129 C.M.R. 2.11
(2) Header and Trailer Records. Each member eligibility file and each medical claims file, and pharmacy claims file that is submitted shallcontain a header record and a trailer record. The "Header record" means the first record of each separate file that is submitted and the "Trailer record" means the last record of each submitted file. The header and trailer record format shall conform to the record specifications in 129 CMR 2.11(2)(a):
(a) Record Specifications. Carriers shall use the record specifications in 129 CMR 2.11(2)(a) through (d) in submitting their claims records. The file header record layout shall be submitted using the data elements in 129 CMR 2.11(2)(a)1. through 8.:
(b) The file header record layout shall conform to the following Table 1:
Table 1: File Header Record Layout
Maximum
Data Element # Element Type Description/Codes/Sources
Length
HD001 Record Type Text 2 HD HD002 Payer Text 6 Payer submitting payments
Council Submitter Code
HD003 National Plan ID Text 30 CMS National Plan ID HD004 Type of File Text 2 MA Member Eligibility
MC Medical Claims PC Pharmacy Claims
HD005 Period Beginning Date Integer 6 CCYYMM
Beginning of paid period for claims Beginning of month covered for eligibility
HD006 Period Ending Date Integer 6 CCYYMM
End of paid period for claims End of month covered for eligibility
HD007 Record Count Integer 10 Total number of records submitted in this file HD008 Comments Text 80 Submitter may use to document this
submission by assigning a filename, system source, etc.
(c) The trailer header record layout shall be submitted using the data elements in 129 CMR 2.11(2)(a)3.a. through g.:
(d) The trailer record layout shall conform to the following Table 2:
Table 2: Trailer Record Layout
Maximum
Data Element # Element Type Description/Codes/Sources
Length
TR001 Record Type Text 2 TR TR002 Payer Text 6 Payer submitting payments
Council Submitter Code
TR003 National Plan ID Text 30 CMS National Plan ID TR004 Type of File Text 2 MA Member Eligibility
MC Medical Claims PC Pharmacy Claims
TR005 Period Beginning Date Integer 6 CCYYMM
Beginning of paid period for claims Beginning of month covered for eligibility
TR006 Period Ending Date Integer 6 CCYYMM
End of paid period for claims End of month covered for eligibility
TR007 Date Processed Date 8 CCYYMMDD
Date file was created
(3) Member Eligibility File.
(a) The specifications for the member eligibility file are listed in 129 CMR 2.11(3)(a)1. and 2.
3. ME003. This element is named "insurance type code/product". The data type of this element is text. Its length is 2. Carriers shall code according to the following Table 3:
Table 3: Insurance Type Code/Product
Code Description
12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 Medicare Secondary End-Stage Renal Disease Beneficiary in the 12-month coordination
period with an Employer 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 or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veterans' Administration 43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan
(LGHP)
47 Medicare Secondary Other Liability Insurance is Primary AP Auto Insurance Policy CP Medicare Conditionally Primary D Disability
DB Disability Benefits EP Exclusive Provider Organization (for self-insured risks) HM Health Maintenance Organization (HMO) HN Health Maintenance Organization (HMO) Medicare Advantage HS Special Low Income Medicare Beneficiary IN Indemnity LC Long Term Care LD Long Term Policy LI Life Insurance LT Litigation MA Medicare Part A MB Medicare Part B MC Medicaid MH Medigap Part A MI Medigap Part B MP Medicare Primary PR Preferred Provider Organization (PPO) PS Point of Service (POS) QM Qualified Medicare Beneficiary SP Supplemental Policy WC Workers' Compensation
7. ME007. This element is named "coverage level code". The data type of this element is text. Its length is 3. Carriers shall code according to the benefit coverage level:
12. ME012. This element is named "individual relationship code". The data type of this element is integer. Its length is 2. Carriers shall code according to the member's relationship to the subscriber as shown on the following Table 4:
Table 4: Individual Relationship Code
Code Description 01 Spouse 18 Self/Employee 19 Child 21 Unknown 34 Other Adult
13. ME013. This element is named "member gender". The data type of this element is text. Its length is1. Carriers shall code according to:
18. ME018. This element is named "medical coverage". The data type of this element is text. Its length is 1. Carriers shall code according to:
19. ME019. This element is named "prescription drug coverage". The data type of this element is text. Its length is 1. Coverage for limited supplies only, such as diabetic test-strips, syringes, and birth control, shall be coded as “No”. Carriers shall code according to:
21. ME021. This element is named “race 2”. The data type of this element is text. Its length is 6. Carriers shall code according to the Race Code below. If none, set as null.
Table 5: Race Code
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
23. ME023. This element is named “Hispanic indicator”. The data type of this element is text. Its length is 1. Carriers shall code according to:
24. ME025. This element is named “ethnicity 2”. The data type of this element is text. Its length is 6. Carriers shall code according to the Ethnicity Code in Table 6.
Table 6: Ethnicity Code
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
27. MEO27. This element is named "language." The data type of this element is text. Its length is 20. Carriers shall code according to the language code as follows in Table 7.
Table 7: Language Code
Code Description
799 African Languages (please specify)
777 Arabic
708 Chinese (please specify)
601 Cape Verdean Creole
600 English
620 French
607 German
637 Greek
623 Haitian Creole
778 Hebrew
663 Hindi
619 Italian
723 Japanese
724 Korean
656 Persian
645 Polish
629 Portuguese
639 Russian
625 Spanish
742 Tagalog
671 Urdu
728 Vietnamese
997 Other Language (please specify)
998 Declined
999 Unavailable
(b) The specifications for the member eligibility file shall be submitted using the following Table 8:
Table 8: Member Eligibility File Layout
Data Max.
Element Type Description/Codes/Sources
Element # Length ME001 Payer Text 6 Payer submitting payments
Council Submitter Code
ME002 National Plan ID Text 30 CMS National Plan ID ME003 Insurance Type Text 2 12 Medicare Secondary Working Aged Beneficiary or Spouse
Code/Product w ith Employer Group Health Plan
13 Medicare Secondary End-Stage Renal Disease Beneficiary in the 12-month coordination period w ith an Employer 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 or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veterans Administration 43 Medicare Secondary Disabled Beneficiary Under Age 65 w ith Large Group Health Plan (LGHP) 47 Medicare Secondary, Other Liability Insurance is Primary AP Auto Insurance Policy CP Medicare Conditionally Primary D Disability DB Disability Benefits EP Exclusive Provider Organization HM Health Maintenance Organization (HMO) HN Health Maintenance Organization (HMO) Medicare Risk HS Special Low Income Medicare Beneficiary IN Indemnity LC Long Term Care LD Long Term Policy LI Life Insurance LT Litigation
Table 8: Member Eligibility File Layout (continued)
Data Max.
Element Type Description/Codes/Sources
Element # Length
MA Medicare Part A MB Medicare Part B MC Medicaid MH Medigap Part A MI Medigap Part B MP Medicare Primary PR Preferred Provider Organization (PPO) PS Point of Service (POS) QM Qualified Medicare Beneficiary SP Supplemental Policy WC Workers' Compensation
ME004 Year Integer 4 Year for which eligibility is reported in this submission ME005 Month Integer 2 Month for which eligibility is reported in this submission ME006 Insured Group or Text 30 Group or policy number (not the number that uniquely
Policy Number identifies the subscriber)
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
ME008 Encrypted Subscriber Text 30 Encrypted subscriber's unique identification number (set as
Unique Identification null if unavailable) Number
ME009 Plan Specific Contract Text 30 Encrypted plan assigned contract number (set as null if
Number contract number = subscriber's social security number)
ME010 Member Suffice or Integer 2 Uniquely numbers the member within the contract
Sequence Number
ME011 Member Identification Text 30 Encrypted member's unique identification number (set as null
Code if unavailable)
ME012 Individual Relationship Integer 2 Member's relationship to insured
Code
01 Spouse 18 Self/Employee
Table 8: Member Eligibility File Layout (continued)
Data Max.
Element Type Description/Codes/Sources
Element # Length
19 Child 21 Unknown 34 Other Adult
ME013 Member Gender Text 1 M Male
F Female U Unknown
ME014 Member Date of Birth Date 8 CCYYMMDD ME015 Member City Name Text 30 City name of member ME016 Member State or Text 2 As defined by the US Postal Service
Province
ME017 Member ZIP Code Text 11 ZIP Code of member – may include non-US codes. (Do not
include dash)
ME018 Medical Coverage Text 1 Y Yes
N No
ME019 Prescription Drug Text 1 Y Yes
Coverage
N No
ME020 Race 1 Text 6 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
ME021 Race 2 Text 6 R1 American Indian/Alaska Native
R2 Asian R3 Black/African American R4 Native Hawaiian or other Pacific Islander R5 White R9 Other Race UNKNOWN Unknown/not specified
ME022 Other Race Text 15 Patient Race, if Race 1 or Race 2 is entered as R9 Other
Race (set as null if none)
ME023 Hispanic Indicator Text 1 Y Patient is Hispanic/Latino/Spanish
N Patient is not Hispanic/Latino/ Spanish U Unknown
ME024 Ethnicity 1 Text 6 2182-4 Cuban
2184-0 Dominican
Table 8: Member Eligibility File Layout (continued)
Data Max.
Element Type Description/Codes/Sources
Element # Length
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
ME025 Ethnicity 2 Text 6 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)
Table 8: Member Eligibility File Layout (continued)
Data Max.
Element Type Description/Codes/Sources
Element # Length
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
ME026 Other Ethnicity Text 20 Patient Ethnicity if Ethnicity 1 or Ethnicity 2 is entered as
OTHER Other Ethnicity. (set as null if none)
ME027 Language Text 20 799 Africian Language (please specify)
777 Arabic 708 Chinese (please specify) 601 Cape Verdean Creole 600 English 620 French 607 German 637 Greek 623 Haitian Creole 778 Hebrew 663 Hindi 619 Italian 723 Japanese
Table 8: Member Eligibility File Layout (continued)
Data Max.
Element Type Description/Codes/Sources
Element # Length
724 Korean 656 Persian 645 Polish 629 Portuguese 639 Russian 625 Spanish 742 Tagalog 671 Urdu 728 Vietnamese 997 Other Language (please specify) 998 Declined 999 Unavailable
ME028 Record Type Text 2
(c) The member eligibility file shall be mapped to a nationalstandard format that conforms to the following Table 9:
Table 9: Member Eligibility File Mapping
Data HIPAA Reference Transaction
Element
Element # 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 ME008 Encrypted Subscriber Unique 271/2100C/NM1/MI/09
Identification Number
ME009 Plan Specific Contract Number 271/2100C/NM1/MI/09 ME010 Member Suffix or Sequence Number N/A ME011 Member Identification Code 271/2100C/MN1/MI/09, 271/2100D/NM1/MI/09 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 Race 1 N/A ME021 Race 2 N/A ME022 Other Race N/A ME023 Hispanic Indicator N/A ME024 Ethnicity 1 N/A ME025 Ethnicity 2 N/A ME026 Other Ethnicity N/A ME027 Language N/A
(4) Medical Claim File.
(a) Medical claim file shallbe submitted using the data elements in 129 CMR 2.11(4)(a)1. through 69.:
3. MC003. This element is named "insurance type/product code". The data type of this element is text. Its length is 2. Carriers shall code according to the following Table 10:
Table 10: Insurance Type/Product Code
Code Description
12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 16 Health Maintenance Organization (HMO) Medicare Risk
DS Disability HM Health Maintenance Organization MA Medicare Part A MB Medicare Part B MC Medicaid VA Veterans Administration Plan WC Workers' Compensation
12. MC011. This element is named "individual relationship code". The data type of this element is integer. Its length is 2. Carriers shall code according to member's relationship to subscriber shown as follows in Table 11:
Table 11: Individual Relationship Code
Code Description 1 Spouse 4 Grandfather or Grandmother 5 Grandson or Granddaughter 7 Nephew or Niece 10 Foster Child 15 Ward 17 Stepson or Stepdaughter 19 Child 20 Employer 21 Unknown 22 Handicapped Dependent 23 Sponsored Dependent 24 Dependent of a Minor Dependent 29 Significant Other 32 Mother 33 Father 36 Emancipated Minor 39 Organ Donor 40 Cadaver Donor 41 Injured Plaintiff 43 Where Insured Has No Financial Responsibility 53 Life Partner 76 Dependent
13. MC012. This element is named "member gender". The data type of this element is text. Its length is 1. Carriers shall code according to:
21. MC020. This element is named "admission type". The data type of this element is text. Its length is 1. Carriers shall code using an integer shown as follows in Table 12:
Table 12: Admission Type
Code Description
1 Emergency 2 Urgent 3 Elective 4 Newborn 5 Trauma Center 9 Information Not Available
22. MC021. This element is named "admission source". The data type of this element is text. Its length is 1. Carriers shall code using text shown as follows in Table 13:
Table 13: Admission Source
Code Description 1 Physician Referral 2 Clinic Referral 3 HMO Referral 4 Transfer from Hospital 5 Transfer from a Skilled Nursing Facility 6 Transfer from another Health Care Facility 7 Emergency Room 8 Court/Law Enforcement 9 Unknown A Transfer from a Rural Primary Care Hospital
24. MC023. This element is named “discharge status". The data type of this element is integer. Its length is 2. Carriers shall code shown as follows in Table 14:
Table 14: 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 nursing facility (NF)
Discharged/transferred to another type of institution for inpatient care or referred for outpatient
05
services to another institution
06 Discharged/transferred to home under care of organized home health service organization 07 Left against medical advice or discontinued care 08 Discharged/transferred to home under care of a Home IV provider 09 Admitted as an inpatient to this hospital
20 Expired 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
28. MC027. This element is named "service provider entity type qualifier". The data type of this element is text. Its length is 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 a "person", and these shall be coded as a person. Carriers shall code according to:
37. MC036. This element is named "type of bill on Facility Claims". The data type of this element is integer. Its length is 2. Carriers shall use this coding on facility claims, including those submitted using UB92 forms, shown as follows in Table 15:
Table 15: Type of Bill on Facility Claims
First Digit Type of Facility
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
Second Digit if First
Bill Classification
Digit = 1 through 6
1 Inpatient (including Medicare Part A) 2 Inpatient (including 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
Second Digit if First
Bill Classification
Digit = 7
1 Rural Health 2 Hospital Based or Independent Renal 3 Dialysis Center 4 Free Standing 5 Outpatient Rehabilitation Facility (ORF) 6 Comprehensive Outpatient Rehabilitation 7 Facilities (CORFs) 9 Other
Second Digit if First
Bill Classification
Digit = 8
1 Hospice, Non-hospital based 2 Hospital, Hospital based 3 Ambulatory Surgery Center 4 Free Standing Birthing Center 9 Other
38. MC037. This element is named "site of service on NSF/CMS 1500 claims". The data type of this element is text. Its length is 2. Carriers shall use this coding on professional claims, including those submitted using NSF CMS 1500 forms, shown as follows in Table 16:
Table 16: Site of Service on NSF/CMS 1500 Claims
Code Facility
11 Office 12 Home 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room – Hospital 24 Ambulatory Surgery Center 25 Birthing Center 26 Military Treatment Facility 31 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice 41 Ambulance – Land 42 Ambulance –Air or Water 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 60 Mass Immunization Center 61 Comprehensive Inpatient Rehabilitation Facility 62 Comprehensive Outpatient Rehabilitation Facility 65 End Stage Renal Disease Treatment Facility 71 State of Local Public Health Clinic 72 Rural Health Clinic 81 Independent Laboratory 99 Other Unlisted Facility
39. MC038. This element is named "claim status". The data type of this element is integer. Its length is 2. This code describes the payment status of the specific service line record. Carriers shall code according to 129 CMR 2.11(4)(a)39.a. through h.:
(b) The file specification for the medical claim file shall conform to the following Table 17:
Table 17: Medical Claims File Layout
Data
Max.
Element Data Element Name Type Description/Codes/Sources
Length
#
MC001 Payer Text 6 Payer submitting payments
Council Submitter Code
MC002 National Plan ID Text 30 CMS National Plan ID MC003 Insurance Type/ Text 2 12 Preferred Provider Organization (PPO)
Product Code
13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 16 Health Maintenance Organization (HMO) Medicare Risk DS Disability HM Health Maintenance Organization MA Medicare Part A MB Medicare Part B MC Medicaid VA Veteran Administration Plan WC Worker's Compensation
MC004 Payer Claim Control Text 35 Must apply to the entire claim and be unique w ithin the
Number payer's system
MC005 Line Counter Integer 4 Line number for this service
The line counter begins w ith 1 and is incremented by 1 for each additional service line of a claim
MC005A Version Number Integer 4 Version number of this claim service line
The version number begins w ith 0 and is incremented by 1 for each subsequent version of that service line
MC006 Insured Group or Text 30 Group or policy number (not the number that uniquely
Policy Number identifies the subscriber)
MC007 Encrypted Text 30 Encrypted subscriber’s Unique Identification number Set as
Subscriber Unique null if unavailable Identification Number
MC008 Plan Specific Text 30 Encrypted plan assigned Set as null if contract number =
Contract Number subscriber’s social security number
MC009 Member Suffix or Integer 2 Uniquely numbers the member w ithin the contract
Sequence Number
MC010 Member Text 30 Encrypted member’s Unique Identification number Set as
Identification Code null if unavailable
MC011 Individual Integer 2 Member's relationship to subscriber
Relationship Code
01 Spouse 04 Grandfather or Grandmother 05 Grandson or Granddaughter 07 Nephew or Niece 10 Foster Child 15 Ward 17 Stepson or Stepdaughter 19 Child 20 Employee
Table 17: Medical Claims File Layout (continued)
Data
Max.
Element Data Element Name Type Description/Codes/Sources
Length
#
21 Unknow n 22 Handicapped Dependent 23 Sponsored Dependent 24 Dependent of a Minor Dependent 29 Significant Other 32 Mother 33 Father 36 Emancipated Minor 39 Organ Donor 40 Cadaver Donor 41 Injured Plaintiff 43 Where Insured Has No Financial Responsibility 53 Life Partner 76 Dependent
MC012 Member Gender Text 1 M Male
F Female U Unknow n
MC013 Member Date of Date 8 CCYYMMDD
Birth
MC014 Member City Name Text 30 City name of member MC015 Member State or Text 2 As defined by the US Postal Service
Province
MC016 Member ZIP Code Text 11 ZIP Code of member - may include non-US codes MC017 Date Service Date 8 CCYYMMDD
Approved (AP Date)
(Generally the same as the paid date)
MC018 Admission Date Date 8 Required for all inpatient claims
CCYYMMDD
MC019 Admission Hour Integer 4 Required for all inpatient claims
Time is expressed in military time – HH or HHMM
MC020 Admission Type Integer 1 MC021 Admission Source Text 1 MC022 Discharge Hour Integer 4 Hour in military time – HH or HHMM
MC022A Discharge Date Date 8 Required for all inpatient claims CCYYMMDD MC023 Discharge Status Integer 2 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 nursing facility (NF) 05 Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution 06 Discharged/transferred to home under care of organized home health service organization 07 Left against medical advice or discontinued care 08 Discharged/transferred to home under care of a Home IV provider
Table 17: Medical Claims File Layout (continued)
Data
Max.
Element Data Element Name Type Description/Codes/Sources
Length
#
09 Admitted as an inpatient to this hospital 20 Expired 30 Still patient or expected to return for outpatient services
MC024 Service Provider Text 30 Payer assigned provider number
Number
MC025 Service Provider Tax Text 10 Federal taxpayer's identification number
ID Number
MC026 National Service Text 20 Required if National Provider ID is mandated for use under
Provider ID HIPAA
MC027 Service Provider Text 1 1 Person
Entity Type Qualifier 2 Non-Person Entity
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”.
MC028 Service Provider Text 25 Individual first name
First Name
Set to null if provider is a facility or organization
MC029 Service Provider Text 25 Individual middle name or initial
Middle Name
Set to null if provider is a facility or organization
MC030 Service Provider Text 50 Full name of provider organization or last name of individual
Last Name or provider Organization Name
MC031 Service Provider Text 10 Suffix to individual name
Suffix
Set to null 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 Text 10 As defined by payer
Specialty
Dictionary for specialty code values must be supplied during testing
MC033 Service Provider Text 30 City name of provider - preferably practice location
City Name
MC034 Service Provider Text 2 As defined by the US Postal Service
State
MC035 Service Provider ZIP Text 11 ZIP Code of provider - may include non-US codes Do not
Code include dash
MC035A Service Provider Text 30 Country name of provider - preferably practice location
Country Name
Table 17: Medical Claims File Layout (continued)
Data
Max.
Element Data Element Name Type Description/Codes/Sources
Length
#
MC036 Type of Bill – on Integer 2 Type of Facility - First Digit
Facility Claims (Should be coded on 1 Hospital facility claim s, such as those subm itted using on UB92 form s)
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 Sw ing Beds Bill Classification - Second Digit if First Digit = 7 1 Rural Health 2 Hospital Based or Independent Renal 3 Dialysis Center 4 Free Standing 5 Outpatient Rehabilitation Facility (ORF) 6 Comprehensive Outpatient Rehabilitation 7 Facilities (CORFs) 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
MC037 Site of Service – on Text 2 11 Office
NSF/CMS 1500 Claims (Should be coded on 12 Home professional claim s, such as those subm itted using NSF [CMS 1500 form s])
21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room – Hospital
Table 17: Medical Claims File Layout (continued)
Data
Max.
Element Data Element Name Type Description/Codes/Sources
Length
#
24 Ambulatory Surgery Center 25 Birthing Center 26 Military Treatment Facility 31 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice 41 Ambulance – Land 42 Ambulance – Air or Water 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 50 Federally Qualified Center 60 Mass Immunization Center 61 Comprehensive Inpatient Rehabilitation Facility 62 Comprehensive Outpatient Rehabilitation Facility 65 End Stage Renal Disease Treatment Facility 71 State of Local Public Health Clinic 72 Rural Health Clinic 81 Independent Laboratory 99 Other Unlisted Facility
MC038 Claim Status Integer 2 01 Processed as primary
(Actually describes 02 Processed as secondary the paym ent status of the specific service line record)
03 Processed as tertiary 04 Denied 19 Processed as primary, forw arded to additional payer(s) 20 Processed as secondary, forw arded to additional payer(s) 21 Processed as tertiary, forw arded to additional payer(s) 22 Reversal of previous payment
MC039 Admitting Diagnosis Text 5 Required on all inpatient admission claims and encounters
ICD-9-CM Do not code decimal point
MC040 E-Code Text 5 Describes an injury, poisoning or adverse effect
ICD-9-CM Do not include decimal
MC041 Principal Diagnosis Text 5 ICD-9-CM Do not code decimal point
This should be the principal diagnosis given on the claim header.
MC042 Other Diagnosis – 1 Text 5 ICD-9-CM Do not code decimal point MC043 Other Diagnosis – 2 Text 5 ICD-9-CM Do not code decimal point MC044 Other Diagnosis – 3 Text 5 ICD-9-CM Do not code decimal point MC045 Other Diagnosis – 4 Text 5 ICD-9-CM Do not code decimal point
Table 17: Medical Claims File Layout (continued)
Data
Max.
Element Data Element Name Type Description/Codes/Sources
Length
#
MC046 Other Diagnosis – 5 Text 5 ICD-9-CM Do not code decimal point MC047 Other Diagnosis – 6 Text 5 ICD-9-CM Do not code decimal point MC048 Other Diagnosis – 7 Text 5 ICD-9-CM Do not code decimal point MC049 Other Diagnosis – 8 Text 5 ICD-9-CM Do not code decimal point MC050 Other Diagnosis – 9 Text 5 ICD-9-CM Do not code decimal point MC051 Other Diagnosis – 10 Text 5 ICD-9-CM Do not code decimal point MC052 Other Diagnosis – 11 Text 5 ICD-9-CM Do not code decimal point MC053 Other Diagnosis – 12 Text 5 ICD-9-CM Do not code decimal point MC054 Revenue Code Text 4 National Uniform Billing Committee Codes
Code using leading zeroes, left-justified, and four digits.
MC055 Procedure 1 Code Text 5 Health Care Common Procedural Coding System (HCPCS)
This includes the CPT codes of the American Medical Association
MC056 Procedure 1 Text 2 Procedure modifier required w hen a modifier clarifies/
Modifier – 1 improves the reporting accuracy of the associated procedure
code
MC057 Procedure 1 Text 2 Procedure modifier required w hen a modifier clarifies/
Modifier – 2 improves the reporting accuracy of the associated procedure
code
MC058 ICD-9-CM Text 4 Primary ICD-9-CM code given on the claim header. Do not
Procedure 1 Code code decimal point
MC059 Date of Service – Date 8 First date of service for this service line
From
CCYYMMDD
MC060 Date of Service – Date 8 Last date of service for this service line
Through
CCYYMMDD
MC061 Quantity Integer 3 Count of services performed
Should be set equal to 1 on all Observation bed service lines, for consistency.
MC062 Charge Amount Decimal 10 Do not code decimal point MC063 Paid Amount Decimal 10 Includes any w ithhold amounts
Do not code decimal point
MC064 Prepaid Amount Decimal 10 For capitated services, the fee for service equivalent amount
Do not code decimal point
MC065 Copay Amount Decimal 10 The preset, fixed dollar amount for w hich the individual is
responsible Do not code decimal point
MC066 Coinsurance Amount Decimal 10 Do not code decimal point MC067 Deductible Amount Decimal 10 Do not code decimal point MC068 Record Type Text 2 MC
(c) The mapping for medical claims file shall conform to the following national standard in Table 18:
Table 18: Medical Claims File Mapping
UB-92 HIPAA Reference
UB-92 (Version HCFA NSF (National Transaction Form 6.0) Record 1500 Standard Format) Set/Loop/Segment/
Type/ Qualifier/
Data
Data Element Name Locator Field # # Locator Data Element
Element #
MC001 Payer N/A N/A N/A N/A N/A MC002 National Plan ID N/A N/A N/A N/A 835/1000A/N1/XV/04 MC003 Product/Claim Filing N/A 30/4 N/A N/A 835/2100/CLP/ /06
Indicator Code
MC004 Payer Claim Control N/A N/A N/A FA0-02.0, FB0-02.0, 835/2100/CLP/ /07
Number FB1-02.0, GA0-02.0,
GC0-02.0, GX0-02.0, GX2-02.0, HA0-02.0, FB2-02.0, GU0-02.0
MC005 Line Counter N/A N/A N/A N/A 837/2400/LX/ /01 MC006 Insured Group or Policy 62 (A-C) 30/10 11C DA0-10.0 837/2000B/SBR/ /03
Number
MC007 Encrypted Subscriber N/A N/A N/A N/A 835/2100/NM1/34/08
Unique Identification Number
MC008 Plan Specific Contract N/A N/A N/A N/A 835/2100/NM1/HN/08
Number
MC009 Member Suffix or N/A N/A N/A N/A N/A
Sequence Number
MC010 Member Identification N/A N/A N/A N/A 835/2100/NM1/34/08
Code
MC011 Individual Relationship 59 (A-C) 30/18 6 DA0-17.0 837/2000B/SBR/ /02,
Code 837/2000C/PAT/ /01
MC012 Member Gender 15 20/7 3 CA0-09.0 837/2010CA/DMG/03 MC013 Member Date of Birth 14 20/8 3 CA0-08.0 837/2010CA/DMG/D8/02 MC014 Member City Name 13 20/14 5 CA0-13.0 837/2010CA/N4/ /01 MC015 Member State or Province 13 20/15 5 CA0-14.0 837/2010CA/N4/ /02 MC016 Member ZIP Code 13 20/16 5 CA0-15.0 837/2010CA/N4/ /03 MC017 Date Service Approved N/A N/A N/A N/A N/A MC018 Admission Date 17 20/17 N/A N/A 837/2300/DTP/435/03 MC019 Admission Hour 18 20/18 N/A N/A 837/2300/DTP/435/03 MC020 Admission Type 19 20/10 N/A N/A 837/2300/CL1/ /01 MC021 Admission Source 20 20/11 N/A 837/2300/CL1/ /02 MC022 Discharge Hour 21 20/22 N/A 837/2300/DTP/096/03 MC023 Discharge Status 22 20/21 N/A N/A 837/2300/CL1/ /03 MC024 Service Provider Number N/A N/A N/A N/A N/A
MC025 Service Provider Tax ID 5 10/4-5 25 BA0-09.0, CA0-28.0, 835/2100/NM1/FI/09
Number BA0-02.0, BA1-02.0,
YA0-02.0,BA0-06.0, BA0-10.0, BA0-12.0, BA0-13.0, BA0-14.0, BA0-15.0, BA0-16.0, BA0-17.0, BA0-24.0, YA0-06.0
Table 18: Medical Claims File Mapping (continued)
UB-92 HIPAA Reference
UB-92 (Version HCFA NSF (National Transaction Form 6.0) Record 1500 Standard Format) Set/Loop/Segment/
Type/ Qualifier/
Data
Data Element Name Locator Field # # Locator Data Element
Element # MC026 National Service Provider N/A 10/6 N/A N/A 835/2100/NM1/XX/09
ID
MC027 Service Provider Entity N/A N/A N/A N/A 835/2100/NM1/82/02
Type Qualifier
MC028 Service Provider First 1 10/12 33 BA0-20.0 835/2100/NM1/82/04
Name
MC029 Service Provider Middle 1 10/12 33 BA0-21.0 835/2100/NM1/82/05
Name
MC030 Service Provider Last 1 10/12 33 BA0-18.0, BA0-19.0 835/2100/NM1/82/03
Name or Organization Name
MC031 Service Provider Suffix 1 10/12 33 BA0-22.0 835/2100/NM1/82/07 MC032 Service Provider Specialty N/A N/A N/A N/A 837/2000A/PRV/ZZ/03 MC033 Service Provider City 1 10/14 N/A BA1-09.0, 15.0 837/2010A/N4/ /01
Name
MC034 Service Provider State or 1 10/15 N/A BA1-10.0, 16.0 837/2010A/N4/ /02
Province
MC035 Service Provider ZIP 1 10/16 N/A BA1-11.0, 17.0 837/2010A/N4/ /03
Code
MC036 Type of Bill – on Facility 4 Positions N/A N/A 837/2300/CLM/ /05-1
Claims 1-2: 40/4
MC037 Site of Service – on N/A N/A N/A FA0-07.0, GU0-0.50 835/2100/CLP/ /08
NSF/CMS 1500 Claims
MC038 Claim Status N/A N/A N/A N/A 835/2100/CLP/ /02 MC039 Admitting Diagnosis 76 70/25 N/A N/A 837/2300/HI/BJ/02-2 MC040 E-Code 77 70/26 N/A N/A 837/2300/HI/BN/03-2 MC041 Principal Diagnosis 67 70/4 21.1 EA0-32.0, GX0-31.0, 837/2300/HI/BK/01-2
GU0-12.0
MC042 Other Diagnosis – 1 68 70/5 21.2 EA0-33.0, GX0-32.0, 837/2300/HI/BF/02-1
GU0-13.0
MC043 Other Diagnosis – 2 69 70/6 21.3 EA0-33.0, GX0-32.0, 837/2300/HI/BF/02-2
GU0-13.0
MC044 Other Diagnosis – 3 70 70/7 21.4 EA0-33.0, GX0-32.0, 837/2300/HI/BF/02-3
GU0-13.0
MC045 Other Diagnosis – 4 71 70/8 N/A EA0-35.0, GX0-34.0, 837/2300/HI/BF/02-4
GU0-15.0
MC046 Other Diagnosis – 5 72 70/9 N/A N/A 837/2300/HI/BF/02-5 MC047 Other Diagnosis – 6 73 70/10 N/A N/A 837/2300/HI/BF/02-6 MC048 Other Diagnosis – 7 74 70/11 N/A N/A 837/2300/HI/BF/02-7 MC049 Other Diagnosis – 8 75 70/12 N/A N/A 837/2300/HI/BF/02-8 MC050 Other Diagnosis – 9 N/A N/A N/A N/A 837/2300/HI/BF/02-9 MC051 Other Diagnosis –10 N/A N/A N/A N/A 837/2300/HI/BF/02-10 MC052 Other Diagnosis –11 N/A N/A N/A N/A 837/2300/HI/BF/02-11 MC053 Other Diagnosis –12 N/A N/A N/A N/A 837/2300/HI/BF/02-12 MC054 Revenue Code 42 50/5,11-13, N/A N/A 835/2110/SVC/RB/01-2,
60/5,15-16, 835/2110/SVC/NU/01-2 61/5,15-16
Table 18: Medical Claims File Mapping (continued)
UB-92 HIPAA Reference
UB-92 (Version HCFA NSF (National Transaction Form 6.0) Record 1500 Standard Format) Set/Loop/Segment/
Type/ Qualifier/
Data
Data Element Name Locator Field # # Locator Data Element
Element # MC055 Procedure Code 44 60/6,15-16, 24.1-6 FA0-09.0, FB0-15.0, 835/2110/SVC/HC/01-2
61/6,15-16 D GU0-07.0
MC056 Procedure Modifier – 1 44 60/7,15-16, 24.1-6 FA0-10.0, GU0-08.0 835/2110/SVC/HC/01-3
61/7, 15-16 D
MC057 Procedure Modifier – 2 44 60/8,15-16, 24.1-6 FA0-11.0 835/2110/SVC/HC/01-3
61/8,15-16 D
MC058 ICD-9-CM Procedure 80, 70/13, 15, N/A N/A 835/2110/SVC/ID/01-2
Code 81(A-E) 17, 19, 21,
23
MC059 Date of Service – From 45 61/13, 15 24.1-6 N/A 835/2110/DTM/150/02
16, 61/13, A 15-16
MC060 Date of Service – Thru N/A N/A 24.1-6 FA0-05.0, FA0-06.0 835/2110/DTM/151/02
A
MC061 Quantity 46 50/7, 11-13, 24.1-6 FA0-19.0, FB0-16.0 835/2110/SVC/ /05
60/9,15-16, G 61/9,15-16
MC062 Charge Amount 47 50/8, 11-13, 24.1-6F FA0-13.0 835/2110/SVC/ /02
60/10, 16 16, 61/11, 15-16
MC063 Paid Amount 48 N/A N/A N/A 835/2110/SVC/ /03 MC064 Prepaid Amount N/A N/A N/A N/A N/A MC065 Co-pay Amount N/A N/A N/A N/A N/A MC066 Coinsurance Amount N/A N/A N/A N/A N/A MC067 Deductible Amount N/A N/A N/A N/A N/A MC068 Record Type N/A N/A N/A N/A N/A
(5) Pharmacy Claims File.
(a) The pharmacy claimfile layout shall be submitted using the format in 129 CMR 2.11(5)(a)1. through 44.:
3. PC003. This element is named "insurance type/product code". The data type of this element is text. Its length is 2. Carriers shall code as follows in Table 19:
Table 19: Pharmacy Insurance Type/Product Code
Code Description
12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 16 Health Maintenance Organization (HMO) Medicare Risk AM Automobile Medical DS Disability HM Health Maintenance Organization LI Liability LM Liability Medical MA Medicare Part A MB Medicare Party B MC Medicaid OF Other Federal Program (e.g. Black Lung) TV Title V VA Veterans Administration Plan WC Workers' Compensation
11. PC011. This element is named "individual relationship code". The data type of this element is integer. Its length is 2. Carriers shall code according to member's relationship to subscriber as follows in Table 20:
Table 20: Individual Relationship Code
Code Description
01 Spouse 04 Grandfather or Grandmother 05 Grandson or Granddaughter 07 Nephew or Niece 10 Foster Child 15 Ward 17 Stepson or Stepdaughter 19 Child 20 Employee/Self 21 Unknown 22 Handicapped Dependent 23 Sponsored Dependent 24 Dependent of a Minor Dependent 29 Significant Other 32 Mother 33 Father 36 Emancipated Minor 39 Organ Donor 40 Cadaver Donor 41 Injured Plaintiff 43 Child Where Insured Has No Financial Responsibility 53 Life Partner 76 Dependent
12. PC012. This element is named "member gender". The data type of this element is integer. Its length is 1. Carriers shall code as follows in Table 21:
Table 21: Member Gender
Code Description
1 Male 2 Female 3 Unknown
25. PC025. This element is named "claim status". The data type of this element is integer. Its length is 2. Carriers shall code according to:
28. PC028. This element is named "new prescription". The data type of this element is text. Its length is 1. Carriers shall code according to:
30. PC029. This element is named "generic drug indicator". The data type of this element is text. Its length is 1. Carriers shall code according to:
31. PC030. This element is named "dispense as written code". The data type of this element is integer. Its length is 1. Carriers shall code according to:
32. PC031. This element is named "compound drug indicator". The data type of this element is text. Its length is 1. Carriers shall code according to:
(b) The specifications for the pharmacy claims file layout shall conform to the following Table 22:
Table 22: Pharmacy Claims File Layout
Data Max. Description/Codes/Sources Element Element Type Length #
PC001 Payer Text 6 Payer submitting payments
Council Submitter Code
PC002 Plan ID Text 30 CMS National Plan ID PC003 Insurance Type/Product Code Text 2 12 Preferred Provider Organization (PPO)
13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 16 Health Maintenance Organization (HMO) Medicare Risk AM Automobile Medical DS Disability HM Health Maintenance Organization LI Liability LM Liability Medical MA Medicare Part A MB Medicare Part B MC Medicaid OF Other Federal Program (e.g. Black Lung) TV Title V VA Veteran Administration Plan WC Worker's Compensation
PC004 Payer Claim Control Number Text 35 Must apply to the entire claim and be unique w ithin
the payer's system
PC005 Line Counter Integer 4 Line number for this service
The line counter begins w ith 1 and is incremented by 1 for each additional service line of a claim
PC006 Insured Group Number Text 30 Group or policy number - not the number that
uniquely identifies the subscriber
PC007 Encrypted Subscriber Unique Text 30 Encrypted subscriber’s Unique Identification
Identification Number number Set as null if unavailable
PC008 Plan Specific Contract Number Text 30 Encrypted plan assigned contract number
Set as null if contract number = subscriber’s social security number
PC009 Member Suffix or Sequence Integer 2 Uniquely numbers the member w ithin the contract
Number
PC010 Member Identification Code Text 30 Encrypted member’s Unique Identification number
Set as null if unavailable
PC011 Individual Relationship Code Integer 2 Member's relationship to subscriber
01 Spouse 04 Grandfather or Grandmother 05 Grandson or Granddaughter 07 Nephew or Niece 10 Foster Child 15 Ward 17 Stepson or Stepdaughter 19 Child
Table 22: Pharmacy Claims File Layout (continued)
Data Max. Description/Codes/Sources Element Element Type Length #
20 Employee/Self 21 Unknow n 22 Handicapped Dependent 23 Sponsored Dependent 24 Dependent of a Minor Dependent 29 Significant Other 32 Mother 33 Father 36 Emancipated Minor 39 Organ Donor 40 Cadaver Donor 41 Injured Plaintiff 43 Child Where Insured Has No Financial Responsibility 53 Life Partner 76 Dependent
PC012 Member Gender Integer 1 1 Male
2 Female 3 Unknow n
PC013 Member Date of Birth Date 8 CCYYMMDD PC014 Member City Name of Text 30 City name of member
Residence
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 Date Service Approved (AP Date 8 CCYYMMDD
Date) (Generally the same as the paid date or the
Pharmacy Benefits Manager’s billing date)
PC018 Pharmacy Number Text 30 pharmacy number (NCPDP or NABP) 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 20 Required if National Provider ID is mandated for
use under HIPAA
PC022 Pharmacy Location City Text 30 City name of pharmacy - preferably pharmacy
location
PC023 Pharmacy Location State Text 2 As defined by the US Postal Service PC024 Pharmacy ZIP Code Text 10 ZIP Code of pharmacy - may include non-US
codes Do not include dash
PC024A Pharmacy Country Name Text 30 Country name of pharmacy PC025 Claim Status Integer 2 01 Processed as primary
02 Processed as secondary 03 Processed as tertiary 04 Denied
Table 22: Pharmacy Claims File Layout (continued)
Data Max. Description/Codes/Sources Element Element Type Length #
19 Processed as primary, forw arded to additional payer(s) 20 Processed as secondary, forw arded to additional payer(s) 21 Processed as tertiary, forw arded to additional payer(s) 22 Reversal of previous payment
PC026 Drug Code Text 11 NDC Code PC027 Drug Name Text 80 Text name of drug PC028 New Prescription Integer 2 00 New prescription
PC028A Refill Number Integer 2 01-99 Number of refill
(‘01’ should be used for all refills, if the specific number of the prescription refill is not available.)
PC029 Generic Drug Indicator Text 1 N No, branded drug
Y Yes, generic drug
PC030 Dispense as Written Code Integer 1 0 Not dispensed as w ritten
1 Physician dispense as w ritten 2 Member dispense as w ritten 3 Pharmacy dispense as w ritten 4 No generic available 5 Brand dispensed as generic 6 Override 7 Substitution not allow ed - brand drug mandated by law 8 Substitution allow ed - 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 CCYYMMDD PC033 Quantity Dispensed Integer 5 Number of metric units of medication dispensed PC034 Days Supply Integer 3 Estimated number of days the prescription w ill last PC035 Charge Amount Decimal 10 Do not code decimal point PC036 Paid Amount Decimal 10 Includes all health plan payments and excludes
all member payments Do not code decimal point
PC037 Average Wholesale Price Decimal 10 Cost of the drug dispensed
(AWP)
Do not code decimal point
PC038 Postage Amount Claimed Decimal 10 Do not code decimal point PC039 Dispensing Fee Decimal 10 Do not code decimal point PC040 Copay Amount Decimal 10 The preset, fixed dollar amount for w hich the
individual is responsible Do not code decimal point
Table 22: Pharmacy Claims File Layout (continued)
Data Max. Description/Codes/Sources Element Element Type Length # PC041 Coinsurance Amount Decimal 10 Do not code decimal point PC042 Deductible Amount Decimal 10 Do not code decimal point PC043 Record Type Text 2 PC
(c) The pharmacy claims file shall be mapped to a national standard as follows in Table 23:
Table 23: Pharmacy Claims File Mapping
Data National Council for Prescription Element Element Drug Programs # Field # PC001 Payer N/A PC002 Plan ID N/A PC003 Insurance Type/Product Code N/A PC004 Payer Claim Control Number N/A PC005 Line Counter N/A PC006 Insured Group Number 301-C1 PC007 Encrypted Subscriber Unique Identification Number 302-C2 PC008 Plan Specific Contract Number N/A PC009 Member Suffix or Sequence Number N/A PC010 Member Identification Code 302-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 Date Service Approved (AP Date) N/A 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 PC025 Claim Status N/A PC026 Drug Code 407-D7 PC027 Drug Name 516-FG PC028 New Prescription 403-D3 PC029 Generic Drug Indicator N/A
Table 23: Pharmacy Claims File Mapping (continued)
Data National Council for Prescription Element Element Drug Programs # Field # 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 Record Type N/A