data submission guide - tasi / phidc€¦ · dental claims file – a data file composed of dental...

1177 Alakea Street, Suite 402 Honolulu, HI 96813

http://health.hawaii.gov/shpda/

State Health Planning & Development Agency State of Hawai‘i All-Payer Claims Database

DATA SUBMISSION GUIDE

March 17, 2018

Version 1.0

State of Hawai‘i State Health Planning & Development Agency


SHPDA/PHIDC Hawai‘i Health Data Center State of Hawai‘i All-Payer Claims Database Data Submission Guide 1.0 Mar 17, 2018 Page | i

Revision History

Date Version Description Author

September 7, 2016 0.1 Initial Draft, distributed to Reporters for comment.

SHPDA/PHIDC

March 17, 2018 1.0 Version 1.0, completed with Interim Administrative Rules, based on discussions with Reporters.

SHPDA/PHIDC

SHPDA/PHIDC Hawai‘i Health Data Center State of Hawai‘i All-Payer Claims Database Data Submission Guide 1.0 Mar 17, 2018 Page | ii

Table of Contents Revision History ....................................................................................................................................................... i

Table of Contents .................................................................................................................................................... ii

Introduction .............................................................................................................................................................. 1

Authority .................................................................................................................................................................... 1

Background ............................................................................................................................................................... 1

Collaboration and Program Overview....................................................................................................... 2

Contact Information .............................................................................................................................................. 2

Definitions and Acronyms................................................................................................................................... 3

General Data Requirements ............................................................................................................................... 6

Mandatory Reporters ....................................................................................................................................... 6

Requirements ...................................................................................................................................................... 6

Overview of Submission Process .................................................................................................................. 11

Required Documentation ............................................................................................................................ 11

File Delivery ...................................................................................................................................................... 11

Submission Schedule ..................................................................................................................................... 11

Other Information .......................................................................................................................................... 12

Encryption Requirements ................................................................................................................................ 12

Submission Instructions ................................................................................................................................... 13

Registration Instructions.................................................................................................................................. 20

Registration Form........................................................................................................................................... 21

File Naming Convention.................................................................................................................................... 22

Transmittal Sheet Instructions ...................................................................................................................... 22

Transmittal Sheet ........................................................................................................................................... 23

Extensions or Waivers to Data Submission Requirements ................................................................ 24

Data Quality Requirements ............................................................................................................................. 24

Test Data Requirements ................................................................................................................................... 25

File Format Specifications ................................................................................................................................ 26

General File Format Specifications .......................................................................................................... 26

Header and Trailer Record Format Specifications ............................................................................ 26

Legend ...................................................................................................................................................................... 27

Header and Trailer Records ............................................................................................................................ 28

Detailed Header Record Requirements ................................................................................................. 28

SHPDA/PHIDC Hawai‘i Health Data Center State of Hawai‘i All-Payer Claims Database Data Submission Guide 1.0 Mar 17, 2018 Page | iii

Detailed Trailer Record Requirements .................................................................................................. 29

Data Submission Sample .................................................................................................................................. 30

Appendix A: Detailed Member Eligibility File Requirements ............................................................ 31

Appendix B: Detailed Medical Claims File Requirements ................................................................... 52

Appendix C: Detailed Pharmacy Claims File Requirements ............................................................ 101

Appendix D: Detailed Dental Claims File Requirements .................................................................. 119

Appendix E: Detailed Provider File Requirements ............................................................................. 136

Appendix F: External Code Sources .......................................................................................................... 148

SHPDA/PHIDC Hawai‘i Health Data Center State of Hawai‘i All-Payer Claims Database Data Submission Guide 1.0 Mar 17, 2018 Page | 1

Introduction The State Health Planning & Development Agency (SHPDA), established by Hawai‘i Revised Statutes §323D-11 in 1975, is the lead State Agency tasked with oversight of data submission to the State of Hawai‘i All-Payer Claims Database. The purpose of this document is to explain, specify, and update the processes and requirements for data submissions to the State of Hawai‘i All-Payer Claims Database. The SHPDA HHDC APCD Data Submission Guide (DSG) provides all Reporters with a means to easily locate information and broad technical details on data submission. The SHPDA HHDC APCD DSG is a living document that will be reviewed and updated annually.

Authority

Hawai‘i Revised Statutes §323D-18.5 governs the reporting requirements of providers of health insurance, herein referred to as Reporters, and submission of administrative data to SHPDA. SHPDA is tasked with adopting the administrative rules relating to data governance, data submission, use and sharing, information security, privacy protection, and reporting. SHPDA’s Interim Administrative Rules can be found in Chapter 188 of Title 11, State of Hawai‘i Administrative Rules. Per HRS §323D-18.5, data shall be submitted to SHPDA’s designee, the Pacific Health Informatics and Data Center (PHIDC) of the University of Hawai‘i. PHIDC is a program component of the University of Hawai‘i Telecommunications and Social Informatics Research Program (UH TASI) of the Social Science Research Institute, under the College of Social Sciences of the University of Hawai‘i at Mānoa.

Background

In the 1960’s, the Office of Comprehensive Health Planning was established as a part of the State of Hawai‘i Department of Health to conduct health planning activities for the State. In 1975, the Office of Comprehensive Health Planning was moved into a separate State Agency and named as the State Health Planning & Development Agency. The purpose of SHPDA is to:

“Promote accessibility for all the people of the State to quality health care services at reasonable cost.”

To accomplish this purpose, SHPDA’s functions are to:

▪ Administer the State’s Certificate of Need (CON) program ▪ Serve as staff in the preparation, revision, and implementation of the State’s Health

Services and Facilities Plan ▪ Conduct studies and investigations regarding the causes of health care costs

http://www.capitol.hawaii.gov/hrscurrent/Vol06_Ch0321-0344/HRS0323D/HRS_0323D-0011.htm

http://www.capitol.hawaii.gov/hrscurrent/Vol06_Ch0321-0344/HRS0323D/HRS_0323D-0018_0005.htm

https://health.hawaii.gov/shpda/files/2018/04/Chapter-11-188-Interim-Hawaii-Admin-Rules.pdf

http://www.capitol.hawaii.gov/hrscurrent/Vol06_Ch0321-0344/HRS0323D/HRS_0323D-0018_0005.htm


▪ Promote the sharing of facilities or services by health care providers to achieve economies of scale and restrict unusual costly services

▪ Conduct coordinated health planning activities and determine health needs of the State

Collaboration and Program Overview The Hawaiʻi Health Data Center (HHDC) is a federally funded special project established by a grant from the Center for Consumer Information and Insurance Oversight (CCIIO) of the Centers for Medicare and Medicaid Services (CMS) and placed in the State of Hawaiʻi Office of Enterprise Technology Services (ETS), formerly known as the Office of Information Management and Technology (OIMT). Once operational the HHDC will help to:

1. Establish baseline information; 2. Monitor and analyze health care costs; 3. Assess population health; 4. Measure utilization of services; 5. Identify health disparities; 6. Inform consumers of cost and quality of healthcare; 7. Support planning and evaluation of healthcare operations and care; 8. Improve coordination of care; 9. Enable oversight of health insurance premium medical loss ratios (MLR); 10. Waste, fraud and abuse studies.

The HHDC is designed to compile health insurer claims data for analysis and integration with other data streams. The first segment of the establishment of the HHDC is to build the State of Hawai‘i All-Payer Claims Database (APCD). The initial data to be analyzed in the first segment are those data readily available from in-state sources, including the Hawai‘i Employer-Union Health Benefits Trust Fund (EUTF), Hawai‘i Med-QUEST (State Medicaid Agency), and Medicare. The second and third segments involve fine-tuning the Hawai‘i APCD and integrating additional data streams to improve functionality, increase data richness, and produce detailed reports to better inform the decisions of consumers, providers, state healthcare programs, and policymakers.

Contact Information The Pacific Health Informatics and Data Center (PHIDC) serves as the primary contact for technical assistance of data submission to the Hawai‘i APCD. For any questions about the submission process, data format, or specifications, please contact: [email protected].

mailto:[email protected]


Definitions and Acronyms

Term Definition

ADA American Dental Association.

Administrative Data or Data

(1) Statistical and financial reports of information; (2) Provider invoices or similar patient encounter data; (3) Records of services used for or resulting from administering delivery of

health care, pharmacy benefits, or dental care, including health care claims data, records of services provided under health benefit plans as defined in Section §87A-1, Hawai‘i Revised Statutes; and

(4) Any other records as established pursuant to administrative rules adopted pursuant to Chapter 91.

Administrator The Administrator of the State Health Planning & Development Agency.

Agency The State Health Planning & Development Agency as established in Section §323D-11, HRS.

AMA American Medical Association

APCD

State of Hawai‘i All-Payer Claims Database – This term is used broadly as a payer claims database. The Hawai‘i APCD will be initiated with the state government-funded data from the Med-QUEST and EUTF, as well as Medicare data from CMS.

CCIIO Center for Consumer Information & Insurance Oversight of the CMS.

CDT Code on Dental Procedures and Nomenclature of the ADA.

CMS Centers for Medicare & Medicaid Services of the U.S. Department of Health Human Services.

CPT Current Procedural Terminology of the AMA.

Data Element

The specific information collected and reported for the purpose of health care and health services delivery. Data Elements include, but, not limited to, information to identify the individual, health care provider, data supplier, service provided, charge for services, payer source, medical diagnosis, and medical treatment.

DC

Dental Claims File – A data file composed of dental service level remittance information for all non-denied adjudicated claims for each billed dental service, including but not limited to member demographics, provider information, care and payment information, and clinical diagnosis and procedure codes.

Designee

A governmental or non-profit entity with which the Agency has entered into an agreement pursuant to Section §323D-18.5, HRS, to perform, on behalf of the Agency, data collection and management, data analysis, reporting, and administrative functions. The Pacific Health Informatics and Data Center is the Agency’s Designee.

DSG Data Submission Guide – The document referenced in Section §11-188-11, HAR for data submissions to the Agency, or its Designee.

Encryption The use of an algorithmic process to transform data into a form in which the data is rendered unreadable or unusable without the use of a confidential process or key pursuant to Section §487N-1, HRS.


Term Definition

ETS State of Hawai‘i Office of Enterprise Technology Services.

EUTF State of Hawai‘i Employer-Union Health Benefits Trust Fund – The Hawai‘i Employer-Union Health Benefits Trust Fund established under Chapter 87A, HRS.

HAR Hawai‘i Administrative Rules. HCPCS Healthcare Common Procedure Coding System. HHDC Hawai‘i Health Data Center. HRS Hawai‘i Revised Statutes.

ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modification. ICD-10-CM International Classification of Diseases, Tenth Revision, Clinical Modification.

ICD-10-PCS International Classification of Diseases, Tenth Revision, Procedure Coding System.

Mandatory Reporter

Providers of health insurance that provide health benefit plans to the Hawai‘i Employer-Union Health Benefits Trust Fund and the State Medicaid Agency, which are required under Section §323D-18.5, HRS to submit data to the Agency or the Agency’s Designee.

MC

Medical Claims File – The data file containing medical service level remittance information for all non-denied adjudicated claims from each billed service including but not limited to member demographics, provider information, care and payment information, and clinical diagnosis and procedure codes, and shall include all claims related to medical, vision, and behavioral health.

ME

Member Eligibility File – The data file containing demographic information for each individual Member eligible for medical, vision, dental, or pharmacy benefits for one or more days of coverage at any time during the reporting period.

Med-QUEST Med-QUEST Division of the State of Hawai‘i Department of Human Services – The Hawai‘i State Medicaid Agency established to administer the Medicaid program.

Member The insured Subscriber and any spouse or dependent covered by the Subscriber’s policy. The Member is the subject of the activities of the claim or claim line performed by the health care provider.

NCPDP National Council for Prescription Drug Programs.

NPI National Provider Identifier.

OIMT State of Hawai‘i Office of Information Management and Technology (now ETS).

PBM

Pharmacy Benefit Manager – Any person, business, or entity that performs pharmacy benefit management, including but not limited to a person or entity under contract with a pharmacy benefit manager to perform pharmacy benefit management on behalf of a managed care company, nonprofit hospital or medical service organization, insurance company, third-party payer, or health program administered by the State, pursuant to Section §431R-1, HRS.

PC

Pharmacy Claims File – The data file containing service level remittance information from all non-denied adjudicated claims for each prescription, including, but not limited to member demographics, provider information, charge and payment information, and National Drug Code.


Term Definition

PHI

Protected Health Information – Individually identifiable health information: (1) Except as provided in paragraph (2) of this definition, that is:

(A) Transmitted by electronic media; (B) Maintained in electronic media; (C) Transmitted or maintained in any other form or medium.

(2) Protected Health Information excludes individually identifiable health information pursuant to 45 C.F.R. §160.103: (A) In education records covered by the Family Educational Rights

and Privacy Act, as amended, 20 U.S.C. §1232g; (B) In records described at 20 U.S.C. §1232g(a)(4)(iv); (C) In employment records held by a covered entity as in its role as

an employer; and (D) Regarding a person who has been deceased for more than 50

years.

PHIDC

Pacific Health Informatics and Data Center – The data center program component of the University of Hawai‘i Telecommunications and Social Informatics Research Program (UH TASI) of the Social Science Research Institute, under the College of Social Sciences of the University of Hawai‘i at Mānoa.

Provider of Health Insurance

A group health insurance contract or service agreement that may include medical, hospital, surgical, prescription drug, vision, or dental services, in which a carrier agrees to provide, pay for, arrange for, or reimburse the cost of the services, including Third Party Administrators.

PV Provider File – The data file containing information on every health care provider contracted by the provider of health insurance during the reporting period.

Reporter Includes both Mandatory Reporters and Voluntary Reporters.

SFTP Secure File Transfer Protocol. SHPDA State Health Planning & Development Agency.

Subscriber The individual responsible for payment of premiums or whose employment is the basis for eligibility for membership in a health benefit plan.

TPA

Third Party Administrator – Any person who, on behalf of a health insurer or purchaser of health benefits, receives or collects charges, contributions, or premiums for, or adjusts or settles claims on or for residents of the State of Hawai‘i health care providers and facilities.

UH TASI University of Hawai‘i Telecommunications and Social Informatics Research Program.

Voluntary Reporter

A provider of health insurance or other data source provider that is not required to provide data but agrees to provide data in accordance with a Data Use Agreement.


General Data Requirements

Mandatory Reporters

▪ Hawai‘i Employer-Union Health Benefits Trust Fund and Plans (including Third-Party Administrators)

▪ Med-QUEST Division and Plans (including Third-Party Administrators) Reporters shall provide the following data files as applicable:

▪ Member Eligibility File (ME) ▪ Medical Claims File (MC) ▪ Pharmacy Claims File (PC) ▪ Dental Claims File (DC) ▪ Provider File (PV)

The files must conform to the specifications, including format and completeness as described in Appendices A – E.

Requirements Member Eligibility File Submission Information Reporters must submit a complete and conforming Member Eligibility (ME) file in accordance with the specifications described in Appendix A: Detailed Member Eligibility File Requirements. that contains information on every covered plan member under a health benefit plan funded by the State of Hawai‘i (Hawai‘i EUTF or Med-QUEST), whether or not the member utilized services during the reporting period. The file must include member identifiers, subscriber identifiers, member relationship to subscriber, name, address, date of birth, gender, race, ethnicity, and other required fields to allow retrieval and linking of related information from the Medical, Pharmacy, and Dental Claims data files. Member Eligibility file specifications include enrollment spans in an effort to capture any changes in eligibility attributes, attributed provider, benefit information, or enrollment/disenrollment. Each Member Eligibility record displays one record per member per product for the given timespan that product was in effect. As a result, overlaps in enrollment start and enrollment end dates are permissible.

File Content

▪ File must include variables specified in Appendix A: Detailed Member Eligibility File Requirements.


▪ File must include member information whether or not the member utilized services during the reporting period.

▪ Member Eligibility File must contain all eligibilities, benefits, attributes and dates of enrollment/disenrollment. This information provides the SHPDA/PHIDC with the necessary information to link claims to the corresponding eligibility segments.

▪ Member is either the Subscriber or the Subscriber’s dependents. In all instances where the Subscriber has dependents, a link between them must be maintained.

▪ If dual coverage exists, submit coverage of eligible members where insurance is primary or tertiary. ME028 – Primary Insurance Indicator is a flag to indicate whether this insurance is primary or tertiary coverage.

▪ Reporter’s Carrier Specific Unique Member ID and Carrier Specific Unique Subscriber ID must be consistent across all files (ME, MC, PC, DC, PV).

▪ Each record in the Member Eligibility File represents one record per member, per product. As a result, a Member who is disenrolled then re-enrolled in a product may have more than a single record submitted in the file.

▪ Members can or will have more than one eligibility record when they are enrolled in more than one product, have secondary coverage, have a break in eligibility, or have multiple active primary care provider (PCP) assignments within a reporting period.

Medical Claims File Submission Information Reporters must submit a complete and conforming Medical Claims (MC) file in accordance with the specifications described in Appendix: Detailed Medical Claims File Requirements. B that contains all adjudicated paid claims and adjudicated encounters for health care services incurred by every Member during the reporting period. Reporters are required to identify encounters corresponding to a capitation payment or other alternative payment arrangement. File Content

▪ File must include variables specified in Appendix B: Detailed Medical Claims File Requirements.

▪ Medical Claims files must include all services provided to the Member, including but not limited to, inpatient, outpatient, professional services, vision, behavioral health, home health, and durable medical equipment.

▪ Reporters must provide one row per claim line. If multiple services are performed and billed on a claim, each of those services would be uniquely identified and reported on a separate line with the claim number linking the lines together.

▪ Files must have an associated Member record in the Member Eligibility File. ▪ Reporter’s Carrier Specific Unique Member ID and Carrier Specific Unique

Subscriber ID must be consistent across all files (ME, MC, PC, DC, PV). ▪ Files must contain all claims based on paid date during the reporting period for all

covered services provided to eligible Members.


▪ Files must contain all claims data during which some action has been taken on that claim (e.g. payment, adjustment, void, or other modification).

▪ Denied claims are not submitted to the State of Hawai‘i APCD. ▪ Any medical claim that is considered paid by the Reporter shall appear in the

Medical Claims File. Paid Amount for global payment and capitated payment arrangements shall be reported as zero (0) and the corresponding Allowed Amount and Deductible Amount shall be calculated and reported accordingly by the Reporter.

▪ Reporters must provide a narrative description of the numbering system or logic used by each payment stream to link prior versions of each claim to a subsequent adjudication action to support “versioning” processes. Examples of such methods include but are not limited to, appending suffixes to transaction numbers or matching on Member/Provider/Date of Service/Procedure processes.

Pharmacy Claims File Submission Information Reporters must submit a complete and conforming Pharmacy Claims (PC) file in accordance with the specifications described in Appendix C: Detailed Pharmacy Claims File Requirements that contains all adjudicated paid claims and adjustment claims for pharmaceutical products and services for every covered plan Member during the reporting period. If the health plan allows for medical coverage without pharmacy benefits (or vice versa), ME019 – Prescription Drug Coverage in Appendix A: Member Eligibility File Requirements provides data elements in which coverage status must be identified in order to effectively and accurately aggregate claims. File Content

▪ Files must include variables specified in Appendix C: Detailed Pharmacy Claims File Requirements.




covered services provided to eligible Members. ▪ Files must contain all claims data during which some action has been taken on that

claim (e.g. payment, adjustment, void, or other modification).


▪ In the event that the Reporter contracts with a pharmacy benefits manager or other service entity that manages claims for members, the Reporter shall be responsible for ensuring that complete and accurate files are submitted to the State of Hawai‘i APCD by the subcontractor. The Reporter shall ensure that the member identification information in the subcontractor’s file(s) is consistent with the member identification information in the health plan’s ME, MC, PC, and DC files. The Reporter shall include utilization and cost information for all services provided to members under any financial arrangement, including sub-capitated, bundled, and global payment arrangements.

▪ Denied claims are not submitted to the State of Hawai‘i APCD. ▪ Reporters must provide a narrative description of the numbering system or logic

used by each payment stream to link prior versions of each claim to a subsequent adjudication action to support “versioning” processes. Examples of such methods include but are not limited to, appending suffixes to transaction numbers or matching on Member/Provider/Date of Service/Procedure processes.

Dental Claims File Submission Information Reporters must submit a complete and conforming Dental Claims (DC) file in accordance with the specifications described in Appendix D: Detailed Dental Claims File Requirements that contains all adjudicated paid claims and adjustment claims for all dental services for every covered plan Member during the reporting period. File Content

▪ Files must include variables specified in Appendix D: Detailed Dental Claims File Requirements.




covered services provided to eligible members. ▪ Files must contain all claims data during which some action has been taken on that

claim (e.g. payment, adjustment, void, or other modification). ▪ Denied claims are not submitted to the State of Hawai‘i APCD. ▪ Any dental claim that is considered paid by the Reporter shall appear in the Dental

Claims File. Paid Amount for global payment and capitated payment arrangements shall be reported as zero (0) and the corresponding Allowed Amount and Deductible Amount shall be calculated and reported accordingly by the Reporter.


▪ Reporters must provide a narrative description of the numbering system or logic used by each payment stream to link prior versions of each claim to a subsequent adjudication action to support “versioning” processes. Examples of such methods include but are not limited to, appending suffixes to transaction numbers or matching on Member/Provider/Date of Service/Procedure processes.

Provider File Submission Information Reporters must submit a complete and conforming Provider File in accordance with the specifications described in Appendix E: Detailed Provider File Requirements that contains information on every provider for whom a claim appears in Appendix B, C, or D and who was part of the Reporter’s contracted network at any time during the reporting period. Any lookup tables necessary for specialty codes shall be included as part of the submission. All providers must have a unique National Provider ID (NPI) or other unique ID assigned by the Reporter. File Content

▪ Files must include variables specified in Appendix E: Detailed Provider File Requirements.

▪ Reporters must provide one record per provider for each unique physical address and NPI.

o For example, the following would be two separate records: ▪ John Smith, MD, 123 Street, NPI: 1234567890 ▪ John Smith, MD, 456 Honolulu Street, NPI: 1234567891

▪ Each Provider File submitted must be a complete and updated replacement of previous submissions.


Overview of Submission Process

Required Documentation Reporters shall provide the following documentation with the first test data submission: Required Documentation

▪ Data Dictionary: maps the Reporter’s internal system data elements to the SHPDA HHDC APCD DSG defined data elements that shall be submitted. If the Reporter updates an element in the Data Dictionary, the Reporter shall provide the specific internal system data element, and a memo indicating the change(s) or update(s).

▪ External Code List(s): code lists that are internal to the Reporter’s system and reported in the file(s), that shall be submitted with the initial submission and resubmitted as any update(s) or change(s) occur.

▪ Transmittal Sheet: summarizes the submission(s) and shall be submitted with every data submission.

Additional Documentation If there are any issues with the data submission(s), the following documentation shall be submitted as requested.

▪ Extract Specifications: describes how the data extracts are created and how the requirements of the SHPDA HHDC APCD DSG are met.

▪ Claims Processing Information: provides detailed descriptions of how the Reporter processes claims.

File Delivery Files will be submitted to the Hawai‘i APCD via Secure File Transfer Protocol (SFTP) according to the Submission Instructions following this section.

Submission Schedule The first test data submissions (Submission Test) of all five file types (ME, MC, PC, DC, PV), as applicable, containing 100 records shall be submitted within thirty (30) calendar days from the date of receipt of request from the SHPDA Administrator. The second test data submissions (Production Test) of all five file types (ME, MC, PC, DC, PV), as applicable, covering a one-month period shall be submitted within fifteen (15) calendar days from the date of request from the SHPDA Administrator. Additional test data may be requested at the discretion of the SHPDA Administrator. See Test Data Requirements for additional information.


Historical production data submissions of all five file types (ME, MC, PC, DC, PV), as applicable, spanning the period of 1/1/2009 – 12/31/2017, shall be submitted within thirty (30) calendar days from the date of request from the SHPDA Administrator. Historical production data submissions shall be split by file type (ME, MC, PC, DC, PV), by calendar year (e.g., Medical Claims data for 2009 will be a single file, Pharmacy Claims data for 2009 will be a single file, etc.). All claims submissions shall be made in accordance with paid dates and not service dates. Reporters may submit all data in the initial data submission OR in two separate installments as outlined below: First Submission Data Period: CY 2013, 2014, 2015, 2016, 2017 Second Submission Data Period: CY 2009, 2010, 2011, 2012 If the Reporter elects to submit data in two installments, the first installment must be submitted within thirty (30) calendar days and the second installment must be submitted no later than sixty (60) calendar days after the notification from the SHPDA Administrator. Subsequent data shall be submitted quarterly by file type. Quarterly submissions shall begin upon notification by the SHPDA Administrator. Reporters must provide complete and conforming quarterly files on the following schedule:

Quarter Submission Due Date

Submission Period Begin Date

Submission Period End Date

Q1 By May 1 January 1 March 31

Q2 By July 1 April 1 June 30

Q3 By November 1 July 1 September 30

Q4 By February 1 October 1 December 31

Other Information In the event that the Reporter contracts an entity that manages claims for members under a health benefit plan funded by the State of Hawai‘i (EUTF or Med-QUEST), the Reporter shall be responsible for ensuring that complete and accurate files are submitted to the State of Hawaiʻi APCD by the subcontractor or third-party administrator (TPA). The Reporter shall ensure that the Member identification information in the subcontractor’s or TPA’s files are consistent with the Member identification information in the Reporter’s ME, MC, PC, DC, and PV files. The Reporter shall include utilization and cost information for all services provided to members under any financial arrangement, including but not limited to, sub-capitated, bundled, and global payment arrangements.

Encryption Requirements All data submitted to State of Hawai‘i APCD must be encrypted. Encryption requirements can be found in the Submission Instructions following this section.


Submission Instructions The SHPDA/PHIDC currently employs a submission process via SFTP for the submission of data to the State of Hawai‘i APCD. Initial Setup

1. All Reporters must complete the Registration Form and submit to [email protected].

2. Once the Registration Form is received and processed by SHPDA/PHIDC, the Reporter shall receive a confirmation notice and will be provided the unique Submitter ID that will be used in all submissions and the subsequent forms (SFTP Form, Extensions or Waivers to DSG Requirements Form).

3. Reporters shall complete the SFTP Form and submit to [email protected].

4. Once the SFTP Form is received and processed by SHPDA/PHIDC, the Reporter shall receive a confirmation notice and will be provided the username to be used for all SFTP submissions as well as the hostname of the PHIDC SFTP server.

5. The PHIDC will provide the password to be used for all SFTP submissions by phone to the Point of Contact indicated on the Registration Form.

6. The Reporter and SHPDA/PHIDC shall work together to test SFTP connectivity.

a. The Reporter will need to change their default password when they login for the first time. Passwords must be a minimum of 14 characters and contain at

least one upper case letter, one lowercase letter, one number and one

symbol. Passwords expire every 60 days and the last 24 passwords are

remembered and cannot be reused.

7. The Reporter shall download and install GPG4WIN with Kleopatra, 7-zip, and WinSCP.

8. The Reporter shall create OpenPGP certificates (or using existing OpenPGP certificates and import into Kleopatra).

9. Create and export an RSA Public / Private Key Pair with Kleopatra:

a. Open Kleopatra

b. Select File and select New Certificate.

c. Select Create a personal OpenPGP key pair.

d. Enter the Name and identify the type of key in the name (RSA = Encryption/Decryption; DSA = Signing/Verification). (e.g., 12345_RSA).

e. Enter Email address.

f. Click on the Advanced Settings tab to configure technical details of the certificate.



https://www.gpg4win.org/

http://www.7-zip.org/

https://winscp.net/


g. On the Advanced Settings tab, select RSA. Make sure +RSA is selected.

▪ Change both bit values from 2048 bits to 4096 bits.

h. Click OK to return to the previous screen.

i. Click on Next to review the Certificate Parameters.

j. Under Review Certificate Parameters, click Create Key.

k. To finalize the key, enter a passphrase.

▪ Note: Passphrases are not recoverable.

▪ As the passphrase is entered, the quality (security) will be measured.

l. Click OK.

m. Re-enter the passphrase.

n. Click OK.

o. If the passphrase is not strong enough, users will receive a warning.

▪ If a warning is received, select Enter new passphrase.

▪ Enter a password with a quality of 100%.

▪ Click OK.

p. Users will receive confirmation after the Key pair has been created. Click Finish.

q. View the RSA certificate listed in bold.

r. After keys have been created, users may export Public Key Certificates. Right

click on the Certificate in the list. Select Export Certificates.

s. Name the exported Public Key Certificate file using the following naming convention: SubmitterID_RSA_PublicKey.asc (e.g., 12345_RSA_PublicKey.asc).

t. Name Private Keys using user-specified naming conventions.

10. Create and export a DSA public key:

a. Open Kleopatra

b. Select File and select New Certificate.

c. Select Create a personal OpenPGP key pair.

d. Enter the Name and identify the type of key in the name (RSA = Encryption/Decryption; DSA = Signing/Verification). (e.g., 12345_DSA).

e. Enter Email address.

f. Click on the Advanced Settings tab to configure technical details of the certificate.

g. On the Advanced Settings tab, select DSA. Make sure +Elgamal is selected.


▪ Change the bit value for +Elgamal from 2048 bits to 4096 bits.

h. Click OK to return to the previous screen.

i. Click on Next to review the Certificate Parameters.

j. Under Review Certificate Parameters, click Create Key.

k. To finalize the key, enter a passphrase.

▪ Note: Passphrases are not recoverable.

▪ As the passphrase is entered, the quality (security) will be measured.

l. Click OK.

m. Re-enter the passphrase.

n. Click OK.

o. If the passphrase is not strong enough, users will receive a warning.

▪ If a warning is received, select Enter new passphrase.

▪ Enter a password with a quality of 100%.

▪ Click OK.

p. Users will receive confirmation after the Key pair has been created. Click Finish.

q. View the DSA certificate listed in bold.

r. After keys have been created, users may export Public Key Certificates. Right click on the Certificate in the list. Select Export Certificates.

s. Name the exported Public Key Certificate file using the following naming convention: SubmitterID_DSA_PublicKey.asc (e.g., 12345_DSA_PublicKey.asc).

t. Name Private Keys using user-specified naming conventions.

11. Establish secure connection to APCD FTP server via WinSCP.

a. SFTP via WinSCP

▪ Open WinSCP.

▪ Click New Site.

▪ Set the File protocol to SFTP.

▪ Enter the provided Host name. The host name will be provided at the same time as your SFTP credentials.

▪ Enter 22 for the Port number.

▪ Enter the Username and Password that were supplied for you.

▪ Click the Advanced button.


▪ Click Key Exchange located in the SSH submenu.

• We support the following key exchange algorithms:

o ecdh-sha2-nistp256



o diffie-hellman-group-exchange-sha256

▪ Click OK.

▪ Click Login.

12. Upload public keys created in step 9 and 10.

a. If not already connected, follow step 11.

b. SFTP via WinSCP.

▪ Navigate to the folder labeled yourAccountName_PublicKeys (e.g., 12345_PublicKeys).

▪ Locate and select the two public key files you created in step 9 and 10.

▪ Click the Upload button.

▪ Alternatively, you can drag the files from your local directory to the remote directory in the WinSCP window.

13. Download Hawaii APCD public keys.


b. SFTP via WinSCP.

▪ Navigate to the folder labeled HI_APCD_PublicKeys.

▪ For both Hawaii APCD Public Keys.

• Select the public key file.

• Click the download button.

• Alternatively, right click and select Download or press F5.

14. Import and trust Hawaii APCD public keys using Kleopatra. Follow these steps for each of the public key certificate files.

a. Launch the Kleopatra application.

b. Click the Import Certificates button.

c. Select one of the two files you downloaded in step 13.

d. Click Open.

e. You will see a confirmation dialogue that tells you the results of the import.

f. Click OK.


g. Click on the tab labeled All Certificates.

h. Right click on the key and select Change Owner Trust.

i. Select I believe checks are casual.

j. Click OK.

Data Submission

1. Extract the data in accordance with Appendices A-E.

a. Files shall be named in accordance with the File Naming Convention.

b. The Transmittal Sheet shall also be sent with all data submissions.

2. Create a zip archive containing all the files that will be submitted. Files shall include: Transmittal Sheet, and all data files to be submitted in this transmission.

a. Select all the files in Windows Explorer, right click, and select 7-zip → Add to archive…

b. Ensure the archive format is set to zip.

c. Click OK.

3. Encrypt the data using the Hawaii APCD RSA Public Key.

a. Create .gpg file.

▪ Locate the zip archive you created in step 2.

▪ Right click on the file in File Explorer.

▪ Select Sign and encrypt.

▪ Select Sign and encrypt (OpenPGP only).

▪ Click Next.

▪ Select the Hawaii APCD RSA key.

NOTE: The public key of the RSA key is used to encrypt the file but only the private key can decrypt the file.

▪ Click Add.

▪ Click Next.

▪ You will get an Encrypt-To-Self Warning, click Continue.

▪ Make sure Sign with OpenPGP is selected.

▪ Select your DSA Signing Certificate in the OpenPGP Signing Certificate dropdown menu.

▪ Click Sign and Encrypt.

▪ Enter the Passphrase for your DSA key.


▪ Click OK.

▪ Click Finish.

4. Sign data using your own DSA Private Key.

a. Create .gpg.sig file.

▪ Locate the .gpg file created in step 3 in File Explorer.

▪ Right click and select More GpgEX options.

▪ Select Sign.

▪ Select Sign.

▪ Select Next.

▪ Select Sign with OpenPGP. Ensure this is the only option selected.

▪ Under OpenPGP Signing Certificate, select the same DSA Key chosen when the encrypted file was created.

▪ Click Sign.

▪ Click Finish.

5. Create checksum with GPG4Win.

a. Launch the Kleopatra application.

b. Click Settings then select Configure Kleopatra.

c. Click Crypto Operations.

d. Click the File Operations tab.

e. Change the Checksum program to use: to sha256sum.

f. Click Apply.

g. Click OK.

h. Select the .gpg and .gpg.sig files created in steps 3 and 4, respectively.

i. Right click and select More GpgEX options.

j. Select Create checksums.

6. Create a zip archive with 7-Zip containing the encrypted data file(s), signature file, and checksum file.

a. Select the encrypted data file (.gpg), signature file (.gpg.sig) and the checksum file in windows explorer.

b. Right click and select 7-Zip → Add to archive…

c. Set the archive name to the original file name with _ALL appended to the end. (e.g., originalName_ALL.zip).

d. Make sure the archive format is set to zip.


e. Click OK.

7. Establish secure connection to APCD FTP server via WinSCP.

a. SFTP via WinSCP

▪ Open WinSCP.

▪ Click New Site.

▪ Set the File protocol to SFTP.

▪ Enter the provided Host name. The host name will be provided at the same time as your SFTP credentials.

▪ Enter 22 for the Port number.

▪ Enter the Username and Password that were supplied for you.

▪ Click the Advanced button.

▪ Click Key Exchange located in the SSH submenu.

• We support the following key exchange algorithms:




o diffie-hellman-group-exchange-sha256

▪ Click OK.

▪ Click Login.

8. Connect to the Hawaii APCD FTP server and submit files via SFTP.


b. SFTP via WinSCP

▪ Navigate to the folder labeled DATA

▪ Locate and select the zip archive you created in step 6.

▪ Click the Upload button.

▪ Alternatively, you can drag the files from your local directory to the remote directory in the WinSCP window.

9. The PHIDC will inform the Reporter of receipt of the data submission.

10. The PHIDC will review the data submission and inform the Reporter of any data validation or data quality issues.

11. Once the submission has been validated and any issues have been corrected, the PHIDC will inform the Reporter of a successful submission.


Registration Instructions

All Reporters shall submit a completed Registration Form to [email protected] (15) calendar days after receiving notification from the SHPDA Administrator. The Registration Form shall contain information, such as the primary point of contact, secondary point of contact, and plan information. The point of contact(s) listed shall be the technical staff responsible for the submission of data to SHPDA/PHIDC and shall work with SHPDA and PHIDC for resolution of data submission and data quality issues. The Reporter shall submit an updated Registration Form if there are modifications to the primary or secondary point of contact or modifications to the contact information. If the Reporter is submitting data for Med-QUEST and Hawai‘i EUTF members, the Reporter shall submit completed Registration Form for each separate line of business (Med-QUEST and Hawai‘i EUTF). Each Reporter business line (Med-QUEST and Hawai‘i EUTF) will be used to create the unique Submitter ID that is to be reported on all data submissions to the State of Hawai‘i APCD. The Registration Form shall be submitted annually to [email protected] by November 1 of each year. See Registration Form on the following page.




Registration Form

Type of Business

____ Health Plan ____ Third-Party Administrator ____ Pharmacy Benefit Manager

____ Dental Health Plan ____ Government Agency ____ Other, please describe ________________________

Primary Point of Contact Information

First Name _______________________________ Last Name _______________________________________

Company Name ______________________________________________________________________________

Title ______________________________ Email Address ___________________________________________

Phone ______________________________________ Fax ______________________________________________

Mailing Address _____________________________________________________________________________

City ______________________________________________ State __________ Zip Code ________________

Secondary Point of Contact Information


Company Name ______________________________________________________________________________


Phone ______________________________________ Fax ______________________________________________

Mailing Address _____________________________________________________________________________


Person Completing Registration Form

Signature ___________________________________________________

First Name _______________________________ Last Name ________________________________________

Title ____________________________________

Submitting Entity Information

Full Company Name _______________________________________________________________________________________

Mailing Address ____________________________________________________________________________________________

City ____________________________________________________________ State __________ Zip Code ________________

State of Domicile _______________________ Date Commenced Business in Hawai‘i _______________________

NAIC Code (if applicable) ______________ Approximate Number of Covered Lives ____________________


File Naming Convention All files submitted to the State of Hawai‘i APCD shall use the naming convention as described in the sample below. Naming Convention Format

SubmitterID_TestorProd_FileType_SubmissionDate_PeriodStartDate_PeriodEndDate.txt SubmitterID – This is the unique identifier for Reporters assigned by SHPDA. TestorProd – Test is for test data files; Prod is for production data files FileType – Abbreviation representing file type

▪ ME = Member Eligibility File ▪ MC = Medical Claims File ▪ PC = Pharmacy Claims File ▪ DC = Dental Claims File ▪ PV = Provider File

SubmissionDate – Date the file was produced. This date shall be in the CCYYMMDD format. PeriodStartDate – Represents the start date of the period for the transmission. This date shall be in the CCYYMMDD format (e.g. PeriodStartDate = 20150101). PeriodEndDate – Represents the end date of the period for the transmission. This date shall be in the CCYYMMDD format (e.g. PeriodEndDate = 20151231). Sample Naming Convention 12345E_Test_MC_20161101_20150101_20151231.txt

Transmittal Sheet Instructions

A Transmittal Sheet shall be included with all data submissions to the State of Hawai‘i APCD. The information contained in the Transmittal Sheet shall match the information submitted in the Header and Trailer Records.

The Transmittal Sheet shall contain the following information: Submitter ID; File Name; File Type(s); Submission Period Start and End Date; Date Submission Compiled; Date Submission Sent; Number of Records Contained in the Submission; and Point of Contact Information. The Transmittal Sheet shall be signed and certified by an authorized Corporate Officer of the Reporter. See Transmittal Sheet on the following page.


Transmittal Sheet

Point of Contact Information for this Submission


Company Name ______________________________________________________________________________


Phone ______________________________________ Fax ______________________________________________

Mailing Address _____________________________________________________________________________


By signing, I certify that all information and data submitted with this Transmittal Sheet is accurate, complete, and fully compliant with the current version of the applicable SHPDA HHDC APCD Data Submission Guide. ** Signatory must be an authorized Corporate Officer of the Reporter. Signature ___________________________________________________


Title ____________________________________

Submission Information

Submitter ID ______________________

File Name(s) (each file name shall be separated by a comma):

_______________________________________________________________________________________________________________

File Type(s) (Select all that apply): ___ ME ___MC ___PC ___DC ___PV

Submission Period Start Date _____________________ Submission Period End Date _____________________

Date Submission Compiled __________________________ Date Submission Sent __________________________

Number of Records Contained in the Submission (For all submitted file types):

_______________ ME _______________ MC _______________ PC _______________ DC ______________ PV


Extensions or Waivers to Data Submission Requirements

Reporters who temporarily cannot meet the terms and conditions of this SHPDA HHDC APCD Data Submission Guide shall submit a written request to the Administrator as soon as the Reporter has determined that an extension or waiver is required. The written request shall include:

1. The specific requirement to be extended or waived; 2. The specific reason the extension or waiver is being requested; 3. The methodology and timeframe proposed to eliminate the necessity of the

extension or waiver; and 4. The timeframe required to come into compliance.

Reporters requesting an extension or waivers shall submit an Extensions or Waivers to Data Submission Guide Requirements Form. The Administrator will review the extension or waiver request and respond within thirty (30) days of receipt of written request.

Data Quality Requirements In addition to field definitions, the data elements in Appendices A-E provide indicators regarding when data elements are required. A data element that is required must contain a valid value. A data element with a threshold percentage (%) of all records must have a valid value in this field based on the expected frequency that this data element is available. Data files that do not achieve this threshold percentage (%) for that data element or data files missing required data elements may be rejected and require follow-up and resubmission prior to load into the State of Hawai‘i APCD. Additionally, data elements will be validated against established ranges and/or other data elements during the data quality evaluation. The objective is to populate the APCD with quality data and each Reporter shall work interactively with PHIDC to develop data extracts that achieve validation and quality requirements. Failure to meet data quality requirements will require Reporters to resubmit data to the Hawai‘i APCD until appropriate data quality requirements are achieved.


Test Data Requirements All Reporters are required to submit two forms of test data prior to submitting production data to the State of Hawai‘i APCD.

▪ Submission Test Data: Reporters shall submit test files containing 100 records with the appropriate header and trailer records, proper file structure, formatting, naming convention, encryption, and data quality requirements. These records shall not contain any PHI identifiers and shall be submitted via SFTP in accordance with the Submission Instructions. The Submission Test Data is to test the SFTP process and submission of data to the Hawai‘i APCD. Test data shall be submitted thirty (30) calendar days from notice from the SHPDA Administrator.

▪ Production Test Data: Reporters shall submit test files containing one-month of production data for all applicable file types (ME, MC, PC, DC, and PV). Test files must be submitted in accordance with header and trailer records, proper file structure, formatting, naming convention, encryption, and data quality requirements. Test data shall be submitted fifteen (15) calendar days from notice from the SHPDA Administrator.

Reporters must provide complete and conforming test files for the historical submissions on the following schedule:

Test Data Type Test Data Due Date Test Data Content

Submission Test Data 30 calendar days from Notice from SHPDA Administrator

100 records of all applicable file types (without PHI identifiers)

Production Test Data 15 calendar days from Notice from SHPDA Administrator

1-month of production data of all applicable file types (with PHI identifiers)

The PHIDC will work with the Reporter’s Technical Point of Contact identified in the Registration Form to resolve any data quality issues or discrepancies in the test data that is submitted. Reporters will be notified of any subsequent test data submission requirements as determined by the SHPDA Administrator. Request for production data will not be sent until PHIDC has certified that the test data submitted is valid and is in conformance with the SHPDA HHDC APCD Data Submission Guide requirements. The SHPDA Administrator will request the submission of production data upon certification of validity of test data.


File Format Specifications

General File Format Specifications All files submitted to the State of Hawai‘i APCD shall be formatted as asterisk (*) delimited, standard text (.txt) files. Text files will comply with the following standards:

▪ One line item per row; No data element may contain carriage return or line feed characters.

▪ All rows are delimited by the carriage return/line feed character. ▪ Each field is defined as variable text length, variable number length, set text length

or set number length and delimited using the asterisk (*) character. It is imperative that no asterisks (*) appear in the data itself.

▪ Text fields are never enclosed in single or double quotes. Any quotes detected are regarded as a part of the actual data.

▪ Unless otherwise stipulated, numbers (ID numbers, account numbers, etc.) do not contain spaces, hyphens, or other punctuation marks.

▪ Data elements are never padded with leading or trailing spaces, unnecessary zeros, or tabs, unless specified.

▪ Numeric fields are never padded with leading or trailing zeros, unless specified. ▪ If a field is not available, or is not applicable, leave it blank. ‘Blank’ means do not

supply any value at all between asterisks (including quotes or other characters).

Header and Trailer Record Format Specifications All files submitted to the State of Hawai‘i APCD shall include a Header Record (HR) and Trailer Record (TR). Headers are defined in the HD series and Trailers are defined in the TR series. Header and Trailer records are used for control counts. See Header and Trailer Records.


Legend 1. Data Element ID: This is the unique identifier of the element with regards to the file

type. 2. Data Element Name: Provides name of the data element. 3. Type: Defines the data as Integer, Numeric, or Text. Additional information provided

for identification (e.g., Date – Integer, Decimal – Numeric). 4. Format: Defines the element format requirements. See below:

a. char – a fixed length element of characters that cannot reported above or below the specified length. This can be any type of data, but is governed by the Type listed for the element.

b. varchar –a variable length field of max characters that cannot be reported above the specified length. This can be any type of data, but is governed by the Type listed for the element.

c. int – a fixed length element for numeric reporting only that cannot be reported above or below the specified length. This can only be used to report numbers with no decimal points or leading zeros.

5. Length: Defines the definite or maximum reporting length depending on the Format 6. Description: Short description that defines the data expected in the element. This may

include a code list defined in the SHPDA HHDC APCD Data Submission Guide or point to an External Code Source.

7. Required: Indicates if and when the data element is required for submission and when there are multi-field dependencies.

8. Threshold: Outlines the minimum percentage of a specific data element that must be submitted to meet the validation requirements of the SHPDA HHDC APCD Data Submission Guide (e.g., a Threshold percentage of 90% means that 90% of all records submitted must have an appropriate value in the specified data element).


Header and Trailer Records

All files that are submitted must have an associated Header and Trailer Record attached to it. The Header Record shall precede the data file submission, and the Trailer Record shall follow the data file submission. See Data Submission Sample.

Detailed Header Record Requirements Data Element ID

Data Element Name Type Format Length Description Required Threshold

HD001 Record Type Text char 2 Record Type Identifier. Report HD here. This indicates the beginning of the Header Elements of the file.

Required 100%

HD002 Submitter Text char 6 Submitter ID. Report the SHPDA defined and maintained unique identifier. This must match Trailer Record field TR002.

Required 100%

HD003 Health Plan ID Integer int 10

CMS Health Plan ID (HPID). Do not report any value here until HPID is fully implemented. This is a unique identifier as outlined by the Centers for Medicare and Medicaid Services (CMS) for Plans or Sub plans. When implemented, this field must match CMS Health Plan ID reported in TR003.

Required when HPID is fully implemented

0%

HD004 Type of File Text char 2

File Type Identifier. Report file type here. This field must match Trailer Record field TR004. ME - Member Eligibility File MC - Medical Claims File PC - Pharmacy Claims File DC - Dental Claims File PV - Provider File

Required 100%

HD005 Period Beginning Date

Date - Integer

int 8 Period Beginning Date. Report the first date covered in the submission period in CCYYMMDD format. This field must match Trailer Record field TR005.

Required 100%

HD006 Period Ending Date

Date - Integer

int 8 Period Ending Date. Report the last date covered in the submission period in CCYYMMDD format. This field must match Trailer Record field TR006.

Required 100%

HD007 Record Count Integer int 10 Record Count. Report the total number of records submitted in this file. Do not report leading zeros, decimals, or any special characters.

Required 100%

HD008 DSG Version Decimal – Numeric

int 3 DSG Version. Report the version number of the Data Submission Guide. For the current version, this field shall be represented as 1.0.

Required 100%


Detailed Trailer Record Requirements

Data Element ID

Data Element Name

Type Format Length Description Required Threshold

TR001 Record Type Text char 2 Record Type Identifier. Report TR here. This indicates the beginning of the Trailer Elements of the file.

Required 100%

TR002 Submitter Text char 6 Submitter ID. Report the SHPDA defined and maintained unique identifier. This must match Header Record field HD002.

Required 100%

TR003 Health Plan ID Integer int 10

CMS Health Plan ID (HPID). Do not report any value here until HPID is fully implemented. This is a unique identifier as outlined by the Centers for Medicare and Medicaid Services (CMS) for Plans or Sub plans. When implemented, this field must match CMS Health Plan ID reported in HD003.


0%

TR004 Type of File Text char 2

File Type Identifier. Report file type here. This field must match Header Record field HD004. ME - Member Eligibility File MC - Medical Claims File PC - Pharmacy Claims File DC - Dental Claims File PV - Provider File

Required 100%

TR005 Period Beginning Date

Date – Integer

int 8 Period Beginning Date. Report the first date covered in the submission period in CCYYMMDD format. This field must match Header Record field HD005.

Required 100%

TR006 Period Ending Date

Date – Integer

int 8 Period Ending Date. Report the last date covered in the submission period in CCYYMMDD format. This field must match Header Record field HD006.

Required 100%

TR007 Date Processed Date – Integer

int 8 Date Submission Compiled. Report the date that the submission was compiled by the Reporter in CCYYMMDD format.

Required 100%


Data Submission Sample Sample for a partial Medical Eligibility (ME) file submission containing 5 records. HD001*HD002*HD003*HD004*HD005*HD006*HD007*HD008 Header Record

HD*12345E**ME*20160101*20160331*5*1.0 Detailed Header Record

ME001*ME002*ME003*ME004*ME005*ME006*ME007 Member Eligibility Header Record

12345E**BL*2016*01*36203AB1*EMP

12345E**BL*2016*01*36203AB1*FAM

12345E**BL*2016*01*37208AB1*IND Detailed Member Eligibility Records (partial)

12345E**BL*2016*01*36103ZQ7*EMP

12345E**BL*2016*01*47109GT5*ECH

TR001*TR002*TR003*TR004*TR005*TR006*TR007 Trailer Record

TR*12345E**ME*20160101*20160331*20160430 Detailed Trailer Record


Appendix A: Detailed Member Eligibility File Requirements Data Element ID

Data Element Name


ME001 Submitter Text char 6 Submitter ID. Report the SHPDA defined and maintained unique identifier. This must match the Submitter ID reported in HD002.

Required 100%

ME002 Health Plan ID Integer int 10

CMS Health Plan ID (HPID). Do not report any value here until HPID is fully implemented. This is a unique identifier as outlined by the Centers for Medicare and Medicaid Services (CMS) for Plans or Sub plans. When implemented, this must match the CMS Health Plan ID reported in HD003.


0%

ME003 Insurance Type Code / Product

Text char 2

Insurance Type / Product Identification Code. Report the code that defines the type of insurance under which this Member's is enrolled. EXAMPLE: HM = Health Maintenance Organization. 09 - Self-pay 10 - Central Certification 11 - Other Non-Federal Programs 12 - Preferred Provider Organization (PPO) 13 - Point of Service (POS) 14 - Exclusive Provider Organization (EPO) 15 - Indemnity Insurance 16 - Health Maintenance Organization (HMO) Medicare Risk 17 - Dental Maintenance Organization (DMO) AM - Automobile Medical BL - Blue Cross/Blue Shield CH - Champus CI - Commercial Insurance Company DS - Disability FI - Federal Employees Program HM - Health Maintenance Organization LM - Liability Medical MA - Medicare Part A MB - Medicare Part B MC - Medicaid MD - Medicare Part D TV - Title V VA - Veteran's Affairs Plan WC - Workers' Compensation Health Claim ZZ - Other

Required 100%


Data Element ID

Data Element Name


ME004 Year Date - Integer

int 4

Eligibility Year. Report the year for which eligibility is reported in this submission in CCYY format. If reporting previous year's data, the year reported here will not match current year. Do not report a future year here.

Required 100%

ME005 Quarter Integer int 2

Reporting Quarter of Eligibility. Report the quarter for which eligibility is reported in this submission. Note: ME005 is not required for initial historical submissions for years 2009-2017. EXAMPLE: 01 = First Quarter 01 - First Quarter (1/1 - 3/31) 02 - Second Quarter (4/1 - 6/30) 03 - Third Quarter (7/1 - 9/30) 04 - Fourth Quarter (10/1 - 12/31)

Required 100%

ME006 Insured Group or Policy Number

Text varchar 30 Insured Group / Policy Number. Report the insured group or policy number. Do not report the number that uniquely identifies the Subscriber or Member.

Required 100%

ME007 Coverage Level Code

Text char 3

Benefit Coverage Level Code. Report the Benefit Coverage Level Code that defines the dependent coverage. EXAMPLE: FAM = Family CHD - Children Only DEP - Dependents Only ECH - Employee and Children ELF - Employee and Life Partner EMP - Employee Only ESP - Employee and Spouse FAM - Family IND - Individual SPC - Spouse and Children SPO - Spouse Only UNK - Unknown

Required 100%

ME008 Subscriber SSN Integer int 9 Subscriber's Social Security Number. Report the Subscriber's 9-digit SSN here. Do not use hyphen.

Required 100%

ME009 Plan Specific Contract Number

Text varchar 30

Plan Specific Contract Number. Report the Reporter-assigned contract number for the Subscriber. Do not include values in this element that will distinguish one Member of the family from another. This should be the contract number for the Subscriber and all of the dependents.

Required 100%


Data Element ID

Data Element Name


ME010 Member Suffix or Sequence Number

Text varchar 20 Member's Sequence Number. Report the unique number of the Member within the contract.

Required 100%

ME011 Member SSN Integer int 9 Member's Social Security Number. Report the Member's 9-digit SSN. Do not use hyphen.

Required 100%

ME012 Individual Relationship Code

Text char 2

Individual Relationship Code. Report the value that defines the Member's relationship to the Subscriber. EXAMPLE: 18 = Self. 01 - Spouse 04 - Grandfather or Grandmother 05 - Grandson or Granddaughter 07 - Nephew or Niece 10 - Foster Child 15 - Ward 17 - Stepson or Stepdaughter 18 - Self 19 - Child 20 - Employee 21 - Unknown 22 - Handicapped Dependent 23 - Sponsored Dependent 24 - Dependent of a Minor Dependent 29 - Significant Other 32 - Mother 33 - Father 34 - Other Adult 36 - Emancipated Minor 39 - Organ Donor 40 - Cadaver Donor 41 - Injured Plaintiff 43 - Child Where Insured Has No Financial Responsibility 53 - Life Partner 76 - Dependent G8 - Other Relationship

Required 100%


Data Element ID

Data Element Name


ME013 Member Gender Text char 1

Member's Gender. Report the Member's gender as found on the claim in alpha format. EXAMPLE: F = Female. F - Female M - Male U - Unknown

Required 100%

ME014 Member Date of Birth

Date - Integer

int 8 Member's Date of Birth. Report the date of birth of the Member in CCYYMMDD format.

Required 100%

ME015 Member City Name

Text varchar 30 Member's City Name. Report the city name of the Member's residence.

Required 100%

ME016 Member State

Text - External Code Source

char 2 Member's State / Province. Report the State of the Member's residence using the two-character abbreviation as defined by the United States Postal Service. See External Code Source.

Required 100%

ME017 Member Zip Code

Integer - External Code Source

varchar 9

Member's Zip Code. Report the 5- or 9-digit Zip Code of the Member's residence as defined by the United States Postal Service. When submitting the 9-digit Zip Code do not include hyphen. See External Code Source.

Required 100%

ME018 Medical Coverage

Integer int 1

Medical Coverage Indicator. Report the value that defines if the Member has medical coverage. EXAMPLE: 1 = Yes, there is Medical Coverage. 1 - Yes 2 - No 3 - Unknown

Required 100%

ME019 Prescription Drug Coverage

Integer int 1

Prescription Drug Coverage Indicator. Report the value that defines if the Member has prescription drug coverage. EXAMPLE: 1 = Yes, there is Prescription Coverage. 1 - Yes 2 - No 3 - Unknown

Required 100%


Data Element ID

Data Element Name


ME020 Dental Coverage Integer int 1

Dental Coverage Indicator. Report the value that defines if the Member has dental coverage. EXAMPLE: 1 = Yes, there is Dental Coverage. 1 - Yes 2 - No 3 - Unknown

Required 100%

ME021 Race 1


varchar 6 Member’s Primary Race. Report the Member-identified primary race here. Do not report any value here if data has not been collected. Report only collected data. See External Code Source.

Required 3%

ME022 Race 2


varchar 6

Member's Secondary Race. Report the Member-identified secondary race here. Do not report any value here if data has not been collected. Report only collected data. See External Code Source

Required 2%

ME023 Other Race Text varchar 15

Member's Other Race. Report the Member's self-disclosed race when ME021 or ME022 is entered as 2131-1 Other Race. Do not report any value here if data has not been collected. Report only collected data.

Required when ME021 or

ME022 = 2131-1

0%

ME024 Hispanic Indicator

Integer int 1

Hispanic Status Indicator. Report the value that defines if the Member has indicated Hispanic Status. The code value “3” for unknown, should be used ONLY when member answers unknown, or refuses to answer. Do not report any value here if the data has not been collected. Report only collected data. EXAMPLE: 1 = Yes, Member has indicated Hispanic status. 1 - Yes 2 - No 3 - Unknown

Required 3%

ME025 Ethnicity 1


varchar 6

Member’s Primary Ethnicity. Report the Member-identified primary ethnicity here. Do not report any value here if data has not been collected. Report only collected data. Report OTHER if Ethnicity not represented by any of the values in the External Code Source. See External Code Source.

Required 3%


Data Element ID

Data Element Name


ME026 Ethnicity 2


varchar 6

Member's Secondary Ethnicity Report the Member-identified secondary ethnicity here. Do not report any value here if data has not been collected. Report only collected data. Report OTHER if Ethnicity not represented by any of the values in the External Code Source. See External Code Source.

Required 2%

ME027 Other Ethnicity Text varchar 20

Member's Other Ethnicity. Report the member's self-disclosed ethnicity when ME025 or ME026 is entered as OTHER. Do not report any value here if data has not been collected. Report only collected data.

Required when ME025 or MC026 = OTHER

0%

ME028 Primary Insurance Indicator

Integer int 1

Primary Insurance Coverage Indicator. Report the value that defines if this coverage is primary. EXAMPLE: 1 = Yes, Insurance is Primary (Products, Plans or Benefits that only cover Copays, Coinsurance and Deductibles [Gap Coverage] will answer 2 = No). 1 - Yes 2 - No 3 - Unknown

Required 100%

ME029 Coverage Type Text char 3

Type of Coverage Code. Report the code that defines the type of insurance policy by which the enrollee is covered. EXAMPLE: UND = Plans underwritten by the insurer. ASW - Self-funded plans that are administered by a third-party administrator, where the employer has purchased stop-loss, or group excess, insurance coverage ASO - Self-funded plans that are administered by a third-party administrator, where the employer has not purchased stop-loss, or group excess, insurance coverage STN - Short-term, non-renewable health insurance UND - Plans underwritten by the insurer OTH - Any other plan

Required 100%


Data Element ID

Data Element Name


ME030 Market Category Code

Text varchar 4

Market Category Code. Report the code that defines the market, by size and or association, to which the policy is directly sold and issued. EXAMPLE: GS3 = Employers having 10 thru 25 employees. IND - Individuals (non-group) FCH - Individuals on a franchise basis GCV - Individuals as group conversion policies GS1 - Employers having exactly 1 employee GS2 - Employers having 2 thru 9 employees GS3 - Employers having 10 thru 25 employees GS4 - Employers having 26 thru 50 employees GLG1 - Employers having 51 thru 99 employees GLG2 - Employers having 100 or more employees GSA - Small employers through a qualified association trust OTH - For policies sold and issued to other types of entities

Required 100%

ME031 Filler Filler char 0 Filler. SHPDA reserves this field for future use. Do not populate with any data.

Required 0%

ME032 Group Name Text varchar 50 Group Name. Report the group name that the policy is attached to. Report IND for individual policies. Do not report any value here if the data is not available.

Required 100%

ME033 Member Language Preference


int 3

Member's Verbal Language Preference. Report the code that defines the self-disclosed spoken language preference of the member. The code value 999 (Unknown / Not Specified), should only be used when member answers unknown or refuses to answer. Do not report any value here if the Reporter does not have the data. Report only collected data. See External Code Source.

Required 3%

ME034

Member Language Preference - Other

Text varchar 20 Member's Other Language Preference. Report the other language the member / subscriber has identified. Do not report any value If no other language identified.

Required when ME033 = 997

0%


Data Element ID

Data Element Name


ME035 PCMH Assigned Flag

Integer int 1

Patient Centered Medical Home (PCMH) Assigned Indicator. Report the value that indicates if the Member has an approved PCMH for this coverage period. EXAMPLE: 1 = Yes, Member has an assigned approved patient centered medical home for this coverage period. 1 - Yes 2 - No 3 - Unknown

Required 0%

ME036 PCMH Number Text varchar 30 Patient Centered Medical Home (PCMH) Identification Number. Report the Reporter-assigned PCMH Identification Number. Do not report any data here if not applicable.


0%

ME037 PCMH Tax ID Number

Integer int 9

Patient Centered Medical Home (PCMH) EIN / Federal Tax ID Number. Report the EIN / Federal Tax ID of the PCMH. If there is not medical home to report, do not report any value. Do not use hyphen or alpha prefix.


0%

ME038 PCMH NPI


int 10

Patient Centered Medical Home (PCMH) National Provider Identifier. Report the National Provider Identifier (NPI) number for the entity or individual serving as the medical home. If there is no medical home to report, do not report any value. See External Code Source.


0%

ME039 PCMH Name Text varchar 60

Patient Centered Medical Home (PCMH) Name. Report the full name of the medical home. If the medical home is an individual, report in the format of Last name, first name and middle initial with no punctuation. If there is not medical home to report, do not report any value.


0%


Required 0%

ME041

Insurance / Product Enrollment Start Date

Date - Integer

int 8 Insurance / Product Enrollment Start Date. Report the date the Member was enrolled in the product in CCYYMMDD format.

Required 100%

ME042

Insurance / Product Enrollment End Date

Date - Integer

int 8

Insurance / Product Enrollment End Date. Report the date the member was disenrolled from the product in CCYYMMDD format. If the member was not disenrolled at the end of the current period, then do not fill with any value.

Required 0%

ME043 Member Street Address

Text varchar 60 Member's Street Address. Report the Member's street address. Required 100%


Data Element ID

Data Element Name


ME044 Member Street Address 2

Text varchar 60 Member's Street Address 2. Report the Member's street address that may contain office number, suite, or other secondary information besides the street.

Required 0%

ME045 Health Insurance Exchange Flag

Integer int 1

Health Insurance Exchange Purchase Indicator. Report the value that defines if the policy for this eligibility was purchased through the Health Insurance Exchange. EXAMPLE: 1 = Yes, policy for this eligibility was purchased through the Health Insurance Exchange. 1 - Yes 2 - No 3 - Unknown

Required 100%

ME046 Member PCP NPI

Integer – External Code Source

int 10 Member's PCP National Provider Identifier. Report the National Provider Identifier (NPI) of the Member's PCP. See External Code Source.

Required 100%

ME047 Member PCP Effective Date

Date - Integer

int 8 Member PCP Effective Date. Report the Member enrollment begin date with the PCP in CCYYMMDD format.

Required when ME046 is populated

100%

ME048 Member PCP Termination Date

Date - Integer

int 8

Member PCP Termination Date. Report the Member termination date from the PCP in CCYYMMDD format. If the member is still active with their PCP at the end of the current month, then do not fill with any value.


1%

ME049 Member Deductible

Integer varchar 10

Annual Maximum Member Deductible. Report the maximum amount of Member / Subscriber's annual deductible across all benefit types (Medical, pharmacy, vision, behavioral health, etc.) before certain services are covered. Report only In-Network Deductibles here if plan has an In and Out-of-Network Deductible. Report 0 when there is no deductible applied to all benefits for this eligibility. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required 100%


Data Element ID

Data Element Name


ME050 Member Deductible Used

Integer varchar 10

Member Deductible Amount Incurred. Report the amount to-date the Member / Subscriber has incurred towards the maximum deductible. Report 0 if no deductible has been incurred. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required when ME049 > 0

100%

ME051 Behavioral Health Benefit Flag

Integer int 1

Behavioral Health Benefit Indicator. Report the value that defines if the Member has Behavioral Health benefits coverage. EXAMPLE: 1 = Yes, Behavioral / Mental Health is a covered benefit. 1 - Yes 2 - No 3 - Unknown

Required 100%

ME052 Laboratory Benefit Flag

Integer int 1

Laboratory Benefit Indicator. Report the value that defines if the Member has Laboratory benefits coverage. EXAMPLE: 1 = Yes, Lab is covered benefit. 1 - Yes 2 - No 3 - Unknown

Required 100%

ME053 Disease Management Enrollee Flag

Integer int 1

Chronic Illness Management Indicator. Report the value that defines if the Member has Chronic Illness Management coverage. EXAMPLE: 1 = Yes, Member's chronic illness is being managed by plan or vendor of plan. 1 - Yes 2 - No 3 - Unknown

Required 100%

ME054 Eligibility Determination Date

Date - Integer

int 8 Eligibility Date. Report the date the member eligibility was determined in CCYYMMDD format.

Required 100%


Data Element ID

Data Element Name


ME055 Business Type Code

Integer int 1

Business Type. Report the value that defines the Reporter's line of business for this line of eligibility. EXAMPLE: 1 = Risk Holder of this line of eligibility. 1 - Risk Holder 2 - TPA - Third Party Administrator 3 - DBA - Delegated Business Administrator 4 - PBM - Pharmacy Benefit Manager 5 - DBM - Dental Benefit Manager 6 - CSO - Computer Service Organization 7 - Other 0 - Unknown / Not Applicable

Required 100%

ME056 Last Activity Date

Date - Integer

int 8

Last Activity Date. Report the date of last activity / change on the Member enrollment file for this line of eligibility in CCYYMMDD format. This includes any/all life change updates, open enrollment changes, or benefit design changes by the Reporter.

Required 100%

ME057 Date of Death Date - Integer

int 8 Member's Date of Death. Report the Member's date of death in CCYYMMDD format. If still alive or date of death is unknown, do not report any value here.

Required when present

0%

ME058 Subscriber Street Address

Text varchar 60 Subscriber's Street Address. Report the Subscriber's street address.

Required 100%

ME058A Subscriber Street Address 2

Text varchar 60 Subscriber's Street Address 2. Report the Subscriber's street address that may contain office number, suite, or other secondary information besides the street.

Required 0%

ME059 Disability Indicator Flag

Integer int 1

Disability Status Indicator. Report the value that defines if the Member has a disability. EXAMPLE: 1 = Yes, Member has a disability. 1 - Yes 2 - No 3 - Unknown

Required 100%


Data Element ID

Data Element Name


ME060 Employment Status

Text char 1

Employment Status Code. Report the code that defines the employment status of the Subscriber. EXAMPLE: A = Active. A - Active I - Involuntary Leave O - Orphan P - Pending R - Retiree Z - Unemployed U - Unknown

Required 100%

ME061 Student Status Integer int 1

Student Status Indicator. Report the value that defines the if the Member is a student. Student status is defined as student under the age of 26 on their parent's plan. EXAMPLE: 1 = Yes, Member is a student. 1 - Yes 2 - No 3 - Unknown

Required 0%

ME062 Marital Status Text char 1

Marital Status Code. Report the member's marital status. EXAMPLE: M = Married. C - Common Law Married D - Divorced M - Married P - Domestic Partnership S - Never Married W - Widowed X - Legally Separated U - Unknown

Required 0%


Data Element ID

Data Element Name


ME063 Benefit Status Text char 1

Benefit Status Code. Report the code that defines status of benefits for the Subscriber. A - Active C - COBRA P - Pending S - Surviving Insured T - TEFRA U - Unknown

Required 100%

ME064 Employee Type Text char 1

Employee Type Code. Report the code that defines the Subscribers employment. H - Hourly Q - Seasonal S - Salaried T - Temporary U - Unknown

Required when ME063 = A

0%

ME065 Date of Retirement

Date - Integer

int 8 Member's date of Retirement. Report the date of the Subscriber's retirement in CCYYMMDD format.

Required when ME060 = R

100%

ME066 COBRA Status Integer int 1

COBRA Status Indicator. Report the value that defines if the Member is covered using a COBRA benefit. EXAMPLE: 1 = Yes, Member is covered using COBRA benefit. 1 - Yes 2 - No 3 - Unknown

Required 100%


Required 0%


Required 0%


Required 0%


Required 0%


Data Element ID

Data Element Name


ME071 Pool Indicator Integer int 1

Pool Indicator Code. Report the value that defines one of the EUTF Risk Pools in which this member is enrolled. This element is required for EUTF Reporters only. Non-EUTF Reporters should not report any value here. EXAMPLE: 1 = State Employee - Active 1 - State Employee - Active 2 - State Employee - Retired 3 - HSTA VB Employee - Active 4 - HSTA VB Employee - Retired


100%

ME072 Family Size Integer varchar 2 Family Size Contracted. Report the number of individuals covered under the policy / contract (ME009) of the Subscriber. No alpha or special characters.

Required 100%

ME073 Fully Insured Member

Integer int 1

Fully Insured identifier. Report the value that defines if the Member is fully insured under this contract. EXAMPLE: 1 = Yes, Member is fully insured. 1 - Yes 2 - No 3 - Unknown

Required 100%

ME074 Interpreter Integer int 1

Interpreter Indicator. Report the value that defines if the Member requires an interpreter. EXAMPLE: 1 = Yes, Member requires an interpreter. 1 - Yes 2 - No 3 - Unknown

Required 0%

ME075 Medicaid ID Text varchar 20 Medicaid-Assigned Member ID. Report the unique ID that Medicaid uses to identify a member. This ID must be on all lines of eligibility for Med-QUEST and Medicaid MCOs.


100%


Required 0%

ME077 Member NAICS / SIC Code


varchar 6

Member Standard NAIC or SIC Code. Report the standard code that describes the industry of the Subscriber / Member. This can be from either the NAICS 6-digit list or the SIC 4-digit list. See External Code Source.

Required 2%


Data Element ID

Data Element Name


ME078 Employer Zip Code


varchar 9

Zip Code of the Employer. Report the 5- or 9-digit Zip Code of the Employer of the Subscriber / Member as defined by the United States Postal Service. When submitting the 9-digit Zip Code do not include hyphen. See External Code Source.

Required 0%


Required 0%


Required 0%

ME081 Medicare Code Integer int 1

Medicare Plan Indicator Code. Report the value that defines if and what type of Medicare coverage that applies to this line of eligibility. EXAMPLE: 1 = Part A Only. 1 - Part A Only 2 - Part B Only 3 - Part A and B 4 - Part C Only 5 - Advantage 6 - Part D Only 9 - Not Applicable 0 - No Medicare Coverage

Required 100%

ME082 Employer Name Text varchar 60 Member's Employer Name. Report the name of the Subscriber's / Member's employer at time of enrollment.

Required when ME060 = A or P

0%

ME083 Employer EIN Integer int 9 Member's Employer EIN / Federal Tax ID Number. Report the EIN / Federal Tax ID of the Member's employer. Do not use hyphen or alpha prefix.


0%

ME101 Subscriber Last Name

Text varchar 60

Subscriber's Last Name. Report the Subscriber's last name. Last name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ʻokinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required 100%

ME102 Subscriber First Name

Text varchar 25

Subscriber's First Name. Report the Subscriber's first name. First name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ʻokinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required 100%


Data Element ID

Data Element Name


ME103 Subscriber Middle Name

Text varchar 25

Subscriber's Middle Name or Initial. Report the Subscriber's middle name or initial here. If Subscriber's middle name is available, report middle name. Middle name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ʻokinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required 2%

ME104 Member Last Name

Text varchar 60

Member's Last Name. Report the Member's last name. Last name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ʻokinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required 100%

ME105 Member First Name

Text varchar 25

Member's First Name. Report the Member's first name. First name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ʻokinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required 100%

ME106 Member Middle Name

Text varchar 25

Member's Middle Name or Initial. Report the Member's middle name or initial here. If Member's middle name is available, report middle name. Middle name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ʻokinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required 2%

ME107 Carrier Specific Unique Member ID

Text varchar 50 Member's Unique ID. Report the identifier the Reporter uses internally to uniquely identify the Member.

Required 100%

ME108 Subscriber City Name

Text varchar 30 Subscriber's City Name. Report the city name of the Subscriber's residence.

Required 100%

ME109 Subscriber State


char 2

Subscriber's State / Province. Report the State of the Subscriber's residence using the two-character abbreviation as defined by the United States Postal Service. See External Code Source.

Required 100%

ME110 Subscriber Zip Code


varchar 9

Subscriber's Zip Code. Report the 5- or 9-digit Zip Code of the Subscriber's residence as defined by the United States Postal Service. When submitting the 9-digit Zip Code do not include hyphen. See External Code Source.

Required 100%


Data Element ID

Data Element Name


ME111 Medical Deductible

Integer varchar 10

Member's Maximum Medical Deductible. Report the maximum amount of the Member's deductible that is applied to medical services before certain services are covered. This is the base deductible for general services. Report 0 when there is no deductible for this benefit. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


100%

ME112 Pharmacy Deductible

Integer varchar 10

Member's Maximum Pharmacy Deductible. Report the maximum amount of the Member's deductible that is applied to pharmacy services before certain prescriptions are covered. Report 0 when there is no deductible for this benefit. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


100%

ME113 Medical and Pharmacy Deductible

Integer varchar 10

Member's Maximum Medical and Pharmacy Deductible. Report the maximum amount of the Member's deductible that is applied to services before certain medical and / or prescriptions are covered. This element should be filled in when the deductible is not strictly based on medical or strictly on pharmacy out of pocket costs, but on the combination of the two. Report 0 when there is no deductible for this combined benefit. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required when both ME018

and ME019 = 1 100%

ME114 Behavioral Health Deductible

Integer varchar 10

Member's Maximum Behavioral Health Deductible. Report the maximum amount of the Member's deductible that is applied to behavioral health services before certain behavioral health services are covered. Report 0 if there is no deductible. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


100%


Data Element ID

Data Element Name


ME115 Dental Deductible

Integer varchar 10

Member's Maximum Dental Deductible. Report the maximum amount of the Member's deductible that is applied to dental services before certain dental services are covered. Report 0 when there is no deductible for this benefit. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


100%

ME116 Vision Deductible

Integer varchar 10

Member's Maximum Vision Deductible. Report the maximum amount of the Member's deductible that is applied to vision services before certain vision services are covered. If deductible does not apply when vision benefits are available, submit as zero. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


100%

ME117 Carrier Specific Unique Subscriber ID

Text varchar 50 Subscriber's Unique ID. Report the identifier the Reporter uses internally to uniquely identify the Subscriber.

Required 100%

ME118 Vision Benefit Integer int 1

Vision Indicator. Report the value that defines if the Member has Vision coverage. EXAMPLE: 1 = Yes, Vision is a covered benefit. 1 - Yes 2 - No 3 - Unknown

Required 100%


Required 0%


Required 0%


Data Element ID

Data Element Name


ME121 Metal Level Integer int 1

Metal Level Tier. Report the Metal Level benefits that the member is associated to in this line of eligibility. EXAMPLE: 1 = Bronze Level. 1 - Bronze 2 - Silver 3 - Gold 4 - Platinum 5 - Catastrophic 0 - Not Applicable


100%

ME122 Coinsurance Maximum %

Integer int 1

Member's Maximum Coinsurance Percentage. Report the value that defines the maximum coinsurance that the Member is responsible for when covered / approved services are rendered and link to this line of eligibility. EXAMPLE: 1 = 10% Maximum Coinsurance. If Maximum Coinsurance falls between two categories, then report it under the higher category. (e.g., 15% should be reported as 2 = 20%.). 1 - 10% Maximum Coinsurance 2 - 20% Maximum Coinsurance 3 - 30% Maximum Coinsurance 4 - 40% Maximum Coinsurance 5 - 50% Maximum Coinsurance 6 - 75% Maximum Coinsurance 7 - 80% Maximum Coinsurance 8 - 90% Maximum Coinsurance 0 - Unknown / Not Applicable

Required 100%

ME123 Monthly Premium

Integer varchar 10

Expected Monthly Premium. Report the amount the Subscriber is responsible for on a monthly basis to maintain this line of eligibility. Report 0 only when the subscriber is contractually free of this obligation. Repeat the Subscriber’s premium on the Member’s record. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required 100%


Required 0%


Data Element ID

Data Element Name



Required 0%


Required 0%


Required 0%


Required 0%


Required 0%


Required 0%


Required 0%

ME132 Total Monthly Premium

Integer varchar 10

Total Monthly Premium. Report the total Employer + Subscriber's total contribution to the monthly premium. Report 0 if no premium is charged. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required when either ME107 =

ME117 or ME012 = 20

100%

ME133 EUTF HB Number

Text char 9

EUTF HB Member Number. Report the EUTF HB Member Identification number as provided to Reporters. All numbers should start with HB and end with 7-digits. If not applicable do not report any value here.


100%


Data Element ID

Data Element Name


ME134 APCD ID Code Integer int 1

Member Enrollment Type. Report the value that describes the member's / subscriber's enrollment into one of the predefined categories; aligns enrollment to appropriate editing and thresholds. EXAMPLE: 3 = EUTF Enrollee. 1 - FIG - Fully-Insured Commercial Group Enrollee 2 - SIG - Self-Insured Group Enrollee 3 - EUTF Enrollee 4 - Med-QUEST Managed Care Organization Enrollee 5 - Supplemental Policy Enrollee 6 - ICO - Integrated Care Organization 0 - Unknown/Not Applicable

Required 100%

ME135 Bargaining Unit Integer int 2

Bargaining Unit of State and County Employees. Report the bargaining unit of all State and County employees or retirees whose health plan is under EUTF. EXAMPLE: 11 = Firefighters. 00 - Elected/Appointed and Other Excluded Employees 01 - Non-supervisory Employees in Blue-collar Positions 02 - Supervisory Employees in Blue-collar Positions 03 - Non-supervisory Employees in White-collar Positions 04 - Supervisory Employees in White-collar Positions 05 - Teachers and Other Personnel under the same Salary Schedule 06 - Education Officers 07 - University of Hawai‘i and Community College Faculty 08 - Administrative, Professional and Technical Employees of the University of Hawai‘i and the Community Colleges 09 - Registered Professional Nurses 10 - Institutional, Health and Correctional Workers 11 - Firefighters 12 - Police 13 - Professional and Scientific Employees 14 - State Law Enforcement Officers and State and County Ocean Safety & Water Safety Officers


100%

ME899 Record Type Text char 2 File Type Identifier. Report ME here. This validates the type of file and the data contained within the file. This must match HD004.

Required 100%


Appendix B: Detailed Medical Claims File Requirements Data Element ID


MC001 Submitter Text char 6 Submitter ID. Report the SHPDA defined and maintained unique identifier. This must match the Submitter ID reported in HD002.

Required 100%

MC002 Health Plan ID Integer int 10



0%

MC003 Insurance Type Code / Product Text char 2

Insurance Type / Product Identification Code. Report the code that defines the type of insurance under which this Member's claim line was processed. EXAMPLE: HM = Health Maintenance Organization. 09 - Self-pay 10 - Central Certification 11 - Other Non-Federal Programs 12 - Preferred Provider Organization (PPO) 13 - Point of Service (POS) 14 - Exclusive Provider Organization (EPO) 15 - Indemnity Insurance 16 - Health Maintenance Organization (HMO) Medicare Risk 17 - Dental Maintenance Organization (DMO) AM - Automobile Medical BL - Blue Cross/Blue Shield CH - Champus CI - Commercial Insurance Company DS - Disability FI - Federal Employees Program HM - Health Maintenance Organization LM - Liability Medical MA - Medicare Part A MB - Medicare Part B MC - Medicaid MD - Medicare Part D TV - Title V VA - Veteran's Affairs Plan WC - Workers' Compensation Health Claim ZZ - Other

Required 100%


Data Element ID


MC004 Payer Claim Control Number Text varchar 35

Payer Claim Control Number. Report the unique identifier used internally by the Reporter to track the claim. This number must apply to the entire claim.

Required 100%

MC005 Line Counter Integer varchar 4

Service Line Number. Report the line number for this service within the claim. The Line Counter begins with 1 and is incremented by 1 for each additional service line of a claim. Do not start with 0 or include alphas or special characters.

Required 100%

MC005A Version Number Integer varchar 4

Line Version Number. Report the 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.

Required 0%

MC006 Insured Group or Policy Number

Text varchar 30

Insured Group / Policy Number. Report the insured group or policy number associated with the group who has purchased the insurance. Do not report the number that uniquely identifies the Subscriber or Member.

Required 100%

MC007 Subscriber SSN Integer int 9 Subscriber's Social Security Number. Report the Subscriber's 9-digit SSN here. Do not use hyphen.

Required 100%

MC008 Plan Specific Contract Number

Text varchar 30

Plan Specific Contract Number. Report the Reporter assigned contract number for the Subscriber. Do not include values in this element that will distinguish one Member of the family from another. This should be the contract number for the Subscriber and all of the dependents.

Required 100%

MC009 Member Suffix or Sequence Number


Required 100%

MC010 Member SSN Integer int 9 Member's Social Security Number. Report the Member's 9-digit SSN. Do not use hyphen.

Required 100%


Data Element ID


MC011 Individual Relationship Code

Text char 2


Required 100%

MC012 Member Gender Text char 1


Required 100%

MC013 Member Date of Birth

Date - Integer int 8

Member's Date of Birth. Report the date of birth of the Member in CCYYMMDD format.

Required 100%


Data Element ID


MC014 Filler Filler Filler 0 SHPDA reserves this field for future use. Do not populate this field with any data.

Required 0%

MC015 Member State



Required 100%

MC016 Member Zip Code


varchar 9


Required 100%

MC017 Date Service Approved (AP Date)


Date Service Approved by Payer. Report the date that the payer approved this claim line for payment in CCYYMMDD format. This element was designed to capture date other than the Paid Date. If Approved Date and Paid Date are the same, then the date here should match Paid Date reported in MC089.

Required 100%

MC018 Admission Date Date - Integer int 8

Inpatient Admit Date. Report the date of admission to a facility in CCYYMMDD Format. Only applies to institutional claims were Type of Bill (MC036) = an inpatient setting.

Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84,

86, or 89

100%

MC019 Admission Hour Integer int 4

Admission Time. Report the Admission Time in HHMM Format. Only applies to institutional claims where Type of Bill (MC036) = an inpatient setting. Time is expressed in military time. If only the hour is known, code the minutes as 00. EXAMPLE: 5 AM = 0500; 5 PM = 1700.


86, or 89

100%


Data Element ID


MC020 Admission Type


int 1

Priority (Type) of Admission or Visit. Report Admission Type Code as it applies to institutional claims where Type of Bill (MC036) = an inpatient setting. This code indicates the type of admission into an inpatient setting. See External Code Source. EXAMPLE: 1 = Emergency. 1 - Emergency 2 - Urgent 3 - Elective 4 - Newborn 5 - Trauma Center 9 - Information Not Available


86, or 89

100%

MC021 Admission Source


char 1

Point of Origin for Admission or Visit. Report the Admission Source Code as it applies to institutional claims where Type of Bill (MC036) = an inpatient setting. This code indicates how the patient was referred into an inpatient setting at the facility. See External Code Source.


86, or 89

100%

MC022 Discharge Hour Integer int 4

Discharge Time. Report the Discharge Time in HHMM Format. Only applies to institutional claims where Type of Bill (MC036) = an inpatient setting. Time is expressed in military time. If only the hour is known, code the minutes as 00. EXAMPLE: 5 AM = 0500; 5 PM = 1700.


86, or 89

100%

MC023 Discharge Status


int 2 Inpatient Discharge Status Code. Report the appropriate Discharge Status Code of the Member. See External Code Source.

Required when MC094 = 002 and MC069 is

populated

100%

MC024 Service Provider Number

Text varchar 30 Service Provider's Identification Number. Report the Reporter assigned, unique Service Provider identification number used internally by the Reporter.

Required 100%

MC025 Service Provider Tax ID Number

Integer int 9 Service Provider's EIN / Federal Tax ID Number. Report the EIN / Federal Tax ID of the Service Provider. Do not use hyphen or alpha prefix.

Required 100%

MC026 Service Provider NPI


int 10 Service Provider's National Provider Identifier. Report the National Provider Identifier (NPI) of the Service Provider. See External Code Source.

Required 100%


Data Element ID


MC027 Service Provider Entity Type Qualifier

Integer int 1

Service Provider's Entity Type Qualifier Code. Report the value that defines the provider entity type. Only individuals should be identified with a 1; facilities, professional groups, and clinic sites should all be identified with a 2. EXAMPLE: 1 = Person. 1 - Person 2 - Non-Person Entity

Required 100%

MC028 Service Provider First Name

Text varchar 25

Service Provider's First Name. Report the Service Provider's first name. If the Service Provider is a facility or organization, do not report any value here. First name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ʻokinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required when MC027 = 1

100%

MC029 Service Provider Middle Name

Text varchar 25

Service Provider's Middle Name or Initial. Report the Service Provider's middle name or initial here. If provider is a facility or organization, do not report any value here. If Service Provider's Middle Name is available, report middle name. Middle name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ʻokinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.


2%

MC030

Service Provider Last Name or Organization Name

Text varchar 100

Service Provider's Last Name or Organization Name. Report the name of the organization or the Service Provider's last name. MC027 determines if an Organization or Service Provider's name is reported here. Last name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ʻokinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required 100%


Data Element ID


MC031 Service Provider Suffix Integer int 1

Service Provider's Name Suffix. Report the individual's name-suffix when applicable here. Used to capture the generation of the individual clinician (e.g., Jr. Sr., III). Do not report degree acronyms here. EXAMPLE: 0 = Unknown / Not Applicable 1 - I. 2 - II. 3 - III. 4 - Jr. 5 - Sr. 0 - Unknown/Not Applicable


2%

MC032 Service Provider Taxonomy


varchar 10

Service Provider's Taxonomy Code. Report the taxonomy 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. See External Code Source.

Required 100%

MC033 Service Provider City Name

Text varchar 30 Service Provider's City Name. Report the city name of the Service Provider's practice location.

Required 100%

MC034 Service Provider State


char 2

Service Provider's State / Province. Report the State of the Service Provider's practice location using the two-character abbreviation as defined by the United States Postal Service. See External Code Source.

Required 100%

MC035 Service Provider Zip Code


varchar 9

Service Provider's Zip Code. Report the 5- or 9-digit Zip Code of the Service Provider's practice location as defined by the United States Postal Service. When submitting the 9-digit Zip Code do not include hyphen. See External Code Source.

Required 100%

MC036 Type of Bill - Institutional


int 2 Type of Bill. Report the Type of Bill Code that defines the Type of Bill on an institutional claim. Do not report leading zero. See External Code Source.


100%

MC037 Place of Service - Professional


int 2 Place of Service Code. Report the Place of Service Code that defines the location code where services were performed by the provider referenced on the claim. See External Code Source.


100%


Data Element ID


MC038 Claim Status Integer int 2

Claim Line Status Code. Report the Claim Line Status Code that defines the payment status of this claim line. EXAMPLE: 01 = Processed as Primary. 01 - Processed as Primary 02 - Processed as Secondary 03 - Processed as Tertiary 04 - Denied 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 23 - Not our Claim, Forwarded to Additional Payer(s) 25 - Predetermination Pricing Only - No Payment

Required 100%

MC039 Admitting Diagnosis


varchar 7 Admitting ICD Diagnosis Code. Report the Admitting Diagnosis Code assigned by provider that supported admission into the inpatient setting. See External Code Source.


86, or 89

100%

MC040 External Injury Code


varchar 7 ICD Diagnostic External Injury Code. Report the External Injury Code when appropriate to the claim. See External Code Source.

Required 3%

MC041 Principal Diagnosis


varchar 7 Principal ICD Diagnosis Code. Report the Principal ICD Diagnosis Code. Do not code decimal point. See External Code Source.

Required 100%

MC042 Other Diagnosis - 1


varchar 7 Other ICD Diagnosis Code - 1. Report the first secondary ICD Diagnosis Code. If not applicable do not report any value here. Do not code decimal point. See External Code Source.


70%



varchar 7 Other ICD Diagnosis Code - 2. Report the second secondary ICD Diagnosis Code. If not applicable do not report any value here. Do not code decimal point. See External Code Source.


25%


Data Element ID




varchar 7 Other ICD Diagnosis Code - 3. Report the third secondary ICD Diagnosis Code. If not applicable do not report any value here. Do not code decimal point. See External Code Source.


15%



varchar 7 Other ICD Diagnosis Code - 4. Report the fourth secondary ICD Diagnosis Code. If not applicable do not report any value here. See External Code Source.


10%



varchar 7 Other ICD Diagnosis Code - 5. Report the fifth secondary ICD Diagnosis Code. If not applicable do not report any value here. Do not code decimal point. See External Code Source.


5%



varchar 7 Other ICD Diagnosis Code - 6. Report the sixth secondary ICD Diagnosis Code. If not applicable do not report any value here. Do not code decimal point. See External Code Source.


3%



varchar 7 Other ICD Diagnosis Code - 7. Report the seventh secondary ICD Diagnosis Code. If not applicable do not report any value here. See External Code Source.


3%



varchar 7 Other ICD Diagnosis Code - 8. Report the eighth secondary ICD Diagnosis Code. If not applicable do not report any value here. Do not code decimal point. See External Code Source.


2%



varchar 7 Other ICD Diagnosis Code - 9. Report the ninth secondary ICD Diagnosis Code. If not applicable do not report any value here. Do not code decimal point. See External Code Source.


1%



varchar 7 Other ICD Diagnosis Code - 10. Report the tenth secondary ICD Diagnosis Code. If not applicable do not report any value here. Do not code decimal point. See External Code Source.


1%



varchar 7 Other ICD Diagnosis Code - 11. Report the eleventh secondary ICD Diagnosis Code. If not applicable do not report any value here. Do not code decimal point. See External Code Source.


1%


Data Element ID




varchar 7 Other ICD Diagnosis Code - 12. Report the twelfth secondary ICD Diagnosis Code. If not applicable do not report any value here. Do not code decimal point. See External Code Source.


1%

MC054 Revenue Code


int 4 Revenue Code. Report the valid National Uniform Billing Committee Revenue Code. Code using leading zeroes, left-justified, and four digits. See External Code Source.


100%

MC055 Procedure Code


varchar 5 HCPCS / CPT Code. Report a valid Procedure code for the claim line as defined by MC130. See External Code Source.

Required 100%

MC056 Procedure Modifier - 1


char 2

HCPCS / CPT Code Modifier - 1. Report a valid procedure modifier indicating that a service or procedure (MC055) has been altered by some specific circumstance but has not been changed in its definition or code. See External Code Source.

Required 20%



char 2


Required 2%

MC058 ICD Principal Procedure Code


varchar 7

ICD Principal Procedure Code. Report the Principal ICD Procedure Code for inpatient claims. Repeat this code on all lines of the inpatient claim it is applicable to. Do not code decimal point. See External Code Source.


86, or 89

55%

MC059 Date of Service - From


Date of Service - From. Report the first date of service for the claim line in CCYYMMDD format.

Required 100%

MC060 Date of Service - Thru


Date of Service - Thru. Report the last date of service for the claim line in CCYYMMDD format. For inpatient claims, the room and board line may or may not be equal to the discharge date. Procedures delivered during a visit should indicate which date they occurred.

Required 100%

MC061 Quantity Quantity - Integer ±varchar 15

Count of Services. Report the count of services / units performed. Use decimals when appropriate.

Required 100%


Data Element ID


MC062 Charge Amount Integer ±varchar 10

Total Charges for the Claim Line. Report the total amount the provider billed the insurance carrier for this claim line service. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required 100%

MC063 Paid Amount Integer ±varchar 10

Total Paid for the Claim Line. Report the total amount paid for the claim line. Report 0 if line is paid as part of another procedure / claim line. Do not report any value if the line is denied. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required when MC038 = 01, 02, 03, 19, 20, or 21

100%

MC064 Fee-for-Service Equivalent Integer ±varchar 10

Fee-for-Service Equivalent Amount. Report the Fee-for-Service equivalent amount that would have been paid by the insurance carrier if the service had not been capitated or paid under a bundled or managed care payment arrangement. Do not report any value if the line is denied. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required when MC113 = 01, 03,

04, 05, 06, 07, or 08

100%

MC065 Copay Amount Integer ±varchar 10

Member Copay Amount. Report the Copay amount that the Member is responsible to pay. Copay is a preset, fixed amount for this claim line service that the Member is responsible to pay. Report 0 if no Copay applies. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required 100%


Data Element ID


MC066 Coinsurance Amount Integer ±varchar 10

Member Coinsurance Amount. Report the Coinsurance amount that the Member is responsible to pay. Coinsurance is a calculated percentage amount for this claim line service that the Member is responsible to pay. Report 0 if no Coinsurance applies. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required 100%

MC067 Deductible Amount Integer ±varchar 10

Member Deductible Amount. Report the Deductible amount that the Member is responsible to pay. Deductible is a preset, fixed amount for this claim line service that the Member is responsible to pay. Report 0 if no Deductible applies to service. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required 100%

MC068 Patient Control Number Text varchar 20

Patient Control Number. Report the provider assigned encounter / visit number to identify Member treatment. Also known as the Patient Account Number.


100%

MC069 Discharge Date Date - Integer int 8

Discharge Date. Report the date the Member was discharged from the facility in CCYYMMDD format.


populated

100%

MC070 Service Provider Country Code


char 3 Country Name of the Service Provider. Report the three-character country code as defined by ISO. See External Code Source.

Required 100%

MC071 DRG Code


varchar 7 Diagnostic Related Group Code. Report the DRG number applied to this claim on every line to which it's applicable. Code using the CMS methodology. See External Code Source.


populated

20%


Data Element ID


MC072 DRG Version Text char 2

Diagnostic Related Group Version Number. Report the version of the DRG used. EXAMPLE: 26 = Version 26 of the MS-DRG is used. 26 - v26, valid from October 1, 2008 to September 30, 2009 27 - v27, valid from October 1, 2009 to September 30, 2010 28 - v28, valid from October 1, 2010 to September 30, 2011 29 - v29, valid from October 1, 2011 to September 30, 2012 30 - v30, valid from October 1, 2012 to September 30, 2013 31 - v31, valid from October 1, 2013 to September 30, 2014 32 - v32, valid from October 1, 2014 to September 30, 2015 33 - v33, valid from October 1, 2015 to September 30, 2016 34 - v34, valid from October 1, 2016 to September 30, 2017 35 - v35, valid from October 1, 2017 to September 30, 2018

Required when MC071 is populated

100%

MC073 APC


char 4

Ambulatory Payment Classification Number. Report the APC number applied to this claim line, with the leading zero(s) when applicable. Code using the CMS methodology. See External Code Source.

Required 0%

MC074 APC Version Text char 2 Ambulatory Payment Classification Version. Report the version of the APC used.


0%

MC075 Drug Code


char 11

National Drug Code (NDC). Report the NDC Code as defined by the FDA in 11-digit format (5-4-2) without hyphenation. Report the NDC code used only when a medication is paid for as part of a medical claim or when a DME device has an NDC code. J codes should be submitted under procedure code (MC055), and have a procedure code type of 'HCPCS'. See External Code Source.

Required 1%

MC076 Billing Provider Number Text varchar 30

Billing Provider's Identification Number. Report the Reporter assigned, unique Billing Provider identification number used internally by the Reporter.

Required 100%

MC077 Billing Provider NPI


int 10 Billing Provider's National Provider Identifier. Report the National Provider Identifier (NPI) of the Billing Provider. See External Code Source.

Required 100%


Data Element ID


MC078

Billing Provider Last Name or Organization Name

Text varchar 100

Billing Provider's Last Name or Organization Name. Report the name of the organization or the Billing Provider's last name. MC027 determines if an Organization or Billing Provider's name is reported here. Last name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ʻokinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required 100%

MC079 Filler Filler Filler Filler SHPDA reserves this field for future use. Do not populate this field with any data.

Required 0%

MC080 Payment Reason


varchar 10

Payment Reason Code. Report the code that defines the reason for payment of the claim line. Either report the Claim Adjustment Reason Code or Carrier-defined Payment Reason Code. If Carrier-defined Payment Code is submitted, Carrier must submit all Payment Reason Codes in separate table to SHPDA. See External Code Source.


100%

MC081 Capitated Encounter Flag Integer int 1

Capitation Payment Indicator. Report if the encounter was paid under a capitated arrangement. EXAMPLE: 1 = Yes payment for this service is covered under a capitated arrangement. 1 - Yes 2 - No 3 - Unknown

Required 100%


Required 0%

MC083 Other ICD Procedure Code - 1


varchar 7

Other ICD Procedure Code - 1. Report the second ICD Procedure Code for inpatient claims. Repeat this code on all lines of the inpatient claim it is applicable to. Do not code decimal point. See External Code Source.


86, or 89

1%



varchar 7

Other ICD Procedure Code - 2. Report the third ICD Procedure Code for inpatient claims. Repeat this code on all lines of the inpatient claim it is applicable to. Do not code decimal point. See External Code Source.


86, or 89

1%


Data Element ID




varchar 7

Other ICD Procedure Code - 3. Report the fourth ICD Procedure Code for inpatient claims. Repeat this code on all lines of the inpatient claim it is applicable to. Do not code decimal point. See External Code Source.


86, or 89

1%



varchar 7

Other ICD Procedure Code - 4. Report the fifth ICD Procedure Code for inpatient claims. Repeat this code on all lines of the inpatient claim it is applicable to. Do not code decimal point. See External Code Source.


86, or 89

1%



varchar 7

Other ICD Procedure Code - 5. Report the sixth ICD Procedure Code for inpatient claims. Repeat this code on all lines of the inpatient claim it is applicable to. Do not code decimal point. See External Code Source.


86, or 89

0%



varchar 7

Other ICD Procedure Code - 6. Report the seventh ICD Procedure Code for inpatient claims. Repeat this code on all lines of the inpatient claim it is applicable to. Do not code decimal point. See External Code Source.


86, or 89

0%

MC088A Other ICD Procedure Code - 7


varchar 7

Other ICD Procedure Code - 7. Report the eighth ICD Procedure Code for inpatient claims. Repeat this code on all lines of the inpatient claim it is applicable to. Do not code decimal point. See External Code Source.


86, or 89

0%

MC088B Other ICD Procedure Code - 8


varchar 7

Other ICD Procedure Code - 8. Report the ninth ICD Procedure Code for inpatient claims. Repeat this code on all lines of the inpatient claim it is applicable to. Do not code decimal point. See External Code Source.


86, or 89

0%


Data Element ID


MC088C Other ICD Procedure Code - 9


varchar 7

Other ICD Procedure Code - 9. Report the tenth ICD Procedure Code for inpatient claims. Repeat this code on all lines of the inpatient claim it is applicable to. Do not code decimal point. See External Code Source.


86, or 89

0%

MC088D Other ICD Procedure Code - 10


varchar 7

Other ICD Procedure Code - 10. Report the eleventh ICD Procedure Code for inpatient claims. Repeat this code on all lines of the inpatient claim it is applicable to. Do not code decimal point. See External Code Source.


86, or 89

0%

MC088E Other ICD Procedure Code - 11


varchar 7

Other ICD Procedure Code - 11. Report the twelfth ICD Procedure Code for inpatient claims. Repeat this code on all lines of the inpatient claim it is applicable to. Do not code decimal point. See External Code Source.


86, or 89

0%

MC088F Other ICD Procedure Code - 12


varchar 7

Other ICD Procedure Code - 12. Report the thirteenth ICD Procedure Code for inpatient claims. Repeat this code on all lines of the inpatient claim it is applicable to. Do not code decimal point. See External Code Source.


86, or 89

0%

MC089 Paid Date Date - Integer int 8

Paid Date of the Claim Line. Report the date that appears on the check and/or remit and/or explanation of benefits and corresponds to any and all types of payment in CCYYMMDD format. This can be the same date as AP Date (MC017).


100%

MC090 LOINC Code


varchar 7 Logical Observation Identifiers Names and Codes (LOINC). Report the LOINC code when applicable and available. Do not report any value if not applicable. See External Code Source.

Required 0%

MC091 Coinsurance Days Integer ±varchar 4

Covered Coinsurance Days. Report the number of partially covered days the Member incurred during this admission. Report 0 if all days were covered and/or Noncovered days.


86, or 89

100%


Data Element ID


MC092 Covered Days or Visits Count Integer ±varchar 4

Covered Inpatient Days. Report the number of covered days the Member incurred during this admission. Report 0 if days were Noncovered or partially covered under Coinsurance Days.


86, or 89

100%

MC093 Noncovered Days Integer ±varchar 4

Noncovered Inpatient Days. Report the number of Noncovered days the Member incurred during this admission. Report 0 if all days were covered.


86, or 89

100%

MC094 Type of Claim Text char 3

Type of Claim Indicator. Report the type of claim submitted for payment. EXAMPLE: 001 = Professional Claim line. 001 - Professional 002 - Institutional 003 - Reimbursement Form

Required 100%

MC095

Coordination of Benefits/TPL Liability Amount

Integer ±varchar 10

Amount Due from a Secondary Carrier. Report the amount that another carrier is liable for after submitting carrier has processed this claim line. Report 0 if there is no COB / TPL amount. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


or 21 100%

MC096 Other Insurance Paid Amount Integer ±varchar 10

Amount Paid by a Primary Carrier. Report the amount that a prior carrier has paid for this claim line. Indicates the submitting carrier is 'secondary' to the prior carrier. Only report 0 if the prior carrier paid 0 towards this claim line. If prior carrier did not pay towards this claim line, do not report any value. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


20, or 21 100%


Data Element ID


MC097 Medicare Paid Amount Integer ±varchar 10

Amount Paid by Medicare. Report the amount Medicare paid for this claim line. Only report 0 here if Medicare paid 0. If Medicare did not pay towards this claim line, do not report any value. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


100%

MC098 Allowed Amount Integer ±varchar 10

Allowed Amount. Report the maximum amount contractually allowed, and that a carrier will pay to a provider for a particular procedure or service. This will vary by provider contract and most often it is less than or equal to the fee charged by the provider. Report 0 when the claim line is denied. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required when MC038 does not = 04, 22, or 23

100%

MC099 Non-Covered Amount


Non-Covered Amount. Report the amount that was charged on a claim that is not reimbursable due to eligibility limitations or provider requirements. Report 0 if all charges are covered. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required 100%


Required 0%

MC101 Subscriber Last Name Text varchar 60

Subscriber’s Last Name. Report the Subscriber’s last name. Last name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ‘okinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required 100%

MC102 Subscriber First Name Text varchar 25

Subscriber’s First Name. Report the Subscriber’s first name. First name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ‘okinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required 100%


Data Element ID


MC103 Subscriber Middle Name Text varchar 25

Subscriber’s Middle Name or Initial. Report the Subscriber’s middle name or initial. If Subscriber’s middle name is available, report middle name. Middle name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ‘okinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required 2%

MC104 Member Last Name Text varchar 60

Member’s Last Name. Report the Member’s last name. Last name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ‘okinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required 100%

MC105 Member First Name Text varchar 25

Member’s First Name. Report the Member’s first name. First name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ‘okinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required 100%

MC106 Member Middle Name Text varchar 25

Member’s Middle Name or Initial. Report the Member’s middle name or initial. If Member’s middle name is available, report middle name. Middle name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ‘okinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required 2%

MC107 ICD Indicator Integer int 1

International Classification of Diseases (ICD) Version Indicator. Report the value that defines whether the diagnoses on claim are ICD-9 or ICD-10. EXAMPLE: 9 = ICD-9. 9 - ICD-9 0 - ICD-10

Required when MC094 = 001 or 002 and any of the following: MC039 thru

MC053, MC058, MC083 thru

MC088F, MC142 thru MC153 is

populated

100%



char 2


Required 0%


Data Element ID




char 2


Required 0%

MC110 Claim Processed Date


Claim Processed Date. Report the date the claim was processed by the Reporter in CCYYMMDD format. This date can be equal to Paid Date (MC089), but cannot be after Paid Date.

Required 100%

MC111 Diagnostic Code Pointer Integer varchar 4

Diagnostic Pointer Number. Report the placement number of the diagnosis(es) a procedure is related to for a professional claim. Can report up to four diagnostic positions within the first nine diagnoses that can be reported. Do not separate multiple mappings with spaces, zeros, or special characters. Do not zero fill. EXAMPLE: Procedure related to diagnoses 1, 4, and 5 = 145.


100%

MC112 Referring Provider NPI


int 10

Referring Provider National Provider Identifier. Report the National Provider Identifier (NPI) of the Referring Provider that submitted the referral for the service or ordered the test that is on the claim (if applicable). See External Code Source.


100%

MC113 Payment Arrangement Type

Integer int 2

Payment Arrangement Type. Report the value that defines the contracted payment methodology for this claim line. EXAMPLE: 02 = Fee for Service. 01 - Capitation 02 - Fee for Service 03 - Percent of Charges 04 - DRG 05 - Pay for Performance 06 - Global Payment 07 - Other 08 - Bundled Payment

Required 100%


Data Element ID


MC114 Excluded Expenses Integer ±varchar 10

Excluded Expenses. Report the amount that the patient has incurred towards covered but over-utilized services. Report 0 if there are no Excluded Expenses. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required 100%

MC115 Medicare Flag Integer int 1

Medicare Payment Indicator. Report the value that defines if Medicare paid for part or all of the services. EXAMPLE: 1 = Yes, Medicare paid for part or all of services. 1 - Yes 2 - No 3 - Unknown 4 - Other 5 - Not Applicable

Required 100%

MC116 Withhold Amount Integer ±varchar 10

Amount to be Paid for Performance Guarantees. Report the amount paid to the provider for this claim line if the provider qualified / met performance guarantees. Report 0 if the provider has the agreement but did not satisfy the measure, else do not report any value. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required 100%

MC117 Pre-Authorization Flag

Integer int 1

Pre-Authorization Indicator. Report the value that defines if the service required pre-authorization. EXAMPLE: 1 = Yes, service required a pre-authorization. 1 - Yes 2 - No 3 - Unknown 4 - Other 5 - Not Applicable

Required 100%


Data Element ID


MC118 Referral Flag Integer int 1

Referral Indicator. Report the value that defines if the service was preceded by a referral. EXAMPLE: 1 = Yes, service was preceded by a referral. 1 - Yes 2 - No 3 - Unknown 4 - Other 5 - Not Applicable

Required 100%

MC119 PCP Flag Integer int 1

PCP Indicator. Report the value that defines if the service was performed by the Member's PCP. EXAMPLE: 1 = Yes, service was performed by the Member's PCP. 1 - Yes 2 - No 3 - Unknown 4 - Other 5 - Not Applicable

Required 100%

MC120 DRG Level Integer int 1

Diagnostic Related Group Code Severity Level. Report the level used for severity adjustment when applicable. EXAMPLE: 1 = Major Complication or Comorbidity (MCC). 1 - Major Complication or Comorbidity (MCC) 2 - Complication or Comorbidity (CC) 3 - Non-Complication or Comorbidity (Non-CC)


80%

MC121 Member Total Out of Pocket Amount


Total Member Out of Pocket Amount. Report the total amount the Member is responsible to pay to the provider as part of their costs for services. This is the sum of copay, coinsurance, deductible, and other charges the Member is responsible for. Report 0 if there are no out of pocket expenses. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required 100%


Data Element ID


MC122 Global Payment Flag Integer int 1

Global Payment Indicator. Report if the claim line was paid under a global payment arrangement. EXAMPLE: 1 = Yes, the claim line was paid under a global payment arrangement. 1 - Yes 2 - No 3 - Unknown

Required 100%

MC123 Denied Flag Integer int 1

Denied Claim Line Indicator. Report if the claim line was denied. EXAMPLE: 1 = Yes, Claim Line was denied. 1 - Yes 2 - No 3 - Unknown


100%

MC124 Denial Reason


varchar 30

Denial Reason Code. Report the code that defines the reason for denial of the claim line. Either report the Claim Adjustment Reason Code or Carrier-defined Denial Reason Code. If Carrier-defined Reason Code is submitted, Carrier must submit all Denial Reason Codes in separate table to SHPDA. See External Code Source.


100%

MC125 Attending Provider NPI


int 10

Attending Provider's National Provider Identifier. Report the National Provider Identifier (NPI) of the Attending Provider that provided general oversight of the Member's care. This individual may or may not be the Servicing or Rendering provider. See External Code Source.


populated

100%

MC126 Accident Flag Integer int 1

Accident Indicator. Report the value that defines if the claim line is accident-related. EXAMPLE: 1 = Yes, claim line is Accident-related. 1 - Yes 2 - No 3 - Unknown


100%


Data Element ID


MC127 Family Planning Flag Integer int 1

Family Planning Indicator. Report the value that defines if family planning services were provided. EXAMPLE: 1 = Yes, Family Planning services were provided. 1 - Yes 2 - No 3 - Unknown


100%

MC128 Employment Related Flag Integer int 1

Employment Related Indicator. Report the value that defines if the claim line was related to an employment accident. EXAMPLE: 1 = Yes, claim line was related to employment accident. 1 - Yes 2 - No 3 - Unknown


100%

MC129 EPSDT Flag Integer int 1

Early Periodic Screening, Diagnosis and Treatment (EPSDT) Indicator. Report if the claim line was related to EPSDT and the type of EPSDT service, such as 'screening', 'treatment' or ‘referral’. EXAMPLE: 1 = Yes, claim line was related to EPSDT. 1 - Yes 2 - No 3 - Unknown


100%

MC130 Procedure Code Type Integer int 1

Claim Line Procedure Code Type Identifier. Report the type of Procedure Code expected in MC055. 1 - CPT or HCPCS Level I Code 2 - HCPCS Level II Code 3 - HCPCS Level III Code (State Medicare Code) 4 - American Dental Association (ADA) Procedure Code (CDT Code) 5 - State-defined Procedure Code 6 - CPT Category II 7 - CPT Category III


100%


Data Element ID


MC131 Network Flag Integer int 1

Network Indicator. Report the value that defines if the claim line was paid at an in-network rate. EXAMPLE: 1 = Yes claim line was paid at an in-network rate. 1 - Yes 2 - No 3 - Unknown

Required 100%

MC132 Filler Filler Filler 0 SHPDA reserves this filed for future use. Do not populate this field with any data.

Required 0%

MC133 Type of Bill Frequency Code


int 1 Type of Bill Frequency Code. Report the valid frequency code of the claim to indicate version, credit/debit activity, and/or settling of claim. See External Code Source.

Required when MC094 = 001 or

002 100%

MC134 Organizational Provider NPI


int 10

Organizational Provider's National Provider Identifier. Report the National Provider Identifier (NPI) of the organization with which the service/rendering/attending provider directly providing the service is associated. See External Code Source.

Required 100%

MC135 Provider Location Address

Text varchar 60

Address of the Rendering Provider. Report the address which identifies the location / site of the service provided by the Rendering Provider identified in MC242. EXAMPLE: Dr. Smith Pediatrics, 123 Main Street

Required 100%

MC135A Provider Location Address 2

Text varchar 60

Address of the Rendering Provider 2. Report the street address that may contain office number, suite, or other secondary information besides the street which identifies the location / site of the service provided by the Rendering Provider identified in MC242. EXAMPLE: Suite 100

Required 2%

MC135B Provider Location City Text varchar 30

Rendering Provider's City Name. Report the city name of the Rendering Provider's location / site of the service.

Required 100%

MC135C Provider Location State


char 2

Rendering Provider's State / Province. Report the State of the Rendering Provider's location / site of the service using the two-character abbreviation as defined by the United States Postal Service. See External Code Source.

Required 100%


Data Element ID


MC135D Provider Location Zip Code


varchar 9

Rendering Provider's Zip Code. Report the 5- or 9-digit Zip Code of the Rendering Provider's location / site of the service as defined by the United States Postal Service. When submitting the 9-digit Zip Code do not include hyphen. See External Code Source.

Required 100%

MC136 Discharge Diagnosis


varchar 7

Discharge ICD Diagnosis Code. Report the Discharge ICD Diagnosis Code as applied to the Member upon discharge. This may or may not be the same as the primary diagnosis or admitting diagnosis. See External Code Source.


80%

MC137 Carrier Specific Unique Member ID


Required 100%

MC138 Claim Line Type Text char 1

Claim Line Type Code. Report the Claim Line Type Code that defines the claim line status in terms of adjudication. EXAMPLE: O = Original. O - Original V - Void R - Replacement B - Back Out A - Amendment

Required 100%

MC139 Former Claim Number Text varchar 35

Previous Claim Number. Report the Claim Control Number (MC004) that was originally sent in a prior filing that this line corresponds to. When reported, this data cannot equal its own MC004.

Required 0%


Required 0%

MC141 Carrier Specific Unique Subscriber ID


Required 100%

MC142 Other Diagnosis Code - 13


varchar 7 Other ICD Diagnosis Code - 13. Report the thirteenth secondary ICD Diagnosis Code. If not applicable do not report any value here. See External Code Source.


0%



varchar 7 Other ICD Diagnosis Code - 14. Report the fourteenth secondary ICD Diagnosis Code. If not applicable do not report any value here. See External Code Source.


0%


Data Element ID




varchar 7 Other ICD Diagnosis Code - 15. Report the fifteenth secondary ICD Diagnosis Code. If not applicable do not report any value here. See External Code Source.


0%



varchar 7 Other ICD Diagnosis Code - 16. Report the sixteenth secondary ICD Diagnosis Code. If not applicable do not report any value here. See External Code Source.


0%



varchar 7 Other ICD Diagnosis Code - 17. Report the seventeenth secondary ICD Diagnosis Code. If not applicable do not report any value here. See External Code Source.


0%



varchar 7 Other ICD Diagnosis Code - 18. Report the eighteenth secondary ICD Diagnosis Code. If not applicable do not report any value here. See External Code Source.


0%



varchar 7 Other ICD Diagnosis Code - 19. Report the nineteenth secondary ICD Diagnosis Code. If not applicable do not report any value here. See External Code Source.


0%



varchar 7 Other ICD Diagnosis Code - 20. Report the twentieth secondary ICD Diagnosis Code. If not applicable do not report any value here. See External Code Source.


0%



varchar 7 Other ICD Diagnosis Code - 21. Report the twenty-first secondary ICD Diagnosis Code. If not applicable do not report any value here. See External Code Source.


0%



varchar 7 Other ICD Diagnosis Code - 22. Report the twenty-second secondary ICD Diagnosis Code. If not applicable do not report any value here. See External Code Source.


0%



varchar 7 Other ICD Diagnosis Code - 23. Report the twenty-third secondary ICD Diagnosis Code. If not applicable do not report any value here. See External Code Source.


0%


Data Element ID




varchar 7 Other ICD Diagnosis Code - 24. Report the twenty-fourth secondary ICD Diagnosis Code. If not applicable do not report any value here. See External Code Source.


0%

MC154

Present on Admission (POA) Indicator - 1


char 1

Present on Admission (POA) Indicator for Principal Diagnosis. Report the code indicating if the principal diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)

Required when MC094 = 002;

MC039 and MC041 is

populated; and MC245 is not = 02, 05, 06, 07,

or 09

100%

MC155



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 1. Report the code indicating if the first secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC042 is


or 09

100%

MC156



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 2. Report the code indicating if the second secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC043 is


or 09

100%


Data Element ID


MC157



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 3. Report the code indicating if the third secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC044 is


or 09

100%

MC158



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 4. Report the code indicating if the fourth secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC045 is


or 09

100%

MC159



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 5. Report the code indicating if the fifth secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC046 is


or 09

100%


Data Element ID


MC160



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 6. Report the code indicating if the sixth secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC047 is


or 09

100%

MC161



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 7. Report the code indicating if the seventh secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC048 is


or 09

100%

MC162



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 8. Report the code indicating if the eighth secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC049 is


or 09

100%


Data Element ID


MC163



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 9. Report the code indicating if the ninth secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC050 is


or 09

100%

MC164



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 10. Report the code indicating if the tenth secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC051 is


or 09

100%

MC165



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 11. Report the code indicating if the eleventh secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC052 is


or 09

100%


Data Element ID


MC166



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 12. Report the code indicating if the twelfth secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC053 is


or 09

100%

MC167



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 13. Report the code indicating if the thirteenth secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC142 is


or 09

100%

MC168



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 14. Report the code indicating if the fourteenth secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC143 is


or 09

100%


Data Element ID


MC169



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 15. Report the code indicating if the fifteenth secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC144 is


or 09

100%

MC170



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 16. Report the code indicating if the sixteenth secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC145 is


or 09

100%

MC171



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 17. Report the code indicating if the seventeenth secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC146 is


or 09

100%


Data Element ID


MC172



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 18. Report the code indicating if the eighteenth secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC147 is


or 09

100%

MC173



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 19. Report the code indicating if the nineteenth secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC148 is


or 09

100%

MC174



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 20. Report the code indicating if the twentieth secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC149 is


or 09

100%


Data Element ID


MC175



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 21. Report the code indicating if the twenty-first secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC150 is


or 09

100%

MC176



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 22. Report the code indicating if the twenty-second secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC151 is


or 09

100%

MC177



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 23. Report the code indicating if the twenty-third secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC152 is


or 09

100%


Data Element ID


MC178



char 1

Present on Admission (POA) Indicator for Other Diagnosis - 24. Report the code indicating if the twenty-fourth secondary diagnosis was present at the time of admission into the inpatient setting. See External Code Source. 1 - Exempt from POA Reporting (Use if POA reporting is not required by the carrier) N - No (Diagnosis was not present at time of inpatient admission) U - Unknown (Documentation insufficient to determine if the condition was present at the time of inpatient admission) W - Clinically Undetermined Y - Yes (Diagnosis was present at time of inpatient admission)


MC039 and MC153 is


or 09

100%

MC179 Condition Code - 1


char 2 Condition Code - 1. Report the Condition Code that indicates a condition relating to a claim. If not applicable do not report any value here. See External Code Source.

Required 1%




Required 1%




Required 1%




Required 1%




Required 1%




Required 1%


Data Element ID





Required 1%




Required 1%




Required 1%




Required 1%




Required 1%




Required 1%

MC191 Value Code - 1


char 2 Value Code - 1. Report the first Value Code that defines a value category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%

MC192 Value Code Amount - 1 Integer ±varchar 10

Value Code Amount - 1. Report the appropriate amount that corresponds to the first Value Code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


100%


Data Element ID




char 2 Value Code - 2. Report the second Value Code that defines a value category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%


Value Code Amount - 2. Report the appropriate amount that corresponds to the second Value Code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


100%



char 2 Value Code - 3. Report the third Value Code that defines a value category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%


Value Code Amount - 3. Report the appropriate amount that corresponds to the third Value Code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


100%



char 2 Value Code - 4. Report the fourth Value Code that defines a value category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%


Value Code Amount - 4. Report the appropriate amount that corresponds to the fourth Value Code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


100%


Data Element ID




char 2 Value Code - 5. Report the fifth Value Code that defines a value category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%


Value Code Amount - 5. Report the appropriate amount that corresponds to the fifth Value Code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


100%



char 2 Value Code - 6. Report the sixth Value Code that defines a value category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%


Value Code Amount - 6. Report the appropriate amount that corresponds to the sixth Value Code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


100%



char 2 Value Code - 7. Report the seventh Value Code that defines a value category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%


Value Code Amount - 7. Report the appropriate amount that corresponds to the seventh Value Code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


100%


Data Element ID




char 2 Value Code - 8. Report the eighth Value Code that defines a value category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%


Value Code Amount - 8. Report the appropriate amount that corresponds to the eighth Value Code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


100%



char 2 Value Code - 9. Report the ninth Value Code that defines a value category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%


Value Code Amount - 9. Report the appropriate amount that corresponds to the ninth Value Code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


100%



char 2 Value Code - 10. Report the tenth Value Code that defines a value category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%


Value Code Amount - 10. Report the appropriate amount that corresponds to the tenth Value Code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


100%


Data Element ID




char 2 Value Code - 11. Report the eleventh Value Code that defines a value category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%


Value Code Amount - 11. Report the appropriate amount that corresponds to the eleventh Value Code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


100%



char 2 Value Code - 12. Report the twelfth Value Code that defines a value category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%


Value Code Amount - 12. Report the appropriate amount that corresponds to the twelfth Value Code. Only code 0 when 0 is an applicable amount for the Value Code Set. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


100%

MC215 Occurrence Code - 1


char 2 Occurrence Code - 1. Report the first Occurrence Code that defines the occurrence category for the claim. If not applicable do not report any value here. See External Code Source.

Required 1%

MC216 Occurrence Date - 1


Occurrence Code Date - 1. Report the date that corresponds to the first Occurrence Code in CCYYMMDD format.


100%



char 2 Occurrence Code - 2. Report the second Occurrence Code that defines the occurrence category for the claim. If not applicable do not report any value here. See External Code Source.

Required 1%



Occurrence Code Date - 2. Report the date that corresponds to the second Occurrence Code in CCYYMMDD format.


100%


Data Element ID




char 2 Occurrence Code - 3. Report the third Occurrence Code that defines the occurrence category for the claim. If not applicable do not report any value here. See External Code Source.

Required 1%



Occurrence Code Date - 3. Report the date that corresponds to the third Occurrence Code in CCYYMMDD format.


100%



char 2 Occurrence Code - 4. Report the fourth Occurrence Code that defines the occurrence category for the claim. If not applicable do not report any value here. See External Code Source.

Required 1%



Occurrence Code Date - 4. Report the date that corresponds to the fourth Occurrence Code in CCYYMMDD format.


100%



char 2 Occurrence Code - 5. Report the fifth Occurrence Code that defines the occurrence category for the claim. If not applicable do not report any value here. See External Code Source.

Required 1%



Occurrence Code Date - 5. Report the date that corresponds to the fifth Occurrence Code in CCYYMMDD format.


100%

MC224A Occurrence Code - 6


char 2 Occurrence Code - 6. Report the sixth Occurrence Code that defines the occurrence category for the claim. If not applicable do not report any value here. See External Code Source.

Required 1%

MC224B Occurrence Date - 6


Occurrence Code Date - 6. Report the date that corresponds to the sixth Occurrence Code in CCYYMMDD format.

Required when MC224A is populated

100%

MC224C Occurrence Code - 7


char 2 Occurrence Code - 7. Report the seventh Occurrence Code that defines the occurrence category for the claim. If not applicable do not report any value here. See External Code Source.

Required 1%

MC224D Occurrence Date - 7


Occurrence Code Date - 7. Report the date that corresponds to the seventh Occurrence Code in CCYYMMDD format.

Required when MC224C is populated

100%


Data Element ID


MC224E Occurrence Code - 8


char 2 Occurrence Code - 8. Report the eighth Occurrence Code that defines the occurrence category for the claim. If not applicable do not report any value here. See External Code Source.

Required 1%

MC224F Occurrence Date - 8


Occurrence Code Date - 8. Report the date that corresponds to the eighth Occurrence Code in CCYYMMDD format.

Required when MC224E is populated

100%

MC224G Occurrence Code - 9


char 2 Occurrence Code - 9. Report the ninth Occurrence Code that defines the occurrence category for the claim. If not applicable do not report any value here. See External Code Source.

Required 1%

MC224H Occurrence Date - 9


Occurrence Code Date - 9. Report the date that corresponds to the ninth Occurrence Code in CCYYMMDD format.

Required when MC224G is populated

100%

MC224I Occurrence Code - 10


char 2 Occurrence Code - 10. Report the tenth Occurrence Code that defines the occurrence category for the claim. If not applicable do not report any value here. See External Code Source.

Required 1%

MC224J Occurrence Date - 10


Occurrence Code Date - 10. Report the date that corresponds to the tenth Occurrence Code in CCYYMMDD format.

Required when MC224I is populated

100%

MC224K Occurrence Code - 11


char 2 Occurrence Code - 11. Report the eleventh Occurrence Code that defines the occurrence category for the claim. If not applicable do not report any value here. See External Code Source.

Required 1%

MC224L Occurrence Date - 11


Occurrence Code Date - 11. Report the date that corresponds to the eleventh Occurrence Code in CCYYMMDD format.

Required when MC224K is populated

100%

MC224M Occurrence Code - 12


char 2 Occurrence Code - 12. Report the twelfth Occurrence Code that defines the occurrence category for the claim. If not applicable do not report any value here. See External Code Source.

Required 1%

MC224N Occurrence Date - 12


Occurrence Code Date - 12. Report the date that corresponds to the twelfth Occurrence Code in CCYYMMDD format.

Required when MC224M is populated

100%


Data Element ID


MC225 Occurrence Span Code - 1


char 2

Occurrence Span Code - 1. Report the first Occurrence Span Code that defines an occurrence span category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%

MC226 Occurrence Span Start Date - 1


Occurrence Span Code Start Date - 1. Report the start date that corresponds to the first Occurrence Span Code in CCYYMMDD format.


100%

MC227 Occurrence Span End Date - 1


Occurrence Span Code End Date - 1. Report the end date that corresponds to the first Occurrence Span Code in CCYYMMDD format.


100%



char 2

Occurrence Span Code - 2. Report the second Occurrence Span Code that defines an occurrence span category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%



Occurrence Span Code Start Date - 2. Report the start date that corresponds to the second Occurrence Span Code in CCYYMMDD format.


100%



Occurrence Span Code End Date - 2. Report the end date that corresponds to the second Occurrence Span Code in CCYYMMDD format.


100%



char 2

Occurrence Span Code - 3. Report the third Occurrence Span Code that defines an occurrence span category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%



Occurrence Span Code Start Date - 3. Report the start date that corresponds to the third Occurrence Span Code in CCYYMMDD format.


100%



Occurrence Span Code End Date - 3. Report the end date that corresponds to the third Occurrence Span Code in CCYYMMDD format.


100%



char 2

Occurrence Span Code - 4. Report the fourth Occurrence Span Code that defines an occurrence span category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%


Data Element ID




Occurrence Span Code Start Date - 4. Report the start date that corresponds to the fourth Occurrence Span Code in CCYYMMDD format.


100%



Occurrence Span Code End Date - 4. Report the end date that corresponds to the fourth Occurrence Span Code in CCYYMMDD format.


100%



char 2

Occurrence Span Code - 5. Report the fifth Occurrence Span Code that defines an occurrence span category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%



Occurrence Span Code Start Date - 5. Report the start date that corresponds to the fifth Occurrence Span Code in CCYYMMDD format.


100%



Occurrence Span Code End Date - 5. Report the end date that corresponds to the fifth Occurrence Span Code in CCYYMMDD format.


100%

MC239A Occurrence Span Code - 6


char 2

Occurrence Span Code - 6. Report the sixth Occurrence Span Code that defines an occurrence span category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%

MC239B Occurrence Span Start Date - 6


Occurrence Span Code Start Date - 6. Report the start date that corresponds to the sixth Occurrence Span Code in CCYYMMDD format.

Required when MC239A is populated

100%

MC239C Occurrence Span End Date - 6


Occurrence Span Code End Date - 6. Report the end date that corresponds to the sixth Occurrence Span Code in CCYYMMDD format.

Required when MC239B is populated

100%

MC239D Occurrence Span Code - 7


char 2

Occurrence Span Code - 7. Report the seventh Occurrence Span Code that defines an occurrence span category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%

MC239E Occurrence Span Start Date - 7


Occurrence Span Code Start Date - 7. Report the start date that corresponds to the seventh Occurrence Span Code in CCYYMMDD format.

Required when MC239D is populated

100%


Data Element ID


MC239F Occurrence Span End Date - 7


Occurrence Span Code End Date - 7. Report the end date that corresponds to the seventh Occurrence Span Code in CCYYMMDD format.

Required when MC239E is populated

100%

MC239G Occurrence Span Code - 8


char 2

Occurrence Span Code - 8. Report the eighth Occurrence Span Code that defines an occurrence span category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%

MC239H Occurrence Span Start Date - 8


Occurrence Span Code Start Date - 8. Report the start date that corresponds to the eighth Occurrence Span Code in CCYYMMDD format.

Required when MC239G is populated

100%

MC239I Occurrence Span End Date - 8


Occurrence Span Code End Date - 8. Report the end date that corresponds to the eighth Occurrence Span Code in CCYYMMDD format.

Required when MC239H is populated

100%

MC239J Occurrence Span Code - 9


char 2

Occurrence Span Code - 9. Report the ninth Occurrence Span Code that defines an occurrence span category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%

MC239K Occurrence Span Start Date - 9


Occurrence Span Code Start Date - 9. Report the start date that corresponds to the ninth Occurrence Span Code in CCYYMMDD format.

Required when MC239J is populated

100%

MC239L Occurrence Span End Date - 9


Occurrence Span Code End Date - 9. Report the end date that corresponds to the ninth Occurrence Span Code in CCYYMMDD format.

Required when MC239K is populated

100%

MC239M Occurrence Span Code - 10


char 2

Occurrence Span Code - 10. Report the tenth Occurrence Span Code that defines an occurrence span category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%

MC239N Occurrence Span Start Date - 10


Occurrence Span Code Start Date - 10. Report the start date that corresponds to the tenth Occurrence Span Code in CCYYMMDD format.

Required when MC239M is populated

100%

MC239O Occurrence Span End Date - 10


Occurrence Span Code End Date - 10. Report the end date that corresponds to the tenth Occurrence Span Code in CCYYMMDD format.

Required when MC239N is populated

100%


Data Element ID


MC239P Occurrence Span Code - 11


char 2

Occurrence Span Code - 11. Report the eleventh Occurrence Span Code that defines an occurrence span category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%

MC239Q Occurrence Span Start Date - 11


Occurrence Span Code Start Date - 11. Report the start date that corresponds to the eleventh Occurrence Span Code in CCYYMMDD format.

Required when MC239P is populated

100%

MC239R Occurrence Span End Date - 11


Occurrence Span Code End Date - 11. Report the end date that corresponds to the eleventh Occurrence Span Code in CCYYMMDD format.

Required when MC239Q is populated

100%

MC239S Occurrence Span Code - 12


char 2

Occurrence Span Code - 12. Report the twelfth Occurrence Span Code that defines an occurrence span category of the claim. If not applicable do not report any value here. See External Code Source.

Required 1%

MC239T Occurrence Span Start Date - 12


Occurrence Span Code Start Date - 12. Report the start date that corresponds to the twelfth Occurrence Span Code in CCYYMMDD format.

Required when MC239S is populated

100%

MC239U Occurrence Span End Date - 12


Occurrence Span Code End Date - 12. Report the end date that corresponds to the twelfth Occurrence Span Code in CCYYMMDD format.

Required when MC239T is populated

100%

MC240 EUTF HB Number Text char 9



100%


Data Element ID


MC241 APCD ID Code Integer int 1


Required 100%

MC242 Rendering Provider NPI


int 10 Rendering Provider's National Provider Identifier. Report the National Provider Identifier (NPI) of the Rendering Provider. See External Code Source.

Required 100%


Required 0%

MC244 Claim Line Paid Flag Integer int 1

Claim Line Paid Indicator. Report the value that defines the element. EXAMPLE: 1 = Yes, Claim Line was paid. 1 - Yes 2 - No 3 - Unknown 4 - Other 5 - Not Applicable


100%


Data Element ID


MC245 Type of Facility Flag Integer int 2

Type of Facility Indicator. Report the value that defines the type of facility setting for this claim. EXAMPLE: 1 = General Acute Care Facility. 01 - General Acute Care Facility 02 - Skilled Nursing Facility/Long Term Care Facility 03 - Intermediate Care Facility 04 - Hospice Facility 05 - Designated Cancer Center 06 - Designated Inpatient Children's Hospital 07 - Inpatient Rehabilitation Facility 08 - Inpatient Psychiatric Hospital 09 - Critical Access Hospital 10 - Home Care 70 - Other Type of Facility

Required 100%

MC246 Medicaid ID Text varchar 20

Medicaid-Assigned Member ID. Report the unique ID that Medicaid uses to uniquely identify a Member. This ID must be on all lines of eligibility for Med-QUEST and Medicaid MCOs. This element is required for Med-QUEST carriers only. Non-Med-QUEST carriers should not report any value here.


100%

MC899 Record Type Text char 2 File Type Identifier. Report MC here. This validates the type of file and the data contained within the file. This must match HD004.

Required 100%


Appendix C: Detailed Pharmacy Claims File Requirements Data Element ID

Data Element Name


PC001 Submitter Text char 6 Submitter ID. Report the SHPDA defined and maintained unique identifier. This must match the Submitter ID reported in HD002.

Required 100%

PC002 Health Plan ID Integer int 10



0%

PC003 Insurance Type Code / Product Text char 2

Insurance Type / Product Identification Code. Report the code that defines the type of insurance under which this Member's claim line was processed. EXAMPLE: HM = Health Maintenance Organization. 09 - Self-pay 10 - Central Certification 11 - Other Non-Federal Programs 12 - Preferred Provider Organization (PPO) 13 - Point of Service (POS) 14 - Exclusive Provider Organization (EPO) 15 - Indemnity Insurance 16 - Health Maintenance Organization (HMO) Medicare Risk 17 - Dental Maintenance Organization (DMO) AM - Automobile Medical BL - Blue Cross/Blue Shield CH - Champus CI - Commercial Insurance Company DS - Disability FI - Federal Employees Program HM - Health Maintenance Organization LM - Liability Medical MA - Medicare Part A MB - Medicare Part B MC - Medicaid MD - Medicare Part D TV - Title V VA - Veteran's Affairs Plan WC - Workers' Compensation Health Claim ZZ - Other

Required 100%


Data Element ID

Data Element Name


PC004 Payer Claim Control Number Text varchar 35


Required 100%

PC005 Line Counter Integer varchar 4


Required 100%

PC005A Version Number Integer varchar 4


Required 0%

PC006 Insured Group or Policy Number

Text varchar 30 Insured Group / Policy Number. Report the insured group or policy number. Do not report the number that uniquely identifies the Subscriber or Member.

Required 100%

PC007 Subscriber SSN Integer int 9 Subscriber's Social Security Number. Report the Subscriber's 9-digit SSN here. Do not use hyphen.

Required 100%

PC008 Plan Specific Contract Number

Text varchar 30


Required 100%

PC009 Member Suffix or Sequence Number


Required 100%

PC010 Member SSN Integer int 9 Member's Social Security Number. Report the Member's 9-digit SSN. Do not use hyphen.

Required 100%


Data Element ID

Data Element Name


PC011 Individual Relationship Code

Text char 2


Required 100%

PC012 Member Gender Text char 1


Required 100%


Data Element ID

Data Element Name


PC013 Member Date of Birth



Required 100%

PC014 Filler Filler char 0 Filler. SHPDA reserves this field for future use. Do not populate with any data.

Required 0%

PC015 Member State



Required 100%

PC016 Member Zip Code


varchar 9


Required 100%

PC017 Date Service Approved (AP Date)


Date Service Approved by Payer. Report the date that the payer approved this claim line for payment in CCYYMMDD format. This element was designed to capture date other than the Paid date. If Approved Date and Paid Date are the same, then the date here should match Paid Date reported in PC063.

Required 100%

PC018 Pharmacy Number


varchar 30 Pharmacy's Identification Number. Report either the NCPDP or NABP number of the dispensing pharmacy. See External Code Source.

Required 100%

PC019 Pharmacy Tax ID Number Integer int 9

Pharmacy EIN / Federal Tax ID Number. Report the EIN / Federal Tax ID of the pharmacy. Do not use hyphen or alpha prefix.

Required 20%

PC020 Pharmacy Name Text varchar 100 Name of Pharmacy. Report the name of the pharmacy. Required 100%

PC021 Pharmacy NPI


int 10 Pharmacy's National Provider Identifier. Report the National Provider Identifier (NPI) of the pharmacy. See External Code Source.

Required 100%

PC022 Pharmacy Location City Text varchar 30

Pharmacy's City Name. Report the city name of pharmacy's location.

Required 100%

PC023 Pharmacy Location State


char 2

Pharmacy's State / Province. Report the State where the dispensing pharmacy is located using the two-character abbreviation as defined by the United States Postal Service. See External Code Source.

Required 100%


Data Element ID

Data Element Name


PC024 Pharmacy Location Zip Code


varchar 9

Pharmacy's Zip Code. Report the 5- or 9-digit Zip Code as defined by the United States Postal Service. When submitting the 9-digit Zip Code do not include hyphen. See External Code Source.

Required 100%

PC024A Pharmacy Location Country Code


char 3 Pharmacy's Country Code. Report the three-character country code as defined by ISO 3166-1, Alpha 3. See External Code Source.

Required 100%

PC025 Claim Status Integer int 2

Claim Line Status Code. Report the Claim Status Code that defines the payment status of this claim line. EXAMPLE: 01 = Processed as primary. 01 - Processed as primary 02 - Processed as secondary 03 - Processed as tertiary 04 - Denied 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 23 - Not our claim, forwarded to additional payer(s) 25 - Predetermination Pricing Only - no payment

Required 100%

PC026 Drug Code


char 11 National Drug Code (NDC). Report the NDC Code as defined by the FDA in 11-digit format (5-4-2) without hyphenation. See External Code Source.

Required 100%

PC027 Drug Name


varchar 80

Name of the Drug as Supplied. Report the name of the drug that aligns to the National Drug Code. Do not report generic names with brand name National Drug Codes. See External Code Source.

Required 100%

PC028 New Prescription or Refill

Integer int 2

Prescription Status Indicator. Report the status of prescription by numeric value. EXAMPLE: 00 = New Prescription; 01 = First Refill, etc.

Required 100%


Data Element ID

Data Element Name


PC029 Generic Drug Indicator Integer int 1

Generic Drug Indicator. Report if the drug dispensed is generic. EXAMPLE: 1 = Yes, the drug reported is a generic. 1 - Yes 2 - No 3 - Unknown

Required 100%

PC030 Dispense as Written Code Integer int 1

Dispense As Written (DAW) / Product Selection Code. Report the value that defines how the drug was dispensed. EXAMPLE: 0 = Not dispensed as written. 1 - Physician dispense as written 2 - Member dispense as written 3 - Pharmacy dispense as written 4 - No generic available 5 - Brand dispensed as generic 6 - Override 7 - Substitution not allowed, brand drug mandated by law 8 - Substitution allowed, generic drug not available in marketplace 9 - Other 0 - Not dispensed as written

Required 100%

PC031 Compound Drug Indicator Integer int 1

Compound Drug Indicator. Report if the drug dispensed is a compound drug. EXAMPLE: 1 = Yes, drug is a compound. 1 - Yes 2 - No 3 - Unknown

Required 100%

PC032 Date Prescription Filled


Prescription Filled Date. Report the date the pharmacy filled AND dispensed prescription to the Member in CCYYMMDD Format.

Required 100%

PC033 Quantity Dispensed

Quantity - Integer ±varchar 20

Claim Line Units Dispensed. Report the number of metric units of medication dispensed. Decimal allowed in this field.

Required 100%

PC034 Days Supply Quantity - Integer ±varchar 4

Prescription Days Supply. Report the number of days the prescription will last if taken as prescribed.

Required 100%


Data Element ID

Data Element Name


PC035 Charge Amount Integer ±varchar 10

Total Charges for the Claim Line. Report the total amount the provider / dispensing facility billed the insurance carrier for this claim line service. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required 100%

PC036 Paid Amount Integer ±varchar 10


Required 100%

PC037 Ingredient Cost / List Price Integer ±varchar 10

Ingredient Cost Paid. Report the amount of the List Price or Ingredient Cost. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required 100%

PC038 Postage Amount Claimed Integer ±varchar 10

Postage Amount. Report the amount of postage for this claim line. Report 0 if postage does not apply. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required 100%

PC039 Dispensing Fee Integer ±varchar 10

Dispensing Fee Amount. Report the amount of the dispensing fee. Report 0 if fee does not apply. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required 100%


Data Element ID

Data Element Name


PC040 Copay Amount Integer ±varchar 10


Required 100%

PC041 Coinsurance Amount Integer ±varchar 10


Required 100%

PC042 Deductible Amount Integer ±varchar 10


Required 100%

PC043 Prescribing Provider ID Text varchar 30

Prescribing Provider Identification Number. Report the Reporter-assigned identification number of the Prescribing Provider.

Required 100%

PC044 Prescribing Provider First Name

Text varchar 25

Prescribing Provider's First Name. Report the Prescribing Provider's first name. First name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ʻokinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required 100%


Data Element ID

Data Element Name


PC045 Prescribing Provider Middle Name

Text varchar 25

Prescribing Provider's Middle Name or Initial. Report the Prescribing Provider's middle name or initial here. If Prescribing Provider's middle name is available, report middle name. Middle name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ʻokinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required 2%

PC046 Prescribing Provider Last Name

Text varchar 60

Prescribing Provider's Last Name. Report the Prescribing Provider's last name. Last name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ʻokinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required 100%

PC047 Prescribing Provider DEA Number

Text char 9 Prescribing Provider's DEA Number. Report the DEA number of the Prescribing Provider.

Required 80%

PC048 Prescribing Provider NPI


int 10

Prescribing Provider's National Provider Identifier. Report the National Provider Identifier (NPI) of the Prescribing Provider. This element is looking to capture the NPI of an individual provider, not a group. See External Code Source.

Required 100%

PC049 Prescribing Provider Plan Number

Text varchar 30 Prescribing Provider's Plan Identification Number. Report the Prescribing Provider's Reporter-assigned Plan Number.

Required 100%

PC050 Prescribing Provider License Number

Text varchar 30

Prescribing Provider's License Number. Report the state license number for the Prescribing Provider identified in PC043. For a doctor, this is the medical license, for a non-doctor this is the practice license. Do not zero-fill. If not available, or not applicable, such as for a group or corporate entity, do not report any value here.

Required 10%

PC050A

Prescribing Provider License Number State


char 2

Prescribing Provider's License State / Province. Report the State that issued the Prescribing Provider's license using the two-character abbreviation as defined by the United States Postal Service. See External Code Source.

Required if PC050 is

populated 100%

PC051 Prescribing Provider Street Address

Text varchar 60 Prescribing Provider's Street Address. Report the Prescribing Provider's street address.

Required 50%

PC052 Prescribing Provider Street Address 2

Text varchar 60 Prescribing Provider's Street Address 2. Report the Prescribing Provider's street address that may contain office number, suite, or other secondary information besides the street.

Required 5%


Data Element ID

Data Element Name


PC053 Prescribing Provider City Name

Text varchar 30 Prescribing Provider's City Name. Report the Prescribing Provider's city name.

Required 50%

PC054 Prescribing Provider State


char 2

Prescribing Provider's State / Province. Report the State of the Prescribing Provider using the two-character abbreviation as defined by the United States Postal Service. See External Code Source.

Required 50%

PC055 Prescribing Provider Zip Code


varchar 9

Prescribing Provider's Zip Code. Report the 5- or 9-digit Zip Code of the Prescribing Provider as defined by the United States Postal Service. When submitting the 9-digit Zip Code do not include hyphen. See External Code Source.

Required 50%


Required 0%

PC057 Mail Order Pharmacy Integer int 1

Mail Order Option Indicator. Report if the pharmacy is a mail order pharmacy. EXAMPLE: 1 = Yes, pharmacy is a mail order pharmacy. 1 - Yes 2 - No 3 - Unknown 4 - Other 5 - Not Applicable

Required 100%

PC058 Script Number Text varchar 20 Prescription Number. Report the unique prescription number. Required 100%

PC059 Member PCP NPI


int 10 Member's PCP National Provider Identifier. Report the National Provider Identifier (NPI) of the Member's PCP. See External Code Source.

Required 0%

PC060 Single / Multiple Source Indicator

Integer int 1

Drug Source Indicator. Report the value that defines the availability of the pharmaceutical. EXAMPLE: 1 = Multi-source brand. 1 - Multi-source brand 2 - Multi-source brand with generic equivalent 3 - Single source brand 4 - Single source brand with generic equivalent 5 - Unknown

Required 100%


Data Element ID

Data Element Name



Required 0%

PC062 Billing Provider Tax ID Number Integer int 9

Billing Provider's EIN / Federal Tax ID Number. Report the EIN / Federal Tax ID of the Billing Provider. Do not use hyphen or alpha prefix.

Required 100%

PC063 Paid Date Date - Integer int 8

Paid Date of the Claim Line. Report the date that appears on the check and/or remit and/or explanation of benefits and corresponds to any and all types of payment in CCYYMMDD format. This can be the same date as AP Date (PC017).

Required 100%

PC064 Date Prescription Written


Date of Prescription. Report the date that was written on the prescription or called-in by the Prescribing Provider's office in CCYYMMDD format.

Required 100%

PC065

Coordination of Benefits / TPL Liability Amount


Secondary Carrier Amount Due. Report the amount that another carrier / insurer is liable for after Reporter has processed this claim line. Report 0 if there is no COB / TPL amount. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required when PC025 = 19, 20,

or 21 100%

PC066 Other Insurance Paid Amount Integer ±varchar 10

Primary / Prior Carrier Paid Amount. Report the amount that a prior payer has paid for this claim line. Indicates the Reporter is 'secondary' to the prior payer. Only report 0 if the Prior Payer paid 0 towards this claim line, else do not report any value here. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.


20, or 21 100%

PC067 Medicare Paid Amount Integer ±varchar 10

Medicare Paid Amount. Report the amount Medicare paid towards this claim line. Only report 0 here if Medicare paid 0. If Medicare did not pay towards this claim line do not report any value here. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required when PC112 = 1

100%


Data Element ID

Data Element Name


PC068 Allowed Amount Integer ±varchar 10

Allowed Amount. Report the maximum amount contractually allowed, and that a carrier will pay to a provider for a particular procedure or service. This will vary by provider contract and most often it is less than or equal to the fee charged by the provider. Report 0 when the claim line is denied. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required when PC025 does not = 04, 22, or 23

100%

PC069 Member Total Out of Pocket Amount


Total Member Out of Pocket Amount. Report the total amount the Member is responsible to pay to the provider as part of their costs for services. This is the sum of copay, coinsurance, deductible, and other charges the Member is responsible for. Report 0 if there are no out of pocket expenses. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required 100%

PC070 Rebate Indicator Integer int 1

Drug Rebate Eligibility Indicator. Report the value that defines the drug rebate status. EXAMPLE: 1 = Yes, drug is eligible for a rebate to any entity. 1 - Yes 2 - No 3 - Unknown

Required 100%

PC071 State Sales Tax Integer ±varchar 10

State Sales Tax. Report the amount of state sales tax applied to this claim line. Report 0 if state sales tax does not apply. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required 100%


Required 0%


Data Element ID

Data Element Name


PC073 Formulary Code Integer int 1

Formulary Inclusion Identifier. Report the value that defines the formulary code status. EXAMPLE: 1 = Yes, drug is on the formulary. 1 - Yes 2 - No 3 - Unknown

Required 100%

PC074 Route of Administration Integer int 2

Route of Administration. Report pharmaceutical Route of Administration indicator that defines method of drug administration. EXAMPLE: 11 = Oral. 01 - Buccal 02 - Dental 03 - Inhalation 04 - Injection 05 - Intraperitoneal 06 - Irrigation 07 - Mouth / Throat 08 - Mucous Membrane 09 - Nasal 10 - Ophthalmic 11 - Oral 12 - Other / Misc 13 - Otic 14 - Perfusion 15 - Rectal 16 - Sublingual 17 - Topical 18 - Transdermal 19 - Translingual 20 - Urethral 21 - Vaginal 22 - Enteral 99 - Other 00 - Not Specified

Required 100%


Data Element ID

Data Element Name


PC075 Drug Unit of Measure Text varchar 3

Units of Measure. Report the value that defines the unit of measure for drug dispensed. EXAMPLE: EA = Each. EA - Each F2 - International Units GM - Grams ML - Milliliters MG - Milligram MEQ - Milliequivalent MM - Millimeter UG - Microgram UU - Unit

Required 100%

PC101 Subscriber Last Name Text

varchar 60


Required 100%

PC102 Subscriber First Name Text

varchar 25


Required 100%

PC103 Subscriber Middle Name Text

varchar 25


Required 2%

PC104 Member Last Name Text

varchar 60


Required 100%


Data Element ID

Data Element Name


PC105 Member First Name Text

varchar 25


Required 100%

PC106 Member Middle Name Text

varchar 25


Required 2%

PC107 Carrier Specific Unique Member ID


Required 100%

PC108 Carrier Specific Unique Subscriber ID


Required 100%


Required 0%

PC110 Claim Line Type Text char 1


Required 100%

PC111 Former Claim Number Text varchar 35

Previous Claim Number. Report the Claim Control Number (PC004) that was originally sent in a prior filing that this line corresponds to. When reported, this data cannot equal its own PC004.

Required 0%


Data Element ID

Data Element Name


PC112 Medicare Indicator Integer int 1

Indicator - Medicare Payment Applied. Report the value that defines if Medicare paid for this claim line. EXAMPLE: 1 = Yes, Medicare paid for part or all of services. 1 - Yes 2 - No 3 - Unknown 4 - Other 5 - Not Applicable

Required 100%

PC113 Pregnancy Indicator Integer int 1

Indicator - Pregnancy. Report the pregnancy status of the Member. EXAMPLE: 1 = Yes, the Member is pregnant. 1 - Yes 2 - No 3 - Unknown 4 - Other 5 - Not Applicable

Required 100%

PC114 Diagnosis Code


varchar 7 ICD Diagnosis Code. Report the ICD Diagnosis Code when applicable. See External Code Source.

Required 1%

PC115 ICD Indicator Integer int 1


Required when PC114 is

populated 100%


Data Element ID

Data Element Name


PC116 Denied Flag Integer int 1

Denied Claim Line Indicator. Report the denial status of the claim line. EXAMPLE: 1 = Yes, Claim Line was denied. 1 - Yes 2 - No 3 - Unknown 4 - Other 5 - Not Applicable


100%

PC117 Denial Reason


varchar 30



100%

PC118 Payment Arrangement Type

Integer int 2


Required 100%

PC119 EUTF HB Number Text char 9



100%


Data Element ID

Data Element Name


PC120 APCD ID Code Integer int 1


Required 100%

PC121 Claim Line Paid Flag Integer int 1

Claim Line Paid Indicator. Report the paid status of the claim line. EXAMPLE: 1 = Yes, Claim Line was paid. 1 - Yes 2 - No 3 - Unknown 4 - Other 5 - Not Applicable


03, 19, 20, 21 100%

PC122 Medicaid ID Text varchar 20

Medicaid-Assigned Member ID. Report the unique ID that Medicaid uses to identify a member. This ID must be on all lines of eligibility for Med-QUEST and Medicaid MCOs. This element is required for Med-QUEST carriers only. Non-Med-QUEST carriers should not report any value here.


100%

PC899 Record Type Text char 2 File Type Identifier. Report PC here. This validates the type of file and the data contained within the file. This must match HD004.

Required 100%


Appendix D: Detailed Dental Claims File Requirements Data Element ID

Data Element Name


DC001 Submitter Text char 6 Submitter ID. Report the SHPDA defined and maintained unique identifier. This must match the Submitter ID reported in HD002.

Required 100%

DC002 Health Plan ID Integer int 10



0%

DC003 Insurance Type Code / Product Text char 2

Insurance Type / Product Identification Code. Report the code that defines the type of insurance under which this Member's claim line was processed. EXAMPLE: 17 = Dental Maintenance Organization. 09 - Self-pay 10 - Central Certification 11 - Other Non-Federal Programs 12 - Preferred Provider Organization (PPO) 13 - Point of Service (POS) 14 - Exclusive Provider Organization (EPO) 15 - Indemnity Insurance 16 - Health Maintenance Organization (HMO) Medicare Risk 17 - Dental Maintenance Organization (DMO) AM - Automobile Medical BL - Blue Cross/Blue Shield CH - Champus CI - Commercial Insurance Company DS - Disability FI - Federal Employees Program HM - Health Maintenance Organization LM - Liability Medical MA - Medicare Part A MB - Medicare Part B MC - Medicaid MD - Medicare Part D TV - Title V VA - Veteran's Affairs Plan WC - Workers' Compensation Health Claim ZZ - Other

Required 100%


Data Element ID

Data Element Name


DC004 Payer Claim Control Number Text varchar 35


Required 100%

DC005 Line Counter Integer varchar 4


Required 100%

DC005A Version Number Integer varchar 4



0%

DC006 Insured Group or Policy Number

Text varchar 30

Insured Group / Policy Number. Report the insured group or policy number associated with the group who has purchased the insurance. Do not report the number that uniquely identifies the Subscriber or Member.

Required 100%

DC007 Subscriber SSN Integer int 9 Subscriber's Social Security Number. Report the Subscriber's 9-digit SSN here. Do not use hyphen.

Required 100%

DC008 Plan Specific Contract Number

Text varchar 30


Required 100%

DC009 Member Suffix or Sequence Number


Required 100%

DC010 Member SSN Integer int 9 Member's Social Security Number. Report the Member's 9-digit SSN. Do not use hyphen.

Required 100%


Data Element ID

Data Element Name


DC011 Individual Relationship Code

Text char 2


Required 100%

DC012 Member Gender Text char 1


Required 100%

DC013 Member Date of Birth



Required 100%


Data Element ID

Data Element Name


DC014 Filler Filler char 0 Filler. SHPDA reserves this field for future use. Do not populate with any data.

Required 0%

DC015 Member State



Required 100%

DC016 Member Zip Code


varchar 9


Required 100%

DC017 Date Service Approved (AP Date)


Date Service Approved by Payer. Report the date that the payer approved this claim line for payment in CCYYMMDD format. This element was designed to capture date other than the Paid Date. If Approved Date and Paid Date are the same, then the date here should match Paid Date reported in DC045.

Required 100%

DC018 Service Provider Number

Text varchar 30 Service Provider's Identification Number. Report the Reporter assigned, unique Service Provider identification number used internally by the Reporter.

Required 100%

DC019 Service Provider Tax ID Number

Integer int 9 Service Provider's EIN / Federal Tax ID Number. Report the EIN / Federal Tax ID of the Service Provider. Do not use hyphen or alpha prefix.

Required 100%

DC020 Service Provider NPI


int 10 Service Provider's National Provider Identifier. Report the National Provider Identifier (NPI) of the Service Provider. See External Code Source.

Required 100%

DC021 Service Provider Entity Type Qualifier

Integer int 1

Service Provider's Entity Type Qualifier Code. Report the value that defines the provider entity type. Individuals should be identified with a 1; facilities, professional groups, and clinic sites should all be identified with a 2. EXAMPLE: 1 = Person. 1 - Person 2 - Non-Person Entity

Required 100%


Data Element ID

Data Element Name


DC022 Service Provider First Name

Text varchar 25

Service Provider's First Name. Report the Service Provider's first name. If the Service Provider is a facility or organization, do not report any value here. First name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ʻokinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required when DC021 = 1

100%

DC023 Service Provider Middle Name

Text varchar 25

Service Provider's Middle Name or Initial. Report the Service Provider's middle name or initial. If the Service Provider is a facility or organization, do not report any value here. If Service Provider's middle name is available, report middle name. Middle name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ʻokinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.


2%

DC024

Service Provider Last Name or Organization Name

Text varchar 60

Service Provider's Last Name or Organization Name. Report the name of the organization or the Service Provider's last name. DC021 determines if an Organization or Service Provider's name is reported here. Last name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ʻokinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces.

Required 100%


Required 0%

DC025A Service Provider Suffix Integer int 1

Service Provider's Name Suffix. Report the Service Provider's name-suffix when applicable here. Used to capture the generation of the individual clinician (e.g., Jr. Sr., III). Do not report degree acronyms here. EXAMPLE: 4 = Jr. 1 - I. 2 - II. 3 - III. 4 - Jr. 5 - Sr. 0 - Unknown/Not Applicable


2%


Data Element ID

Data Element Name


DC026 Service Provider Taxonomy


varchar 10

Service Provider's Taxonomy Code. Report the taxonomy code that defines this provider for this line of service. Taxonomy values allow for the reporting of hygienists, assistants and laboratory technicians, where applicable, as well as Dentists, Orthodontists, etc. See External Code Source.

Required 100%

DC027 Service Provider City Name

Text varchar 30 Service Provider's City Name. Report the city name of the Service Provider's practice location.

Required 100%

DC028 Service Provider State


char 2

Service Provider's State / Province. Report the State of the Service Provider's practice location as location using the two-character abbreviation as defined by the United States Postal Service. See External Code Source.

Required 100%

DC029 Service Provider Zip Code


varchar 9

Service Provider's Zip Code. Report the 5- or 9-digit Zip Code of the Service Provider's practice location as defined by the United States Postal Service. When submitting the 9-digit Zip Code do not include hyphen. See External Code Source.

Required 100%

DC030 Facility Type - Professional


int 2 Place of Service Code. Report the Place of Service Code that defines the location code where services were performed by the provider referenced on the claim. See External Code Source.

Required 100%

DC031 Claim Status Integer int 2

Claim Line Status Code. Report the Claim Status Code that defines the payment status of this claim line. EXAMPLE: 01 = Processed as Primary. 01 - Processed as Primary 02 - Processed as Secondary 03 - Processed as Tertiary 04 - Denied 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 23 - Not our Claim, Forwarded to Additional Payer(s) 25 - Predetermination Pricing Only - No Payment

Required 100%

DC032 CDT Code


varchar 5 Code on Dental Procedures and Nomenclature (CDT) Code. Report the Code on Dental Procedures and Nomenclature here. See External Code Source.

Required 100%


Data Element ID

Data Element Name


DC033 Procedure Modifier - 1


char 2

Procedure Code Modifier. Report a valid Procedure modifier when a modifier clarifies / improves the reporting accuracy of the associated procedure code (DC032). See External Code Source.


0%

DC034 Procedure Modifier - 2


char 2



0%

DC034A Procedure Modifier - 3


char 2



0%

DC034B Procedure Modifier - 4


char 2



0%

DC035 Date of Service - From


Date of Service - From. Report the first date of service for the claim line in CCYYMMDD format.

Required 100%

DC036 Date of Service - Thru


Date of Service - Thru. Report the last date of service for the claim line in CCYYMMDD format. This equals DC035 when a single date of service is reported.

Required 100%

DC037 Charge Amount Integer ±varchar 10

Total Charges for the Claim Line. Report the total amount the provider billed the insurance carrier for this claim line service. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required 100%

DC038 Paid Amount Integer ±varchar 10


Required 100%


Data Element ID

Data Element Name


DC039 Copay Amount Integer ±varchar 10


Required 100%

DC040 Coinsurance Amount Integer ±varchar 10


Required 100%

DC041 Deductible Amount Integer ±varchar 10


Required 100%


Required 0%


Required 0%

DC044 Billing Provider Tax ID Number Integer int 9

Billing Provider's EIN / Federal Tax ID Number. Report the EIN / Federal Tax ID of the Billing Provider. Do not use hyphen or alpha prefix.

Required 100%

DC045 Paid Date Date - Integer int 8

Paid Date of the Claim Line. Report the date that appears on the check and / or remit and/or explanation of benefits and corresponds to any and all types of payment in CCYYMMDD format. This can be the same date as AP Date (DC017).

Required 100%


Data Element ID

Data Element Name


DC046 Allowed Amount Integer ±varchar 10

Allowed Amount. Report the maximum amount contractually allowed, and that a carrier will pay to a provider for a particular procedure or service. This will vary by provider contract and most often it is less than or equal to the fee charged by the provider. Report 0 when the claim line is denied. Do not code decimal or round up / down to whole dollars. Code zero cents (00) when applicable. EXAMPLE: 100.00 is reported as 10000; 100.50 is reported as 10050.

Required when DC031 does not = 04, 22, or 23

100%

DC047 Tooth Number/Letter


varchar 2

Tooth Number or Letter Identification. Report the Tooth Number or Letter Identification when DC032 is within the given range. This should be in accordance with the Universal National Tooth Designation System. See External Code Source.

Required 90%

DC048 Dental Quadrant - 1


int 2

Dental Quadrant. Report the standard Dental Quadrant identifier. Provides further detail on procedure(s). See External Code Source. EXAMPLE: 00 = Entire Oral Cavity 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

Required 90%

DC048A Dental Quadrant - 2


int 2

Dental Quadrant. Report the second standard Dental Quadrant identifier. Provides further detail on procedure(s). See External Code Source. EXAMPLE: 00 = Entire Oral Cavity 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

Required 1%


Data Element ID

Data Element Name


DC048B Dental Quadrant - 3


int 2

Dental Quadrant. Report the third standard Dental Quadrant identifier. Provides further detail on procedure(s). See External Code Source. EXAMPLE: 00 = Entire Oral Cavity 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

Required 1%

DC048C Dental Quadrant - 4


int 2

Dental Quadrant. Report the fourth standard Dental Quadrant identifier. Provides further detail on procedure(s). See External Code Source. EXAMPLE: 00 = Entire Oral Cavity 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

Required 1%

DC048D Dental Quadrant - 5


int 2

Dental Quadrant. Report the fifth standard Dental Quadrant identifier. Provides further detail on procedure(s). See External Code Source. EXAMPLE: 00 = Entire Oral Cavity 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

Required 1%


Data Element ID

Data Element Name


DC049 Tooth Surface Code - 1


char 1

Tooth Surface Code. Report the Tooth Surface Code that this service relates to. See External Code Source. EXAMPLE: D = Distal B - Buccal D - Distal F - Facial (or Labial) I - Incisal L - Lingual M - Mesial O - Occlusal

Required 90%

DC049A Tooth Surface Code - 2


char 1

Tooth Surface Code. Report the second Tooth Surface Code that this service relates to. See External Code Source. EXAMPLE: D = Distal B - Buccal D - Distal F - Facial (or Labial) I - Incisal L - Lingual M - Mesial O - Occlusal

Required 1%

DC049B Tooth Surface Code - 3


char 1

Tooth Surface Code. Report the third Tooth Surface Code that this service relates to. See External Code Source. EXAMPLE: D = Distal B - Buccal D - Distal F - Facial (or Labial) I - Incisal L - Lingual M - Mesial O - Occlusal

Required 1%


Data Element ID

Data Element Name


DC049C Tooth Surface Code - 4


char 1

Tooth Surface Code. Report the fourth Tooth Surface Code that this service relates to. See External Code Source. EXAMPLE: D = Distal B - Buccal D - Distal F - Facial (or Labial) I - Incisal L - Lingual M - Mesial O - Occlusal

Required 1%

DC049D Tooth Surface Code - 5


char 1

Tooth Surface Code. Report the fifth Tooth Surface Code that this service relates to. See External Code Source. EXAMPLE: D = Distal B - Buccal D - Distal F - Facial (or Labial) I - Incisal L - Lingual M - Mesial O - Occlusal

Required 1%

DC050 Subscriber Last Name Text

varchar 60


Required 100%

DC051 Subscriber First Name Text

varchar 25


Required 100%


Data Element ID

Data Element Name


DC052 Subscriber Middle Name Text

varchar 25


Required 2%

DC053 Member Last Name Text

varchar 60


Required 100%

DC054 Member First Name Text

varchar 25


Required 100%

DC055 Member Middle Name Text

varchar 25


Required 2%

DC056 Carrier Specific Unique Member ID


Required 100%

DC057 Carrier Specific Unique Subscriber ID


Required 100%

DC058 Filler Filler Filler 0 Filler. SHPDA reserves this field for future use. Do not populate with any data.

Required 0%


Data Element ID

Data Element Name


DC059 Claim Line Type Text char 1


Required 100%

DC060 Former Claim Number Text varchar 35

Previous Claim Number. Report the Claim Control Number (DC004) that was originally sent in a prior filing that this line corresponds to. When reported, this data cannot equal its own DC004.

Required 0%

DC061 Principal Diagnosis Code


varchar 7 Principal ICD Diagnosis Code. Report the Principal ICD Diagnosis Code when applicable. See External Code Source.


1%

DC061A Other Diagnosis Code - 1


varchar 7 Other ICD Diagnosis Code - 1. Report the Other ICD Diagnosis Code - 1 when applicable. See External Code Source.


0%

DC061B Other Diagnosis Code - 2




0%

DC061C Other Diagnosis Code - 3




0%

DC062 ICD Indicator Integer int 1


Required when DC061 is

populated 100%


Data Element ID

Data Element Name


DC062A Diagnostic Code Pointer Integer varchar 4

Diagnostic Pointer Number. Report the placement number of the diagnosis(es) a procedure is related to for a professional claim. Can report up to four diagnostic positions within the first nine diagnoses that can be reported. Do not separate multiple mappings with spaces, zeros, or special characters. Do not zero fill.

Required when DC061, DC061A,

DC61B, or DC061C is populated

100%

DC062B Quantity Quantity - Integer ±varchar 15

Count of Services. Report the count of services / units of the procedure performed in DC032. EXAMPLE: 01 = One procedure performed.

Required when DC032 is

populated, and procedure performed

more than once.

100%

DC063 Denied Flag Integer int 1

Denied Claim Line Indicator. Report the denial status of the claim line. EXAMPLE: 1 = Yes, Claim Line was denied. 1 - Yes 2 - No 3 - Unknown 4 - Other 5 - Not Applicable


100%

DC064 Denial Reason


varchar 20



100%


Data Element ID

Data Element Name


DC065 Payment Arrangement Type

Integer int 2


Required 100%

DC066 EUTF HB Number Text char 9



100%

DC067 APCD ID Code Integer int 1


Required 100%

DC068 Claim Line Paid Flag Integer int 1

Claim Line Paid Indicator. Report the paid status of the claim line. EXAMPLE: 1 = Yes, Claim Line was paid. 1 - Yes 2 - No 3 - Unknown 4 - Other 5 - Not Applicable

Required when DC031 = 01, 02,

03, 19, 20, 21 100%


Data Element ID

Data Element Name


DC069 Medicaid ID Text varchar 20

Medicaid-Assigned Member ID. Report the unique ID that Medicaid uses to identify a member. This ID must be on all lines of eligibility for Med-QUEST and Medicaid MCOs. This element is required for Med-QUEST carriers only. Non-Med-QUEST carriers should not report any value here.


100%

DC899 Record Type Text char 2 File Type Identifier. Report DC here. This validates the type of file and the data contained within the file. This must match HD004.

Required 100%


Appendix E: Detailed Provider File Requirements Data Element ID

Data Element Name


PV001 Submitter Text char 6 Submitter ID. Report the SHPDA defined and maintained unique identifier. This must match the Submitter ID reported in HD002.

Required 100%

PV002 Provider ID Text varchar 30

Provider's Identification Number. Report the Reporter assigned, unique Provider identification number used internally by the Reporter for every Service Provider (persons, facilities or other entities involved in claims transactions) that it has in its system(s). This element may or may not contain the provider NPI.

Required 100%

PV003 Tax ID Integer int 9 Provider's EIN / Federal Tax ID Number. Report the EIN/Federal Tax ID of the Provider. Do not use hyphen or alpha prefix.

Required when PV034 = 2, 3, 4,

5, 6, 7, or 0 100%

PV004 UPIN ID Text char 6 Provider's UPIN Number. Report the UPIN for the Provider identified in PV002. To report other Medicare Identifiers, use PV036.

Required when PV034 = 1

100%

PV005 DEA ID Text char 9 Provider's DEA Number. Report the DEA number of the individual provider, group, or facility defined by PV002. If not available or applicable, do not report any value here.


3, 4, or 5 100%

PV006 License ID Text varchar 25

Provider's License Number. Report the state license number for the provider identified in PV002. For a doctor, this is the medical license for a non-doctor this is the practice license. Do not use zero-fill. If not available, or not applicable, such as for a group or corporate entity, do not report any value here.

Required 100%

PV006A License ID State


char 2

Provider's License State / Province. Report the State that issued the Provider's license using the two-character abbreviation as defined by the United States Postal Service. See External Code Source.

Required 100%

PV007 Medicaid ID Text varchar 30

Provider's Med-QUEST-assigned Number. Report the Medicaid number for the provider identified in PV002. Do not use zero-fill. Do not report any value if not available, or not applicable, such as for a group or corporate entity.

Required 100%


Data Element ID

Data Element Name


PV008 Provider Last Name Text varchar 50

Provider's Last Name. Report the Provider's last name. Last name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ʻokinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces. Do not report any value here for facility or non-individual provider records. Report non-person entities in PV012 Entity Name.


100%

PV009 Provider First Name Text varchar 25

Provider's First Name. Report the Provider's first name. First name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ʻokinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces. Do not report any value here for facility or non-individual provider records. Report non-person entities in PV012 Facility Name.


100%

PV010 Provider Middle Initial Text varchar 25

Provider's Middle Name or Initial. Report the Provider's middle name or initial. If Provider's middle name is available, report middle name. Middle name should exclude all punctuation, including but not limited to, hyphens, apostrophes, ʻokinas, and kahakōs, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces. Do not report any value here for facility or non-individual provider records. Report non-person entities in PV012 Facility Name.


2%

PV011 Provider Suffix Integer int 1

Provider Name Suffix. Report the individuals name-suffix when applicable here. Used to capture the generation of the individual clinician (e.g., Jr. Sr., III). Do not report degree acronyms here. Do not report any value here for facility or non-individual provider records. Report non-person entities in PV012 Facility Name. EXAMPLE: 0 = Unknown / Not Applicable 1 - I. 2 - II. 3 - III. 4 - Jr. 5 - Sr. 0 - Unknown/Not Applicable


2%


Data Element ID

Data Element Name


PV012 Entity Name Text varchar 100 Group / Facility Name. Report the Provider's Entity Name when PV034 does not equal 1. This should only be populated for facilities or groups. Limited punctuation may be included.


5, 6, 7, or 0 100%

PV013 Entity Code Integer int 2

Provider Entity Code. Report the value that defines the entity provider type. EXAMPLE: 12 = Acute Hospital 01 - Academic Institution 02 - Adult Foster Care 03 - Ambulance Services 04 - Hospital Based Clinic 05 - Stand-Alone, Walk-In / Urgent Care Clinic 06 - Other Clinic 07 - Community Health Center - General 08 - Community Health Center - Urgent Care 09 - Government Agency 10 - Health Care Corporation 11 - Home Health Agency 12 - Acute Hospital 13 - Chronic Hospital 14 - Rehabilitation Hospital 15 - Psychiatric Hospital 16 - DPH Hospital 17 - State Hospital 18 - Veterans Hospital 19 - DMH Hospital 20 - Sub-Acute Hospital 21 - Licensed Hospital Satellite Emergency Facility 22 - Hospital Emergency Center 23 - Nursing Home 24 - Freestanding Ambulatory Surgery Center 25 - Hospital Licensed Ambulatory Surgery Center 26 - Non-Health Corporations 27 - School Based Health Center 28 - Rest Home 29 - Licensed Hospital Satellite Facility 30 - Hospital Licensed Health Center 31 - Other Facility 40 - Physician (PV034 = 1) 50 - Physician Group (PV034 = 3) 60 - Nurse (PV034 = 1) 70 - Clinician (PV034 = 1) 80 - Technician (PV034 = 1) 90 - Pharmacy / Site or Mail Order (PV034 = 4 or 5) 99 - Other Individual or Group (PV034 = 1 or 3)


5, 6, 7, or 0 100%


Data Element ID

Data Element Name


PV014 Provider Gender Text char 1

Provider's Gender. Report Provider's gender as found on certification, contract, and/or license in alpha format. EXAMPLE: F = Female. F - Female M - Male U - Unknown


100%

PV015 Provider Date of Birth


Provider's Date of Birth. Report the Provider's date of birth in CCYYMMDD Format. This only applies to providers identified as Person. Do not report any value here for non-person entities, e.g. Professional Groups, Medical Sites.


100%

PV016 Provider Street Address Text varchar 60

Provider's Street Address. Report the physical street address where provider sees plan Members. If only mailing address is available, please send the mailing address in this element in addition to putting it in the mailing address element. If the provider sees Members at two or more locations, the provider should have a unique record for each to capture each site where the provider practices.

Required 100%

PV017 Provider Street Address 2 Text varchar 60

Provider's Street Address 2. Report the physical street address where provider sees plan members. If only mailing address is available, please send the mailing address in this element in addition to putting it in the mailing address element. If the provider sees Members at two or more locations, the provider should have a unique record for each to capture each site where the provider practices.

Required 25%

PV018 Provider City Name Text varchar 30

Provider's City Name. Report the city name where provider sees Members. If only mailing address is available, please send the mailing address in this element in addition to putting it in the mailing address element. If the provider sees Members at two or more locations, the provider should have a unique record for each to capture each site where the provider practices.

Required 100%

PV019 Provider State

Text - External Source Code

char 2

Provider's State / Province. Report the State of the site in which the provider sees plan Members. When only a mailing address is available, populate with Mailing State here as well as PV026. If the provider sees Members at two or more locations, the provider should have a unique record for each location to capture each site where the provider practices. See External Code Source.

Required 100%


Data Element ID

Data Element Name


PV020 Provider Country Code


char 3 Provider's Country Code. Report the three-character country code as defined by ISO 3166-1, Alpha 3. See External Code Source.

Required 100%

PV021 Provider Zip Code

Integer - External Source Code

varchar 9

Provider's Zip Code. Report the 5- or 9-digit Zip Code of the Provider as defined by the United States Postal Service. When submitting the 9-digit Zip Code do not include hyphen. See External Code Source.

Required 100%

PV022 Provider Taxonomy


char 10

Provider's Taxonomy Code. Report the WPC taxonomy code that defines this provider. Taxonomy values allow for the reporting of clinicians, assistants, and technicians, where applicable, as well as physicians, nurses, medical groups, facilities, etc. See External Code Source.


3, 4, or 5 100%

PV023 Provider Mailing Address Text varchar 60

Provider's Mailing Street Address. Report the mailing street address of the Provider / Entity in PV002.

Required 100%

PV024 Provider Mailing Address 2

Text varchar 60 Provider's Mailing Street Address 2. Report the mailing street address of the Provider / Entity in PV002.

Required 50%

PV025 Provider Mailing City Name

Text varchar 30 Provider's Mailing City Name. Report the city of the mailing address of the Provider / Entity in PV002.

Required 100%

PV026 Provider Mailing State


char 2 Provider's Mailing State. Report the state of the mailing address of the Provider / Entity in PV002. See External Code Source.

Required 100%

PV027 Provider Mailing Country Code


char 3 Provider's Mailing Country Code. Report the mailing three-character country code of as defined by ISO 3166-1, Alpha 3 of the Provider / Entity in PV002. See External Code Source.

Required 100%

PV028 Provider Mailing Zip Code

Integer - External Source Code

varchar 9

Provider's Mailing Zip Code. Report the 5- or 9-digit mailing Zip Code of the Provider as defined by the United States Postal Service. When submitting the 9-digit Zip Code do not include hyphen. See External Code Source.

Required 100%


Data Element ID

Data Element Name


PV029 Provider Type Code

Carrier Defined Table - Text

varchar 10

Provider Type Code. Report the Provider Type code associated with the individual provider or facility. The Reporter must provide the SHPDA with Reference tables. This element distinguishes clinicians, facilities, and other. Clinicians are physicians and other practitioners who can perform an E&M service (thereby start an episode of care). Facilities can sometimes start episodes (i.e. patient goes to ER at onset of symptoms). Providers classified as 'other' never start episodes. The SHPDA may use this element to perform further clinical and analytic grouping. Entities not seeing patients should have a classification of 'Other'.

Required 100%

PV030 Primary Specialty Code


char 2 Specialty Code. Report the standard CMS Primary Specialty code of the Provider. See External Code Source.


3, 4, or 5 100%

PV031 Filler Filler char 0 Filler. SHPDA reserves this field for future use. Do not populate with any data.

Required 0%


Required 0%


Required 0%


Data Element ID

Data Element Name


PV034 Provider ID Code Integer int 1

Provider Identification Code. Report the value that defines type of entity associated with PV002. The value reported here drives intake edits for quality purposes. EXAMPLE: 1 = Person, Physician, Clinician, Orthodontist, etc. 1 - Person; physician, clinician, orthodontist, and any individual that is licensed/certified to perform health care services. 2 - Facility; hospital, health center, long term care, rehabilitation and any building that is licensed to transact health care services. 3 - Professional Group; collection of licensed/certified health care professionals that are practicing health care services under the same entity name and Federal Tax Identification Number. 4 - Retail Site; brick-and-mortar licensed/certified place of transaction that is not solely a health care entity, i.e., pharmacies, independent laboratories, vision services. 5 - E-Site; internet-based order/logistic system of health care services, typically in the form of durable medical equipment, pharmacy or vision services. Address assigned should be the address of the company delivering services or order fulfillment. 6 - Financial Parent; financial governing body that does not perform health care services itself but directs and finances health care service entities, usually through a Board of Directors. 7 - Transportation; any form of transport that conveys a patient to/from a healthcare provider. 0 - Other; any type of entity not otherwise defined that performs health care services.

Required 100%


Required 0%

PV036 Medicare ID Text varchar 30

Provider's Medicare Number, other than UPIN. Report the Medicare ID (OSCAR, Certification, Other, Unspecified, NSC or PIN) of the provider or entity in PV002. Do not report UPIN here, see PV004.


3, 4, or 5 90%

PV037 Begin Date Date - Integer int 8

Provider Start Date. Report the date the provider or facility becomes eligible / contracted to perform services for plan Members in CCYYMMDD Format.

Required 100%

PV038 End Date Date - Integer int 8

Provider End Date. Report the date the provider or facility is no longer eligible to perform services for plan Members in CCYYMMDD Format. Do not report any value here for providers that are still actively eligible to provide services.

Required 0%


Data Element ID

Data Element Name


PV039 National Provider ID


int 10 National Provider Identifier (NPI) of the Provider. Report the NPI of the Provider / Clinician / Facility / Organization defined in this record.


3, 4, or 5 100%

PV040 National Provider ID - 2


int 10 National Provider Identifier (NPI) of the Provider. Report the Secondary or Other NPI of the Provider / Clinician / Facility / Organization defined in this record.


3, 4, or 5 1%


Required 0%

PV042 Proprietary Specialty Code


varchar 10

Specialty Code. Report the Reporter's proprietary specialty code for the provider here. Known additional specialty code for a provider should be populated in elements PV043 and PV044. Value comes from a Reporter Defined Table only.


3, 4, or 5 and PV030 is blank

100%

PV043 Other Specialty Code - 2


varchar 10

Other Specialty Code - 2. See mapping notes for primary specialty code in PV030. Known additional specialty code for a provider should be populated in this element. Value can come from either a Reporter Table or the External Code Source.


3, 4, or 5 0%

PV044 Other Specialty Code - 3


varchar 10

Specialty Code. See mapping notes for primary specialty code in PV030. Known additional specialty code for a provider should be populated in this element. Value can come from either a Reporter Defined Table or the External Code Source.


3, 4, or 5 0%

PV045 Pay for Performance Flag

Integer int 1

Provider Contract Payment Indicator. Report the value that defines the element. Pay-for-performance bonuses or year-end withhold returns based on performance for at least one service performed by this provider within the month. EXAMPLE: 1 = Yes, provider has a contract incentive. 1 - Yes 2 - No 3 - Unknown 4 - Other 5 - Not Applicable

Required when PV034 = 1, 2, or

3 100%


Data Element ID

Data Element Name


PV046 Non-Claims Flag Integer int 1

Provider Contract Payment Indicator. Report the value that defines if the provider is eligible to receive other payments not flowing through the claims system. Non-Claims payments that occur at least once within the month must be reported. EXAMPLE: 1 = Yes, provider may be eligible to receive other payments not flowing through the claims system. 1 - Yes 2 - No 3 - Unknown 4 - Other 5 - Not Applicable

Required 100%


Required 0%


Required 0%

PV049 New Patients Flag Integer int 1

New Patients Accepted Indicator. Report the value that defines if the provider is accepting new patients as of the date the file was created for this submission. EXAMPLE: 1 = Yes, provider or provider group is accepting new patients. 1 - Yes 2 - No 3 - Unknown 4 - Other 5 - Not Applicable


3 100%


Required 0%


Required 0%


Data Element ID

Data Element Name


PV052 Multiple Office Provider Flag Integer int 1

Multiple Office Provider Indicator. Report the value that defines if the provider has multiple offices. EXAMPLE: 1 = Yes, provider has multiple offices. 1 - Yes 2 - No 3 - Unknown 4 - Other 5 - Not Applicable


3 100%


Required 0%

PV054 PCMH ID Text varchar 15

Patient Centered Medical Home (PCMH) Identification Number. Report the identifier of the patient-centered medical home the provider is linked-to here. The value in this element must have a corresponding Provider ID (PV002) in this or a previously submitted provider file.


3 0%

PV055 PCP Flag Integer int 1

Indicator - Provider is a PCP. Report the value that defines the element. EXAMPLE: 1 = Yes, provider is a PCP. 1 - Yes 2 - No 3 - Unknown 4 - Other 5 - Not Applicable


100%

PV056 Provider Affiliation Text varchar 30

Provider Affiliation Code. Report the Provider ID for any affiliation the provider has with another entity or parent company. If the provider is associated only with self, record the same value here as PV002.

Required 90%


Required 0%


Required 0%


Required 0%


Data Element ID

Data Element Name


PV060 Office Type Integer int 1

Office Type Code. Report the value that defines the provider's service setting. EXAMPLE: 1 = Facility 1 - Facility 2 - Doctors office 3 - Clinic 4 - Walk in Clinic 5 - Laboratory 0 - Other


3, 4, or 5 100%

PV061 Prescribing Provider Flag Integer int 1

Indicator - Prescribing Authority. Report if the provider has prescribing privileges. EXAMPLE: 1 = Yes, provider has prescribing privileges for pharmaceuticals or DME. 1 - Yes 2 - No 3 - Unknown

Required 100%

PV062 Provider Affiliation Start Date


Provider Start Date. Report the start date of provider's relationship with parent entity / group in PV056 (Provider Affiliation) in CCYYMMDD Format. Providers that are self-affiliated (or no affiliation) should have the same value reported here as in PV037.

Required 100%

PV063 Provider Affiliation End Date


Provider End Date. Report the end date of provider's relationship with parent entity / group in PV056 (Provider Affiliation) in CCYYMMDD Format. Do not report any value here if the affiliation is still active, or if there is no known affiliation in PV056. Self-affiliations should report the same value here as in PV038.

Required 0%


Data Element ID

Data Element Name


PV064 PPO Indicator Integer int 1

Indicator - Provider PPO Contract. Report the value that defines the element. EXAMPLE: 1 = Yes, provider is a contracted network provider. 1 - Yes 2 - No 3 - Unknown 4 - Other 5 - Not Applicable


3, 4, or 5 100%

PV899 Record Type Text char 2 File Type Identifier. Report PV here. This validates the type of file and the data contained within the file. This must match HD004.

Required 100%


Appendix F: External Code Sources

1. State Codes, Zip Codes, and Other Geographic Associations

External Code Source: United States Postal Service (USPS)

Link to Code Source: https://www.usps.com/

Relevant Data Elements: ME016, ME017, ME078, ME109, ME110; MC015, MC016, MC034, MC035, MC135C, MC135D; PC015, PC016, PC023, PC024, PC054, PC055; DC015, DC016, DC028, DC029; PV019, PV021, PV026, PV028

2. ISO 3166-1, Alpha-3 Country Codes

External Code Source: International Organization for Standardization (ISO)

Link to Code Source: https://www.iso.org/obp/ui

Relevant Data Elements: MC070; PC024A; PV020, PV027

3. Race and Ethnicity Codes

External Code Source: Centers for Disease Control and Prevention (CDC)

Link to Code Source: http://www.cdc.gov/nchs/data/dvs/Race Ethnicity CodeSet.pdf

Relevant Data Elements: ME021, ME022, ME025, ME026

4. Language Codes

External Code Source: United States Census Bureau

Link to Code Source: https://www2.census.gov/topics/language-use/appendix-a language-code-list.pdf

Relevant Data Elements: ME033

5. Type of Bill (and Type of Bill Frequency Codes)

External Code Source: National Uniform Billing Committee (NUBC)

Link to Code Source: http://www.nubc.org/

Relevant Data Elements: MC036, MC133

https://www.usps.com/

https://www.iso.org/obp/ui

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

https://www2.census.gov/topics/language-use/appendix-a_language-code-list.pdf

https://www2.census.gov/topics/language-use/appendix-a_language-code-list.pdf

http://www.nubc.org/


6. Facility Type/Place of Service Codes

External Code Source: Centers for Medicare & Medicaid Services (CMS)

Link to Code Source: https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place of Service Code Set.html

Relevant Data Elements: MC037; DC030

7. National Provider Identifier (NPI)


Link to Code Source: https://nppes.cms.hhs.gov/NPPES/

Relevant Data Elements: ME038, ME046; MC026, MC077, MC112, MC125, MC134, MC242; PC021, PC048, PC059; DC020; PV039, PV040

8. Health Care Provider Taxonomy Codes

External Code Source: Washington Publishing Company (WPC)

Link to Code Source: http://www.wpc-edi.com/reference/codelists/healthcare/health-care-provider-taxonomy-code-set/

Relevant Data Elements: MC032; DC026; PV022

9. International Classification of Diseases, Clinical Modification, 9th Revision (ICD-9-CM)


Link to Code Source: https://www.cms.gov/medicare/coding/ICD9providerdiagnosticcodes/codes.html

Relevant Data Elements: MC039, MC040, MC041, MC042, MC043, MC044, MC045, MC046, MC047, MC048, MC049, MC050, MC051, MC052, MC053, MC058, MC083, MC084, MC085, MC086, MC087, MC088, MC088A, MC088B, MC088C, MC088D, MC088E, MC088F, MC136, MC142, MC143, MC144, MC145, MC146, MC147, MC148, MC149, MC150, MC151, MC152, MC153; PC114; DC061, DC061A, DC061B, DC061C

10. International Classification of Diseases, Clinical Modification, 10th Revision (ICD-10-CM)


Link to Code Source: https://www.cms.gov/Medicare/Coding/ICD10/index.html

Relevant Data Elements: MC039, MC040, MC041, MC042, MC043, MC044, MC045, MC046, MC047, MC048, MC049, MC050, MC051, MC052, MC053, MC136, MC142, MC143, MC144, MC145, MC146, MC147, MC148, MC149, MC150, MC151, MC152, MC153; PC114; DC061, DC061A, DC061B, DC061C

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

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

https://nppes.cms.hhs.gov/NPPES/

http://www.wpc-edi.com/reference/codelists/healthcare/health-care-provider-taxonomy-code-set/

http://www.wpc-edi.com/reference/codelists/healthcare/health-care-provider-taxonomy-code-set/

https://www.cms.gov/medicare/coding/ICD9providerdiagnosticcodes/codes.html

https://www.cms.gov/Medicare/Coding/ICD10/index.html


11. International Classification of Diseases, Procedure Coding System, 10th Revision (ICD-10-PCS)


Link to Code Source: https://www.cms.gov/Medicare/Coding/ICD10/index.html

Relevant Data Elements: MC058, MC083, MC084, MC085, MC086, MC087, MC088, MC088A, MC088B, MC088C, MC088D, MC088E, MC088F

12. Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), Procedure Modifier Codes

External Code Source: American Medical Association (AMA)

Link to Code Source: http://www.ama-assn.org/

Relevant Data Elements: MC055, MC056, MC057, MC108, MC109; DC033, DC034, DC034A, DC034B

13. Code on Dental Procedures and Nomenclature (CDT) Codes

External Code Source: American Dental Association (ADA)

Link to Code Source: http://www.ada.org/

Relevant Data Elements: DC032, DC033, DC034, DC034A, DC034B

14. Priority (Type) of Admission or Visit (Admission Type Code)



Relevant Data Elements: MC020

15. Point of Origin for Admission or Visit (Admission Source Code)




16. Discharge Status Codes




https://www.cms.gov/Medicare/Coding/ICD10/index.html

http://www.ama-assn.org/

http://www.ada.org/





17. Revenue Codes




18. National Drug Codes and Names

External Code Source: U.S. Food and Drug Administration (FDA)

Link to Code Source: http://www.fda.gov/Drugs/InformationOnDrugs/ucm142438.htm

Relevant Data Elements: MC075; PC026, PC027

19. Logical Observation Identifiers Names and Codes (LOINC)

External Code Source: The Regenstrief Institute

Link to Code Source: http://loinc.org/


20. Tooth Number Codes (Universal Numbering System)


Link to Code Source: http://www.ada.org/~/media/ADA/Member%20Center%20/FIles/ada dental claimform completion instructions 2012.pdf

Relevant Data Elements: DC047

21. Dental Quadrant Codes



Relevant Data Elements: DC048, DC048A, DC048B, DC048C, DC048D

22. Tooth Surface Codes



Relevant Data Elements: DC049, DC049A, DC049B, DC049C, DC049D


http://www.fda.gov/Drugs/InformationOnDrugs/ucm142438.htm

http://loinc.org/

http://www.ada.org/~/media/ADA/Member%20Center%20/FIles/ada_dental_claim_form_completion_instructions_2012.pdf


http://www.ada.org/~/media/ADA/Member%20Center%20/%20FIles/ada_dental_claim_form_completion_instructions_2012.pdf

http://www.ada.org/~/media/ADA/Member%20Center%20/%20FIles/ada_dental_claim_form_completion_instructions_2012.pdf




23. Diagnostic Related Group (DRG)


Link to Code Source: https://www.cms.gov


24. Ambulatory Payment Classification (APC)


Link to Code Source: https://www.cms.gov


25. Present on Admission (POA) Codes


Link to Code Source: https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitalacqcond/coding.html

Relevant Data Elements: MC154, MC155, MC156, MC157, MC158, MC159, MC160, MC161, MC162, MC163, MC164, MC165, MC166, MC167, MC168, MC169, MC170, MC171, MC172, MC173, MC174, MC175, MC176, MC177

26. Condition Codes



Relevant Data Elements: MC179, MC180, MC181, MC182, MC183, MC184, MC185, MC186, MC187, MC188, MC189, MC190

27. Value Codes



Relevant Data Elements: MC191, MC193, MC195, MC197, MC199, MC201, MC203, MC205, MC207, MC209, MC211, MC213

https://www.cms.gov/

https://www.cms.gov/

https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitalacqcond/coding.html

https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitalacqcond/coding.html




28. Occurrence Codes and Occurrence Span Codes



Relevant Data Elements: MC215, MC217, MC219, MC221, MC223, MC224A, MC224C, MC224E, MC224G, MC224I, MC224K, MC224M, MC225, MC228, MC231, MC234, MC237, MC239A, MC239D, MC239G, MC239J, MC239M, MC239P, MC239S

29. North American Industry Classification System (NAICS)

External Code Source: U.S. Census Bureau

Link to Code Source: http://www.census.gov/eos/www/naics/


30. Standard Industrial Classification (SIC) System

External Code Source: U.S. Department of Labor (DOL), Occupational Safety & Health Administration (OSHA)

Link to Code Source: https://www.osha.gov/pls/imis/sic manual.html


31. Claim Adjustment Reason Codes

External Code Source: Washington Publishing Company (WPC)

Link to Code Source: http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/

Relevant Data Elements: MC080, MC124; PC117; DC064

32. CMS Physician Specialty Codes


Link to Code Source: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3762CP.pdf

Relevant Data Elements: PV030


http://www.census.gov/eos/www/naics/

https://www.osha.gov/pls/imis/sic_manual.html

http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/

http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3762CP.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3762CP.pdf

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