90-590 C.M.R. ch. 243 – Uniform Reporting System for Health Care Claims Data Sets

90-590 MAINE HEALTH DATA ORGANIZATION

Chapter 243: UNIFORM REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS

SUMMARY: This Chapter contains the provisions for filing health care claims data sets from all third-party payors, third-party administrators, Medicare health plan sponsors and pharmacy benefits managers.

The provisions include:
1. Identification of the organizations required to report;
  Establishment of requirements for the content, format, method, and time frame for filing health care claims data;
  Establishment of standards for the data reported; and
  Compliance provisions.
2. 1. Definitions
  Unless the context indicates otherwise, the following words and phrases shall have the following meanings:

Billing Provider. “Billing provider” means a provider or other entity that submits claims to health care claims processors for health care services directly performed or provided to a subscriber or member by a service provider.
Capitated Services. “Capitated services” means services rendered by a provider through a contract where payments are based upon a fixed dollar amount for each member monthly.
Carrier. "Carrier" means an insurance company licensed in accordance with 24-A M.R.S., including a health maintenance organization, a multiple employer welfare arrangement licensed pursuant to Title 24-A, Chapter 81, a preferred provider organization, a fraternal benefit society, or a nonprofit hospital or medical service organization or health plan licensed pursuant to 24 M.R.S. An employer exempted from the applicability of 24-A M.R.S., Chapter 56-A under the federal Employee Retirement Income Security Act of 1974, 29 United States Code, Sections 1001 to 1461 (1988) (“ERISA”) is not considered a carrier.
Co-Insurance. “Co-insurance” means the dollar amount a member pays as a pre-determined percentage of the cost of a covered service after the deductible has been paid.
Co-Payment. “Co-payment” means the fixed dollar amount a member pays to a health care provider at the time a covered service is provided or the full cost of a service when that is less than the fixed dollar amount.
Deductible. "Deductible" means the total dollar amount a member pays towards the cost of covered services over an established period before any payments are made by the contracted third-party payor.
Dental Claims File. “Dental claims file” means a data file composed of service level remittance information including, but not limited to, member demographics, provider information, charge/payment information, and current dental terminology codes from all non-denied adjudicated claims for each billed service.
Designee. "Designee" means an entity with which the MHDO has entered into an arrangement under which the entity performs data collection, validation and management functions for the MHDO and is strictly prohibited from releasing information obtained in such a capacity.
Health Care Claims Processor. “Health care claims processor” means a third-party payor, third-party administrator, Medicare health plan sponsor, or pharmacy benefits manager.
Hospital. "Hospital" means any acute care institution required to be licensed pursuant to 22 M.R.S., Chapter 405.
MBI. “MBI” means the Center for Medicare and Medicaid Services Medicare Beneficiary Identifier.
Medical Claims File. “Medical claims file” means a data file composed of service level remittance information including, but not limited to, member demographics, provider information, charge/payment information, and clinical diagnosis/procedure codes from all non-denied adjudicated claims for each billed service.
Medicare Health Plan Sponsor. “Medicare health plan sponsor” means a health insurance carrier or other private company authorized by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services to administer Medicare Part C and Part D benefits under a health plan or prescription drug plan.
Member. “Member” includes the subscriber and any spouse or dependent who is covered by the subscriber’s policy.
Member Eligibility File. “Member eligibility file” means a data file composed of demographic information for each individual member eligible for medical, pharmacy, or dental insurance benefits for one or more days of coverage any time during the reporting month.
MHDO. "MHDO" means the Maine Health Data Organization.
M.R.S. “M.R.S.” means Maine Revised Statutes.
Non-hospital Provider. "Non-hospital provider" means any provider of health care services other than a hospital.
Pharmacy. “Pharmacy” means a drug outlet licensed under 32 M.R.S., Chapter 117.
Pharmacy Benefits Manager. "Pharmacy benefits manager" means an entity that performs pharmacy benefits management as defined in 24-A M.R.S. §4347, sub-section 17.
Pharmacy Benefits Manager Compensation. “Pharmacy benefits manager compensation” means the difference between:
1. the value of payments made by a carrier to its pharmacy benefits manager; and
2. the value of payments made by the pharmacy benefits manager to dispensing pharmacies for the provision of prescription drugs or pharmacy services with regard to pharmacy benefits covered by the carrier.
Pharmacy Claims File. “Pharmacy claims file” means a data file composed of service level remittance information including, but not limited to, member demographics, provider information, charge/payment information, and national drug codes from all non-denied adjudicated claims for each prescription filled.
Plan Sponsor. “Plan sponsor” means any person, other than an insurer, who establishes or maintains a plan covering residents of the State of Maine, including, but not limited to, plans established or maintained by two or more employers or jointly by one or more employers and one or more employee organizations, or the association, committee, joint board of trustees or other similar group of representatives of the parties that establish or maintain the plan.
POS. “POS” means point of sale.
Provider. "Provider" means a health care facility, health care practitioner, health product manufacturer, health product vendor or pharmacy.
Rebate. “Rebate” means a discount, chargeback, or other price concession that affects the price of a prescription drug product, regardless of whether conferred through regular aggregate payments, on a claim-by-claim basis at the point-of-sale, as part of retrospective financial reconciliations (including reconciliations that also reflect other contractual arrangements), or by any other method. “Rebate” does not mean a “bona fide service fee”, as such term is defined in Section 447.502 of Title 42 of the Code of Federal Regulations, published October 1, 2019.
Service Provider. “Service provider” means the provider who directly performed or provided a health care service to a subscriber or member.
Subscriber. “Subscriber” is the insured individual.
Substance Use Disorder (SUD). “SUD” means a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems such as impaired control, social impairment, risky use, and pharmacological tolerance and withdrawal, excluding tobacco/nicotine or caffeine use.
SUD Claims File: “SUD Claims File” means a data file composed of service level remittance information, de-identified in accordance with HIPPA regulations, including member demographics, provider information, charge/payment information, and clinical diagnosis/procedure codes from all non-denied, adjudicated claims and claim lines for each billed service for SUD or SUD related parts of medical and pharmacy claims.
Third-party Administrator. “Third-party administrator” means any person licensed by the Maine Bureau of Insurance under 24-A M.R.S., Chapter 18 who, on behalf of a plan sponsor, health care service plan, nonprofit hospital or medical service organization, health maintenance organization or insurer, receives or collects charges, contributions or premiums for, or adjusts or settles claims on residents of this State.
Third-party Payor. "Third-party payor" means a state agency that pays for health care services or a health insurer, carrier, including a carrier that provides only administrative services for plan sponsors, nonprofit hospital, medical services organization, or managed care organization licensed in the State.

2. Health Care Claims Data Set Filing Description

Health care claims processors shall submit to the MHDO or its designee a completed health care claims data set for all members who are Maine residents in accordance with the requirements of this section. Each health care claims processor is also responsible for the submission of all health care claims processed by any sub-contractor on its behalf. The health care claims data set shall include, where applicable, a member eligibility file containing records associated with each of the claims files reported: a medical claims file, a pharmacy claims file, and/or a dental claims file. The data set shall also include supporting definition files for payor specific provider specialty codes. Third-party administrators and carriers acting as third-party administrators for self-funded employee benefit plans regulated by ERISA are not required to submit data for members in such plans.
1. A. General Requirements
  1. (1) Adjustment Records. Adjustment records shall be reported with the appropriate positive or negative fields with the medical, pharmacy, and dental claims file submissions. Negative values shall contain the negative sign before the value. No sign shall appear before a positive value.
    1. (2) Capitated Payment Arrangements. A capitated payment record shall be reported for every month that a member is covered under a particular payment arrangement. In addition, capitated service records shall be included in the medical claims file, if any services were provided to the member in a given month. Specific instructions for reporting capitated payments and services are provided below. For capitated payment arrangements that a payor indicates are 42 CFR Part 2 SUD-related, the payor shall provide a de-identified payment record in the capitated payments file and a de-identified capitated service record in the medical claims file for every SUD-related service provided. Associated 42 CFR Part 2 SUD-related payment and service records shall contain the same CSUM IDs. Follow the additional instructions in Appendices D-1 and G-1.

1. 1. Payment Record. The purpose of a capitation payment summary record is to indicate the payment made to a provider each month for a member covered by a capitated service contract, regardless of whether any services were provided to the member in a given month. Only one summary claim record or line per member per month on a capitated service contract is reported in the capitated payments file, as specified in Appendix G-1.
  2. Service Record. Separate service lines for each service provided under a capitated service contract shall be reported in the medical claims file, Appendix D-1, and flagged as capitated services. If no services were provided to a member on a capitated service contract in a given month, then no service lines are reported. All data fields should be treated as on any other claim, except for the following ones, which are populated or left blank as specified: Paid Amount (MC063) is ‘0’; Payment Arrangement Type Indicator field (MC331) is ‘09’; the Procedure Code (MC055) for the specific procedure or service; Service Line Dates (MC334 and MC335) for the specific procedure or service; and the appropriate Quantity (MC061) greater than or equal to ‘1’.

(3) Claims Records. Records for the medical, pharmacy, and dental claims file submissions shall be reported at the visit, service, or prescription level. The submission of the medical, pharmacy, and dental claims is based upon the paid dates and not upon the dates of service associated with the claims.
1. (4) Codes
  1. (a) Code Sources. Unless otherwise specified, the code sources listed and described in Appendix A are to be utilized in association with the member eligibility file and medical, pharmacy, and dental claims file submissions.
    1. (b) Specific/Unique Coding. Except for provider, provider specialty, and individual, non-bundled procedure/diagnosis codes, specific or unique coding systems shall not be permitted as part of the health care claims data set submission.
    2. (5) Co-Insurance/Co-Payment. Co-insurance and co-payment are to be reported in two separate fields in the medical, pharmacy, and dental claims file submissions.
    3. (6) Coordination of Benefits Claims. Claims where multiple parties have financial responsibility shall be included with all medical, pharmacy, and dental claims file submissions.
    4. (7) Denied Claims. Denied claims shall be excluded from all medical, pharmacy, and dental claims file submissions. When a claim contains both approved and denied service lines, only the approved service lines shall be included as part of the health care claims data set submittal.
    5. (8) Eligibility Records. Records for the member eligibility file submission shall be reported at the individual member level with one record submitted for each claim type if the product codes are different. If a member is covered as both a subscriber and a dependent on two different policies during the same month, two records must be submitted.
    6. (9) Exclusions
    7. (a) Filing. Health care claims processors that have less than $2,000,000 per calendar year of adjusted premiums or claims processed, for premiums or claims subject to required reporting, are excluded from filing health care claim data sets and from the annual registration requirements of Section 3(A).
    8. (b) Medical Claims File Exclusions. All claims related to health care policies issued for specific disease, accident, injury, hospital indemnity, disability, long-term care, student comprehensive health, or vision coverage of durable medical equipment are to be excluded from the medical claims file submission. Claims related to Medicare supplemental, Tricare supplemental, or other supplemental health insurance policies are to be excluded if the claims are not considered to be primary. If the policies cover health care services entirely excluded by the Medicare, Tricare, or other program, the claims must be submitted. Claims for dental services containing current dental terminology codes are to be excluded from the medical claims file.
    9. (c) Member Eligibility File Exclusions. Members without medical, pharmacy, and/or dental coverage during the month reported shall be excluded.
    10. (d) Pharmacy Claims File Exclusions. Pharmacy services claims generated from non-retail pharmacies that do not contain national drug codes are part of the medical claims file and not the pharmacy claims file.
    11. (10) File Format. Each data file submission shall be an encrypted (AES-256) ASCII file, variable field length, and asterisk delimited.
    12. (11) Header and Trailer Records. 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. The header and trailer record formats are described in Appendices B-1 and B-2.
    13. (12) Non-Duplicated Claims. A carrier or health care claims processor and any contracted entity acting on its behalf shall use best efforts to ensure that duplicate claims are not submitted to the MHDO or its designee.
    14. (13) Subscriber or Member Identification
    15. (a) Social Security Numbers. Health care claims processors shall assign to each of their members a unique identification code that is the member’s social security number. If a health care claims processor does not collect the social security numbers for all members, the health care claims processor shall use the number of the subscriber and then assign a discrete two-digit suffix for each member under the subscriber’s contract.
    16. (b) Contract Numbers. If the subscriber’s social security number is not collected by the health care claims processor, the subscriber’s certificate or contract number shall be used in its place. The discrete two-digit suffix shall also be used with the certificate or contract number.
      The unique member identification code assigned by each health care claims processor shall remain with each subscriber or member for the entire period of coverage for that individual.
    17. (c) Names. Health care claims processors shall submit the complete names of all subscribers and members.
    18. (d) Consistent, Inter-file Identifiers. A carrier or health care claims processor and any contracted entity acting on its behalf shall ensure that member and subscriber identifiers for the same individuals are unique and consistent across all eligibility and claims files.
    19. (e) Carrier Specific Unique Member (CSUM) ID. As an inter-file identifier, the CSUM ID should uniquely and consistently identify a member in both the medical claims and the capitated payments files. The CSUM ID shall be used when the payor indicates that related records in the medical and capitation files contain 42 CFR Part 2 SUD-related data, and other inter-file identifiers shall be left blank. For fully identifiable data records that do not contain 42 CFR Part 2-related data, the CSUM ID shall be left blank, and all other inter-file identifiers shall be populated, when available. This ID must differ from any of the other identifiers on the record and may not be derived from any of these in a manner that the original values could be determined.

B. Detailed File Specifications

(1) Filled Fields. All required fields shall be filled where applicable. Non-required text and number fields shall be left blank when unavailable.
1. (2) Position. All text fields are to be left justified. All numeric fields are to be right justified.
  1. (3) Signs. Positive values are assumed and need not be indicated as such. Negative values must be indicated with a minus sign and must appear in the left-most position of all numeric fields. Signed over punch characters are not to be utilized.
    1. (4) Individual Elements and Mapping. Individual data elements, data types, field lengths, field description/code assignments, and mapping locators (UB-04, CMS 1500, ANSI X12N 270/271, 835, 837) for each file type are presented in the following appendices:
    2. (a) (i) Member Eligibility File Specifications – Appendix C-1
    3. (ii) Member Eligibility File Mapping to National Standard Formats – Appendix C-2
    4. (b) (i) Medical Claims File Specifications – Appendix D-1
    5. (ii) Medical Claims File Mapping to National Standard Formats – Appendix D-2
    6. (c) (i) Pharmacy Claims File Specifications – Appendix E-1
    7. (ii) Pharmacy Claims File Mapping to National Standard Formats – Appendix E-2
    8. (d) (i) Dental Claims File Specifications – Appendix F-1
    9. (ii) Dental Claims File Mapping to National Standard Formats – Appendix F-2
    10. (e) (i) Capitated Payments File Specifications – Appendix G-1
    11. (ii) Capitated Payments File Mapping to National Standard Formats – Appendix G-2

3. Submission Requirements

A. Registration/Contact and Enrollment Update. Each health care claims processor not excluded from submitting claims data under Section 2(A)(9)(a) shall complete a registration survey or update an existing one at https://mhdo.maine.gov/portal by February 28^thof each year. It is the responsibility of the health care claims processor to amend, as needed, all company, contact and enrollment information.
1. B. File Organization. The member eligibility file, medical claims file, pharmacy claims file, and the dental claims file are to be submitted to the MHDO or its designee as separate ASCII files. Each record shall be terminated with a carriage return (ASCII 13) or a carriage return line feed (ASCII 13, ASCII 10).
  1. C. Filing Method. Data files must be submitted to the MHDO’s Data Warehouse Portal via secure FTP or secure web upload interface. E-mail attachments shall not be accepted.
  2. D. Testing of Files. Within one hundred and eighty days of the adoption of any changes to the data element content of the files as described in Section 2 and at least sixty days prior to the initial submission of the files or whenever the data element content of the files as described in Section 2 is subsequently altered, each health care claims processor shall submit to the MHDO or its designee a data set for comparison to the standards listed in Section 4. Based upon a calendar period of one month or one quarter, the size of the data files submitted shall correspond to the filing period established for each health care claims processor under subsection F of this Section.
  3. E. Rejection of Files. Failure to conform to the requirements subsections
    A, B, or C of this Section shall result in the rejection of the applicable data file(s). All rejected files must be resubmitted in the appropriate, corrected form to the MHDO or its designee within 15 days.
  4. F. Filing Periods. The filing period for each applicable claims data file listed in Section 2 shall be determined by the minimum monthly total of Maine-resident members for whom claims are being paid by each health care claims processor. The data files are to be submitted in accordance with the following schedule:

Total # of Members	Filing Period	Filing Schedule
≥ 2,000	monthly	prior to the end of the month following the month in which claims were paid
< 2,000	quarterly	prior to April 30, July 31, October 31, January 31 for each preceding calendar quarter in which claims were paid

If the data files submitted by an individual health care claims processor support or are related to the files submitted by another health care claims processor, the MHDO shall determine a filing period that is consistent for all parties involved.
1. G. Replacement of Data Files. No health care claims processor may replace a complete data file submission more than one year after the end of the month in which the file was submitted unless it can establish exceptional circumstances for the replacement. Any replacements after this period must be approved by the MHDO. Individual adjustment records may be submitted with any monthly data file submission.
  1. H. Run-Out Period. Health care claims processors shall submit medical, pharmacy, and/or dental claims files for a six-month period following the termination of coverage date for all members who are Maine residents.
2. 4. Standards for Data; Notification; Response
  1. A. Standards. The MHDO or its designee shall evaluate each member eligibility file, medical claims file, pharmacy claims file, and dental claims file submission in accordance with the following standards:
    1. (1) The applicable code for each data element identified in Appendices C-1, D-1, E-1, and F-1 shall be included within eligible values for the element;
    2. (2) Coding values indicating “data not available”, “data unknown”, or the equivalent shall not be used for individual data elements unless specified as an eligible value for the element;
    3. (3) Member sex, diagnosis and procedure codes, and date of birth and all other date fields shall be consistent within an individual record; and
    4. (4) Member identifiers shall be consistent across files.
  2. B. Notification. Upon completion of this evaluation, the MHDO or its designee will promptly notify each health care claims processor whose data submissions do not satisfy the standards for any filing period. This notification will identify the specific file and the data elements within them that do not satisfy the standards.
  3. C. Response. Each health care claims processor notified under subsection 4(B) will respond within 60 days of the notification by making the changes necessary in order to satisfy the standards.
3. 5. Voluntary File Submissions
  Any self-funded employee benefit plan regulated by ERISA may voluntarily submit completed healthcare data sets for Maine residents. The MHDO shall collect such data sets in accordance with the provisions of this chapter for uniform reporting system for health care claims data sets. Any such data shall be subject to the same laws and regulations as other MHDO data.
4. 6. Public Access
  Information collected, processed and/or analyzed under this rule shall be subject to release to the public or retained as confidential information in accordance with 22 M.R.S. Chapter 1683 and Code of Maine Rules 90-590, Chapter 120, unless prohibited by state or federal law.
5. 7. Extensions or Waivers to Data Submission Requirements
  If a health care claims processor due to circumstances beyond its control is temporarily unable to meet the terms and conditions of this rule, a written request must be made to the Compliance Officer of the MHDO as soon as it is practicable after the health care claims processor has determined that an extension or waiver is required. The written request shall include: the specific requirement to be extended or waived; an explanation of the cause; the methodology proposed to eliminate the necessity of the extension or waiver; and the time frame required to come into compliance. If the Compliance Officer does not approve the requested extension or waiver, the health claims processor making the request may submit a written request appealing the decision to the MHDO Board. The appeal shall be heard by the MHDO Board at the next regularly scheduled meeting following receipt of the request at the MHDO.
6. 8. Compliance
  The failure to file, report, or correct health care claims data sets when required in accordance with the provisions of this rule may be considered a violation under 22 M.R.S. Sec. 8705-A and Code of Maine Rules 90-590, Chapter 100: Enforcement Procedures.

STATUTORY AUTHORITY: 22 M.R.S. §§ 8703(1), 8704(4), 8708(6-A) and 8712(2)

EFFECTIVE DATE:
1. July 29, 2002
  1. AMENDED:
    June 2, 2003 – filing 2003-173
    NON-SUBSTANTIVE CORRECTIONS:
    September 8, 2003 – formatting only
    AMENDED:
    February 28, 2006 – filing 2006-89
    CORRECTION:
    May 24, 2006 – restored item in Appendix C-1 under ME012, “34 Other Adult”
    AMENDED:
    April 15, 2009 – filing 2009-157
    October 31, 2012 – filing 2012-295
    May 27, 2014 – filing 2014-100
    October 6, 2015 – filing 2015-183
    March 13, 2017 – filing 2017-045
    June 27, 2018 – filing 2018-111
    December 22, 2019 – filing 2019-246
    October 12, 2020 – filing 2020-217
    November 15, 2021 – filing 2021-230
    December 17, 2023 – filing 2023-249
    June 25, 2024 – filing 2024-145

APAO WORD VERSION CONVERSION (IF NEEDED) AND ACCESSIBILITY CHECK: July 17, 2025

(with references to specific MHDO data elements by file type)

American Dental Association

Current Dental Terminology (CDT) Codes

(MHDO Data Element: DC032, MC055)

SOURCE: Current Dental Terminology (CDT) Manual

AVAILABLE FROM:

American Dental Association

211 East Chicago Avenue

Chicago, IL 60611‑2678

ABSTRACT: The CDT contains the American Dental Association’s codes for dental procedures and nomenclature and is the nationally accepted set of numeric codes and descriptive terms for reporting dental treatments.

American Medical Association

Current Procedural Terminology (CPT) Codes

(MHDO Data Element: MC055)

SOURCE: Physicians’ Current Procedural Terminology (CPT) Manual

AVAILABLE FROM:

American Medical Association

515 North State Street

Chicago, IL 60654

ABSTRACT: A listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians.

Accredited Standards Committee (ASC)

ASC X12 Directories

(MHDO Data Elements: CF003, CF015, DC003, DC011, DC012, DC021, DC031, MC003, MC011, MC012, MC027, MC038, ME003, ME007, ME012, ME013, PC003, PC025)

SOURCE: Complete ASC X12 005010 Standard

AVAILABLE FROM:

https://www.nex12.org/

Data Interchange Standards Association, Inc. (DISA)

7600 Leesburg Pike Ste 430

Falls Church, VA 22043

ABSTRACT: The complete standard includes design rules and guidelines, control standards, transaction set tables, data element dictionary, segment directory and code sources. The data element dictionary contains the format and descriptions of data elements used to construct X12 segments. It also contains code lists associated with these data elements. The segment directory contains the format and definitions of the data segments used to construct X12 transaction sets.

Canada Post

Canadian Provinces

(MHDO Data Elements: CF033, DC015, DC028, DC049, DC056, MC015, MC083, MC090, ME016, PC015, PC023)

Cities and ZIP Code

(MHDO Data Elements: CF032, CF034, DC014, DC016, DC027, DC029, DC048, DC050, DC055, DC057, MC014, MC016, MC082, MC084, MC089, MC091, ME015, ME017, PC014, PC016, PC022, PC024)

SOURCE : Canada Post

AVAILABLE FROM :

http://www.canadapost.ca/

Centers for Disease Control and Prevention

HL7/CDC Race and Ethnicity Code Set

(MHDO Data Element: ME021, ME022, ME023, ME024, ME025, ME026, ME027)

SOURCE: Race and Ethnicity Code Set

AVAILABLE FROM:

http://www.cdc.gov/nchs/data/dvs/Race_Ethnicity_CodeSet.pdf

Centers for Disease Control and Prevention

1600 Clifton Road

Atlanta, GA 30329-4027

ABSTRACT: The race and ethnicity code set to be used for coding the race and ethnicity of members.

Centers for Medicare and Medicaid Services

Health Care Common Procedural Coding System

(MHDO Data Element: MC055)

SOURCE: Health Care Common Procedural Coding System

AVAILABLE FROM :

www.cms.gov/HCPCSReleaseCodeSets/

Centers for Medicare and Medicaid Services

7500 Security Boulevard

Baltimore, MD 21244‑1850

ABSTRACT: HCPCS is the Centers for Medicare and Medicaid Services (CMS) coding scheme to group procedures performed for payment to providers.

Health Insurance Prospective Payment System (HIPPS)

(MHDO Data Element: MC055)

SOURCE: Center for Medicare & Medicaid Services

AVAILABLE FROM:

http://www.cms.gov/Medicare/Medicare-fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes.html

Center for Medicare and Medicaid Services

7500 Security Boulevard

Baltimore, MD 21244

ABSTRACT: Health Insurance Prospective Payment System (HIPPS) rate codes represent specific sets of patient characteristics (or case-mix groups) on which payment determinations are made under several prospective payment systems. Case-mix groups are developed based on research into utilization patterns among various provider types. For the payment systems that use HIPPS codes, clinical assessment data is the basic input used to determine which case-mix group applies to a particular patient. A standard patient assessment instrument is interpreted by case-mix grouping software algorithms, which assign the case mix group. For payment purposes, at least one HIPPS code is defined to represent each case-mix group. These HIPPS codes are reported on claims to insurers.

National Provider Identifier

(MHDO Data Elements: CF020, CF025, DC020, DC043, MC026, MC077, MC086, MC108, MC115, MC121, PC021, PC048)

SOURCE: National Provider System

AVAILABLE FROM:

Centers for Medicare and Medicaid Services

7500 Security Boulevard

Baltimore, MD 21244-1850

ABSTRACT: The Centers for Medicare and Medicaid Services developed the National Provider Identifier as the standard, unique identifier for each health care provider under the Health Insurance Portability and Accountability Act of 1996.

Place of Service Codes for Professional Claims

(MHDO Data Element: DC030, MC037)

SOURCE: Place of Service Codes for Professional Claims

AVAILABLE FROM :

https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set

Centers for Medicare and Medicaid Services

7500 Security Boulevard

Baltimore, MD 21244‑1850

ABSTRACT: The place of service code identifies the location where the healthcare service was rendered.

International Country Codes

(MHDO Data Elements: ME109, MC093, MC094, MC329, PC024A, PC109, DC109)

SOURCE: www.nationsonline.org/oneworld/country_code_list.htm

ABSTRACT: The ISO country codes are internationally recognized codes that designate each country and most of the dependent areas with a two- or three-letter combination or a numeric code.

National Council for Prescription Drug Programs

National Association of Boards of Pharmacy Number

(MHDO Data Element: PC018)

SOURCE: National Association of Boards of Pharmacy Database and Listings

AVAILABLE FROM:

www.ncpdp.org

National Council for Prescription Drug Programs

9240 East Raintree Drive

Scottsdale, AZ 85260-7518

ABSTRACT: A unique number assigned in the U.S. and its territories to individual clinic, hospital, chain, and independent pharmacy locations that conduct business at retail by billing third‑party drug benefit payors. The National Council for Prescription Drug Programs (NCPDP) maintains this database under contract from the National Association of Boards of Pharmacy. The National Association of Boards of Pharmacy is a seven-digit numeric number with the following format SSNNNNC, where SS=NCPDP assigned state code number, NNNN=NCPDP assigned pharmacy location number, and C=check digit calculated by algorithm from previous six digits.

Uniform Healthcare Payor Data

(MHDO Data Elements: PC011, PC012, PC030)

SOURCE: NCPDP Uniform Healthcare Payor Data Standard Implementation Guide

AVAILABLE FROM:

www.ncpdp.org

National Council for Prescription Drug Programs

9240 East Raintree Drive

Scottsdale, AZ 85260

ABSTRACT: This standard is intended to meet an industry need to supply detailed drug or utilization claim information from adjudicated claims that processors/payors or their clients report to States or their Agents.

National Uniform Billing Committee (NUBC)

NUBC Codes

(MHDO Data Elements: MC020, MC021, MC023, MC036, MC054, MC201, MC207, MC209, MC211, MC213, MC215, MC217, MC219, MC221, MC223, MC225, MC227, MC229, MC231, MC233, MC235, MC237, MC239, MC241, MC243, MC245, MC247, MC249, MC251, MC255, MC257, MC259, MC261, MC263, MC265, MC267, MC269, MC271, MC273, MC275, MC277, MC279, MC281, MC283, MC285, MC287, MC289, MC291, MC293, MC295, MC297, MC299, MC301)

SOURCE: National Uniform Billing Committee Official Data Specifications Manual

AVAILABLE FROM:

National Uniform Billing Committee

American Hospital Association

155 N Wacker Drive

Chicago, IL 60606

ABSTRACT: This serves as the official source of information for institutional health care billing. It contains all billing conventions and codes, including form locators, data element descriptions, definitions, reporting requirements, field attributes, approval and effective dates, and revenue, condition, occurrence, and value codes.

National Uniform Claim Committee
1. Healthcare Provider Taxonomy Code Set
  (MHDO Data Element: CF017, DC026, MC032, MC113)
  SOURCE: Washington Publishing Company

MAINTAINED BY: National Uniform Claim Committee

https://www.cms.gov/medicare/provider-enrollment-and-certification/medicareprovidersupenroll/taxonomy.html

AVAILABLE FROM: Washington Publishing Company

www.wpc-edi.com/products/code-lists/

ABSTRACT: The Healthcare Provider Taxonomy Code Set is a hierarchical code set that consists of codes, descriptions, and definitions. Healthcare Provider Taxonomy Codes are designed to categorize the type, classification, and/or specialization of health care providers. The Code Set consists of two sections: Individuals and Groups of Individuals, and Non-Individual.

United States Food and Drug Administration

National Drug Codes

(MHDO Data Element: PC026, MC075)

SOURCE: National Drug Data File

AVAILABLE FROM:

www.fda.gov or http://www.accessdata.fda.gov/scripts/cder/ndc/default.cfm

U.S. Food and Drug Administration

Center for Drug Evaluation and Research

Division of Data Management and Services

10903 New Hampshire Avenue

Silver Spring, MD 20993

ABSTRACT: The National Drug Code is a coding convention established by the Food and Drug Administration to identify the labeler, product number, and package sizes of FDA-approved prescription drugs. There are over 170,000 National Drug Codes on file.

United States Postal Service

States and Outlying Areas of the U.S.

(MHDO Data Elements: CF033, DC015, DC028, DC049, DC056, MC015, MC083, MC090, ME016, PC015, PC023)

ZIP Code

(MHDO Data Elements: CF032, CF034, DC014, DC016, DC027, DC029, DC048, DC050, DC055, DC057, MC014, MC016, MC082, MC084, MC089, MC091, ME015, ME017, PC014, PC016, PC022, PC024)

SOURCE : United States Postal Service

AVAILABLE FROM :

https://www.usps.com

U.S. Postal Service

National Information Data Center

P.O. Box 9408

Gaithersburg, MD 20898-9408

https://ribbs.usps.gov/index.cfm?page=address_manage_quality

Address Information Systems Products

National Customer Support Center

U.S. Postal Service

6060 Primacy Pkwy Ste 231

Memphis, TN 38119-5772

ABSTRACT: Provides names, abbreviations, and codes for the 50 states, the District of Columbia, and the outlying areas of the U.S. The ZIP Code is a geographic identifier of areas within the United States and its territories for purposes of expediting mail distribution by the U.S. Postal Service. It is five or nine numeric digits. The ZIP Code structure divides the U.S. into ten large groups of states. The leftmost digit identifies one of these groups. The next two digits identify a smaller geographic area within the large group. The two right-most digits identify a local delivery area. In the 9-digit ZIP Code, the four digits that follow the hyphen further subdivide the delivery area. The two leftmost digits identify a sector which may consist of several large buildings, blocks or groups of streets. The rightmost digits divide the sector into segments such as a street, a block, a floor of a building, or a cluster of mailboxes.

World Health Organization (WHO)

International Classification of Diseases, 10^th Edition, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS)

(MHDO Data Elements: MC200, MC202, MC203, MC204, MC205, MC206, MC208, MC210, MC212, MC214, MC216, MC218, MC220, MC222, MC224, MC226, MC228, MC230, MC232, MC234, MC236, MC238, MC240, MC242, MC244. MC246, MC248, MC250, MC252, MC254, MC256, MC258, MC260, MC262, MC264, MC266, MC268, MC270, MC272, MC274, MC276, MC278, MC280, MC282, MC284, MC286, MC288, MC290, MC292, MC294, MC296, MC298, MC300, MC302, MC303, MC304, MC305, MC306, MC307, MC308, MC309, MC310, MC311, MC312, MC313, MC314, MC315, MC316, MC317, MC318, MC319, MC320, MC321, MC322, MC323, MC324, MC325, MC326)

SOURCE: International Classification of Diseases, 10^th Revision, (ICD‑10-CM/PCS)

AVAILABLE FROM:

www.cdc.gov/nchs/icd/icd10cm.htm#9update

WHO Publications Center AUS

49 Sheridan Avenue

Albany, NY 12210

ABSTRACT: The International Classification of Diseases, 10^th Revision, is used to report medical diagnosis and inpatient procedures. ICD-10-CM is for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM, but the format of the code sets is similar. ICD-10-PCS is for use in U.S. inpatient hospital settings only. ICD-10PCS uses 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding. The transition to ICD-10 is occurring because ICD-9 produces limited data about patients’ medical conditions and hospital inpatient procedures. ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice. Also, the structure of ICD-9 limits the number of new codes that can be created, and many ICD-9 categories are full.

Data Element		Date		Maximum
#	Data Element Name	Effective	Type	Length	Description/Codes/Sources

HD001	Record Type	1/1/2003	Text	2	HD

HD002	Submitter	1/1/2003	Text	8	MHDO-assigned identifier of payor submitting claims data. Do not leave blank.

HD003	Payor	7/1/2012	Text	8	MHDO-assigned code of the insurer/ underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage

HD004	Type of File	1/1/2003	Text	2	CF Capitated Payments File DC Dental Claims
					MC Medical Claims
					ME Member Eligibility
					PC Pharmacy Claims

HD005	Period Beginning Date	1/1/2003	Text	6	CCYYMM
					Beginning of paid period for Claims
					Beginning of month covered for Eligibility Beginning of performance period for Capitated Payments

HD006	Period Ending Date	1/1/2003	Text	6	CCYYMM
					End of paid period for Claims
					End of month covered for Eligibility End of performance period for Capitated Payments

HD007	Record Count	1/1/2003	Number	10	Total number of records submitted in this file
					Exclude header and trailer record in count

HD008	Comments	1/1/2003	Text	80	Submitter may use to document this submission by assigning a filename, system source, etc.

Data Element		Date		Maximum
#	Data Element Name	Effective	Type	Length	Description/Codes/Sources

TR001	Record Type	1/1/2003	Text	2	TR

TR002	Submitter	1/1/2003	Text	8	MHDO-assigned identifier of payor submitting claims data. Do not leave blank.

TR003	Payor	7/1/2012	Text	8	MHDO-assigned code of the insurer/ underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage

TR004	Type of File	1/1/2003	Text	2	CF Capitated Payments File DC Dental Claims
					MC Medical Claims
					ME Member Eligibility
					PC Pharmacy Claims

TR005	Period Beginning Date	1/1/2003	Text	6	CCYYMM
					Beginning of paid period for Claims
					Beginning of month covered for Eligibility Beginning of performance period for Capitated Payments

TR006	Period Ending Date	1/1/2003	Text	6	CCYYMM
					End of paid period for Claims
					End of month covered for Eligibility End of performance period for Capitated Payments

TR007	Date Processed	1/1/2003	Text	8	CCYYMMDD
					Date file was created


Data Element		Date		Maximum
#	Data Element Name	Effective	Type	Length	Description/Codes/Sources

ME001	Submitter	1/1/2003	Text	8	MHDO-assigned identifier of payor submitting claims data. Do not leave blank.

ME002	Payor	7/1/2012	Text	8	MHDO-assigned code of the insurer/underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage. Do not leave blank.

ME003	Insurance Type/Product Code	1/1/2003	Text	2	Code identifying the type of insurance policy within a specific insurance program. Refer to Appendix A HN Medicare Part C MD Medicare Part D

ME004	Year	1/1/2003	Number	4	Year for which eligibility is reported in this submission

ME005	Month	1/1/2003	Text	2	Month for which eligibility is reported in this submission

ME006	Insured Group or Policy Number	1/1/2003	Text	30	Group or policy number – not the number that uniquely identifies the subscriber

ME007	Coverage Level Code	1/1/2003	Text	3	Benefit coverage level Refer to Appendix A

ME008	Subscriber Social Security Number	1/1/2003	Text	9	Subscriber’s social security number Leave blank if unavailable

ME009	Plan Specific Contract Number	1/1/2003	Text	80	Plan-assigned subscriber’s contract number Leave blank if contract number = subscriber’s social security number

ME010	Member Suffix or Sequence Number	1/1/2003	Text	20	Unique number of the member within the contract

ME011	Member Identification Code	1/1/2003	Text	50	Member’s social security number Leave blank if unavailable


ME012	Individual Relationship Code	1/1/2003	Text	2	Member’s relationship to insured Refer to Appendix A

ME013	Member Gender	1/1/2003	Text	1	Refer to Appendix A

ME014	Member Date of Birth	1/1/2003	Text	8	CCYYMMDD

ME015	Member City Name	4/1/2004	Text	30	City name of member Refer to Appendix A

ME016	Member State or Province	4/1/2004	Text	2	As defined by the US Postal Service and Canada Post Refer to Appendix A

ME017	Member ZIP Code	1/1/2003	Text	11	ZIP Code of member – may include non-US codes. Do not include dash Refer to Appendix A

ME018	Medical Coverage	1/1/2003	Text	1	N No Y Yes

ME019	Prescription Drug Coverage	1/1/2003	Text	1	N No Y Yes

ME020	Dental Coverage	1/1/2003	Text	1	N No Y Yes

ME021	Race 1	1/1/2021	Text	2	Report the Member-identified race using the first two characters of the CDC Hierarchical Code. The code value “UN” (Unknown/not specified) should be used ONLY when Member answers unknown or refuses to answer. Report only collected data. If not available, leave blank. Refer to Appendix A. For quick reference, the two-character subset of the CDC race list is: R1 American Indian/Alaska Native R2 Asian R3 Black/African American
					R4 Native Hawaiian or Other Pacific Islander
					R5 White R9 Other Race UN Unknown/Not Specified

ME022	Race 2	1/1/2021	Text	2	Report the Member-identified race using the first two characters of the CDC Hierarchical Code. The code value “UN” (Unknown/not specified) should be used ONLY when Member answers unknown or refuses to answer. Report only collected data. If not available, leave blank. Refer to Appendix A.

ME023	Race 3	1/1/2021	Text	2	Report the Member-identified race using the first two characters of the CDC Hierarchical Code. The code value “UN” (Unknown/not specified) should be used ONLY when Member answers unknown or refuses to answer. Report only collected data. If not available, leave blank. Refer to Appendix A.

ME024	Hispanic Indicator	1/1/2021	Text	1	Report the value that defines the element. The code value “U” for unknown should be used ONLY when member answers unknown or refuses to answer. Report only collected data. If not available, leave blank. Y Member is Hispanic/Latino/Spanish N Member is not Hispanic/Latino/Spanish U Unknown/not specified.

ME025	Ethnicity 1	1/1/2021	Text	6	Report the Member-identified ethnicity from the External Code Source that best describes the information obtained from the Member / Subscriber. The value “UNKNOW” should be used ONLY when the Member answers unknown or refuses to answer. Report only collected data. If not available, leave blank. Refer to Appendix A. Report the CDC Unique Identifiers (format NNNN-N; 6 characters).

ME026	Ethnicity 2	1/1/2021	Text	6	Report the Member-identified ethnicity from the External Code Source that best describes the information obtained from the Member / Subscriber. The value “UNKNOW” should be used ONLY when the Member answers unknown or refuses to answer. Report only collected data. If not available, leave blank. Refer to Appendix A. Report the CDC Unique Identifiers (format NNNN-N; 6 characters).

ME027	Ethnicity 3	1/1/2021	Text	6	Report the Member-identified ethnicity from the External Code Source that best describes the information obtained from the Member / Subscriber. The
					value “UNKNOW” should be used ONLY when the Member answers unknown or refuses to answer. Report only collected data. If not available, leave blank. Refer to Appendix A. Report the CDC Unique Identifiers (format NNNN-N; 6 characters).

ME028	Primary Insurance Indicator	1/1/2010	Number	1	1 Yes – primary insurance 2 No – secondary, or tertiary insurance

ME029	Coverage Type	1/1/2010	Text	3	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
					ASW – self-funded plans that are administered by a third-party administrator, where the employer has purchased stop-loss, or group excess, insurance coverage
					OTH – any other plan. Insurers using this code shall obtain prior approval.
					STN – short-term, non-renewable health insurance
					UND – plans underwritten by the insurer

ME030	Market Category Code	1/1/2010	Text	4	IND – coverage sold and issued directly to individuals (non-group)
					FCH – coverage sold and issued directly to individuals on a franchise basis
					GCV – coverage sold and issued directly to individuals as group conversion policies
					GS1 – coverage sold and issued directly to employers having exactly one employee
					GS2 – coverage sold and issued directly to employers having between two and nine employees
					GS3 – coverage sold and issued directly to employers having between 10 and 25 employees
					GS4 – coverage sold and issued directly to employers having between 26 and 50 employees
					GLG1 – coverage sold and issued directly to employers having between 51 and 99 employees
					GLG2 – coverage sold and issued directly to employers having 100 or more employees
					GSA – coverage sold and issued directly to small employers through a qualified association trust
					OTH – coverage sold to other types of entities. Insurers using this market code shall obtain prior approval.

ME031	Special Coverage	N/A	Number	3	State-specific assignment. Default value for Maine is “0”.

ME032	Group Name	1/1/2010	Text	128	Group name or IND for individual policies, and BLANK if data is not available

ME101	Subscriber Last Name	1/1/2010	Text	60	The subscriber last name

ME102	Subscriber First Name	1/1/2010	Text	35	The subscriber first name

ME103	Subscriber Middle Name	1/1/2010	Text	25	The subscriber middle name or initial

ME104	Member Last Name	1/1/2010	Text	60	The member last name

ME105	Member First Name	1/1/2010	Text	35	The member first name

ME106	Member Middle Name	1/1/2010	Text	25	The member middle name or initial

ME107	Member Address Line 1	2/1/2019	Text	55

ME108	Member Address Line 2	2/1/2019	Text	55

ME109	Member Country Code	2/1/2019	Text	2	Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A.

ME110	Placeholder	2/1/2021	N/A	0	Subscriber’s Health Insurance Claim Number retired. Leave blank.

ME111	Subscriber MBI	2/1/2019	Text	11	Subscriber’s Medicare Beneficiary Identifier. May be populated starting February 1, 2019 or as soon as MBI is available for reporting. Required starting January 1, 2020 or if ME110 is not present.

ME112	Placeholder	2/1/2021	N/A	0	Member’s Health Insurance Claim Number retired. Leave blank.

ME113	Member MBI	2/1/2019	Text	11	Member’s Medicare Beneficiary Identifier. Required only for Medicare Supplemental/Companion Plans for which 1) the subscriber and the member are not the same person, 2) the payor is primary and 3) ME112 is not present. Otherwise, leave blank. If not the same as ME111, may be populated starting February 1, 2019; however, only required starting January 1, 2020.

ME114	Plan Begin Date (Member Effective Date)	2/1/2020	Text	8	CCYYMMDD. Effective date of coverage. Date eligibility started for this member under this plan type.

ME115	Plan End Date (Member Cancellation Date)	2/1/2020	Text	8	CCYYMMDD. Last continuous day of coverage (date eligibility ended) for this member under this plan. For open contracts, leave blank.

ME116	Grandfathered Plan Indicator	2/1/2025	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.federalregister.gov/select- citation/2013/06/03/45-CFR-147. The values of the indicator are as follows: 1=Grandfathered; 2=Non-Grandfathered; 3=Transitional; 4=Not Applicable.

ME117	Metal Tier	2/1/2025	Text	1	For Non-Grandfathered health plans for the Individual and Small Group markets (under ACA) ONLY. Health benefit plan metal tier for qualified health plans (QHPs) and catastrophic plans as defined in the Patient Protection and Affordable Care Act, Public Law 111-148, Section 1302: Essential Health Benefits Requirements: 0=Not a QHP or catastrophic plan; 1=Catastrophic; 2=Bronze; 3=Silver; 4=Gold; 5=Platinum. If not applicable, leave blank.


ME118	Enrolled Through a Public Health Insurance Exchange	2/1/2025	Text	1	For Non-Grandfathered health plans for the Individual and Small Group markets (under ACA) ONLY. Use this field to report whether the policy for this eligibility record was enrolled through a Public Health Insurance Exchange. Valid codes include: 1=Yes; 2=No; 3=Unknown/not applicable.

ME119	Cost-Sharing Reduction Indicator	2/1/2025	Text	1	For Non-Grandfathered health plans for the Individual and Small Group markets (under ACA) ONLY. Indicates cost-sharing reduction under the Affordable Care Act (ACA). This is a person- level indicator in which enrollees who qualify for cost-sharing reduction are assigned cost- sharing indicator values of 1-8. Non-Cost-Sharing recipients are assigned a cost-sharing indicator value of zero. Valid codes include: 1=Enrollees in 94% Actuarial Value (AV) Silver Plan Variation; 2=Enrollees in 87% AV Silver Plan Variation; 3=Enrollees in 73% AV Silver Plan Variation; 4=Enrollees in Zero Cost Sharing Plan Variation of Platinum Level QHP (Qualified Health Plan); 5=Enrollee in Zero Cost Sharing Plan Variation of Gold Level QHP; 6=Enrollee in Zero Cost Sharing Plan Variation of Silver Level QHP; 7=Enrollee in Zero Cost Sharing Plan Variation of Bronze Level QHP; 8=Enrollee in Limited Cost Sharing Plan Variation; 0=Non-CSR recipient, and enrollees with unknown CSR.

ME899	Record Type	1/1/2003	Text	2	ME

		HIPAA Reference ASC X12N/005010
Data		Transaction Set/Loop/
Element		Segment ID/Code Value/
#	Data Element Name	Reference Designator
ME001	Submitter	N/A
ME002	Payor	N/A
ME003	Insurance Type/Product Code	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/02, 271/2110D/EB/02
ME008	Subscriber Social Security Number	271/2100C/REF/SY/02
ME009	Plan Specific Contract Number	271/2100C/NM1/MI/09
ME010	Member Suffix or Sequence Number	271/2100C/REF/49/02, 271/2100D/REF/49/02
ME011	Member Identification Code	271/2100C/REF/SY/02, 271/2100D/REF/SY/02
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	271/2100C/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	Race 3	N/A
ME024	Hispanic Indicator	N/A
ME025	Ethnicity 1	N/A
ME026	Ethnicity 2	N/A
ME027	Ethnicity 3	N/A
ME028	Primary Insurance Indicator	N/A
ME029	Coverage Type	N/A
ME030	Market Category Code	N/A
ME031	Special Coverage	N/A
ME032	Group Name	271/2100C/REF/18/03, 271/2100D/REF/28/03, 271/2100C/REF/6P/03, 271/2100D/REF/6P/03, 271/2100C/REF/N6/03, 271/2100D/REF/N6/03
ME101	Subscriber Last Name	271/2100C/NM1/ /03
ME102	Subscriber First Name	271/2100C/NM1/ /04
ME103	Subscriber Middle Name	271/2100C/NM1/ /05
ME104	Member Last Name	271/2100C/NM1/ /03, 271/2100D/NM1/ /03
ME105	Member First Name	271/2100C/NM1/ /04, 271/2100D/NM1/ /04
ME106	Member Middle Name	271/2100C/NM1/ /05, 271/2100D/NM1/ /05
ME107	Member Address Line 1	271/2100C/N3/01, 271/2100D/N3/01
ME108	Member Address Line 2	271/2100C/N3/02, 271/2100D/N3/02
ME109	Member Country Code	271/2100C/N4/04, 271/2100D/N4/04
ME110	Placeholder	N/A
ME111	Subscriber MBI	271/2100C/NM1/MI/09
ME112	Placeholder	N/A
ME113	Member MBI	271/2100D/NM1/MI/09, 271/2100D/REF/F6/02
ME114	Plan Begin Date (Member Effective Date)	271/2100C/DTP/346/D8, 271/2100D/DTP/346/D8
ME115	Plan End Date (Member Cancellation Date)	271/2100C/DTP/347/D8, 271/2100D/DTP/347/D8
ME116	Grandfathered Plan Indicator	N/A
ME117	Metal Tier	N/A
ME118	Enrolled Through a Public Health Insurance Exchange	N/A
ME119	Cost-Sharing Reduction Indicator	N/A
ME899	Record Type	N/A


Data Element #	Data Element Name	Date Effective	Type	Maximum Length	Description/Codes/Sources

MC001	Submitter	1/1/2003	Text	8	MHDO-assigned identifier of payor submitting claims data. Do not leave blank.

MC002	Payor	7/1/2012	Text	8	MHDO-assigned code of the insurer/underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage. Do not leave blank.

MC003	Insurance Type/Product Code	1/1/2003	Text	2	Code identifying the type of insurance policy within a specific insurance program. Refer to Appendix A
					16 Medicare Part C
					MD Medicare Part D
					SP Supplemental Policy

MC004	Payor Claim Control Number	1/1/2003	Text	35	Must apply to the entire claim and be unique within the payor’s system. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC005	Line Counter	4/1/2004	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. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC005A	Version Number	1/1/2010	Number	4	The version number of this claim service line.
					The original claim will have a version number of 0, with the next version being assigned a 1, and each subsequent version being incremented by 1 for that service line. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC006	Insured Group or Policy Number	1/1/2003	Text	30	Group or policy number – not the number that uniquely identifies the subscriber. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC007	Subscriber Social Security Number	1/1/2003	Text	9	Subscriber’s social security number Leave blank if unavailable.
					Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC008	Plan Specific Contract Number	1/1/2003	Text	80	Plan-assigned contract number Leave blank if contract number = subscriber’s social security number. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC009	Member Suffix or Sequence Number	1/1/2003	Text	20	Uniquely numbers the member within the contract. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC010	Member Identification Code	1/1/2003	Text	50	Member’s social security number Leave blank if unavailable. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC011	Individual Relationship Code	1/1/2003	Text	2	Member’s relationship to insured Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC012	Member Gender	1/1/2003	Text	1	Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC013	Member Date of Birth	1/1/2003	Text	8	CCYYMMDD Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.
MC014	Member City Name	4/1/2004	Text	30	City name of member Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC015	Member State or Province	4/1/2004	Text	2	As defined by the US Postal Service and Canada Post Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC016	Member ZIP Code	1/1/2003	Text	11	ZIP Code of member – may include non-US codes Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC017	Date Service Approved (AP Date)	1/1/2003	Text	8	CCYYMMDD The value ‘CCYY0101’, where CCYY is the year in which the service was approved, shall be used when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC018	Admission Date	1/1/2003	Text	8	Required for all inpatient claims
					CCYYMMDD The value ‘CCYY0101’, where CCYY is the year in which the admission occurred, shall be used when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC019	Admission Hour	4/1/2004	Text	2	Required for all inpatient claims
					Time is expressed in military time – HH

MC020	Priority (Type) of Admission or Visit	4/1/2004	Number	1	Required for all inpatient claims Refer to Appendix A

MC021	Point of Origin for Admission or Visit	4/1/2004	Text	1	Required for all inpatient claims Refer to Appendix A

MC022	Discharge Hour	4/1/2004	Text	2	Time expressed in military time – HH

MC023	Patient Discharge Status	1/1/2003	Text	2	Required for all inpatient claims Refer to Appendix A

MC024	Rendering Provider Number	1/1/2003	Text	30	Payor-assigned rendering provider number

MC025	Rendering Provider Tax ID Number	1/1/2003	Text	10	Federal taxpayer’s identification number

MC026	National Provider ID – Rendering Provider	4/1/2004	Text	20	National Provider ID for Rendering Provider This data element pertains to the entity or individual directly providing the service. Refer to Appendix A

MC027	Rendering Provider Entity Type Qualifier	4/1/2004	Number	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. Refer to Appendix A

MC028	Rendering Provider First Name	1/1/2003	Text	40	Individual first name Leave blank if provider is a facility or organization.

MC029	Rendering Provider Middle Name	1/1/2003	Text	25	Individual middle name or initial Leave blank if provider is a facility or organization.

MC030	Rendering Provider Last Name or Organization Name	1/1/2003	Text	60	Full name of provider organization or last name of individual provider

MC031	Rendering Provider Suffix	1/1/2003	Text	10	Suffix to individual name Leave blank if provider is a facility or organization.
					The service provider suffix shall 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, LCSW).

MC032	Rendering Provider Specialty	1/1/2003	Text	10	Refer to Appendix A If defined by payor, then dictionary for specialty code values must be supplied during testing.

MC033	Placeholder	10/1/2014	N/A	0	Leave blank Service Provider City Name retired; refer to MC089 – Service Facility Location City Name

MC034	Placeholder	10/1/2014	N/A	0	Leave blank Service Provider State or Province retired; refer to MC090 – Service Facility Location Address State or Province

MC035	Placeholder	10/1/2014	N/A	0	Leave blank Service Provider ZIP Code retired; refer to MC091 – Service Facility Location Address State or Province

MC036	Type of Bill – Institutional	4/1/2004	Text	3	Required for institutional claims Not to be used for professional claims Exclude leading zero, but include frequency indicator, if present Refer to Appendix A

MC037	Place of Service – Professional	4/1/2004	Text	2	Required for professional claims Not to be used for institutional claims Refer to Appendix A

MC038	Claim Status	1/1/2003	Text	2	Refer to Appendix A

MC039	Placeholder	2/1/2025	N/A	0	Leave blank. ICD-9 Admitting Diagnosis retired.
					See MC202 for ICD-10 Admitting Diagnosis.

MC040	Placeholder	2/1/2025	N/A	0	Leave blank. ICD-9 E-Code retired. See MC206 and following fields for ICD-10 External Cause of Injury codes.

MC041	Placeholder	2/1/2025	N/A	0	Leave blank. ICD-9 Principal Diagnosis retired. See MC200 for ICD-10 Principal Diagnosis.

MC042	Placeholder	2/1/2025	N/A	0	Leave blank. Other ICD-9 Diagnosis – 1 retired. See MC254 and following fields for ICD-10 secondary, etc. diagnoses.

MC043	Placeholder	2/1/2025	N/A	0	Leave blank. Other Diagnosis – 2 retired
MC044	Placeholder	2/1/2025	N/A	0	Leave blank. Other Diagnosis – 3 retired
MC045	Placeholder	2/1/2025	N/A	0	Leave blank. Other Diagnosis – 4 retired
MC046	Placeholder	2/1/2025	N/A	0	Leave blank. Other Diagnosis – 5 retired
MC047	Placeholder	2/1/2025	N/A	0	Leave blank. Other Diagnosis – 6 retired
MC048	Placeholder	2/1/2025	N/A	0	Leave blank. Other Diagnosis – 7 retired
MC049	Placeholder	2/1/2025	N/A	0	Leave blank. Other Diagnosis – 8 retired
MC050	Placeholder	2/1/2025	N/A	0	Leave blank. Other Diagnosis – 9 retired
MC051	Placeholder	2/1/2025	N/A	0	Leave blank. Other Diagnosis – 10 retired
MC052	Placeholder	2/1/2025	N/A	0	Leave blank. Other Diagnosis – 11 retired
MC053	Placeholder	2/1/2025	N/A	0	Leave blank. Other Diagnosis – 12 retired
MC054	Revenue Code	1/1/2003	Text	4	National Uniform Billing Committee Codes Code using leading zeroes, left justified, and four digits. Refer to Appendix A

MC055	Procedure Code	1/1/2003	Text	10	Health Care Common Procedural Coding System (HCPCS), the CPT codes of the American Medical Association, the CDT from the American Dental Association, and the HIPPS codes from the Health Insurance Prospective Payment System. Specify the procedure or service on a capitated service record and set the Payment Arrangement Type Indicator (MC331) = ‘09’.
					Refer to Appendix A

MC056	Procedure Modifier – 1	1/1/2003	Text	2	Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code.

MC057	Procedure Modifier – 2	1/1/2003	Text	2	Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code.

MC057A	Procedure Modifier – 3	10/1/2014	Text	2	Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code.

MC057B MC058	Procedure Modifier – 4 Placeholder	10/1/2014, 2/1/2025	Text N/A	2 0	Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code. Leave blank. ICD-9-CM Procedure Code retired See MC302 and following fields for ICD-10 procedure codes.

MC059	Claim Date – From	1/1/2003	Text	8	First date of service for this claim. See mapping to form locators and the 005010 in Appendix D-2. See MC334 for line-level service from date. CCYYMMDD The Payment Arrangement Type Indicator (MC331) = ‘09’ for all capitated service records. The value ‘CCYY0101’, where CCYY is year of the first date of service for the claim, shall be used when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC060	Claim Date – Thru	1/1/2003	Text	8	Last date of service for this claim. See mapping to form locators and the 005010 in Appendix D-2. See MC335 for line-level service through date. CCYYMMDD The Payment Arrangement Type Indicator (MC331) = ‘09’ for all capitated service records. The value ‘CCYY0101’, where CCYY is year of the last date of service for the claim, shall be used when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC061	Quantity	1/1/2003	Number	10	Count of services performed, which shall be set equal to one on all observation bed service lines and should be set equal to zero on all other room and board service lines, regardless of the length of stay. Code decimal point. On a capitated service record, the value of this field is greater than or equal to 1. The Payment Arrangement Type Indicator (MC331) = ‘09’ for all capitated service records.

MC062	Charge Amount	1/1/2003	Number	10	Do not code decimal point. Two decimal places implied.

MC063	Paid Amount	1/1/2003	Number	10	Includes any withhold amounts. On a capitated service record, set the value of this field = ‘0’. The Payment Arrangement Type Indicator (MC331) = ‘09’ for all capitated service records.
					Do not code decimal point. Two decimal places implied.

MC064	Placeholder	2/1/2025	N/A	0	Prepaid amount retired.

MC065	Co-pay Amount	1/1/2003	Number	10	The preset, fixed dollar amount for which the individual is responsible.
					Do not code decimal point. Two decimal places implied.

MC066	Coinsurance Amount	1/1/2003	Number	10	The dollar amount an individual is responsible for – not the percentage. Do not code decimal point. Two decimal places implied.

MC067	Deductible Amount	1/1/2003	Number	10	Do not code decimal point. Two decimal places implied.

MC068	Patient Account/Control Number	7/1/2006	Text	20	Identifier assigned by hospital

MC069	Discharge Date	7/1/2006	Text	8	Date patient discharged. Required for all inpatient claims. CCYYMMDD The value ‘CCYY0101’, where CCYY is the year in which discharge occurred, shall be used when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC070	Placeholder	2/1/2016	N/A	0	Leave blank. Service Provider Country Name retired
MC071	Placeholder	2/1/2025	N/A	0	Leave blank. DRG retired
MC072	Placeholder	2/1/2025	N/A	0	Leave blank. DRG Version retired
MC073	Placeholder	2/1/2025	N/A	0	Leave blank. APC retired
MC074	Placeholder	2/1/2025	N/A	0	Leave blank. APC Version retired
MC075	Drug Code	1/1/2010	Text	11	An NDC code used only when a medication is paid for as part of a medical claim. Refer to Appendix A

MC076	Billing Provider Number	1/1/2010	Text	30	Payor-assigned billing provider number. This number should be the identifier used by the payor for internal identification purposes, and does not routinely change.

MC077	National Provider ID – Billing Provider	1/1/2010	Text	20	National Provider ID for billing provider Refer to Appendix A

MC078	Billing Provider Last Name or Organization Name	1/1/2010	Text	60	Full name of provider billing organization or last name of individual billing provider.

MC079	Billing Provider Tax ID	10/1/2014	Text	10	Federal taxpayer's identification number

MC080	Billing Provider Address Line 1	10/1/2014	Text	55	Address information for billing provider

MC081	Billing Provider Address Line 2	10/1/2014	Text	55	Address information for billing provider

MC082	Billing Provider City Name	10/1/2014	Text	30	City name of billing provider Refer to Appendix A

MC083	Billing Provider State or Province	10/1/2014	Text	2	As defined by the US Postal Service and Canada Post Refer to Appendix A

MC084	Billing Provider Zip Code	10/1/2014	Text	11	ZIP Code of billing provider - may include non-US codes Do not include dash Refer to Appendix A

MC085	Service Facility Location Name	10/1/2014	Text	60	Laboratory or service facility name If not available or not specified, do not populate.

MC086	National Provider ID – Service Facility	10/1/2014	Text	20	National Provider ID for laboratory or service facility If not available or not specified, do not populate. Refer to Appendix A

MC087	Service Facility Location Address Line 1	10/1/2014	Text	55	Address information for laboratory or service facility If not available or not specified, do not populate. Address Line 1.

MC088	Service Facility Location Address Line 2	10/1/2014	Text	55	Address information for laboratory or service facility If not available or not specified, do not populate. Address Line 2.
MC089	Service Facility Location City Name	10/1/2014	Text	30	City name of laboratory or service facility If not available or not specified, do not populate. City Name. Refer to Appendix A

MC090	Service Facility Location State or Province	10/1/2014	Text	2	As defined by the US Postal Service and Canada Post If not available or not specified, do not populate. Refer to Appendix A

MC091	Service Facility Location Zip Code	10/1/2014	Text	11	ZIP Code of service facility - may include non-US codes Do not include dash If not available or not specified, do not populate. Refer to Appendix A

MC092	Service Facility Number	2/1/2016	Text	30	Payor-assigned service facility number. This number should be the identifier used by the payor for internal identification purposes and does not routinely change. If not available or not specified, do not populate.

MC093	Service Facility Location Country Code	2/1/2016	Text	2	Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A. If not available or not specified, do not populate.

MC094	Billing Provider Country Code	2/1/2016	Text	2	Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A.

MC101	Subscriber Last Name	1/1/2010	Text	60	The subscriber last name Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC102	Subscriber First Name	1/1/2010	Text	35	The subscriber first name Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC103	Subscriber Middle Name	1/1/2010	Text	25	The subscriber middle name or initial Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC104	Member Last Name	1/1/2010	Text	60	The member last name Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC105	Member First Name	1/1/2010	Text	35	The member first name Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC106	Member Middle Name	1/1/2010	Text	25	The member middle name or initial Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC107	Attending Provider Number	2/1/2016	Text	30	Payor-assigned attending provider number. This number should be the identifier used by the payor for internal identification purposes and does not routinely change.

MC108	National Provider ID – Attending Provider	2/1/2016	Text	20	National Provider ID for attending provider Refer to Appendix A

MC109	Attending Provider First Name	2/1/2016	Text	40	Individual first name

MC110	Attending Provider Middle Name	2/1/2016	Text	25	Individual middle name or initial

MC111	Attending Provider Last Name	2/1/2016	Text	60	Individual last name

MC112	Attending Provider Suffix	2/1/2016	Text	10	Individual name suffix The attending provider suffix shall 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, LCSW).

MC113	Attending Provider Specialty	2/1/2016	Text	10	Refer to Appendix A If defined by payor, then dictionary for specialty code values must be supplied during testing.

MC114	Operating Provider Number	2/1/2016	Text	30	Payor-assigned operating provider number. This number should be the identifier used by the payor for internal identification purposes and does not routinely change.

MC115	National Provider ID – Operating Provider	2/1/2016	Text	20	National Provider ID for operating provider Refer to Appendix A

MC116	Operating Provider First Name	2/1/2016	Text	40	Individual first name

MC117	Operating Provider Middle Name	2/1/2016	Text	25	Individual middle name or initial

MC118	Operating Provider Last Name	2/1/2016	Text	60	Individual last name

MC119	Operating Provider Suffix	2/1/2016	Text	10	Individual name suffix The operating provider suffix shall 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, LCSW).

MC120	Referring Provider Number	2/1/2016	Text	30	Payor-assigned referring provider number. This number should be the identifier used by the payor for internal identification purposes and does not routinely change.

MC121	National Provider ID – Referring Provider	2/1/2016	Text	20	National Provider ID for referring provider Refer to Appendix A

MC122	Referring Provider First Name	2/1/2016	Text	40	Individual first name

MC123	Referring Provider Middle Name	2/1/2016	Text	25	Individual middle name or initial

MC124	Referring Provider Last Name	2/1/2016	Text	60	Individual last name

MC125	Referring Provider Suffix	2/1/2016	Text	10	Individual name suffix The referring provider suffix shall 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, LCSW).

MC200	Principal Diagnosis	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC201	Present On Admission Indicator	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC202	Admitting Diagnosis	10/1/2004	Text	7	Required on all inpatient admission claims and encounters
					ICD-10-CM Do not code decimal point. Refer to Appendix A

MC203	Reason for Visit Diagnosis - 1	10/1/2014	Text	7	ICD-10 CM Do not code decimal point. Refer to Appendix A

MC204	Reason for Visit Diagnosis - 2	10/1/2014	Text	7	ICD-10 CM Do not code decimal point. Refer to Appendix A

MC205	Reason for Visit Diagnosis - 3	10/1/2014	Text	7	ICD-10 CM Do not code decimal point. Refer to Appendix A

MC206	External Cause of Injury - 1	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A
					Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC207	Present On Admission Indicator - 1	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC208	External Cause of Injury - 2	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC209	Present On Admission Indicator - 2	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC210	External Cause of Injury - 3	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC211	Present On Admission Indicator - 3	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC212	External Cause of Injury - 4	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC213	Present On Admission Indicator - 4	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC214	External Cause of Injury - 5	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC215	Present On Admission Indicator - 5	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC216	External Cause of Injury - 6	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC217	Present On Admission Indicator - 6	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC218	External Cause of Injury - 7	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC219	Present On Admission Indicator - 7	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC220	External Cause of Injury - 8	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC221	Present On Admission Indicator - 8	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC222	External Cause of Injury - 9	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC223	Present On Admission Indicator - 9	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC224	External Cause of Injury - 10	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC225	Present On Admission Indicator - 10	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC226	External Cause of Injury - 11	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC227	Present On Admission Indicator - 11	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC228	External Cause of Injury - 12	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC229	Present On Admission Indicator - 12	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC230	External Cause of Injury - 13	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC231	Present On Admission Indicator - 13	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC232	External Cause of Injury - 14	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC233	Present On Admission Indicator - 14	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC234	External Cause of Injury - 15	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC235	Present On Admission Indicator - 15	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC236	External Cause of Injury - 16	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC237	Present On Admission Indicator - 16	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC238	External Cause of Injury - 17	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC239	Present On Admission Indicator - 17	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC240	External Cause of Injury - 18	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC241	Present On Admission Indicator - 18	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC242	External Cause of Injury - 19	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC243	Present On Admission Indicator - 19	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC244	External Cause of Injury - 20	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC245	Present On Admission Indicator - 20	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC246	External Cause of Injury - 21	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC247	Present On Admission Indicator - 21	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC248	External Cause of Injury - 22	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC249	Present On Admission Indicator - 22	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC250	External Cause of Injury - 23	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC251	Present On Admission Indicator - 23	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC252	External Cause of Injury - 24	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC253	Present On Admission Indicator - 24	10/1/2014	Text	1	Standard POA code set Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC254	Other Diagnosis – 1	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC255	Present On Admission Indicator – 1	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC256	Other Diagnosis – 2	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC257	Present On Admission Indicator – 2	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC258	Other Diagnosis – 3	10/1/2004	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC259	Present On Admission Indicator – 3	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC260	Other Diagnosis – 4	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC261	Present On Admission Indicator – 4	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC262	Other Diagnosis – 5	10/1/2004	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC263	Present On Admission Indicator – 5	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC264	Other Diagnosis – 6	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC265	Present On Admission Indicator – 6	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC266	Other Diagnosis – 7	10/1/2004	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC267	Present On Admission Indicator – 7	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC268	Other Diagnosis – 8	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC269	Present On Admission Indicator – 8	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC270	Other Diagnosis – 9	10/1/2004	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC271	Present On Admission Indicator – 9	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC272	Other Diagnosis – 10	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC273	Present On Admission Indicator – 10	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC274	Other Diagnosis – 11	10/1/2004	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC275	Present On Admission Indicator – 11	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC276	Other Diagnosis – 12	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC277	Present On Admission Indicator – 12	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC278	Other Diagnosis – 13	10/1/2004	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC279	Present On Admission Indicator – 13	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC280	Other Diagnosis – 14	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC281	Present On Admission Indicator – 14	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC282	Other Diagnosis – 15	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC283	Present On Admission Indicator – 15	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC284	Other Diagnosis – 16	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC285	Present On Admission Indicator – 16	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC286	Other Diagnosis – 17	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC287	Present On Admission Indicator – 17	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC288	Other Diagnosis – 18	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC289	Present On Admission Indicator – 18	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC290	Other Diagnosis – 19	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC291	Present On Admission Indicator – 19	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC292	Other Diagnosis – 20	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC293	Present On Admission Indicator – 20	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC294	Other Diagnosis – 21	10/1/2004	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC295	Present On Admission Indicator – 21	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC296	Other Diagnosis – 22	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC297	Present On Admission Indicator – 22	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC298	Other Diagnosis – 23	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC299	Present On Admission Indicator – 23	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC300	Other Diagnosis – 24	10/1/2014	Text	7	ICD-10-CM Do not code decimal point. Refer to Appendix A

MC301	Present On Admission Indicator – 24	10/1/2014	Text	1	Standard POA code set Refer to Appendix A

MC302	Principal Procedure Code	10/1/2014	Text	7	IDC-10-PCS Primary procedure code for this line of service Do not code decimal point. Refer to Appendix A

MC303	Other Procedure Code - 1	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC304	Other Procedure Code - 2	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC305	Other Procedure Code - 3	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC306	Other Procedure Code - 4	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC307	Other Procedure Code - 5	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC308	Other Procedure Code - 6	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC309	Other Procedure Code - 7	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC310	Other Procedure Code - 8	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC311	Other Procedure Code - 9	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC312	Other Procedure Code - 10	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC313	Other Procedure Code - 11	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC314	Other Procedure Code - 12	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC315	Other Procedure Code - 13	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC316	Other Procedure Code - 14	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC317	Other Procedure Code - 15	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC318	Other Procedure Code - 16	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC319	Other Procedure Code - 17	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC320	Other Procedure Code - 18	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC321	Other Procedure Code - 19	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC322	Other Procedure Code - 20	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC323	Other Procedure Code - 21	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC324	Other Procedure Code - 22	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC325	Other Procedure Code - 23	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC326	Other Procedure Code - 24	10/1/2014	Text	7	ICD-10 PCS Do not code decimal point. Refer to Appendix A

MC327	Member Address Line 1	2/1/2019	Text	55	Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC328	Member Address Line 2	2/1/2019	Text	55	Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC329	Member Country Code	2/1/2019	Text	2	Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC330	In-Plan Network Indicator	2/1/2021	Text	1	A yes/no indicator that specifies if the Billing Provider (not the benefit) is within the health plan network. Valid codes are: N=No; Y=Yes.

MC331	Payment Arrangement Type Indicator	2/1/2022	Text	2	Indicates the payment methodology. Valid codes are: 01=Unused/Retired 02=Fee for Service 03=Percent of Charges 04=DRG 05=Pay for Performance 06=Global Payment 07=APC 08=Other Claims-based Payment 09= Capitation contract per member per month (PMPM)

MC332	Member Age	2/1/2025	Text	2	Member’s calculated age as of the service date. Round to the nearest integer. For ages ≥ 90, indicate ‘90’.
MC333	Substance Use Disorder (SUD) Indicator	2/1/2025	Text	1	Indicates whether a record contains 42 CFR Part 2 SUD-related data or not. Valid values are: N = Record does not contain 42 CFR Part 2 SUD-related data. Send all available values of all requested fields. Y = Record contains 42 CFR Part 2 SUD-related data. The following fields shall be left blank: MC004-MC016; MC101-MC106; MC206 – MC253; and MC327-MC329. Fields MC017, MC018, MC059, MC060, MC069, MC334 and MC335 may be recoded to CCYY0101, where CCYY is the year of the date. NOTE: only 42 CFR Part 2 SUD-related claim lines shall be marked with ‘Y’; other claim lines in the claim that are not 42 CFR Part 2 SUD-related shall be marked with ‘N’.
MC334	Service Line Date – From	2/1/2025	Text	8	First date of service for this service line. Indicate the date of service at the line level, not the claim level. See mapping to form locators and the 005010 in Appendix D-2. CCYYMMDD On a capitated service record, this is the first day of service. The Payment Arrangement Type Indicator (MC331) = ‘09’ for all capitated service records. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC335	Service Line Date – Thru	2/1/2025	Text	8	Last date of service for this service line. Indicate the date of service at the line level, not the claim level. See mapping to form locators and the 005010 in Appendix D-2. CCYYMMDD On a capitated service record, this is the last day of service. The Payment Arrangement Type Indicator (MC331) = ‘09’ for all capitated service records. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

MC336	Carrier Specific Unique Member (CSUM) ID	2/1/2025	Text	50	This ID should uniquely and consistently identify a member in both the medical claims and the capitated payments files. It shall be used when the payor indicates that related records in the medical and capitation files contain 42 CFR Part 2 SUD-related data (MC333 = ‘Y’ and CF035 = ‘Y’), and other inter-file identifiers shall be left blank. For fully identified data records that do not contain 42 CFR Part 2-related data (MC333 = ‘N’ and CF035 = ‘N’), the CSUM ID shall be left blank, and all other inter-file identifiers shall be populated, when available. This ID must differ from any of the other identifiers on the record and may not be derived from any of these in a manner that the original values could be determined.

MC899	Record Type	1/1/2003	Text	2	Value = MC

				HIPAA Reference ASC X12N/005010A1
Data		UB-04	CMS	Transaction Set/Loop/
Element		Form	1500	Segment ID/Code Value/
#	Data Element Name	Locator	#	Reference Designator
MC001	Submitter	N/A	N/A	N/A
MC002	Payor	N/A	N/A	N/A
MC003	Insurance Type/Product Code	N/A	N/A	835/2100/CLP/06
MC004	Payor 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)	11	837/2000B/SBR/03
MC007	Subscriber Social Security Number	N/A	N/A	835/2100/NM1/MI/09
MC008	Plan Specific Contract Number	60 (A-C)	1a	835/2100/NM1/MI/09
MC009	Member Suffix or Sequence Number	N/A	N/A	N/A
MC010	Member Identification Code	N/A	N/A	835/2100/NM1/34/09
MC011	Individual Relationship Code	59 (A-C)	6	837/2000B/SBR/02, 837/2000C/PAT/01
MC012	Member Gender	11	3	837/2010BA/DMG/03, 837/2010CA/DMG/03
MC013	Member Date of Birth	10	3	837/2010BA/DMG/D8/02, 837/2010CA/DMG/D8/02
MC014	Member City Name	9b	5	837/2010BA/N4/01, 837/2010CA/N4/01
MC015	Member State or Province	9c	5	837/2010BA/N4/02, 837/2010CA/N4/02
MC016	Member ZIP Code	9d	5	837/2010BA/N4/03, 837/2010CA/N4/03
MC017	Date Service Approved	N/A	N/A	835/Header Financial Information/BPR/16
MC018	Admission Date	12	18	837/2300/DTP/435/03
MC019	Admission Hour	13	N/A	837/2300/DTP/435/03
MC020	Priority (Type) of Admission or Visit	14	N/A	837/2300/CL1/01
MC021	Point of Origin for Admission or Visit	15	N/A	837/2300/CL1/02
MC022	Discharge Hour	16	N/A	837/2300/DTP/096/03
MC023	Patient Discharge Status	17	N/A	837/2300/CL1/03
MC024	Rendering Provider Number	57	N/A	835/2100/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
MC025	Rendering Provider Tax ID Number	5	25 (only if EIN)	835/2100/NM1/FI/09
MC026	National Provider ID – Rendering Provider	56	24J	professional: 837/2420A/NM1/XX/09; 837/2310B/NM1/XX/09; institutional: 837/2010AA/NM1/XX/09
MC027	Rendering Provider Entity Type Qualifier	N/A	N/A	professional: 837/2420A/NM1/82/02; 837/2310B/NM1/82/02; institutional: 837/2010AA/NM1/85/02
MC028	Rendering Provider First Name	N/A	31	professional: 837/2420A/NM1/82/04; 837/2310B/NM1/82/04; institutional: N/A
MC029	Rendering Provider Middle Name	N/A	31	professional: 837/2420A/NM1/82/05; 837/2310B/NM1/82/05; institutional: N/A
MC030	Rendering Provider Last Name or Organization Name	1	31	professional: 837/2420A/NM1/82/1/03; 837/2310B/NM1/82/1/03; institutional: 837/2010AA/NM1/85/2/03
MC031	Rendering Provider Suffix	N/A	31	professional: 837/2420A/NM1/82/07; 837/2310B/NM1/82/07; institutional: N/A
MC032	Rendering Provider Specialty	N/A	N/A	professional: 837/2420A/PRV/PXC/03; 837/2310B/PRV/PXC/03; institutional: 837/2000A/PRV/PXC/03
MC033	Placeholder	N/A	N/A	N/A
MC034	Placeholder	N/A	N/A	N/A
MC035	Placeholder	N/A	N/A	N/A
MC036	Type of Bill – Institutional	4	N/A	837/2300/CLM/05-1
MC037	Place of Service - Professional	N/A	24B	837/2300/CLM/05-1
MC038	Claim Status	N/A	N/A	835/2100/CLP/02
MC039	Placeholder	N/A	N/A	N/A
MC040	Placeholder	N/A	N/A	N/A
MC041	Placeholder	N/A	N/A	N/A
MC042	Placeholder	N/A	N/A	N/A
MC043	Placeholder	N/A	N/A	N/A
MC044	Placeholder	N/A	N/A	N/A
MC045	Placeholder	N/A	N/A	N/A
MC046	Placeholder	N/A	N/A	N/A
MC047	Placeholder	N/A	N/A	N/A
MC048	Placeholder	N/A	N/A	N/A
MC049	Placeholder	N/A	N/A	N/A
MC050	Placeholder	N/A	N/A	N/A
MC051	Placeholder	N/A	N/A	N/A
MC052	Placeholder	N/A	N/A	N/A
MC053	Placeholder	N/A	N/A	N/A
MC054	Revenue Code	42	N/A	835/2110/SVC/NU/01-2, 835/2110/SVC/04
MC055	Procedure Code	44	24D	835/2110/SVC/HC/01-2, 835/2110/SVC/HP/01-2
MC056	Procedure Modifier - 1	44	24D	835/2110/SVC/HC/01-3
MC057	Procedure Modifier - 2	44	24D	835/2110/SVC/HC/01-4
MC057A	Procedure Modifier - 3	44	24D	835/2110/SVC/HC/01-5
MC057B	Procedure Modifier - 4	44	24D	835/2110/SVC/HC/01-6
MC058	Placeholder	N/A	N/A	N/A
MC059	Claim Date – From	6	N/A	837/2300/DTP/434/D8
MC060	Claim Date – Thru	6	N/A	837/2300/DTP/434/D8
MC061	Quantity	46	24G	835/2110/SVC/05
MC062	Charge Amount	47	24F	835/2110/SVC/02
MC063	Paid Amount	N/A	N/A	835/2110/SVC/03
MC064	Placeholder	N/A	N/A	N/A
MC065	Co-pay Amount	N/A	N/A	835/2110/CAS/PR/3-03
MC066	Coinsurance Amount	N/A	N/A	835/2110/CAS/PR/2-03
MC067	Deductible Amount	N/A	N/A	835/2110/CAS/PR/1-03
MC068	Patient Account/Control Number	3a	26	837/2300/CLM/01
MC069	Discharge Date	6	18	837/2300/DTP/434/03
MC070	Placeholder	N/A	N/A	N/A
MC071	Placeholder	N/A	N/A	N/A
MC072	Placeholder	N/A	N/A	N/A
MC073	Placeholder	N/A	N/A	N/A
MC074	Placeholder	N/A	N/A	N/A
MC075	Drug Code	N/A	N/A	837/2410/LIN/N4/03
MC076	Billing Provider Number	57	33b	837/2010BB/REF/G2/02
MC077	National Provider ID – Billing Provider	56	33a	837/2010AA/NM1/85/ /XX/09
MC078	Billing Provider Last Name	1	33	837/2010AA/NM1/85/ /03
MC079	Billing Provider Tax ID Number	NA	NA	837/2010AA/REF/EI/02
MC080	Billing Provider Address Line 1	1	33	837/2010AA/N3/01
MC081	Billing Provider Address Line 2	1	33	837/2010AA/N3/02
MC082	Billing Provider City Name	1	33	837/2010AA/N4/01
MC083	Billing Provider State or Province	1	33	837/2010AA/N4/02
MC084	Billing Provider Zip Code	1	33	837/2010AA/N4/03
MC085	Service Facility Location Name	1	32	professional: 837/2310C/NM1/77/2/03; institutional: 837/2310E/NM1/77/2/03
MC086	National Provider ID – Service Facility	56	32a	professional: 837/2310C/NM1/77/2/XX/09; institutional: 837/2310E/NM1/77/2/XX/09
MC087	Service Facility Location Address Line 1	1	32	professional: 837/2310C/N3/01; institutional: 837/2310E/N3/01
MC088	Service Facility Location Address Line 2	1	32	professional: 837/2310C/N3/02; institutional: 837/2310E/N3/02
MC089	Service Facility Location City Name	1	32	professional: 837/2310C/N4/01; institutional: 837/2310E/N4/01
MC090	Service Facility Location Address State or Province	1	32	professional: 837/2310C/N4/02; institutional: 837/2310E/N4/02
MC091	Service Facility Location Address Zip Code	1	32	professional: 837/2310C/N4/03; institutional: 837/2310E/N4/03
MC092	Service Facility Number	57	32b	professional: 837/2310C/REF/G2/02; institutional: 837/2310E /REF/G2/02
MC093	Service Facility Location Country Code	(1)	(32)	professional: 837/2310C/N4/04; institutional: 837/2310E/N4/04
MC094	Billing Provider Country Code	(1)	(33)	837/2010AA/N4/04
MC101	Subscriber Last Name	58(A-C)	4	837/2010BA/NM1/ /03
MC102	Subscriber First Name	58(A-C)	4	837/2010BA/NM1/ /04
MC103	Subscriber Middle Name	N/A	4	837/2010BA/NM1/ /05
MC104	Member Last Name	8b	2	837/2010CA/NM1/ /03, 837/2010BA/NM1/ /03
MC105	Member First Name	8b	2	837/2010CA/NM1/ /04, 837/2010BA/NM1/ /04
MC106	Member Middle Name	8b	2	837/2010CA/NM1/ /05, 837/2010BA/NM1/ /05
MC107	Attending Provider Number	N/A	N/A	professional: N/A institutional: 837/2310A/REF/G2/02
MC108	National Provider ID – Attending Provider	76	N/A	837/2310A/NM1/71/1/XX/09
MC109	Attending Provider First Name	76	N/A	837/2310A/NM1/71/1/04
MC110	Attending Provider Middle Name	N/A	N/A	837/2310A/NM1/71/1/05
MC111	Attending Provider Last Name	76	N/A	837/2310A/NM1/71/1/03
MC112	Attending Provider Suffix	N/A	N/A	837/2310A/NM1/71/1/07
MC113	Attending Provider Specialty	N/A	N/A	837/2310A/PRV/AT/PXC/03
MC114	Operating Provider Number	N/A	N/A	professional: N/A institutional: 837/2310B/REF/G2/02; 837/2420A/REF/G2/02
MC115	National Provider ID – Operating Provider	77	N/A	professional: N/A institutional: 837/2420A/NM1/72/1/XX/09; 837/2420A/NM1/72/1/XX/09
MC116	Operating Provider First Name	77	N/A	professional: N/A institutional: 837/2420A/NM1/72/1/04; 837/2420A/NM1/72/1/04
MC117	Operating Provider Middle Name	N/A	N/A	professional: N/A institutional: 837/2420A/NM1/72/1/05; 837/2420A/NM1/72/1/05
MC118	Operating Provider Last Name	77	N/A	professional: N/A institutional: 837/2420A/NM1/72/1/03; 837/2420A/NM1/72/1/03
MC119	Operating Provider Suffix	N/A	N/A	professional: N/A institutional: 837/2420A/NM1/72/1/07; 837/2420A/NM1/72/1/07
MC120	Referring Provider Number	N/A	N/A	professional: 837/2310A/REF/G2/02; 837/2420F/REF/G2/02 institutional: 837/2310F/REF/G2/02; 837/2420D/REF/G2/02
MC121	National Provider ID – Referring Provider	78 or 79	17b	professional: 837/2310A/NM1/DN/1/XX/09; 837/2420F/NM1/DN/1/XX/09 institutional: 837/2310F/NM1/DN/1/XX/09; 837/2420D/NM1/DN/1/XX/09
MC122	Referring Provider First Name	78 or 79	17	professional: 837/2310A/NM1/DN/1/04; 837/2420F/NM1/DN/1/04 institutional: 837/2310F/NM1/DN/1/04; 837/2420D/NM1/DN/1/04
MC123	Referring Provider Middle Name	N/A	17	professional: 837/2310A/NM1/DN/1/05; 837/2420F/NM1/DN/1/05 institutional: 837/2310F/NM1/DN/1/05; 837/2420D/NM1/DN/1/05
MC124	Referring Provider Last Name	78 or 79	17	professional: 837/2310A/NM1/DN/1/03; 837/2420F/NM1/DN/1/03 institutional: 837/2310F/NM1/DN/1/03; 837/2420D/NM1/DN/1/03
MC125	Referring Provider Suffix	N/A	17	professional: 837/2310A/NM1/DN/1/07; 837/2420F/NM1/DN/1/07 institutional: 837/2310F/NM1/DN/1/07; 837/2420D/NM1/DN/1/07
MC200	Principal Diagnosis	67	N/A	837/2300/HI/ABK/01-2
MC201	Present On Admission Indicator	67 (pos 8)	N/A	837/2300/HI/01-9
MC202	Admitting Diagnosis	69	N/A	837/2300/HI/ABJ/01-2
MC203	Reason for Visit Diagnosis - 1	70A	N/A	837/2300/HI/APR/01-2
MC204	Reason for Visit Diagnosis - 2	70B	N/A	837/2300/HI/APR/02-2
MC205	Reason for Visit Diagnosis - 3	70C	N/A	837/2300/HI/APR/03-2
MC206	External Cause of Injury - 1	72A	N/A	837/2300/HI/ABN/01-2
MC207	Present On Admission Indicator - 1	72A (pos 8)	N/A	837/2300/HI/01-9
MC208	External Cause of Injury - 2	72B	N/A	837/2300/HI/ABN/02-2
MC209	Present On Admission Indicator - 2	72B (pos 8)	N/A	837/2300/HI/02-9
MC210	External Cause of Injury - 3	72C	N/A	837/2300/HI/ABN/03-2
MC211	Present On Admission Indicator - 3	72C (pos 8)	N/A	837/2300/HI/03-9
MC212	External Cause of Injury - 4	N/A	N/A	837/2300/HI/ABN/04-2
MC213	Present On Admission Indicator - 4	N/A	N/A	837/2300/HI/04-9
MC214	External Cause of Injury - 5	N/A	N/A	837/2300/HI/ABN/05-2
MC215	Present On Admission Indicator - 5	N/A	N/A	837/2300/HI/05-9
MC216	External Cause of Injury - 6	N/A	N/A	837/2300/HI/ABN/06-2
MC217	Present On Admission Indicator - 6	N/A	N/A	837/2300/HI/06-9
MC218	External Cause of Injury - 7	N/A	N/A	837/2300/HI/ABN/07-2
MC219	Present On Admission Indicator - 7	N/A	N/A	837/2300/HI/07-9
MC220	External Cause of Injury - 8	N/A	N/A	837/2300/HI/ABN/08-2
MC221	Present On Admission Indicator - 8	N/A	N/A	837/2300/HI/08-9
MC222	External Cause of Injury - 9	N/A	N/A	837/2300/HI/ABN/09-2
MC223	Present On Admission Indicator - 9	N/A	N/A	837/2300/HI/09-9
MC224	External Cause of Injury - 10	N/A	N/A	837/2300/HI/ABN/10-2
MC225	Present On Admission Indicator - 10	N/A	N/A	837/2300/HI/10-9
MC226	External Cause of Injury - 11	N/A	N/A	837/2300/HI/ABN/11-2
MC227	Present On Admission Indicator - 11	N/A	N/A	837/2300/HI/11-9
MC228	External Cause of Injury - 12	N/A	N/A	837/2300/HI/ABN/12-2
MC229	Present On Admission Indicator - 12	N/A	N/A	837/2300/HI/12-9
MC230	External Cause of Injury - 13	N/A	N/A	837/2300/HI/ABN/01-2
MC231	Present On Admission Indicator - 13	N/A	N/A	837/2300/HI/01-9
MC232	External Cause of Injury - 14	N/A	N/A	837/2300/HI/ABN/02-2
MC233	Present On Admission Indicator - 14	N/A	N/A	837/2300/HI/02-9
MC234	External Cause of Injury - 15	N/A	N/A	837/2300/HI/ABN/03-2
MC235	Present On Admission Indicator - 15	N/A	N/A	837/2300/HI/03-9
MC236	External Cause of Injury - 16	N/A	N/A	837/2300/HI/ABN/04-2
MC237	Present On Admission Indicator - 16	N/A	N/A	837/2300/HI/04-9
MC238	External Cause of Injury - 17	N/A	N/A	837/2300/HI/ABN/05-2
MC239	Present On Admission Indicator - 17	N/A	N/A	837/2300/HI/05-9
MC240	External Cause of Injury - 18	N/A	N/A	837/2300/HI/ABN/06-2
MC241	Present On Admission Indicator - 18	N/A	N/A	837/2300/HI/06-9
MC242	External Cause of Injury - 19	N/A	N/A	837/2300/HI/ABN/07-2
MC243	Present On Admission Indicator - 19	N/A	N/A	837/2300/HI/07-9
MC244	External Cause of Injury - 20	N/A	N/A	837/2300/HI/ABN/08-2
MC245	Present On Admission Indicator - 20	N/A	N/A	837/2300/HI/08-9
MC246	External Cause of Injury - 21	N/A	N/A	837/2300/HI/ABN/09-2
MC247	Present On Admission Indicator - 21	N/A	N/A	837/2300/HI/09-9
MC248	External Cause of Injury - 22	N/A	N/A	837/2300/HI/ABN/10-2
MC249	Present On Admission Indicator - 22	N/A	N/A	837/2300/HI/10-9
MC250	External Cause of Injury - 23	N/A	N/A	837/2300/HI/ABN/11-2
MC251	Present On Admission Indicator - 23	N/A	N/A	837/2300/HI/11-9
MC252	External Cause of Injury - 24	N/A	N/A	837/2300/HI/ABN/12-2
MC253	Present On Admission Indicator - 24	N/A	N/A	837/2300/HI/12-9
MC254	Other Diagnosis – 1	67A	21A	837/2300/HI/ABF/01-2
MC255	Present On Admission Indicator – 1	67A (pos 8)	N/A	837/2300/HI/01-9
MC256	Other Diagnosis – 2	67B	21B	837/2300/HI/ABF/02-2
MC257	Present On Admission Indicator – 2	67B (pos 8)	N/A	837/2300/HI/02-9
MC258	Other Diagnosis – 3	67C	21C	837/2300/HI/ABF/03-2
MC259	Present On Admission Indicator – 3	67C (pos 8)	N/A	837/2300/HI/03-9
MC260	Other Diagnosis – 4	67D	21D	837/2300/HI/ABF/04-2
MC261	Present On Admission Indicator – 4	67D (pos 8)	N/A	837/2300/HI/04-9
MC262	Other Diagnosis – 5	67E	21E	837/2300/HI/ABF/05-2
MC263	Present On Admission Indicator – 5	67E (pos 8)	N/A	837/2300/HI/05-9
MC264	Other Diagnosis – 6	67F	21F	837/2300/HI/ABF/06-2
MC265	Present On Admission Indicator – 6	67F (pos 8)	N/A	837/2300/HI/06-9
MC266	Other Diagnosis – 7	67G	21G	837/2300/HI/ABF/07-2
MC267	Present On Admission Indicator – 7	67G (pos 8)	N/A	837/2300/HI/07-9
MC268	Other Diagnosis – 8	67H	21H	837/2300/HI/ABF/08-2
MC269	Present On Admission Indicator – 8	67H (pos 8)	N/A	837/2300/HI/08-9
MC270	Other Diagnosis – 9	67I	21I	837/2300/HI/ABF/09-2
MC271	Present On Admission Indicator – 9	67I (pos 8)	N/A	837/2300/HI/09-9
MC272	Other Diagnosis – 10	67J	21J	837/2300/HI/ABF/10-2
MC273	Present On Admission Indicator – 10	67J (pos 8)	N/A	837/2300/HI/10-9
MC274	Other Diagnosis – 11	67K	21K	837/2300/HI/ABF/11-2
MC275	Present On Admission Indicator – 11	67K (pos 8)	N/A	837/2300/HI/11-9
MC276	Other Diagnosis – 12	67L	21L	837/2300/HI/ABF/12-2
MC277	Present On Admission Indicator – 12	67L (pos 8)	N/A	837/2300/HI/12-9
MC278	Other Diagnosis – 13	N/A	N/A	837/2300/HI/ABF/01-2
MC279	Present On Admission Indicator – 13	N/A	N/A	837/2300/HI/01-9
MC280	Other Diagnosis – 14	N/A	N/A	837/2300/HI/ABF/02-2
MC281	Present On Admission Indicator – 14	N/A	N/A	837/2300/HI/02-9
MC282	Other Diagnosis – 15	N/A	N/A	837/2300/HI/ABF/03-2
MC283	Present On Admission Indicator – 15	N/A	N/A	837/2300/HI/03-9
MC284	Other Diagnosis – 16	N/A	N/A	837/2300/HI/ABF/04-2
MC285	Present On Admission Indicator – 16	N/A	N/A	837/2300/HI/04-9
MC286	Other Diagnosis – 17	N/A	N/A	837/2300/HI/ABF/05-2
MC287	Present On Admission Indicator – 17	N/A	N/A	837/2300/HI/05-9
MC288	Other Diagnosis – 18	N/A	N/A	837/2300/HI/ABF/06-2
MC289	Present On Admission Indicator – 18	N/A	N/A	837/2300/HI/06-9
MC290	Other Diagnosis – 19	N/A	N/A	837/2300/HI/ABF/07-2
MC291	Present On Admission Indicator – 19	N/A	N/A	837/2300/HI/07-9
MC292	Other Diagnosis – 20	N/A	N/A	837/2300/HI/ABF/08-2
MC293	Present On Admission Indicator – 20	N/A	N/A	837/2300/HI/08-9
MC294	Other Diagnosis – 21	N/A	N/A	837/2300/HI/ABF/09-2
MC295	Present On Admission Indicator – 21	N/A	N/A	837/2300/HI/09-9
MC296	Other Diagnosis – 22	N/A	N/A	837/2300/HI/ABF/10-2
MC297	Present On Admission Indicator – 22	N/A	N/A	837/2300/HI/10-9
MC298	Other Diagnosis – 23	N/A	N/A	837/2300/HI/ABF/11-2
MC299	Present On Admission Indicator – 23	N/A	N/A	837/2300/HI/11-9
MC300	Other Diagnosis – 24	N/A	N/A	837/2300/HI/ABF/12-2
MC301	Present On Admission Indicator – 24	N/A	N/A	837/2300/HI/12-9
MC302	Principal Procedure Code	74	N/A	837/2300/HI/BBR/01-2
MC303	Other Procedure Code - 1	74A	N/A	837/2300/HI/BBQ/01-2
MC304	Other Procedure Code - 2	74B	N/A	837/2300/HI/BBQ/02-2
MC305	Other Procedure Code - 3	74C	N/A	837/2300/HI/BBQ/03-2
MC306	Other Procedure Code - 4	74D	N/A	837/2300/HI/BBQ/04-2
MC307	Other Procedure Code - 5	74E	N/A	837/2300/HI/BBQ/05-2
MC308	Other Procedure Code - 6	N/A	N/A	837/2300/HI/BBQ/06-2
MC309	Other Procedure Code - 7	N/A	N/A	837/2300/HI/BBQ/07-2
MC310	Other Procedure Code - 8	N/A	N/A	837/2300/HI/BBQ/08-2
MC311	Other Procedure Code - 9	N/A	N/A	837/2300/HI/BBQ/09-2
MC312	Other Procedure Code - 10	N/A	N/A	837/2300/HI/BBQ/10-2
MC313	Other Procedure Code - 11	N/A	N/A	837/2300/HI/BBQ/11-2
MC314	Other Procedure Code - 12	N/A	N/A	837/2300/HI/BBQ/12-2
MC315	Other Procedure Code - 13	N/A	N/A	837/2300/HI/BBQ/01-2
MC316	Other Procedure Code - 14	N/A	N/A	837/2300/HI/BBQ/02-2
MC317	Other Procedure Code - 15	N/A	N/A	837/2300/HI/BBQ/03-2
MC318	Other Procedure Code - 16	N/A	N/A	837/2300/HI/BBQ/04-2
MC319	Other Procedure Code - 17	N/A	N/A	837/2300/HI/BBQ/05-2
MC320	Other Procedure Code - 18	N/A	N/A	837/2300/HI/BBQ/06-2
MC321	Other Procedure Code - 19	N/A	N/A	837/2300/HI/BBQ/07-2
MC322	Other Procedure Code - 20	N/A	N/A	837/2300/HI/BBQ/08-2
MC323	Other Procedure Code - 21	N/A	N/A	837/2300/HI/BBQ/09-2
MC324	Other Procedure Code - 22	N/A	N/A	837/2300/HI/BBQ/10-2
MC325	Other Procedure Code - 23	N/A	N/A	837/2300/HI/BBQ/11-2
MC326	Other Procedure Code - 24	N/A	N/A	837/2300/HI/BBQ/12-2
MC327	Member Address Line 1	9a	5	837/2010BA/N3/01, 837/2010CA/N3/01
MC328	Member Address Line 2	9a	5	837/2010BA/N3/02, 837/2010CA/N3/02
MC329	Member Country Code	9e	N/A	837/2010BA/N4/04, 837/2010CA/N4/04
MC330	In-Plan Network Indicator	N/A	N/A	N/A
MC331	Payment Arrangement Type Indicator	N/A	N/A	N/A
MC332	Member Age	N/A	N/A	N/A
MC333	Substance Use Disorder (SUD) Indicator	N/A	N/A	N/A
MC334	Service Line Date – From	FL45	24A	837/2400/DTP/472/D8
MC335	Service Line Date – Thru	FL45	24A	837/2400/DTP/472/D8
MC336	Carrier Specific Unique Member (CSUM) ID	N/A	N/A	N/A
MC899	Record Type	N/A	N/A	N/A

Data Element #	Data Element Name	Date Effective	Type	Maximum Length	Description/Codes/Sources

PC001	Submitter	1/1/2003	Text	8	MHDO-assigned identifier of payor submitting claims data. Do not leave blank.

PC002	Payor	7/1/2012	Text	8	MHDO-assigned code of the insurer/underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage. Do not leave blank.

PC003	Insurance Type/Product Code	1/1/2003	Text	2	Code identifying the type of insurance policy within a specific insurance program. Refer to Appendix A
					16 Medicare Part C
					MD Medicare Part D
					SP Supplemental Policy

PC004	Payor Claim Control Number	1/1/2003	Text	35	Must apply to the entire claim and be unique within the payor's system. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC005	Line Counter	4/1/2004	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. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC006	Insured Group or Policy Number	1/1/2003	Text	30	Group or policy number - not the number that uniquely identifies the
					Subscriber Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC007	Subscriber Social Security Number	1/1/2003	Text	9	Subscriber’s social security number Leave blank if unavailable. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.


PC008	Plan Specific Contract Number	1/1/2003	Text	80	Plan-assigned contract number
					Leave blank if contract number = subscriber’s social security number. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC009	Member Suffix or Sequence Number	1/1/2003	Text	20	Uniquely numbers the member within the contract Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC010	Member Identification Code	1/1/2003	Text	50	Member’s social security number Leave blank if unavailable Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC011	Individual Relationship Code	1/1/2003	Text	2	Member's relationship to insured Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC012	Member Gender	1/1/2003	Number	1	Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.
PC013	Member Date of Birth	1/1/2003	Text	8	CCYYMMDD Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC014	Member City Name	4/1/2004	Text	30	City name of member Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC015	Member State or Province	4/1/2004	Text	2	As defined by the US Postal Service and Canada Post Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC016	Member ZIP Code	1/1/2003	Text	11	ZIP Code of member - may include non-US codes Do not include dash Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC017	Date Service Approved (AP Date)	1/1/2003	Text	8	CCYYMMDD The value ‘CCYY0101’, where CCYY is the year in which the service was approved, shall be used when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

PC018	Pharmacy Number	1/1/2003	Text	30	Payor-assigned pharmacy number
					Not required if PC021 is populated.

PC019	Pharmacy Tax ID Number	1/1/2003	Text	10	Federal taxpayer’s identification number

PC020	Pharmacy Name	1/1/2003	Text	100	Name of pharmacy

PC021	National Provider ID – Pharmacy Provider	4/1/2004	Text	20	National Provider ID for Pharmacy This data element pertains to the entity or individual directly providing the service. Refer to Appendix A

PC022	Pharmacy Location City	4/1/2004	Text	30	City name of pharmacy – preferably pharmacy location Refer to Appendix A

PC023	Pharmacy Location State	4/1/2004	Text	2	As defined by the US Postal Service and Canada Post Refer to Appendix A

PC024	Pharmacy ZIP Code	1/1/2003	Text	11	ZIP Code of pharmacy – may include non-US codes Do not include dash. Refer to Appendix A

PC024A	Pharmacy Country Code	1/1/2010	Text	30	Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A.

PC025	Claim Status	1/1/2003	Text	2	Refer to Appendix A

PC026	Drug Code	1/1/2003	Text	11	NDC Code Refer to Appendix A

PC027	Drug Name	1/1/2003	Text	80	Text name of drug

PC028	New Prescription or Refill	1/1/2003	Text	2	00 New prescription
					01-99 Number of refill

PC029	Generic Drug Indicator	1/1/2003	Text	1	N No, branded drug
					Y Yes, generic drug

PC030	Dispense as Written Code	1/1/2003	Text	1	Refer to Appendix A

PC031	Compound Drug Indicator	4/1/2004	Text	1	N Non-compound drug
					U Non-specified drug compound
					Y Compound drug

PC032	Date Prescription Filled	1/1/2003	Text	8	CCYYMMDD The value ‘CCYY0101’, where CCYY is the year in which the service was approved, shall be used when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = ‘Y’.

PC033	Quantity Dispensed	1/1/2003	Number	10	Number of metric units of medication dispensed. Code decimal point.

PC034	Days’ Supply	1/1/2003	Number	3	Estimated number of days the prescription will last

PC035	Charge Amount	1/1/2003	Number	10	Do not code decimal point. Two decimal places implied.

PC036	Paid Amount	1/1/2003	Number	10	Includes all health plan payments and excludes all member payments. Do not deduct POS rebate amount, if applicable. Do not include Pharmacy Benefits Manager Compensation.
					Do not code decimal point. Two decimal places implied.

PC037	Ingredient Cost/List Price	1/1/2003	Number	10	Cost of the drug dispensed Do not code decimal point. Two decimal places implied.

PC038	Postage Amount Claimed	4/1/2004	Number	10	Do not code decimal point. Two decimal places implied.

PC039	Dispensing Fee	1/1/2003	Number	10	Do not code decimal point. Two decimal places implied.

PC040	Co-pay Amount	1/1/2003	Number	10	The preset, fixed dollar amount for which the individual is responsible. Do not deduct POS rebate amount, if applicable.
					Do not code decimal point. Two decimal places implied.

PC041	Coinsurance Amount	1/1/2003	Number	10	The dollar amount an individual is responsible for – not the percentage. Do not deduct POS rebate amount, if applicable. Do not code decimal point. Two decimal places implied.

PC042	Deductible Amount	1/1/2003	Number	10	Do not deduct POS rebate amount, if applicable. Do not code decimal point. Two decimal places implied.

PC043	Patient Pay Amount	1/1/2013	Number	10	Amount that is calculated by the payor and returned to the pharmacy as the total amount to be paid by the patient to the pharmacy. $0 is acceptable; if “data not available” leave blank. Do not include decimal point. Two decimal places implied.

PC044	Prescribing Physician First Name	7/1/2006	Text	40	Physician first name Optional if PC047 is filled.

PC045	Prescribing Physician Middle Name	7/1/2006	Text	25	Physician middle name or initial Optional if PC047 is filled.

PC046	Prescribing Physician Last Name	7/1/2006	Text	60	Physician last name. Optional if PC047 is filled.

PC047	Prescribing Physician DEA	7/1/2006	Text	20	DEA for prescribing physician

PC048	Prescribing Physician NPI	10/1/2014	Text	20	NPI for prescribing physician Refer to Appendix A

PC101	Subscriber Last Name	1/1/2010	Text	60	The subscriber last name Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC102	Subscriber First Name	1/1/2010	Text	35	The subscriber first name Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC103	Subscriber Middle Name	1/1/2010	Text	25	The subscriber middle name or initial Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC104	Member Last Name	1/1/2010	Text	60	The member last name Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC105	Member First Name	1/1/2010	Text	35	The member first name Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC106	Member Middle Name	1/1/2010	Text	25	The member middle name or initial Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC107	Member Address Line 1	2/1/2019	Text	55	Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC108	Member Address Line 2	2/1/2019	Text	55	Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC109	Member Country Code	2/1/2019	Text	2	Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = ‘Y’.

PC110	In-Plan Network Indicator	2/1/2021	Text	1	Use this field to specify if services from the requested Pharmacy Provider were provided within the health plan network. Valid values are: N=No; Y=Yes.

PC111	Placeholder	2/1/2025	N/A	0	Leave blank. Payment Arrangement Type Indicator retired
PC112	Member Age	2/1/2025	Text	3	Member’s calculated age as of the service date. Round to the nearest integer. For ages ≥ 90, indicate ‘90’.
PC113	Substance Use Disorder (SUD) Indicator	2/1/2025	Text	1	Indicates whether a record contains 42 CFR Part 2 SUD-related data or not. Valid values are: N = Record does not contain 42 CFR Part 2 SUD-related data. Send all available values of all requested fields. Y = Record contains 42 CFR Part 2 SUD-related data. The following fields shall be left blank: PC004-PC016; and PC101-PC109.
PC114	Total POS Rebate Amount	2/1/2025	Number	10	The total dollar amount of all reductions to amounts paid by the health plan or an individual member resulting from POS (point-of-sale) rebates. The total POS rebate amount should be reported in full and should not be deducted from either plan paid or member copay, deductible, or coinsurance amounts. Do not code decimal point. Two decimal places implied.

PC115	Member POS Rebate Amount	2/1/2025	Number	10	The dollar amount of all reductions to amounts paid by an individual member resulting from POS rebates. The member POS rebate amount should not be deducted from member copay, deductible, or coinsurance amounts. Do not code decimal point. Two decimal places implied.
PC116	PBM Compensation Amount	2/1/2025	Number	10	The value of payments made by the payor to its pharmacy benefits manager that is not paid to the pharmacy The pharmacy benefits manager compensation amount should not be included in the plan paid amount. PBM compensation does not include any compensation paid by a manufacturer, developer, or labeler for the performance of services. Do not code decimal point. Two decimal places implied.

PC899	Record Type	1/1/2003	Text	2	PC

Data Element #	Data Element Name	National Council for Prescription
Data Element #	Data Element Name	Drug Programs Field #
PC001	Submitter	879-N2
PC002	Payor	569-J8
PC003	Insurance Type/Product Code	A90
PC004	Payor Claim Control Number	993-A7
PC005	Line Counter	A91
PC006	Insured Group or Policy Number	246
PC007	Subscriber Social Security Number	A89
PC008	Plan Specific Contract Number	302-C2
PC009	Member Suffix or Sequence Number	303-C3
PC010	Member Identification Code	332-CY
PC011	Individual Relationship Code	247
PC012	Member Gender	305-C5
PC013	Member Date of Birth	304-C4
PC014	Member City Name	728-SU
PC015	Member State or Province	729-TA
PC016	Member ZIP Code	730-TC
PC017	Date Service Approved (AP Date)	578
PC018	Pharmacy Number	201-B1
PC019	Pharmacy Tax ID Number	N/A
PC020	Pharmacy Name	833-5P
PC021	National Provider ID – Pharmacy Provider	201-B1
PC022	Pharmacy Location City	728-SU
PC023	Pharmacy Location State	729-TA
PC024	Pharmacy ZIP Code	730-TC
PC024A	Pharmacy Country Code	A93-1T
PC025	Claim Status	A88
PC026	Drug Code	407-D7
PC027	Drug Name	397
PC028	New Prescription	254
Data Element #	Data Element Name	National Council for Prescription Drug Programs Field #
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	430-DU
PC036	Paid Amount	281
PC037	Ingredient Cost/List Price	506-F6
PC038	Postage Amount Claimed	N/A
PC039	Dispensing Fee	507-F7
PC040	Co-pay Amount	518-FI
PC041	Coinsurance Amount	572-4U
PC042	Deductible Amount	517-FH
PC043	Patient Pay Amount	505-F5
PC044	Prescribing Physician First Name	717
PC045	Prescribing Physician Middle Name	A92
PC046	Prescribing Physician Last Name	716
PC047	Prescribing Physician DEA	411-DB
PC048	Prescribing Physician NPI	411-DB
PC101	Subscriber Last Name	716
PC102	Subscriber First Name	717
PC103	Subscriber Middle Name	718
PC104	Member Last Name	716
PC105	Member First Name	717
PC106	Member Middle Name	718
PC107	Member Address Line 1	B08-7A
PC108	Member Address Line 2	B09-7B
PC109	Member Country Code	A43-1K
PC110	In-Plan Network Indicator	N/A
PC111	Placeholder	N/A
Data Element #	Data Element Name	National Council for Prescription Drug Programs Field #
PC112	Member Age	N/A
PC113	Substance Use Disorder (SUD) Indicator	N/A
PC114	Total POS Rebate Amount	N/A
PC115	Member POS Rebate Amount	N/A
PC116	Pharmacy Benefits Manager Compensation Amount	N/A
PC899	Record Type	A94

Data Element		Date		Maximum
#	Data Element Name	Effective	Type	Length	Description/Codes/Sources

DC001	Submitter	1/1/2003	Text	8	MHDO-assigned identifier of payor submitting claims data. Do not leave blank.

DC002	Payor	7/1/2012	Text	8	MHDO-assigned code of the insurer/ underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage. Do not leave blank.

DC003	Insurance Type/Product Code	1/1/2003	Text	2	Code identifying the type of insurance policy within a specific insurance program. Refer to Appendix A

DC004	Payor Claim Control Number	1/1/2003	Text	35	Must apply to entire claim and be unique within the payor's system

DC005	Line Counter	4/1/2004	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	1/1/2003	Text	30	Group or policy number - not the number that uniquely identifies the subscriber

DC007	Subscriber Social Security Number	1/1/2003	Text	9	Subscriber’s social security number Leave blank if unavailable.

DC008	Plan Specific Contract Number	1/1/2003	Text	80	Plan-assigned contract number Leave blank if contract number = subscriber’s social security number.

DC009	Member Suffix or Sequence Number	1/1/2003	Text	20	Uniquely numbers the member within the contract

DC010	Member Identification Code	1/1/2003	Text	50	Member’s social security number Leave blank if unavailable.



DC011	Individual Relationship Code	1/1/2003	Text	2	Member's relationship to insured Refer to Appendix A

DC012	Member Gender	1/1/2003	Text	1	Refer to Appendix A

DC013	Member Date of Birth	1/1/2003	Text	8	CCYYMMDD

DC014	Member City Name	4/1/2004	Text	30	City name of member Refer to Appendix A

DC015	Member State or Province	4/1/2004	Text	2	As defined by the US Postal Service and Canada Post Refer to Appendix A

DC016	Member ZIP Code	1/1/2003	Text	11	ZIP Code of member - may include non-US codes Do not include dash. Refer to Appendix A

DC017	Date Service Approved (AP Date)	1/1/2003	Text	8	CCYYMMDD

DC018	Rendering Provider Number	1/1/2003	Text	30	Payor-assigned provider number

DC019	Rendering Provider Tax ID Number	1/1/2003	Text	10	Federal taxpayer's identification number

DC020	National Provider ID – Rendering Provider	4/1/2004	Text	20	National Provider ID This data element pertains to the entity or individual directly providing the service. Refer to Appendix A

DC021	Rendering Provider Entity Type Qualifier	4/1/2004	Number	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.
					Refer to Appendix A


DC022	Rendering Provider First Name	1/1/2003	Text	40	Individual first name Leave blank if provider is a facility or organization.

DC023	Rendering Provider Middle Name	1/1/2003	Text	25	Individual middle name or initial Leave blank if provider is a facility or organization.

DC024	Rendering Provider Last Name or Organization Name	1/1/2003	Text	60	Full name of provider organization or last name of individual provider

DC025	Rendering Provider Suffix	1/1/2003	Text	10	Suffix to individual name Leave blank if provider is a facility or organization. The service provider suffix shall 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, LCSW).

DC026	Rendering Provider Specialty	1/1/2003	Text	10	Refer to Appendix A If defined by payor, then dictionary for specialty code values must be supplied during testing.

DC027	Placeholder	2/1/2016	N/A	0	Leave blank Service Provider City Name retired; refer to DC055 – Service Facility Location City Name

DC028	Placeholder	2/1/2016	N/A	0	Leave blank Service Provider State or Province retired; refer to DC056 – Service Facility Location Address State or Province

DC029	Placeholder	2/1/2016	N/A	0	Leave blank Service Provider ZIP Code retired; refer to DC057 – Service Facility Location Address State or Province

DC030	Place of Service - Professional	4/1/2004	Text	2	Refer to Appendix A


DC031	Claim Status	1/1/2003	Text	2	Refer to Appendix A

DC032	CDT Code	1/1/2003	Text	5	Common Dental Terminology code Refer to Appendix A

DC033	Procedure Modifier - 1	1/1/2003	Text	2	Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code

DC034	Procedure Modifier - 2	1/1/2003	Text	2	Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code

DC035	Date of Service - From	1/1/2003	Text	8	First date of service for this service line CCYYMMDD

DC036	Date of Service - Thru	1/1/2003	Text	8	Last date of service for this service line CCYYMMDD

DC037	Charge Amount	1/1/2003	Number	10	Do not code decimal point. Two decimal places implied.

DC038	Paid Amount	1/1/2003	Number	10	Do not code decimal point. Two decimal places implied.

DC039	Co-pay Amount	1/1/2003	Number	10	The preset, fixed dollar amount for which the individual is responsible Do not code decimal point. Two decimal places implied.

DC040	Coinsurance Amount	1/1/2003	Number	10	The dollar amount an individual is responsible for – not the percentage Do not code decimal point. Two decimal places implied.

DC041	Deductible Amount	1/1/2003	Number	10	Do not code decimal point. Two decimal places implied.

DC042	Billing Provider Number	1/1/2010	Text	30	Payor-assigned billing provider number. This number should be the identifier used by the payor for internal identification purposes, and does not routinely change.

DC043	National Provider ID – Billing Provider	1/1/2010	Text	20	National Provider ID for billing provider Refer to Appendix A

DC044	Billing Provider Last Name or Organization Name	1/1/2010	Text	60	Full name of provider billing organization or last name of individual billing provider.

DC045	Billing Provider Tax ID	2/1/2016	Text	10	Federal taxpayer’s identification number

DC046	Billing Provider Address Line 1	2/1/2016	Text	55	Address information for billing provider

DC047	Billing Provider Address Line 2	2/1/2016	Text	55	Address information for billing provider

DC048	Billing Provider City Name	2/1/2016	Text	30	City name of billing provider Refer to Appendix A

DC049	Billing Provider State or Province	2/1/2016	Text	2	As defined by the US Postal Service and Canada Post Refer to Appendix A

DC050	Billing Provider Zip Code	2/1/2016	Text	11	Zip Code of billing provider – may include non-US codes Do not include dash Refer to Appendix A

DC051	Service Facility Location Name	2/1/2016	Text	60	Laboratory or service facility name If not available or not specified, do not populate.

DC052	National Provider ID – Service Facility	2/1/2016	Text	20	National Provider ID for laboratory or service facility If not available or not specified, do not populate. Refer to Appendix A

DC053	Service Facility Location Address Line 1	2/1/2016	Text	55	Address information for laboratory or service facility If not available or not specified, do not populate.

DC054	Service Facility Location Address Line 2	2/1/2016	Text	55	Address information for laboratory or service facility If not available or not specified, do not populate.

DC055	Service Facility Location City Name	2/1/2016	Text	30	City name of laboratory or service facility If not available or not specified, do not populate. Refer to Appendix A

DC056	Service Facility Location State or Province	2/1/2016	Text	2	As defined by the US Postal Service and Canada Post If not available or not specified, do not populate. Refer to Appendix A

DC057	Service Facility Location Zip Code	2/1/2016	Text	11	Zip Code of service facility – may include non-US codes Do not include dash If not available or not specified, do not populate. Refer to Appendix A

DC058	Service Facility Number	2/1/2016	Text	30	Payor-assigned service facility number. This number should be the identifier used by the payor for internal identification purposes and does not routinely change. If not available or not specified, do not populate.

DC101	Subscriber Last Name	1/1/2010	Text	60	The subscriber last name

DC102	Subscriber First Name	1/1/2010	Text	35	The subscriber first name

DC103	Subscriber Middle Name	1/1/2010	Text	25	The subscriber middle name or initial

DC104	Member Last Name	1/1/2010	Text	60	The member last name

DC105	Member First Name	1/1/2010	Text	35	The member first name

DC106	Member Middle Name	1/1/2010	Text	25	The member middle name or initial

DC107	Member Address Line 1	2/1/2019	Text	55

DC108	Member Address Line 2	2/1/2019	Text	55


DC109	Member Country Code	2/1/2019	Text	2	Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A.

DC110	In-Plan Network Indicator	2/1/2021	Text	1	A yes/no indicator that specifies if the Billing Provider (not the benefit) is within the health plan network. Valid codes are: N=No; Y=Yes.

DC111	Placeholder	2/1/2025	N/A	0	Leave blank. Payment Arrangement Type Indicator retired
DC112	Oral Cavity 1	2/1/2025	Text	2	Always report the area of the oral cavity when the procedure reported in field DC032 (CDT Code) refers to a quadrant or arch and the area of the oral cavity is not uniquely defined by the procedure’s nomenclature. Area of the oral cavity is designated by a two-digit code, selected from the following code list: 00=entire oral cavity; 01=maxillary arch; 02=mandibular arch; 10=upper right quadrant; 20=upper left quadrant; 30=lower left quadrant; 40=lower right quadrant.

DC113	Oral Cavity 2	2/1/2025	Text	2	Always report the area of the oral cavity when the procedure reported in field DC032 (CDT Code) refers to a quadrant or arch and the area of the oral cavity is not uniquely defined by the procedure’s nomenclature. Area of the oral cavity is designated by a two-digit code, selected from the following code list: 00=entire oral cavity; 01=maxillary arch; 02=mandibular arch; 10=upper right quadrant; 20=upper left quadrant; 30=lower left quadrant; 40=lower right quadrant.

DC114	Oral Cavity 3	2/1/2025	Text	2	Always report the area of the oral cavity when the procedure reported in field DC032 (CDT Code) refers to a quadrant or arch and the area of the oral cavity is not uniquely defined by the procedure’s nomenclature. Area of the oral cavity is designated by a two-digit code, selected from the following code list: 00=entire oral cavity; 01=maxillary arch; 02=mandibular arch; 10=upper right quadrant; 20=upper left quadrant; 30=lower left quadrant; 40=lower right quadrant.

DC115	Oral Cavity 4	2/1/2025	Text	2	Always report the area of the oral cavity when the procedure reported in field DC032 (CDT Code) refers to a quadrant or arch and the area of the oral cavity is not uniquely defined by the procedure’s nomenclature. Area of the oral cavity is designated by a two-digit code, selected from the following code list: 00=entire oral cavity; 01=maxillary arch; 02=mandibular arch; 10=upper right quadrant; 20=upper left quadrant; 30=lower left quadrant; 40=lower right quadrant.

DC116	Oral Cavity 5	2/1/2025	Text	2	Always report the area of the oral cavity when the procedure reported in field DC032 (CDT Code) refers to a quadrant or arch and the area of the oral cavity is not uniquely defined by the procedure’s nomenclature. Area of the oral cavity is designated by a two-digit code, selected from the following code list: 00=entire oral cavity; 01=maxillary arch; 02=mandibular arch; 10=upper right quadrant; 20=upper left quadrant; 30=lower left quadrant; 40=lower right quadrant.

DC117	Tooth Number or Letter (1)	2/1/2025	Text	2	Required when DC032 = D2000 thru D2999. Enter the appropriate tooth number or letter when the procedure directly involves a tooth or range of teeth. If not available, leave blank. Tooth Number codes are maintained by the American Dental Association. See Appendix A.

DC118	Tooth – 1 Surface – 1	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). Required when Tooth Number/ Letter DC117 is populated.

DC119	Tooth – 1 Surface – 2	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC120	Tooth – 1 Surface – 3	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC121	Tooth – 1 Surface – 4	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC122	Tooth – 1 Surface – 5	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC123	Tooth Number or Letter (2)	2/1/2025	Text	2	Report the tooth identifier(s) when DC032 is within the given range if a second tooth is involved in the procedure. Required when DC032 = D2000 thru D2999. See Appendix A.

DC124	Tooth – 2 Surface – 1	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). Required when Tooth Number/ Letter DC123 is populated.

DC125	Tooth – 2 Surface – 2	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC126	Tooth – 2 Surface – 3	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC127	Tooth – 2 Surface – 4	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC128	Tooth – 2 Surface – 5	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC129	Tooth Number or Letter (3)	2/1/2025	Text	2	Report the tooth identifier(s) when DC032 is within the given range if a third tooth is involved in the procedure. Required when DC032 = D2000 thru D2999. See Appendix A.

DC130	Tooth – 3 Surface – 1	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). Required when Tooth Number/ Letter DC129 is populated.

DC131	Tooth – 3 Surface – 2	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC132	Tooth – 3 Surface – 3	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC133	Tooth – 3 Surface – 4	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC134	Tooth – 3 Surface – 5	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC135	Tooth Number or Letter (4)	2/1/2025	Text	2	Report the tooth identifier(s) when DC032 is within the given range if a fourth tooth is involved in the procedure. Required when DC032 = D2000 thru D2999. See Appendix A.

DC136	Tooth – 4 Surface – 1	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). Required when Tooth Number/ Letter DC135 is populated.

DC137	Tooth – 4 Surface – 2	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC138	Tooth – 4 Surface – 3	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC139	Tooth – 4 Surface – 4	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC140	Tooth – 4 Surface – 5	2/1/2025	Text	1	Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC899	Record Type	1/1/2003	Text	2	DC

			HIPAA Reference ASC X12N/005010A1
Data		ADA J400	Transaction Set/Loop/
Element			Segment ID/Code Value/
#	Data Element Name	Form Locator	Reference Designator
DC001	Submitter	N/A	N/A
DC002	Payor	N/A	N/A
DC003	Insurance Type/Product Code	N/A	835/2100/CLP/06
DC004	Payor Claim Control Number	N/A	835/2100/CLP/07
DC005	Line Counter	N/A	837/2400/LX/01
DC006	Insured Group or Policy Number	16	837/2000B/SBR/03
DC007	Subscriber Social Security Number	15	837/2010BA/REF/SY/02
DC008	Plan Specific Contract Number	N/A	835/2100/NM1/MI/08
DC009	Member Suffix or Sequence Number	N/A	N/A
DC010	Member Identification Code	N/A	835/2100/NM1/34/09
DC011	Individual Relationship Code	18	837/2000B/SBR/02, 837/2000C/PAT/01
DC012	Member Gender	22	837/2010BA/DMG/03, 837/2010CA/DMG/03
DC013	Member Date of Birth	21	837/2010BA/DMG/D8/02, 837/2010CA/DMG/D8/02
DC014	Member City Name	20	837/2010BA/N4/01, 837/2010CA/N4/01
DC015	Member State or Province	20	837/2010BA/N4/02, 837/2010CA/N4/02
DC016	Member ZIP Code of Residence	20	837/2010BA/N4/03, 837/2010CA/N4/03
DC017	Date Service Approved	N/A	835/Header Financial Information/BPR/16
DC018	Rendering Provider Number	58	835/2100/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	Rendering Provider Tax ID Number	51	835/2100/NM1/FI/09
DC020	National Provider ID – Rendering Provider	54	837/2310B/NM1/XX/09
DC021	Rendering Provider Entity Type Qualifier	N/A	837/2310B/NM1/82/02
DC022	Rendering Provider First Name	N/A	837/2310B/NM1/82/04
DC023	Rendering Provider Middle Name	N/A	837/2310B/NM1/82/05
DC024	Rendering Provider Last Name or Organization Name	N/A	837/2310B/NM1/82/03
DC025	Rendering Provider Suffix	N/A	837/2310B/NM1/82/07
DC026	Rendering Provider Specialty	56A	837/2310B/PRV/PXC/03
DC027	Placeholder	N/A	N/A
DC028	Placeholder	N/A	N/A
DC029	Placeholder	N/A	N/A
DC030	Place of Service - 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	24	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	Co-pay 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	52A	837/2010BB/REF/G2/02
DC043	National Provider ID – Billing Provider	49	837/2010AA/NM1/XX/09
DC044	Billing Provider Last Name	48	837/2010AA/NM1/ /03
DC045	Billing Provider Tax ID	51	837/2010AA/REF/EI/02
DC046	Billing Provider Address Line 1	48	837/2010AA/N3/01
DC047	Billing Provider Address Line 2	48	837/2010AA/N3/02
DC048	Billing Provider City Name	48	837/2010AA/N4/01
DC049	Billing Provider State or Province	48	837/2010AA/N4/02
DC050	Billing Provider Zip Code	48	837/2010AA/N4/03
DC051	Service Facility Location Name	N/A	837/2310C/NM1/77/2/03
DC052	National Provider ID – Service Facility	N/A	837/2310C/NM1/77/2/XX/09
DC053	Service Facility Location Address Line 1	56	837/2310C/N3/01
DC054	Service Facility Location Address Line 2	56	837/2310C/N3/02
DC055	Service Facility Location City Name	56	837/2310C/N4/01
DC056	Service Facility Location State or Province	56	837/2310C/N4/02
DC057	Service Facility Location Zip Code	56	837/2310C/N4/03
DC058	Service Facility Number	N/A	837/2310C/REF/G2/02
DC101	Subscriber Last Name	12	837/2010BA/NM1/ /03
DC102	Subscriber First Name	12	837/2010BA/NM1/ /04
DC103	Subscriber Middle Name	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 Name	20	837/2010BA/NM1/ /05, 837/2010CA/NM1/ /05
DC107	Member Address Line 1	20	837/2010BA/N3/01, 837/2010CA/N3/01
DC108	Member Address Line 2	20	837/2010BA/N3/02, 837/2010CA/N3/02
DC109	Member Country Code		837/2010BA/N4/04, 837/2010CA/N4/04
DC110	In-Plan Network Indicator	N/A	N/A
DC111	Placeholder	N/A	N/A
DC112	Oral Cavity 1	25	837/2400/SV304-01
DC113	Oral Cavity 2	25	837/2400/SV304-02
DC114	Oral Cavity 3	25	837/2400/SV304-03
DC115	Oral Cavity 4	25	837/2400/SV304-04
DC116	Oral Cavity 5	25	837/2400/SV304-05
DC117	Tooth Number or Letter (1)	27	837/2400/TOO/JP/02
DC118	Tooth – 1 Surface – 1	28	837/2400/TOO03-01
DC119	Tooth – 1 Surface – 2	28	837/2400/TOO03-02
DC120	Tooth – 1 Surface – 3	28	837/2400/TOO03-03
DC121	Tooth – 1 Surface – 4	28	837/2400/TOO03-04
DC122	Tooth – 1 Surface – 1	28	837/2400/TOO03-05
DC123	Tooth Number or Letter (2)	27	837/2400/TOO/JP/02
DC124	Tooth – 2 Surface – 1	28	837/2400/TOO03-01
DC125	Tooth – 2 Surface – 2	28	837/2400/TOO03-02
DC126	Tooth – 2 Surface – 3	28	837/2400/TOO03-03
DC127	Tooth – 2 Surface – 4	28	837/2400/TOO03-04
DC128	Tooth – 2 Surface – 5	28	837/2400/TOO03-05
DC129	Tooth Number or Letter (3)	27	837/2400/TOO/JP/02
DC130	Tooth – 3 Surface – 1	28	837/2400/TOO03-01
DC131	Tooth – 3 Surface – 2	28	837/2400/TOO03-02
DC132	Tooth – 3 Surface – 3	28	837/2400/TOO03-03
DC133	Tooth – 3 Surface – 4	28	837/2400/TOO03-04
DC134	Tooth – 3 Surface – 5	28	837/2400/TOO03-04
DC135	Tooth Number or Letter (4)	27	837/2400/TOO/JP/02
DC136	Tooth – 4 Surface – 1	28	837/2400/TOO03-01
DC137	Tooth – 4 Surface – 2	28	837/2400/TOO03-02
DC138	Tooth – 4 Surface – 3	28	837/2400/TOO03-03
DC139	Tooth – 4 Surface – 4	28	837/2400/TOO03-04
DC140	Tooth – 4 Surface – 5	28	837/2400/TOO03-05
DC899	Record Type	N/A	N/A

Data Element		Date		Maximum
#	Data Element Name	Effective	Type	Length	Description/Codes/Sources

CF001	Submitter	2/1/2025	Text	8	MHDO-assigned identifier of payor submitting payment data. Do not leave blank.

CF002	Payor	2/1/2025	Text	8	MHDO-assigned code of the insurer/ underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage. Do not leave blank.

CF003	Insurance Type/Product Code	2/1/2025	Text	2	Code identifying the type of insurance policy within a specific insurance program. Refer to Appendix A

CF004	Subscriber Social Security Number	2/1/2025	Text	9	Subscriber’s social security number Leave blank if unavailable. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF005	Member Identification Code	2/1/2025	Text	10	Member’s social security number Leave blank if unavailable. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF006	Plan Specific Contract Number	2/1/2025	Text	80	Plan-assigned contract number Leave blank if contract number = subscriber’s social security number. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF007	Member Suffix or Sequence Number	2/1/2025	Text	20	Uniquely numbers the member within the contract. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF008	Carrier Specific Unique Member (CSUM) ID	2/1/2025	Text	50	This ID should uniquely and consistently identify a member in both the medical claims and the capitated payments files. It shall be used when the payor indicates that related records in the medical and capitation files contain 42 CFR Part 2 SUD-related data (CF035 = ‘Y’ and MC333 = ‘Y’ on the related service records), and other inter-file identifiers shall be left blank. For fully identified data records that do not contain 42 CFR Part 2-related data (CF035 = ‘N’ and MC333 = ‘N’ on the related service records), the CSUM ID shall be left blank, and all other inter-file identifiers shall be populated, when available. This ID must differ from any of the other identifiers on the record and may not be derived from any of these in a manner that the original values could be determined.

CF009	Insured Group or Policy Number	2/1/2025	Text	30	Group or policy number – not the number that uniquely identifies the subscriber. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF010	Monetary Amount/Provider Adjustment Amount	2/1/2025	Number	10	This is the per member per month amount paid to the provider. Excludes any withhold amounts.
					Do not code decimal point. Two decimal places implied.
CF011	Payment Subcategory	2/1/2025	Text	2	D1 = Primary care capitation D2 = Professional capitation D3 = Facility Capitation D4 = Behavioral health capitation D5 = Global capitation D6 = Payment to integrated, comprehensive payment and delivery systems

CF012	Performance Period Year	2/1/2025	Number	4	Year of the performance period covered by the payment on this record.

CF013	Performance Period Month	2/1/2025	Text	2	Month of the performance period covered by the payment on this record.

CF014	Withhold Amount	2/1/2025	Number	10	The amount that is deducted from the payment to the physician group/physician that may or may not be returned depending on specific predetermined factors. This could be an amount being withheld until an agreed upon quality goal is met. This may be part of an ACO agreement. Do not code decimal point. Two decimal places implied.

CF015	Member Gender	2/1/2025	Text	1	Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF016	Member Date of Birth	2/1/2025	Text	8	CCYYMMDD Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF017	Rendering Provider Specialty	2/1/2025	Text	10	Refer to Appendix A If defined by payor, then dictionary for specialty code values must be supplied during testing. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF018	Rendering Provider Number	2/1/2025	Text	30	Payor-assigned rendering provider number Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF019	Rendering Provider Tax ID	2/1/2025	Text	10	Federal taxpayer’s identification number Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF020	National Provider ID – Rendering Provider	2/1/2025	Text	20	National Provider ID for Rendering Provider This data element pertains to the entity or individual directly providing the service. Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF021	Rendering Provider Last Name or Organization Name	2/1/2025	Text	60	Full name of provider organization or last name of individual Provider Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF022	Rendering Provider First Name	2/1/2025	Text	40	Individual first name Leave blank if provider is a facility or organization. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF023	Billing Provider Number	2/1/2025	Text	30	Payor-assigned billing provider number. This number should be the identifier used by the payor for internal identification purposes, and does not routinely change. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF024	Billing Provider Tax ID	2/1/2025	Text	10	Federal taxpayer's identification number Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF025	National Provider ID – Billing Provider	2/1/2025	Text	20	National Provider ID for billing provider Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF026	Billing Provider Last Name or Organization Name	2/1/2025	Text	60	Full name of provider billing organization or last name of individual billing provider. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF027	Member First Name	2/1/2025	Text	35	The member first name Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF028	Member Middle Name	2/1/2025	Text	25	The member middle name or initial Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF029	Member Last Name	2/1/2025	Text	60	The member last name Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF030	Member Address Line 1	2/1/2025	Text	55	Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF031	Member Address Line 2	2/1/2025	Text	55	Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF032	Member City Name	2/1/2025	Text	30	City name of member Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF033	Member State or Province	2/1/2025	Text	2	As defined by the US Postal Service and Canada Post Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF034	Member ZIP Code	2/1/2025	Text	11	ZIP Code of member – may include non-US codes Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the values of CF035 = ‘Y’ and MC333 = ‘Y’ on any 42 CFR Part 2 SUD-related service records for this member in the medical claims file.

CF035	Substance Use Disorder (SUD) Indicator	2/1/2025	Text	1	Indicates whether a record contains 42 CFR Part 2 SUD-related data or not. Valid values are: N = Record does not contain 42 CFR Part 2 SUD-related data. Send all available values of all requested fields. Y = Record contains 42 CFR Part 2 SUD-related data. The following fields shall be left blank: CF004-CF007; CF009; CF015-CF034. NOTE: only 42 CFR Part 2 SUD-related payment records shall be marked with ‘Y’; other payment records that are not 42 CFR Part 2 SUD-related shall be marked with ‘N’.
CF899	Record Type	2/1/2025	Text	2	Value = CF

				HIPAA Reference ASC X12N/005010A1
Data		UB-04	CMS	Transaction Set/Loop/
Element		Form	1500	Segment ID/Code Value/
#	Data Element Name	Locator	#	Reference Designator
CF001	Submitter	N/A	N/A	N/A
CF002	Payor	N/A	N/A	N/A
CF003	Insurance Type/Product Code	N/A	N/A	835/2100/CLP/06
CF004	Subscriber Social Security Number	N/A	N/A	835/2100/NM1/MI/09
CF005	Member Identification Code	N/A	N/A	835/2100/NM1/34/09
CF006	Plan Specific Contract Number	60 (A-C)	1a	835/2100/NM1/MI/09
CF007	Member Suffix or Sequence Number	N/A	N/A	N/A
CF008	Carrier Specific Unique Member (CSUM) ID	N/A	N/A	N/A
CF009	Insured Group or Policy Number	62 (A-C)	11	837/2000B/SBR/03
CF010	Monetary Amount/Provider Adjustment Amount	N/A	N/A	835/PLB/CT/04
CF011	Payment Subcategory	N/A	N/A	N/A
CF012	Performance Period Year	N/A	N/A	N/A
CF013	Performance Period Month	N/A	N/A	N/A
CF014	Withhold Amount	N/A	N/A	835/PLB/E3/04
CF015	Member Gender	11	3	837/2010BA/DMG/03, 837/2010CA/DMG/03
CF016	Member Date of Birth	10	3	837/2010BA/DMG/D8/02, 837/2010CA/DMG/D8/02
CF017	Rendering Provider Specialty	N/A	N/A	professional: 837/2420A/PRV/PXC/03; 837/2310B/PRV/PXC/03; institutional: 837/2000A/PRV/PXC/03
CF018	Rendering Provider Number	57	N/A	835/2100/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
CF019	Rendering Provider Tax ID	5	25 (only if EIN)	835/2100/NM1/FI/09
CF020	National Provider ID – Rendering Provider	56	24J	835/PLB/01; professional: 837/2420A/NM1/XX/09; 837/2310B/NM1/XX/09; institutional: 837/2010AA/NM1/XX/09
CF021	Rendering Provider Last Name or Organization Name	1	31	professional: 837/2420A/NM1/82/1/03; 837/2310B/NM1/82/1/03; institutional: 837/2010AA/NM1/85/2/03
CF022	Rendering Provider First Name	N/A	31	professional: 837/2420A/NM1/82/04; 837/2310B/NM1/82/04; institutional: N/A
CF023	Billing Provider Number	57	33b	837/2010BB/REF/G2/02
CF024	Billing Provider Tax ID	NA	NA	837/2010AA/REF/EI/02
CF025	National Provider ID – Billing Provider	56	33a	837/2010AA/NM1/85/ /XX/09
CF026	Billing Provider Last Name or Organization Name	1	33	837/2010AA/NM1/85/ /03
CF027	Member First Name	8b	2	837/2010CA/NM1/ /04, 837/2010BA/NM1/ /04
CF028	Member Middle Name	8b	2	837/2010CA/NM1/ /05, 837/2010BA/NM1/ /05
CF029	Member Last Name	8b	2	837/2010CA/NM1/ /03, 837/2010BA/NM1/ /03
CF030	Member Address Line 1	9a	5	837/2010BA/N3/01, 837/2010CA/N3/01
CF031	Member Address Line 2	9a	5	837/2010BA/N3/02, 837/2010CA/N3/02
CF032	Member City Name	9b	5	837/2010BA/N4/01, 837/2010CA/N4/01
CF033	Member State or Province	9c	5	837/2010BA/N4/02, 837/2010CA/N4/02
CF034	Member ZIP Code	9d	5	837/2010BA/N4/03, 837/2010CA/N4/03
CF035	Substance Use Disorder (SUD) Indicator	N/A	N/A	N/A
CF899	Record Type	N/A	N/A	N/A

90-590 MAINE HEALTH DATA ORGANIZATION

Date

Date

Date

ME019

Prescription Drug Coverage

Element

DateEffective

Insurance Type/Product Code

Admission Hour

Data

Date

Date

Date

Data

Date
Effective