(cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event and the person’s status (e.g. civilian, military). E. Hospital. "Hospital" means any acute care institution required to be licensed pursuant to 22 M.R.S.A., chapter 405;. and/or a Parent Entity, which means the person, organization or corporation that has control, directly or indirectly through majority ownership, affiliation, contract or membership of a hospital and/or any affiliated health care facility. A parent entity may be an individual hospital or, as a parent of a health care facility, may be considered a health care facility. F. Hospital Inpatient Data. "Hospital inpatient data" pertains to the information generated at the time of discharge which is associated with patients who are provided with room, board, and continuous nursing service based on a physician’s written order in an area of the hospital where patients generally stay more than twenty-four hours. G. Hospital Outpatient Data. "Hospital outpatient data" pertains to the data generated for any patient visit that is not considered an inpatient admission, at any department of the hospital, regardless of its physical location. Hospital Outpatient Data also includes services provided by specialty groups or primary care practices.pertains to information which is associated with patients who receive services in a formally organized ambulatory department, clinic, practice considered a department of the hospital, and/or other departments of a hospital when those patients are not considered to be inpatients. H. MHDO. "MHDO" means the Maine Health Data Organization. I. M.R.S.A. “M.R.S.A.” means Maine Revised Statutes Annotated. J. NAIC. "NAIC" means National Association of Insurance Commissioners. JK. Third-party Administrator. “Third-party administrator” means any person licensed by the Maine Bureau of Insurance under 24-A M.R.S.A., chapter 18 who, on behalf of a plan sponsor, health care service plan, nonprofit hospital or medical service organization, health maintenance organization or insurer, receives or collects charges, contributions or premiums for, or adjusts or settles claims on residents of this State.
IP9097 Filler T 20 IP9004 Total Accommodation Charges – Revenue Centers N 10 Must equal the sum of record type 50 revenue code data Two decimal places implied IP9098 Filler NT 10 IP9005 Ancillary Charges – Revenue Centers N 10 Must the sum of record type 60 revenue code data Two decimal places implied IP9099 Filler T 118 Data Element # Data Element Implementation Date for New Data Elements Type Length Description/Codes/Sources IP9901 Record Type T 2 99 IP9999 Filler T 190 Data Element # Data Element Name UB-04 Form Locator HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator IP0101 Record Type NA NA IP0102 MHDO-Assigned Provider ID Submitter EIN NA NA IP0103 ProviderSubmitter Name 1 837/2010AA/NM1/85/2/03 IP0104 Address 1 837/2010AA/N3/01 IP0105 City 1 837/2010AA/N4/01
IP0106 State 1 837/2010AA/N4/02 IP0107 Zip Code 1 837/2010AA/N4/03 IP0108 Version NA NA Data Element # Data Element Name UB-04 Form Locator HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator IP2001 Record Type NA NA IP2003 Patient Control Number 3A 837/2300/CLM/01 IP2004 Patient Sex 11 837/2010CA/DMG/03 837/2010BA/DMG/03 IP2005 Patient Birth Date 10 837/2010CA/DMG/D8/02 837/2010BA/DMG/D8/02 IP2006 Priority (Type) of Admission or Visit 14 837/2300/CL1/01 IP2007 Point of Origin for Admission or Visit 15 837/2300/CL1/02 IP2008 Patient City 9B 837/2010CA/N4/01 837/2010BA/N4/01 IP2009 Patient State 9C 837/2010CA/N4/02 837/2010BA/N4/02 IP2010 Patient Zip Code 9D 837/2010CA/N4/03 837/2010BA/N4/03 IP2011 of Care Date 12 837/2300/DTP/435/DT/03
Data Element # Data Element Name UB-04 Form Locator HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator IP4001 Record Type NA NA IP4002 Sequence Number NA NA IP4003 Patient Control Number 3A 837/2300/CLM/01 IP4004 Type of Bill 4 837/2300/CLM/05-1 837/2300/CLM/05-3 Data Element # Data Element Name UB-04 Form Locator HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator IP5001 Record Type NA NA IP5002 Sequence Number NA NA IP5003 Patient Control Number 3A 837/2300/CLM/01 IP5004 Accommodations Revenue Code - 1 42 837/2400/SV2/01 IP5005 Accommodations Service Units - 1 46 837/2400/SV2/DA/05 IP5006 Accommodations Total Charges - 1 47 837/2400/SV2/03 IP5007 Accommodations Revenue Code - 2 42 837/2400/SV2/01 IP5008 Accommodations Service Units - 2 46 837/2400/SV2/DA/05 IP5009 Accommodations Total Charges - 2 47 837/2400/SV2/03 IP5010 Accommodations Revenue Code - 3 42 837/2400/SV2/01 IP5011 Accommodations Service Units - 3 46 837/2400/SV2/DA/05 IP5012 Accommodations Total Charges - 3 47 837/2400/SV2/03
IP7002 Sequence Number NA NA IP7003 Patient Control Number 3A 837/2300/CLM/01 IP7004 Principal Diagnosis Code 67 837/2300/HI/BK/01-2 IP7004A Present on Admission Indicator 67 837/2300/HI/01-9 IP7005 Other Diagnosis Code – 1 67A 837/2300/HI/BF/01-2 IP7006 Present on Admission Indicator – 1 67A (pos 8) 837/2300/HI/01-9 IP7007 Other Diagnosis Code – 2 67B 837/2300/HI/BF/02-2 IP7008 Present on Admission Indicator – 2 67B (pos 8) 837/2300/HI/02-9 IP7009 Other Diagnosis Code – 3 67C 837/2300/HI/BF/03-2 IP7010 Present on Admission Indicator – 3 67C (pos 8) 837/2300/HI/03-9 IP7011 Other Diagnosis Code – 4 67D 837/2300/HI/BF/04-2 IP7012 Present on Admission Indicator – 4 67D (pos 8) 837/2300/HI/04-9 IP7013 Other Diagnosis Code – 5 67E 837/2300/HI/BF/05-2 IP7014 Present on Admission Indicator – 5 67E (pos 8) 837/2300/HI/05-9 IP7015 Diagnosis Code – 6 67F 837/2300/HI/BF/06-2 IP7016 Present on Admission Indicator – 6 67F (pos 8) 837/2300/HI/06-9 IP7017 Other Diagnosis Code – 7 67G 837/2300/HI/BF/07-2 IP7018 Present on Admission Indicator – 7 67G (pos 8) 837/2300/HI/07-9 IP7019 Other Diagnosis Code – 8 67H 837/2300/HI/BF/08-2 IP7020 Present on Admission Indicator – 8 67H (pos 8) 837/2300/HI/08-9 IP7021 Principal Procedure Code 74 837/2300/HI/BR/01-2
IP7022 Principal Procedure Date 74 837/2300/HI/D8/01-4 IP7023 Other Procedure Code – 1 74A 837/2300/HI/BQ/01-2 IP7024 Other Procedure Date – 1 74A 837/2300/HI/D8/01-4 IP7025 Procedure Code – 2 74B 837/2300/HI/BQ/02-2 IP7026 Other Procedure Date – 2 74B 837/2300/HI/D8/02-4 IP7027 Other Procedure Code – 3 74C 837/2300/HI/BQ/03-2 IP7028 Procedure Date – 3 74C 837/2300/HI/D8/03-4 IP7029 Other Procedure Code – 4 74D 837/2300/HI/BQ/04-2 IP7030 Procedure Date – 4 74D 837/2300/HI/D8/04-4 IP7031 Other Procedure Code – 5 74E 837/2300/HI/BQ/05-2 IP7032 Other Procedure Date – 5 74E 837/2300/HI/D8/05-4 IP7033 Admitting Diagnosis Code 69 837/2300/HI/BJ/01-2 IP7034 External Cause of Injury (E-Code) - 1 72A 837/2300/HI/BN/01-2 IP7034A Present on Admission Indicator - 1 72A (pos 8) 837/2300/HI/01-9 IP7035 External Cause of Injury (E-code) - 2 72B 837/2300/HI/BN/02-2 IP7035A Present on Admission Indicator - 2 72B (pos 8) 837/2300/HI/02-9
OP7012 Other Diagnosis Code - 8 T 6 ICD9-CM - Do not code decimal point - Left Justified OP7013 Principal Procedure Code (optional) T 7 ICD9-CM - Do not code decimal point - Left Justified OP7014 Principal Procedure Date (optional) T 8 CCYYMMDD OP7015 Other Procedure Code – 1 (optional) T 7 ICD9-CM - Do not code decimal point - Left Justified OP7016 Other Procedure Date – 1 (optional) T 8 CCYYMMDD OP7017 Other Procedure Code – 2 (optional) T 7 ICD9-CM - Do not code decimal point - Left Justified OP7018 Other Procedure Date – 2 (optional) T 8 CCYYMMDD OP7019 Other Procedure Code – 3 (optional) T 7 ICD9-CM - Do not code decimal - Left Justified OP7020 Other Procedure Date – 3 (optional) T 8 CCYYMMDD OP7021 Other Procedure Code – 4 (optional) T 7 ICD9-CM - Do not code decimal - Left Justified OP7022 Other Procedure Date – 4 (optional) T 8 CCYYMMDD OP7023 Other Procedure Code – 5 (optional) T 7 ICD9-CM - Do not code decimal - Left Justified OP7024 Other Procedure Date – 5 (optional) T 8 CCYYMMDD OP7025 Patient's Reason for Visit T 6 Required for all unscheduled outpatient visits when revenue code 045X, 0516 or 0526 are present OP7026 External of Injury (E- code) - 1 T 6 ICD9-CM - Do not code decimal point - Left Justified Describes the external causes of injury, poisoning or adverse effect OP7027 External Cause of Injury (E-code) - 2 April 1, 2009 T 6 ICD9-CM - Do not code decimal point - Left Justified Describes the external causes of injury, poisoning or adverse effect OP7099 Filler T 6 Note: E-codes when applicable must be reported in the E-Code field. If there are additional e-codes they can be reported in one of the 8 other diagnosis code fields.
OP3007 Insured’s Group Number (Primary) 62A 11 837/2000B/SBR/P/03 Insured’s Number (Secondary) 62B 9A 837/2320/SBR/S/03 OP3008 Insured’s Unique Identifier (Primary) 60A 1A 837/2010BA/NM1/MI/09 Insured’s Unique Identifier (Secondary) 60B NA OP3009 Payer Name (Primary) 50A Header/ Carrier Block 837/2010BB/NM1/PR/2/03 Payer Name (Secondary) 50B Header/ Carrier Block 837/2330B/NM1/PR/2/03 Data Element # Data Element Name UB-04 Form Locator HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator OP4001 Record Type NA NA NA OP4002 Sequence Number NA NA NA OP4003 Patient Control Number 3A 26 837/2300/CLM/01 OP4004 Type of Bill 4 NA 837/2300/CLM/A/05-1 837/2300/CLM/05-3
OP6121 Modifier - 2 (HCPCS & CPT-4) - 3 44 24D-3 837I/2400/SV2/HC/02-4 837P/2400/SV1/HC/01-4 OP6122 Service - 3 46 24G-3 837I/2400/SV2/DA/05 837I/2400/SV2/UN/05 837P/2400/SV1/UN/04 OP6123 Outpatient Total Charges - 3 47 24F-3 837I/2400/SV2/03 837P/2400/SV1/02 OP6124 Service Date - 3 45 24A-3 837/2400/DTP/472/D8/03 Data Element # Data Element Name UB-04 Form Locator Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator OP7001 Record Type NA NA NA OP7002 Sequence Number NA NA NA OP7003 Patient Control Number 3A 26 837/2300/CLM/01 OP7004 Principal Diagnosis Code 67 21A 837/2300/HI/BK/01-2 OP7005 Other Diagnosis Code – 1 67A 21B 837I/2300/HI/BF/01-2 837P/2300/HI/BF/02-2 OP7006 Other Diagnosis Code – 2 67B 21C 837I/2300/HI/BF/02-2 837P/2300/HI/BF/03-2
OP7023 Other Procedure Code - 5 74E NA 837/2300/HI/BQ/05-2 OP7024 Other Procedure Date -5 74E NA 837/2300/HI/D8/05-4 OP7025 Admitting Diagnosis/ Patient's Reason for Visit 70 NA 837/2300/HI/PR/01-2 OP7026 External Cause of Injury (E-Code) - 1 72A NA 837/2300/HI/BN/01-2 OP7027 External Cause of Injury (E-Code) - 2 72B NA 837/2300/HI/BN/02-2