Amount 10/3/10 Integer Currency Amount paid by the carrier for the claim line Report the amount paid for the claim line. Report 0 if line is paid as part of another procedure / claim line. Do not report any value if the line is denied. Do not code decimal or round up / down to whole dollars code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 All 99% A0
DC 40 Copay Amount 6/24/10 Integer Currency Amount of Copay is responsible to pay Report the amount that defines a preset, fixed amount for this claim line service that the patient is responsible to pay. Report 0 if no Copay applies. Do not code decimal or round up / down to whole dollars code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 All 99% A1 DC 41 Amount 6/24/10 Integer Currency Amount of coinsurance is responsible to pay Report the amount that defines a calculated percentage amount for this claim line service that the patient is responsible to pay. Report 0 if no Coinsurance applies. Do not code decimal or round up / down to whole dollars code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 All 99% A1 DC 42 Amount 6/24/10 Integer Currency Amount of deductible is responsible to pay on the claim line Report the amount that defines a preset, fixed amount for this claim line service that the patient is responsible to pay. Report 0 if no Deductible applies to service. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 All 99% A1 DC 43 Product ID Number 11/8/12 Text ID Link to PR001 varchar[30] Product Identification Report the submitter-assigned identifier as it appears in PR001 in the Product File. This element is used to understand Product and Eligibility attributes of the member / subscriber as applied to this record All 100% A0 DC 44 DC 45 Billing Provider Tax ID Number 11/8/12 Numeric ID Tax char[9] The Billing Provider's Federal Tax Identification Number (FTIN) Report the Federal Tax ID of the Billing Provider here. Do not use hyphen or alpha prefix. All 90% C
DC 46 Paid Date 6/24/10 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Paid date of the claim line Report the date that appears on the check and/or remit and/or explanation of benefits and corresponds to any and all types of payment in CCYYMMDD Format. This can be the same date as Processed Date. EXAMPLE: Claims paid in full, partial or zero paid. All 98% A0 DC 47 Allowed Amount 11/8/12 Integer Currency Allowed Amount Report the maximum amount contractually allowed, and that a carrier will pay to a provider for a particular procedure or service. This will vary by provider contract and most often it is less than or equal to the fee charged by the provider. Report 0 when the claim line is denied. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when DC031 does not = 4, 22, or 23 99% A2 DC 48 Tooth 10/30/14 External Code Source 10 - Text External Code Source 10 - Numbering varchar[2] Tooth Number or Letter Identification Report the tooth identifier(s) when DC032 is within the given range Required when DC032 = D2000 thru D2999 100% A2 DC 49 Dental Quadrant 10/30/14 External Code Source 10 - Numeric External Code Source 10 - Dental Quadrants char[2] Dental Quadrant Report the standard quadrant identifier from the External Code Source here. Provides further detail on procedure(s). Required when DC032 reports Dental Code 100% B DC 50 Tooth Surface 10/30/14 External Code Source 10 - Text External Code Source 10 - Tooth Surfaces varchar[5] Tooth Service Identification Report the tooth surface(s) that this service relates to. Provides further detail on procedure. Required when 100% A2
DC 51 DC 52 DC 53 DC 54 DC 55 DC 56 DC 57 Carrier Specific Unique Member ID 11/8/12 Text ID Link to ME107 varchar[50] Member's Unique ID Report the identifier the carrier / submitter uses internally to uniquely identify the member. Used to validate Unique Member ID and link back to Member Eligibility All 100% A0
DC 58 Carrier Specific Unique ID 11/8/12 Text ID Link to varchar[50] Subscriber's Unique ID Report the identifier the carrier / submitteruses internally to uniquely identify the subscriber. Used to validate Unique Member ID and link back to Member Eligibility (ME117) All 100% A0 DC 59 DC 60 Claim Line Type 11/8/12 Lookup Table - Text char[1] Line Activity Type Code Report the code that defines the claim line status in terms of adjudication. EXAMPLE: O = Original All 98% A2 Code Description O Original V Void R Replacement B Back Out A Amendment DC 61 Former Claim Number 12/1/10 Text ID Claim Number varchar[35] Previous Number Report the Claim Control Number (DC004) that was originally sent in a prior filing that this line corresponds to. When reported, this data cannot equal its own DC004. Use of “Former Claim Number” to version claims can only be used if approved by the MA APCD. Contact the MA APCD for conditions of use. All 0% B DC 62 Code 11/8/12 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code Report the ICD Diagnosis Code when applicable Required when is within the ranges of or D9220 or D9221 1% B
DC 63 ICD Indicator 11/8/12 Lookup - Integer tlkpICDIndicator int[1] International Classification of Diseases version Report the value that defines whether the diagnoses on claim are ICD9 or ICD10. EXAMPLE: 9 = ICD9 Required when DC061 is populated 100% B Value Description 9 ICD-9 0 ICD-10 DC 64 Denied Flag 11/8/12 Lookup Table - Integer int[1] Denied Claim Line Indicator Report the value that defines the element. EXAMPLE: 1 = Yes, Claim Line was denied. Required when DC031 = 04 100% A0 Value Description 1 Yes 2 No 3 Unknown 4 5 Not Applicable DC 65 Denial Reason 11/8/12 Carrier Defined Table - OR - External Code Source 16 External Code Source 16 - Reason Codes OR – Carrier Defined Table - varchar[20] Denial Reason Code Report the code that defines the reason for denial of the claim line. Carrier must submit denial reason codes in separate table to the APCD. Required when DC063 = 1 98% A2 DC 66 Payment Type 11/8/12 Lookup Table - Numeric char[2] Payment Arrangement Type Value Report the value that defines the contracted payment methodology for this claim line. EXAMPLE: 02 = Fee for Service All 98% A0 Value Description 01 Capitation 02 Fee for Service 03 Percent of Charges
04 DRG 05 Pay for Performance 06 Global Payment 07 Other 08 Bundled Payment 09 Payment Amount Per Episode (PAPE) (MassHealth) (Valid for MassHealth ONLY) DC 67 DC 68 APCD ID Code 10/30/14 Lookup Table - Integer int[1] Member Enrollment Type Report the that describes the member's / subscriber's enrollment into one of the predefined categories; aligns enrollment to appropriate editing and thresholds. EXAMPLE: 1 = FIG - Fully Insured Commercial Group Enrollee. All 100% A2 Value Description 1 FIG - Fully-Insured Commercial Group Enrollee 2 SIG - Self-Insured Group Enrollee 3 GIC - Group Insurance Commission Enrollee 4 MCO - MassHealth Managed Care Organization Enrollee 5 Supplemental Policy Enrollee 6 ICO - Integrated Care Organization or SCO – Senior Care Option 0 Unknown / Not Applicable DC 69 Claim Line Paid Flag 10/30/14 Lookup - 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 DC 70 Record Type 11/8/12 Text ID File char[2] File Type Identifier Report DC here. This validates the type of file and the data contained within the file. This must match HD004 All 100% A0 1 Record Type 6/24/10 Text ID Record char[2] Trailer Record Identifier Report TR here. Indicates the end of the data file Mandatory 100% TM 2 Submitter 11/8/12 Integer ID Submitter varchar[6] Trailer Submitter / Carrier ID defined by CHIA Report the Unique Submitter ID as defined by CHIA here. This must match the Submitter ID reported in HD002 Mandatory 100% TM 3 National Plan ID 11/8/12 Integer ID Nat'l PlanID int[10] CMS National Plan Identification Number (PlanID) Do not report any value here until National PlanID is fully implemented. This is a unique identifier as outlined by Centers for Medicare and Medicaid Services (CMS) for Plans or Sub plans Situational 0% TS 4 Type of File 11/8/12 Text ID File char[2] Validates the file type defined in HD004. Report DC here. This must match the File Type reported in HD004 Mandatory 100% TM 5 Period 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 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