N.H. Code Admin. R. Ins 4010.02
(b) Medical Claims File Header Record Layout
Table 4010.02 (b) Medical Claims File Header Record Layout
Data Element #
Element
Type
Length (decimal places)
Description/Codes/Sources
HD001
Record Type
Text
2
HD
HD002
Payer
Text
8
Payer submitting payments. NHID Submitter Code
HD003
National Plan ID
Text
30
CMS National Plan ID
HD004
Type of File
Text
2
MC Medical Claims
HD005
Period Beginning Date
Date
8
Beginning of paid period for claims or beginning of month covered for eligibility
HD006
Period Ending Date
Date
8
End of paid period for claims or end of month covered for eligibility
HD007
Comments
Text
80
Submitter may use to document this submission by assigning a filename, system source, etc.
(c) Medical Claims Files Trailer Record Layout
Table 4010.02 (c) Medical Claims File Trailer Record Layout
Data Element #
Element
Type
Length (decimal places
Description/Codes/Sources
TR001
Record Type
Text
2
TR
TR002
Payer
Text
8
Payer submitting payments. NHID Submitter Code
TR003
National Plan ID
Text
30
CMS National Plan ID
TR004
Type of File
Text
2
MC Medical Claims
TR005
Period Beginning Date
Date
8
Beginning of paid period for claims or beginning of month covered for eligibility
TR006
Period Ending Date
Date
8
End of paid period for claims or beginning of month covered for eligibility
TR007
Extraction Date
Date
8
Date file was created
TR008
Record Count
Number
10 (0)
Total number of records submitted in this file
(d) Medical Claims File Detailed Specifications
Table 4010.02 (d) Medical Claims File Detailed Specifications
Data Element #
Element
Type
Length (decimal places)
Description/Codes/Sources
MC001
Payer
Text
8
Payer submitting payments NHID Submitter Code
MC002
National Plan ID
Text
30
CMS National Plan ID
MC003
Insurance Type/Product Code
Text
2
As established by X12 Accredited Standards Committee available at https://ushik.ahrq.gov/ViewItemDetails?system=sdo&itemKey=133161000
MC004
Payer Claim Control Number
Text
35
Must apply to the entire claim and be unique within the payer's system
MC005
Line Counter
Text
4
Line number for this service. The line counter begins with 1 and is incremented by 1 for each additional service line of a claim
MC005A
Version Number
Number
4 (0)
Version number of this claim service line. The version number begins with 0 and is incremented by 1 for each subsequent version of that service line
MC006
Insured Group or Policy Number
Text
50
Group or policy number (not the number that uniquely identifies the subscriber)
MC007
Subscriber Social Security Number
Text
9
Subscriber's social security number. Do not include dashes. Leave blank if not available.
MC008
Plan Specific Contract Number
Text
50
Plan assigned contract number. Leave blank if Plan Specific Contract Number is subscriber’s social security number.
If this is a Medicaid claim, provide Medicaid ID.
MC009
Member Suffix or Sequence Number
Text
20
Uniquely identifies the member within the contract
MC010
Member Social Security Number
Text
9
Member’s social security number. Do not include dashes. Leave blank if not available.
MC011
Individual Relationship Code
Text
2
See Table 4010.6 (b) Relationship Codes
MC012
Member Gender
Text
1
M Male
F Female
U Unknown
O Other
MC013
Member Date of Birth
Date
8
Date of birth of member
MC014
Member City Name
Text
30
City name of member
MC015
Member State or Province
Text
2
As defined by the US Postal Service
MC016
Member ZIP Code
Text
9
ZIP Code of member – may include non- US codes. Do not include dash.
MC017
Paid Date (AP Date)
Date
8
MC018
Admission Date
Date
8
Required for all inpatient claims.
MC019
Admission Hour
Text
2 (0)
Required for all inpatient claims. Time is expressed in military time – HH
MC020
Admission Type
Text
1
Required for all inpatient claims (SOURCE: National Uniform Billing Data Element Specifications):
1 = Emergency
2 = Urgent
3 = Elective
4 = Newborn
5 = Trauma Center
9 = Information not available
MC021
Admission Source
Text
1
See Table 4010.6 (i) Point of Origin Codes
MC022
Discharge Hour
Text
2 (0)
Required for all inpatient claims. Time is expressed in military time – HH
MC023
Discharge Status
Text
2
See Table 4010.6 (f): Discharge Status
MC024
Service Provider Number
Text
30
Payer assigned servicing provider number by the payer for internal identification purposes
MC025
Service Provider Tax ID Number
Text
10
Federal taxpayer's identification number – if the tax id is a provider’s social security number, use ‘SSN’ and ‘NA’ if unavailable
MC026
National Service Provider ID
Text
20
Provider NPI
MC027
Service Provider Entity Type Qualifier
Text
1
HIPAA provider taxonomy classifies provider groups (clinicians who bill as a group practice or under a corporate name, even if that group is composed of one provider) as “Person”.
1 Person
2 Non-Person Entity
MC028
Service Provider First Name
Text
35
Individual first name. Leave blank if provider is a facility or organization
MC029
Service Provider Middle Name
Text
25
Individual middle name or initial. Leave blank if provider is a facility or organization
MC030
Servicing Provider Last Name or Organization Name
Text
60
Report the name of the organization or last name of the individual provider. MC027 determines if this is an organization or Individual Name reported here.
MC031
Service Provider Suffix
Text
10
Suffix to individual name. Leave blank if provider is a facility or organization. Should be used to capture the generation of the individual clinician (e.g., Jr. Sr., III), if applicable, rather than the clinician’s degree [e.g., ‘MD’, ‘LICSW’].
MC032
Service Provider Specialty
Text
10
National Uniform Claims Committee (NUCC) standard code that defines this provider for this line of service. Taxonomy values allow for the reporting of nurses, assistants and laboratory technicians, where applicable, as well as Physicians, Medical Groups, Facilities, etc.
MC033
Service Provider City Name
Text
30
City name of rendering provider - practice location
MC034
Service Provider State
Text
2
As defined by the US Postal Service
MC035
Service Provider ZIP Code
Text
9
ZIP Code of provider - may include non-US codes.
MC036
Type of Bill – Institutional
Text
3
For facility claims only submitted using UB04 forms
Type of Facility - First Digit
1 Hospital
2 Skilled Nursing
3 Home Health
4 Christian Science Hospital
5 Christian Science Extended Care
6 Intermediate Care
7 Clinic
8 Special Facility
Bill Classification - Second Digit if First Digit = 1-6
1 Inpatient (Including Medicare Part A)
2 Inpatient (Medicare Part B Only)
3 Outpatient
4 Other (for hospital referenced diagnostic services
or home health not under a plan of treatment)
5 Nursing Facility Level I
6 Nursing Facility Level II
7 Intermediate Care - Level III Nursing Facility
8 Swing Beds
Bill Classification - Second Digit if First Digit = 7
1 Rural Health
2 Hospital Based or Independent Renal Dialysis Center
3 Free Standing Outpatient Rehabilitation Facility (ORF)
5 Comprehensive Outpatient Rehabilitation Facility (ORF)
6 Community Mental Health Center
9 Other
Bill Classification – Second Digit if First Digit = 8
1 Hospice (Non Hospital Based
2 Hospice (Hospital-Based)
3 Ambulatory Surgery Center
4 Free Standing Birthing Center
9 Other
Frequency – Third Digit
0 Non-Payment/Zero
1 Admit Through Discharge
2 Interim – First Claim
3 Interim - Continuing Claims
4 – Interim – Last Claim
5 – Late Charge Only
7 – Replacement of Prior Claim
8 – Void/Cancel of a Prior Claim
9 – Final Claim for a Home Health PPS Episode
MC037
Place of Service – Professional)
Text
2
For professional claims only, such as those submitted using CMS1500 forms
See Table 4010.6 (g) Place of Service -- Professional
MC038
Service Line Status
Text
2
Describes the payment status of the specific service line record
01 Processed as primary
02 Processed as secondary
03 Processed as tertiary
04 Denied
06 Approved as amended
19 Processed as primary, forwarded to additional payer(s)
20 Processed as secondary, forwarded to additional payer(s)
21 Processed as tertiary, forwarded to additional payer(s)
22 Reversal of previous payment
26 Documentation Claim – No Payment Associated
28 Repriced
MC039
Admitting Diagnosis
Text
7
ICD-CM Diagnosis Codes. Required on all inpatient admission claims and encounters. Do not include decimals.
MC040
E-Code
Text
7
ICD-CM Diagnosis Codes. Describes an injury, poisoning or adverse effect ICD-CM.
MC041
Principal Diagnosis
Text
7
ICD-CM Diagnosis Codes. Principal Diagnosis should be the principal diagnosis given on the claim header. Do not include decimals.
MC042
Other Diagnosis -1
Text
7
ICD-CM Diagnosis Codes. Do not include decimals.
MC043
Other Diagnosis -2
Text
7
ICD-CM Diagnosis Codes. Do not include decimals.
MC044
Other Diagnosis -3
Text
7
ICD-CM Diagnosis Codes. Do not include decimals.
MC045
Other Diagnosis -4
Text
7
ICD-CM Diagnosis Codes. Do not include decimals.
MC046
Other Diagnosis -5
Text
7
ICD-CM Diagnosis Codes. Do not include decimals.
MC047
Other Diagnosis -6
Text
7
ICD-CM Diagnosis Codes. Do not include decimals.
MC048
Other Diagnosis -7
Text
7
ICD-CM Diagnosis Codes. Do not include decimals.
MC049
Other Diagnosis -8
Text
7
ICD-CM Diagnosis Codes. Do not include decimals.
MC050
Other Diagnosis -9
Text
7
ICD-CM Diagnosis Codes. Do not include decimals.
MC051
Other Diagnosis -10
Text
7
ICD-CM Diagnosis Codes. Do not include decimals.
MC052
Other Diagnosis -11
Text
7
ICD-CM Diagnosis Codes. Do not include decimals.
MC053
Other Diagnosis -12
Text
7
ICD-CM Diagnosis Codes. Do not include decimals.
MC054
Revenue Code
Text
4
National Uniform Billing Committee Codes. Code using leading zeroes, left-justified, and four digits.
MC055
Procedure Code
Text
5
Health Care Common Procedural Coding System (HCPCS). This includes the CPT codes of the American Medical Association
MC056
Procedure Modifier – 1
Text
2
Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code
MC057
Procedure Modifier – 2
Text
2
Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code
MC058
ICD-9-CM Procedure Code
Text
4
Primary ICD-9/10-CM code given on the claim header.
MC059
Date of Service – From
Date
8
First date of service for this service line.
MC060
Date of Service – Thru
Date
12
Last date of service for this service line
MC061
Quantity
Number
12 (0)
Count of services performed.
MC062
Charge Amount
Number
10 (2)
The full, undiscounted total and service-specific charges billed by the provider.
MC063
Paid Amount
Number
10 (2)
Includes any withhold amounts.
MC064
Fee for Service Equivalent
Number
10 (2)
For capitated services, the fee for service equivalent amount.
MC065
Copay Amount
Number
10 (2)
The preset, fixed dollar amount for which the individual is responsible.
MC066
Coinsurance Amount
Number
10 (2)
Coinsurance , dollar amount
MC067
Deductible Amount
Number
10 (2)
Amount in dollars met by the patient/family in a deductible plan
MC068
Patient Account/Control Number
Text
20
MC069
Discharge Date
Date
8
Required for all inpatient(s)
MC070
Service Provider Country Name
Text
30
MC071
DRG
Text
7
Carriers and third-party administrators shall code using the CMS methodology when available. Precedence shall be given to DRGs transmitted from the hospital provider. When the CMS methodology for DRGs is not available, but the All Payer DRG system is available, then that system shall be used. If the All Payer DRG system is used, the carrier shall format the DRG and the complexity level within the same field with an "A" prefix, and with a hyphen separating the DRG and the complexity level (e.g. AXXX-XX)
MC072
DRG Version
Text
2
This element is the version number of the grouper used.
MC073
APC
Text
4
Carriers and third-party administrators shall code using CMS methodology. Precedence shall be given to APCs transmitted from the health care provider
MC074
APC Version
Text
2
This element is the version number of the grouper used
MC075
Drug Code
Text
11
NDC Code Used only when a medication is paid for as part of a medical claim.
MC076
Billing Provider Number
Text
30
Payer assigned billing provider number. This number should be the identifier used by the payer for internal identification purposes and does not routinely change
MC077
National Billing Provider Number ID
Text
30
This is the NPI for the billing provider
MC078
Billing Provider Organization or Last Name
Text
60
MC101
Subscriber Last Name
Text
60
MC102
Subscriber First Name
Text
35
MC103
Subscriber Middle Initial
Text
1
MC104
Member Last Name
Text
60
MC105
Member First Name
Text
35
MC106
Member Middle Initial
Text
1
MC200
ICD Indicator
Text
1
Report the value that defines whether the diagnoses on claim are ICD9 or ICD10.
0 ICD-9
1 ICD-10
MC202
Other ICD-CM Procedure Code - 2
Text
7
ICD Secondary Procedure Code
MC203
Other ICD-CM Procedure Code - 3
Text
7
ICD Secondary Procedure Code
MC204
Other ICD-CM Procedure Code - 4
Text
7
ICD Secondary Procedure Code
MC205
Other ICD-CM Procedure Code - 5
Text
7
ICD Secondary Procedure Code
MC206
Other ICD-CM Procedure Code - 6
Text
7
ICD Secondary Procedure Code
MC207
Carrier Associated with Claim
Text
8
For each claim, the NAIC code of the carrier when a TPA processes claims on behalf of the carrier. Optional if all medical claims processed by a TPA under contract to a carrier for carved-out services are submitted by the carrier with unified member IDs in all files.
MC208
Carrier Plan Specific Contract Number or Subscriber/Member Social Security Number
Text
128
When a TPA processes claims on behalf of the carrier, for each claim, report the carrier specific contract number or subscriber/member social security number. Optional if all medical claims processed by a TPA under contract to a carrier for carved-out services are submitted by the carrier with unified member IDs in all files.
MC209
Practitioner Group Practice
Text
60
Name of group practice to which a practitioner is affiliated if different from MC078
MC210
Coordination of Benefits/Third Party Liability Amount
Number
10 (2)
Coordination of Benefits (COB)/Third Party Liability (TPL) is the dollar amount paid from a prior payer (e.g. auto claim, workers comp, dual medical coverage). Report 0 if there is no COB/TPL amount.
MC211
Cross Reference Claims ID
Text
35
The original Payer Claim Control Number (MC004). Used when a new Payer Claim Control Number is assigned to an adjusted claim and a Version Number (MC005A) is not used.
MC212
Allowed Amount
Number
10 (2)
Report the maximum dollar amount contractually allowed and that a carrier will pay to a provider for a particular procedure or service. This will vary by provider contract and most often it is less than or equal to the fee charged by the provider.
MC215
Service Line Type
Text
1
Report the code that defines the claim line status in terms of adjudication
O Original
V Void
R Replacement
B Back Out
A Amendment
MC216
Payment Arrangement Type
Text
1
Defines the contracted payment methodology for this claim line
1 Capitation
2 Fee for service
3 Percent of charges
4 DRG
5 Pay for Performance
6 Global Payment
7 Other
8 Bundled payment
MC217
Pay for Performance Flag
Text
1
Does this provider have pay-for-performance bonuses or year-end withhold returns based on performance for at least one service performed by this provider within the month?
Required when MP005 = 1, 2, or 3
Y Yes
N No
MC218
Claim Processing Level Indicator
Text
1
1 Claim Level
2 Service Line level
MC219
Denied Claim Indicator
Text
1
1 Fully Paid – the entire claim was paid at the allowed amount
2 Partially denied – some of the claims lines were paid at the allowed amount
3 Encounter claim – this claim records a service provided that is paid under a non Fee For Service (FFS) payment arrangement such as capitation
4 No payment – no payment made for reasons other than non FFS payment arrangement
MC220
Denial Reason
Text
15
Denial reason code. Required when denied claim indicator = 2 or 4
http://www.wpc-edi.com/reference/
MC221
Procedure Modifier – 3
Text
2
Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code
MC222
Procedure Modifier – 4
2
Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code
MC223
HIOS Plan ID
Text
16
The 16 character HIOS Plan ID (Standard component), including a 5 digit issuer ID, 2 character state ID, 3 digit product number, 4 digit standard component number, and 2 digit variant component ID. This field may not be available for all market segments. Leave blank if not available
MC899
Record Type
Text
2
MC
MC900
In Network Indicator
Text
1
A yes/no indicator that specifies that the provider (not the benefit) is within the health plan network. Valid codes: Y=Yes, N=No
MC901
Unit of Measure
Text
2
Type of units reported in MC061. Codes accepted DA=days, MN=minutes, UN=units. If MC061 is not reported, MC901=NA
Source. #10877, eff 7-10-15; ss by #13136, eff 11-24-20