CHAPTER Ins 4000  UNIFORM REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS

 

Statutory Authority:  RSA 400-A:15 I; RSA 420-G:11; RSA 420-G:11-a; RSA 420-G:14

 

PART Ins 4001  PURPOSE AND SCOPE

 

          Ins 4001.01  Purpose and Scope.  This chapter contains procedures and substantive requirements for the submission of health care data under RSA 420-G:11, II to the New Hampshire Comprehensive Health Information System by insurance companies, third-party payers, third-party administrators, and carriers that provide administrative services for a plan sponsor.

 

Source.  #8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136, eff 11-24-20

 

PART Ins 4002  DEFINITIONS

 

          Ins 4002.01  Definitions.  Unless the context indicates otherwise, the following words and phrases shall have the following meanings:

 

          (a)  Address” means street addresses, post office box numbers, apartment numbers, e-mail addresses, web universal resource locators (URLs), and internet protocol (IP) address numbers.

 

          (b)  Alternative payment arrangements” means those claims considered paid by the carrier or third-party administrator under a capitated services arrangement or a global payment, resulting in zero paid amounts on the claim.

 

          (c)  Blanket health insurance” means that form of accident and health insurance defined under RSA 415:18, I-a that is not “health coverage” under RSA 420-G:2, IX, that does not require individual applications from covered persons, and that does not require a carrier or third-party administrator to furnish each person with a certificate of coverage.

 

          (d)  Capitated services” means services rendered by a provider through a contract in which payment is based upon a fixed dollar amount for each member on a monthly basis.

 

          (e)  “Carrier” means any entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to provide, deliver, arrange for, pay for, or reimburse any of the costs of health services, or to administer on behalf of a third-party payer, and includes an insurance company, a health maintenance organization, a nonprofit health services corporation, a dental benefits administrator, a third-party administrator, or any other entity arranging for or providing health coverage, Medicare Supplemental, and Medicare Advantage plans.

 

          (f)  Commissioner” means the insurance commissioner.

 

          (g)  Dental claims file” means a data file composed of service level remittance information for all adjudicated claims for each billed dental service provided to members, including data for services provided under alternative payment arrangements with zero paid amounts.

 

          (h)  Department (NHID)” means the New Hampshire insurance department.

 

          (i)  Designee” means an entity with which the department or the department of health and human services have entered into an arrangement pursuant to which the entity performs data management and collecting functions and under which the entity is strictly prohibited from using or releasing the information and data obtained in such a capacity for any purposes other than those specified in the agreement.

 

          (j)  Department of Health and Human Services (DHHS)” means the New Hampshire department of health and human services.

 

          (k)  Direct identifier” means any information, other than case or code numbers used to create anonymous or encrypted data, that plainly discloses the identity of an individual as referenced in 45 CFR Part 164.514 (e)(2).

 

          (l)  Encryption” means a method by which the true value of data has been disguised in order to prevent the identification of persons or groups and which does not provide the means for recovering the true value of the data.

 

          (m)  Exchange” means a governmental agency or non-profit entity that meets the applicable standards of 42 U.S.C. section 13031 and makes qualified health plans available to qualified individuals and qualified employers in accordance with federal law. 

 

          (n)  Health care claims data” means the set of data files that are filed by carriers and third-party administrators under this chapter consisting of, or derived directly from, member eligibility, medical claims, pharmacy claims, and dental claims files, including a provider file.  "Health care claims data" does not include analysis, reports, or studies containing information from health care claims data sets, if those analyses, reports, or studies have already been released in response to another request for information or as part of a general distribution of public information by the department.

 

          (o)  Hospital” means a licensed acute or specialty care institution.

 

          (p)  Insured” means an individual in whose name an insurance policy is issued.

 

          (q)  Medical claims file” means a data file composed of service level remittance information for all adjudicated claims for each billed medical service provided to members, including data for services provided under alternative payment arrangements with zero paid amounts.

 

          (r)  Members” means all individuals, employees, and dependents for which the health carrier or third-party administrator has an obligation to adjudicate, pay, or disburse claim payments.  The term includes covered lives.  For employer-sponsored group coverage, members include certificate holders and their dependents.

 

          (s)  Member eligibility file” means a data file containing demographic information for each individual member eligible for medical, pharmacy, or dental benefits for one or more days of coverage at any time during the reporting month as well as any retrospective updates that correspond to previously submitted eligibility data.  The term also includes benefits attributed and associated effective periods.

 

          (t)  New Hampshire Comprehensive Health Information System (NHCHIS)” means the system established and operated by the department and the department of health and human services or its designee to collect, store, and analyze health care claims data.

 

          (u)  Pharmacy claims file” means a data file composed of service level remittance information from all adjudicated claims for each billed prescription provided to members, including data for services provided under alternative payment arrangements with zero paid amounts.

 

          (v)  Plan ID” means the 14-character Health Insurance and Oversight System (HIOS) Plan ID, standard component.  The full HIOS ID is unique to each fully insured carrier, product, or plan.

 

          (w)  Plan sponsor” means any persons, other than an insurer, who establishes or maintains a plan covering residents of the state of New Hampshire, including plans established or maintained by employers or jointly by one or more employers and one or more employee organizations, committee, joint board of trustees, or other similar group of representatives of the parties that establish or maintain the plan.

 

          (x)  Prepaid amount” means the amount that would have been paid by the health care claims processor for a specific service if the service had not been capitated or otherwise did not result in a transfer of funds.

 

          (y)  Provider” means a health care facility, medical, dental or behavioral health care practitioner, health product manufacturer, health product vendor, or pharmacy.

 

          (z)  Provider file” means a data file listing information about the service providers identified in the medical claims, pharmacy claims, and the dental claims file as servicing billing, prescribing, or primary providers.

 

          (aa)  Release” means to make data or information available for inspection and copying to persons other than the data submitter.

 

          (ab)  Subcontractor” means a vendor or contractor who manages carved out categories of services, including behavioral health services, pharmacy services, or any other subcontractor that processes claims on behalf of a carrier.

 

          (ac)  Subscriber” means the certificate holder who receives coverage from a carrier or third-party administrator as defined in these rules.  For employer-sponsored group coverage, the employee or subscriber is considered the certificate holder.  For individual coverage, the policyholder is considered the certificate holder.  For other types of group coverage, the certificate holder is considered the person who is the principal insured.

 

          (ad)  Third party administrator” means any persons licensed by the department that receives or collects charges, contributions, or premiums for, or adjusts or settles claims for, residents of the state on behalf of a plan sponsor, health care services plan, dental services plan, nonprofit hospital or medical service organization, health maintenance organization, or insurer.

 

Source.  #8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136, eff 11-24-20

 

PART Ins 4003  ANNUAL REGISTRATION REQUIREMENT

 

          Ins 4003.01  Annual Registration Requirement.

 

          (a)  Each carrier and each third-party administrator shall submit a completed NHCHIS registration form, available at https://nhchis.com/, to the department or its designee by March 15 of every calendar year. 

 

          (b)  Carriers and third-party administrators shall notify the department or its designee within 30 days of changes to any of the annual NHCHIS registration information.

 

          (c)  Carriers and third-party administrators shall notify the department or its designee of any changes to the individual contact information submitted on the NHCHIS registration form as soon as possible, but no later than 30 days after a reassignment occurs.

 

Source.  #8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20

 

          Ins 4003.02  Contents of NHCHIS Registration Form.  The NHCHIS registration form for carriers and third-party administrators submitting data under RSA 420-G:11, II shall contain the fields required under Ins 4009.01.

 

Source.  #8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20

 

          Ins 4003.03  Submission of NHCHIS Registration Form.  Carriers and third-party administrators shall submit the NHCHIS registration form through the NHCHIS website.

 

Source.  #10877, eff 7-10-15; ss by #13136 eff 11-24-20

 

PART Ins 4004  FILING SCHEDULES

 

          Ins 4004.01  Filing Schedules.

 

          (a)  The deadline for submitting NHCHIS data files shall be determined by the total number of members for whom claims are being paid or processed by each carrier or third-party administrator.

 

          (b)  Carriers and third-party administrators that have 10,000 or more New Hampshire members shall submit required NHCHIS files monthly, no later than 30 days after the close of the reporting month.

 

          (c)  Carriers and third-party administrators that have fewer than 10,000 New Hampshire members, but do not meet the exclusion criteria in Ins 4005.02, shall submit required NHCHIS files quarterly, no later than 30 days after the end of the reporting quarter.

 

Source.  #8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20

 

          Ins 4004.02  First-time Filers.

 

          (a)  Carriers and third-party administrators that have not previously submitted files to the department or its designee and that have never registered under this rule shall register no later than 30 days after the first applicable requirement to submit data, using the NHCHIS registration form outlined in Ins 4003.02.

 

          (b)  First-time submitters shall provide test files within 120 days after registration.  The test file size shall correspond to the size required for that carrier or third-party administrator as specified in Ins 4004.01 (a).

 

          (c)  No later than 150 days after registration, newly-submitting carriers and third-party administrators shall submit files containing the 3 most recent calendar years of data, January through December.  Year-to-date information and monthly or quarterly files shall be provided no later than 180 days after registration.

 

Source.  #8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20

 

          Ins 4004.03  Changes to Data Submitter’s Process, Format, or Sources.

 

          (a)  Carriers and third-party administrators that change health plan identifiers or implement new data submission platforms through acquisitions, mergers, or reorganization shall be subject to the requirements for first-time submitters.

 

          (b)  Carriers and third-party administrators filing under new health plan identifiers or through new production systems shall provide additional documentation pursuant to instructions from the department or its designee to ensure that NHCHIS maintains a continuous record of member enrollment and claims history before and after the changes.

 

Source.  #10877, eff 7-10-15; ss by #13136 eff 11-24-20

 

PART Ins 4005  REQUIRED FILERS AND EXCLUSIONS

 

          Ins 4005.01  Required Filers and Data Sets.

 

          (a)  In accordance with the submission schedule set forth in Ins 4004, each carrier and third-party administrator shall submit to the department or its designee a complete and accurate health care claims data set.

 

          (b)  Carriers and third-party administrators shall submit health care claims data for all residents of New Hampshire and for all members who receive services under a policy issued in New Hampshire, as follows:

 

(1)  Any policy that provides coverage to the employees of a New Hampshire employer that has a business location in New Hampshire shall be considered a policy that is issued in New Hampshire;

 

(2)  An out-of-state employer’s branch location in New Hampshire shall be considered a New Hampshire employer, and the carrier and third-party administrator shall submit a claims data set for all members who are employed at that branch location; and

 

(3)  Carriers and third-party administrators shall submit health care claims data for New Hampshire state and municipal employees.

 

          (c)  When more than one entity is involved in the administration of a policy, data shall be submitted in accordance with the following:

 

(1)  A carrier shall be responsible for submitting the claims data on policies that it has written;

 

(2)  A third-party administrator shall be responsible for submitting claims data on self-insured plans that it administers;

 

(3)  Each carrier and third-party administrator shall submit all health care claims processed by any subcontractor on its behalf, including claims related to pharmacy services, dental services, and behavioral health, mental health, and substance abuse treatment services;

 

(4)  Each carrier and third-party administrator shall ensure that the subcontractor is not submitting duplicate claims to the department or its designee if the subcontractor falls under the definition of a carrier, meets the requirements of this section, and is required to submit data as a separate entity; and

 

(5)  Each carrier and third-party administrator shall ensure that member and subscriber identifiers in any files processed by subcontracts are consistent with member and subscriber identifiers in the medical and pharmacy claims files and the member eligibility files.

 

          (d)  Carriers and third-party administrators shall continue to submit claims data for each month in which they meet the criteria and for the 180 days after the month in which the carrier or third-party administrator withdraws or falls below the exclusion criteria listed in Ins 4005.02.

 

Source.  #8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20

 

          Ins 4005.02  Exclusions from Filing Requirements.

 

          (a)  Carriers and third-party administrators shall not be required to submit health care claims data files, Health Care Effectiveness Data and Information Set (HEDIS®) data, or Consumer Assessment of Health Plans Survey (CAHPS) survey data if they meet the following criteria:

 

(1)  For carriers that do not offer any products on the health insurance exchange for residents of New Hampshire and that did not cover more than 9,999 members in New Hampshire at any point in any medical, pharmacy, or dental coverage class during the prior calendar year; or

 

(2)  For third-party administrators that did not cover more than 9,999 members in New Hampshire at any point in any medical, pharmacy, or dental coverage class during the prior calendar year.

 

          (b)  Carriers and third-party administrators shall perform the calculation for (a) above at the entity level, meaning the level at which major governance decisions are made under a senior leadership team, regardless of the number of companies operating under separate corporate divisions.  Carriers or third-party administrators experiencing a drop in membership below the de minimis threshold shall submit claims data and any corrections to membership files for a period of 180 days from the point the carrier or third-party administrator meets the de minimis exemption.

 

          (c)  Carriers and third-party administrators shall not be required to submit health care claims data about coverage that is not part of a comprehensive medical insurance policy, including the following:

 

(1)  Specific disease;

 

(2)  Accident;

 

(3)  Injury;

 

(4)  Hospital indemnity;

 

(5)  Disability;

 

(6)  Long-term care;

 

(7)  Vision coverage;

 

(8)  Durable medical equipment; or

 

(9)  Blanket health insurance.

 

Source.  #8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20

 

          Ins 4005.03  Opt-In by Self-Funded Private Employers.

 

          (a)  Each third-party administrator or carrier providing claims administration services to any self-funded private employer that maintains a business location in New Hampshire, including a branch location, shall, within 60 days of the effective date of this rule for current clients or, for new or renewing clients, within 30 days of the date its claims administration services are retained or renewed, present to each such self-funded employer a copy of the “NHID Opt-In Form” for purposes of determining whether the employer directs the carrier or third-party administrator to submit its health care claims data pursuant to Ins 4000.

 

          (b)  The “NHID Opt-In Form” shall be presented at least once for each contractual period but need not be presented annually if the contractual period exceeds one year.

 

          (c)  Health care claims data for each self-funded private employer that directs the submission of its data shall be included as part of the carrier’s or third-party administrator’s data submission as indicated on the “NHID Opt-In Form” for that employer.

 

          (d)  Each carrier and third-party administrator shall provide to the department annually on March 15 an attestation of compliance with this section with respect to all accounts to which this section was applicable during the prior year.  The attestation shall include a list of the self-funded private employers to whom the “NHID Opt-In Form” was presented.  However, the association of a particular employer with a particular carrier or third-party administrator may be designated as proprietary information which the department shall, if so designated, hold confidential.

 

          (e)  A carrier whose submission includes all relevant data under Ins 4000, without regard to whether the data relate to a self-funded private employer, shall not be required to comply with paragraphs (a) through (d).

 

          (f)  The types of employers listed in RSA 420-G:11, IV shall not be considered self-funded private employers under this section, and the “NHID Opt-In Form” shall not be presented to any such employer.

 

          (g)  If a self-funded private employer chooses to include the health care claims data of its employees in the state’s All-Payer Claims Database (APCD), the employer, or its designee, shall:

 

(1)  Complete and sign the “NHID Opt-In Form” (2016); and

 

(2)  Submit the completed form to its claims administrator.

 

          (h)  If the employer has questions about NH’s APCD or the department’s efforts to improve health care cost transparency, the employer may contact the department at 603-271-2261, or requests@ins.nh.gov, or visit http://www.nh.gov/insurance/.

 

Source.  #12044, eff 11-17-16; ss by #13136 eff 11-24-20

 

PART Ins 4006  HEALTH CARE CLAIMS DATA SET FILING

 

          Ins 4006.01  General Requirements.

 

          (a)  Carriers and third-party administrators shall comply with all the technical specifications contained in Ins 4009 and shall include all data elements contained in Ins 4010, including required formats, definitions, and sources.

 

          (b)  Carriers and third-party administrators shall utilize a data transmission tool provided by the department or its designee to assign a unique identification code to each member and subscriber’s record in every file, transform direct identifiers, encrypt the files, and securely transmit the files to the department or its designee.

 

          (c)  Upon an amendment to this chapter, carriers and third-party administrators shall submit data that conform to the updated specifications no later than 180 days after the effective date of the new version of the rule.

 

          (d)  If the department or its designee identifies technical deficiencies in data submitted by a carrier or third-party administrator, the carrier or third-party administrator shall respond to the department within 10 days with a corrective action plan that the department determines will remove the deficiencies.

 

Source.  #8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20

 

          Ins 4006.02  Subscriber and Member Identification Data Elements.

 

          (a)  Carriers and third-party administrators shall:

 

(1)  Provide a unique identification number for each member and subscriber included in the submitted files; and

 

(2)  Maintain that unique identifier for each member and subscriber for the entire period of coverage for that individual by that carrier or third-party administrator.

 

          (b)  Subscriber and member identifiers shall be:

 

(1)  Consistent across all files that contain information about the subscriber or member;

 

(2)  Matched across the member eligibility, medical claims, pharmacy, and dental files, as well as behavioral health claims, as applicable, even where the claims are processed by a subcontractor such as a pharmacy benefits manager; and

 

(3)  Consistent with the technical specifications in Ins 4009.02.

 

Source.  #10877, eff 7-10-15; ss by #13136 eff 11-24-20

 

          Ins 4006.03  Included Records and Data Requirements.

 

          (a)  Carriers and third-party administrators shall report health care claims data for all members meeting the criteria set forth in Ins 4005.01 (b).

 

          (b)  Records for medical, pharmacy, and dental claims file submissions shall be reported at the visit, service, or prescription level.

 

          (c)  Medical, pharmacy, and dental claims files shall contain all of a claim’s payment and adjustment activity during the reporting month regardless of the date of service on the claim.

 

          (d)  Claims where multiple parties have financial responsibility shall be included with all medical and pharmacy claims file submissions.

 

          (e)  Co-payment or co-insurance amounts shall be reported in 2 separate fields in the medical, pharmacy, and dental claims file submissions.

 

          (f)  Carriers and third-party administrators shall include records for services provided under alternative payment arrangements with zero paid amounts.

 

          (g)  Carriers and third-party administrators shall include records for services provided by out of network providers and services provided after member exceeds benefits with complete patient liability paid.

 

          (h)  Carriers and third-party administrators shall include all service lines associated with fully-processed claims that have gone through an accounts payable run and been booked to the health plan ledger in all medical, dental, and pharmacy claims file submissions.

 

Source.  #10877, eff 7-10-15; ss by #13136 eff 11-24-20

 

          Ins 4006.04  Observation Period for Record Selection.

 

          (a)  Carriers and third-party administrators shall submit a member eligibility file that contains data for each member eligible for medical, dental, or pharmacy benefits for one or more dates of coverage at any time during a reporting month as well as any retrospective updates that correspond to previously submitted eligibility data.  It shall include benefits, attributes, and associated effective periods.

 

          (b)  Carriers and third-party administrators shall include all claims adjudicated during the reporting month for all members in the member eligibility file for that month.

 

          (c)  Carriers’ and third-party administrators’ data submissions shall contain 180 days claims run out for members in all current or previously submitted files.

 

Source.  #10877, eff 7-10-15; ss by #13136 eff 11-24-20

 

          Ins 4006.05  Health Care Effectiveness Data and Information Set (HEDIS®) Reporting Requirements.

 

          (a)  Each carrier that calculates using HEDIS®, a system of performance measures maintained by the national committee for quality assurance (NCQA), and submits those data to NCQA, shall report those data that pertain to members who receive their benefits under a policy or plan issued in New Hampshire.

 

          (b)  The carrier shall submit HEDIS® data to the DHHS or its designee by July 31st of each year as follows:

 

(1)  The carrier shall submit the data utilizing the appropriate NCQA interactive data submission system (IDSS) import template; and

 

(2)  The carrier shall also submit the results via a workbook, generated with results for each HEDIS® measure appearing on its own worksheet.

 

Source.  #10877, eff 7-10-15; ss by #13136 eff 11-24-20

 

          Ins 4006.06  Consumer Assessment of Health Plans Survey (CAHPS®) Reporting Requirements.

 

          (a)  Each carrier that collects CAHPS® data, a survey overseen by the United States Department of Health and Human Services, agency for healthcare research and quality (AHRQ) and used by NCQA as part of HEDIS® reporting, shall report those data that are collected and that pertain to members who receive their benefits under a policy or plan issued in New Hampshire.

 

          (b)  The carrier shall submit CAHPS® data to the DHHS or its designee by July 31st of each year, as follows:

 

(1)  The carrier shall submit the NCQA generated survey results reports; and 

 

(2) The carrier shall also submit all results generated via the NCQA CAHPS® analysis program.

 

Source.  #10877, eff 7-10-15; ss by #13136 eff 11-24-20

 

PART Ins 4007  DATA STANDARDS COMPLIANCE

 

          Ins 4007.01  Data Standards Compliance.

 

          (a)  Carriers and third-party administrators shall submit files that conform to the formats and standards in these rules, including the technical specifications in Ins 4009.

 

          (b)  Carrier and third-party administrator files shall be evaluated upon receipt by the department or its designee to assess compliance with the data quality standards in the submission instructions.

 

          (c)  Carriers and third-party administrators shall:

 

(1)  Resubmit nonconforming files at the direction of the department or its designee;

 

(2)  Resubmit a corrected and conforming version of the original submission within 10 business days of the rejection notification from the department or its designee; and

 

(3)  Not submit partial replacement files or record specific corrections.

 

          (d) Carriers and third-party administrators shall submit tables and descriptions about all nonconforming and plan-specific codes appearing in the submission.  Files with nonconforming and plan-specific codes without such explanatory information shall be rejected.

 

Source.  #8279, eff 2-3-05; ss by #9500, eff 7-6-09; ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20

 

PART Ins 4008  WAIVERS

 

          Ins 4008.01  Waiver of Requirement to Submit Specific Data Element.

 

          (a)  Upon application of a carrier or third-party administrator, the department shall grant a waiver of the requirement to submit a particular data element required under these rules, upon a showing by the carrier or third-party administrator that:

 

(1)  The data element does not exist on the carrier’s or third-party administrator’s transaction system;

 

(2)  The data element cannot be derived reliably from other information available on the carrier’s or third-party administrator’s transaction system; and

 

(3)  The data element does not reflect information necessary to process claims or to conduct business operations in accordance with generally accepted industry standards, such that it should reasonably be available.

 

          (b)  A carrier or third-party administrator granted a waiver shall populate that data field in its claims data submissions in the manner specified in the waiver. 

 

Source.  #10877, eff 7-10-15; ss by #13136 eff 11-24-20

 

PART Ins 4009  TECHNICAL SPECIFICATIONS

 

          Ins 4009.01  Subscriber and Member Identification Data Elements.

 

          (a)  The following table lists the subscriber and member identifiers that must be identical when reporting information about a subscriber or a member:

 

Table 1: Matching Requirements for Subscriber/Member

 Identifiers Across Files

Data Element Name*

Subscriber and Member Identifiers

Member Eligibility

Medical Claims**

Dental Claims

Pharmacy Claims

Subscriber Social Security Number

ME008

MC007

DC007

PC007

Plan Specific Contract Number

ME009

MC008

DC008

PC008

Member Suffix or Sequence Number

ME010

MC009

DC009

PC009

Member Identification Code

ME011

MC010

DC010

PC010

Subscriber Last Name

ME101

MC101

DC101

PC101

Subscriber First Name

ME102

MC102

DC102

PC102

Subscriber Middle Initial

ME103

MC103

DC103

PC103

Member Last Name

ME104

MC104

DC104

PC104

Member First Name

ME105

MC105

DC105

PC105

Member Middle Initial

ME106

MC106

DC106

PC106

*The NHCHIS preprocessor hashes these data elements as part of the file encryption and transmission process.

**Also pertains to Behavioral Health.

 

          (b)  The NHCHIS preprocessor application will hash all subscriber and member identification codes and names before data are transmitted to the department’s designee. To ensure consistent hashing, subscriber and member identifiers should not be encrypted or hashed on the initial extract loaded into the preprocessor.

 

          (c)  If a third-party administrator does not collect the social security numbers for its members, the third-party administrator shall provide the social security number of the subscriber and assign a discrete two digit suffix for each member under the subscriber’s contract using the following criteria:

 

(1)  If the subscriber's social security number is not collected by the third-party administrator, the subscriber's certificate or contract number shall be used in its place.  This data element is de-identified by the NHCHIS preprocessor application.

 

(2)  The discrete two-digit suffix shall also be used with the certificate or contract number.  This data element is de-identified by the NHCHIS preprocessor application.

 

(3)  The certificate or contract number with the two-digit suffix shall be at least 11, but no more than 30 characters in length.  This data element is de-identified by the NHCHIS preprocessor application.

 

Source.  #10877, eff 7-10-15; ss by #13136 eff 11-24-20 (formerly Ins 4009.02)

 

          Ins 4009.02  Technical Specifications and Format for File Transfer.

 

          (a)  Carriers and third-party administrators shall use the values in the data tables contained in Ins 4010 or the corresponding externally maintained code tables referenced therein, and:

 

(1)  Carriers and third-party administrators shall submit tables and descriptions for all non-conforming and plan-specific codes appearing in the submission; and

 

(2)  The department and DHHS or its designee shall reject files with non-conforming and plan-specific codes if explanatory information is not provided in advance of the data submission.

 

          (b)  Carriers and third-party administrators shall report adjustment records with the appropriate positive or negative fields with the medical, pharmacy, and dental file submissions. Negative values shall contain the negative sign before the value. No sign shall appear before a positive value.

 

          (c)  When more than one version of a fully-processed claim service line is submitted, each version of a claim service line shall be enumerated sequentially with a higher version number (MC005A) so that the latest version of that service line is the record with the highest version number (MC005A) and the same claim number + line counter. Where a version number is not available, provide the former claim number in data element MC211. Similar requirements apply to the pharmacy claim file.

 

          (d)  All service lines associated with fully-processed claims that have gone through an accounts payable run and been booked to the health plan ledger shall be included on medical, pharmacy, and dental claims data submissions.  Do not include service lines:

 

(1)  Rejected due to failed edits;

 

(2)  That are duplicates;

 

(3)  That are from an inactive member; or

 

(4)  Claims that are voided for point of sale adjustments.

 

          (e)  Subsequent incremental claims submissions shall include all reversal and adjustment or restated versions of previously submitted claim service lines and all new, fully-processed service lines associated with the claim, provided that they have paid dates in the reporting period, and:

 

(1)  Each version of a claim service line shall be enumerated sequentially with a higher line version number (MC005A); and

 

(2)  Reversal versions of a claim service line shall be indicated by a claim status code = '22' (Field MC038).

 

          (f)  Capitated service claims, sometimes known as encounter claims, for capitated services shall be reported with all medical and pharmacy file submissions.

 

          (g)  If a claim contains service lines that do not contain a payment because their costs are covered on another line of the claim line, such as under a global payment arrangement, those line(s) shall be:

 

(1)  Included in the data submission; and

 

(2)  Clearly indicated by a claim status code = 04’ (Field MC038).

 

          (h)  Member eligibility data suppliers must provide a data set that contains information on every covered plan member, regardless of whether the member utilized services during the reporting period.  One record per member per month per plan is required.  For example, if a member is covered as both a subscriber and a dependent on two different policies during the same month, 2 records must be submitted.  If a member has 2 contract numbers for 2 different coverage types, 2 member eligibility records must be submitted.

 

          (i)  The Provider ID (MP003) is the unique identifier for a single provider. The Provider ID should only occur once in the table. However, in the event the same provider delivered, and was reimbursed for, services rendered from two or more different physical locations, then the provider data file shall contain two separate records for that same provider reflecting each of those physical locations. One record should be provided for each unique physical location.

 

          (j)  Carriers and third-party administrators must use the File Submission “Preprocessor” provided by the DHHS and their designee.  The preprocessor hashes or de-identifies member and subscriber information before the data leaves the carrier’s and third-party administrator’s system.

 

          (k)  Carriers and third party administrators must report the minimum value for fully insured and self-insured products to support the department’s supplemental reporting reviews. The minimum value is defined as the percentage of the total allowed costs of benefits provided under a group health plan or health insurance coverage. The minimum value measure is outlined in Section 1302 (d)(2)(C) of the Affordable Care Act. Plans may use the HHS MV calculator available at http://www.cms.gov/cciio/resources/regulations-and-guidance/index.html; may apply a safe harbor developed by HHS and the IRS; or may, for nonstandard plans, provide an actuarial certification from a member of the American Academy of Actuaries.

 

          (l)  Each member eligibility file and each medical, pharmacy, and dental claims file submission must contain a header record and a trailer record. The header record is the first record of each separate file submission and the trailer record is the last.

 

          (m)  All carriers and third-party administrators submitting APCD files shall be provided with code in the form of a pre-processor, which generates the files in the required format and encrypts them prior to submission. The pre-processor code shall be provided to all carriers and third-party administrators as a down load through a password protected portal.

 

          (n)  Carriers and third-party administrators may submit APCD files using the following methods:

 

(1)  Secure File Transport Protocol (SFTP) is the preferred method for submitting files.  This method requires logging on to the appropriate SFTP site and sending or receiving files using the SFTP client server. This protocol assumes that it is run over a secure channel, that the server has already authenticated the client, and that the identity of the client user is available to the protocol.

 

(2)  The web upload method allows the sending and receiving of files and messages without the installation of additional software. This method requires internet access, a username, and password.  It is not the preferred method due to limitations on the size of the files that can be received, but can be utilized if it is the only method available to the healthcare claims processor.

 

          (o)  The member eligibility file, medical claims file, pharmacy claims file, dental claims file, and provider file shall be submitted as separate ASCII files, with variable field lengths and pipe delimited, and shall comply with the following standards:

 

(1)  Each record shall be terminated with a carriage return and line feed (ASCII 13, ASCII 10).

 

(2)  All fields shall be filled where applicable.

 

(3)  Text and date fields shall be left blank when not applicable or if a value is not available.

 

(4)  Blank” means do not supply any value at all between consecutive field delimiters or last field delimiter and line terminator.  Numeric fields without a value shall be filled with a single

zero.

 

(5)  Only one record per row shall be submitted. No single line item of data shall contain carriage return or line feed characters.

 

(6)  Text fields shall not be padded with leading or trailing spaces or tabs.

 

(7)  Numeric fields:

 

a.  Shall not be padded with leading zeroes;

 

b.  The integer portion of numeric fields shall not be padded with leading zeros;

 

c.   The decimal portion of numeric fields, if required, shall be padded with trailing zeros up to the number of decimal places indicated; and

 

d.  Positive values are assumed and need not be indicated as such. Negative values shall be indicated with a minus sign and shall appear in the left-most position of all numeric fields;

 

(8)  Date fields:

 

a.  Shall be CCYYMMDD, when a value is provided, unless otherwise indicated;

 

b.  Shall not be padded with leading or trailing spaces or tabs; and

 

c.  Shall be left blank when not applicable or if a value is not available.

 

Source.  #10877, eff 7-10-15; ss by #13136 eff 11-24-20(formerly Ins 4009.03)

 

          Ins 4009.03  Data Quality Requirements.

 

          (a)  A validation process shall be employed to ensure that the format and content of the submitted files are valid and complete. The validation process is primarily composed of three groups of audits, field level audits, quality audits, and post data consolidation reasonableness, longitudinal, and relational audits, as follows:

 

(1)  All transmitted files are first checked to determine if they are in the correct form and have been created using the provided pre-processor.  Field level audits are then employed to evaluate field length and type, code values, and the percentage at which the fields are filled;

 

(2)  Quality audits are employed to determine if the data submitted meet a pre-determined level of reasonableness, for example, percent of institutional claims versus percent of professional claims.

Default thresholds, which can be rates or ranges, have been established for approximately 200 quality audits; and

 

(3)  After the files are loaded into staging tables, additional audits are run on the consolidated data to identify any global issues that would not be evident during the field and quality level audit process.  The reasonableness, longitudinal, and relational audits confirm whether the appropriate and correct amount of data was received for the corresponding membership volume.  Examples of these audits include frequency of individual field values, volume reconciliation, and cost or utilization reasonableness.

 

          (b)  Default thresholds or rates shall be applied to the field level audits for each element in the eligibility, claims files, and provider file, and for each quality audit.  The standard acceptable threshold for field length, field type, and data value audits is 100 percent.  However, there are some fields where the acceptable thresholds for data value will be set at less than 100 percent.  Individual field completeness thresholds are established for each data element in the eligibility, medical, pharmacy, dental, and provider files and will vary accordingly.  All of the pre-determined default thresholds can be individually adjusted if extenuating circumstances arise which may impact the data completeness or content.  If a file is processed and rejected for failing to meet the field level or quality audit default thresholds, the healthcare claims processor can request an exemption to the default threshold through a standardized process.  Exemptions or adjustments may be granted for data variances that cannot be corrected due to systematic issues.

 

          (c)  At least 30 days prior to the initial submission of the files, or whenever the data element content of the files is subsequently altered, each healthcare claims processor must submit a data set for comparison to the same validation process used for actual submissions. Iterative rounds of testing may be necessary until the files conform to the submission requirements.  A test file should contain data covering a period of one month.

 

          (d)  Failure to conform to any of the submission requirements shall result in the rejection and return of the applicable data file(s).  All rejected and returned files shall be resubmitted in the appropriate, corrected form within 10 days, or the healthcare claims processor may request an exemption to adjust the threshold for the failing field(s). Due to the large amount and complexity of the data processed, it is more efficient to resubmit an entire file rather than to correct data within the file.

 

Source.  #10877, eff 7-10-15; ss by #13136, eff 11-24-20 (formerly Ins 4009.04)

 

          Ins 4009.04  External Code Sources.

 

          (a)  Countries

American National Standards Institute

http://webstore.ansi.org/SdoInfo.aspx?sdoid=39&source=iso_member_body

 

          (b)  States, Zip Codes and Other Areas of the US

U.S. Postal Service

https://www.usps.com/

 

          (c)  National Provider Identifiers

National Plan & Provider Enumeration System

https://nppes.cms.hhs.gov/NPPES/

 

          (d)  Health Care Provider Taxonomy

National Uniform Claim Committee (NUCC)

http://www.nucc.org

 

          (e)  International Classification of Diseases 9 & 10

American Medical Association

http://www.who.int/classifications/icd/en/

 

          (f)  HCPCS, CPTs and Modifiers

American Medical Association

http://www.ama-assn.org/

 

          (g)  Dental Procedure Codes and Identifiers

American Dental Association

http://www.ada.org/

 

          (h)  National Drug Codes and Names

U.S. Food and Drug Administration

http://www.fda.gov/drugs/informationondrugs/ucm142438.htm

 

          (i)  Standard Professional Billing Elements

Centers for Medicare and Medicaid Services (Rev. 10/26/12)

http://www.cms.gov/Regulations-and-fGuidance/Guidance/Manuals/downloads/clm104c26.pdf

 

          (j)  Standard Facility Billing Elements

National Uniform Billing Committee (NUBC)

http://www.nubc.org/

 

          (k)  DRGs, APCs and POA Codes

Centers for Medicare and Medicaid Services

http://www.cms.gov/

 

          (l)  Claim Adjustment Reason Codes

Washington Publishing Company

http://www.wpc-edi.com/reference/

 

Source.  #10877, eff 7-10-15; ss by #13136, eff 11-24-20 (formerly Ins 4009.05)

 

         


 

PART Ins 4010  DATA TABLES

 

          Ins 4010.01  Member Eligibility Data Tables.

 

          (a)  Use Table 4010.7 (a) to determine member eligibility file mapping and formatting.

 

          (b)  Member File Header Record Layout

 

Table 4010.01(b) Member File Header Record Layout

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

HD001

Record Type

Text

2

HD

HD002

Payer

Text

8

Payer submitting payments. NHID Submitter Code

HD003

National Plan ID

Text

30

CMS National Plan ID

HD004

Type of File

Text

2

ME Member Eligibility

HD005

Period Beginning Date

Date

8

Beginning of paid period for claims or beginning of month covered for eligibility

HD006

Period Ending Date

Date

8

End of paid period for claims or end of month covered for eligibility

HD007

Comments

Text

80

Submitter may use to document this submission by assigning a filename, system source, etc.

 

          (c)  Member File Trailer Record Layout

 

Table 4010.01(c) Member File Trailer Record Layout

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

TR001

Record Type

Text

2

TR

TR002

Payer

Text

8

Payer submitting payments. NHID Submitter Code

TR003

National Plan ID

Text

30

CMS National Plan ID

TR004

Type of File

Text

2

ME Member Eligibility

TR005

Period Beginning Date

Date

8

Beginning of paid period for claims or beginning of month covered for eligibility

TR006

Period Ending Date

Date

8

End of paid period for claims or beginning of month covered for eligibility

TR007

Extraction Date

Date

8

Date file was created

TR008

Record Count

Number

10 (0)

Total number of records submitted in this file

 

          (d)  Member File Detailed Specification

 

 

Table 4010.01(d) Member File Detailed Specification

 

 

 

Column Position

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

1

ME001

Payer

Text

8

Payer submitting payments NHID Submitter Code

2

ME002

National Plan ID

Text

30

CMS National Plan ID

3

ME003

Insurance Type Code/Product

Text

2

See Table 4010.6 (a) Insurance Type/Product Code-Eligibility File

4

ME004

Start Year

Number

4 (0)

Year for which eligibility is reported in this submission. CCYY format

5

ME005

Start Month

Number

2 (0)

Month for which eligibility is reported in this submission. MM format. Leading zero is required for reporting January through September files

6

ME006

Insured Group or Policy Number

Text

50

Group or policy number (not the number that uniquely identifies the subscriber)

7

ME007

Coverage Level Code

Text

3

Benefit Coverage Level

 

 

 

 

 

CHD Children Only

 

 

 

 

 

DEP Dependents Only

 

 

 

 

 

ECH Employee and Children

 

 

 

 

 

EMP Employee Only

 

 

 

 

 

ESP Employee and Spouse

 

 

 

 

 

FAM Family

 

 

 

 

 

IND Individual

 

 

 

 

 

SPC Spouse and Children

 

 

 

 

 

SPO Spouse Only

8

ME008

Subscriber Social Security Number

Text

9

Subscriber's social security number. Do not include dashes.  Leave blank if not available.

9

ME009

Plan Specific Contract Number

Text

50

Plan assigned contract number. Leave blank if Plan Specific Contract Number is subscriber's social security number.  If this is a Medicaid member, provide Medicaid ID

10

ME010

Member Suffix or Sequence Number

Text

20

Uniquely identifies the member within the contract

11

ME011

Member Social Security Number

Text

9

Member's social security number.  Do not include dashes.  Leave blank if not available.

12

ME012

Individual Relationship Code

Text

2

See Table 4010.6 (b) Relationship Codes

13

ME013

Member Gender

Text

1

M Male

 

 

 

 

 

F Female

 

 

 

 

 

U Unknown

 

 

 

 

 

O Other

14

ME014

Member Date of Birth

Date

8

Date of birth of member

15

ME015

Member City Name

Text

30

City name of member

16

ME016

Member State or Province

Text

2

As defined by the US Postal Service

17

ME017

Member ZIP Code

Text

9

ZIP Code of member – may include non- US codes. Do not include dash.

18

ME018

Medical Coverage

Text

1

Y Yes

 

 

 

 

 

N No

19

ME019

Prescription Drug Coverage

Text

1

Y Yes, member has prescription drug coverage in the period defined with this payer

 

 

 

 

 

N No, member does not have prescription drug coverage in the period defined with this payer

20

ME020

Dental Coverage

Text

1

Y Yes, member has dental coverage in the period defined with this payer

 

 

 

 

 

N No, member does not have dental coverage in the period defined with this payer

21

ME021

Race 1

Text

6

See Table 4010.6 (c) Race 1/Race 2

22

ME022

Race 2

Text

6

See Table 4010.6 (c) Race 1/Race 2

23

ME023

Placeholder

 

 

 

24

ME024

Hispanic Indicator

Text

1

Y Yes, member is Hispanic/Latino/Spanish

 

 

 

 

 

N No, member is not Hispanic/Latino/Spanish

 

 

 

 

 

U Unknown

25

ME025

Ethnicity 1

Text

6

See Table 4010.6 (d): Ethnicity 1/ Ethnicity 2

26

ME026

Ethnicity 2

Text

6

See Table 4010.6 (d): Ethnicity 1/ Ethnicity 2

27

ME027

Placeholder

 

20

 

28

ME028

Primary Insurance Indicator

Text

1

Y Yes, this is the member’s primary insurance

 

 

 

 

 

N No, this is not the member’s primary insurance

29

ME029

Coverage Type

Text

3

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, as defined pursuant to RSA 415:5 III

 

 

 

 

 

MCD Medicaid

 

 

 

 

 

MCR Medicare

 

 

 

 

 

UND Plans underwritten by the carrier

 

 

 

 

 

OTH Any other plan. Carriers and third-party administrators using this code shall obtain prior approval from the N.H. Insurance Department

30

ME030

Market Category

Text

4

Three or four digit character code for identifying market category. Employer size is based on the number of eligible employees in the group as define in INS 4100, (INS 4103.03 (g) for the Small Group market, INS 4104.03 (i) for the Large Group market)

 

 

 

 

 

IND Policies sold and issued directly to individuals, other than those sold on a franchise basis, as defined pursuant to RSA 415:19, or as group conversion Policies as defined pursuant to RSA 415:18 VII (a)

 

 

 

 

 

FCH Policies sold and issued directly to individuals on a franchise basis as defined pursuant to RSA 415:19

 

 

 

 

 

GCV Policies sold and issued directly to individuals as group conversion Policies as required pursuant to RSA 415:18 VII (a)

 

 

 

 

 

GS1 Policies sold and issued directly to employers having exactly one employee

 

 

 

 

 

GS2 Policies sold and issued directly to employers having between 2 and 9 employees

 

 

 

 

 

GS3 Policies sold and issued directly to employers having between 10 and 25 employees

 

 

 

 

 

GS4 Policies sold and issued directly to employers having between 26 and 50 employees

 

 

 

 

 

GLG1 Policies sold and issued directly to employers having between 51 and 99 employees

 

 

 

 

 

GLG2 Policies sold and issued directly to employers having 100 or more employees

 

 

 

 

 

GSA Policies sold and issued directly to small employers through a qualified association trust

 

 

 

 

 

OTH Policies sold to other types of entities. Carriers and third-party administrators using this market code shall obtain prior approval from the NH Insurance Department

 

 

 

 

 

BLC Policies sold and issued as blanket health insurance Policies to a common carrier

 

 

 

 

 

BLE Policies sold and issued as blanket health insurance Policies to an employer

 

 

 

 

 

BLV Policies sold and issued as blanket health insurance Policies to a volunteer fire department, first aid, or other such volunteer group

 

 

 

 

 

BLS Policies sold and issued as blanket health insurance Policies to a sports team or a camp

 

 

 

 

 

BLT Policies sold and issued as blanket health insurance Policies to a travel agency, or other organization that provides travel-related services

 

 

 

 

 

BLU Policies sold and issued as blanket health insurance Policies to a university or college

 

 

 

 

 

SLG Policies sold and issued as student major medical expense large group coverage to enrolled students at an accredited college, university, or other educational institution

 

 

 

 

 

STS Policies sold and issued as group short term student health insurance

 

 

 

 

 

SMG Policies sold and issued as student major medical group health insurance

 

 

 

 

 

SNM Policies sold and issued as student group health insurance that is not major medical coverage

 

 

 

 

 

SIM Policies sold and issued as student individual major medical health insurance

 

 

 

 

 

SIN Policies sold and issued as student individual health insurance that is not major medical coverage

31

ME031

NH Health Protection Program

Text

60

For enrollees in the New Hampshire Health Protection Program (NHHPP), indicate if enrollee is part of the Premium Assistance Program (PAP) or Health Insurance Premium Payment (HIPP).  Leave blank if enrollee is not a member of the NHHPP

32

ME032

Group Name

Text

4

Name of the group that the member is covered by.  If the member is part of a group of one or non-group, indicate I

 

 

 

 

 

 

 

 

 

 

33

ME101

Subscriber Last Name

Text

60

 

34

ME102

Subscriber First Name

Text

35

 

35

ME103

Subscriber Middle Initial

Text

1

 

36

ME104

Member Last Name

Text

60

 

37

ME105

Member First Name

Text

35

 

38

ME106

Member Middle Initial

Text

1

 

39

Placeholder

40

ME203

Member’s Assigned PCP

Text

20

National Provider ID of the member’s Primary Care Physician as designated by healthcare claims processor.

41

ME204

HIOS Plan ID

Text

16

The 16 character HIOS Plan ID (Standard component). Including a five digit issuer ID, two character state ID, three digit product number, four digit standard component number and two digit variant component ID. This field may not be available for all market segments;

42

ME205

Plan Effective Date

Date

8

For the plan reported in ME204, report the date eligibility started for this member under this plan type. The purpose of this data element is to maintain an eligibility span for each member.

43

ME206

Minimum Value

Number

3 (0)

For the plan reported in ME204, report the Minimum Value as described in Part Ins4009.03 (j). This is reported as a percentage.

44

ME207

Exchange Indicator

Text

1

The plan reported in ME204 was available on the Exchange Marketplace in the month and year reflected in ME004 and ME005

 

 

 

 

 

Y Yes

 

 

 

 

 

N No

45

ME208

High deductible health plan

Text

1

The plan reported in ME204 meets the IRS definition of a HDHP

 

 

 

 

 

Y Yes

 

 

 

 

 

N No

 

 

 

 

 

U Unknown

46

ME209

Active enrollment

Text

1

The plan reported in ME204 was open for enrollment in the year and month reflected in ME004 and ME005

 

 

 

 

 

Y Yes

 

 

 

 

 

N No

47

ME210

New Coverage

Text

1

The plan reported in ME204 was being offered for the first time in the reporting year reflected in ME004

 

 

 

 

 

Y Yes

 

 

 

 

 

N No

48

ME211

Placeholder

 

49

ME899

Record Type

Text

2

ME

50

ME900

Plan State

Text

2

State in which the plan is sold or used.  State codes are maintained by the US Postal Service

51

ME901

 

Advanced Premium Tax Credit

Number

2(2)

Dollar value of Advanced Premium Tax Credit (APTC) subsidy

52

ME902

NAIC Number

Text

5

Number that the National Association of Insurance Commissioners (NAIC) assigns to each individual underwriting company

53

ME903

Grandfather Plan indicator

Text

1

Indicates if a plan qualifies as a “Grandfathered” or “Transitional Plan” under the Affordable Care Act (ACA). Please see definition for “grandfathered” and “transitional” in HHS rules 45-CFR-147.140: https://www.federalregister.gov/select- citation/2013/06/03/45-CFR-147. The values of the indicator are as follows: 1= Grandfathered; 2 = Non-Grandfathered; 3 =Transitional; 4 = Not Applicable

54

ME904

Metal Level

Text

10

The metal representation of the plan reported in ME204 on the Exchange Marketplace

 

Source.  #10877, eff 7-10-15; ss by #13136, eff 11-24-20

 

          Ins 4010.02  Member Claims Data Tables.

 

          (a)  Medical Eligibility File Mapping and Format Information.  Use Table 4010.7 (b) to determine medical eligibility file mapping and formatting.

 

          (b)  Medical Claims File Header Record Layout

 

Table 4010.02 (b) Medical Claims File Header Record Layout

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

HD001

Record Type

Text

2

HD

HD002

Payer

Text

8

Payer submitting payments. NHID Submitter Code

HD003

National Plan ID

Text

30

CMS National Plan ID

HD004

Type of File

Text

2

MC Medical Claims

HD005

Period Beginning Date

Date

8

Beginning of paid period for claims or beginning of month covered for eligibility

HD006

Period Ending Date

Date

8

End of paid period for claims or end of month covered for eligibility

HD007

Comments

Text

80

Submitter may use to document this submission by assigning a filename, system source, etc.

 

          (c)  Medical Claims Files Trailer Record Layout

 

Table 4010.02 (c) Medical Claims File Trailer Record Layout

Data Element #

Element

Type

Length (decimal places

Description/Codes/Sources

TR001

Record Type

Text

2

TR

TR002

Payer

Text

8

Payer submitting payments. NHID Submitter Code

TR003

National Plan ID

Text

30

CMS National Plan ID

TR004

Type of File

Text

2

MC Medical Claims

TR005

Period Beginning Date

Date

8

Beginning of paid period for claims or beginning of month covered for eligibility

TR006

Period Ending Date

Date

8

End of paid period for claims or beginning of month covered for eligibility

TR007

Extraction Date

Date

8

Date file was created

TR008

Record Count

Number

10 (0)

Total number of records submitted in this file

 

          (d)  Medical Claims File Detailed Specifications

 

Table 4010.02 (d) Medical Claims File Detailed Specifications

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

MC001

Payer

Text

8

Payer submitting payments NHID Submitter Code

MC002

National Plan ID

Text

30

CMS National Plan ID

MC003

Insurance Type/Product Code

Text

2

As established by X12 Accredited Standards Committee available at https://ushik.ahrq.gov/ViewItemDetails?system=sdo&itemKey=133161000

MC004

Payer Claim Control Number

Text

35

Must apply to the entire claim and be unique within the payer's system

MC005

Line Counter

Text

4

Line number for this service. The line counter begins with 1 and is incremented by 1 for each additional service line of a claim

MC005A

Version Number

Number

4 (0)

Version number of this claim service line. The version number begins with 0 and is incremented by 1 for each subsequent version of that service line

MC006

Insured Group or Policy Number

Text

50

Group or policy number (not the number that uniquely identifies the subscriber)

MC007

Subscriber Social Security Number

Text

9

Subscriber's social security number. Do not include dashes.  Leave blank if not available.

MC008

Plan Specific Contract Number

Text

50

Plan assigned contract number. Leave blank if Plan Specific Contract Number is subscriber’s social security number. 

If this is a Medicaid claim, provide Medicaid ID.

MC009

Member Suffix or Sequence Number

Text

20

Uniquely identifies the member within the contract

MC010

Member Social Security Number

Text

9

Member’s social security number. Do not include dashes.  Leave blank if not available.

MC011

Individual Relationship Code

Text

2

See Table 4010.6 (b) Relationship Codes

MC012

Member Gender

Text

1

M Male

 

 

 

 

F Female

 

 

 

 

U Unknown

 

 

 

 

O Other

MC013

Member Date of Birth

Date

8

Date of birth of member

MC014

Member City Name

Text

30

City name of member

MC015

Member State or Province

Text

2

As defined by the US Postal Service

MC016

Member ZIP Code

Text

9

ZIP Code of member – may include non- US codes. Do not include dash.

MC017

Paid Date (AP Date)

Date

8

 

MC018

Admission Date

Date

8

Required for all inpatient claims.

MC019

Admission Hour

Text

2 (0)

Required for all inpatient claims. Time is expressed in military time – HH

MC020

Admission Type

Text

1

Required for all inpatient claims (SOURCE: National Uniform Billing Data Element Specifications):

 

 

 

 

1 = Emergency

 

 

 

 

2 = Urgent

 

 

 

 

3 = Elective

 

 

 

 

4 = Newborn

 

 

 

 

5 = Trauma Center

 

 

 

 

9 = Information not available

MC021

Admission Source

Text

1

See Table 4010.6 (i)  Point of Origin Codes

MC022

Discharge Hour

Text

2 (0)

Required for all inpatient claims. Time is expressed in military time – HH

MC023

Discharge Status

Text

2

See Table 4010.6 (f): Discharge Status

MC024

Service Provider Number

Text

30

Payer assigned servicing provider number by the payer for internal identification purposes

MC025

Service Provider Tax ID Number

Text

10

Federal taxpayer's identification number – if the tax id is a provider’s social security number, use ‘SSN’ and ‘NA’ if unavailable

MC026

National Service Provider ID

Text

20

Provider NPI

MC027

Service Provider Entity Type Qualifier

Text

1

HIPAA provider taxonomy classifies provider groups (clinicians who bill as a group practice or under a corporate name, even if that group is composed of one provider) as “Person”.

 

 

 

 

1 Person

 

 

 

 

2 Non-Person Entity

MC028

Service Provider First Name

Text

35

Individual first name. Leave blank if provider is a facility or organization

MC029

Service Provider Middle Name

Text

25

Individual middle name or initial. Leave blank if provider is a facility or organization

MC030

Servicing Provider Last Name or Organization Name

Text

60

Report the name of the organization or last name of the individual provider. MC027 determines if this is an organization or Individual Name reported here.

MC031

Service Provider Suffix

Text

10

Suffix to individual name. Leave blank if provider is a facility or organization. Should be used to capture the generation of the individual clinician (e.g., Jr. Sr., III), if applicable, rather than the clinician’s degree [e.g., ‘MD’, ‘LICSW’].

MC032

Service Provider Specialty

Text

10

National Uniform Claims Committee (NUCC) standard code that defines this provider for this line of service.  Taxonomy values allow for the reporting of nurses, assistants and laboratory technicians, where applicable, as well as Physicians, Medical Groups, Facilities, etc.

MC033

Service Provider City Name

Text

30

City name of rendering provider - practice location

MC034

Service Provider State

Text

2

As defined by the US Postal Service

MC035

Service Provider ZIP Code

Text

9

ZIP Code of provider - may include non-US codes.

MC036

Type of Bill – Institutional

Text

3

For facility claims only submitted using UB04 forms

Type of Facility - First Digit

 

 

 

 

1 Hospital

 

 

 

 

2 Skilled Nursing

 

 

 

 

3 Home Health

 

 

 

 

4 Christian Science Hospital

 

 

 

 

5 Christian Science Extended Care

 

 

 

 

6 Intermediate Care

 

 

 

 

7 Clinic

 

 

 

 

8 Special Facility

 

 

 

 

Bill Classification - Second Digit if First Digit = 1-6

 

 

 

 

1 Inpatient (Including Medicare Part A)

 

 

 

 

2 Inpatient (Medicare Part B Only)

 

 

 

 

3 Outpatient

 

 

 

 

4 Other (for hospital referenced diagnostic services

 

 

 

 

or home health not under a plan of treatment)

 

 

 

 

5 Nursing Facility Level I

 

 

 

 

6 Nursing Facility Level II

 

 

 

 

7 Intermediate Care - Level III Nursing Facility

 

 

 

 

8 Swing Beds

 

 

 

 

Bill Classification - Second Digit if First Digit = 7

 

 

 

 

1 Rural Health

 

 

 

 

2 Hospital Based or Independent Renal Dialysis Center

 

 

 

 

3 Free Standing Outpatient Rehabilitation Facility (ORF)

 

 

 

 

5 Comprehensive Outpatient Rehabilitation Facility (ORF)

 

 

 

 

6 Community Mental Health Center

 

 

 

 

9 Other

 

 

 

 

Bill Classification – Second Digit if First Digit = 8

 

 

 

 

1 Hospice (Non Hospital Based

 

 

 

 

2 Hospice (Hospital-Based)

 

 

 

 

3 Ambulatory Surgery Center

 

 

 

 

4 Free Standing Birthing Center

 

 

 

 

9 Other

 

 

 

 

Frequency – Third Digit

 

 

 

 

0  Non-Payment/Zero

 

 

 

 

1 Admit Through Discharge

 

 

 

 

2 Interim – First Claim

 

 

 

 

3 Interim -  Continuing Claims

 

 

 

 

4 – Interim – Last Claim

 

 

 

 

5 – Late Charge Only

 

 

 

 

7 – Replacement of Prior Claim

 

 

 

 

8 – Void/Cancel of a Prior Claim

 

 

 

 

9 – Final Claim for a Home Health PPS Episode

MC037

Place of Service – Professional)

Text

2

For professional claims only, such as those submitted using CMS1500 forms

See Table 4010.6 (g) Place of Service -- Professional

MC038

Service Line Status

Text

2

Describes the payment status of the specific service line record

 

 

 

 

01 Processed as primary

 

 

 

 

02 Processed as secondary

 

 

 

 

03 Processed as tertiary

 

 

 

 

04 Denied

 

 

 

 

06 Approved as amended

 

 

 

 

19 Processed as primary, forwarded to additional payer(s)

 

 

 

 

20 Processed as secondary, forwarded to additional payer(s)

 

 

 

 

21 Processed as tertiary, forwarded to additional payer(s)

 

 

 

 

22 Reversal of previous payment

 

 

 

 

26 Documentation Claim – No Payment Associated

 

 

 

 

28 Repriced

MC039

Admitting Diagnosis

Text

7

ICD-CM Diagnosis Codes.  Required on all inpatient admission claims and encounters.  Do not include decimals.

MC040

E-Code

Text

7

ICD-CM Diagnosis Codes.  Describes an injury, poisoning or adverse effect ICD-CM.

MC041

Principal Diagnosis

Text

7

ICD-CM Diagnosis Codes.  Principal Diagnosis should be the principal diagnosis given on the claim header.  Do not include decimals.

MC042

Other Diagnosis -1

Text

7

ICD-CM Diagnosis Codes.  Do not include decimals.

MC043

Other Diagnosis -2

Text

7

ICD-CM Diagnosis Codes.  Do not include decimals.

MC044

Other Diagnosis -3

Text

7

ICD-CM Diagnosis Codes.  Do not include decimals.

MC045

Other Diagnosis -4

Text

7

ICD-CM Diagnosis Codes.  Do not include decimals.

MC046

Other Diagnosis -5

Text

7

ICD-CM Diagnosis Codes.  Do not include decimals.

MC047

Other Diagnosis -6

Text

7

ICD-CM Diagnosis Codes.  Do not include decimals.

MC048

Other Diagnosis -7

Text

7

ICD-CM Diagnosis Codes.  Do not include decimals.

MC049

Other Diagnosis -8

Text

7

ICD-CM Diagnosis Codes.  Do not include decimals.

MC050

Other Diagnosis -9

Text

7

ICD-CM Diagnosis Codes.  Do not include decimals.

MC051

Other Diagnosis -10

Text

7

ICD-CM Diagnosis Codes.  Do not include decimals.

MC052

Other Diagnosis -11

Text

7

ICD-CM Diagnosis Codes.  Do not include decimals.

MC053

Other Diagnosis -12

Text

7

ICD-CM Diagnosis Codes.  Do not include decimals.

MC054

Revenue Code

Text

4

National Uniform Billing Committee Codes. Code using leading zeroes, left-justified, and four digits.

MC055

Procedure Code

Text

5

Health Care Common Procedural Coding System (HCPCS). This includes the CPT codes of the American Medical Association

MC056

Procedure Modifier – 1

Text

2

Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code

MC057

Procedure Modifier – 2

Text

2

Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code

MC058

ICD-9-CM Procedure Code

Text

4

Primary ICD-9/10-CM code given on the claim header.

MC059

Date of Service – From

Date

8

First date of service for this service line.

MC060

Date of Service – Thru

Date

12

Last date of service for this service line

MC061

Quantity

Number

12 (0)

Count of services performed.

MC062

Charge Amount

Number

10 (2)

The full, undiscounted total and service-specific charges billed by the provider.

MC063

Paid Amount

Number

10 (2)

Includes any withhold amounts.

MC064

Fee for Service Equivalent

Number

10 (2)

For capitated services, the fee for service equivalent amount.

MC065

Copay Amount

Number

10 (2)

The preset, fixed dollar amount for which the individual is responsible.

MC066

Coinsurance Amount

Number

10 (2)

Coinsurance , dollar amount

MC067

Deductible Amount

Number

10 (2)

Amount in dollars met by the patient/family in a deductible plan

MC068

Patient Account/Control Number

Text

20

 

MC069

Discharge Date

Date

8

Required for all inpatient(s)

MC070

Service Provider Country Name

Text

30

 

MC071

DRG

Text

7

Carriers and third-party administrators shall code using the CMS methodology when available. Precedence shall be given to DRGs transmitted from the hospital provider. When the CMS methodology for DRGs is not available, but the All Payer DRG system is available, then that system shall be used. If the All Payer DRG system is used, the carrier shall format the DRG and the complexity level within the same field with an "A" prefix, and with a hyphen separating the DRG and the complexity level (e.g. AXXX-XX)

MC072

DRG Version

Text

2

This element is the version number of the grouper used.

MC073

APC

Text

4

Carriers and third-party administrators shall code using CMS methodology. Precedence shall be given to APCs transmitted from the health care provider

MC074

APC Version

Text

2

This element is the version number of the grouper used

MC075

Drug Code

Text

11

NDC Code Used only when a medication is paid for as part of a medical claim.

MC076

Billing Provider Number

Text

30

Payer assigned billing provider number. This number should be the identifier used by the payer for internal identification purposes and does not routinely change

MC077

National Billing Provider Number ID

Text

30

This is the NPI for the billing provider

MC078

Billing Provider Organization or Last Name

Text

60

 

MC101

Subscriber Last Name

Text

60

 

MC102

Subscriber First Name

Text

35

 

MC103

Subscriber Middle Initial

Text

1

 

MC104

Member Last Name

Text

60

 

MC105

Member First Name

Text

35

 

MC106

Member Middle Initial

Text

1

 

MC200

ICD Indicator

Text

1

Report the value that defines whether the diagnoses on claim are ICD9 or ICD10.

 

 

 

 

0 ICD-9

 

 

 

 

1 ICD-10

MC202

Other ICD-CM Procedure Code - 2

Text

7

ICD Secondary Procedure Code

MC203

Other ICD-CM Procedure Code - 3

Text

7

ICD Secondary Procedure Code

MC204

Other ICD-CM Procedure Code - 4

Text

7

ICD Secondary Procedure Code

MC205

Other ICD-CM Procedure Code - 5

Text

7

ICD Secondary Procedure Code

MC206

Other ICD-CM Procedure Code - 6

Text

7

ICD Secondary Procedure Code

MC207

Carrier Associated with Claim

Text

8

For each claim, the NAIC code of the carrier when a TPA processes claims on behalf of the carrier. Optional if all medical claims processed by a TPA under contract to a carrier for carved-out services are submitted by the carrier with unified member IDs in all files.

MC208

Carrier Plan Specific Contract Number or Subscriber/Member Social Security Number

Text

128

When a TPA processes claims on behalf of the carrier, for each claim, report the carrier specific contract number or subscriber/member social security number. Optional if all medical claims processed by a TPA under contract to a carrier for carved-out services are submitted by the carrier with unified member IDs in all files.

MC209

Practitioner Group Practice

Text

60

Name of group practice to which a practitioner is affiliated if different from MC078

MC210

Coordination of Benefits/Third Party Liability Amount

Number

10 (2)

Coordination of Benefits (COB)/Third Party Liability (TPL) is the dollar amount paid from a prior payer (e.g. auto claim, workers comp, dual medical coverage). Report 0 if there is no COB/TPL amount.

MC211

Cross Reference Claims ID

Text

35

The original Payer Claim Control Number (MC004). Used when a new Payer Claim Control Number is assigned to an adjusted claim and a Version Number (MC005A) is not used.

MC212

Allowed Amount

Number

10 (2)

Report the maximum dollar amount contractually allowed and that a carrier will pay to a provider for a particular procedure or service.  This will vary by provider contract and most often it is less than or equal to the fee charged by the provider.

MC215

Service Line Type

Text

1

Report the code that defines the claim line status in terms of adjudication

 

 

 

 

O Original

 

 

 

 

V Void

 

 

 

 

R Replacement

 

 

 

 

B Back Out

 

 

 

 

A Amendment

MC216

Payment Arrangement Type

Text

1

Defines the contracted payment methodology for this claim line

 

 

 

 

1 Capitation

 

 

 

 

2 Fee for service

 

 

 

 

3 Percent of charges

 

 

 

 

4 DRG

 

 

 

 

5 Pay for Performance

 

 

 

 

6 Global Payment

 

 

 

 

7 Other

 

 

 

 

8 Bundled payment

MC217

Pay for Performance Flag

Text

1

Does this provider have pay-for-performance bonuses or year-end withhold returns based on performance for at least one service performed by this provider within the month?

Required when MP005 = 1, 2, or 3

 

 

 

 

Y Yes

 

 

 

 

N No

MC218

Claim Processing Level Indicator

Text

1

1 Claim Level

 

 

 

 

2 Service Line level

MC219

Denied Claim Indicator

Text

1

1 Fully Paid – the entire claim was paid at the allowed amount

 

 

 

 

2 Partially denied – some of the claims lines were paid at the allowed amount

 

 

 

 

3 Encounter claim – this claim records a service provided that is paid under a non Fee For Service (FFS) payment arrangement such as capitation

 

 

 

 

4 No payment – no payment made for reasons other than non FFS payment arrangement

MC220

Denial Reason

Text

15

Denial reason code. Required when denied claim indicator = 2 or 4

http://www.wpc-edi.com/reference/

MC221

Procedure Modifier – 3

Text

2

Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code

MC222

Procedure Modifier – 4

 

2

Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code

MC223

HIOS Plan ID

Text

16

The 16 character HIOS Plan ID (Standard component), including a 5 digit issuer ID, 2 character state ID, 3 digit product number, 4 digit standard component number, and 2 digit variant component ID.  This field may not be available for all market segments.  Leave blank if not available

MC899

Record Type

Text

2

MC

MC900

In Network Indicator

Text

1

A yes/no indicator that specifies that the provider (not the benefit) is within the health plan network.  Valid codes:  Y=Yes, N=No

MC901

Unit of Measure

Text

2

Type of units reported in MC061.  Codes accepted DA=days, MN=minutes, UN=units.  If MC061 is not reported, MC901=NA

 

 

 

 

 

 

Source.  #10877, eff 7-10-15; ss by #13136, eff 11-24-20

 

          Ins 4010.03  Pharmacy Claims Data Tables.

 

          (a)  Pharmacy Claims Mapping and Format Information.  Use Table 4010.7 (c) to determine pharmacy claims file mapping and formatting.

 

          (b)  Pharmacy Claims File Header Record Layout

 

Table 4010.03(b) Pharmacy Claims File Header Record Layout

Data Element #

Element

Type

Length

(decimal places

Description/Codes/Sources

HD001

Record Type

Text

2

HD

HD002

Payer

Text

8

Payer submitting payments. NHID Submitter Code

HD003

National Plan ID

Text

30

CMS National Plan ID

HD004

Type of File

Text

2

PC Pharmacy Claims

HD005

Period Beginning Date

Date

8

Beginning of paid period for claims or beginning of month covered for eligibility

HD006

Period Ending Date

Date

8

End of paid period for claims or end of month covered for eligibility

HD007

Comments

Text

80

Submitter may use to document this submission by assigning a filename, system source, etc.

 

          (c)  Pharmacy Claims File Trailer Record Layout

 

Table 4010.03 (c) Pharmacy Claims File Trailer Record Layout

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

TR001

Record Type

Text

2

TR

TR002

Payer

Text

8

Payer submitting payments. NHID Submitter Code

TR003

National Plan ID

Text

30

CMS National Plan ID

TR004

Type of File

Text

2

PC Pharmacy Claims

TR005

Period Beginning Date

Date

8

Beginning of paid period for claims or beginning of month covered for eligibility

TR006

Period Ending Date

Date

8

End of paid period for claims or beginning of month covered for eligibility

TR007

Extraction Date

Date

8

Date file was created

TR008

Record Count

Number

10 (0)

Total number of records submitted in this file

 

          (d)  Pharmacy Claims Detailed File Specifications

 

Table 4010.03 (d) Pharmacy Claims Detailed File Specification

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

PC001

Payer

Text

8

Payer submitting payments NHID Submitter Code

PC002

Plan ID

Text

30

CMS National Plan ID

PC003

Insurance Type/Product Code

Text

2

As established by X12 Accredited Standards Committee, available at https://ushik.ahrq.gov/ViewItemDetails?system=sdo&itemKey=133161000

PC004

Payer Claim Control Number

Text

35

Must apply to the entire claim and be unique within the payer's system

PC005

Line Counter

Text

4

Line number for this service The line counter begins with 1 and is incremented by 1 for each additional service line of a claim

PC006

Insured Group Number

Text

50

Group or policy number (not the number that uniquely identifies the subscriber)

PC007

Subscriber Social Security Number

Text

9

Subscriber's social security number. Do not include dashes.  Leave blank if not available.

PC008

Plan Specific Contract Number

Text

50

Plan assigned contract number. Leave blank if Plan Specific Contract Number is subscriber’s social security number. 

If this is a Medicaid claim, provide Medicaid ID.

PC009

Member Suffix or Sequence Number

Text

20

Uniquely identifies the member within the contract

PC010

Member Social Security Number

Text

9

Member’s social security number. Do not include dashes.  Leave blank if not available.

PC011

Individual Relationship Code

Text

2

See Table 4010.6 (b) Relationship Codes

PC012

Member Gender

Text

1

M Male

 

 

 

 

F Female

 

 

 

 

U Unknown

 

 

 

 

O Other

PC013

Member Date of Birth

Date

8

 

PC014

Member City Name of Residence

Text

30

City name of member

PC015

Member State

Text

2

As defined by the US Postal Service

PC016

Member ZIP Code

Text

9

ZIP Code of member – may include non- US codes. Do not include dash.

PC017

Paid Date (AP Date)

Date

8

Paid date or the Pharmacy Benefits Manager’s billing date

PC018

Pharmacy Number

Text

30

Payer assigned pharmacy number. AHFS number is acceptable

PC019

Pharmacy Tax ID Number

Text

10

Federal taxpayer's identification number (Please provide the pharmacy chain’s federal tax identification number, if the individual retail pharmacy’s tax ID# is not available.)

PC020

Pharmacy Name

Text

30

Name of pharmacy

PC021

National Pharmacy ID Number

Text

20

Required if National Provider ID is mandated for use under HIPAA

PC022

Pharmacy Location City

Text

30

City name of pharmacy

PC023

Pharmacy Location State

Text

2

As defined by the US Postal Service

PC024

Pharmacy ZIP Code

Text

9

ZIP Code of pharmacy - may include non- US codes. Do not include dash

PC024A

Pharmacy Country Name

Text

30

Code US

PC025

Service Line Status

Text

2

See Table 4010.6 (h) Claim Status

PC026

Drug Code

Text

11

NDC Code in CMS configuration with leading zeros and no hyphens.

PC027

Drug Name

Text

80

Text name of drug

PC028

New Prescription

Number

2 (0)

00 New prescription. 01-99 Number of refill(s)

PC029

Generic Drug Indicator

Text

2

01 No, branded drug

 

 

 

 

02 Yes, generic drug

PC030

Dispense as Written Code

Text

1

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

PC031

Compound Drug Indicator

Text

1

N Non-compound drug

 

 

 

 

Y Compound drug

 

 

 

 

U Non-specified drug compound

PC032

Date Prescription Filled

Date

8

 

PC033

Quantity Dispensed

Number

10

Number of metric units of medication dispensed

PC034

Days’ Supply

Number

3

Estimated number of days the prescription will last

PC035

Charge Amount

Number

10 (2)

The full, undiscounted total and service-specific charges billed by the provider.

PC036

Paid Amount

Number

10 (2)

Includes any withhold amounts.

PC037

Ingredient Cost/List Price

Number

10 (2)

Cost of the drug dispensed. Do not code decimal point

PC038

Postage Amount Claimed

Number

10 (2)

Postage amount in dollars

PC039

Dispensing Fee

Number

10 (2)

Dispensing fess in dollars

PC040

Copay Amount

Number

10 (2)

The preset, fixed dollar amount for which the individual is responsible.

PC041

Coinsurance Amount

Number

10 (2)

Coinsurance amount in dollars

PC042

Deductible Amount

Number

10 (2)

Deductible amount in dollars

PC043

Prescription Number

 Text

20

The number generated by the pharmacy when a new prescription is ordered for a person - a unique code assigned to a person’s prescribed medicine

PC044

Prescribing Physician First Name

Text

35

Physician first name

PC045

Prescribing Physician Middle Name

Text

25

Physician middle name

PC046

Prescribing Physician Last Name

Text

60

Physician last name

PC047

Prescribing Physician Number

Text

20

Provider NPI

PC101

Subscriber Last Name

Text

60

 

PC102

Subscriber First Name

Text

35

 

PC103

Subscriber Middle Initial

Text

1

 

PC104

Member Last Name

Text

60

 

PC105

Member First Name

Text

35

 

PC106

Member Middle Initial

Text

1

 

PC203

Carrier Associated with Claim

Text

8

For each claim, the NAIC code of the carrier when a PBM processes claims on behalf of the carrier. Optional if all pharmacy claims processed by a PBM under contract to a carrier for carved-out services are submitted by the carrier with unified member IDs in all files.

PC204

Carrier Plan Specific Contract Number or Subscriber/Member Social Security Number

Text

128

For each claim, the carrier specific contract number or subscriber/member social security number when a PBM processes claims on behalf of the carrier. Optional if all pharmacy claims processed by a PBM under contract to a carrier for carved-out services are submitted by the carrier with unified member IDs in all files.

PC211

Cross Reference Claims ID

Text

35

The original Payer Claim Control Number (PC004). Used when a new Payer Claim Control Number is assigned to an adjusted claim.

PC212

Allowed amount

Number

10 (2)

Report the maximum amount contractually allowed 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.

PC213

HIOS Plan ID

Text

16

The 16 character HIOS Plan ID (Standard component). Including a five digit issuer ID, two character state ID, three digit product number, four digit standard component number and two digit variant component ID. This field may not be available for all market segments; Leave blank if not available

PC214

Claim Processing Level Indicator

Text

1

1 Claim Level

 

 

 

 

 

2 Service Line level

PC215

Service Line Type

Text

1

Report the code that defines the claim line status in terms of adjudication

 

 

 

 

O Original

 

 

 

 

V Void

 

 

 

 

R Replacement

 

 

 

 

B Back Out

 

 

 

 

A Amendment

PC216

Denied Claim Indicator

Text

1

1 Fully Paid – the entire claim was paid at the allowed amount

 

 

 

 

2 Partially denied – some of the claims lines were paid at the allowed amount

 

 

 

 

3 Encounter claim – this claim records a service provided that is paid under a non FFS payment arrangement such as capitation

 

 

 

 

4 No payment – no payment made for reasons other than non FFS payment arrangement

PC217

Denial Reason

Text

4

Denial reason code. Required when denied claim indicator = 2 or 4 NCPDP denial reason codes and CARC/RARC code list accepted, available at http://www.wpc-edi.com/reference/codelists/healthcare/health-care-services-decision-reason-codes/

PC899

Record Type

Text

2

PC

PC900

Mail Order Pharmacy Indicator

Text

1

A yes/no indicator that specifies that the pharmacy is a mail order pharmacy.  Valid codes:  Y=Yes, N=No

PC901

In Network Indicator

Text

1

A yes/no indicator that specifies that the provider(not the benefit) is within the health plan network.  Valid codes:  Y=Yes, N=No

PC902

Version Number

Number

4(0)

Version number of this claim.  The version number begins with 0 and is incremented by 1 for each subsequent version of that service line

 

Source.  #10877, eff 7-10-15; ss by #13136, eff 11-24-20

 


          Ins 4010.04  Dental Claims Data Tables.

 

          (a)  Dental Claims Mapping and Format Information.  Use Table 4010.7 (d) to determine dental claims file mapping and formatting.

 

          (b)  Dental Claims File Header Record Layout

 

Table 4010.04 (b) Dental Claims Header File Record Layout

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

HD001

Record Type

Text

2

HD

HD002

Payer

Text

8

Payer submitting payments. NHID Submitter Code

HD003

National Plan ID

Text

30

CMS National Plan ID

HD004

Type of File

Text

2

DC Dental Claims

HD005

Period Beginning Date

Date

8

Beginning of paid period for claims or beginning of month covered for eligibility

HD006

Period Ending Date

Date

8

End of paid period for claims or end of month covered for eligibility

HD007

Comments

Text

80

Submitter may use to document this submission by assigning a filename, system source, etc.

 

          (c)  Dental Claims File Trailer Record Layout

 

Table 4010.04 (c)  Dental Claims Trailer File Record Layout

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

TR001

Record Type

Text

2

TR

TR002

Payer

Text

8

Payer submitting payments. NHID Submitter Code

TR003

National Plan ID

Text

30

CMS National Plan ID

TR004

Type of File

Text

2

DC Dental Claims

TR005

Period Beginning Date

Date

8

Beginning of paid period for claims or beginning of month covered for eligibility

TR006

Period Ending Date

Date

8

End of paid period for claims or beginning of month covered for eligibility

TR007

Extraction Date

Date

8

Date file was created

TR008

Record Count

Number

10 (0)

Total number of records submitted in this file

 

          (d)  Dental Claims Detailed File Specifications

 

Table 4010.04 (d) Dental Claims Detailed File Specifications

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

DC001

Payer

Text

8

Payer submitting payments

DC002

National Plan ID

Text

30

CMS National Plan ID

DC003

Insurance Type/Product Code

Text

2

As established by X12 Accredited Standards Committee, available at https://ushik.ahrq.gov/ViewItemDetails?system=sdo&itemKey=133161000

DC004

Payer Claim Control Number

Text

35

Must apply to entire claim and be unique within payer's system

DC005

Line Counter

Text

4

Line number for this service. The line counter begins with 1 and is incremented by 1 for each additional service line of a claim

DC006

Insured Group or Policy Number

Text

50

Group or policy number (not the number that uniquely identifies the subscriber)

DC007

Subscriber Social Security Number

Text

9

Subscriber's social security number. Do not include dashes.  Leave blank if not available.

DC008

Plan Specific Contract Number

Text

50

Plan assigned contract number. Leave blank if Plan Specific Contract Number is subscriber’s social security number. 

If this is a Medicaid claim, provide Medicaid ID.

DC009

Member Suffix or Sequence Number

Text

20

Uniquely identifies the member within the contract

DC010

Member Social Security Number

Text

9

Member’s social security number. Do not include dashes.  Leave blank if not available.

DC011

Individual Relationship Code

Text

2

See Table 4010.6 (b) Relationship Codes

DC012

Member Gender

Text

1

M Male

 

 

 

 

F Female

 

 

 

 

U Unknown

 

 

 

 

O Other

DC013

Member Date of Birth

Date

8

 

DC014

Member City Name

Text

30

City name of member

DC015

Member State or Province

Text

2

As defined by the U.S. Postal Service

DC016

Member ZIP Code

Text

9

ZIP Code of member – may include non- US codes. Do not include dash.

DC017

Paid Date/AP Date

Date

8

 

DC018

Service Provider Number

Text

30

Payer assigned provider number

DC019

Service Provider Tax ID Number

Text

10

Federal taxpayer's identification number if the tax id is a provider’s social security number use ‘SSN’ and ‘NA’ if unavailable

DC020

National Service Provider ID

Text

20

Required if National Provider ID is mandated for use under HIPAA

DC021

Service Provider Entity Type Qualifier

Text

1

HIPAA provider taxonomy classifies provider groups (clinicians who bill as a group practice or under a corporate name, even if that group is composed of one provider) as “Person”.

 

 

 

 

1 Person

 

 

 

 

2 Non-Person Entity

DC022

Service Provider First Name

Text

35

Individual first name. Leave blank if provider is a facility or organization

DC023

Service Provider Middle Name

Text

25

Individual middle name or initial. Leave blank if provider is a facility or organization

DC024

Servicing Provider Last Name or Organization Name

Text

60

Report the name of the organization or last name of the individual provider.  DC021 determines if this is an Organization or Individual Name reported here.

DC025

Service Provider Suffix

Text

10

Suffix to individual name. Leave blank if provider is a facility or organization

DC026

Service Provider Specialty

Text

10

National Uniform Claims Committee (NUCC) standard code that defines this provider for this line of service. Dictionary for specialty code values must be supplied during testing.

DC027

Service Provider City Name

Text

30

City name of provider - practice location

DC028

Service Provider State or Province

Text

2

As defined by the U.S. Postal Service

DC029

Service Provider ZIP Code

Text

9

ZIP Code of provider - may include non-US codes.

DC030

Place of Service - Professional

Text

2

 See Table 4010.6 (g) Place of Service  -- Professional

DC031

Claim Status

Text

2

 See Table 4010.6 (h) Claim Status

DC032

CDT Code

Text

5

Common Dental Terminology code

DC033

Procedure Modifier - 1

Text

2

Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code

DC034

Procedure Modifier - 2

Text

2

Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code

DC035

Date of Service - From

Date

8

First date of service for this service line.

DC036

Date of Service - Thru

Date

8

Last date of service for this service line.

DC037

Charge Amount

Number

10 (2)

The full, undiscounted total and service-specific charges billed by the provider.

DC038

Paid Amount

Number

10 (2)

Includes any withhold amounts.

DC039

Copay Amount

Number

10 (2)

The present, fixed dollar amount for which the individual is responsible.

DC040

Coinsurance Amount

Number

10 (2)

The dollar amount an individual is responsible for - not the percentage.

DC041

Deductible Amount

Number

10 (2)

Deductible amount in dollars

DC042

Billing Provider Number

Text

30

Carriers, third-party administrators, and dental claims processors shall code using the payer assigned billing provider number. This number should be the identifier used by the payer for internal identification purposes, and does not routinely change

DC043

National Billing Provider Number ID

Text

30

This is the NPI for the billing provider

DC044

Billing Provider Last Name

Text

60

 Full name of provider billing organization or last name of individual billing provider.

DC101

Subscriber Last Name

Text

60

 

DC102

Subscriber First Name

Text

35

 

 

DC103

Subscriber Middle Initial

Text

1

 

DC104

Member Last Name

Text

60

 

DC105

Member First Name

Text

35

 

DC106

Member Middle Initial

Text

1

 

DC201

Carrier Associated with Claim

Text

8

For each claim, the NAIC code of the carrier when a TPA processes claims on behalf of the carrier. Optional if all dental claims processed by a TPA under contract to a carrier for carved-out services are submitted by the carrier with unified member IDs in all files.

DC202

Carrier Plan Specific Contract Number or Subscriber/Member Social Security Number

Text

128

For each claim, the carrier specific contract number or subscriber/member social security number when a TPA processes claims on behalf of the carrier. Optional if all medical claims processed by a TPA under contract to a carrier for carved-out services are submitted by the carrier with unified member IDs in all files.

DC203

Practitioner Group Practice

Text

60

Name of group practice to which a practitioner is affiliated if different from DC044.

DC204

Tooth Number/Letter

Text

2

Report the tooth identifier(s) when DC032 is within the given range. Required when DC032 = D2000 thru D2999

DC205

Dental Quadrant

Text

2

Standard quadrant identifier from the External Code Source referenced in Ins 4009.05.  Provides further detail on procedure(s)

DC206

Tooth Surface

Text

5

Tooth surface(s) that this service relates to.  Provides further detail on procedure

DC207

Claim Version

Text

4

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.  No alpha or special characters.

DC208

Diagnosis Code

Text

7

ICD CM Diagnosis Code when applicable

DC209

ICD Indicator

Text

1

Report the value that defines whether the diagnoses on claim are ICD9 or ICD10.

 

 

 

 

0 ICD-9

 

 

 

 

1 ICD-10

DC211

Cross Reference Claims ID

Text

35

The original Payer Claim Control Number (DC004). Used when a new Payer Claim Control Number is assigned to an adjusted claim.

DC212

Allowed amount

Number

10 (0)

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.  Shall be reported even when paid amount = 0 but member receives care. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable.  EXAMPLE:  150.00 is reported as 15000; 150.70 is reported as 15070

DC213

HIOS Plan ID

Text

16

The 16 character HIOS Plan ID (Standard component). Including a five digit issuer ID, two character state ID, three digit product number, four digit standard component number and two digit variant component ID. This field may not be available for all market segments; Leave blank where not available

DC215

Service Line Type

Text

1

Report the code that defines the claim line status in terms of adjudication

 

 

 

 

O Original

 

 

 

 

V Void

 

 

 

 

R Replacement

 

 

 

 

B Back Out

 

 

 

 

A Amendment

DC218

Claim Processing Level Indicator

Text

1

1 Claim Level

 

 

 

 

 

2 Service Line level

DC219

Denied Claim Indicator

Text

1

1 Fully Paid – the entire claim was paid at the allowed amount

 

 

 

 

2 Partially denied – some of the claims lines were paid at the allowed amount

 

 

 

 

3 Encounter claim – this claim records a service provided that is paid under a non FFS payment arrangement such as capitation

 

 

 

 

4 No payment – no payment made for reasons other than non FFS payment arrangement

DC220

Denial Reason

Text

4

Denial reason code. Required when denied claim indicator = 2 or 4 http://www.wpc-edi.com/reference/

DC899

Record Type

Text

2

DC

DC900

In Network Indicator

Text

1

A yes/no indicator that specifies that the provider (not the benefit) is within the health plan network.  Valid codes:   Y=Yes, N=No

DC901

Quantity

Number

12(0)

Count of services performed

 

Source.  #10877, eff 7-10-15; ss by #13136, eff 11-24-20

 

          Ins 4010.05  Provider File Data Tables.

 

          (a)  Provider  File Header Record Layout

 

Table 4010.05 (a) Provider File Header Record Layout

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

HD001

Record Type

Text

2

HD

HD002

Payer

Text

8

Payer submitting payments. NHID Submitter Code

HD003

National Plan ID

Text

30

CMS National Plan ID

HD004

Type of File

Text

2

MP Provider File

HD005

Period Beginning Date

Date

8

Beginning of span of coverage period

HD006

Period Ending Date

date

8

End of span of coverage period

HD008

Comments

Text

80

Submitter may use to document this submission by assigning a filename, system source, etc.

 

          (b)  Provider File Trailer Record Layout

 

Table 4010.05 (b) Provider File Trailer Record Layout

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

TR001

Record Type

Text

2

TR

TR002

Payer

Text

8

Payer submitting payments. NHID Submitter Code

TR003

National Plan ID

Text

30

CMS National Plan ID

TR004

Type of File

Text

2

MP Provider File

TR005

Period Beginning Date

Date

8

Beginning of span of coverage period

TR006

Period Ending Date

Date

8

End of span of coverage period

TR007

Extraction Date

Date

8

Date file was created

TR008

Record Count

Number

10 (0)

Total number of records submitted in this file

 

          (c)  Provider File Detailed Specifications

 

Table 4010.05 (c)  Provider File Detailed Specifications

Data Element #

Element

Type

Length (decimal places)

Description/Codes/Sources

MP001

Payer

Text

8

Payer submitting payments. NHID Submitter Code

MP002

Plan ID

Text

30

CMS National Plan ID or NAIC code.

MP003

Provider ID

Text

30

Unique identified for the provider as assigned by the reporting entity

MP004

Provider Tax ID

Text

10

Federal taxpayer's identification number –if the tax id is a provider’s social security number use ‘SSN’ and ‘NA’ if unavailable.  Do not code punctuation.

MP005

Provider Entity

Text

1

Specify the value that defines the type of entity

 

 

 

 

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.

 

 

 

 

8 Other; any type of entity not otherwise defined that performs health care services.

MP006

Provider First Name

Text

35

Individual first name.  Leave blank if provider is a facility or organization

MP007

Provider Middle Name or Initial

Text

25

 

MP008

Provider Last Name or Organization Name

Text

60

Full name of provider organization or last name of individual provider

MP009

Provider Suffix

Text

10

Example: Jr; Set as leave blank if provider is an organization.  Do not use credentials such as MD or PhD

MP010

Provider Specialty

Text

10

Report the HIPAA-compliant health care provider taxonomy code.  Code set is available at the National Uniform Claims Committee’s web site  at http://www.nucc.org/

MP011

Provider Office Street Address

Text

50

Physical address – address where provider delivers health care services

MP012

Provider Office City

Text

30

Physical address – address where provider delivers health care services

MP013

Provider Office State

Text

2

Physical address – address where provider delivers health care services.  Use postal service standard 2 letter abbreviations

MP014

Provider Office Zip

Text

9

Physical address – address where provider delivers health care services.  Minimum 5 digit code. Do not include dashes

MP015

Provider DEA Number

Text

12

 

MP016

Provider NPI

Text

20

 

MP017

Provider State License Number

Text

30

 

MP018

Entity Code

Text

2

Enter the value that defines the entity provider type. Required when MP005 does not = 1

 

 

 

 

1 Academic Institution

 

 

 

 

2 Adult Foster Care

 

 

 

 

3 Ambulance Services

 

 

 

 

4 Hospital Based Clinic

 

 

 

 

5 Stand-Alone, Walk-In/Urgent Care Clinic

 

 

 

 

6 Other Clinic

 

 

 

 

7 Community Health Center - General

 

 

 

 

8 Community Health Center - Urgent Care

 

 

 

 

9 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

 

 

 

 

21 Licensed Hospital Satellite Emergency Facility

 

 

 

 

22 Hospital Emergency Center

 

 

 

 

23 Nursing Home

 

 

 

 

24 Pharmacy

MP899

Record Type

Text

2

MP

 

Source.  #10877, eff 7-10-15; ss by #13136, eff 11-24-20

 

          Ins 4010.06  Data Submission Manual Code Tables.

 

          (a)  Insurance Type/Product Code – Eligibility File

 

Table 4010.06 (a) Insurance Type/Product Code-Eligibility File

Code

Description

12

Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan

13

Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer’s Group Health Plan

14

Medicare Secondary, No-Fault Insurance including Insurance in which Auto Is Primary

15

Medicare Secondary Workers' Compensation

16

Medicare Secondary Public Health Service (PHS) or Other Federal Agency

17

Dental

18

Vision

19

Prescription Drugs

41

Medicare Secondary Black Lung

42

Medicare Secondary Veterans' Administration

43

Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)

AP

Auto Insurance Policy

C1

Commercial

CO

Consolidated Omnibus Reconciliation Act (COBRA)

CP

Medicare Conditionally Primary

D

Disability

DB

Disability Benefits

E

Medicare – Point of Service (POS)

EP

Exclusive Provider Organization

FI

Federal Employees Health Benefits Program

FF

Family or Friends

HM

Health Maintenance Organization (HMO)

HN

Health Maintenance Organization (HMO) Medicare Advantage/Risk

HS

Special Low Income Medicare Beneficiary

IN

Indemnity

IP

Individual Policy

LC

Long Term Care

LD

Long Term Policy

LI

Life Insurance

LT

Litigation

MA

Medicare Part A

MB

Medicare Part B

MC

Medicaid

MD

Medicare Part D

MH

Medigap Part A

MI

Medigap Part B

MP

Medicare Primary

OT

Other

PE

Property Insurance – Personal

PR

Preferred Provider Organization (PPO)

PS

Point of Service (POS)

QM

Qualified Medicare Beneficiary

RP

Property Insurance – Real

SP

Supplemental Policy

TF

Tax Equity Fiscal Responsibility Act (TEFRA)

TR

Tricare

U

Multiple Options Health Plan

VA

Veterans Administration Plan

WU

Wrap Up Policy

 

 

 

          (b)  Relationship Codes

 

Table 4010.06 (b) Relationship Codes

Code

Description

01

Spouse

02

Son or daughter

03

Father or Mother

04

Grandfather or Grandmother

05

Grandson or Granddaughter

06

Uncle or Aunt

07

Nephew or Niece

08

Cousin

09

Adopted Child

10

Foster Child

11

Son-in-Law or Daughter-in-Law

12

Brother-in-Law or Sister-in-Law

13

Mother-in-Law or Sister-in-Law

14

Brother or Sister

15

Ward

16

Stepparent

17

Stepson or Stepdaughter

18

Self

19

Child

20

Employee/Self

21

Unknown

22

Handicapped Dependent

23

Sponsored Dependent

24

Dependent of a Minor Dependent

25

Ex-spouse

26

Guardian

27

Student

28

Friend

29

Significant Other

30

Both Parents

31

Court Appointed Guardian

32

Mother

33

Father

34

Other Adult

36

Emancipated Minor

37

Agency Representative

38

Collateral Dependent

39

Organ Donor

40

Cadaver Donor

41

Injured Plaintiff

43

Child Where Insured Has No Financial Responsibility

53

Life Partner

76

Dependent

 

          (c)  Race 1/Race 2

 

Table 4010.06 (c) Race 1/Race 2

Code

Description

R1

American Indian/Alaska Native  

R2

Asian

R3

Black/African American

R4

Native Hawaiian or Other Pacific Islander

R5

White

R9

Other Race

UNKOW

Unknown/Not Specified

 

          (d)  Ethnicity 1/ Ethnicity 2

 

Table 4010.06 (d) Ethnicity 1/Ethnicity 2

Code

Description

2182-4

Cuban

2184-0

Dominican

2148-5

Mexican, Mexican American, Chicano

2180-8

Puerto Rican

2161-8

Salvadoran

2155-0

Central American (not otherwise specified)

2165-9

South American (not otherwise specified)

2060-2

African

2058-6

African American

AMERCN

American

2028-9

Asian

2029-7

Asian Indian

BRAZIL

Brazilian

2033-9

Cambodian

CVERDN

Cape Verdean

CARIBI

Caribbean Island

2034-7

Chinese

2169-1

Columbian

2108-9

European

2036-2

Filipino

2157-6

Guatemalan

2071-9

Haitian

2158-4

Honduran

2039-6

Japanese

2040-4

Korean

2041-2

Laotian

2118-8

Middle Eastern

PORTUG

Portuguese

RUSSIA

Russian

EASTEU

Eastern European

2047-9

Vietnamese

OTHER

Other Ethnicity

UNKNOW

Unknown/Not Specified

 

          (e)  Insurance Type/Product Code – Claims Files

 

Table 4010.06 (e) Insurance Type/Product Code – Claims Files

Code

Description

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 Advantage/Risk

17

Dental Maintenance Organization

AM

Automobile Medical

CH

Champus

DS

Disability

FI

Federal Employees Health Benefits Program

HM

Health Maintenance Organization

LI

Liability

LM

Liability Medical

MA

Medicare Part A

MB

Medicare Part B

MC

Medicaid

MD

Medicare Part D

OF

Other Federal Program (e.g., Black Lung)

SP

Supplemental Policy

TR

Tricare

TV

Title V

VA

Veterans Administration Plan

WC

Workers’ Comp

ZZ

Mutually Defined (Use code ZZ when Type of Insurance is Unknown)

 

          (f)  Discharge Status

 

Table 4010.06 (f) Discharge Status

Code

Description

01

Discharged to home or self-care

02

Discharged/transferred to another short term general hospital for inpatient care

03

Discharged/transferred to skilled nursing facility (SNF)

04

Discharged/transferred to a facility that provides custodial or supportive care

05

Discharged/transferred to a designated cancer center of children’s hospital

06

Discharged/transferred to home under care of organized home health service organization

07

Left against medical advice or discontinued care

08

Reserved for assignment by the NUBC

09

Admitted as an inpatient to this hospital

20

Expired

21

Discharged/transferred to court/law enforcement

30

Still patient or expected to return for outpatient services

40

Expired at home

41

Expired in a medical facility

42

Expired, place unknown

43

Discharged/ transferred to a Federal Hospital

50

Hospice – home

51

Hospice – medical facility

61

Discharged/transferred within this institution to a hospital-based Medicare-approved swing bed

62

Discharged/transferred to an inpatient rehabilitation facility including distinct parts of a hospital

63

Discharged/transferred to a long-term care hospital

64

Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare

65

Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital

66

Discharged/transferred to a critical access hospital (CAH)

69

Discharged/transferred to a designated disaster alternative care site (effective 10/1/13)

70

Discharged/transferred to another type of healthcare institution not defined elsewhere in this code list

81

Discharged to home or self-care with a planned acute care hospital inpatient readmission (effective 10/1/13)

82

Discharged/transferred to a short term general hospital for inpatient care with a planned acute care hospital inpatient readmission (effective 10/1/13)

83

Discharged/transferred to a skilled nursing facility (SNF) with Medicare certification with a planned acute care hospital inpatient readmission (effective 10/1/13)

84

Discharged/transferred to a facility that provides custodial or supportive care with a planned acute care hospital inpatient readmission (effective 10/1/13)

85

Discharged/transferred to designated cancer center of children’s hospital with a planned acute care hospital inpatient readmission (effective 10/1/13)

86

Discharged/transferred to home under care of organized home health service organization with a planned acute care hospital inpatient readmission (effective 10/1/13)

87

Discharged/transferred to court / law enforcement with a planned acute care hospital inpatient readmission (effective 10/1/13)

88

Discharged/transferred to a federal healthcare facility with a planned acute care hospital inpatient readmission (effective 10/1/13)

89

Discharged/transferred to a hospitalbased Medicare approved swing bed with a planned acute care hospital inpatient readmission (effective 10/1/13)

90

Discharged/transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital with a planned acute care hospital inpatient readmission (effective 10/1/13)

91

Discharged/transferred to a Medicare certified long term care hospital (LTCH) with a planned acute care hospital inpatient readmission (effective 10/1/13)

92

Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare with a planned acute care hospital inpatient readmission (effective 10/1/13)

93

Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital with a planned acute care hospital inpatient readmission (effective 10/1/13)

94

Discharged/transferred to a critical access hospital (CAH) with a planned acute care hospital inpatient readmission (effective 10/1/13)

95

Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare with a planned acute care hospital inpatient readmission (effective 10/1/13)

 

          (g)  Place of Service – Professional

 

Table 4010.06 (g) Place of Service  -- Professional

Code

Description

01

Pharmacy

02

Unassigned

03

School

04

Homeless Shelter

05

Indian Health Service Free-Standing Facility

06

Indian Health Service Provider-Based Facility

07

Tribal 638 Free-Standing Facility

08

Tribal 638 Provider-Based Facility

09

Prison/Correctional Facility

10

Unassigned

11

Office

12

Home

13

Assisted Living Facility Congregate

14

Group Home

15

Mobile Unit

16

Temporary Lodging

17

Walk-in Retail Health Clinic

18

Place of Employment-Worksite

19

Unassigned

20

Urgent Care Facility

21

Inpatient Hospital

22

Outpatient Hospital

23

Emergency Room – Hospital

24

Ambulatory Surgery Center

25

Birthing Center

26

Military Treatment Facility

27-30

Unassigned

31

Skilled Nursing Facility

32

Nursing Facility

33

Custodial Care Facility

34

Hospice

35-40

Unassigned

41

Ambulance – Land

42

Ambulance – Air or Water

43-48

Unassigned

50

Federally Qualified Center

51

Inpatient Psychiatric Facility

52

Psychiatric Facility Partial Hospitalization

53

Community Mental Health Center

54

Intermediate Care Facility/Mentally Retarded

55

Residential Substance Abuse Treatment Facility

56

Psychiatric Residential Treatment Center

57

Non-Residential Substance Abuse Treatment Facility

58-59

Unassigned

60

Mass Immunization Center

61

Comprehensive Inpatient Rehabilitation Facility

62

Comprehensive Outpatient Rehabilitation Facility

63-64

Unassigned

65

End Stage Renal Disease Treatment Facility

66-70

Unassigned

71

State or Local Public Health Clinic

72

Rural Health Clinic

73-80

Unassigned

81

Independent Laboratory

82-98

Unassigned

99

Other Unlisted Facility

 

          (h)  Claim Status

 

Table 4010.06 (h) Claim Status

Code

Description

01

Processed as primary

02

Processed as secondary

03

Processed as tertiary

04

Denied

06

Approved as amended

19

Processed as primary, forwarded to additional payer(s)

21

Processed as tertiary, forwarded to additional payer(s)

22

Reversal of previous payment

26

Documentation Claim - No Payment Associated

28

Repriced

 

          (i)  MC021 Point of Origin Codes

 

(1)  If MC020 = 4 (Newborn), then use the following values at MC021:

 

Table 4010.06 (i) (1) MC021 Point of Origin Codes

Code

Description

5

Born Inside the Hospital

6

Born Outside the Hospital

 

(2)  For all other values at MC020, use the following table for MC021:

 

Table 4010.06 (i) (2) Point of Origin Codes

Code

Description

1

Non-Healthcare Facility Point of Origin (Physician Referral)

2

Clinic Referral

3

HMO Referral

4

Transfer from a Hospital (Different Facility)

5

Transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF)

6

Transfer from Another Health Care Facility

7

Emergency Room

8

Court/Law Enforcement

9

Information Not Available

A

Reserved for National Assignment

B

Transfer from Another Home Health Agency(Discontinued July 1,2010)

C

Readmission to Same Home Health Agency (Discontinued July 1,2010)

D

Transfer from Hospital Inpatient in the Same Facility Resulting in a Separate Claim to the Payer

E

Transfer from Ambulatory Surgical Center

F

Transfer from Hospice and is Under a Hospice Plan of Care or Enrolled in Hospice Program

 

Source.  #10877, eff 7-10-15; ss by #13136, eff 11-24-20

 

          Ins 4010.07  Mapping and Format Information Tables.

 

          (a)  Member Eligibility File Mapping and Format Information

 

Table 4010.07 (a) Member Eligibility File Mapping and Format Information

Data Element #

Element

HIPAA Reference

Transaction Set/Loop/

Segment/Qualifier/

Data Element

ME001

Payer

N/A

ME002

National Plan ID

271/2100A/NM1/XV/09

ME003

Insurance Type Code/Product

271/2110C/EB/ /04, 271/2110D/EB/ /04

ME004

Year

N/A

ME005

Month

N/A

ME006

Insured Group or Policy Number

271/2100C/REF/1L/02, 271/2100C/REF/IG/02, 271/2100C/REF/6P/02, 271/2100D/REF/1L/02, 271/2100D/REF/IG/02, 271/2100D/REF/6P/02

ME007

Coverage Level Code

271/2110C/EB/ /03, 271/2100D/EB/ /03

ME008

Subscriber Social Security Number

271/2100C/NM1/MI/09

ME009

Plan Specific Contract Number

271/2100C/NM1/MI/09

ME010

Member Suffix or Sequence Number

N/A

ME011

Member Social Security Number

271/2100C/MN1/MI/09, 271/2100D/NM1/MI/09

ME012

Individual Relationship Code

271/2100C/INS/Y/02, 271/2100D/INS/N/02

ME013

Member Gender

271/2100C/DMG/ /03,      271/2100D/DMG/ /03

ME014

Member Date of Birth

271/2100C/DMG/D8/02, 271/2100D/DMG/D8/02

ME015

Member City Name

271/2100C/N4/ /01, 271/2100D/N4/ /01

ME016

Member State or Province

217/2100C/N4/ /02, 271/2100D/N4/ /02

ME017

Member ZIP Code

271/2100C/N4/ /03, 271/2100D/N4/ /03

ME018

Medical Coverage

N/A

ME019

Prescription Drug Coverage

N/A

ME020

Dental Coverage

N/A

ME021

Race 1

N/A

ME022

Race 2

N/A

ME023

Place holder

N/A

ME024

Hispanic Indicator

N/A

ME025

Ethnicity 1

N/A

ME026

Ethnicity 2

N/A

ME027

Place holder

N/A

ME028

Primary Insurance Indicator

N/A

ME029

Coverage Type

N/A

ME030

Market Category

N/A

ME031

NH Health Protection Program

N/A

ME032

Group Name

N/A

ME101

Subscriber Last Name

270/2100C/NM1/IL/1/3

ME102

Subscriber First Name

270/2100C/NM1/IL/1/4

ME103

Subscriber Middle Initial

270/2100C/NM1/IL/1/5

ME104

Member Last Name

270/2100D/NM1/QC/1/3

ME105

Member First Name

270/2100D/NM1/QC/1/4

ME106

Member Middle Initial

270/2100D/NM1/QC/1/5

271/2100/N3//01, 02

271/2100D/N3/ /01, 02

ME203

Member’s Assigned PCP

Loop 2000B SBR02 = 18 - ELSE - Loop

ME204

HIOS Plan ID

N/A

ME205

Plan Effective Date

N/A

ME206

Minimum Value

2010CA Segment N301

ME207

Exchange Indicator

N/A

ME208

High Deductible Health Plan

N/A

ME209

Active Enrollment

N/A

ME210

New Coverage

N/A

ME211

N/A

ME899

Record Type

N/A

ME900

Plan State

N/A

ME901

Premium Tax Credit

N/A

ME902

NAIC Number

N/A

ME903

Grandfather Plan Indicator

N/A

 

 

 

 

          (b)  Medical Claims File Mapping and Format Information

 

Table 4010.07 (b) Medical Claims File Mapping and Format Information

 

Data Element #

 

Data Element Name

UB-92

Form

Locator

UB-92

(Version 6.0)

Record Type/

Field #

HCFA

1500

#

NSF

(National Standard Format)

Locator

HIPAA Reference  Transaction Set/Loop/

Segment/Qualifier/

Data Element

MC001

Payer

N/A

N/A

N/A

N/A

  N/A

MC002

National Plan ID

N/A

N/A

N/A

N/A

   835/1000A/N1/XV/04

MC003

Product/Claim Filing Indicator Code

N/A

30/4

N/A

N/A

   835/2100/CLP/ /06

MC004

Payer Claim Control Number

N/A

N/A

N/A

FA0-02.0, FB0-02.0, FB1-02.0, GA0-02.0, GC0-02.0, GX0-02.0, GX2-02.0, HA0-02.0, FB2-02.0, GU0-02.0

  835/2100/CLP/ /07

MC005

Line Counter

N/A

N/A

N/A

N/A

  837/2400/LX/ /01

MC005A

Version Number

N/A

N/A

N/A

N/A

N/A

MC006

Insured Group or Policy Number

62 (A-C)

30/10

11C

DA0-10.0

  837/2000B/SBR/ /03

MC007

Subscriber Social Security Number

N/A

N/A

N/A

N/A

  835/2100/NM1/34/08

MC008

Plan Specific Contract Number

N/A

N/A

N/A

N/A

  835/2100/NM1/HN/08

MC009

Member Suffix or Sequence Number

N/A

N/A

N/A

N/A

   N/A

MC010

Member Social Security Number

N/A

N/A

N/A

N/A

  835/2100/NM1/34/08

MC011

Individual Relationship Code

59 (A-C)

30/18

6

DA0-17.0

8 37/2000B/SBR/ /02, 837/2000C/PAT/ /01

MC012

Member Gender

15

20/7

3

CA0-09.0

 837/2010CA/DMG/03

MC013

Member Date of Birth

14

20/8

3

CA0-08.0

 837/2010CA/DMG/D8/02

MC014

Member City Name

13

20/14

5

CA0-13.0

 837/2010CA/N4/ /01

MC015

Member State or Province

13

20/15

5

CA0-14.0

 837/2010CA/N4/ /02

MC016

Member ZIP Code

13

20/16

5

CA0-15.0

 837/2010CA/N4/ /03

MC017

Paid Date (AP Date)

N/A

N/A

N/A

N/A

   N/A

MC018

Admission Date

17

20/17

N/A

N/A

 837/2300/DTP/435/03

MC019

Admission Hour

18

20/18

N/A

N/A

 837/2300/DTP/435/03

MC020

Admission Type

19

20/10

N/A

N/A

 837/2300/CL1/ /01

MC021

Admission Source

20

20/11

 

N/A

 837/2300/CL1/ /02

MC022

Discharge Hour

21

20/22

 

N/A

 837/2300/DTP/096/03

MC023

Discharge Status

22

20/21

N/A

N/A

 837/2300/CL1/ /03

MC024

Service Provider Number

N/A

N/A

N/A

N/A

 N/A

MC025

Service Provider Tax ID Number

5

10/4-5

25

BA0-09.0, CA0-28.0, BA0-02.0, BA1-02.0, YA0-02.0,BA0-06.0, BA0-10.0, BA0-12.0, BA0-13.0, BA0-14.0,BA0-15.0, BA0-16.0, BA0-17.0, BA0-24.0, YA0-06.0

 835/2100/NM1/FI/09

MC026

National Service Provider ID

N/A

10/6

N/A

N/A

 835/2100/NM1/XX/09

MC027

Service Provider Entity Type Qualifier

N/A

N/A

N/A

N/A

 835/2100/NM1/82/02

MC028

Service Provider First Name

1

10/12

33

BA0-20.0

 835/2100/NM1/82/04

MC029

Service Provider Middle Name

1

10/12

33

BA0-21.0

 835/2100/NM1/82/05

MC030

Service Provider Last Name or Organization Name

1

10/12

33

BA0-18.0, BA0-19.0

 835/2100/NM1/82/03

MC031

Service Provider Suffix

1

10/12

33

BA0-22.0

 835/2100/NM1/82/07

MC032

Service Provider Specialty

N/A

N/A

N/A

N/A

 837/2000A/PRV/ZZ/03

MC033

Service Provider City Name

1

10/14

N/A

BA1-09.0, 15.0

 837/2010A/N4/ /01

MC034

Service Provider State or Province

1

10/15

N/A

BA1-10.0, 16.0

 837/2010A/N4/ /02

MC035

Service Provider ZIP Code

1

10/16

N/A

BA1-11.0, 17.0

 837/2010A/N4/ /03

MC036

Type of Bill – Institutional

4

Positions 1-2: 40/4

N/A

N/A

 837/2300/CLM/ /05-1

MC037

Facility Type - Professional

N/A

N/A

N/A

FA0-07.0, GU0-0.50

 835/2100/CLP/ /08

MC038

Service Line Status

N/A

N/A

N/A

N/A

 835/2100/CLP/ /02

MC039

Admitting Diagnosis

76

70/25

N/A

N/A

 837/2300/HI/BJ/02-2

MC040

E-Code

77

70/26

N/A

N/A

 837/2300/HI/BN/03-2

MC041

Principal Diagnosis

67

70/4

21.1

EA0-32.0, GX0-31.0, GU0-12.0

 837/2300/HI/BK/01-2

MC042

Other Diagnosis – 1

68

70/5

21.2

EA0-33.0, GX0-32.0, GU0-13.0

 837/2300/HI/BF/02-1

MC043

Other Diagnosis – 2

69

70/6

21.3

EA0-33.0, GX0-32.0, GU0-13.0

 837/2300/HI/BF/02-2

MC044

Other Diagnosis – 3

70

70/7

21.4

EA0-33.0, GX0-32.0, GU0-13.0

 837/2300/HI/BF/02-3

MC045

Other Diagnosis – 4

71

70/8

N/A

EA0-35.0, GX0-34.0, GU0-15.0

 837/2300/HI/BF/02-4

MC046

Other Diagnosis – 5

72

70/9

N/A

N/A

 837/2300/HI/BF/02-5

MC047

Other Diagnosis – 6

73

70/10

N/A

N/A

 837/2300/HI/BF/02-6

MC048

Other Diagnosis – 7

74

70/11

N/A

N/A

 837/2300/HI/BF/02-7

MC049

Other Diagnosis – 8

75

70/12

N/A

N/A

 837/2300/HI/BF/02-8

MC050

Other Diagnosis – 9

N/A

N/A

N/A

N/A

 837/2300/HI/BF/02-9

MC051

Other Diagnosis –10

N/A

N/A

N/A

N/A

 837/2300/HI/BF/02-10

MC052

Other Diagnosis –11

N/A

N/A

N/A

N/A

 837/2300/HI/BF/02-11

MC053

Other Diagnosis –12

N/A

N/A

N/A

N/A

 837/2300/HI/BF/02-12

MC054

Revenue Code

42

50/5,11-13, 60/5,15-16, 61/5,15-16

N/A

N/A

 835/2110/SVC/RB/01-2,

 835/2110/SVC/NU/01-2

MC055

Procedure Code

44

60/6,15-16, 61/6,15-16

24.1-6 D

FA0-09.0, FB0-15.0, GU0-07.0

 835/2110/SVC/HC/01-2

MC056

Procedure Modifier – 1

44

60/7,15-16, 61/7, 15-16

24.1-6 D

FA0-10.0, GU0-08.0

  835/2110/SVC/HC/01-3

MC057

Procedure Modifier – 2

44

60/8,15-16, 61/8,15-16

24.1-6 D

FA0-11.0

  835/2110/SVC/HC/01-3

MC058

ICD-9-CM Procedure Code

80,

81(A-E)

70/13, 15, 17, 19, 21, 23

N/A

N/A

  835/2110/SVC/ID/01-2

MC059

Date of Service – From

45

61/13, 15-16, 61/13, 15-16

24.1-6 A

N/A

  835/2110/DTM/150/02

MC060

Date of Service – Thru

N/A

N/A

24.1-6 A

FA0-05.0, FA0-06.0

   835/2110/DTM/151/02

MC061

Quantity

46

50/7, 11-13, 60/9,15-16, 61/9,15-16

24.1-6 G

FA0-19.0, FB0-16.0

   835/2110/SVC/ /05

MC062

Charge Amount

47

50/8, 11-13, 60/10, 16-16, 61/11, 15-16

24.1-6F

FA0-13.0

835/2110/SVC/ /02

MC063

Paid Amount

48

N/A

N/A

N/A

835/2110/SVC/ /03

MC064

Fee for Service Equivalent

N/A

N/A

N/A

N/A

N/A

MC065

Co-pay Amount

N/A

N/A

N/A

N/A

N/A

MC066

Coinsurance Amount

N/A

N/A

N/A

N/A

N/A

MC067

Deductible Amount

N/A

N/A

N/A

N/A

N/A

MC068

Patient Account/Control Number

3

N/A

N/A

 

837/2300/CLM/1

MC069

Discharge Date

 

 

 

 

 

MC070

Service Provider Country Name

N/A

N/A

N/A

N/A

N/A

MC071

DRG

N/A

N/A

N/A

N/A

837/2300/HI/DR/2

MC072

DRG Version

N/A

N/A

N/A

N/A

N/A

MC073

APC

N/A

N/A

N/A

N/A

N/A

MC074

APC Version

N/A

N/A

N/A

N/A

N/A

MC075

Drug Code

N/A

 

 

 

837/2400/SV2/N1/2

837/2400/SV2/N2/2

837/2400/SV2/N3/2

837/2400/SV2/N4/2

837/2400/SV2/ND/2

MC076

Billing Provider Number

N/A

N/A

N/A

N/A

N/A

MC077

National Billing Provider Number ID

N/A

N/A

N/A

N/A

N/A

MC078

Billing Provider Organization or Last Name

N/A

N/A

N/A

N/A

N/A

MC101

Encrypted Subscriber Last Name

N/A

N/A

N/A

N/A

837/2110BA/NM1/IL/1/3

MC102

Encrypted Subscriber First Name

N/A

N/A

N/A

N/A

837/2110BA/NM1/IL/1/4

MC103

Encrypted Subscriber Middle Initial

N/A

N/A

N/A

N/A

837/2110BA/NM1/IL/1/5

MC104

Encrypted Member Last Name

N/A

N/A

N/A

N/A

837/2110CA/NM1/QC/1/3

MC105

Encrypted Member First Name

N/A

N/A

N/A

N/A

837/2110CA/NM1/QC/1/4

MC106

Encrypted Member Middle Initial

N/A

N/A

N/A

N/A

837/2110CA/NM1/QC/1/5

MC200

ICD Indicator

N/A

N/A

N/A

N/A

Set value here based upon Loop 2300 Segment H101-01 starting with the letter A

MC202

Other ICD-CM Procedure code - 2

N/A

N/A

N/A

N/A

837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)

MC203

Other ICD-CM Procedure code - 3

N/A

N/A

N/A

N/A

837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)

MC204

Other ICD-CM Procedure code - 4

N/A

N/A

N/A

N/A

837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)

MC205

Other ICD-CM Procedure code - 5

N/A

N/A

N/A

N/A

837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)

MC206

Other ICD-CM Procedure code - 6

N/A

N/A

N/A

N/A

837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)

MC207

Carrier Associated with Claim

N/A

N/A

N/A

N/A

N/A

MC208

Carrier Plan Specific contract Number or Subscriber/Member Social Security Number

N/A

N/A

N/A

N/A

N/A

MC209

Practitioner Group Practice

N/A

N/A

N/A

N/A

N/A

MC210

Coordination of Benefits/Third Party Liability Amount

N/A

N/A

N/A

N/A

835/2320 AMT02

MC211

Cross Reference Claims ID

N/A

N/A

N/A

N/A

N/A

MC212

Allowed Amount

N/A

N/A

N/A

N/A

837/2300 HCP02

MC215

Service Line Type

N/A

N/A

N/A

N/A

N/A

MC216

Payment Arrangement Type

N/A

N/A

N/A

N/A

Loop 2400 Segment HCP01

MC217

Pay for Performance Flag

N/A

N/A

N/A

N/A

N/A

MC218

Claim Processing Level Indicator

N/A

N/A

N/A

N/A

N/A

MC219

Denied Claim Indicator

N/A

N/A

N/A

N/A

Loop 2430 CAS identification

MC220

Denial Reason

N/A

N/A

N/A

N/A

Loop 2430 CAS identification

MC221

Procedure Modifier – 3

N/A

N/A

N/A

N/A

837/2430 SVD03-05

MC222

Procedure Modifier – 4

N/A

N/A

N/A

N/A

837/2430 SVD03-06

MC899

Record Type

N/A

N/A

N/A

N/A

N/A

MC900

In Network Indicator

N/A

N/A

N/A

N/A

N/A

MC901

Unit of Measure

N/A

N/A

N/A

N/A

 

 

          (c)  Pharmacy Claims File Mapping and Format Information

 

Table 4010.07 (c) Pharmacy Claims File Mapping and Format Information

Data

Element

 

Element

National Council for Prescription

Drug Programs Field #

PC001

Payer

879

PC002

Plan ID

879

PC003

Insurance Type/Product Code

N/A

PC004

Payer Claim Control Number

993-A7

PC005

Line Counter

N/A

PC006

Insured Group Number

301-C1

PC007

Subscriber Social Security Number

302-C2

PC008

Plan Specific Contract Number

N/A

PC009

Member Suffix or Sequence Number

N/A

PC010

Member Identification Code

302-CY

PC011

Individual Relationship Code

306-C6

PC012

Member Gender

305-C5

PC013

Member Date of Birth

304-C4

PC014

Member City Name of Residence

323-CN

PC015

Member State or Province

324-CO

PC016

Member ZIP Code

325-CP

PC017

Paid Date (AP Date)

N/A

PC018

Pharmacy Number

202-B2

PC019

Pharmacy Tax ID Number

N/A

PC020

Pharmacy Name

833-5P

PC021

National Pharmacy ID Number

N/A

PC022

Pharmacy Location City

831-5N

PC023

Pharmacy Location State

832-6F

PC024

Pharmacy ZIP Code

835-5R

PC024A

Pharmacy Country Name

N/A

PC025

Service Line Status

N/A

PC026

Drug Code

407-D7

PC027

Drug Name

516-FG

PV028

New Prescription

403-D3

PC029

Generic Drug Indicator

N/A

PC030

Dispense as Written Code

408-D8

PC031

Compound Drug Indicator

406-D6

PC032

Date Prescription Filled

401-D1

PC033

Quantity Dispensed

442-E7

PC034

Days Supply

405-D5

PC035

Charge Amount

804-5B

PC036

Paid Amount

509-F9

PC037

Ingredient Cost/List Price

506-F6

PC038

Postage Amount Claimed

428-DS

PC039

Dispensing Fee

507-F7

PC040

Copay Amount

518-FI

PC041

Coinsurance Amount

518-FI

PC042

Deductible Amount

505-F5

PC043

Placeholder

N/A

PC044

Prescribing Physician First Name

717

PC045

Prescribing Physician Middle Name

N/A

PC046

Prescribing Physician Last Name

716

PC047

Prescribing Physician Number

411-DB

PC101

Subscriber Last Name

716

PC102

Subscriber First Name

717

PC103

Subscriber Middle Initial

718

PC104

Member Last Name

716

PC105

Member First Name

717

PC106

Member Middle Initial

718

PC203

Carrier Associated with Claim

N/A

PC204

Carrier Plan Specific Contract Number or Subscriber/Member Social Security Number

N/A

PC211

Cross Reference Claims ID

N/A

PC212

Allowed Amount

N/A

PC213

HIOS Plan ID

N/A

PC214

Claim Processing Level Indicator

N/A

PC215

Service Line Type

N/A

PC216

Denied Claim Indicator

N/A

PC217

Denial Reason

N/A

PC899

Record Type

N/A

PC900

Mail Order Pharmacy Indicator

N/A

PC901

In Network Indicator

N/A

PC902

Version Number

N/A

 

          (d)  Dental Claims File Mapping and Format Information

 

Table 4010.07 (d) Dental Claims File Mapping and Format Information

Data Element

#

Data Element Name

NSF

(National Standard Format)

Locator

HIPAA Reference  Transaction Set/Loop/

Segment/Qualifier/

Data Element

DC001

Payer

N/A

N/A

DC002

National Plan Id

N/A

N/A

DC003

Insurance Type/Product Code

N/A

835/2100/CLP/ /06

DC004

Payer Claim Control Number

N/A

835/2100/CLP/ /07

DC005

Line Counter

FA0-02.0, FB0-02.0, FB1-02.0, GA0-02.0, GC0-02.0, GX0-02.0, GX2-02.0, HA0-02.0, FB2-02.0GU0-02.0

837/2400/LX/ /01

DC006

Insured Group or Policy Number

DA0-10.0

837/2000B/SBR/ /03

DC007

Subscriber Social Security Number

N/A

837/2010BA/REF/SY/02

DC008

Plan Specific Contract Number

N/A

835/2100/NM1/MI/08

DC009

Member Suffix or Sequence Number

N/A

N/A

DC010

Member Social Security Number

N/A

835/2100/NM1/34/09

DC011

Individual Relationship Code

DA0-17.0

837/2000B/SBR/ /02, 837/20000C/PAT/ /01

DC012

Member Gender

CA0-09.0

 837/2010BA/DMB/ /03, 837/2010CA/DMB/ /03

DC013

Member Date of Birth

CA0-08.0

837/2010BA/DMB/D8/02, 837/2010CA/DMB/D8/02

DC014

Member City Name of Residence

CA0-13.0

837/2010BA/N4/ /01, 837/2010CA/N4/ /01

DC015

Member State or Province

CA0-14.0

837/2010BA/N4/ /02, 837/2010CA/N4/ /02

DC016

Member ZIP Code of Residence

CA0-15.0

837/2010BA/N4/ /03, 837/2010CA/N4/ /03

DC017

Date Service Approved

N/A

835/Header Financial Information/BPR/ /16

DC018

Service Provider Number

N/A

835/21000/REF/1A/02, 835/2100/REF/1B/02,

835/2100/REF/1C/02, 835/2100/REF/1D/02, 835/2100/REF/G2/02, 835/2100/NM1/BD/09, 835/2100/NM1/BS/09, 835/2100/NM1/MC/09, 835/2100/NM1/PC/09

DC019

Service Provider Tax ID Number

BA0-09.0, CA0-28.0, BA0-02.0,BA1-02.0, YA0-02.0, BA0-06.0, BA0-10.0, BA0-12.0, BA0-13.0, BA0-14.0, BA0-15.0, BA0-16.0,BA0-17.0, BA0-24.0, YA0-06.0

835/2100/NM1/FI/09

DC020

National Service Provider ID

N/A

837/2310B/NM1/XX/09

DC021

Service Provider Entity Type Qualifier

N/A

837/2310B/NM1/82/02

DC022

Service Provider First Name

BA0-20.0

837/2310B/NM1/82/04

DC023

Service Provider Middle Name

BA0-21.0

837/2310B/NM1/82/05

DC024

Service Provider Last Name or Organization Name

BA0-18.0, BA0-19.0

837/2310B/NM1/82/03

DC025

Service Provider Suffix

BA0-22.0

837/2310B/NM1/82/07

DC026

Service Provider Specialty

N/A

837/2310B/PRV/PXC/03

DC027

Service Provider City name

BA1-09.0, 15.0

837/2310C/N4/ /01

DC028

Service Provider State or Province

BA1-10.0, 16.0

837/2310C /N4/ /02

DC029

Service Provider ZIP Code

BA1-11.0, 17.0

837/2310C /N4/ /03

DC030

Facility Type - Professional

FA0-07.0, GU0-0.50

837/2300/CLM/05-1

DC031

Claim Status

 

835/2100/CLP/ /02

DC032

CDT Code

FA0-09.0, FB0-15.0, GU0-07.0

837/2400/SV3/AD/01-2

DC033

Procedure Modifier - 1

FA0-10.0, GU0-08.0

837/2400/SV3/AD/01-3

DC034

Procedure Modifier - 2

FA0-11.0

837/2400/SV3/AD/01-4

DC035

Date of Service - From

N/A

837/2400/DTP/472/D8/03, 837/2300/DTP/472/D8/03

DC036

Date of Service - Thru

FA0-05.0, FA0-06.0

837/2400/DTP/472/D8/03, 837/2300/DTP/472/D8/03

DC037

Charge Amount

FA0-13.0

837/2400/SV3/ /02

DC038

Paid Amount

N/A

835/2110/SVC/ /03

DC039

Copay Amount

N/A

835/2110/CAS/PR/3-03

DC040

Coinsurance Amount

N/A

835/2110/CAS/PR/2-03

DC041

Deductible Amount

N/A

835/2110/CAS/PR/1-03

DC042

Billing Provider Number

N/A

837/2010BB/REF/G2/02

DC044

National Billing Provider ID

N/A

837/2010AA/NM1/XX/09

DC044

Billing Provider Last Name

N/A

837/2010AA/NM1/ /03

DC101

Subscriber Last Name

N/A

837/2010BA/NM1/ /03

DC102

Subscriber First Name

N/A

837/2010BA/NM1/ /04

DC103

Subscriber Middle Initial

N/A

837/2010BA/NM1/ /05

DC104

Member Last Name

N/A

837/2010BA/NM1/ /03, 837/2010CA/NM1/ /03

DC105

Member First Name

N/A

837/2010BA/NM1/ /04, 837/2010CA/NM1/ /04

DC106

Member Middle Initial

N/A

837/2010BA/NM1/ /05, 837/2010CA/NM1/ /05

DC201

Carrier Associated with Claim

N/A

N/A

DC202

Carrier Plan Specific Contract Number or Subscriber/Member Social Security Number

N/A

N/A

DC203

Practitioner Group Practice

N/A

N/A

DC204

Tooth Number/Letter

N/A

837/2400 TOO02

DC205

Dental Quadrant

N/A

N/A

DC206

Tooth Surface

 

837/2400 TOO03

DC207

Claim Version

N/A

N/A

DC208

Diagnosis Code

N/A

837/2300 H101-2

DC209

ICD Indicator

N/A

N/A

DC211

Cross Reference Claims ID

N/A

N/A

DC212

Allowed Amount

N/A

837/2300 HCP02

DC213

HIOS Plan ID

N/A

N/A

DC215

Service Line Type

N/A

N/A

DC218

Claim Processing Level Indicator

N/A

N/A

DC219

Denied Claim Indicator

N/A

N/A

DC220

Denial Reason

N/A

N/A

DC899

Record Type

N/A

N/A

DC900

In Network Indicator

N/A

N/A

DC901

Quantity

N/A

N/A

 

Source.  #10877, eff 7-10-15; ss by #13136, eff 11-24-20

 

APPENDIX

 

RULE

STATUTE

 

 

Ins 4001.01

RSA 400-A:15, I; 420-G:14

Ins 4002.01

RSA 400-A:15, I; 420-G:14

Ins 4003.01

RSA 400-A:15, I; 420-G:14

Ins 4003.02

RSA 400-A:15, I; 420-G:14

Ins 4003.03

RSA 400-A:15, I; 420-G:14

Ins 4004.01

RSA 400-A:15, I; 420-G:14

Ins 4004.02

RSA 400-A:15, I; 420-G:14

Ins 4004.03

RSA 400-A:15, I; 420-G:14

Ins 4005.01

RSA 400-A:15, I; 420-G:14

Ins 4005.02

RSA 400-A:15, I; 420-G:14

Ins 4005.03

RSA 400-A:15, I; 420-G:11; 420-G:14

Ins 4006.01

RSA 400-A:15, I; 420-G:14

Ins 4006.02

RSA 400-A:15, I; 420-G:14

Ins 4006.03

RSA 400-A:15, I; 420-G:14

Ins 4006.04

RSA 400-A:15, I; 420-G:14

Ins 4006.05

RSA 400-A:15, I; 420-G:14

Ins 4006.06

RSA 400-A:15, I; 420-G:14

Ins 4007.01

RSA 400-A:15, I; 420-G:14

Ins 4008.01

RSA 400-A:15, I; 420-G:14

Ins 4009.01

RSA 400-A:15, I; 420-G:14; 541-A:21, VI(a)(2)

Ins 4009.02

RSA 400-A:15, I; 420-G:14; 541-A:21, VI(a)(2)

Ins 4009.03

RSA 400-A:15, I; 420-G:14; 541-A:21, VI(a)(2)

Ins 4009.04

RSA 400-A:15, I; 420-G:14; 541-A:21, VI(a)(2)

Ins 4010.01

RSA 400-A:15, I; 420-G:14; 541-A:21, VI(a)(2)

Ins 4010.02

RSA 400-A:15, I; 420-G:14; 541-A:21, VI(a)(2)

Ins 4010.03

RSA 400-A:15, I; 420-G:14; 541-A:21, VI(a)(2)

Ins 4010.04

RSA 400-A:15, I; 420-G:14; 541-A:21, VI(a)(2)

Ins 4010.05

RSA 400-A:15, I; 420-G:14; 541-A:21, VI(a)(2)

Ins 4010.06

RSA 400-A:15, I; 420-G:14; 541-A:21, VI(a)(2)

Ins 4010.07

RSA 400-A:15, I; 420-G:14; 541-A:21, VI(a)(2)

 

 

Appendix B – NHID Opt-In Form

 

 

 

The State of New Hampshire

Insurance Department

               21 South Fruit Street, Suite 14

Concord, NH 03301

(603) 271-2261 Fax (603) 271-1406

TDD Access: Relay NH 1-800-735-2964

 

  Description: The image “file:///C:/Documents%20and%20Settings/kcassin/My%20Documents/My%20Pictures/DeptSeal.gif” cannot be displayed, because it contains errors.

NHID Opt-In Form

 

All-Payer Claims Database Indication of Intent for Private Employers

Offering Self-Funded Health Coverage in New Hampshire

 

You are receiving this form under a 2016 New Hampshire law allowing a self-funded private employer to direct its claims administrator to include the health care claims data of its employees and covered dependents in the state’s All-Payer Claims Database (APCD) (NH RSA 420-G:11, V).

 

  • In response to rising health care costs, the New Hampshire Insurance Department has, since 2003, collected health care claims data from insurers and third-party administrators in an APCD. To protect privacy, under state law the database “shall not include or disclose any data that contains direct personal identifiers”.

(NH RSA 420-G:11-a, I)

 

  • The APCD enhances transparency, providing employers, policymakers, payers, and health care providers with vital information about the factors contributing to rising health care costs in New Hampshire.  In addition, the Insurance Department uses the database to provide health cost information to the public, including employers and their employees, through the NH HealthCost website:  http://nhhealthcost.nh.gov/

 

  • New Hampshire’s database has always included data from self-funded employers, because the accuracy of information derived from the database increases when more claims are included.  In 2016, the U.S. Supreme Court ruled that Vermont could not require self-funded private employers to submit data to the state’s APCD.  To clarify New Hampshire law after that ruling, the legislature required the creation of this form to allow self-funded private employers to direct their claims administrators to include their data.

 

If you elect to participate, please indicate your intent below by checking, signing, and providing the requested information; then return this form to your claims administrator. If you have questions about New Hampshire’s APCD or the department’s efforts to improve health care cost transparency, contact the NH Insurance Department at 603.271.2261 or requests@ins.nh.gov, or visit http://www.nh.gov/insurance/. Thank you.

 

 

Please check, sign, and supply information requested below, if electing to participate:

 

            On behalf of the Employer listed below, I elect to participate in claims data submission to the NH APCD.  I direct the Third-Party Administrator listed below to submit data to the NH APCD and to disclose this election to the NH Insurance Department.

 

Authorizing Signature:     __________________________________________

 

Name and Title of Person Authorizing:            ____________________________________

 

Date of Signature:                                 ____________________________________

 

Employer Name:                                   ____________________________________

 

Employer Address:                               ____________________________________

 

Employer Contact Name:                      ____________________________________

 

Employer Contact Phone and Email:            ____________________________________

 

Approximate # of enrolled lives in NH:            ____________________________________

 

Third-Party Administrator:                    ____________________________________

 

INSTRUCTIONS FOR COMPLETING “NH Opt-In Form”

 

Fill in the blank next to the requested information as follows:

 

Authorizing Signature means the signature of the person authorized to act on behalf of the employer.

 

Name and Title of Person Authorizing means the printed name and title of the person signing on behalf of the employer.

 

Date of Signature means the date the form is signed.

 

Employer Name means the name of the employer being presented the form.

 

Employer Address means the business address of the employer.

 

Employer Contact Name means the name of a person, acting on behalf of the employer, that can be contacted with any questions.

 

Employer Contact Phone and Email means the phone number and email address of the Employer Contact person.

 

Approximate # of Enrolled Lives in NH means the number of enrollees in the self-funded health coverage, to the best knowledge of the authorizing person.

 

Third-Party Administrator means the name of the claims administrator for the Employer named on the form.

 

Fill in the blank next to the requested information as follows:

 

Authorizing Signature means the signature of the person authorized to act on behalf of the employer.

 

Name and Title of Person Authorizing means the printed name and title of the person signing on behalf of the employer.

 

Date of Signature means the date the form is signed.

 

Employer Name means the name of the employer being presented the form.

 

Employer Address means the business address of the employer.

 

Employer Contact Name means the name of a person, acting on behalf of the employer, that can be contacted with any questions.

 

Employer Contact Phone and Email means the phone number and email address of the Employer Contact person.

 

Approximate # of Enrolled Lives in NH means the number of enrollees in the self-funded health coverage, to the best knowledge of the authorizing person.

 

Third-Party Administrator means the name of the claims administrator for the Employer named on the form.