Thank you for your partnership with CHIA on the all payer claims database. 957 CMR 8.00: APCD and Case Mix Data Submission administrative simplification state entities in Massachusetts. 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 – 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 – Insurance Commission ID – Identification; Identifier MA APCD – Massachusetts’ All-Payer 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 – Party Administrator The File Types: DC – Dental Claims MC – Medical Claims ME – Member Eligibility
PC 27 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 forwarded to additional payer(s) 25 Predetermination Pricing Only - no payment PC 28 Drug Code 11/8/12 External Code Source 12 - Text External Code Source 12 - National Drug Codes char[11] National Drug Code (NDC) Report the NDC Code as defined by the FDA in 11 digit format (5-4-2) without hyphenation All 98% A0 PC 29 Drug Name External Code Source 12 - Text External Code Source 12 - National Drug Names Name of the drug as supplied Report the name of the drug that aligns to the National Drug Code. Do not report generic names with brand National Drug Codes All 95% B PC 30 New or Refill 6/24/10 Numeric ID Count char[2] Prescription Status Indicator Report the status of prescription by numeric value. EXAMPLE: 00 = new prescription; First Refill = 01, etc. All 99% A0 PC 31 Generic Drug Indicator 11/8/12 Lookup Table - Integer tlkpFlagIndicators int[1] Generic Drug Indicator Report the that defines the element. EXAMPLE: 1 = Yes, the drug reported is a generic. All 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 Other
PC 42 Copay Amount 6/24/10 Integer Currency Amount of member/patient is responsible to pay Report the amount that defines a preset, amount for this claim line service that the patient is responsible to pay. Report 0 if no Copay applies. Do not code decimal or round up / down to whole dollars code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 All 99% A1 PC 43 Amount 6/24/10 Integer Currency Amount of coinsurance member/patient is responsible to pay Report the amount that defines a calculated percentage amount for this claim line service that the patient is responsible to pay. Report 0 if no Coinsurance applies. Do not code decimal or round up / down to whole dollars code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 All 99% A1 PC 44 Deductible Amount 6/24/10 Integer Currency Amount of deductible member/patient is responsible to pay on the claim line Report the amount that defines a preset, fixed amount for this claim line service that the patient is responsible to pay. Report 0 if no Deductible applies to service. Do not code decimal or round up / down to whole dollars code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 All 99% A1 PC 45 ProviderID 11/8/12 Text ID Link to PV002 Prescribing Provider Number Report the number of the prescribing provider here. This value in this element must have corresponding Provider ID (PV002) in the Provider File. All 98% A0 PC 46 Physician First Name 6/24/10 Text Name First Provider First name of Prescribing Physician Report the name of the prescribing physician here. All 50% B
PC 54 Physician Street Address 2 6/24/10 Text Address 2 Provider Secondary Street Address of the Prescribing Physician Report the street address of the Prescribing Physician that may contain office number, suite number of PO Box. All 2% C PC 55 Physician City 6/24/10 Text Address City Provider City name of the Prescribing Physician Report the Prescribing Physician City All 10% C PC 56 Physician 11/8/12 External Code Source 2 - Text Address External Code Source 2 - States char[2] State of the Physician Report the state of the prescribing physician here. All 10% C PC 57 Physician Zip 11/8/12 External Code Source 2 - Text Address Zip External Code Source 2 - Zip Codes varchar[9] Zip code of the Prescribing Physician 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 10% C PC 58 Product ID Number 11/8/12 Text ID Link to PR001 Product Identification Report the submitter-assigned identifier as it appears in 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 PC 59 Mail pharmacy 11/8/12 Lookup Table - Integer tlkpFlagIndicators int[1] Indicator - Mail Option Report the value that defines the element. EXAMPLE: 1 = Yes, pharmacy is a mail order pharmacy All 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 5 Not Applicable PC 60 Script number 6/24/10 Text ID Claim Number Prescription Number Report the unique identifier of the prescription All 100% B PC 61 Recipient PCP ID 6/24/10 Text ID Link to PV002 Patient's PCP ID Number Report the member's PCP ID here. The value in this element must have a corresponding Provider ID (PV002) in the Provider File. All 98% B
PC 72 Rebate Indicator 11/8/12 Lookup Table - Integer tlkpFlagIndicators int[1] Drug Rebate Eligibility Indicator Report the value that defines the element. EXAMPLE: 1 = Yes, drug is eligible for a rebate to any entity. All 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable PC 73 State Sales Tax 11/8/12 Integer Currency Amount of applicable sales tax on the claim line Report the amount of state sales tax applied to this claim line. Report 0 if state sales tax does not apply. 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 PC023 does not = MA 98% A2 PC 74 Delegated Benefit ID 11/8/12 Integer ID Link to varchar[6] CHIA defined and maintained Org ID for linking across submitters Riskholders 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 PC001 All 98% A2 PC 75 Formulary Code 11/8/12 Lookup - Integer tlkpFlagIndicators int[1] Formulary inclusion identifier Report the value that defines the element. EXAMPLE: 1 = Yes, drug is on the formulary. All 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable PC 76 of 11/8/12 Lookup Table - Numeric char[2] Route of Administration Report Pharmaceutical Route of Administration Indicator that defines method of drug administration. EXAMPLE: 11 = Oral All 80% A2 Value Description
01 Buccal 02 Dental 03 Inhalation 04 Injection 05 Intraperitoneal 06 Irrigation 07 Mouth / Throat 08 Mucous Membrane 09 10 Ophthalmic 11 Oral 12 Other / Misc 13 Otic 14 Perfusion 15 Rectal 16 Sublingual 17 Topical 18 Transdermal 19 Translingual 20 Urethral 21 Vaginal 22 Enteral 00 Not Specified PC 77 Drug Unit of Measure Lookup - Text char[3] Units of Measure Report the code that defines the unit of measure for drug dispensed. EXAMPLE: EA = Each All 80% A1 Code Description EA Each F2 International Units GM ML Milliliters MG Milligram MEQ Milliequivalent MM Millimeter UG Microgram UU Unit PC 78
PC 79 PC 80 PC 81 PC 82 PC 83 PC 84 Carrier Specific Unique Member ID 11/8/12 Text ID Link to ME107 Member's Unique ID Report the identifier the carrier / submitter uses internally to uniquely identify the member. Used to validate Unique Member ID and link back to Member Eligibility (ME107) All 100% A0 PC 85 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 PC 86 PC 87 Line Type 11/8/12 Lookup - Text tlkpClaimLineType 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 PC 88 Former Claim Number 12/1/10 Text ID Claim Number Previous Claim Number Report the Claim Control Number (PC004) that was originally sent in a prior filing that this line corresponds to. When reported, this data cannot equal its own PC004. Use of “Former Claim Number” to version claims can only be used if approved by the APCD. Contact the APCD for conditions of use. All 0% B
PC 94 Denial Reason 11/8/12 Carrier Defined Table - OR - External Code Source 16 External Code Source 16 - Reason Codes -OR – Carrier Defined Table 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 APCD. Required when PC116 = 1 98% A2 PC 95 Payment Type 11/8/12 Lookup Table - Numeric char[2] Payment Arrangement Type Value Report the 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) (09 Valid for HD002 = MassHealth orgid ONLY ) PC 96 PC 97 APCD ID Code Lookup Table - Integer tlkpADCDIdentifier 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 - 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 PC 98 Claim Line Paid Flag Lookup Table - Integer tlkpFlagIndicators int[1] Line Paid Indicator Report the value that defines the element. EXAMPLE: 1 = Yes, Claim Line was paid. Required 100% B Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable PC 99 Record Type 6/24/10 Text ID File char[2] File Type Identifier Report PC here. This validates the type of file and the data contained within the file. This must match HD004 All 100% A0 1 Record Type 6/24/10 Text ID Record char[2] Trailer Record Identifier Report TR here. Indicates the end of the data file Mandatory 100% TM 2 Submitter 11/8/12 Integer ID Submitter varchar[6] Trailer Submitter / Carrier ID defined by CHIA Report the Unique Submitter ID as defined by CHIA here. This must match the Submitter ID reported in HD002 Mandatory 100% TM 3 National Plan ID 11/8/12 Integer ID Nat'l PlanID int[10] CMS National Plan Identification Number (PlanID) Do not report any here until National PlanID is fully implemented. This is a unique identifier as outlined by Centers for Medicare and Medicaid Services (CMS) for Plans or Sub plans Situational 0% TS 4 Type of File 6/24/10 Text ID File char[2] Validates the file type defined in HD004. Report PC 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 D – External Code Sources 1. Countries American National Standards Institute PC024A 2. States, Zip Codes and Other Areas of the US U.S. Postal Service PC015 PC023 PC024 PC054 PC055 3. National Provider Identifiers National Plan & Provider Enumeration System PC021 PC048