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 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’ All-Payer Claims Database NPI – National Provider Identifier PBM – Pharmacy Benefit Manager QA – Quality Assurance RA – Risk Adjustment; Risk Adjuster TME / RP – Medical Expense / Relative Pricing TPA – 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 File
will be de-duplicated at CHIA. Are denied claims to be reported? No. Wholly denied claims should not be reported at this time. However, if a single procedure is denied within a paid that denied line should be reported. Denied line items of an adjudicated claim aid with cost analysis. Should claims that are paid under a ‘global payment’, or ‘capitated payment’ thus zero paid, be reported in this file. Yes. Any medical claim that is considered ‘paid’ by the carrier should appear in this filing. Paid amount should be reported as 0 and the corresponding Allowed, Contractual, Deductible Amounts should be calculated accordingly. The reporting of Zero Paid Medical Claims is required to accurately capture encounters and to further understand contractual arrangements. Should previously paid but now Voided claims be reported? Yes. Claims that were paid and reported in one period and voided by either the Provider or the Carrier in a subsequent period should be reported in the subsequent file. See MC139 below. The reporting of Voided Claims maintains logic integrity related to medical costs and utilization. What types of claims are to be included? The Medical Claims file is used to report both institutional and professional claims. The unique elements that apply to each are included; however only those elements that apply to the claim type should be submitted. Example: Diagnostic Pointer is a Professional Claim element and would not be a required element on an Institutional Claim record. See MC094 below for claim type ID. CHIA has adopted the most widely used specification at this time. It is important to note that adhering to rules for each specific type will provide cleaner analysis. The word ‘Member’ is used in the specification. Are Yes. Member and Patient are to be used in the same manner in this specification Member is used in the specification to strengthen the reporting bond between
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 CLAIM-based. This must match the File Type reported in TR004. Mandatory 100% HM 5 Period Beginning Date 11/8/12 Date Period Integer Century Year Month 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 Month - 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 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 10/30/14 Decimal - Numeric ID Version char[3] Submission Guide 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 - -
15 Ward 17 Stepson or Stepdaughter 19 Child 20 Self/Employee 21 Unknown 22 Handicapped Dependent 23 Sponsored Dependent 24 Dependent of a Minor Dependent 29 Significant Other 32 Mother 33 Father 36 Emancipated 39 Organ Donor 40 Cadaver Donor 41 Injured Plaintiff 43 Child Where Insured Has No Financial Responsibility 53 Life Partner 76 Dependent MC 13 Member Gender 6/24/10 Lookup Table Text tlkpGender char[1] Patient's Gender Report patient gender as on the claim in alpha format. Used to validate clinical services when applicable and Unique Member ID. EXAMPLE: F = Female All 98% B Code Description F Female M Male O Other
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 Type as it applies to facility claims where Type of Bill = an inpatient setting. This code indicates the type of admission into an inpatient setting. Also known as Admission Priority. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 98% A1 MC 22 Admission Source 11/8/12 External Code Source 14 - Text External Code Source 14 - Admission Source char[1] Admission Source Code Report the code that applies to facility claims where Type of Bill = an inpatient setting. This code indicates how the patient was referred into an inpatient setting at the facility. Required when = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 98% A1
MC 23 Filler 10/30/14 Filler Filler char[4] Filler The MA APCD reserves this for future use. Do not populate with any data. All 0% Z MC 24 Discharge Status 11/8/12 External Code Source 14 - Numeric External Code Source 14 - Discharge Status char[2] Inpatient Discharge Status Code Report the appropriate Discharge Status Code of the patient as defined by External Code Source Required when MC094 = 002 and MC069 is populated 98% A1 MC 25 Service Provider Number 6/24/10 Text ID Link to PV002 Service Provider Identification Number Report the carrier / submitter assigned service provider number. This number should be the identifier used for internal identification purposes, and does not routinely change. The value in this field must match a record in the provider file in PV002. All 99% A1 MC 26 Service Provider Tax ID Number 11/8/12 Numeric ID Tax char[9] Service Provider's Tax ID number Report the Federal Tax ID of the Service Provider here. Do not use hyphen or alpha prefix. All 97% C MC 27 National Provider ID - Service 10/30/14 External Code Source 3 - Integer External Code Source 3 - National Provider ID int[10] National Provider Identification (NPI) of the Service Provider Report the Primary National Provider ID (NPI) of the Service Provider in MC024. This ID should be found on the Provider File in the NPI Field (PV039) All 98% A2 MC 28 Service Provider Entity Type Qualifier 11/8/12 Lookup Table - integer int[1] Service Provider Entity Identifier Code Report the value that defines the Service Provider entity type. Only individuals should be identified with a 1. Facilities, professional groups and clinic sites should all be identified with a 2. EXAMPLE: 1 = Person All 98% A0 Value Description 1 Person 2 Non-person entity 24
MC 29 Service Provider First Name 10/30/14 Text Name First Provider First name of Service Provider Report the individual's first name here. If provider is a facility or organization , do not report any value here Required when MC027 = 1 92% C MC 30 Service Provider Middle Initial 10/30/14 Text Name Middle Provider Middle initial of Service Provider Report the individual's middle initial here. If provider is a facility or organization , do not report any here Required when MC027 = 1 2% C MC 31 Servicing Provider Last Name or Name 6/24/10 Text Name Last / Org Provider Last name or Organization Name of Service Provider Report the name of the organization or last name of the individual provider. determines if this is an Organization or Individual Name reported here. All 94% A2 MC 32 Service Provider Suffix 10/30/14 Lookup - Integer int[1] Provider Name Suffix Report the individuals name-suffix when applicable here. Used to capture the generation of the individual clinician (e.g., Jr. Sr., III). Do not report degree acronyms here. EXAMPLE: 0 = Unknown / Not Applicable Required when MC027 = 1 2% Z Description 1 I. 2 II. 3 III. 4 Jr. 5 Sr. 0 Unknown / Not Applicable MC 33 Service Provider Taxonomy 11/8/12 External Code Source 5 - Text External Code Source 5 - Taxonomy Taxonomy Code Report the standard code that defines this provider for this line of service. Taxonomy values 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 11/8/12 External Code Source 2 - Text Address State 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. 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 two-digit value that defines the Type of Bill on an institutional claim. Do not report leading zero Required when = 002 98% A0 MC 38 Site of Service - on NSF/CMS 1500 Claims 11/8/12 External Code Source 13 - Numeric External Code Source 13 - Place of Service char[2] Place of Service Code Report the two-digit value that defines the Place of Service on professional claim Required when MC094 = 001 100% A0 MC 39 Claim Status 11/8/12 Lookup Table - Numeric tlkpClaimStatus varchar[2] 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 20 Processed as secondary, forwarded to additional payer(s) 21 Processed as tertiary, forwarded to additional
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 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 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Primary Diagnosis Code Report the Primary ICD Diagnosis Code here. All 99% A0 MC 43 Other Diagnosis - 1 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Secondary Diagnosis Code Report the Secondary ICD Diagnosis Code here. If not applicable do not report any value here. All 70% B MC 44 Other Diagnosis - 2 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 2. If not applicable do not report any value here. All 24% B
MC 45 Diagnosis - 3 11/8/12 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. All 13% C MC 46 Other Diagnosis - 4 11/8/12 External Code Source 8 - Text External Codes 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. All 7% C MC 47 Diagnosis - 5 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code ICD Diagnosis Code - 5. If not applicable do not report any value here. All 4% C MC 48 Other Diagnosis - 6 11/8/12 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. All 3% C MC 49 Diagnosis - 7 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code Other ICD Diagnosis Code - 7. If not applicable do not report any value here. All 3% C MC 50 Other Diagnosis - 8 11/8/12 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. All 2% C
MC 51 Other Diagnosis - 9 11/8/12 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 9. If not applicable do not report any value here. All 1% C MC 52 Other Diagnosis - 10 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code Other ICD Diagnosis Code - 10. If not applicable do not report any value here. All 1% C MC 53 Other Diagnosis - 11 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 11. If not applicable do not report any value here. All 1% C MC 54 Other Diagnosis - 12 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 12. If not applicable do not report any value here. All 1% C MC 55 Revenue Code 11/8/12 External Code Source 14 - Numeric External Code Source 14 - Revenue Code char[4] Revenue Code Report the 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 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] / 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 Source 8 - Text External Code Source 8 - Procedure Codes varchar[7] ICD Primary Procedure Code Report the primary ICD CM procedure code when appropriate. Repeat this code on all lines of the inpatient claim. Do not code decimal point. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 55% A2 MC 60 Date of Service - From 6/24/10 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Date of Service Report the date of service for the claim line in CCYYMMDD Format. All 98% A0 MC 61 Date of Service - To 11/8/12 Full Date - Integer Century Year 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 Number Patient Control Number Report the provider assigned Encounter / 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 MC094 = 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 73 DRG Version 11/8/12 External Code Source 15 - Text External Code Source 15 - DRG char[2] Diagnostic Related Group Version Number Report the version of the grouper used. Required when is populated 20% B MC 74 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 75 Filler 10/30/14 Filler Filler char[2] Filler The MA APCD reserves this field for future use. Do not populate with any data. All 0% Z MC 76 Drug Code 6/24/10 External Code Source 12 - Text External Code Source 12 - National Drug Codes char[11] National Drug Code (NDC) Report the NDC code used only when a medication is paid for as part of a medical claim or when a DME device has an NDC code. J codes should be submitted under procedure code (MC055), and have a procedure code type of 'HCPCS'. Drug Code as defined by the FDA in 11 digit format (5-4-2) without hyphenation. All 1% B MC 77 Billing Provider Number 6/24/10 Text ID Link to PV002 Billing Provider Number Report the carrier / submitter assigned billing provider number. This number should be the identifier used for internal identification purposes, and does not routinely change. The value in this field must match a record in the provider file in PV002. All 99% B MC 78 National Provider ID - Billing 10/30/14 External Code Source 3 - Integer External Code Source 3 - National Provider ID int[10] National Provider Identification (NPI) of the Billing Provider Report the Primary National Provider ID (NPI) here. This ID should be found on the Provider File in the NPI field (PV039). All 99% A2 MC 79 Billing Provider Last Name or Name 6/24/10 Text Name Last / Org Provider Last name or Organization Name of Billing Provider Report the name of the organization or last name of the individual provider. All 99% 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 - OR - External Code Source 16 - Text External Code Source 16 - Claim Adjustment Reasons- OR – Carrier Defined Table Payment Reason Code Report the value that describes how the claim line was paid, either using a standard code set or a proprietary list pre-sent by submitter. Required when = 1, 2, 3, 19, 20, or 21 100% A0 MC 82 Capitated Encounter Flag 11/8/12 Lookup Table - Integer int[1] Indicator - Capitation Payment Report the value that defines the element. EXAMPLE: 1 = Yes payment for this service is covered under a capitated arrangement. All 100% A0 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 Procedure Code - 1 10/30/14 External 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 Other Procedure Code Report the ICD procedure code when applicable. The Integer point is not coded. The ICD procedure must be repeated for all lines of the claim if necessary. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 1% C
MC 86 Other ICD-CM Procedure Code - 3 10/30/14 External Source 8 - Text External Code Source 8 - ICDCM Procedure Codes varchar[7] ICD Procedure Code Report the fourth ICD procedure code when applicable. The Integer point is not coded. The ICD procedure must be repeated for all lines of the claim if necessary. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 1% C MC 87 Other ICD-CM Procedure Code - 4 10/30/14 External Codes Source 8 - Text External Code Source 8 - ICDCM Procedure Codes varchar[7] ICD Other Procedure Code Report the fifth ICD procedure code when applicable. The Integer point is not coded. The ICD procedure must be repeated for all lines of the claim if necessary. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 1% C
MC 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 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 LOINC here, a standardized test code (lab work) when applicable and available. Do not report any value if not applicable. All 0% B MC 92 Days 10/30/14 Quantity - Integer Days Partially Covered Covered Coinsurance Days Report the number of partially covered days the patient incurred during this admission. Report 0 if all days were covered and/or Noncovered days. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 98% B MC 93 Covered Days 10/30/14 Quantity - Integer Days Covered Covered Inpatient Days Report the number of covered days the patient incurred during this admission. Report 0 if days were Noncovered or partially covered 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 11/8/12 Lookup Table - Text char[3] Type of Indicator Report the value that defines the type of claim submitted for payment. EXAMPLE: 001 = Professional Claim Line All 100% A0 Value 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 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 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 = 1 98% A2 MC 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 Description 01 Capitation 02 Fee for Service Percent of Charges 04 DRG 05 Pay for Performance Global Payment Other Bundled Payment 09 Payment Amount Per Episode (PAPE) (MassHealth) ( 09 Valid for HD002 = MassHealth orgid ONLY )
MC Filler 10/30/14 Filler Filler int[1] Filler The MA APCD reserves this field for future use. Do not populate. All 0% Z MC Referral Indicator 11/8/12 Lookup Table - Integer int[1] Indicator - Referral Needed Report the value that defines the element. EXAMPLE: 1 = Yes service was preceded by a referral. All 100% A0 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable MC PCP Indicator 11/8/12 Lookup Table - Integer int[1] Indicator - PCP Rendered Service Report the 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 MC DRG Level 11/8/12 External Code Source 15 - Integer External Code Source 15 - DRG int[1] Diagnostic Related Group Code Severity Level Report the level used for severity adjustment when applicable. Required when MC071 is populated 80% B 18
MC Denial Reason 11/8/12 Carrier Defined Table - OR - External Code Source 16 - Text External Code Source 16 - Denial Reason OR Carrier-Defined lookup Denial Reason Code Report the code that defines the reason for denial of the claim line. Carrier must submit denial reason codes in separate table to the MA APCD. Required when = 1 98% A2 MC Attending Provider 10/30/14 Text ID Link to Attending Provider ID Report the ID that reflects the provider that provided general oversight of the patient's care. This individual may or may not be the Servicing or Rendering provider. This 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 - Integer int[1] Indicator - Accident Related Report the value that defines the element. EXAMPLE: 1 = Yes, Claim Line is Accident related. All 100% A2 Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable MC Family Planning Indicator 11/8/12 Lookup - 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 Description
1 Family planning services provided 2 Abortion services provided 3 Sterilization services provided 4 No family planning services provided 0 Unknown / Not Applicable / Not Avail MC Related Indicator 11/8/12 Lookup - Integer int[1] Indicator - Accident Related Report the value that defines the element. EXAMPLE: 1 = Yes, Claim Line was related to employment accident. All 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable MC EPSDT Indicator 11/8/12 Lookup - Integer int[1] Service related to Early Periodic Screening, Diagnosis and Treatment (EPSDT) Report the that defines if service was related to EPSDT and the type of EPSDT service, such as 'screening', 'treatment' or ‘referral’. EXAMPLE: 0 = Unknown / Not Applicable All 98% B Value Description 1 EPSDT Screen 2 EPSDT Treatment 3 EPSDT Referral 0 Unknown / Not Applicable / Not Available MC Procedure Code Type 10/30/14 Lookup Table - Integer int[1] line Procedure Code Type Identifier Report the value that defines the type of Procedure Code expected in MC055. All 98% A1 Value Description
MC Plan Rendering Provider Identifier 11/8/12 Text ID Link to Plan Rendering Number Report the unique code which identifies for the carrier / submitter who or which individual provider cared for the patient for the claim line in question. This code must be able to link to the Provider File. Any value in this field must also show up as a value in field PV002 (Provider ID) on the Provider File. All 100% A0 MC Provider Location 11/8/12 Text ID Link to Location of Provider Report the unique code identifies the location / site of the service provided by the plan rendering provider identified in MC134. The code should link to a provider record in field PV002 (Provider ID) and indicate that the service was performed at a specific location; e.g.: Dr. Jones Pediatrics, 123 Main St, Boston, MA, or Pediatric Associates, or Mass General Hospital, etc. Only the code is needed in this field, and the link to the Provider ID in the field PV002 (Provider ID) will allow the physical address and other identifying information about the service location to be captured. Type of location is an incorrect value. All 98% A2 MC Discharge Diagnosis 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Discharge Diagnosis Code Report the ICD diagnosis code as applied to the patient upon discharge. This may or may not be the same as the primary diagnosis or admitting diagnosis. Required when is populated 80% B MC 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 All 100% A0
MC Diagnosis - 14 11/8/12 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 14. If not applicable do not report any value here. All 1% C MC Other Diagnosis - 15 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 15. If not applicable do not report any value here. All 1% C MC Other Diagnosis - 16 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 16. If not applicable do not report any value here. All 1% C MC Other Diagnosis - 17 11/8/12 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 17. If not applicable do not report any value here. All 1% C MC Other Diagnosis - 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code ICD Diagnosis Code - 18. If not applicable do not report any value here. All 1% C MC Other Diagnosis - 19 11/8/12 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. All 1% C
MC Other Diagnosis - 20 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code ICD Diagnosis Code - 20. If not applicable do not report any value here. All 1% C MC Other Diagnosis - 21 11/8/12 External Code Source 8 - Text External 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. All 1% C MC Other Diagnosis - 22 11/8/12 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code ICD Diagnosis Code - 22. If not applicable do not report any value here. All 1% C MC Diagnosis - 23 11/8/12 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 23. If not applicable do not report any value here. All 1% C MC Other Diagnosis - 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 24. If not applicable do not report any value here. All 1% C
MC Present on Admission Code (POA) - 01 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Principal Diagnosis Report the appropriate 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 MC041 is populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 02 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Diagnosis - 1 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 MC042 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 03 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 2 Report the appropriate from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC043 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2
MC Present on Admission Code (POA) - 04 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 3 Report the appropriate 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 Other Diagnosis - 5 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC046 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2
MC Present on Admission Code (POA) - 13 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 12 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 MC053 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 14 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 13 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 MC142 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 15 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 14 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 MC143 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 Diagnosis - 15 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 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 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 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 Other Diagnosis - 18 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 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 Diagnosis - 19 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when MC094 = 002, MC039 and MC148 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2 MC Present on Admission Code (POA) - 21 10/30/14 External Code Source 15 - Text External Code Source 15 - Present on Admission char[1] POA code for Other Diagnosis - 20 Report the appropriate value from the lookup table to describe diagnosis presence upon admission. Do not report blanks in lieu of Exempt, reporting 1 is required for exempt. Required when = 002, MC039 and MC149 are populated and MC245 is not = 2, 5, 6, 7 or 9 100% A2
MC Present on Admission Code (POA) - 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 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 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 Other 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 Value Amount - 2 11/8/12 Integer Currency Amount that corresponds to Value Code - 2 Report the appropriate amount that corresponds to the value code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when is populated 100% B MC Value Code - 3 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Value Code Report the appropriate value that defines a value category of the claim. If not applicable do not report any value here. All 1% B MC Value Amount - 3 11/8/12 Integer Currency Amount that corresponds to Code - 3 Report the appropriate amount that corresponds to the code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when MC195 is populated 100% B MC Value Code - 4 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Value Code Report the appropriate value that defines a value category of the claim. If not applicable do not report any value here. All 1% B MC Value Amount - 4 11/8/12 Integer Currency Amount that corresponds to Value Code - 4 Report the appropriate amount that corresponds to the value code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when MC197 is populated 100% B MC Value Code - 5 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] 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 Value Code - 5 Report the appropriate amount that corresponds to the code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when MC199 is populated 100% B MC Value Code - 6 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Code Report the appropriate value that defines a value category of the claim. If not applicable do not report any value here. All 1% B MC Value Amount - 6 11/8/12 Integer Currency Amount that corresponds to Code - 6 Report the appropriate amount that corresponds to the value code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when MC201 is populated 100% B MC Value Code - 7 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Value Code Report the appropriate value that defines a value category of the claim. If not applicable do not report any value here. All 1% B MC Amount - 7 11/8/12 Integer Currency Amount that corresponds to Value Code - 7 Report the appropriate amount that corresponds to the 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 - Value Codes char[2] Value Code Report the appropriate value that defines a value category of the claim. If not applicable do not report any value here. All 1% B
MC Value Amount - 8 11/8/12 Integer Currency Amount that corresponds to Value Code - 8 Report the appropriate amount that corresponds to the value code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when MC205 is populated 100% B MC Value Code - 9 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Value Code Report the appropriate value that defines a value category of the claim. If not applicable do not report any value here. All 1% B MC Value Amount - 9 11/8/12 Integer Currency Amount that corresponds to Value Code - 9 Report the appropriate amount that corresponds to the value code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when MC207 is populated 100% B MC Value Code - 10 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Value Code Report the appropriate 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 Value Code - 10 Report the appropriate amount that corresponds to the value code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when is populated 100% B MC Value Code - 11 11/8/12 External Code Source 14 - Text External Code Source 14 - Codes char[2] Code Report the appropriate value that defines a value category of the claim. If not applicable do not report any value here. All 1% B
MC Value Amount - 11 11/8/12 Integer Currency Amount that corresponds to Code - 11 Report the appropriate amount that corresponds to the value code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when 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 value 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 value that defines an occurrence category for the claim or patient. If not applicable do not report any value here. All 1% B MC Date - 2 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Date that corresponds to Occurrence Code - 2 Report the appropriate date that corresponds to the occurrence code in CCYYMMDD Format. Required when MC217 is populated 100% B
MC Span Code - 5 11/8/12 External Code Source 14 - Text External Code Source 14 - Value Codes char[2] Occurrence Span Code Report the appropriate code that defines an occurrence span category of the claim or patient. If not applicable do not report any value here. All 1% B MC Span Start Date - 5 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Start Date that corresponds to Occurrence Span Code - 5 Report the appropriate start date that corresponds to the occurrence code in CCYYMMDD Format. Required when MC237 is populated 100% B MC Span End Date - 5 11/8/12 Full Date - Integer Century Year Day - CCYYMMDD int[8] End Date that corresponds to Occurrence Span Code - 5 Report the appropriate date that corresponds to the occurrence code in CCYYMMDD Format. Required when MC238 is populated 100% B MC GIC ID 11/8/12 Text ID GIC varchar[9] GIC Member ID Report the GIC Member Identification number as provided to GIC Plan Submitters. If not applicable do not report any value here. Required when MC241 = 3 100% A0 MC APCD ID Code 10/30/14 Lookup Table - Integer int[1] Member Enrollment Type Report the value that describes the member's / subscriber's enrollment into one of the predefined categories; aligns enrollment to appropriate editing and thresholds. EXAMPLE: 1 = FIG - Fully Insured Commercial Group Enrollee. All 100% A2 Value Description 1 FIG - Fully-Insured Commercial Group Enrollee 2 SIG - Self-Insured Group Enrollee 3 GIC - 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 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 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 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
Value Description 1 General Care Facility 2 Skilled Nursing Facility/Long Term Care Facility 3 Intermediate Care Facility 4 Hospice Facility 5 Designated Cancer Center 6 Designated Inpatient Children’s Hospital 7 Inpatient Rehabilitation Facility 8 Inpatient Pyschiatric Hospital 9 Critical Access Hospital 70 Other Type of Facility MC Claim Type 10/30/14 specific claim type code Text Char[1] MassHealth Claim Type Indicator Report the value that defines the element Required when submitter is 100% A2 Value Description A INPATIENT PART A CROSSOVER UB92 B PROFESSIONAL PART B CROSSOVER
C OUTPATIENT PART B CROSSOVER UB-04 D DENTAL H HOME HEALTH AND COMMUNITY HEALTH I HOSPITAL INPATIENT L LONG TERM CARE M PHYSICIAN CLAIM O HOSPITAL OUTPATIENT P PHARMACY Q COMPOUND DRUG CLAIMS MC Rate Code 10/30/14 Rate code Text varchar[3] MassHealth Rate Code Indicator Report the value that defines the element Required when submitter is and MC094 = 002 and MC246 = I or A 100% A2 MC Record Type 6/24/10 Text ID File char[2] File Type Identifier Report MC 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 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 Month of the reported submission period in CCYYMM format. This date period must match the date period reported in HD005 and HD006. Mandatory 100% TM 6 Period Ending Date 6/24/10 Date Period - Integer Century Year Month - CCYYMM int[6] Trailer Period Ending Date Report the Year and Month of the reporting submission period in CCYYMM format. This date period must match the date period reported in TR005 and HD005 and HD006. Mandatory 100% TM 7 Date Processed 6/24/10 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Trailer Processed Date Report the full date that the submission was compiled by the submitter in CCYYMMDD Format. Mandatory 100% TM Appendix – External Code Sources 1. Countries American National Standards Institute