N.H. Code Admin. R. Ins 4010.07 – Mapping and Format Information Tables

(a) Member Eligibility File Mapping and Format Information
Table 4010.07 (a) Member Eligibility File Mapping and Format Information
Data Element #
Element
HIPAA Reference
Transaction Set/Loop/
Segment/Qualifier/
Data Element
ME001
Payer
N/A
ME002
National Plan ID
271/2100A/NM1/XV/09
ME003
Insurance Type Code/Product
271/2110C/EB/ /04, 271/2110D/EB/ /04
ME004
Year
N/A
ME005
Month
N/A
ME006
Insured Group or Policy Number
271/2100C/REF/1L/02, 271/2100C/REF/IG/02, 271/2100C/REF/6P/02, 271/2100D/REF/1L/02, 271/2100D/REF/IG/02, 271/2100D/REF/6P/02
ME007
Coverage Level Code
271/2110C/EB/ /03, 271/2100D/EB/ /03
ME008
Subscriber Social Security Number
271/2100C/NM1/MI/09
ME009
Plan Specific Contract Number
271/2100C/NM1/MI/09
ME010
Member Suffix or Sequence Number
N/A
ME011
Member Social Security Number
271/2100C/MN1/MI/09, 271/2100D/NM1/MI/09
ME012
Individual Relationship Code
271/2100C/INS/Y/02, 271/2100D/INS/N/02
ME013
Member Gender
271/2100C/DMG/ /03, 271/2100D/DMG/ /03
ME014
Member Date of Birth
271/2100C/DMG/D8/02, 271/2100D/DMG/D8/02
ME015
Member City Name
271/2100C/N4/ /01, 271/2100D/N4/ /01
ME016
Member State or Province
217/2100C/N4/ /02, 271/2100D/N4/ /02
ME017
Member ZIP Code
271/2100C/N4/ /03, 271/2100D/N4/ /03
ME018
Medical Coverage
N/A
ME019
Prescription Drug Coverage
N/A
ME020
Dental Coverage
N/A
ME021
Race 1
N/A
ME022
Race 2
N/A
ME023
Place holder
N/A
ME024
Hispanic Indicator
N/A
ME025
Ethnicity 1
N/A
ME026
Ethnicity 2
N/A
ME027
Place holder
N/A
ME028
Primary Insurance Indicator
N/A
ME029
Coverage Type
N/A
ME030
Market Category
N/A
ME031
NH Health Protection Program
N/A
ME032
Group Name
N/A
ME101
Subscriber Last Name
270/2100C/NM1/IL/1/3
ME102
Subscriber First Name
270/2100C/NM1/IL/1/4
ME103
Subscriber Middle Initial
270/2100C/NM1/IL/1/5
ME104
Member Last Name
270/2100D/NM1/QC/1/3
ME105
Member First Name
270/2100D/NM1/QC/1/4
ME106
Member Middle Initial
270/2100D/NM1/QC/1/5
271/2100/N3//01, 02
271/2100D/N3/ /01, 02
ME203
Member’s Assigned PCP
Loop 2000B SBR02 = 18 - ELSE - Loop
ME204
HIOS Plan ID
N/A
ME205
Plan Effective Date
N/A
ME206
Minimum Value
2010CA Segment N301
ME207
Exchange Indicator
N/A
ME208
High Deductible Health Plan
N/A
ME209
Active Enrollment
N/A
ME210
New Coverage
N/A
ME211
N/A
ME899
Record Type
N/A
ME900
Plan State
N/A
ME901
Premium Tax Credit
N/A
ME902
NAIC Number
N/A
ME903
Grandfather Plan Indicator
N/A
(b) Medical Claims File Mapping and Format Information
Table 4010.07 (b) Medical Claims File Mapping and Format Information
Data Element #
Data Element Name
UB-92
Form
Locator
UB-92
(Version 6.0)
Record Type/
Field #
HCFA
1500
#
NSF
(National Standard Format)
Locator
HIPAA Reference Transaction Set/Loop/
Segment/Qualifier/
Data Element
MC001
Payer
N/A
N/A
N/A
N/A
N/A
MC002
National Plan ID
N/A
N/A
N/A
N/A
835/1000A/N1/XV/04
MC003
Product/Claim Filing Indicator Code
N/A
30/4
N/A
N/A
835/2100/CLP/ /06
MC004
Payer Claim Control Number
N/A
N/A
N/A
FA0-02.0, FB0-02.0, FB1-02.0, GA0-02.0, GC0-02.0, GX0-02.0, GX2-02.0, HA0-02.0, FB2-02.0, GU0-02.0
835/2100/CLP/ /07
MC005
Line Counter
N/A
N/A
N/A
N/A
837/2400/LX/ /01
MC005A
Version Number
N/A
N/A
N/A
N/A
N/A
MC006
Insured Group or Policy Number
62 (A-C)
30/10
11C
DA0-10.0
837/2000B/SBR/ /03
MC007
Subscriber Social Security Number
N/A
N/A
N/A
N/A
835/2100/NM1/34/08
MC008
Plan Specific Contract Number
N/A
N/A
N/A
N/A
835/2100/NM1/HN/08
MC009
Member Suffix or Sequence Number
N/A
N/A
N/A
N/A
N/A
MC010
Member Social Security Number
N/A
N/A
N/A
N/A
835/2100/NM1/34/08
MC011
Individual Relationship Code
59 (A-C)
30/18
6
DA0-17.0
8 37/2000B/SBR/ /02, 837/2000C/PAT/ /01
MC012
Member Gender
15
20/7
3
CA0-09.0
837/2010CA/DMG/03
MC013
Member Date of Birth
14
20/8
3
CA0-08.0
837/2010CA/DMG/D8/02
MC014
Member City Name
13
20/14
5
CA0-13.0
837/2010CA/N4/ /01
MC015
Member State or Province
13
20/15
5
CA0-14.0
837/2010CA/N4/ /02
MC016
Member ZIP Code
13
20/16
5
CA0-15.0
837/2010CA/N4/ /03
MC017
Paid Date (AP Date)
N/A
N/A
N/A
N/A
N/A
MC018
Admission Date
17
20/17
N/A
N/A
837/2300/DTP/435/03
MC019
Admission Hour
18
20/18
N/A
N/A
837/2300/DTP/435/03
MC020
Admission Type
19
20/10
N/A
N/A
837/2300/CL1/ /01
MC021
Admission Source
20
20/11
N/A
837/2300/CL1/ /02
MC022
Discharge Hour
21
20/22
N/A
837/2300/DTP/096/03
MC023
Discharge Status
22
20/21
N/A
N/A
837/2300/CL1/ /03
MC024
Service Provider Number
N/A
N/A
N/A
N/A
N/A
MC025
Service Provider Tax ID Number
5
10/4-5
25
BA0-09.0, CA0-28.0, BA0-02.0, BA1-02.0, YA0-02.0,BA0-06.0, BA0-10.0, BA0-12.0, BA0-13.0, BA0-14.0,BA0-15.0, BA0-16.0, BA0-17.0, BA0-24.0, YA0-06.0
835/2100/NM1/FI/09
MC026
National Service Provider ID
N/A
10/6
N/A
N/A
835/2100/NM1/XX/09
MC027
Service Provider Entity Type Qualifier
N/A
N/A
N/A
N/A
835/2100/NM1/82/02
MC028
Service Provider First Name
1
10/12
33
BA0-20.0
835/2100/NM1/82/04
MC029
Service Provider Middle Name
1
10/12
33
BA0-21.0
835/2100/NM1/82/05
MC030
Service Provider Last Name or Organization Name
1
10/12
33
BA0-18.0, BA0-19.0
835/2100/NM1/82/03
MC031
Service Provider Suffix
1
10/12
33
BA0-22.0
835/2100/NM1/82/07
MC032
Service Provider Specialty
N/A
N/A
N/A
N/A
837/2000A/PRV/ZZ/03
MC033
Service Provider City Name
1
10/14
N/A
BA1-09.0, 15.0
837/2010A/N4/ /01
MC034
Service Provider State or Province
1
10/15
N/A
BA1-10.0, 16.0
837/2010A/N4/ /02
MC035
Service Provider ZIP Code
1
10/16
N/A
BA1-11.0, 17.0
837/2010A/N4/ /03
MC036
Type of Bill – Institutional
4
Positions 1-2: 40/4
N/A
N/A
837/2300/CLM/ /05-1
MC037
Facility Type - Professional
N/A
N/A
N/A
FA0-07.0, GU0-0.50
835/2100/CLP/ /08
MC038
Service Line Status
N/A
N/A
N/A
N/A
835/2100/CLP/ /02
MC039
Admitting Diagnosis
76
70/25
N/A
N/A
837/2300/HI/BJ/02-2
MC040
E-Code
77
70/26
N/A
N/A
837/2300/HI/BN/03-2
MC041
Principal Diagnosis
67
70/4
21.1
EA0-32.0, GX0-31.0, GU0-12.0
837/2300/HI/BK/01-2
MC042
Other Diagnosis – 1
68
70/5
21.2
EA0-33.0, GX0-32.0, GU0-13.0
837/2300/HI/BF/02-1
MC043
Other Diagnosis – 2
69
70/6
21.3
EA0-33.0, GX0-32.0, GU0-13.0
837/2300/HI/BF/02-2
MC044
Other Diagnosis – 3
70
70/7
21.4
EA0-33.0, GX0-32.0, GU0-13.0
837/2300/HI/BF/02-3
MC045
Other Diagnosis – 4
71
70/8
N/A
EA0-35.0, GX0-34.0, GU0-15.0
837/2300/HI/BF/02-4
MC046
Other Diagnosis – 5
72
70/9
N/A
N/A
837/2300/HI/BF/02-5
MC047
Other Diagnosis – 6
73
70/10
N/A
N/A
837/2300/HI/BF/02-6
MC048
Other Diagnosis – 7
74
70/11
N/A
N/A
837/2300/HI/BF/02-7
MC049
Other Diagnosis – 8
75
70/12
N/A
N/A
837/2300/HI/BF/02-8
MC050
Other Diagnosis – 9
N/A
N/A
N/A
N/A
837/2300/HI/BF/02-9
MC051
Other Diagnosis –10
N/A
N/A
N/A
N/A
837/2300/HI/BF/02-10
MC052
Other Diagnosis –11
N/A
N/A
N/A
N/A
837/2300/HI/BF/02-11
MC053
Other Diagnosis –12
N/A
N/A
N/A
N/A
837/2300/HI/BF/02-12
MC054
Revenue Code
42
50/5,11-13, 60/5,15-16, 61/5,15-16
N/A
N/A
835/2110/SVC/RB/01-2,
835/2110/SVC/NU/01-2
MC055
Procedure Code
44
60/6,15-16, 61/6,15-16
24.1-6 D
FA0-09.0, FB0-15.0, GU0-07.0
835/2110/SVC/HC/01-2
MC056
Procedure Modifier – 1
44
60/7,15-16, 61/7, 15-16
24.1-6 D
FA0-10.0, GU0-08.0
835/2110/SVC/HC/01-3
MC057
Procedure Modifier – 2
44
60/8,15-16, 61/8,15-16
24.1-6 D
FA0-11.0
835/2110/SVC/HC/01-3
MC058
ICD-9-CM Procedure Code
80,
81(A-E)
70/13, 15, 17, 19, 21, 23
N/A
N/A
835/2110/SVC/ID/01-2
MC059
Date of Service – From
45
61/13, 15-16, 61/13, 15-16
24.1-6 A
N/A
835/2110/DTM/150/02
MC060
Date of Service – Thru
N/A
N/A
24.1-6 A
FA0-05.0, FA0-06.0
835/2110/DTM/151/02
MC061
Quantity
46
50/7, 11-13, 60/9,15-16, 61/9,15-16
24.1-6 G
FA0-19.0, FB0-16.0
835/2110/SVC/ /05
MC062
Charge Amount
47
50/8, 11-13, 60/10, 16-16, 61/11, 15-16
24.1-6F
FA0-13.0
835/2110/SVC/ /02
MC063
Paid Amount
48
N/A
N/A
N/A
835/2110/SVC/ /03
MC064
Fee for Service Equivalent
N/A
N/A
N/A
N/A
N/A
MC065
Co-pay Amount
N/A
N/A
N/A
N/A
N/A
MC066
Coinsurance Amount
N/A
N/A
N/A
N/A
N/A
MC067
Deductible Amount
N/A
N/A
N/A
N/A
N/A
MC068
Patient Account/Control Number
3
N/A
N/A
837/2300/CLM/1
MC069
Discharge Date
MC070
Service Provider Country Name
N/A
N/A
N/A
N/A
N/A
MC071
DRG
N/A
N/A
N/A
N/A
837/2300/HI/DR/2
MC072
DRG Version
N/A
N/A
N/A
N/A
N/A
MC073
APC
N/A
N/A
N/A
N/A
N/A
MC074
APC Version
N/A
N/A
N/A
N/A
N/A
MC075
Drug Code
N/A
837/2400/SV2/N1/2
837/2400/SV2/N2/2
837/2400/SV2/N3/2
837/2400/SV2/N4/2
837/2400/SV2/ND/2
MC076
Billing Provider Number
N/A
N/A
N/A
N/A
N/A
MC077
National Billing Provider Number ID
N/A
N/A
N/A
N/A
N/A
MC078
Billing Provider Organization or Last Name
N/A
N/A
N/A
N/A
N/A
MC101
Encrypted Subscriber Last Name
N/A
N/A
N/A
N/A
837/2110BA/NM1/IL/1/3
MC102
Encrypted Subscriber First Name
N/A
N/A
N/A
N/A
837/2110BA/NM1/IL/1/4
MC103
Encrypted Subscriber Middle Initial
N/A
N/A
N/A
N/A
837/2110BA/NM1/IL/1/5
MC104
Encrypted Member Last Name
N/A
N/A
N/A
N/A
837/2110CA/NM1/QC/1/3
MC105
Encrypted Member First Name
N/A
N/A
N/A
N/A
837/2110CA/NM1/QC/1/4
MC106
Encrypted Member Middle Initial
N/A
N/A
N/A
N/A
837/2110CA/NM1/QC/1/5
MC200
ICD Indicator
N/A
N/A
N/A
N/A
Set value here based upon Loop 2300 Segment H101-01 starting with the letter A
MC202
Other ICD-CM Procedure code - 2
N/A
N/A
N/A
N/A
837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)
MC203
Other ICD-CM Procedure code - 3
N/A
N/A
N/A
N/A
837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)
MC204
Other ICD-CM Procedure code - 4
N/A
N/A
N/A
N/A
837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)
MC205
Other ICD-CM Procedure code - 5
N/A
N/A
N/A
N/A
837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)
MC206
Other ICD-CM Procedure code - 6
N/A
N/A
N/A
N/A
837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)
MC207
Carrier Associated with Claim
N/A
N/A
N/A
N/A
N/A
MC208
Carrier Plan Specific contract Number or Subscriber/Member Social Security Number
N/A
N/A
N/A
N/A
N/A
MC209
Practitioner Group Practice
N/A
N/A
N/A
N/A
N/A
MC210
Coordination of Benefits/Third Party Liability Amount
N/A
N/A
N/A
N/A
835/2320 AMT02
MC211
Cross Reference Claims ID
N/A
N/A
N/A
N/A
N/A
MC212
Allowed Amount
N/A
N/A
N/A
N/A
837/2300 HCP02
MC215
Service Line Type
N/A
N/A
N/A
N/A
N/A
MC216
Payment Arrangement Type
N/A
N/A
N/A
N/A
Loop 2400 Segment HCP01
MC217
Pay for Performance Flag
N/A
N/A
N/A
N/A
N/A
MC218
Claim Processing Level Indicator
N/A
N/A
N/A
N/A
N/A
MC219
Denied Claim Indicator
N/A
N/A
N/A
N/A
Loop 2430 CAS identification
MC220
Denial Reason
N/A
N/A
N/A
N/A
Loop 2430 CAS identification
MC221
Procedure Modifier – 3
N/A
N/A
N/A
N/A
837/2430 SVD03-05
MC222
Procedure Modifier – 4
N/A
N/A
N/A
N/A
837/2430 SVD03-06
MC899
Record Type
N/A
N/A
N/A
N/A
N/A
MC900
In Network Indicator
N/A
N/A
N/A
N/A
N/A
MC901
Unit of Measure
N/A
N/A
N/A
N/A
(c) Pharmacy Claims File Mapping and Format Information
Table 4010.07 (c) Pharmacy Claims File Mapping and Format Information
Data
Element
Element
National Council for Prescription
Drug Programs Field #
PC001
Payer
879
PC002
Plan ID
879
PC003
Insurance Type/Product Code
N/A
PC004
Payer Claim Control Number
993-A7
PC005
Line Counter
N/A
PC006
Insured Group Number
301-C1
PC007
Subscriber Social Security Number
302-C2
PC008
Plan Specific Contract Number
N/A
PC009
Member Suffix or Sequence Number
N/A
PC010
Member Identification Code
302-CY
PC011
Individual Relationship Code
306-C6
PC012
Member Gender
305-C5
PC013
Member Date of Birth
304-C4
PC014
Member City Name of Residence
323-CN
PC015
Member State or Province
324-CO
PC016
Member ZIP Code
325-CP
PC017
Paid Date (AP Date)
N/A
PC018
Pharmacy Number
202-B2
PC019
Pharmacy Tax ID Number
N/A
PC020
Pharmacy Name
833-5P
PC021
National Pharmacy ID Number
N/A
PC022
Pharmacy Location City
831-5N
PC023
Pharmacy Location State
832-6F
PC024
Pharmacy ZIP Code
835-5R
PC024A
Pharmacy Country Name
N/A
PC025
Service Line Status
N/A
PC026
Drug Code
407-D7
PC027
Drug Name
516-FG
PV028
New Prescription
403-D3
PC029
Generic Drug Indicator
N/A
PC030
Dispense as Written Code
408-D8
PC031
Compound Drug Indicator
406-D6
PC032
Date Prescription Filled
401-D1
PC033
Quantity Dispensed
442-E7
PC034
Days Supply
405-D5
PC035
Charge Amount
804-5B
PC036
Paid Amount
509-F9
PC037
Ingredient Cost/List Price
506-F6
PC038
Postage Amount Claimed
428-DS
PC039
Dispensing Fee
507-F7
PC040
Copay Amount
518-FI
PC041
Coinsurance Amount
518-FI
PC042
Deductible Amount
505-F5
PC043
Placeholder
N/A
PC044
Prescribing Physician First Name
717
PC045
Prescribing Physician Middle Name
N/A
PC046
Prescribing Physician Last Name
716
PC047
Prescribing Physician Number
411-DB
PC101
Subscriber Last Name
716
PC102
Subscriber First Name
717
PC103
Subscriber Middle Initial
718
PC104
Member Last Name
716
PC105
Member First Name
717
PC106
Member Middle Initial
718
PC203
Carrier Associated with Claim
N/A
PC204
Carrier Plan Specific Contract Number or Subscriber/Member Social Security Number
N/A
PC211
Cross Reference Claims ID
N/A
PC212
Allowed Amount
N/A
PC213
HIOS Plan ID
N/A
PC214
Claim Processing Level Indicator
N/A
PC215
Service Line Type
N/A
PC216
Denied Claim Indicator
N/A
PC217
Denial Reason
N/A
PC899
Record Type
N/A
PC900
Mail Order Pharmacy Indicator
N/A
PC901
In Network Indicator
N/A
PC902
Version Number
N/A
(d) Dental Claims File Mapping and Format Information
Table 4010.07 (d) Dental Claims File Mapping and Format Information
Data Element
#
Data Element Name
NSF
(National Standard Format)
Locator
HIPAA Reference Transaction Set/Loop/
Segment/Qualifier/
Data Element
DC001
Payer
N/A
N/A
DC002
National Plan Id
N/A
N/A
DC003
Insurance Type/Product Code
N/A
835/2100/CLP/ /06
DC004
Payer Claim Control Number
N/A
835/2100/CLP/ /07
DC005
Line Counter
FA0-02.0, FB0-02.0, FB1-02.0, GA0-02.0, GC0-02.0, GX0-02.0, GX2-02.0, HA0-02.0, FB2-02.0GU0-02.0
837/2400/LX/ /01
DC006
Insured Group or Policy Number
DA0-10.0
837/2000B/SBR/ /03
DC007
Subscriber Social Security Number
N/A
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 Social Security Number
N/A
835/2100/NM1/34/09
DC011
Individual Relationship Code
DA0-17.0
837/2000B/SBR/ /02, 837/20000C/PAT/ /01
DC012
Member Gender
CA0-09.0
837/2010BA/DMB/ /03, 837/2010CA/DMB/ /03
DC013
Member Date of Birth
CA0-08.0
837/2010BA/DMB/D8/02, 837/2010CA/DMB/D8/02
DC014
Member City Name of Residence
CA0-13.0
837/2010BA/N4/ /01, 837/2010CA/N4/ /01
DC015
Member State or Province
CA0-14.0
837/2010BA/N4/ /02, 837/2010CA/N4/ /02
DC016
Member ZIP Code of Residence
CA0-15.0
837/2010BA/N4/ /03, 837/2010CA/N4/ /03
DC017
Date Service Approved
N/A
835/Header Financial Information/BPR/ /16
DC018
Service Provider Number
N/A
835/21000/REF/1A/02, 835/2100/REF/1B/02,
835/2100/REF/1C/02, 835/2100/REF/1D/02, 835/2100/REF/G2/02, 835/2100/NM1/BD/09, 835/2100/NM1/BS/09, 835/2100/NM1/MC/09, 835/2100/NM1/PC/09
DC019
Service Provider Tax ID Number
BA0-09.0, CA0-28.0, BA0-02.0,BA1-02.0, YA0-02.0, BA0-06.0, BA0-10.0, BA0-12.0, BA0-13.0, BA0-14.0, BA0-15.0, BA0-16.0,BA0-17.0, BA0-24.0, YA0-06.0
835/2100/NM1/FI/09
DC020
National Service Provider ID
N/A
837/2310B/NM1/XX/09
DC021
Service Provider Entity Type Qualifier
N/A
837/2310B/NM1/82/02
DC022
Service Provider First Name
BA0-20.0
837/2310B/NM1/82/04
DC023
Service Provider Middle Name
BA0-21.0
837/2310B/NM1/82/05
DC024
Service Provider Last Name or Organization Name
BA0-18.0, BA0-19.0
837/2310B/NM1/82/03
DC025
Service Provider Suffix
BA0-22.0
837/2310B/NM1/82/07
DC026
Service Provider Specialty
N/A
837/2310B/PRV/PXC/03
DC027
Service Provider City name
BA1-09.0, 15.0
837/2310C/N4/ /01
DC028
Service Provider State or Province
BA1-10.0, 16.0
837/2310C /N4/ /02
DC029
Service Provider ZIP Code
BA1-11.0, 17.0
837/2310C /N4/ /03
DC030
Facility Type - Professional
FA0-07.0, GU0-0.50
837/2300/CLM/05-1
DC031
Claim Status
835/2100/CLP/ /02
DC032
CDT Code
FA0-09.0, FB0-15.0, GU0-07.0
837/2400/SV3/AD/01-2
DC033
Procedure Modifier - 1
FA0-10.0, GU0-08.0
837/2400/SV3/AD/01-3
DC034
Procedure Modifier - 2
FA0-11.0
837/2400/SV3/AD/01-4
DC035
Date of Service - From
N/A
837/2400/DTP/472/D8/03, 837/2300/DTP/472/D8/03
DC036
Date of Service - Thru
FA0-05.0, FA0-06.0
837/2400/DTP/472/D8/03, 837/2300/DTP/472/D8/03
DC037
Charge Amount
FA0-13.0
837/2400/SV3/ /02
DC038
Paid Amount
N/A
835/2110/SVC/ /03
DC039
Copay Amount
N/A
835/2110/CAS/PR/3-03
DC040
Coinsurance Amount
N/A
835/2110/CAS/PR/2-03
DC041
Deductible Amount
N/A
835/2110/CAS/PR/1-03
DC042
Billing Provider Number
N/A
837/2010BB/REF/G2/02
DC044
National Billing Provider ID
N/A
837/2010AA/NM1/XX/09
DC044
Billing Provider Last Name
N/A
837/2010AA/NM1/ /03
DC101
Subscriber Last Name
N/A
837/2010BA/NM1/ /03
DC102
Subscriber First Name
N/A
837/2010BA/NM1/ /04
DC103
Subscriber Middle Initial
N/A
837/2010BA/NM1/ /05
DC104
Member Last Name
N/A
837/2010BA/NM1/ /03, 837/2010CA/NM1/ /03
DC105
Member First Name
N/A
837/2010BA/NM1/ /04, 837/2010CA/NM1/ /04
DC106
Member Middle Initial
N/A
837/2010BA/NM1/ /05, 837/2010CA/NM1/ /05
DC201
Carrier Associated with Claim
N/A
N/A
DC202
Carrier Plan Specific Contract Number or Subscriber/Member Social Security Number
N/A
N/A
DC203
Practitioner Group Practice
N/A
N/A
DC204
Tooth Number/Letter
N/A
837/2400 TOO02
DC205
Dental Quadrant
N/A
N/A
DC206
Tooth Surface
837/2400 TOO03
DC207
Claim Version
N/A
N/A
DC208
Diagnosis Code
N/A
837/2300 H101-2
DC209
ICD Indicator
N/A
N/A
DC211
Cross Reference Claims ID
N/A
N/A
DC212
Allowed Amount
N/A
837/2300 HCP02
DC213
HIOS Plan ID
N/A
N/A
DC215
Service Line Type
N/A
N/A
DC218
Claim Processing Level Indicator
N/A
N/A
DC219
Denied Claim Indicator
N/A
N/A
DC220
Denial Reason
N/A
N/A
DC899
Record Type
N/A
N/A
DC900
In Network Indicator
N/A
N/A
DC901
Quantity
N/A
N/A
Source. #10877, eff 7-10-15; ss by #13136, eff 11-24-20
APPENDIX
Appendix B – NHID Opt-In Form
The State of New Hampshire
Insurance Department
21 South Fruit Street, Suite 14
Concord, NH 03301
(603) 271-2261 Fax (603) 271-1406
TDD Access: Relay NH 1-800-735-2964
[if gte vml 1]><v:shapetype id="_x0000_t75" coordsize="21600,21600" o:spt="75" o:preferrelative="t" path="m@4@5l@4@11@9@11@9@5xe" filled="f" stroked="f"> <v:stroke joinstyle="miter"/> <v:formulas> <v:f eqn="if lineDrawn pixelLineWidth 0"/> <v:f eqn="sum @0 1 0"/> <v:f eqn="sum 0 0 @1"/> <v:f eqn="prod @2 1 2"/> <v:f eqn="prod @3 21600 pixelWidth"/> <v:f eqn="prod @3 21600 pixelHeight"/> <v:f eqn="sum @0 0 1"/> <v:f eqn="prod @6 1 2"/> <v:f eqn="prod @7 21600 pixelWidth"/> <v:f eqn="sum @8 21600 0"/> <v:f eqn="prod @7 21600 pixelHeight"/> <v:f eqn="sum @10 21600 0"/> </v:formulas> <v:path o:extrusionok="f" gradientshapeok="t" o:connecttype="rect"/> <o:lock v:ext="edit" aspectratio="t"/> </v:shapetype><v:shape id="Picture_x0020_2" o:spid="_x0000_i1025" type="#_x0000_t75" alt="Description: The image “file:///C:/Documents%20and%20Settings/kcassin/My%20Documents/My%20Pictures/DeptSeal.gif” cannot be displayed, because it contains errors." style='width:94.7pt;height:90pt;visibility:visible;mso-wrap-style:square'> <v:imagedata src="ins4000_files/image001.png" o:title="DeptSeal.gif” cannot be displayed, because it contains errors"/> </v:shape><![endif]if !vml?endif?
NHID Opt-In Form
All-Payer Claims Database Indication of Intent for Private Employers
Offering Self-Funded Health Coverage in New Hampshire
You are receiving this form under a 2016 New Hampshire law allowing a self-funded private employer to direct its claims administrator to include the health care claims data of its employees and covered dependents in the state’s All-Payer Claims Database (APCD) (NH RSA 420-G:11, V).
(NH RSA 420-G:11-a, I)
If you elect to participate, please indicate your intent below by checking, signing, and providing the requested information; then return this form to your claims administrator. If you have questions about New Hampshire’s APCD or the department’s efforts to improve health care cost transparency, contact the NH Insurance Department at 603.271.2261 or requests@ins.nh.gov, or visit http://www.nh.gov/insurance/. Thank you.
Please check, sign, and supply information requested below, if electing to participate:
On behalf of the Employer listed below, I elect to participate in claims data submission to the NH APCD. I direct the Third-Party Administrator listed below to submit data to the NH APCD and to disclose this election to the NH Insurance Department.
Authorizing Signature: __________________________________________
Name and Title of Person Authorizing: ____________________________________
Date of Signature: ____________________________________
Employer Name: ____________________________________
Employer Address: ____________________________________
Employer Contact Name: ____________________________________
Employer Contact Phone and Email: ____________________________________
Approximate # of enrolled lives in NH: ____________________________________
Third-Party Administrator: ____________________________________
INSTRUCTIONS FOR COMPLETING “NH Opt-In Form”
Fill in the blank next to the requested information as follows:
Authorizing Signature means the signature of the person authorized to act on behalf of the employer.
Name and Title of Person Authorizing means the printed name and title of the person signing on behalf of the employer.
Date of Signature means the date the form is signed.
Employer Name means the name of the employer being presented the form.
Employer Address means the business address of the employer.
Employer Contact Name means the name of a person, acting on behalf of the employer, that can be contacted with any questions.
Employer Contact Phone and Email means the phone number and email address of the Employer Contact person.
Approximate # of Enrolled Lives in NH means the number of enrollees in the self-funded health coverage, to the best knowledge of the authorizing person.
Third-Party Administrator means the name of the claims administrator for the Employer named on the form.
Fill in the blank next to the requested information as follows:
Authorizing Signature means the signature of the person authorized to act on behalf of the employer.
Name and Title of Person Authorizing means the printed name and title of the person signing on behalf of the employer.
Date of Signature means the date the form is signed.
Employer Name means the name of the employer being presented the form.
Employer Address means the business address of the employer.
Employer Contact Name means the name of a person, acting on behalf of the employer, that can be contacted with any questions.
Employer Contact Phone and Email means the phone number and email address of the Employer Contact person.
Approximate # of Enrolled Lives in NH means the number of enrollees in the self-funded health coverage, to the best knowledge of the authorizing person.
Third-Party Administrator means the name of the claims administrator for the Employer named on the form.