CHAPTER
Ins 4000 UNIFORM REPORTING SYSTEM FOR
HEALTH CARE CLAIMS DATA SETS
Statutory Authority: RSA 400-A:15, I; RSA 420-G:11; RSA
420-G:11-a; RSA 420-G:14
PART
Ins 4001 PURPOSE AND SCOPE
Ins 4001.01 Purpose and Scope. This chapter contains procedures and
substantive requirements for the submission of health care data under RSA
420-G:11, II to the New Hampshire Comprehensive Health Information System by
insurance companies, third-party payers, third-party administrators, pharmacy
benefit managers, and carriers that provide administrative
services for a plan sponsor.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09;
ss by #10877, eff 7-10-15; ss by #13136, eff 11-24-20; ss by #14560, eff
4-22-26, EXPIRES: 4-22-36
PART
Ins 4002 DEFINITIONS
Ins 4002.01 Definitions. Unless the context indicates otherwise, the
following words and phrases shall have the following meanings:
(a)
“Address” means street addresses, post office box numbers, apartment
numbers, email addresses, web universal resource locators (URLs), and internet
protocol (IP) address numbers;
(b)
“Alternative payment arrangements” means those claims considered paid by
the carrier or third-party administrator under a capitated services arrangement
or a global payment, resulting in zero paid amounts on the claim;
(c)
“Blanket health insurance” means “blanket health insurance” as defined in
RSA 415:18, I-a;
(d)
“Capitated services” means services rendered by a provider through a
contract in which payment is based upon a fixed dollar amount for each member on a monthly basis;
(e)
“Carrier” means any entity subject to the insurance laws and rules of
this state, or subject to the jurisdiction of the commissioner, that contracts
or offers to provide, deliver, arrange for, pay for, or reimburse any of the
costs of health services, or to administer on behalf of a third-party payer,
and includes an insurance company, a health maintenance organization, a
nonprofit health services corporation, a dental benefits administrator, a
third-party administrator, or any other entity arranging for or providing
health coverage, Medicare Supplemental, and Medicare Advantage plans;
(f)
“Commissioner” means the New Hampshire insurance commissioner;
(g)
“Dental claims file” means a data file composed of service level
remittance information for all adjudicated claims for each billed dental
service provided to members, including data for services provided under
alternative payment arrangements with zero paid amounts;
(h)
“Department (NHID)” means the New Hampshire insurance department;
(i) “Designee” means an entity with which the
department or the department of health and human services have entered into an
arrangement pursuant to which the entity performs data management and
collecting functions and under which the entity is strictly prohibited from
using or releasing the information and data obtained in such a capacity for any
purposes other than those specified in the agreement;
(j)
“Department of Health and Human Services (DHHS)” means the New Hampshire
department of health and human services;
(k)
“Direct identifier” means any information, other than case or code
numbers used to create anonymous or encrypted data, that plainly discloses the
identity of an individual as referenced in 45 CFR Part 164.514 (e)(2);
(l)
“Encryption” means a method by which the true value of data has been
disguised in order to prevent the identification of
persons or groups and which does not provide the means
for recovering the true value of the data;
(m)
“Exchange” means a governmental agency or non-profit entity that meets
the applicable standards of 42 U.S.C. section 13031 and makes qualified health
plans available to qualified individuals and qualified employers in accordance
with federal law;
(n)
“Health care claims data” means the set of data files that are filed by
carriers and third-party administrators under this chapter consisting of, or
derived directly from, member eligibility, medical claims, pharmacy claims, and
dental claims files, including a provider file.
“Health care claims data” does not include analysis, reports, or studies
containing information from health care claims data sets, if those analyses,
reports, or studies have already been released in response to another request
for information or as part of a general distribution of public information by
the department;
(o)
“Hospital” means a licensed acute or specialty care institution;
(p)
“Insured” means an individual in whose name an insurance policy is
issued;
(q)
“Medical claims file” means a data file composed of service level
remittance information for all adjudicated claims for each billed medical
service provided to members, including data for services provided under
alternative payment arrangements with zero paid amounts;
(r)
“Members” means all individuals, employees, and dependents for which the
health carrier or third-party administrator has an obligation to adjudicate,
pay, or disburse claim payments. The
term includes “covered lives”. For
employer-sponsored group coverage, members include certificate holders and
their dependents;
(s)
“Member eligibility file” means a data file containing demographic
information for each individual member eligible for medical, pharmacy, or
dental benefits for one or more days of coverage at any time during the
reporting month as well as any retrospective updates that correspond to
previously submitted eligibility data.
The term also includes benefits attributed and associated effective
periods;
(t)
“New Hampshire Comprehensive Health Information System (NHCHIS)” means
the system established and operated by the department and the department of
health and human services or its designee to collect, store, and analyze health
care claims data;
(u)
“Pharmacy
benefit
manager” means “pharmacy benefit manager” as defined in RSA 402-N:1;
(v) “Pharmacy claims file” means a data file
composed of service level remittance information from all adjudicated claims
for each billed prescription provided to members, including data for services
provided under alternative payment arrangements with zero paid amounts;
(w) “Plan ID” means the 14-character Health
Insurance and Oversight System (HIOS) Plan ID, standard component. The full HIOS ID is unique to each fully
insured carrier, product, or plan;
(x) “Plan sponsor” means any persons, other than
an insurer, who establishes or maintains a plan covering residents of the state
of New Hampshire, including plans established or maintained by employers or
jointly by one or more employers and one or more employee organizations,
committee, joint board of trustees, or other similar group of representatives
of the parties that establish or maintain the plan;
(y)
“Prepaid amount” means the amount that would have been paid by the
health care claims processor for a specific service if the service had not been
capitated or otherwise did not result in a transfer of funds;
(z) “Provider” means a health care facility,
medical, dental, or behavioral health care practitioner, health product
manufacturer, health product vendor, or pharmacy;
(aa) “Provider file” means a data file listing
information about the service providers identified in the medical claims,
pharmacy claims, and the dental claims file as servicing billing, prescribing,
or primary providers;
(ab) “Release” means to make data or information
available for inspection and copying to persons other than the data submitter;
(ac) “Subcontractor” means a vendor or contractor
who manages carved out categories of services, including behavioral health
services, pharmacy services, or any other subcontractor that processes claims on behalf of a carrier;
(ad) “Subscriber” means the certificate holder who
receives coverage from a carrier or third-party administrator. For employer-sponsored group coverage, the
employee or subscriber is considered the certificate holder. For individual coverage, the policyholder is
considered the certificate holder. For
other types of group coverage, the certificate holder is considered the person
who is the principal insured; and
(ae) “Third party administrator” means any persons
licensed by the department that receives or collects charges, contributions, or
premiums for, or adjusts or settles claims for, residents of the state on
behalf of a plan sponsor, health care services plan, dental services plan,
nonprofit hospital or medical service organization, health maintenance
organization, or insurer.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09;
ss by #10877, eff 7-10-15; ss by #13136, eff 11-24-20; ss by #14560, eff
4-22-26, EXPIRES: 4-22-36
PART
Ins 4003 ANNUAL REGISTRATION REQUIREMENT
Ins 4003.01 Annual Registration Requirement.
(a)
Each carrier, third party administrator and pharmacy
benefit manager shall submit a completed NHCHIS registration form, available at
https://nhchis.com/, to the department or its
designee by March 15 of every calendar year.
(b)
Carriers, third party administrators, and pharmacy benefit managers
shall notify the department or its designee within 30 days of changes to any of
the annual NHCHIS registration information.
(c)
Carriers, third party administrators, and pharmacy benefit managers
shall notify the department or its designee of any changes to the individual
contact information submitted on the NHCHIS registration form as soon as
possible, but no later than 30 days after a reassignment occurs.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09;
ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff
4-22-26, EXPIRES: 4-22-36
Ins 4003.02 Contents of NHCHIS Registration Form. The NHCHIS registration form for carriers,
pharmacy benefit managers, and third-party administrators
submitting data under RSA 420-G:11, II shall contain the fields required under Ins
4008.01.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09;
ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20;
ss by #14560, eff 4-22-26, EXPIRES: 4-22-36
Ins 4003.03 Submission of NHCHIS Registration Form. Carriers, pharmacy benefit
managers, and third-party administrators shall submit the NHCHIS
registration form through the NHCHIS website.
Source. #10877, eff 7-10-15; ss by #13136 eff
11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36
PART
Ins 4004 FILING SCHEDULES
Ins 4004.01 Filing Schedules.
(a)
The deadline for submitting NHCHIS data files shall be determined by the
total number of members for whom claims are being paid or processed by each carrier,
third party administrator, or pharmacy benefit manager.
(b)
Carriers, third-party administrators, and pharmacy benefit managers
that have 10,000 or more New Hampshire members shall submit required
NHCHIS files monthly, no later than 30 days after the close of the reporting
month.
(c)
Carriers, third-party administrators, and pharmacy benefit managers
that have fewer than 10,000 New Hampshire members, but do not meet the
exclusion criteria in Ins 4005.02, shall submit required NHCHIS files
quarterly, no later than 30 days after the end of the reporting quarter.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09;
ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff
4-22-26, EXPIRES: 4-22-36
Ins 4004.02 First-time Filers.
(a)
Carriers, third party administrators, and pharmacy benefit managers that
have not previously submitted files to the department or its designee
and that have never registered under this chapter shall register no later than
30 days after the first applicable requirement to submit data, using the NHCHIS
registration form outlined in Ins 4003.02.
(b)
First-time submitters shall provide test files within 120 days after
registration. The test file size shall correspond to the size required for that
carrier, third party administrator, or pharmacy benefit manager as specified in
Ins 4004.01(a).
(c)
No later than 150 days after registration, newly-submitting carriers, third
party administrators, and pharmacy benefit managers shall submit files
containing the 3 most recent calendar years of data, January through December. Year-to-date
information and monthly or quarterly files shall be provided no later than 180
days after registration.
Source. #8279, eff
2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15;
ss by #13136 eff 11-24-20; ss by #14560, eff 4-22-26,
EXPIRES: 4-22-36
Ins 4004.03 Changes to Data Submitter’s Process,
Format, or Sources.
(a)
Carriers, third-party administrators, and pharmacy benefit managers,
that change health plan identifiers or implement new data submission platforms
through acquisitions, mergers, or reorganization shall be subject to the
requirements for first-time submitters.
(b)
Carriers, third-party administrators, and pharmacy benefit managers,
filing under new health plan identifiers or through new production systems
shall provide additional documentation pursuant to instructions from the
department or its designee to ensure that NHCHIS
maintains a continuous record of member enrollment and claims
history before and after the changes.
Source. #10877, eff 7-10-15; ss by #13136 eff
11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36
PART
Ins 4005 REQUIRED FILERS AND EXCLUSIONS
Ins 4005.01 Required Filers and Data Sets.
(a)
In accordance with the submission schedule set forth in Ins 4004, each
carrier, third party administrator, and pharmacy benefit manager shall submit
to the department or its designee a complete and accurate health care claims
data set.
(b)
Carriers, third-party administrators, and pharmacy benefit managers shall
submit health care claims data for all residents of New Hampshire and for all
members who receive services under a policy issued in New Hampshire, as
follows:
(1)
Any policy that provides coverage to the employees of a New Hampshire
employer that has a business location in New Hampshire shall be considered a
policy that is issued in New Hampshire;
(2)
An out-of-state employer’s branch location in New Hampshire shall be
considered a New Hampshire employer, and the carrier, third-party administrator,
and pharmacy benefit manager shall submit a claims data set for all members who
are employed at that branch location; and
(3)
Carriers, third-party administrators, and pharmacy benefit managers
shall submit health care claims data for New Hampshire state and municipal
employees.
(c)
When more than one entity is involved in the administration of a policy,
data shall be submitted in accordance with the following:
(1)
A carrier shall be responsible for submitting the claims data on
policies that it has written;
(2)
Third-party administrators and pharmacy benefit managers shall be
responsible for submitting claims data on self-insured plans that it
administers;
(3)
Each carrier, third-party administrator, and pharmacy benefit manager
shall submit all health care claims processed by any subcontractor on its
behalf, including claims related to pharmacy services, dental services, and
behavioral health, mental health, and substance abuse treatment services;
(4)
Each carrier, third-party administrator, and pharmacy benefit manager
shall ensure that the subcontractor shall not submit duplicate claims to the
department or its designee if the subcontractor falls under the definition of a
carrier, meets the requirements of this section, and is required to submit data
as a separate entity; and
(5)
Each carrier, third-party administrator, and pharmacy benefit manager
shall ensure that member and subscriber identifiers in any files
processed by subcontracts are consistent with member and subscriber identifiers
in the medical and pharmacy claims files and the member eligibility files.
(d)
Carriers, third-party administrators, and pharmacy benefit managers
shall continue to submit claims data for each month in which they meet the
criteria and for the 180 days after the month in which the carrier, third-party
administrator, or pharmacy benefit managers withdraws or falls
below the exclusion criteria listed in Ins 4005.02.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09;
ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff
4-22-26, EXPIRES: 4-22-36
Ins 4005.02 Exclusions from Filing Requirements.
(a)
Carriers, third-party administrators, and pharmacy benefit managers
shall not be required to submit health care claims data files, Health Care
Effectiveness Data and Information Set (HEDIS®) data, or Consumer Assessment of
Health Plans Survey (CAHPS) survey data if they meet the following criteria:
(1)
For carriers that do not offer any products on the health insurance
exchange for residents of New Hampshire and that did not cover more than 9,999
members in New Hampshire at any point in any medical, pharmacy, or dental
coverage class during the prior calendar year; or
(2)
For third-party administrators and pharmacy benefit managers that did
not cover more than 9,999 members in New Hampshire at any point in any medical,
pharmacy, or dental coverage class during the prior calendar year.
(b)
Carriers, third-party administrators, and pharmacy benefit
managers shall perform the calculation for (a) above at the entity level,
meaning the level at which major governance decisions are made under a senior
leadership team, regardless of the number of companies operating under separate
corporate divisions. Carriers, third-party
administrators, or pharmacy benefit managers experiencing a drop in membership
below the de minimis threshold shall submit claims data and any corrections to
membership files for a period of 180 days from the point the carrier,
third-party administrator, or pharmacy benefit manager no longer meets the de
minimis exemption.
(c)
Carriers, third-party administrators, and pharmacy benefit
managers shall not be required to submit health care claims data about coverage
that is not part of a comprehensive medical insurance policy, including the
following:
(1)
Specific disease;
(2)
Accident;
(3)
Injury;
(4)
Hospital indemnity;
(5)
Disability;
(6)
Long-term care;
(7)
Vision coverage;
(8)
Durable medical equipment; or
(9)
Blanket health insurance.
Source. #8279, eff
2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136 eff
11-24-20; ss by
#14560, eff 4-22-26, EXPIRES: 4-22-36
Ins 4005.03 Opt-In by Self-Funded Private Employers.
(a)
Each carrier, third-party
administrator, or pharmacy benefit manager providing claims administration
services to any self-funded private employer that maintains a business location
in New Hampshire, including a branch location, shall, within 60 days for
current clients or, for new or renewing clients, within 30 days of the date its
claims administration services are retained or renewed, present to each such
self-funded employer a copy of the “NHID Opt-In Form” for purposes of
determining whether the employer directs the carrier, third-party administrator, or
pharmacy benefit manager to submit its health care claims data
pursuant to Ins 4000.
(b)
The “NHID Opt-In Form” shall be presented at least once for each
contractual period but need not be presented annually if the contractual period
exceeds one year.
(c)
Health care claims data for each self-funded private employer that
directs the submission of its data shall be included as part of the carrier’s,
third-party administrator’s,
or pharmacy benefit manager’s data submission as indicated on the “NHID Opt-In
Form” for that employer.
(d)
Each carrier,
third-party administrator, and pharmacy benefit manager
shall provide to the department annually by March 15
an attestation of compliance with this section with respect to all accounts to
which this section was applicable during the prior year. The attestation shall include a list of the
self-funded private employers to whom the “NHID Opt-In Form” was
presented. However, the association of
a particular employer with a particular carrier,
third-party administrator, or pharmacy benefit manager may
be designated as proprietary information which the department shall, if so
designated, hold confidential.
(e)
A carrier whose submission includes all relevant data under Ins 4000,
without regard to whether the data relate to a
self-funded private employer, shall not be required to comply with paragraphs
(a) through (d).
(f)
The types of employers listed in RSA 420-G:11, IV shall not be
considered self-funded private employers under this section, and the “NHID
Opt-In Form” shall not be presented to any such employer.
(g) If a self-funded private employer chooses to
include the health care claims data of its employees in the state’s All-Payer
Claims Database (APCD), the employer, or its designee,
shall:
(1)
Complete and sign the “NHID Opt-In Form”; and
(2)
Submit the completed form to its claims administrator.
(h)
If the employer has questions about NH’s APCD or the department’s
efforts to improve health care cost transparency, the employer may contact the
department at 603-271-2261, or requests@ins.nh.gov,
or visit https://www.insurance.nh.gov/.
Source. #12044, eff 11-17-16; ss by #13136 eff
11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36
PART
Ins 4006 HEALTH CARE CLAIMS DATA SET
FILING
Ins 4006.01 General Requirements.
(a)
Carriers, third-party administrators, and pharmacy benefit
managers shall comply with all the technical specifications contained in Ins
4008 and shall include all data elements contained in Ins 4009, including
required formats, definitions, and sources.
(b)
Carriers, third-party administrators, and pharmacy benefit
managers shall utilize a data transmission tool provided by the department or
its designee to assign a unique identification code to
each member’s and subscriber’s record in every file, transform direct
identifiers, encrypt the files, and securely transmit the files to the
department or its designee.
(c)
Upon an amendment to this chapter, carriers,
third-party administrators, and pharmacy benefit managers shall submit
data that conforms to the updated specifications no later than 180 days after
the effective date of the amendment(s) to this chapter.
(d)
If the department or its designee identifies
technical deficiencies in data submitted by a carrier, third-party
administrator, or pharmacy benefit manager, the carrier, third-party
administrator, or pharmacy benefit manager shall respond to the department
within 10 days with a corrective action plan that will remove the deficiencies.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09;
ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff
4-22-26, EXPIRES: 4-22-36
Ins 4006.02 Subscriber and Member Identification Data
Elements.
(a)
Carriers, third-party administrators, and pharmacy benefit
managers shall:
(1)
Provide a unique identification number for each member and subscriber
included in the submitted files; and
(2)
Maintain that unique identifier for each member and subscriber for the
entire period of coverage for that individual by that carrier, third-party
administrator, or pharmacy benefit manager.
(b)
Subscriber and member identifiers shall be:
(1)
Consistent across all files that contain information about the
subscriber or member;
(2)
Matched across the member eligibility, medical claims, pharmacy, and
dental files, as well as behavioral health claims, as applicable, even where
the claims are processed by a subcontractor such as a pharmacy benefits
manager; and
(3)
Consistent with the technical specifications in Ins 4008.02.
Source.
#10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36
Ins 4006.03 Included Records and Data Requirements.
(a)
Carriers, third-party administrators, and pharmacy benefit
managers shall report health care claims data for all members meeting the
criteria set forth in Ins 4005.01(b).
(b)
Records for medical, pharmacy, and dental claims file submissions shall
be reported at the visit, service, or prescription level.
(c)
Medical, pharmacy, and dental claims files shall contain all of a claim’s payment and adjustment activity during the
reporting month regardless of the date of service on the claim.
(d)
Claims where multiple parties have financial responsibility shall be
included with all medical and pharmacy claims file submissions.
(e)
Co-payment or co-insurance amounts shall be reported in 2 separate
fields in the medical, pharmacy, and dental claims file submissions.
(f)
Carriers, third-party administrators, and pharmacy benefit
managers shall include records for services provided under alternative payment
arrangements with zero paid amounts.
(g)
Carriers, third-party administrators, and pharmacy benefit
managers shall include records for services provided by out of network
providers and services provided after member exceeds benefits with complete
patient liability paid.
(h) Carriers, third-party
administrators, and pharmacy benefit managers shall include all service lines
associated with fully-processed claims that have gone through an accounts
payable run and been booked to the health plan ledger in all medical, dental,
and pharmacy claims file submissions.
Source. #10877, eff 7-10-15; ss by #13136 eff
11-24-20; ss by #14560,
eff 4-22-26, EXPIRES: 4-22-36
Ins 4006.04 Observation Period for Record Selection.
(a)
Carriers, third-party administrators, and pharmacy benefit
managers shall submit a member eligibility file that contains data for each
member eligible for medical, dental, or pharmacy benefits for one or more dates
of coverage at any time during a reporting month as well as any retrospective
updates that correspond to previously submitted eligibility data. The file shall include benefits, attributes,
and associated effective periods.
(b)
Carriers, third-party administrators, and pharmacy benefit
managers shall include all claims adjudicated during the reporting month for
all members in the member eligibility file for that month.
(c)
Carriers’, third-party administrators’, and pharmacy
benefit managers’ data submissions shall contain 180 days claims run out for
members in all current or previously submitted files.
(d) Claims files and other records
shall be maintained as required in RSA 400-B
Source.
#10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560,
eff 4-22-26, EXPIRES: 4-22-36
Ins 4006.05 Health Care Effectiveness Data and
Information Set (HEDIS®) Reporting Requirements.
(a)
Each carrier that calculates using HEDIS®, a system of performance
measures maintained by the national committee for quality assurance (NCQA), and
submits those data to NCQA, shall report those data that pertain to members who
receive their benefits under a policy or plan issued in New Hampshire.
(b)
The carrier shall submit HEDIS® data to the DHHS or its designee by July
31st of each year as follows:
(1)
The carrier shall submit the data utilizing the appropriate NCQA
interactive data submission system (IDSS) import template; and
(2)
The carrier shall also submit the results via a workbook, generated with
results for each HEDIS® measure appearing on its own worksheet.
Source. #10877, eff 7-10-15; ss by #13136 eff
11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36
Ins 4006.06 Consumer Assessment of Health Plans Survey
(CAHPS®) Reporting Requirements.
(a)
Each carrier that collects CAHPS® data, a survey overseen by the United
States Department of Health and Human Services, agency for healthcare research
and quality (AHRQ) and used by NCQA as part of HEDIS® reporting, shall report
those data that are collected and that pertain to members who receive their
benefits under a policy or plan issued in New Hampshire.
(b)
The carrier shall submit CAHPS® data to the DHHS or its designee by July
31st of each year, as follows:
(1)
The carrier shall submit the NCQA generated survey results reports;
and
(2) The carrier shall also submit all results
generated via the NCQA CAHPS® analysis program.
Source. #10877, eff 7-10-15; ss by #13136 eff
11-24-20;
ss by #14560, eff 4-22-26, EXPIRES: 4-22-36
PART
Ins 4007 DATA STANDARDS COMPLIANCE
Ins 4007.01 Data Standards Compliance.
(a)
Carriers, third-party administrators, and pharmacy benefit
managers shall submit files that conform to the formats and standards in this
chapter, including the technical specifications in Ins 4008.
(b)
Carrier, third-party administrator, and pharmacy benefit
manager files shall be evaluated upon receipt by the department
or its designee to assess compliance with the data quality standards in the
submission instructions.
(c)
Carriers, third-party administrators, and pharmacy benefit
managers shall:
(1)
Resubmit nonconforming files at the direction of the department or its designee;
(2)
Resubmit a corrected and conforming version of
the original submission within 10 business days of the rejection notification
from the department or its designee; and
(3)
Not submit partial replacement files or record specific corrections.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09;
ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20; ss by #14560,
eff 4-22-26, EXPIRES: 4-22-36
PART
Ins 4008 TECHNICAL SPECIFICATIONS
Ins 4008.01 Subscriber and Member Identification Data
Elements.
(a)
The following table lists the subscriber and member identifiers that shall
be identical when reporting information about a subscriber or a member:
|
Table 1: Matching Requirements for Subscriber/Member Identifiers
Across Files |
||||
|
Data
Element Name* |
Subscriber
and Member Identifiers |
|||
|
Member
Eligibility |
Medical
Claims** |
Dental
Claims |
Pharmacy
Claims |
|
|
Plan
Specific Contract Number |
ME009 |
MC008,
MC20 |
DC008,
DC202 |
PC008,
PC204 |
|
Member
Suffix or Sequence Number |
ME010 |
MC009 |
DC009 |
PC009 |
|
Subscriber
Last Name |
ME101 |
MC101 |
DC101 |
PC101 |
|
Subscriber
First Name |
ME102 |
MC102 |
DC102 |
PC102 |
|
Subscriber
Middle Initial |
ME103 |
MC103 |
DC103 |
PC103 |
|
Member
Last Name |
ME104 |
MC104 |
DC104 |
PC104 |
|
Member First Name |
ME105 |
MC105 |
DC105 |
PC105 |
|
Member Middle Initial |
ME106 |
MC106 |
DC106 |
PC106 |
|
*The NHCHIS preprocessor hashes these data elements as part of
the file encryption and transmission process. |
||||
|
**Also pertains to Behavioral Health. |
||||
(b)
The NHCHIS preprocessor application will hash all subscriber and member
identification codes and names before data are transmitted to the department’s
designee. To ensure consistent hashing, subscriber and member identifiers shall
not be encrypted or hashed on the initial extract loaded into the preprocessor:
(1)
The discrete two-digit suffix shall also be used with the certificate or
contract number. This data element is
de-identified by the NHCHIS preprocessor application.
(2)
The certificate or contract number with the two-digit suffix shall be at
least 11, but no more than 30 characters in length. This data element is de-identified by the
NHCHIS preprocessor application.
Source. #10877, eff 7-10-15; ss by #13136 eff
11-24-20 (formerly Ins 4009.02); ss by #14560, eff 4-22-26, EXPIRES: 4-22-36
(formerly Ins 4009.01)
Ins 4008.02 Technical Specifications and Format for
File Transfer.
(a)
Carriers, third-party administrators, and pharmacy benefit
managers shall use the values in the data tables contained in Ins 4009 or the
corresponding externally maintained code tables referenced therein, and:
(1)
Carriers, third-party administrators, and pharmacy benefit
managers shall submit tables and descriptions for all non-conforming and
plan-specific codes appearing in the submission; and
(2)
The department and DHHS or its designee shall reject files with
non-conforming and plan-specific codes if explanatory information is not
provided in advance of the data submission.
(b)
Carriers, third-party administrators, and pharmacy benefit
managers shall report adjustment records with the appropriate positive or
negative fields with the medical, pharmacy, and dental file submissions.
Negative values shall contain the negative sign before the value. No sign shall
appear before a positive value.
(c) All service lines associated with
fully-processed claims that have gone through an accounts payable run and been
booked to the health plan ledger shall be included on medical, pharmacy, and
dental claims data submissions. Do not
include service lines:
(1)
Rejected due to failed edits;
(2)
That are duplicates;
(3)
That are from an inactive member; or
(4)
Claims that are voided for point of sale
adjustments.
(d) When more than one version of a
fully-processed claim service line is submitted, each version of a claim
service line shall be enumerated sequentially with a higher version number
(MC005A/DC207/PC902) so that the latest version of that service line is the
record with the highest version number (MC005A/DC207/PC9) and the same claim
number + line counter. There shall be no
leading zeros on the version numbers. Where a version number is not available, and
a new claim ID is used, provide the former claim number in data
element MC211. Similar requirements shall apply to the pharmacy claim file.
(e)
Subsequent incremental claims submissions shall include all reversal and
adjustment or restated versions of previously submitted claim service lines and all new, fully-processed service lines associated
with the claim, provided that they have paid dates in
the reporting period, and:
(1)
Each version of a claim service line shall be enumerated sequentially with a higher line version number (MC005A/DC207/PC902); and
(2)
Reversal versions of a claim service line shall be indicated by a claim
status code = '22' (Field MC038/DC031/PC025).
(f)
Capitated service claims, sometimes known as encounter claims, for
capitated services shall be reported with all medical and pharmacy file
submissions.
(g) If a claim contains
service lines that do
not contain a payment because their costs are covered on another line of the claim line, such as under a global
payment arrangement, those line(s) shall be:
(1)
Included in the data submission; and
(2)
Clearly indicated by a
claim
status code = ‘04’ (Field MC038/DC031/PC025).
(h)
Member eligibility data suppliers shall provide a data set that contains
information on every covered plan member, regardless of whether the member
utilized services during the reporting period.
One record per member per month per plan shall be required. For example, if a member is covered as both a
subscriber and a dependent on two different policies during the same month, 2
records shall be submitted. If a member
has 2 contract numbers for 2 different coverage types, 2
member eligibility records shall be submitted. For each product type (ME018, ME019 and
ME020), a separate eligibility record shall be submitted.
(i) The Provider ID (MP003) is the unique
identifier for a single provider. The Provider ID should only occur once in the table. However, in the event the same provider
delivered, and was reimbursed for, services rendered from two or more different
physical locations, then the provider data file shall contain two separate
records for that same provider reflecting each of those physical locations. One
record should be provided for each unique physical location.
(j)
Carriers, third-party administrators, and pharmacy benefit
managers shall use the File Submission “Preprocessor” provided by the DHHS and
their designee. The preprocessor hashes
or de-identifies member and subscriber information before the data leaves the
carrier’s, pharmacy benefit managers, and third-party administrator’s system.
(k)
Carriers, third-party administrators, and pharmacy benefit
managers shall report the minimum value for fully insured and self-insured
products to support the department’s supplemental reporting reviews. The
minimum value is defined as the percentage of the total allowed costs of
benefits provided under a group health plan or health insurance coverage. The
minimum value measure is outlined in Section 1302 (d)(2)I of the Affordable
Care Act. Plans may use the HHS MV calculator available at http://www.cms.gov/cciio/resources/regulations-and-guidance/index.html;
may apply a safe harbor developed by HHS and the IRS; or may, for nonstandard
plans, provide an actuarial certification from a member of the American Academy
of Actuaries.
(l)
Each member eligibility file and each medical, pharmacy, and dental
claims file submission shall contain a header record and a trailer record. The
header record is the first record of each separate file submission
and the trailer record is the last.
(m)
All carriers, third-party administrators, and pharmacy
benefit managers submitting APCD files shall be provided with code in the form
of a pre-processor, which generates the files in the required format and
encrypts them prior to submission. The pre-processor code shall be provided to
all carriers, third-party administrators, and pharmacy benefit managers as a download
through a password protected portal.
(n)
Carriers, third-party administrators, and pharmacy benefit
managers may submit APCD files using the following methods:
(1)
Secure File Transport Protocol (SFTP) is the preferred method for
submitting files. This method requires
logging on to the appropriate SFTP site and sending or receiving files using
the SFTP client server. This protocol assumes that it is run over a secure
channel, that the server has already authenticated the client, and that the
identity of the client user is available to the protocol; or
(2)
The web upload method allows the sending and receiving of files and
messages without the installation of additional software. This method requires
internet access, a username, and password.
It is not the preferred method due to limitations on the size of the
files that can be received, but may be utilized if it
is the only method available to the healthcare claims processor.
(o)
The member eligibility file, medical claims file, pharmacy claims file,
dental claims file, and provider file shall be submitted as separate
ASCII files, with variable field lengths and pipe delimited, and shall comply
with the following standards:
(1)
Each record shall be terminated with a carriage return and line feed
(ASCII 13, ASCII 10);
(2)
All fields shall be filled where applicable;
(3)
Text and date fields shall be left blank when not applicable or if a
value is not available;
(4)
“Blank” means do not supply any value at all between consecutive field
delimiters or last field delimiter and line terminator. Numeric fields without a value shall be
filled with a single zero;
(5)
Only one record per row shall be submitted. No single line item of data
shall contain carriage return or line feed characters;
(6)
Text fields shall not be padded with leading or trailing spaces or tabs;
(7)
Numeric fields:
a.
Shall
not be padded
with leading zeroes;
b.
The
integer portion
of numeric fields shall not be padded with leading zeros;
c.
The
decimal portion
of numeric fields, if required, shall be padded with trailing zeros up to the
number of decimal places indicated; and
d.
Positive
values are assumed and need not be indicated as such. Negative values shall be indicated with
a minus sign and shall appear in the left-most position of all numeric fields; and
(8) Date fields:
a.
Shall be CCYYMMDD, when a value is provided, unless
otherwise indicated;
b.
Shall
not be padded with leading or trailing spaces or tabs; and
c.
Shall
be left blank when not applicable or if a value is not available.
(p) Carriers, third-party administrators, and
pharmacy benefit managers shall use the federal CARC/RARC codes when submitting
medical or dental claim denial reason codes (MC220 & DC220), and either
NCPDP or CARC/RARC codes with submitting pharmacy claim denial reason code (PC217).
Internal denial reason codes shall not be accepted. Carriers, third-party
administrators, and pharmacy benefit managers shall submit a crosswalk of
internal codes to NHID upon request.
(q) When reporting Drug Code (MC075 & PC026) carriers, third-party
administrators, and pharmacy benefit managers shall use
the 11 digit NDC with no dashes. Carriers, third-party
administrators, and pharmacy benefit managers shall report the 11 digit NDC anytime a HCPCS J code is reported in the
Medical Claims.
Source. #10877, eff 7-10-15; ss by #13136 eff
11-24-20(formerly Ins 4009.03); ss by #14560, eff 4-22-26, EXPIRES: 4-22-36
(formerly Ins 4009.02)
Ins 4008.03 Data Quality Requirements.
(a)
A validation process shall be employed to ensure that the format and
content of the submitted files are valid and complete. The validation process
is primarily composed of three groups of audits, field level audits, quality
audits, and post data consolidation reasonableness, longitudinal, and
relational audits, as follows:
(1)
All transmitted files are first checked to determine if they are in the
correct form and have been created using the provided pre-processor. Field level audits are then employed to
evaluate field length and type, code values, and the percentage at which the
fields are filled;
(2) Quality audits are employed to determine if
the data submitted meet a pre-determined level of
reasonableness, for example, percent of institutional claims versus percent of
professional claims. Default thresholds, which can be rates or ranges, have
been established for approximately 200 quality audits; and
(3)
After the files are loaded into staging tables, additional audits are
run on the consolidated data to identify any global issues that would not be
evident during the field and quality level audit process. The reasonableness, longitudinal, and
relational audits confirm whether the appropriate and correct amount of data
was received for the corresponding membership volume. Examples of these audits include frequency of
individual field values, volume reconciliation, and cost or utilization
reasonableness.
(b)
Default thresholds or rates shall be applied to the field level audits
for each element in the eligibility, claims files, and provider file for each
quality audit. The standard acceptable threshold for field length,
field type, and data value audits is 100 percent. However, there are some
fields where the acceptable thresholds for data value will be set at less than
100 percent. Individual field
completeness thresholds are established for each data element in the
eligibility, medical, pharmacy, dental, and provider files and will vary accordingly. All of the
pre-determined default thresholds can be individually adjusted if extenuating
circumstances arise which might impact the data completeness or content. If a file is processed and rejected for
failing to meet the field level or quality audit default thresholds, the
healthcare claims processor may request an exemption to the default threshold
through a standardized process.
Exemptions or adjustments may be granted for data variances that cannot
be corrected due to systematic issues.
(c)
At least 30 days prior to the initial submission of the files, or
whenever the data element content of the files is subsequently altered, each
healthcare claims processor shall submit a data set for comparison to the same
validation process used for actual submissions. Iterative rounds of testing may
be necessary until the files conform to the submission requirements. A test file should contain data covering a
period of one month.
(d)
Failure to conform to any of the submission requirements shall result in
the rejection and return of the applicable data file(s). All rejected and returned files shall be resubmitted
in the appropriate, corrected form within 10 days, or the healthcare claims
processor may request an exemption to adjust the threshold for the failing
field(s). Due to the large amount and complexity of the data processed, it is
more efficient to resubmit an entire file rather than to correct data within
the file.
Source. #10877, eff 7-10-15; ss by #13136, eff
11-24-20 (formerly Ins 4009.04); ss by #14560, eff 4-22-26, EXPIRES: 4-22-36
(formerly Ins 4009.03)
Ins 4008.04 External Code Sources.
(a)
Countries
American National Standards
Institute
http://webstore.ansi.org/SdoInfo.aspx?sdoid=39&source=iso_member_body
(b)
States, Zip Codes and Other Areas of the US
U.S. Postal Service
(c) National Provider Identifiers
National Plan & Provider
Enumeration System
https://nppes.cms.hhs.gov/NPPES/
(d)
Health Care Provider Taxonomy
National Uniform Claim Committee
(NUCC)
(e) International Classification of Diseases 9
& 10
American Medical Association
http://www.who.int/classifications/icd/en/
(f)
HCPCS, CPTs and Modifiers
American Medical Association
https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system
(g)
Dental Procedure Codes and Identifiers
American Dental Association
(h)
National Drug Codes and Names
U.S. Food and Drug Administration
http://www.fda.gov/drugs/informationondrugs/ucm142438.htm
(i) Standard Professional Billing Elements
Centers for Medicare and Medicaid
Services
https://www.cms.gov/files/document/837p-cms-1500pdf
(j)
Standard Facility Billing Elements
National Uniform Billing Committee
(NUBC)
(k)
DRGs, APCs and POA Codes
Centers for Medicare and Medicaid
Services
(l)
Claim Adjustment Reason Codes
X12
https://x12.org/codes/claim-adjustment-reason-codes
(m) Remittance Advice
Remark Codes
X12
https://x12.org/codes/remittance-advice-remark-codes
(n) NCPDP Telecommunication
Reject Codes
PrimeWest
https://www.primewest.org/ncpdp-telecommunication-reject-codes
(o) NCPDP Telecommunication Reject Codes NCPDC
https://www.ncpdp.org/resources.aspx
Source. #10877, eff 7-10-15; ss by #13136, eff
11-24-20 (formerly Ins 4009.05); ss by #14560, eff 4-22-26, EXPIRES: 4-22-36
(formerly Ins 4009.04)
PART Ins 4009 DATA
TABLES
Ins 4009.01 Member Eligibility
Data Tables.
(a)
Use Table 4009.07(a) to determine member eligibility file mapping and
formatting.
(b)
Member File Header Record Layout:
|
Table 4009.01(b) Member File Header
Record Layout |
||||
|
Data Element # |
Element |
Type |
Length (decimal places) |
Description/Codes/Sources |
|
HD001 |
Record Type |
Text |
2 |
HD |
|
HD002 |
Payer |
Text |
8 |
Payer submitting payments. NHID Submitter Code |
|
HD003 |
National Plan ID |
Text |
30 |
CMS National Plan ID |
|
HD004 |
Type of File |
Text |
2 |
ME Member Eligibility |
|
HD005 |
Period Beginning Date |
Number |
6 |
Beginning of paid period for claims or beginning of month
covered for eligibility |
|
HD006 |
Period Ending Date |
Number |
6 |
End of paid period for claims or end of month covered for
eligibility |
|
HD007 |
Comments |
Text |
80 |
Submitter may use to document this
submission by assigning a filename, system source, etc. |
(c) Member File
Trailer Record Layout:
|
Table 4009.01(c) Member File Trailer
Record Layout |
||||
|
Data Element # |
Element |
Type |
Length (decimal places) |
Description/Codes/Sources |
|
TR001 |
Record Type |
Text |
2 |
TR |
|
TR002 |
Payer |
Text |
8 |
Payer submitting payments. NHID Submitter Code |
|
TR003 |
National Plan ID |
Text |
30 |
CMS National Plan ID |
|
TR004 |
Type of File |
Text |
2 |
ME Member Eligibility |
|
TR005 |
Period
Beginning Date |
Number |
6 |
Beginning
of paid period for claims or beginning of month covered for eligibility |
|
TR006 |
Period
Ending Date |
Number |
6 |
End
of paid period for claims or beginning of month covered for eligibility |
|
TR007 |
Extraction
Date |
Date |
8 |
Date
file was created |
|
TR008 |
Record Count |
Number |
10 (0) |
Total number of records submitted in this file |
(d) Member File
Detailed Specification:
|
Table 4009.01(d) Member File Detailed
Specification |
|||||
|
|
|
||||
|
Column Position |
Data Element # |
Element |
Type |
Length (decimal places) |
Description/Codes/Sources |
|
1 |
ME001 |
Payer |
Text |
8 |
Payer submitting payments NHID Submitter Code |
|
2 |
ME002 |
National Plan ID |
Text |
30 |
CMS National Plan ID |
|
3 |
ME003 |
Insurance Type
Code/Product |
Text |
2 |
See Table 4009.06(a)
Insurance Type/Product Code |
|
4 |
ME004 |
Start Year |
Number |
4 (0) |
Year for which eligibility is reported in this submission. CCYY
format |
|
5 |
ME005 |
Start Month |
Number |
2 (0) |
Month for which eligibility is reported in this submission. MM
format. Leading zero is required for reporting January through September
files |
|
6 |
ME006 |
Insured Group or Policy Number |
Text |
50 |
Group or policy number (not the number that uniquely identifies
the subscriber) |
|
7 |
ME007 |
Coverage Level Code |
Text |
3 |
Benefit Coverage Level |
|
|
|
|
|
|
CHD Children Only |
|
|
|
|
|
|
DEP Dependents Only |
|
|
|
|
|
|
ECH Employee and Children |
|
|
|
|
|
|
EMP Employee Only |
|
|
|
|
|
|
ESP Employee and Spouse |
|
|
|
|
|
|
FAM Family |
|
|
|
|
|
|
IND Individual |
|
|
|
|
|
|
SPC Spouse and Children |
|
|
|
|
|
|
SPO Spouse Only |
|
8 |
ME008 |
Placeholder |
|
|
|
|
9 |
ME009 |
Plan Specific Contract
Number |
Text |
50 |
Plan assigned contract
number. If this is a Medicaid member, provide Medicaid ID Must match the ID in the
corresponding claim file (MC008, PC008 and DC008) |
|
10 |
ME010 |
Member Suffix or
Sequence Number |
Text |
20 |
Unique number of the member. This column is the
unique identifying column for membership and related medical, pharmacy, and
dental claims. Only 1 record per insurance product type, per eligibility
month. Must match MC009, PC009 and DC009. |
|
11 |
ME011 |
Placeholder |
|
|
|
|
12 |
ME012 |
Individual Relationship Code |
Text |
2 |
See
Table 4009.06(b) Relationship Codes |
|
13 |
ME013 |
Member Gender |
Text |
1 |
M Male |
|
|
|
|
|
|
F Female |
|
|
|
|
|
|
U Unknown |
|
|
|
|
|
|
O Other |
|
14 |
ME014 |
Member Date of Birth |
Date |
8 |
Date of birth of member |
|
15 |
ME015 |
Member City Name |
Text |
30 |
City name of member |
|
16 |
ME016 |
Member State or Province |
Text |
2 |
As defined by the US Postal Service |
|
17 |
ME017 |
Member ZIP Code |
Text |
9 |
ZIP Code of member – may include non- US codes. Do not include
dash. |
|
18 |
ME018 |
Medical Coverage |
Text |
1 |
Y Yes |
|
|
|
|
|
|
N No |
|
19 |
ME019 |
Prescription Drug Coverage |
Text |
1 |
Y Yes, member has prescription drug coverage in the period
defined with this payer |
|
|
|
|
|
|
N No, member does not have prescription
drug coverage in the period defined with this payer |
|
20 |
ME020 |
Dental Coverage |
Text |
1 |
Y Yes, member has dental coverage in the period defined with
this payer |
|
|
|
|
|
|
N No, member does not have dental coverage in the period defined with this payer |
|
21 |
ME021 |
Race 1 |
Text |
6 |
See Table
4009.06(c) Race 1/Race 2 |
|
22 |
ME022 |
Race 2 |
Text |
6 |
See Table
4009.06(c) Race 1/Race 2 |
|
23 |
ME023 |
Placeholder |
|
|
|
|
24 |
ME024 |
Hispanic Indicator |
Text |
1 |
Y Yes, member is Hispanic/Latino/Spanish |
|
|
|
|
|
|
N No, member is not Hispanic/Latino/Spanish |
|
|
|
|
|
|
U Unknown |
|
25 |
ME025 |
Ethnicity 1 |
Text |
6 |
See Table 4009.06(d): Ethnicity 1/ Ethnicity 2 |
|
26 |
ME026 |
Ethnicity 2 |
Text |
6 |
See Table 4009.06(d): Ethnicity 1/ Ethnicity 2 |
|
27 |
ME027 |
Placeholder |
|
20 |
|
|
28 |
ME028 |
Primary Insurance Indicator |
Text |
1 |
Y: Yes, this is the member’s primary insurance |
|
|
|
|
|
|
N: No, this is not the member’s primary insurance |
|
29 |
ME029 |
Coverage Type |
Text |
3 |
ASW Self-funded plans that are administered by a third party administrator, where the employer has
purchased stop-loss, or group excess insurance coverage |
|
|
|
|
|
|
ASO Self-funded plans that are administered by a third party administrator, where the employer has not
purchased stop-loss, or group excess insurance coverage |
|
|
|
|
|
|
STN Short-term non-renewable health insurance, as defined
pursuant to RSA 415:5, III |
|
|
|
|
|
|
MCD Medicaid |
|
|
|
|
|
|
MCR Medicare |
|
|
|
|
|
|
UND Plans underwritten by the carrier |
|
|
|
|
|
|
OTH Any other plan. Carriers and third-party administrators
using this code shall obtain prior approval from the N.H. Insurance
Department |
|
30 |
ME030 |
Market Category |
Text |
4 |
Three
or four digit
character code for identifying market category. Employer size is based on the
number of eligible employees in the group as defined in Ins 4100, (Ins
4103.03(g)) for the Small Group market, INS 4104.03(i)
for the Large Group market) |
|
|
|
|
|
|
IND Policies sold and issued directly to individuals, other than
those sold on a franchise basis, as defined pursuant to RSA 415:19, or as
group conversion Policies as defined pursuant to RSA 415:18 VII(a) |
|
|
|
|
|
|
FCH Policies sold and issued directly to individuals on a
franchise basis as defined pursuant to RSA 415:19 |
|
|
|
|
|
|
GCV Policies sold and issued directly to individuals as group
conversion Policies as required pursuant to RSA 415:18 VII(a) |
|
|
|
|
|
|
GS1 Policies sold and issued directly to employers having
exactly one employee |
|
|
|
|
|
|
GS2 Policies sold and issued directly to employers having between
2 and 9 employees |
|
|
|
|
|
|
GS3 Policies sold and issued directly to employers having
between 10 and 25 employees |
|
|
|
|
|
|
GS4 Policies sold and issued directly to employers having
between 26 and 50 employees |
|
|
|
|
|
|
GLG1 Policies sold and issued directly to employers having
between 51 and 99 employees |
|
|
|
|
|
|
GLG2 Policies sold and issued directly to employers having 100
or more employees |
|
|
|
|
|
|
GSA Policies sold and issued directly to small employers through
a qualified association trust |
|
|
|
|
|
|
OTH Policies sold to other types of
entities. Carriers and third-party administrators using this market code
shall obtain prior approval from the NH Insurance Department |
|
|
|
|
|
|
BLC Policies sold and issued as blanket health insurance
Policies to a common carrier |
|
|
|
|
|
|
BLE Policies sold and issued as blanket health insurance
Policies to an employer |
|
|
|
|
|
|
BLV Policies sold and issued as blanket health insurance
Policies to a volunteer fire department, first aid, or other such volunteer
group |
|
|
|
|
|
|
BLS Policies sold and issued as blanket health insurance
Policies to a sports team or a camp |
|
|
|
|
|
|
BLT Policies sold and issued as blanket health insurance
Policies to a travel agency, or other organization that provides
travel-related services |
|
|
|
|
|
|
BLU Policies sold and issued as blanket health insurance
Policies to a university or college |
|
|
|
|
|
|
SLG Policies sold and issued as student major medical expense
large group coverage to enrolled students at an accredited college,
university, or other educational institution |
|
|
|
|
|
|
STS Policies sold and issued as group short term student health
insurance |
|
|
|
|
|
|
SMG Policies sold and issued as student major medical group
health insurance |
|
|
|
|
|
|
SNM Policies sold and issued as student group health insurance
that is not major medical coverage |
|
|
|
|
|
|
SIM Policies sold and issued as student individual major medical
health insurance |
|
|
|
|
|
|
SIN Policies sold and issued as student individual health
insurance that is not major medical coverage |
|
31 |
ME031 |
NH Health Protection Program |
Text |
4 |
For enrollees in the New Hampshire
Health Protection Program (NHHPP), indicate if enrollee is part of the
Premium Assistance Program (PAP) or Health Insurance Premium Payment
(HIPP). Leave blank if enrollee is not
a member of the NHHPP |
|
32 |
ME032 |
Group Name |
Text |
90 |
Name
of the group that the member is covered by.
If the member is part of a group of one or non-group, indicate “I” for
individual. |
|
33 |
ME101 |
Subscriber Last Name |
Text |
60 |
|
|
34 |
ME102 |
Subscriber First Name |
Text |
35 |
|
|
35 |
ME103 |
Subscriber Middle Initial |
Text |
1 |
|
|
36 |
ME104 |
Member Last Name |
Text |
60 |
|
|
37 |
ME105 |
Member First Name |
Text |
35 |
|
|
38 |
ME106 |
Member Middle Initial |
Text |
1 |
|
|
39 |
Placeholder |
||||
|
40 |
ME203 |
Member’s Assigned PCP |
Text |
10U |
National Provider ID of the member’s Primary Care Physician as
designated by healthcare claims processor. |
|
41 |
ME204 |
HIOS
Plan ID |
Text |
16 |
The 16 character HIOS Plan ID (Standard component). Including
a five digit issuer ID, two
character state ID, three digit product
number, four digit standard component number and two digit variant component ID. This field may not be
available for all market segments; |
|
42 |
ME205 |
Plan
Effective Date |
Date |
8 |
For
the plan reported in ME204, report the date eligibility started for this
member under this plan type. The purpose of this data element is to maintain
an eligibility span for each member. |
|
43 |
ME206 |
Minimum Value |
Number |
3 (0) |
For the plan reported in ME204, report the Minimum Value as described in
Part Ins 4008.02(k). This is reported as a
percentage. |
|
44 |
ME207 |
Exchange Indicator |
Text |
1 |
The plan reported in ME204 was available on the Exchange
Marketplace in the month and year reflected in ME004 and ME005 |
|
|
|
|
|
|
Y: Yes |
|
|
|
|
|
|
N: No |
|
|
|
|
|
|
U: Unknown |
|
45 |
ME208 |
High deductible health plan |
Text |
1 |
The plan reported in ME204 meets the IRS definition of a HDHP |
|
|
|
|
|
|
Y: Yes |
|
|
|
|
|
|
N: No |
|
|
|
|
|
|
U: Unknown |
|
46 |
ME209 |
Active enrollment |
Text |
1 |
The plan reported in ME204 was open for enrollment in the year
and month reflected in ME004 and ME005 |
|
|
|
|
|
|
Y: Yes |
|
|
|
|
|
|
N: No |
|
47 |
ME210 |
New Coverage |
Text |
1 |
The plan reported in ME204 was being offered for the first time
in the reporting year reflected in ME004 |
|
|
|
|
|
|
Y: Yes |
|
|
|
|
|
|
N: No |
|
48 |
ME211 |
Placeholder |
|
||
|
49 |
ME899 |
Record
Type |
Text |
2 |
ME |
|
50 |
ME900 |
Plan State |
Text |
2 |
State in which the plan is sold or used. State codes are maintained by the US Postal
Service |
|
51 |
ME901 |
Advanced Premium Tax Credit |
Number |
2(2) |
Dollar value of Advanced Premium Tax Credit (APTC) subsidy |
|
52 |
ME902 |
NAIC Number |
Text |
5 |
Number that the National Association of Insurance Commissioners
(NAIC) assigns to each individual underwriting company. |
|
53 |
ME903 |
Grandfather Plan
indicator |
Text |
1 |
Indicates if a plan
qualifies as a “Grandfathered” or “Transitional Plan” under the Affordable
Care Act (ACA). Please see definition for “grandfathered” and “transitional”
in HHS rules 45-CFR-147.140: https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-147/section-147.140 The values of the
indicator are as follows: 1= Grandfathered; 2 = Non-Grandfathered;
3 =Transitional; 4 = Not Applicable |
|
54 |
ME904 |
Metal Level |
Text |
10 |
The metal representation of the plan reported in ME204 on the
Exchange Marketplace |
Source. #10877, eff 7-10-15; ss by #13136, eff
11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36 (formerly Ins 4010.01)
Ins 4009.02 Member
Claims Data Tables.
(a) Medical
Eligibility File Mapping and Format Information. Use Table 4009.07(b) to determine medical
eligibility file mapping and formatting.
(b) Medical
Claims File Header Record Layout:
|
Table 4009.02(b) Medical Claims File
Header Record Layout |
||||
|
Data Element # |
Element |
Type |
Length (decimal places) |
Description/Codes/Sources |
|
HD001 |
Record Type |
Text |
2 |
HD |
|
HD002 |
Payer |
Text |
8 |
Payer submitting payments. NHID Submitter Code |
|
HD003 |
National Plan ID |
Text |
30 |
CMS National Plan ID |
|
HD004 |
Type of File |
Text |
2 |
MC Medical Claims |
|
HD005 |
Period Beginning Date |
Number |
6 |
Beginning of paid period for claims or beginning of month
covered for eligibility |
|
HD006 |
Period Ending Date |
Number |
6 |
End of paid period for claims or end of month covered for
eligibility |
|
HD007 |
Comments |
Text |
80 |
Submitter may use to document this
submission by assigning a filename, system source, etc. |
(c) Medical
Claims Files Trailer Record Layout:
|
Table 4009.02(c) Medical Claims File
Trailer Record Layout |
||||
|
Data Element # |
Element |
Type |
Length (decimal places) |
Description/Codes/Sources |
|
TR001 |
Record Type |
Text |
2 |
TR |
|
TR002 |
Payer |
Text |
8 |
Payer submitting payments. NHID Submitter Code |
|
TR003 |
National Plan ID |
Text |
30 |
CMS National Plan ID |
|
TR004 |
Type of File |
Text |
2 |
MC Medical Claims |
|
TR005 |
Period Beginning Date |
Number |
6 |
Beginning of paid period for claims or beginning of month
covered for eligibility |
|
TR006 |
Period
Ending Date |
Number |
6 |
End
of paid period for claims or beginning of month covered for eligibility |
|
TR007 |
Extraction
Date |
Date |
8 |
Date
file was created |
|
TR008 |
Record Count |
Number |
10 (0) |
Total number of records submitted in this file |
(d) Medical
Claims File Detailed Specifications:
|
Table 4009.02(d) Medical Claims File
Detailed Specifications |
||||
|
Data Element # |
Element |
Type |
Length (decimal places) |
Description/Codes/Sources |
|
MC001 |
Payer |
Text |
8 |
Payer submitting payments NHID Submitter Code |
|
MC002 |
National Plan ID |
Text |
30 |
CMS National Plan ID |
|
MC003 |
Insurance Type/Product
Code |
Text |
2 |
Table 4009.6(a) Insurance
Type/Product Code |
|
MC004 |
Payer Claim Control Number |
Text |
35 |
Shall apply to the entire claim and be unique within the payer's
system |
|
MC005 |
Line Counter |
Text |
4 |
Line number for this service. The line counter begins with 1 and
is incremented by 1 for each additional service line of a claim |
|
MC005A |
Version Number |
Number |
4 (0) |
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. There
shall be only one version number per claim line. The most recent version of
the claim shall have the highest version number. |
|
MC006 |
Insured Group or Policy Number |
Text |
50 |
Group or policy number (not the number that uniquely identifies
the subscriber) |
|
MC007 |
Placeholder |
|
|
|
|
MC008 |
Plan Specific Contract
Number |
Text |
50 |
Plan assigned contract
number. Leave blank if Plan Specific Contract If this is a Medicaid
claim, provide Medicaid ID. Shall match the ID in
ME009, PC008, and DC008 |
|
MC009 |
Member Suffix or
Sequence Number |
Text |
20 |
Unique number of the member. This column is the
unique identifying column for membership and related medical, pharmacy, and
dental claims. Only 1 record per insurance product type, per eligibility
month. Shall match ME010, PC009 and DC009. |
|
MC010 |
Placeholder |
|
|
|
|
MC011 |
Individual Relationship Code |
Text |
2 |
See
Table 4009.06(b) Relationship Codes |
|
MC012 |
Member Gender |
Text |
1 |
M Male |
|
|
|
|
|
F Female |
|
|
|
|
|
U Unknown |
|
|
|
|
|
O Other |
|
MC013 |
Member Date of Birth |
Date |
8 |
Date of birth of member |
|
MC014 |
Member City Name |
Text |
30 |
City name of member |
|
MC015 |
Member State or Province |
Text |
2 |
As defined by the US Postal Service |
|
MC016 |
Member ZIP Code |
Text |
9 |
ZIP Code of member – may include non- US codes. Do not include
dash. |
|
MC017 |
Paid Date (AP Date) |
Date |
8 |
Date the claim
was adjudicated for reversals and denials Date the
provider was paid via EFT or date the paper check was mailed for paid claims. |
|
MC018 |
Admission Date |
Date |
8 |
Required for all inpatient claims. |
|
MC019 |
Admission Hour |
Text |
2 (0) |
Required for all inpatient claims. Time is expressed in military
time – HH |
|
MC020 |
Admission Type |
Text |
1 |
Required for all inpatient claims (SOURCE: National Uniform
Billing Data Element Specifications): |
|
|
|
|
|
1 = Emergency |
|
|
|
|
|
2 = Urgent |
|
|
|
|
|
3 = Elective |
|
|
|
|
|
4 = Newborn |
|
|
|
|
|
5 = Trauma Center |
|
|
|
|
|
9 = Information not available |
|
MC021 |
Admission Source |
Text |
1 |
See Table 4009.06(h) Point of Origin Codes |
|
MC022 |
Discharge Hour |
Text |
2 (0) |
Required for all inpatient claims. Time is expressed in military
time – HH |
|
MC023 |
Discharge Status |
Text |
2 |
See Table 4009.06(c): Discharge Status |
|
MC024 |
Service Provider Number |
Text |
30 |
Payer assigned servicing provider number by the payer for
internal identification purposes |
|
MC025 |
Service Provider Tax ID Number |
Text |
10 |
Federal taxpayer’s identification number – if the tax id is a
provider’s social security number, use ‘SSN’ and ‘NA’ if unavailable |
|
MC026 |
National Service Provider ID |
Text |
10 |
Provider NPI. |
|
MC027 |
Service Provider Entity Type Qualifier |
Text |
1 |
HIPAA provider taxonomy classifies provider groups (clinicians
who bill as a group practice or under a corporate name, even if that group is
composed of one provider) as “Person”. |
|
|
|
|
|
1 Person |
|
|
|
|
|
2 Non-Person Entity |
|
MC028 |
Service Provider First Name |
Text |
35 |
Individual first name. Leave blank if provider is a facility or
organization |
|
MC029 |
Service Provider Middle Name |
Text |
25 |
Individual middle name or initial. Leave blank if provider is a
facility or organization |
|
MC030 |
Servicing Provider Last Name or Organization Name |
Text |
60 |
Report the name of the organization or last name of the individual
provider. MC027 determines if this is an organization or Individual Name
reported here. |
|
MC031 |
Service Provider Suffix |
Text |
10 |
Suffix to individual name. Leave blank if provider is a facility
or organization. Should be used to capture the generation of the individual
clinician (e.g., Jr. Sr., III), if applicable, rather than the clinician’s
degree [e.g., ‘MD’, ‘LICSW’]. |
|
MC032 |
Service Provider Specialty |
Text |
10 |
National Uniform Claims Committee (NUCC) standard code that
defines this provider for this line of service. Taxonomy values allow for the reporting of
nurses, assistants and laboratory technicians, where applicable, as well as
Physicians, Medical Groups, Facilities, etc. |
|
MC033 |
Service Provider City Name |
Text |
30 |
City name of rendering provider - practice location |
|
MC034 |
Service Provider State |
Text |
2 |
As defined by the US Postal Service |
|
MC035 |
Service Provider ZIP Code |
Text |
9 |
ZIP Code of provider - may include non-US codes. |
|
MC036 |
Type of Bill – Institutional |
Text |
3 |
For facility claims only submitted using UB04 forms Type of Facility - First Digit |
|
|
|
|
|
1 Hospital |
|
|
|
|
|
2 Skilled Nursing |
|
|
|
|
|
3 Home Health |
|
|
|
|
|
4 Christian Science Hospital |
|
|
|
|
|
5 Christian Science Extended Care |
|
|
|
|
|
6 Intermediate Care |
|
|
|
|
|
7 Clinic |
|
|
|
|
|
8 Special Facility |
|
|
|
|
|
Bill Classification - Second Digit if First Digit = 1-6 |
|
|
|
|
|
1 Inpatient (Including Medicare Part A) |
|
|
|
|
|
2 Inpatient (Medicare Part B Only) |
|
|
|
|
|
3 Outpatient |
|
|
|
|
|
4 Other (for hospital referenced diagnostic services |
|
|
|
|
|
or home health not under a plan of treatment) |
|
|
|
|
|
5 Nursing Facility Level I |
|
|
|
|
|
6 Nursing Facility Level II |
|
|
|
|
|
7 Intermediate Care - Level III Nursing Facility |
|
|
|
|
|
8 Swing Beds |
|
|
|
|
|
Bill Classification - Second Digit if First Digit = 7 |
|
|
|
|
|
1 Rural Health |
|
|
|
|
|
2 Hospital Based or Independent Renal Dialysis Center |
|
|
|
|
|
3 Free Standing Outpatient Rehabilitation Facility (ORF) |
|
|
|
|
|
5 Comprehensive Outpatient Rehabilitation Facility (ORF) |
|
|
|
|
|
6 Community Mental Health Center |
|
|
|
|
|
9 Other |
|
|
|
|
|
Bill Classification – Second Digit if First Digit = 8 |
|
|
|
|
|
1 Hospice (Non Hospital Based) |
|
|
|
|
|
2 Hospice (Hospital-Based) |
|
|
|
|
|
3 Ambulatory Surgery Center |
|
|
|
|
|
4 Free Standing Birthing Center |
|
|
|
|
|
9 Other |
|
|
|
|
|
Frequency – Third Digit |
|
|
|
|
|
0 Non-Payment/Zero |
|
|
|
|
|
1 Admit Through Discharge |
|
|
|
|
|
2 Interim – First Claim |
|
|
|
|
|
3 Interim - Continuing Claims |
|
|
|
|
|
4 – Interim – Last Claim |
|
|
|
|
|
5 – Late Charge Only |
|
|
|
|
|
7 – Replacement of Prior Claim |
|
|
|
|
|
8 – Void/Cancel of a Prior Claim |
|
|
|
|
|
9 – Final Claim for a Home Health PPS Episode |
|
MC037 |
Place
of Service – Professional |
Text |
2 |
For professional claims only, such as those submitted using
CMS1500 forms See
Table 4009.06(f) Place of Service -- Professional |
|
MC038 |
Service Line Status |
Text |
2 |
Describes the payment status of the specific service line record |
|
|
|
|
|
01 Processed as primary |
|
|
|
|
|
02 Processed as secondary |
|
|
|
|
|
03 Processed as tertiary |
|
|
|
|
|
04 Denied |
|
|
|
|
|
06 Approved as amended |
|
|
|
|
|
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 |
|
|
|
|
|
26 Documentation Claim – No Payment Associated |
|
|
|
|
|
28 Repriced |
|
MC039 |
Admitting Diagnosis |
Text |
7 |
ICD-CM Diagnosis Codes.
Required on all inpatient admission claims and encounters. Do not include decimals. |
|
MC040 |
E-Code |
Text |
7 |
ICD-CM Diagnosis Codes.
Describes an injury, poisoning or adverse effect ICD-CM. |
|
MC041 |
Principal Diagnosis |
Text |
7 |
ICD-CM Diagnosis Codes.
Principal Diagnosis should be the principal diagnosis given on the
claim header. Do not include decimals. |
|
MC042 |
Other Diagnosis -1 |
Text |
7 |
ICD-CM Diagnosis Codes.
Do not include decimals. |
|
MC043 |
Other Diagnosis -2 |
Text |
7 |
ICD-CM Diagnosis Codes.
Do not include decimals. |
|
MC044 |
Other Diagnosis -3 |
Text |
7 |
ICD-CM Diagnosis Codes.
Do not include decimals. |
|
MC045 |
Other Diagnosis -4 |
Text |
7 |
ICD-CM Diagnosis Codes.
Do not include decimals. |
|
MC046 |
Other Diagnosis -5 |
Text |
7 |
ICD-CM Diagnosis Codes.
Do not include decimals. |
|
MC047 |
Other Diagnosis -6 |
Text |
7 |
ICD-CM Diagnosis Codes.
Do not include decimals. |
|
MC048 |
Other Diagnosis -7 |
Text |
7 |
ICD-CM Diagnosis Codes.
Do not include decimals. |
|
MC049 |
Other Diagnosis -8 |
Text |
7 |
ICD-CM Diagnosis Codes.
Do not include decimals. |
|
MC050 |
Other Diagnosis -9 |
Text |
7 |
ICD-CM Diagnosis Codes.
Do not include decimals. |
|
MC051 |
Other Diagnosis -10 |
Text |
7 |
ICD-CM Diagnosis Codes.
Do not include decimals. |
|
MC052 |
Other Diagnosis -11 |
Text |
7 |
ICD-CM Diagnosis Codes.
Do not include decimals. |
|
MC053 |
Other Diagnosis -12 |
Text |
7 |
ICD-CM Diagnosis Codes.
Do not include decimals. |
|
MC054 |
Revenue Code |
Text |
4 |
National Uniform Billing Committee Codes. Code using leading
zeroes, left-justified, and four digits. |
|
MC055 |
Procedure Code |
Text |
5 |
Health Care Common Procedural Coding System (HCPCS). This
includes the CPT codes of the American Medical Association |
|
MC056 |
Procedure Modifier – 1 |
Text |
2 |
Procedure modifier required when a modifier clarifies/improves
the reporting accuracy of the associated procedure code |
|
MC057 |
Procedure Modifier – 2 |
Text |
2 |
Procedure modifier required when a modifier clarifies/improves
the reporting accuracy of the associated procedure code |
|
MC058 |
ICD-9/10-CM Procedure Code |
Text |
7 |
Primary ICD-9/10-CM code given on the claim header. |
|
MC059 |
Date of Service – From |
Date |
8 |
First date of service for this service line. |
|
MC060 |
Date of Service – Thru |
Date |
8 |
Last date of service for this service line |
|
MC061 |
Quantity |
Number |
12 (0) |
Count of services performed. |
|
MC062 |
Charge Amount |
Number |
10 (2) |
The
full, undiscounted total and service-specific charges billed by the provider.
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 |
|
MC063 |
Paid Amount |
Number |
10 (2) |
Includes any withhold amounts. 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 |
|
MC064 |
Fee for Service Equivalent |
Number |
10 (2) |
For capitated services, the fee for service equivalent amount. |
|
MC065 |
Copay Amount |
Number |
10 (2) |
The preset, fixed dollar amount for which the individual is
responsible. 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 |
|
MC066 |
Coinsurance Amount |
Number |
10 (2) |
Coinsurance, dollar 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 |
|
MC067 |
Deductible Amount |
Number |
10 (2) |
Amount in dollars met by the patient/family
in a deductible plan. 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 |
|
MC068 |
Patient Account/Control Number |
Text |
20 |
|
|
MC069 |
Discharge Date |
Date |
8 |
Required for all inpatient(s) |
|
MC070 |
Service Provider Country Name |
Text |
30 |
|
|
MC071 |
DRG |
Text |
7 |
Carriers, pharmacy benefit managers, and
third-party administrators shall code using the CMS methodology when
available. Precedence shall be given to DRGs transmitted from the hospital
provider. When the CMS methodology for DRGs is not available, but the All Payer DRG system is available, then that system shall
be used. If the All Payer DRG system is used, the
carrier shall format the DRG and the complexity level within the same field
with an "A" prefix, and with a hyphen separating the DRG and the
complexity level (e.g. AXXX-XX) |
|
MC072 |
DRG Version |
Text |
2 |
This element is the version number of the grouper used. |
|
MC073 |
APC |
Text |
4 |
Carriers, pharmacy benefit managers, and
third-party administrators shall code using CMS methodology. Precedence shall
be given to APCs transmitted from the health care provider |
|
MC074 |
APC Version |
Text |
2 |
This element is the version number of the grouper used |
|
MC075 |
Drug Code |
Text |
11 |
NDC Code Used only
when a medication is paid for as part of a medical claim. The
NDC shall be the 11 digit code with no dashes. The
NDC shall be reported when a HCPCS J code (MC055) is reported for hospital
administered drugs. |
|
MC076 |
Billing Provider Number |
Text |
30 |
Payer assigned billing provider number. This number should be
the identifier used by the payer for internal identification purposes and
does not routinely change |
|
MC077 |
National Billing Provider Number ID |
Text |
10 |
This is the NPI for the billing provider |
|
MC078 |
Billing Provider Organization or Last Name |
Text |
60 |
|
|
MC101 |
Subscriber Last Name |
Text |
60 |
|
|
MC102 |
Subscriber First Name |
Text |
35 |
|
|
MC103 |
Subscriber Middle Initial |
Text |
1 |
|
|
MC104 |
Member Last Name |
Text |
60 |
|
|
MC105 |
Member First Name |
Text |
35 |
|
|
MC106 |
Member Middle Initial |
Text |
1 |
|
|
MC200 |
ICD Indicator |
Text |
1 |
Report the value that defines whether the diagnoses on claim are
ICD9 or ICD10. |
|
|
|
|
|
0 ICD-9 |
|
|
|
|
|
1 ICD-10 |
|
MC202 |
Other ICD-CM Procedure Code - 2 |
Text |
7 |
ICD Secondary Procedure Code |
|
MC203 |
Other ICD-CM Procedure Code - 3 |
Text |
7 |
ICD Secondary Procedure Code |
|
MC204 |
Other ICD-CM Procedure Code - 4 |
Text |
7 |
ICD Secondary Procedure Code |
|
MC205 |
Other ICD-CM Procedure Code - 5 |
Text |
7 |
ICD Secondary Procedure Code |
|
MC206 |
Other ICD-CM Procedure Code - 6 |
Text |
7 |
ICD Secondary Procedure Code |
|
MC207 |
Carrier Identifier |
Text |
20 |
If you are a
TPA that processes claims and are submitting
files on behalf of a carrier, indicate the carrier
name here. Shall use the full legal name of company, no
acronyms. Else, leave blank. |
|
MC208 |
Carrier Plan Specific Contract Number |
Text |
128 |
When a TPA processes claims on behalf
of the carrier, for each claim, report the carrier
specific contract number. Optional if all medical claims processed by a TPA
under contract to a carrier for carved-out services are submitted by the
carrier with unified member IDs in all files. |
|
MC209 |
Practitioner
Group Practice |
Text |
60 |
Name
of group practice to which a practitioner is affiliated if different from
MC078 |
|
MC210 |
Coordination
of Benefits/Third Party Liability Amount |
Number |
10
(2) |
Coordination
of Benefits (COB)/Third Party Liability (TPL) is the dollar amount paid from
a prior payer (e.g. auto claim, workers comp, dual medical coverage). 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 |
|
MC211 |
Cross Reference Claims ID |
Text |
35 |
The original Payer Claim Control Number (MC004). Used when a new
Payer Claim Control Number is assigned to an adjusted claim and a Version
Number (MC005A) is not used. |
|
MC212 |
Allowed Amount |
Number |
10 (2) |
Report the maximum dollar 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. 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 |
|
MC215 |
Service Line Type |
Text |
1 |
Report the code that defines the claim line status in terms of
adjudication |
|
|
|
|
|
O Original |
|
|
|
|
|
V Void |
|
|
|
|
|
R Replacement |
|
|
|
|
|
B Back Out |
|
|
|
|
|
A Amendment |
|
MC216 |
Payment Arrangement Type |
Text |
1 |
Defines the contracted payment methodology for this claim line |
|
|
|
|
|
1 Capitation |
|
|
|
|
|
2 Fee for service |
|
|
|
|
|
3 Percent of charges |
|
|
|
|
|
4 DRG |
|
|
|
|
|
5 Pay for Performance |
|
|
|
|
|
6 Global Payment |
|
|
|
|
|
7 Other |
|
|
|
|
|
8 Bundled payment |
|
MC217 |
Pay
for Performance Flag |
Text |
1 |
Does
this provider have pay-for-performance bonuses or year-end withhold returns
based on performance for at least one service performed by this provider
within the month? Required
when MP005 = 1, 2, or 3 |
|
|
|
|
|
Y: Yes |
|
|
|
|
|
N: No |
|
MC218 |
Claim Processing Level Indicator |
Text |
1 |
1 Claim Level |
|
|
|
|
|
2 Service Line level |
|
MC219 |
Denied Claim Indicator |
Text |
1 |
1 Fully Paid – the entire claim was paid at the allowed amount |
|
|
|
|
|
2 Partially denied – some of the claims
lines were paid at the allowed amount |
|
|
|
|
|
3 Encounter claim – this claim records a service provided that
is paid under a non Fee
For Service (FFS) payment arrangement such as capitation |
|
|
|
|
|
4 No payment – no payment made for reasons other than non FFS payment arrangement |
|
MC220 |
Denial Reason |
Text |
4 |
Denial reason code.
Required when Service Line Status (MC038) = 2 or 4. The
denial reason code must correspond with federal CARC/RARC codes. See Ins 4008.04 |
|
MC221 |
Procedure Modifier – 3 |
Text |
2 |
Procedure modifier required when a modifier clarifies/improves
the reporting accuracy of the associated procedure code |
|
MC222 |
Procedure Modifier – 4 |
Text |
2 |
Procedure modifier required when a modifier clarifies/improves
the reporting accuracy of the associated procedure code |
|
MC223 |
HIOS Plan ID |
Text |
16 |
The 16 character HIOS Plan ID (Standard
component), including a 5 digit issuer ID, 2 character state ID, 3 digit
product number, 4 digit standard component number,
and 2 digit variant component ID. This field may not be available for all
market segments. Leave blank if not
available |
|
MC899 |
Record Type |
Text |
2 |
MC |
|
MC900 |
In Network Indicator |
Text |
1 |
A yes/no indicator that specifies that the provider (not the
benefit) is within the health plan network.
Valid codes: Y=Yes, N=No |
|
MC901 |
Unit of Measure |
Text |
2 |
Type of units reported in MC061.
Codes accepted DA=days, MN=minutes,
UN=units. If MC061 is not reported,
MC901=NA |
|
MC902 |
Claim Source |
Text |
1 |
What form the claim was received
in: E: Electronic P: Paper |
|
MC903 |
Claim Received Date |
Date |
8 |
Date that the claim was received
from the provider and it shall be in CCYYMMDD format. |
|
MC904 |
Insurance Group Name |
Text |
30 |
Name of the Insurance Group whose
Insured Group or Policy Number was listed in MC006. The name shall match
ME032 |
|
MC905 |
Prior Authorization |
Text |
1 |
If that claim required a prior authorization Y: Yes N: No |
|
MC906 |
TPA Identifier |
Text |
20 |
If you are a carrier whose claims
were processed by a TPA and you are submitting the files, please indicate the
TPA here. The full legal name of company, no acronyms shall be used. Else,
leave blank. |
Source. #10877, eff 7-10-15; ss by #13136, eff
11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36 (formerly Ins 4010.02)
Ins
4009.03 Pharmacy Claims Data
Tables.
(a) Pharmacy Claims Mapping and Format Information. Use Table 4009.07(c) to determine pharmacy
claims file mapping and formatting.
(b) Pharmacy Claims File Header Record Layout:
|
Table 4009.03(b) Pharmacy Claims File Header Record
Layout |
||||
|
Data Element # |
Element |
Type |
Length (decimal places) |
Description/Codes/Sources |
|
HD001 |
Record Type |
Text |
2 |
HD |
|
HD002 |
Payer |
Text |
8 |
Payer submitting
payments. NHID Submitter Code |
|
HD003 |
National Plan ID |
Text |
30 |
CMS National Plan ID |
|
HD004 |
Type of File |
Text |
2 |
PC Pharmacy Claims |
|
HD005 |
Period Beginning Date |
Number |
6 |
Beginning of paid
period for claims or beginning of month covered for eligibility |
|
HD006 |
Period Ending Date |
Number |
6 |
End of paid period for
claims or end of month covered for eligibility |
|
HD007 |
Comments |
Text |
80 |
Submitter may use to document this submission by assigning a filename,
system source, etc. |
(c) Pharmacy Claims File Trailer Record Layout:
|
Table 4009.03(c) Pharmacy Claims File Trailer
Record Layout |
||||
|
Data
Element # |
Element |
Type |
Length
(decimal places) |
Description/Codes/Sources |
|
TR001 |
Record Type |
Text |
2 |
TR |
|
TR002 |
Payer |
Text |
8 |
Payer submitting
payments. NHID Submitter Code |
|
TR003 |
National Plan ID |
Text |
30 |
CMS National Plan ID |
|
TR004 |
Type of File |
Text |
2 |
PC Pharmacy Claims |
|
TR005 |
Period Beginning Date |
Number |
6 |
Beginning of paid
period for claims or beginning of month covered for eligibility |
|
TR006 |
Period Ending Date |
Number |
6 |
End of paid period for claims or
beginning of month covered for eligibility |
|
TR007 |
Extraction Date |
Date |
8 |
Date file was created |
|
TR008 |
Record Count |
Number |
10 (0) |
Total number of
records submitted in this file |
(d) Pharmacy Claims Detailed File Specifications:
|
Table 4009.03(d) Pharmacy Claims Detailed File
Specification |
||||
|
Data
Element # |
Element |
Type |
Length
(decimal places) |
Description/Codes/Sources |
|
PC001 |
Payer |
Text |
8 |
Payer submitting
payments NHID Submitter Code |
|
PC002 |
Plan ID |
Text |
30 |
CMS National Plan ID |
|
PC003 |
Insurance Type/Product
Code |
Text |
2 |
Table 4009.6 (a)
Insurance Type/Product Code |
|
PC004 |
Payer Claim Control
Number |
Text |
35 |
Shall apply to the
entire claim and be unique within the payer's system |
|
PC005 |
Line Counter |
Text |
4 |
Line number for this
service The line counter begins with 1 and is incremented by 1 for each
additional service line of a claim |
|
PC006 |
Insured Group Number |
Text |
50 |
Group or policy number
(not the number that uniquely identifies the subscriber) |
|
PC007 |
Placeholder |
|
|
|
|
PC008 |
Plan Specific Contract
Number |
Text |
50 |
Plan assigned contract
number. If this is a Medicaid
claim, provide Medicaid ID. Shall match the ID in
ME009, MC008, and DC008 |
|
PC009 |
Member Suffix or
Sequence Number |
Text |
20 |
Unique number of the member. This column is the
unique identifying column for membership and related medical, pharmacy, and
dental claims. Only 1 record per insurance product type, per eligibility
month. Shall match ME010, MC009 and DC009. |
|
PC010 |
Placeholder |
|
|
|
|
PC011 |
Individual
Relationship Code |
Text |
2 |
See Table 4009.06(b)
Relationship Codes |
|
PC012 |
Member Gender |
Text |
1 |
M: Male |
|
|
|
|
|
F: Female |
|
|
|
|
|
U: Unknown |
|
|
|
|
|
O: Other |
|
PC013 |
Member Date of Birth |
Date |
8 |
Date of birth of
member |
|
PC014 |
Member City Name of
Residence |
Text |
30 |
City name of member |
|
PC015 |
Member State |
Text |
2 |
As defined by the US
Postal Service |
|
PC016 |
Member ZIP Code |
Text |
9 |
ZIP Code of member –
may include non- US codes. Do not include dash. |
|
PC017 |
Paid Date (AP Date) |
Date |
8 |
Paid date or the
Pharmacy Benefits Manager’s billing date |
|
PC018 |
Pharmacy Number |
Text |
30 |
Payer assigned
pharmacy number. AHFS number is acceptable |
|
PC019 |
Pharmacy Tax ID Number |
Text |
10 |
Federal taxpayer's
identification number (Please provide the pharmacy chain’s federal tax
identification number, if the individual retail pharmacy’s tax ID# is not
available.) |
|
PC020 |
Pharmacy Name |
Text |
30 |
Name of pharmacy |
|
PC021 |
National Pharmacy ID
Number |
Text |
10 |
Required if National
Provider ID is mandated for use under HIPAA |
|
PC022 |
Pharmacy Location City |
Text |
30 |
City name of pharmacy |
|
PC023 |
Pharmacy Location
State |
Text |
2 |
As defined by the US
Postal Service |
|
PC024 |
Pharmacy ZIP Code |
Text |
9 |
ZIP Code of pharmacy -
may include non- US codes. Do not include dash |
|
PC024A |
Pharmacy Country Name |
Text |
30 |
Code US |
|
PC025 |
Service Line Status |
Text |
2 |
See Table
4009.06(g)
Claim Status |
|
PC026 |
Drug Code |
Text |
11 |
NDC Code in CMS
configuration with leading zeros and no hyphens. |
|
PC027 |
Drug Name |
Text |
80 |
Text name of drug |
|
PC028 |
New Prescription |
Number |
2 (0) |
00 New prescription.
01-99 Number of refill(s) |
|
PC029 |
Generic Drug Indicator |
Text |
2 |
01 No, branded drug |
|
|
|
|
|
02 Yes, generic drug |
|
PC030 |
Dispense as Written
Code |
Text |
1 |
0 Not dispensed as
written |
|
|
|
|
|
1 Physician dispense
as written |
|
|
|
|
|
2 Member dispense as
written |
|
|
|
|
|
3 Pharmacy dispense as
written |
|
|
|
|
|
4 No generic available |
|
|
|
|
|
5 Brand dispensed as
generic |
|
|
|
|
|
6 Override |
|
|
|
|
|
7 Substitution not
allowed - brand drug mandated by law |
|
|
|
|
|
8 Substitution allowed
- generic drug not available in marketplace |
|
|
|
|
|
9 Other |
|
PC031 |
Compound Drug
Indicator |
Text |
1 |
N Non-compound drug |
|
|
|
|
|
Y Compound drug |
|
|
|
|
|
U Non-specified drug
compound |
|
PC032 |
Date Prescription
Filled |
Date |
8 |
|
|
PC033 |
Quantity Dispensed |
Number |
10 |
Number of metric units
of medication dispensed |
|
PC034 |
Days’ Supply |
Number |
4 |
Estimated number of
days the prescription will last |
|
PC035 |
Charge Amount |
Number |
10 (2) |
The full, undiscounted total and
service-specific charges billed by the provider. 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 |
|
PC036 |
Paid Amount |
Number |
10 (2) |
Includes any withhold
amounts. 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 |
|
PC037 |
Ingredient Cost/List
Price |
Number |
10 (2) |
Cost of the drug
dispensed. Do not code decimal point 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 |
|
PC038 |
Postage Amount Claimed |
Number |
10 (2) |
Postage amount in
dollars. 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 |
|
PC039 |
Dispensing Fee |
Number |
10 (2) |
Dispensing fees in
dollars. 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 |
|
PC040 |
Copay Amount |
Number |
10 (2) |
The preset, fixed
dollar amount for which the individual is responsible. 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 |
|
PC041 |
Coinsurance Amount |
Number |
10 (2) |
Coinsurance amount in
dollars. 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 |
|
PC042 |
Deductible Amount |
Number |
10 (2) |
Deductible amount in
dollars. 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 |
|
PC043 |
Prescription Number |
Text |
20 |
The number generated
by the pharmacy when a new prescription is ordered for a person - a unique
code assigned to a person’s prescribed medicine |
|
PC044 |
Prescribing Physician
First Name |
Text |
35 |
Physician first name |
|
PC045 |
Prescribing Physician
Middle Name |
Text |
25 |
Physician middle name |
|
PC046 |
Prescribing Physician
Last Name |
Text |
60 |
Physician last name |
|
PC047 |
Prescribing Physician
Number |
Text |
10 |
Provider NPI |
|
PC101 |
Subscriber Last Name |
Text |
60 |
|
|
PC102 |
Subscriber First Name |
Text |
35 |
|
|
PC103 |
Subscriber Middle
Initial |
Text |
1 |
|
|
PC104 |
Member Last Name |
Text |
60 |
|
|
PC105 |
Member First Name |
Text |
35 |
|
|
PC106 |
Member Middle Initial |
Text |
1 |
|
|
PC203 |
Carrier Identifier |
Text |
20 |
If you are a
PBM that processes claims and are submitting
files on behalf of a carrier, indicate the carrier
name here. The full legal name of the company, no acronyms shall
be used. Else, leave blank. |
|
PC204 |
Carrier Plan Specific
Contract Number |
Text |
128 |
For each claim, the
carrier specific contract number when a PBM processes
claims on behalf of the carrier. Optional if all pharmacy claims processed by
a PBM under contract to a carrier for carved-out services are submitted by
the carrier with unified member IDs in all files. |
|
PC211 |
Cross Reference Claims ID |
Text |
35 |
The original Payer Claim Control
Number (PC004). Used when a new Payer Claim Control Number is assigned to an
adjusted claim. |
|
PC212 |
Allowed amount |
Number |
10 (2) |
Report
the maximum amount contractually allowed 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. |
|
PC213 |
HIOS Plan ID |
Text |
16 |
The 16
character HIOS Plan ID (Standard component). Including a five digit issuer ID, two character
state ID, three digit product number, four digit standard component number and two digit variant component ID. This field may not be
available for all market segments; Leave blank if not available |
|
PC214 |
Claim Processing Level
Indicator |
Text |
1 |
1 Claim Level |
|
|
|
|
|
2 Service Line level |
|
PC215 |
Service Line Type |
Text |
1 |
Report the code that defines
the claim line status in terms of adjudication |
|
|
|
|
|
O Original |
|
|
|
|
|
V Void |
|
|
|
|
|
R Replacement |
|
|
|
|
|
B Back Out |
|
|
|
|
|
A Amendment |
|
PC216 |
Denied Claim Indicator |
Text |
1 |
1 Fully Paid – the
entire claim was paid at the allowed amount |
|
|
|
|
|
2 Partially denied –
some of the claims lines were paid at the allowed
amount |
|
|
|
|
|
3 Encounter claim –
this claim records a service provided that is paid under a non
FFS payment arrangement such as capitation |
|
|
|
|
|
4 No payment – no
payment made for reasons other than non FFS payment
arrangement |
|
PC217 |
Denial Reason |
Text |
4 |
Denial reason code.
Required when Service Line Status (PC025) = 2 or
4 NCPDP denial reason codes and CARC/RARC code list. See Ins 4008.04 |
|
PC899 |
Record Type |
Text |
2 |
PC |
|
PC900 |
Mail Order Pharmacy
Indicator |
Text |
1 |
A yes/no indicator
that specifies that the pharmacy is a mail order pharmacy. Valid codes: Y=Yes, N=No |
|
PC901 |
In Network Indicator |
Text |
1 |
A yes/no indicator
that specifies that the provider (not the benefit) is within the health plan
network. Valid codes: Y=Yes, N=No |
|
PC902 |
Version Number |
Number |
4(0) |
Version number of this
claim. The version number begins with
0 and is incremented by 1 for each subsequent version of that service line |
|
PC903 |
Claim Source |
Text |
1 |
What form the claim is being
processed as: E: Electronic P: Paper |
|
PC904 |
Claim Received Date |
Date |
8 |
Date that the claim was received
from the provider. The date shall be in CCYYMMDD format. |
|
PC905 |
Insurance Group Name |
Text |
30 |
Name of the Insurance Group whose
Insured Group or Policy Number was listed in PC006. The name shall match
ME032 |
|
PC906 |
Coordination of Benefits/Third
Party Liability Amount |
Number |
2(10) |
Coordination of Benefits
(COB)/Third Party Liability (TPL) is the dollar amount paid from a prior
payer (e.g. auto claim, workers comp, dual medical coverage). 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 |
|
PC907 |
PBM Identifier |
Text |
20 |
If you are a carrier whose
claims were processed by a PBM and you are submitting the files, please
indicate the PBM here. The full legal name of the company, no acronyms shall
be used. Else, leave blank |
|
PC908 |
Prior Authorization |
Text |
1 |
If that claim required a prior authorization Y: Yes N: No |
|
PC909 |
Drug Unit of Measure |
Text |
3 |
Report the code that defines the
unit of measure for the drug dispensed in PC034. Valid codes are: EA=Each; F2=International Units; GM=Grams; ML=Milliliters; MG=Milligrams; MEQ=Milliequivalent; MM=Millimeter; UG=Microgram; UU=Unit; OT=Other |
Source. #10877, eff 7-10-15; ss by #13136, eff
11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36 (formerly Ins 4010.03)
Ins 4009.04 Dental Claims Data Tables.
(a) Dental Claims Mapping and Format
Information. Use Table 4009.07(d) to
determine dental claims file mapping and formatting.
(b) Dental Claims File Header Record Layout:
|
Table
4009.04(b) Dental Claims Header File Record Layout |
||||
|
Data
Element # |
Element |
Type |
Length
(decimal places) |
Description/Codes/Sources |
|
HD001 |
Record Type |
Text |
2 |
HD |
|
HD002 |
Payer |
Text |
8 |
Payer submitting
payments. NHID Submitter Code |
|
HD003 |
National Plan ID |
Text |
30 |
CMS National Plan ID |
|
HD004 |
Type of File |
Text |
2 |
DC Dental Claims |
|
HD005 |
Period Beginning Date |
Number |
6 |
Beginning of paid
period for claims or beginning of month covered for eligibility |
|
HD006 |
Period Ending Date |
Number |
6 |
End of paid period
for claims or end of month covered for eligibility |
|
HD007 |
Comments |
Text |
80 |
Submitter may use to document this submission by assigning a filename,
system source, etc. |
(c) Dental Claims File Trailer Record Layout:
|
Table
4009.04(c) Dental Claims Trailer File Record Layout |
||||
|
Data
Element # |
Element |
Type |
Length
(decimal places) |
Description/Codes/Sources |
|
TR001 |
Record Type |
Text |
2 |
TR |
|
TR002 |
Payer |
Text |
8 |
Payer submitting
payments. NHID Submitter Code |
|
TR003 |
National Plan ID |
Text |
30 |
CMS National Plan ID |
|
TR004 |
Type of File |
Text |
2 |
DC Dental Claims |
|
TR005 |
Period Beginning Date |
Number |
6 |
Beginning of paid
period for claims or beginning of month covered for eligibility |
|
TR006 |
Period Ending Date |
Number |
6 |
End of paid period for claims or
beginning of month covered for eligibility |
|
TR007 |
Extraction Date |
Date |
8 |
Date file was created |
|
TR008 |
Record Count |
Number |
10 (0) |
Total number of
records submitted in this file |
(d) Dental Claims Detailed File Specifications:
|
Table
4009.04(d) Dental Claims Detailed File Specifications |
||||
|
Data
Element # |
Element |
Type |
Length
(decimal places) |
Description/Codes/Sources |
|
DC001 |
Payer |
Text |
8 |
Payer submitting
payments |
|
DC002 |
National Plan ID |
Text |
30 |
CMS National Plan ID |
|
DC003 |
Insurance Type/Product Code |
Text |
2 |
Table
4009.6(a) Insurance Type/Product Code |
|
DC004 |
Payer Claim Control
Number |
Text |
35 |
Shall apply to entire
claim and be unique within payer's system |
|
DC005 |
Line Counter |
Number |
4 |
Line number for this
service. The line counter begins with 1 and is incremented by 1 for each
additional service line of a claim |
|
DC006 |
Insured Group or
Policy Number |
Text |
50 |
Group or policy
number (not the number that uniquely identifies the subscriber) |
|
DC007 |
Placeholder |
|
|
|
|
DC008 |
Plan Specific Contract Number |
Text |
50 |
Plan assigned contract number. Leave blank if Plan Specific
Contract Number is subscriber’s social security number. If this is a Medicaid claim, provide Medicaid ID. Shall match the ID in ME009, MC008, and PC008 |
|
DC009 |
Member Suffix or Sequence Number |
Text |
20 |
Unique number of the member. This
column is the unique identifying column for
membership and related medical, pharmacy, and dental claims. Only 1 record
per insurance product type, per eligibility month. Shall match ME010, MC009
and PC009. |
|
DC010 |
Member Social
Security Number |
Text |
9 |
Member’s social
security number. Do not include dashes.
Leave blank if not available. |
|
DC011 |
Individual
Relationship Code |
Text |
2 |
See Table 4009.06(b) Relationship
Codes |
|
DC012 |
Member Gender |
Text |
1 |
M Male |
|
|
|
|
|
F Female |
|
|
|
|
|
U Unknown |
|
|
|
|
|
O Other |
|
DC013 |
Member Date of Birth |
Date |
8 |
|
|
DC014 |
Member City Name |
Text |
30 |
City name of member |
|
DC015 |
Member State or
Province |
Text |
2 |
As defined by the
U.S. Postal Service |
|
DC016 |
Member ZIP Code |
Text |
9 |
ZIP Code of member –
may include non- US codes. Do not include dash. |
|
DC017 |
Paid Date/AP Date |
Date |
8 |
|
|
DC018 |
Service Provider
Number |
Text |
30 |
Payer assigned
provider number |
|
DC019 |
Service Provider Tax
ID Number |
Text |
10 |
Federal taxpayer's
identification number – if the tax id is a provider’s social
security number use ‘SSN’ and ‘NA’ if unavailable |
|
DC020 |
National Service Provider ID |
Text |
10 |
Required if National Provider ID is mandated for use under HIPAA
(See MC 220 in Table 4009.02(d) above.) |
|
DC021 |
Service Provider
Entity Type Qualifier |
Text |
1 |
HIPAA provider
taxonomy classifies provider groups (clinicians who bill as a group practice
or under a corporate name, even if that group is composed of one provider) as
“Person”. |
|
|
|
|
|
1 Person |
|
|
|
|
|
2 Non-Person Entity |
|
DC022 |
Service Provider
First Name |
Text |
35 |
Individual first
name. Leave blank if provider is a facility or organization |
|
DC023 |
Service Provider
Middle Name |
Text |
25 |
Individual middle
name or initial. Leave blank if provider is a facility or organization |
|
DC024 |
Servicing Provider
Last Name or Organization Name |
Text |
60 |
Report the name of the organization or last name of the individual
provider. DC021 determines if this is
an Organization or Individual Name reported here. |
|
DC025 |
Service Provider
Suffix |
Text |
10 |
Suffix to individual
name. Leave blank if provider is a facility or organization |
|
DC026 |
Service Provider
Specialty |
Text |
10 |
National Uniform
Claims Committee (NUCC) standard code that defines this provider for this
line of service. Dictionary for specialty code values must be supplied during
testing. |
|
DC027 |
Service Provider City
Name |
Text |
30 |
City name of provider
- practice location |
|
DC028 |
Service Provider
State or Province |
Text |
2 |
As defined by the
U.S. Postal Service |
|
DC029 |
Service Provider ZIP
Code |
Text |
9 |
ZIP Code of provider
- may include non-US codes. |
|
DC030 |
Place of Service -
Professional |
Text |
2 |
See Table 4009.06(f) Place of
Service -- Professional |
|
DC031 |
Claim Status |
Text |
2 |
See Table 4009.06(g)
Claim Status |
|
DC032 |
CDT Code |
Text |
5 |
Common Dental
Terminology code |
|
DC033 |
Procedure Modifier -
1 |
Text |
2 |
Procedure modifier
required when a modifier clarifies/improves the reporting accuracy of the
associated procedure code |
|
DC034 |
Procedure Modifier -
2 |
Text |
2 |
Procedure modifier
required when a modifier clarifies/improves the reporting accuracy of the
associated procedure code |
|
DC035 |
Date of Service -
From |
Date |
8 |
First date of service
for this service line. |
|
DC036 |
Date of Service -
Thru |
Date |
8 |
Last date of service
for this service line. |
|
DC037 |
Charge Amount |
Number |
10 (2) |
The full, undiscounted total and
service-specific charges billed by the provider. |
|
DC038 |
Paid Amount |
Number |
10 (2) |
Includes any withhold
amounts. 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 |
|
DC039 |
Copay Amount |
Number |
10 (2) |
The present, fixed
dollar amount for which the individual is responsible. 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 |
|
DC040 |
Coinsurance Amount |
Number |
10 (2) |
The
dollar amount an individual
is responsible for - not the percentage. 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 |
|
DC041 |
Deductible Amount |
Number |
10 (2) |
Deductible amount in
dollars. 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 |
|
DC042 |
Billing Provider
Number |
Text |
30 |
Carriers, third-party
administrators, and dental claims processors shall code using the payer
assigned billing provider number. This number should be the identifier used
by the payer for internal identification purposes, and does not routinely
change |
|
DC043 |
National Billing
Provider Number ID |
Text |
10 |
This is the NPI for
the billing provider |
|
DC044 |
Billing Provider Last
Name |
Text |
60 |
Full name of provider
billing organization or last name of individual billing provider. |
|
DC101 |
Subscriber Last Name |
Text |
60 |
|
|
DC102 |
Subscriber First Name
|
Text |
35 |
|
|
DC103 |
Subscriber Middle
Initial |
Text |
1 |
|
|
DC104 |
Member Last Name |
Text |
60 |
|
|
DC105 |
Member First Name |
Text |
35 |
|
|
DC106 |
Member Middle Initial
|
Text |
1 |
|
|
DC201 |
Carrier Identifier |
Text |
20 |
If you are a TPA that processes claims
and are submitting files on behalf of a carrier, indicate the carrier name here. The full legal name of company, without
acronyms shall be used. Else, leave blank. |
|
DC202 |
Carrier Plan Specific Contract
Number or Subscriber/Member Social Security Number |
Text |
128 |
For each claim, the carrier
specific contract number or subscriber/member social security number when a TPA processes claims on behalf of the carrier. Optional if
all medical claims processed by a TPA under contract to a carrier for
carved-out services are submitted by the carrier with unified member IDs in
all files. |
|
DC203 |
Practitioner Group Practice |
Text |
60 |
Name of group practice to which a
practitioner is affiliated if different from DC044. |
|
DC204 |
Tooth Number/Letter |
Text |
2 |
Report the tooth
identifier(s) when DC032 is within the given range. Required when DC032 =
D2000 thru D2999 |
|
DC205 |
Dental Quadrant |
Text |
2 |
Standard quadrant
identifier from the External Code Source referenced in Ins
4008.05.
Provides further detail on procedure(s) |
|
DC206 |
Tooth Surface |
Text |
5 |
Tooth surface(s) that
this service relates to. Provides
further detail on procedure. See Ins 4008.04. |
|
DC207 |
Claim Version |
Text |
4 |
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. |
|
DC208 |
Diagnosis Code |
Text |
7 |
ICD CM Diagnosis Code
when applicable |
|
DC209 |
ICD Indicator |
Text |
1 |
Report the value that
defines whether the diagnoses on claim are ICD9 or ICD10. |
|
|
|
|
|
0 ICD-9 |
|
|
|
|
|
1 ICD-10 |
|
DC211 |
Cross Reference Claims ID |
Text |
35 |
The original Payer Claim Control
Number (DC004). Used when a new Payer Claim Control Number is assigned to an
adjusted claim. |
|
DC212 |
Allowed amount |
Number |
10 (0) |
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. Shall be reported
even when paid amount = 0 but member receives care. 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 |
|
DC213 |
HIOS Plan ID |
Text |
16 |
The 16 character HIOS Plan ID (Standard component). Including
a five digit issuer ID, two
character state ID, three digit product
number, four digit standard component number and two digit variant component ID. This field may not be
available for all market segments; Leave blank where not available |
|
DC215 |
Service Line Type |
Text |
1 |
Report the code that defines the claim line status in terms of
adjudication |
|
|
|
|
|
O Original |
|
|
|
|
|
V Void |
|
|
|
|
|
R Replacement |
|
|
|
|
|
B Back Out |
|
|
|
|
|
A Amendment |
|
DC218 |
Claim Processing
Level Indicator |
Text |
1 |
1 Claim Level |
|
|
|
|
|
2 Service Line level |
|
DC219 |
Denied Claim
Indicator |
Text |
1 |
1 Fully Paid – the
entire claim was paid at the allowed amount |
|
|
|
|
|
2 Partially denied –
some of the claims lines were paid at the allowed
amount |
|
|
|
|
|
3 Encounter claim –
this claim records a service provided that is paid under a non
FFS payment arrangement such as capitation |
|
|
|
|
|
4 No payment – no
payment made for reasons other than non FFS payment
arrangement |
|
DC220 |
Denial Reason |
Text |
4 |
Denial reason code. Required when denied claim indicator = 2 or 4.
See Ins 4008.04 |
|
DC899 |
Record Type |
Text |
2 |
DC |
|
DC900 |
In Network Indicator |
Text |
1 |
A yes/no indicator
that specifies that the provider (not the benefit) is within the health plan
network. Valid codes: Y=Yes, N=No |
|
DC901 |
Quantity |
Number |
12(0) |
Count of services
performed |
|
DC902 |
Claim
Source |
Text |
1 |
What form the claim is being processed as: E:
Electronic P:
Paper |
|
DC903 |
Claim
Received Date |
Date |
8 |
Date
that the claim was received from the provider. The date shall be in CCYYMMDD
format. |
|
DC904 |
Insurance
Group Name |
Text |
30 |
Name
of the Insurance Group whose Insured Group or Policy Number was listed in
DC006. The name shall match ME032 |
|
DC905 |
Coordination
of Benefits/Third Party Liability Amount |
Number
|
2(10) |
Coordination
of Benefits (COB)/Third Party Liability (TPL) is the dollar amount paid from
a prior payer (e.g. auto claim, workers comp, dual medical coverage).
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 |
|
DC906 |
TPA Identifier |
Text |
20 |
If
you are a carrier whose claims were processed by a TPA and you are submitting
the files, please indicate the TPA here. The full legal name of company, without
acronyms shall be used. Else, leave blank. |
|
DC907 |
Prior Authorization |
Text |
1 |
If
that claim required a prior authorization Y:
Yes N:
No |
Source. #10877, eff 7-10-15; ss by #13136, eff
11-24-20; ss by #14560, eff 4-22-26, EXPIRES: 4-22-36 (formerly Ins 4010.04)
Ins 4009.05 Provider File Data Tables.
(a)
Provider File Header Record
Layout:
|
Table 4009.05(a) Provider File Header
Record Layout |
||||
|
Data Element # |
Element |
Type |
Length (decimal places) |
Description/Codes/Sources |
|
HD001 |
Record Type |
Text |
2 |
HD |
|
HD002 |
Payer |
Text |
8 |
Payer submitting payments. NHID Submitter Code |
|
HD003 |
National Plan ID |
Text |
30 |
CMS National Plan ID |
|
HD004 |
Type of File |
Text |
2 |
MP Provider File |
|
HD005 |
Period Beginning Date |
Number |
6 |
Beginning of span of coverage period |
|
HD006 |
Period Ending Date |
Number |
6 |
End of span of coverage period |
|
HD008 |
Comments |
Text |
80 |
Submitter may use to document this
submission by assigning a filename, system source, etc. |
(b) Provider
File Trailer Record Layout:
|
Table 4009.05(b) Provider File Trailer
Record Layout |
||||
|
Data Element # |
Element |
Type |
Length (decimal places) |
Description/Codes/Sources |
|
TR001 |
Record Type |
Text |
2 |
TR |
|
TR002 |
Payer |
Text |
8 |
Payer submitting payments. NHID
Submitter Code |
|
TR003 |
National Plan ID |
Text |
30 |
CMS National Plan ID |
|
TR004 |
Type of File |
Text |
2 |
MP Provider File |
|
TR005 |
Period Beginning Date |
Number |
6 |
Beginning of span of coverage period |
|
TR006 |
Period Ending Date |
Number |
6 |
End of span of coverage period |
|
TR007 |
Extraction Date |
Date |
8 |
Date file was created |
|
TR008 |
Record Count |
Number |
10 (0) |
Total number of records submitted in
this file |
(c) Provider
File Detailed Specifications:
|
Table 4009.05(c) Provider File Detailed Specifications |
||||
|
Data Element # |
Element |
Type |
Length (decimal places) |
Description/Codes/Sources |
|
MP001 |
Payer |
Text |
8 |
Payer
submitting payments. NHID Submitter Code |
|
MP002 |
Plan ID |
Text |
30 |
CMS National Plan ID or NAIC code. |
|
MP003 |
Provider ID |
Text |
30 |
Unique identified for the provider as assigned by the reporting
entity |
|
MP004 |
Provider Tax ID |
Text |
10 |
Federal taxpayer's identification number –if the tax id is a
provider’s social security number use ‘SSN’ and ‘NA’ if unavailable. Do not code punctuation. |
|
MP005 |
Provider Entity |
Text |
1 |
Specify the value that defines the type of entity |
|
|
|
|
|
1 Person; physician, clinician, orthodontist, and any individual
that is licensed/certified to perform health care services. |
|
|
|
|
|
2 Facility; hospital, health center, long term care,
rehabilitation and any building that is licensed to transact health care
services. |
|
|
|
|
|
3 Professional Group; collection of licensed/certified health
care professionals that are practicing health care services under the same
entity name and Federal Tax Identification Number. |
|
|
|
|
|
4 Retail Site; brick-and-mortar licensed/certified place of
transaction that is not solely a health care entity, i.e., pharmacies,
independent laboratories, vision services. |
|
|
|
|
|
5 E-Site; internet-based order/logistic system of health care
services, typically in the form of durable medical equipment, pharmacy or
vision services. Address assigned
should be the address of the company delivering services or order
fulfillment. |
|
|
|
|
|
6 Financial Parent; financial governing body that does not
perform health care services itself but directs and finances health care
service entities, usually through a Board of Directors. |
|
|
|
|
|
7 Transportation; any form of transport that conveys a patient
to/from a healthcare provider. |
|
|
|
|
|
8 Other; any type of entity not otherwise defined that performs
health care services. |
|
MP006 |
Provider First Name |
Text |
35 |
Individual first name.
Leave blank if provider is a facility or organization |
|
MP007 |
Provider Middle Name or Initial |
Text |
25 |
|
|
MP008 |
Provider Last Name or Organization Name |
Text |
60 |
Full name of provider organization or last name of individual
provider |
|
MP009 |
Provider Suffix |
Text |
10 |
Example: Jr; Set as leave blank if provider is an
organization. Do not use credentials
such as MD or PhD |
|
MP010 |
Provider Specialty |
Text |
10 |
Report the HIPAA-compliant
health care provider taxonomy code.
Code set is available at the National Uniform Claims Committee’s web site
at http://www.nucc.org/ |
|
MP011 |
Provider Office Street Address |
Text |
50 |
Physical address – address where provider delivers health care
services |
|
MP012 |
Provider Office City |
Text |
30 |
Physical address – address where provider delivers health care
services |
|
MP013 |
Provider Office State |
Text |
2 |
Physical address – address where provider delivers health care
services. Use postal service standard
2 letter abbreviations |
|
MP014 |
Provider Office Zip |
Text |
9 |
Physical address – address where provider delivers health care
services. Minimum 5
digit code. Do not include dashes |
|
MP015 |
Provider DEA Number |
Text |
12 |
|
|
MP016 |
Provider NPI |
Text |
20 |
|
|
MP017 |
Provider State License Number |
Text |
30 |
|
|
MP018 |
Entity Code |
Text |
2 |
Enter the value that defines the entity provider type. Required
when MP005 does not = 1 |
|
|
|
|
|
1 Academic Institution |
|
|
|
|
|
2 Adult Foster Care |
|
|
|
|
|
3 Ambulance Services |
|
|
|
|
|
4 Hospital Based Clinic |
|
|
|
|
|
5 Stand-Alone, Walk-In/Urgent Care Clinic |
|
|
|
|
|
6 Other Clinic |
|
|
|
|
|
7 Community Health Center - General |
|
|
|
|
|
8 Community Health Center - Urgent Care |
|
|
|
|
|
9 Government Agency |
|
|
|
|
|
10 Health Care Corporation |
|
|
|
|
|
11 Home Health Agency |
|
|
|
|
|
12 Acute Hospital |
|
|
|
|
|
13 Chronic Hospital |
|
|
|
|
|
14 Rehabilitation Hospital |
|
|
|
|
|
15 Psychiatric Hospital |
|
|
|
|
|
16 DPH Hospital |
|
|
|
|
|
17 State Hospital |
|
|
|
|
|
21 Licensed Hospital Satellite Emergency Facility |
|
|
|
|
|
22 Hospital Emergency Center |
|
|
|
|
|
23 Nursing Home |
|
|
|
|
|
24 Pharmacy |
|
MP899 |
Record Type |
Text |
2 |
MP |
Source. #10877, eff 7-10-15; ss by #13136, eff
11-24-20;
ss by #14560, eff 4-22-26, EXPIRES: 4-22-36 (formerly Ins 4010.05)
Ins 4009.06 Data Submission Manual Code Tables.
(a) Insurance
Type/Product Code:
|
Table 4009.06(a) Insurance Type/Product Code |
|
|
Code |
Description |
|
11 |
Other
Non-Federal Programs |
|
12 |
Medicare
Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan |
|
13 |
Medicare
Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination
Period with an Employer’s Group Health Plan |
|
14 |
Medicare Secondary,
No-Fault Insurance including Insurance in which Auto Is Primary |
|
15 |
Medicare
Secondary Workers' Compensation |
|
16 |
Medicare
Secondary Public Health Service (PHS) or Other Federal Agency |
|
17 |
Dental |
|
18 |
Vision |
|
19 |
Prescription
Drugs (Commercial Coverage) |
|
41 |
Medicare
Secondary Black Lung |
|
42 |
Medicare
Secondary Veterans' Administration |
|
43 |
Medicare
Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan
(LGHP) |
|
AP |
Auto
Insurance Policy |
|
C1 |
Commercial |
|
CO |
Consolidated
Omnibus Reconciliation Act (COBRA) |
|
CP |
Medicare
Conditionally Primary |
|
D |
Disability |
|
E |
Medicare –
Point of Service (POS) |
|
EP |
Exclusive
Provider Organization |
|
FH |
Federal
Employees Health Benefits Program (HMO) |
|
FP |
Federal
Employees Health Benefits Program (PPO) |
|
HM |
Health
Maintenance Organization (HMO) |
|
HN |
Health
Maintenance Organization (HMO) Medicare Advantage/Risk |
|
IN |
Indemnity |
|
IP |
Individual
Policy |
|
LC |
Long Term
Care |
|
LD |
Long Term
Policy |
|
LI |
Life
Insurance |
|
LT |
Litigation |
|
MA |
Medicare Part
A (not to be used for commercial plans) |
|
MB |
Medicare Part
B (not to be used for commercial plans) |
|
MC |
Medicaid |
|
MD |
Medicare Part
D |
|
MH |
Medigap Part
A |
|
MI |
Medigap Part
B |
|
MO |
Medicare
Advantage PPO |
|
MP |
Medicare
Primary (not to be used for commercial plans) |
|
OT |
Other |
|
PL |
Personal |
|
PR |
Preferred
Provider Organization (PPO) |
|
PS |
Point of
Service (POS) |
|
QM |
Qualified
Medicare Beneficiary |
|
RP |
Property
Insurance – Real |
|
SP |
Medicare
Supplemental Policy |
|
TR |
Tricare |
|
U |
Multiple
Options Health Plan |
|
WU |
Wrap Up
Policy |
|
DM |
Dental
Maintenance Organization |
|
AM |
Automobile
Medical |
|
LB |
Liability |
|
OF |
Other Federal
Program |
|
TV |
Title V |
(b) Relationship Codes:
|
Table
4009.06(b) Relationship Codes |
|
|
Code |
Description |
|
01 |
Spouse |
|
02 |
Son or daughter |
|
03 |
Father or Mother |
|
04 |
Grandfather or Grandmother |
|
05 |
Grandson or Granddaughter |
|
06 |
Uncle or Aunt |
|
07 |
Nephew or Niece |
|
08 |
Cousin |
|
09 |
Adopted Child |
|
10 |
Foster Child |
|
11 |
Son-in-Law or Daughter-in-Law |
|
12 |
Brother-in-Law or Sister-in-Law |
|
13 |
Mother-in-Law or Father-in-Law |
|
14 |
Brother or Sister |
|
15 |
Ward |
|
16 |
Stepparent |
|
17 |
Stepson or Stepdaughter |
|
18 |
Self |
|
19 |
Child |
|
20 |
Employee/Self |
|
21 |
Unknown |
|
22 |
Handicapped Dependent |
|
23 |
Sponsored Dependent |
|
24 |
Dependent of a Minor Dependent |
|
25 |
Ex-spouse |
|
26 |
Guardian |
|
27 |
Student |
|
28 |
Friend |
|
29 |
Significant Other |
|
30 |
Both Parents |
|
31 |
Court Appointed Guardian |
|
32 |
Mother |
|
33 |
Father |
|
34 |
Other Adult |
|
36 |
Emancipated Minor |
|
37 |
Agency Representative |
|
38 |
Collateral Dependent |
|
39 |
Organ Donor |
|
40 |
Cadaver Donor |
|
41 |
Injured Plaintiff |
|
43 |
Child Where Insured Has No
Financial Responsibility |
|
53 |
Life Partner |
|
76 |
Dependent |
(c) Race 1/Race 2:
|
Table 4009.06(c) Race 1/Race 2 |
|
|
Code |
Description |
|
R1 |
American Indian/Alaska Native |
|
R2 |
Asian |
|
R3 |
Black/African American |
|
R4 |
Native Hawaiian or Other Pacific
Islander |
|
R5 |
White |
|
R9 |
Other Race |
|
UNKNOW |
Unknown/Not Specified |
(d) Ethnicity 1/ Ethnicity 2:
|
Table 4009.06(d) Ethnicity 1/Ethnicity
2 |
|
|
Code |
Description |
|
2182-4 |
Cuban |
|
2184-0 |
Dominican |
|
2148-5 |
Mexican, Mexican American,
Chicano |
|
2180-8 |
Puerto Rican |
|
2161-8 |
Salvadoran |
|
2155-0 |
Central American (not otherwise
specified) |
|
2165-9 |
South American (not otherwise
specified) |
|
2060-2 |
African |
|
2058-6 |
African American |
|
AMERCN |
American |
|
2028-9 |
Asian |
|
2029-7 |
Asian Indian |
|
BRAZIL |
Brazilian |
|
2033-9 |
Cambodian |
|
CVERDN |
Cape Verdean |
|
CARIBI |
Caribbean Island |
|
2034-7 |
Chinese |
|
2169-1 |
Columbian |
|
2108-9 |
European |
|
2036-2 |
Filipino |
|
2157-6 |
Guatemalan |
|
2071-9 |
Haitian |
|
2158-4 |
Honduran |
|
2039-6 |
Japanese |
|
2040-4 |
Korean |
|
2041-2 |
Laotian |
|
2118-8 |
Middle Eastern |
|
PORTUG |
Portuguese |
|
RUSSIA |
Russian |
|
EASTEU |
Eastern European |
|
2047-9 |
Vietnamese |
|
OTHER |
Other Ethnicity |
|
UNKNOW |
Unknown/Not Specified |
|
Table 4009.06(e) Discharge Status |
|
|
Code |
Description |
|
01 |
Discharged to home or self-care |
|
02 |
Discharged/transferred to another
short term general hospital for inpatient care |
|
03 |
Discharged/transferred to skilled
nursing facility (SNF) |
|
04 |
Discharged/transferred to a
facility that provides custodial or supportive care |
|
05 |
Discharged/transferred to a
designated cancer center of children’s hospital |
|
06 |
Discharged/transferred to home
under care of organized home health service organization |
|
07 |
Left against medical advice or
discontinued care |
|
08 |
Reserved for assignment by the
NUBC |
|
09 |
Admitted as an inpatient to this
hospital |
|
20 |
Expired |
|
21 |
Discharged/transferred to
court/law enforcement |
|
30 |
Still patient or expected to
return for outpatient services |
|
40 |
Expired at home |
|
41 |
Expired in a medical facility |
|
42 |
Expired, place unknown |
|
43 |
Discharged/ transferred to a
Federal Hospital |
|
50 |
Hospice – home |
|
51 |
Hospice – medical facility |
|
61 |
Discharged/transferred within
this institution to a hospital-based Medicare-approved swing bed |
|
62 |
Discharged/transferred to an
inpatient rehabilitation facility including distinct parts of a hospital |
|
63 |
Discharged/transferred to a
long-term care hospital |
|
64 |
Discharged/transferred to a
nursing facility certified under Medicaid but not certified under Medicare |
|
65 |
Discharged/transferred to a
psychiatric hospital or psychiatric distinct part unit of a hospital |
|
66 |
Discharged/transferred to a
critical access hospital (CAH) |
|
69 |
Discharged/transferred to a
designated disaster alternative care site (effective 10/1/13) |
|
70 |
Discharged/transferred to another
type of healthcare institution not defined elsewhere in this code list |
|
81 |
Discharged to home or self-care
with a planned acute care hospital inpatient readmission (effective 10/1/13) |
|
82 |
Discharged/transferred to a short term general hospital for inpatient care with a
planned acute care hospital inpatient readmission (effective 10/1/13) |
|
83 |
Discharged/transferred to a
skilled nursing facility (SNF) with Medicare certification with a planned
acute care hospital inpatient readmission (effective 10/1/13) |
|
84 |
Discharged/transferred to a
facility that provides custodial or supportive care with a planned acute care
hospital inpatient readmission (effective 10/1/13) |
|
85 |
Discharged/transferred to
designated cancer center of children’s hospital with a planned acute care
hospital inpatient readmission (effective 10/1/13) |
|
86 |
Discharged/transferred to home
under care of organized home health service organization with a planned acute
care hospital inpatient readmission (effective 10/1/13) |
|
87 |
Discharged/transferred to court /
law enforcement with a planned acute care hospital inpatient readmission
(effective 10/1/13) |
|
88 |
Discharged/transferred to a
federal healthcare facility with a planned acute care hospital inpatient
readmission (effective 10/1/13) |
|
89 |
Discharged/transferred to a
hospital‐based
Medicare approved swing bed with a planned acute care hospital inpatient
readmission (effective 10/1/13) |
|
90 |
Discharged/transferred to an
inpatient rehabilitation facility (IRF) including rehabilitation distinct
part units of a hospital with a planned acute care hospital inpatient
readmission (effective 10/1/13) |
|
91 |
Discharged/transferred to a
Medicare certified long term care hospital (LTCH) with a planned acute care
hospital inpatient readmission (effective 10/1/13) |
|
92 |
Discharged/transferred to a nursing
facility certified under Medicaid but not certified under Medicare with a
planned acute care hospital inpatient readmission (effective 10/1/13) |
|
93 |
Discharged/transferred to a
psychiatric hospital or psychiatric distinct part unit of a hospital with a
planned acute care hospital inpatient readmission (effective 10/1/13) |
|
94 |
Discharged/transferred to a
critical access hospital (CAH) with a planned acute care hospital inpatient
readmission (effective 10/1/13) |
|
95 |
Discharged/transferred to a
nursing facility certified under Medicaid but not certified under Medicare
with a planned acute care hospital inpatient readmission (effective 10/1/13) |
(f) Place of
Service – Professional:
|
Table
4009.06(f) Place of Service – Professional |
|
|
Code |
Description |
|
01 |
Pharmacy |
|
02 |
Unassigned |
|
03 |
School |
|
04 |
Homeless Shelter |
|
05 |
Indian Health Service
Free-Standing Facility |
|
06 |
Indian Health Service
Provider-Based Facility |
|
07 |
Tribal 638 Free-Standing Facility |
|
08 |
Tribal 638 Provider-Based
Facility |
|
09 |
Prison/Correctional Facility |
|
10 |
Unassigned |
|
11 |
Office |
|
12 |
Home |
|
13 |
Assisted Living Facility
Congregate |
|
14 |
Group Home |
|
15 |
Mobile Unit |
|
16 |
Temporary Lodging |
|
17 |
Walk-in Retail Health Clinic |
|
18 |
Place of Employment-Worksite |
|
19 |
Unassigned |
|
20 |
Urgent Care Facility |
|
21 |
Inpatient Hospital |
|
22 |
Outpatient Hospital |
|
23 |
Emergency Room – Hospital |
|
24 |
Ambulatory Surgery Center |
|
25 |
Birthing Center |
|
26 |
Military Treatment Facility |
|
27-30 |
Unassigned |
|
31 |
Skilled Nursing Facility |
|
32 |
Nursing Facility |
|
33 |
Custodial Care Facility |
|
34 |
Hospice |
|
35-40 |
Unassigned |
|
41 |
Ambulance – Land |
|
42 |
Ambulance – Air or Water |
|
43-48 |
Unassigned |
|
50 |
Federally Qualified Center |
|
51 |
Inpatient Psychiatric Facility |
|
52 |
Psychiatric Facility Partial
Hospitalization |
|
53 |
Community Mental Health Center |
|
54 |
Intermediate Care
Facility/Mentally Retarded |
|
55 |
Residential Substance Abuse
Treatment Facility |
|
56 |
Psychiatric Residential Treatment
Center |
|
57 |
Non-Residential Substance Abuse
Treatment Facility |
|
58-59 |
Unassigned |
|
60 |
Mass Immunization Center |
|
61 |
Comprehensive Inpatient Rehabilitation
Facility |
|
62 |
Comprehensive Outpatient
Rehabilitation Facility |
|
63-64 |
Unassigned |
|
65 |
End Stage Renal Disease Treatment
Facility |
|
66-70 |
Unassigned |
|
71 |
State or Local Public Health
Clinic |
|
72 |
Rural Health Clinic |
|
73-80 |
Unassigned |
|
81 |
Independent Laboratory |
|
82-98 |
Unassigned |
|
99 |
Other Unlisted Facility |
(g) Claim Status:
|
Table 4009.06(g) Claim Status |
|
|
Code |
Description |
|
01 |
Processed as primary |
|
02 |
Processed as secondary |
|
03 |
Processed as tertiary |
|
04 |
Denied |
|
06 |
Approved as amended |
|
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 |
|
26 |
Documentation Claim - No Payment
Associated |
|
28 |
Repriced |
(h)
MC021 Point of Origin Codes:
(1) If MC020 = 4 (Newborn), then use the following
values at MC021:
|
Table
4009.06(h)(1) MC021 Point of Origin Codes |
|
|
Code |
Description |
|
5 |
Born Inside the Hospital |
|
6 |
Born Outside the Hospital |
(2)
For all other values at MC020, use the following table for MC021:
|
Table
4009.06 (h)(2) Point of Origin Codes |
|
|
Code |
Description |
|
1 |
Non-Healthcare Facility Point of
Origin (Physician Referral) |
|
2 |
Clinic Referral |
|
3 |
HMO Referral |
|
4 |
Transfer from a Hospital
(Different Facility) |
|
5 |
Transfer from a Skilled Nursing
Facility (SNF) or Intermediate Care Facility (ICF) |
|
6 |
Transfer from Another Health Care
Facility |
|
7 |
Emergency Room |
|
8 |
Court/Law Enforcement |
|
9 |
Information Not Available |
|
A |
Reserved for National Assignment |
|
B |
Transfer from Another Home Health
Agency (Discontinued July 1, 2010) |
|
C |
Readmission to Same Home Health
Agency (Discontinued July 1, 2010) |
|
D |
Transfer from Hospital Inpatient
in the Same Facility Resulting in a Separate Claim to the Payer |
|
E |
Transfer from Ambulatory Surgical
Center |
|
F |
Transfer from Hospice and is
Under a Hospice Plan of Care or Enrolled in Hospice Program |
Source.
#10877, eff 7-10-15; ss by #13136, eff 11-24-20; ss by #14560, eff 4-22-26,
EXPIRES: 4-22-36 (formerly Ins 4010.06)
Ins 4009.07 Mapping
and Format Information Tables.
(a) Member
Eligibility File Mapping and Format Information:
|
Table 4009.07(a) Member Eligibility
File Mapping and Format Information |
||
|
Data Element # |
Element |
HIPAA Reference Transaction Set/Loop/ Segment/Qualifier/ Data Element |
|
ME001 |
Payer |
N/A |
|
ME002 |
National
Plan ID |
271/2100A/NM1/XV/09 |
|
ME003 |
Insurance
Type Code/Product |
271/2110C/EB/
/04, 271/2110D/EB/ /04 |
|
ME004 |
Year |
N/A |
|
ME005 |
Month |
N/A |
|
ME006 |
Insured
Group or Policy Number |
271/2100C/REF/1L/02,
271/2100C/REF/IG/02, 271/2100C/REF/6P/02, 271/2100D/REF/1L/02,
271/2100D/REF/IG/02, 271/2100D/REF/6P/02 |
|
ME007 |
Coverage
Level Code |
271/2110C/EB/
/03, 271/2100D/EB/ /03 |
|
ME009 |
Plan
Specific Contract Number |
271/2100C/NM1/MI/09 |
|
ME010 |
Member
Suffix or Sequence Number |
N/A |
|
ME012 |
Individual
Relationship Code |
271/2100C/INS/Y/02,
271/2100D/INS/N/02 |
|
ME013 |
Member
Gender |
271/2100C/DMG/
/03, 271/2100D/DMG/ /03 |
|
ME014 |
Member
Date of Birth |
271/2100C/DMG/D8/02,
271/2100D/DMG/D8/02 |
|
ME015 |
Member
City Name |
271/2100C/N4/
/01, 271/2100D/N4/ /01 |
|
ME016 |
Member
State or Province |
217/2100C/N4/
/02, 271/2100D/N4/ /02 |
|
ME017 |
Member
ZIP Code |
271/2100C/N4/
/03, 271/2100D/N4/ /03 |
|
ME018 |
Medical
Coverage |
N/A |
|
ME019 |
Prescription
Drug Coverage |
N/A |
|
ME020 |
Dental
Coverage |
N/A |
|
ME021 |
Race
1 |
N/A |
|
ME022 |
Race
2 |
N/A |
|
ME023 |
Place
holder |
N/A |
|
ME024 |
Hispanic
Indicator |
N/A |
|
ME025 |
Ethnicity
1 |
N/A |
|
ME026 |
Ethnicity
2 |
N/A |
|
ME027 |
Place
holder |
N/A |
|
ME028 |
Primary
Insurance Indicator |
N/A |
|
ME029 |
Coverage
Type |
N/A |
|
ME030 |
Market
Category |
N/A |
|
ME031 |
NH
Health Protection Program |
N/A |
|
ME032 |
Group
Name |
N/A |
|
ME101 |
Subscriber
Last Name |
270/2100C/NM1/IL/1/3 |
|
ME102 |
Subscriber
First Name |
270/2100C/NM1/IL/1/4 |
|
ME103 |
Subscriber
Middle Initial |
270/2100C/NM1/IL/1/5 |
|
ME104 |
Member
Last Name |
270/2100D/NM1/QC/1/3 |
|
ME105 |
Member
First Name |
270/2100D/NM1/QC/1/4 |
|
ME106 |
Member
Middle Initial |
270/2100D/NM1/QC/1/5 |
|
271/2100/N3/ /01, 02 271/2100D/N3/ /01, 02 |
||
|
ME203 |
Member’s
Assigned PCP |
Loop
2000B SBR02 = 18 - ELSE - Loop |
|
ME204 |
HIOS
Plan ID |
N/A |
|
ME205 |
Plan
Effective Date |
N/A |
|
ME206 |
Minimum
Value |
2010CA
Segment N301 |
|
ME207 |
Exchange
Indicator |
N/A |
|
ME208 |
High
Deductible
Health Plan |
N/A |
|
ME209 |
Active
Enrollment |
N/A |
|
ME210 |
New
Coverage |
N/A |
|
ME211 |
N/A |
|
|
ME899 |
Record
Type |
N/A |
|
ME900 |
Plan
State |
N/A |
|
ME901 |
Advance
Premium Tax Credit |
N/A |
|
ME902 |
NAIC
Number |
N/A |
|
ME903 |
Grandfather
Plan Indicator |
N/A |
|
ME904 |
Metal
Value |
N/A |
(b) Medical
Claims File Mapping and Format Information:
|
Table 4009.07(b) Medical Claims File Mapping and Format
Information |
||||
|
Data Element # |
Data Element Name |
CMS 1450/UB-04 Form Locator |
CMS 1500 # |
HIPAA Reference Transaction Set/Loop/ Segment/Qualifier/ Data Element |
|
MC001 |
Payer |
N/A |
N/A |
N/A |
|
MC002 |
National Plan ID |
N/A |
N/A |
835/1000A/N1/XV/04 |
|
MC003 |
Product/Claim Filing Indicator Code |
N/A |
N/A |
835/2100/CLP/ /06 |
|
MC004 |
Payer Claim Control Number |
N/A |
N/A |
835/2100/CLP/ /07 |
|
MC005 |
Line Counter |
N/A |
N/A |
837/2400/LX/ /01 |
|
MC005A |
Version Number |
N/A |
N/A |
N/A |
|
MC006 |
Insured Group or Policy Number |
62 (A-C) |
11C |
837/2000B/SBR/ /03 |
|
MC007 |
Placeholder |
|
|
|
|
MC008 |
Plan Specific Contract Number |
60 |
1 a |
835/2100/NM1/HN/08 |
|
MC009 |
Member Suffix or Sequence Number |
N/A |
N/A |
N/A |
|
MC010 |
Placeholder |
|
|
|
|
MC011 |
Individual Relationship Code |
59 (A-C) |
6 |
837/2000B/SBR/ /02, 837/2000C/PAT/ /01 |
|
MC012 |
Member Gender |
11 |
3 |
837/2010CA/DMG/03 |
|
MC013 |
Member Date of Birth |
10 |
3 |
837/2010CA/DMG/D8/02 |
|
MC014 |
Member City Name |
9 |
5 |
837/2010CA/N4/ /01 |
|
MC015 |
Member State or Province |
9 |
5 |
837/2010CA/N4/ /02 |
|
MC016 |
Member ZIP Code |
9 |
5 |
837/2010CA/N4/ /03 |
|
MC017 |
Paid Date (AP Date) |
N/A |
N/A |
N/A |
|
MC018 |
Admission Date |
12 |
N/A |
837/2300/DTP/435/03 |
|
MC019 |
Admission Hour |
13 |
N/A |
837/2300/DTP/435/03 |
|
MC020 |
Admission Type |
14 |
N/A |
837/2300/CL1/ /01 |
|
MC021 |
Admission Source |
15 |
|
837/2300/CL1/ /02 |
|
MC022 |
Discharge Hour |
16 |
|
837/2300/DTP/096/03 |
|
MC023 |
Discharge Status |
17 |
N/A |
837/2300/CL1/ /03 |
|
MC024 |
Service Provider Number |
76-79 |
N/A |
N/A |
|
MC025 |
Service Provider Tax ID Number |
5 |
25 |
835/2100/NM1/FI/09 |
|
MC026 |
National Service Provider ID |
N/A |
N/A |
835/2100/NM1/XX/09 |
|
MC027 |
Service Provider Entity Type Qualifier |
N/A |
N/A |
835/2100/NM1/82/02 |
|
MC028 |
Service Provider First Name |
1 |
33 |
835/2100/NM1/82/04 |
|
MC029 |
Service Provider Middle Name |
1 |
33 |
835/2100/NM1/82/05 |
|
MC030 |
Service Provider Last Name or Organization Name |
1 |
33 |
835/2100/NM1/82/03 |
|
MC031 |
Service Provider Suffix |
1 |
33 |
835/2100/NM1/82/07 |
|
MC032 |
Service Provider Specialty |
N/A |
N/A |
837/2000A/PRV/ZZ/03 |
|
MC033 |
Service Provider City Name |
1 |
N/A |
837/2010A/N4/ /01 |
|
MC034 |
Service Provider State or Province |
1 |
N/A |
837/2010A/N4/ /02 |
|
MC035 |
Service Provider ZIP Code |
1 |
N/A |
837/2010A/N4/ /03 |
|
MC036 |
Type of Bill – Institutional |
4 |
N/A |
837/2300/CLM/ /05-1 |
|
MC037 |
Facility Type - Professional |
N/A |
N/A |
835/2100/CLP/ /08 |
|
MC038 |
Service Line Status |
N/A |
N/A |
835/2100/CLP/ /02 |
|
MC039 |
Admitting Diagnosis |
69 |
N/A |
837/2300/HI/BJ/02-2 |
|
MC040 |
E-Code |
72 |
N/A |
837/2300/HI/BN/03-2 |
|
MC041 |
Principal Diagnosis |
67 |
21.1 |
837/2300/HI/BK/01-2 |
|
MC042 |
Other Diagnosis – 1 |
67 |
21.2 |
837/2300/HI/BF/02-1 |
|
MC043 |
Other Diagnosis – 2 |
67 |
21.3 |
837/2300/HI/BF/02-2 |
|
MC044 |
Other Diagnosis – 3 |
67 |
21.4 |
837/2300/HI/BF/02-3 |
|
MC045 |
Other Diagnosis – 4 |
67 |
N/A |
837/2300/HI/BF/02-4 |
|
MC046 |
Other Diagnosis – 5 |
67 |
N/A |
837/2300/HI/BF/02-5 |
|
MC047 |
Other Diagnosis – 6 |
67 |
N/A |
837/2300/HI/BF/02-6 |
|
MC048 |
Other Diagnosis – 7 |
67 |
N/A |
837/2300/HI/BF/02-7 |
|
MC049 |
Other Diagnosis – 8 |
67 |
N/A |
837/2300/HI/BF/02-8 |
|
MC050 |
Other Diagnosis – 9 |
67 |
N/A |
837/2300/HI/BF/02-9 |
|
MC051 |
Other Diagnosis –10 |
67 |
N/A |
837/2300/HI/BF/02-10 |
|
MC052 |
Other Diagnosis –11 |
67 |
N/A |
837/2300/HI/BF/02-11 |
|
MC053 |
Other Diagnosis –12 |
67 |
N/A |
837/2300/HI/BF/02-12 |
|
MC054 |
Revenue Code |
42 |
N/A |
835/2110/SVC/RB/01-2, 835/2110/SVC/NU/01-2 |
|
MC055 |
Procedure Code |
44 |
24.1-6 D |
837/2400/SV202-02 835/2110/SVC/HC/01-2 |
|
MC056 |
Procedure Modifier – 1 |
44 |
24.1-6 D |
837/2400/SV202-03 835/2110/SVC/HC/01-3 |
|
MC057 |
Procedure Modifier – 2 |
44 |
24.1-6 D |
837/2400/SV202-04 835/2110/SVC/HC/01-3 |
|
MC058 |
ICD-9-CM Procedure Code |
74 |
N/A |
835/2110/SVC/ID/01-2 |
|
MC059 |
Date of Service – From |
45 |
24.1-6 A |
835/2110/DTM/150/02 |
|
MC060 |
Date of Service – Thru |
N/A |
24.1-6 A |
835/2110/DTM/151/02 |
|
MC061 |
Quantity |
46 |
24.1-6 G |
835/2110/SVC/ /05 |
|
MC062 |
Charge Amount |
47 |
24.1-6F |
835/2110/SVC/ /02 |
|
MC063 |
Paid Amount |
N/A |
N/A |
835/2110/SVC/ /03 |
|
MC064 |
Fee for Service Equivalent |
N/A |
N/A |
N/A |
|
MC065 |
Co-pay Amount |
N/A |
N/A |
N/A |
|
MC066 |
Coinsurance Amount |
N/A |
N/A |
N/A |
|
MC067 |
Deductible Amount |
N/A |
N/A |
N/A |
|
MC068 |
Patient Account/Control Number |
3 |
N/A |
837/2300/CLM/1 |
|
MC069 |
Discharge Date |
|
|
|
|
MC070 |
Service Provider Country Name |
N/A |
N/A |
N/A |
|
MC071 |
DRG |
N/A |
N/A |
837/2300/HI/DR/2 |
|
MC072 |
DRG Version |
N/A |
N/A |
N/A |
|
MC073 |
APC |
N/A |
N/A |
N/A |
|
MC074 |
APC Version |
N/A |
N/A |
N/A |
|
MC075 |
Drug Code |
44 |
|
837/2400/SV2/N1/2 837/2400/SV2/N2/2 837/2400/SV2/N3/2 837/2400/SV2/N4/2 837/2400/SV2/ND/2 |
|
MC076 |
Billing Provider Number |
N/A |
N/A |
N/A |
|
MC077 |
National Billing Provider Number ID |
N/A |
N/A |
N/A |
|
MC078 |
Billing Provider Organization or Last Name |
N/A |
N/A |
N/A |
|
MC101 |
Subscriber Last Name |
N/A |
N/A |
837/2110BA/NM1/IL/1/3 |
|
MC102 |
Subscriber First Name |
N/A |
N/A |
837/2110BA/NM1/IL/1/4 |
|
MC103 |
Subscriber Middle Initial |
N/A |
N/A |
837/2110BA/NM1/IL/1/5 |
|
MC104 |
Member Last Name |
8b |
N/A |
837/2110CA/NM1/QC/1/3 |
|
MC105 |
Member First Name |
8b |
N/A |
837/2110CA/NM1/QC/1/4 |
|
MC106 |
Member Middle Initial |
8b |
N/A |
837/2110CA/NM1/QC/1/5 |
|
MC200 |
ICD Indicator |
N/A |
N/A |
Set
value here based upon Loop 2300 Segment H101-01 starting with the letter A |
|
MC202 |
Other ICD-CM Procedure code - 2 |
74 a-e |
N/A |
837/2300
H102-1=BQ (ICD-9) or = BBQ (ICD-10) |
|
MC203 |
Other ICD-CM Procedure code - 3 |
74 a-e |
N/A |
837/2300
H102-1=BQ (ICD-9) or = BBQ (ICD-10) |
|
MC204 |
Other ICD-CM Procedure code - 4 |
74 a-e |
N/A |
837/2300
H102-1=BQ (ICD-9) or = BBQ (ICD-10) |
|
MC205 |
Other ICD-CM Procedure code - 5 |
74 a-e |
N/A |
837/2300
H102-1=BQ (ICD-9) or = BBQ (ICD-10) |
|
MC206 |
Other ICD-CM Procedure code - 6 |
74 a-e |
N/A |
837/2300
H102-1=BQ (ICD-9) or = BBQ (ICD-10) |
|
MC207 |
Carrier Associated with Claim |
N/A |
N/A |
N/A |
|
MC208 |
Carrier Plan Specific contract Number |
N/A |
N/A |
N/A |
|
MC209 |
Practitioner Group Practice |
N/A |
N/A |
N/A |
|
MC210 |
Coordination of Benefits/Third Party Liability Amount |
54 |
29 |
835/2320
AMT02 |
|
MC211 |
Cross Reference Claims ID |
N/A |
N/A |
N/A |
|
MC212 |
Allowed Amount |
N/A |
N/A |
837/2300
HCP02 |
|
MC215 |
Service Line Type |
N/A |
N/A |
N/A |
|
MC216 |
Payment Arrangement Type |
N/A |
N/A |
Loop
2400 Segment HCP01 |
|
MC217 |
Pay for Performance Flag |
N/A |
N/A |
N/A |
|
MC218 |
Claim Processing Level Indicator |
N/A |
N/A |
N/A |
|
MC219 |
Denied Claim Indicator |
N/A |
N/A |
Loop
2430 CAS identification |
|
MC220 |
Denial Reason |
N/A |
N/A |
Loop
2430 CAS identification |
|
MC221 |
Procedure Modifier – 3 |
N/A |
N/A |
837/2430
SVD03-05 |
|
MC222 |
Procedure Modifier – 4 |
N/A |
N/A |
837/2430
SVD03-06 |
|
MC899 |
Record Type |
N/A |
N/A |
N/A |
|
MC900 |
In Network Indicator |
N/A |
N/A |
N/A |
|
MC901 |
Unit of Measure |
N/A |
N/A |
N/A |
|
MC902 |
Claim Source |
N/A |
N/A |
N/A |
|
MC903 |
Claim Received Date |
N/A |
N/A |
N/A |
|
MC904 |
Insurance Group Name |
62 |
11C |
N/A |
|
MC905 |
Prior Authorization |
63 |
23 |
837/2300 REF02 |
|
MC906 |
TPA Identifier |
N/A |
N/A |
N/A |
(c)
Pharmacy Claims File Mapping and Format Information:
|
Table 4009.07(c) Pharmacy Claims File Mapping and Format
Information |
||
|
Data Element |
Element |
National Council for Prescription Drug Programs Field # |
|
PC001 |
Payer |
N/A |
|
PC002 |
Plan ID |
N2 |
|
PC003 |
Insurance Type/Product Code |
N/A |
|
PC004 |
Payer Claim Control Number |
993-A7 |
|
PC005 |
Line Counter |
A91 |
|
PC006 |
Insured Group Number |
301-C1 |
|
PC007 |
Placeholder |
A89 |
|
PC008 |
Plan Specific Contract Number |
302-C2 |
|
PC009 |
Member Suffix or Sequence Number |
303-C3 |
|
PC010 |
Placeholder |
332-CY |
|
PC011 |
Individual Relationship Code |
306-C6 |
|
PC012 |
Member Gender |
305-C5 |
|
PC013 |
Member Date of Birth |
304-C4 |
|
PC014 |
Member City Name of Residence |
323-CN |
|
PC015 |
Member State or Province |
324-CO |
|
PC016 |
Member ZIP Code |
325-CP |
|
PC017 |
Paid Date (AP Date) |
216 or 578 |
|
PC018 |
Pharmacy Number |
202-B2 |
|
PC019 |
Pharmacy Tax ID Number |
N/A |
|
PC020 |
Pharmacy Name |
833-5P |
|
PC021 |
National Pharmacy ID Number |
N/A |
|
PC022 |
Pharmacy Location City |
831-5N |
|
PC023 |
Pharmacy Location State |
832-6F |
|
PC024 |
Pharmacy ZIP Code |
835-5R |
|
PC024A |
Pharmacy Country Name |
A93-IT |
|
PC025 |
Service Line Status |
N/A |
|
PC026 |
Drug Code |
407-D7 |
|
PC027 |
Drug Name |
516-FG |
|
PV028 |
New Prescription |
403-D3 |
|
PC029 |
Generic Drug Indicator |
425-DP |
|
PC030 |
Dispense as Written Code |
408-D8 |
|
PC031 |
Compound Drug Indicator |
406-D6 |
|
PC032 |
Date Prescription Filled |
401-D1 |
|
PC033 |
Quantity Dispensed |
442-E7 |
|
PC034 |
Days Supply |
405-D5 |
|
PC035 |
Charge Amount |
804-5B |
|
PC036 |
Paid Amount |
509-F9 |
|
PC037 |
Ingredient Cost/List Price |
506-F6 |
|
PC038 |
Postage Amount Claimed |
428-DS |
|
PC039 |
Dispensing Fee |
507-F7 |
|
PC040 |
Copay Amount |
518-FI |
|
PC041 |
Coinsurance Amount |
518-FI |
|
PC042 |
Deductible Amount |
505-F5 |
|
PC043 |
Prescription
Number |
402-D2 |
|
PC044 |
Prescribing Physician First Name |
717 |
|
PC045 |
Prescribing Physician Middle Name |
N/A |
|
PC046 |
Prescribing Physician Last Name |
716 |
|
PC047 |
Prescribing Physician Number |
411-DB |
|
PC101 |
Subscriber Last Name |
716 |
|
PC102 |
Subscriber First Name |
717 |
|
PC103 |
Subscriber Middle Initial |
718 |
|
PC104 |
Member Last Name |
716 |
|
PC105 |
Member First Name |
717 |
|
PC106 |
Member Middle Initial |
718 |
|
PC203 |
Carrier Associated with Claim |
N/A |
|
PC204 |
Carrier Plan Specific Contract Number |
N/A |
|
PC211 |
Cross Reference Claims ID |
N/A |
|
PC212 |
Allowed Amount |
N/A |
|
PC213 |
HIOS Plan ID |
N/A |
|
PC214 |
Claim Processing Level Indicator |
N/A |
|
PC215 |
Service Line Type |
N/A |
|
PC216 |
Denied Claim Indicator |
N/A |
|
PC217 |
Denial Reason |
511-FB |
|
PC899 |
Record Type |
N/A |
|
PC900 |
Mail Order Pharmacy Indicator |
N/A |
|
PC901 |
In Network Indicator |
N/A |
|
PC902 |
Version Number |
102-A2 |
|
PC903 |
Claim Source |
N/A |
|
PC904 |
Claim Received Date |
N/A |
|
PC905 |
Insurance Group Name |
N/A |
|
PC906 |
Coordination of Benefits/Third Party Liability Amount |
565-J4 |
|
PC907 |
PBM Identifier |
N/A |
|
PC908 |
Prior Authorization |
N/A |
|
PC909 |
Drug Unit of Measure |
N/A |
(d)
Dental Claims File Mapping and Format Information:
|
Table 4009.07(d) Dental Claims File Mapping and Format Information |
|||
|
Data Element # |
Data Element Name |
ADA Dental Claim |
HIPAA Reference Transaction Set/Loop/ Segment/Qualifier/ Data Element |
|
DC001 |
Payer |
N/A |
N/A |
|
DC002 |
National
Plan Id |
N/A |
N/A |
|
DC003 |
Insurance
Type/Product Code |
N/A |
835/2100/CLP/
/06 |
|
DC004 |
Payer
Claim Control Number |
N/A |
835/2100/CLP/
/07 |
|
DC005 |
Line
Counter |
N/A |
837/2400/LX/
/01 |
|
DC006 |
Insured
Group or Policy Number |
9 |
837/2000B/SBR/
/03 |
|
DC007 |
Placeholder |
|
|
|
DC008 |
Plan
Specific Contract Number |
8 |
835/2100/NM1/MI/08 |
|
DC009 |
Member
Suffix or Sequence Number |
N/A |
N/A |
|
DC010 |
Placeholder |
|
|
|
DC011 |
Individual
Relationship Code |
18 |
837/2000B/SBR/
/02, 837/20000C/PAT/ /01 |
|
DC012 |
Member
Gender |
14 |
837/2010BA/DMB/
/03, 837/2010CA/DMB/ /03 |
|
DC013 |
Member
Date of Birth |
13 |
837/2010BA/DMB/D8/02,
837/2010CA/DMB/D8/02 |
|
DC014 |
Member
City Name of Residence |
12 |
837/2010BA/N4/
/01, 837/2010CA/N4/ /01 |
|
DC015 |
Member
State or Province |
12 |
837/2010BA/N4/
/02, 837/2010CA/N4/ /02 |
|
DC016 |
Member
ZIP Code of Residence |
12 |
837/2010BA/N4/
/03, 837/2010CA/N4/ /03 |
|
DC017 |
Date
Service Approved |
N/A |
835/Header
Financial Information/BPR/ /16 |
|
DC018 |
Service
Provider Number |
49 |
835/21000/REF/1A/02,
835/2100/REF/1B/02, 835/2100/REF/1C/02,
835/2100/REF/1D/02, 835/2100/REF/G2/02, 835/2100/NM1/BD/09,
835/2100/NM1/BS/09, 835/2100/NM1/MC/09, 835/2100/NM1/PC/09 |
|
DC019 |
Service
Provider Tax ID Number |
51 |
835/2100/NM1/FI/09 |
|
DC020 |
National
Service Provider ID |
N/A |
837/2310B/NM1/XX/09 |
|
DC021 |
Service
Provider Entity Type Qualifier |
N/A |
837/2310B/NM1/82/02 |
|
DC022 |
Service
Provider First Name |
N/A |
837/2310B/NM1/82/04 |
|
DC023 |
Service
Provider Middle Name |
N/A |
837/2310B/NM1/82/05 |
|
DC024 |
Service
Provider Last Name or Organization Name |
N/A |
837/2310B/NM1/82/03 |
|
DC025 |
Service
Provider Suffix |
N/A |
837/2310B/NM1/82/07 |
|
DC026 |
Service
Provider Specialty |
56a |
837/2310B/PRV/PXC/03 |
|
DC027 |
Service
Provider City name |
56 |
837/2310C/N4/ /01 |
|
DC028 |
Service
Provider State or Province |
56 |
837/2310C /N4/ /02 |
|
DC029 |
Service
Provider ZIP Code |
56 |
837/2310C /N4/ /03 |
|
DC030 |
Facility
Type - Professional |
38 |
837/2300/CLM/05-1 |
|
DC031 |
Claim
Status |
N/A |
835/2100/CLP/ /02 |
|
DC032 |
CDT
Code |
29 |
837/2400/SV3/AD/01-2 |
|
DC033 |
Procedure
Modifier - 1 |
N/A |
837/2400/SV3/AD/01-3 |
|
DC034 |
Procedure
Modifier - 2 |
N/A |
837/2400/SV3/AD/01-4 |
|
DC035 |
Date
of Service - From |
24 |
837/2400/DTP/472/D8/03, 837/2300/DTP/472/D8/03 |
|
DC036 |
Date
of Service - Thru |
N/A |
837/2400/DTP/472/D8/03, 837/2300/DTP/472/D8/03 |
|
DC037 |
Charge
Amount |
31 |
837/2400/SV3/ /02 |
|
DC038 |
Paid
Amount |
N/A |
835/2110/SVC/ /03 |
|
DC039 |
Copay
Amount |
N/A |
835/2110/CAS/PR/3-03 |
|
DC040 |
Coinsurance
Amount |
N/A |
835/2110/CAS/PR/2-03 |
|
DC041 |
Deductible
Amount |
N/A |
835/2110/CAS/PR/1-03 |
|
DC042 |
Billing
Provider Number |
49 |
837/2010BB/REF/G2/02 |
|
DC043 |
National
Billing Provider ID |
N/A |
837/2010AA/NM1/XX/09 |
|
DC044 |
Billing
Provider Last Name |
48 |
837/2010AA/NM1/
/03 |
|
DC101 |
Subscriber
Last Name |
12 |
837/2010BA/NM1/
/03 |
|
DC102 |
Subscriber
First Name |
12 |
837/2010BA/NM1/
/04 |
|
DC103 |
Subscriber
Middle Initial |
12 |
837/2010BA/NM1/
/05 |
|
DC104 |
Member
Last Name |
20 |
837/2010BA/NM1/
/03, 837/2010CA/NM1/ /03 |
|
DC105 |
Member
First Name |
20 |
837/2010BA/NM1/
/04, 837/2010CA/NM1/ /04 |
|
DC106 |
Member
Middle Initial |
20 |
837/2010BA/NM1/
/05, 837/2010CA/NM1/ /05 |
|
DC201 |
Carrier
Associated with Claim |
N/A |
N/A |
|
DC202 |
Carrier
Plan Specific Contract Number |
15 |
N/A |
|
DC203 |
Practitioner
Group Practice |
N/A |
N/A |
|
DC204 |
Tooth
Number/Letter |
26 |
837/2400
TOO02 |
|
DC205 |
Dental
Quadrant |
25 |
N/A |
|
DC206 |
Tooth
Surface |
28 |
837/2400
TOO03 |
|
DC207 |
Claim
Version |
N/A |
N/A |
|
DC208 |
Diagnosis
Code |
34,
34a-d |
837/2300
H101-2 |
|
DC209 |
ICD
Indicator |
N/A |
N/A |
|
DC211 |
Cross
Reference Claims ID |
N/A |
N/A |
|
DC212 |
Allowed
Amount |
N/A |
837/2300
HCP02 |
|
DC213 |
HIOS
Plan ID |
N/A |
N/A |
|
DC215 |
Service
Line Type |
N/A |
N/A |
|
DC218 |
Claim
Processing Level Indicator |
N/A |
N/A |
|
DC219 |
Denied
Claim Indicator |
N/A |
N/A |
|
DC220 |
Denial
Reason |
N/A |
N/A |
|
DC899 |
Record
Type |
N/A |
N/A |
|
DC900 |
In
Network Indicator |
N/A |
N/A |
|
DC901 |
Quantity |
N/A |
N/A |
|
DC902 |
Claim
Source |
N/A |
N/A |
|
DC903 |
Claim
Received Date |
N/A |
N/A |
|
DC904 |
Insurance
Group Name |
N/A |
N/A |
|
DC905 |
Coordination
of Benefits/Third Party Liability Amount |
N/A |
835/2320
AMT02 |
|
DC906 |
TPA
Identifier |
11 |
N/A |
|
DC907 |
Prior
Authorization |
N/A |
N/A |
Source. #10877, eff 7-10-15;
ss by #13136, eff 11-24-20;
ss by #14560, eff 4-22-26, EXPIRES: 4-22-36 (formerly Ins 4010.07)
APPENDIX
|
RULE |
STATUTE |
|
Ins 4001.01 |
RSA 400-A:15, I; RSA 420-G:14 |
|
Ins 4002.01 |
RSA 400-A:15, I; RSA 420-G:14 |
|
Ins 4003.01 |
RSA 400-A:15, I; RSA 420-G:14 |
|
Ins 4003.02 |
RSA 400-A:15, I; RSA 420-G:14 |
|
Ins 4003.03 |
RSA 400-A:15, I; RSA 420-G:14 |
|
Ins 4004.01 |
RSA 400-A:15, I; RSA 420-G:14 |
|
Ins 4004.02 |
RSA 400-A:15, I; RSA 420-G:14 |
|
Ins 4004.03 |
RSA 400-A:15, I; RSA 420-G:14 |
|
Ins 4005.01 |
RSA 400-A:15, I; RSA 420-G:14 |
|
Ins 4005.02 |
RSA 400-A:15, I; RSA 420-G:14 |
|
Ins 4005.03 |
RSA 400-A:15, I; RSA 420-G:11; RSA 420-G:14 |
|
Ins 4006.01 |
RSA 400-A:15, I; RSA 420-G:14 |
|
Ins 4006.02 |
RSA 400-A:15, I; RSA 420-G:14 |
|
Ins 4006.03 |
RSA 400-A:15, I; RSA 420-G:14 |
|
Ins 4006.04 |
RSA 400-A:15, I; RSA 420-G:14 |
|
Ins 4006.05 |
RSA 400-A:15, I; RSA 420-G:14 |
|
Ins 4006.06 |
RSA 400-A:15, I; RSA 420-G:14 |
|
Ins 4007.01 |
RSA 400-A:15, I; RSA 420-G:14 |
|
Ins
4008.01 |
RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21,
VI(a)(2) |
|
Ins
4008.02 |
RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21,
VI(a)(2) |
|
Ins
4008.03 |
RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21,
VI(a)(2) |
|
Ins
4008.04 |
RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21,
VI(a)(2) |
|
Ins
4009.01 |
RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21,
VI(a)(2) |
|
Ins
4009.02 |
RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21,
VI(a)(2) |
|
Ins
4009.03 |
RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21,
VI(a)(2) |
|
Ins
4009.04 |
RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21,
VI(a)(2) |
|
Ins
4009.05 |
RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21,
VI(a)(2) |
|
Ins
4009.06 |
RSA 400-A:15, I; RSA 420-G:14; RSA 541-A:21,
VI(a)(2) |
|
Ins
4009.07 |
RSA
400-A:15, I; RSA 420-G:14; RSA 541-A:21, VI(a)(2) |