USHIK: APCD File Submission Comparison

File Submission Comparison

Selected Items

Item Name	Version	State	Type	Organization
Dental Claims File Submission	2010-03-16	Maine	File Specification	Maine Health Data Organization (MHDO)
Dental Claims File Submission	v1.1	Maine	File Specification	Maine Health Data Organization (MHDO)

Identifying Attributes

File Specification:	Dental Claims File Submission - 2010-03-16 (Maine)	Dental Claims File Submission - v1.1 (Maine)
Responsible Organization:	Maine Health Data Organization	Maine Health Data Organization
Definition:	Not Provided	"Dental claims file" means a data file composed of service level remittance information including, but not limited to, member demographics, provider information, charge/payment information, and current dental terminology codes from all non-denied adjudicated claims for each billed service.

Data Elements & Codes

File Specification:

Dental Claims File Submission - 2010-03-16 (Maine)

Dental Claims File Submission - v1.1 (Maine)

DC001

Name:	Payer
Type:	varchar
Length:	8
Codes:

Name:	Payer
Type:	CHAR
Length:	6
Codes:
C	Commercial carrier
T	Third Party Administrator
U	Unlicensed entity

DC002

Name:	National Plan ID
Type:	varchar
Length:	30

Name:	National Plan ID
Type:	CHAR
Length:	30

DC003

Name:	Insurance Type/Product Code
Type:	varchar
Length:	2
Codes:

Name:	Insurance Type/Product Code - Original
Type:	CHAR
Length:	2
Codes:
12	Preferred Provider Organization (PPO)
13	Point of Service
14	Exclusive Provider Organization (EPO)
15	Indemnity Insurance
16	Health Maintenance Organization (HMO) Medicare Risk
AM	Automobile medical
DS	Disability
HM	Health Maintenance Organization
LI	Liability
LM	Liability medical
MA	Medicare part A
MB	Medicare part B
MC	Medicaid
OF	Other Federal Program (e.g. black lung)
TV	Title V
VA	Veteran Administration Plan
WC	Workers' Compensation

DC004

Name:	Payer Claim Control Number
Type:	varchar
Length:	35

Name:	Payer Claim Control Number Original
Type:	CHAR
Length:	35

DC005

Name:	Line Counter
Type:	integer
Length:	4

Name:	Line Counter
Type:	NUMBER
Length:	4

DC006

Name:	Insured Group or Policy Number
Type:	varchar
Length:	30

Name:	Insured Group or Policy Number
Type:	CHAR
Length:	30

DC007

Name:	Month
Type:	varchar
Length:	128

Name:	Encrypted Subscriber Social Security Number Original
Type:	CHAR
Length:	32

DC008

Name:	Plan Specific Contract Number
Type:	varchar
Length:	128

Name:	Plan Specific Contract Number Original
Type:	CHAR
Length:	64

DC009

Name:	Member Suffix or Sequence Number
Type:	integer
Length:	20

Name:	Member Suffix or Sequence Number
Type:	CHAR
Length:	20

DC010

Name:	Member Identification Code
Type:	varchar
Length:	128

Name:	Member Identification Code Original
Type:	CHAR
Length:	30

DC011

Name:	Individual Relationship Code
Type:	integer
Length:	2
Codes:

Name:	Individual Relationship Code
Type:	CHAR
Length:	2
Codes:
01	Spouse
04	Grandfather or Grandmother
05	Grandson or Granddaughter
07	Nephew or Niece
10	Foster Child
15	Ward
17	Stepson or Stepdaughter
19	Child
20	Employee/Self
21	Unknown
22	Handicapped Dependent
23	Sponsored Dependent
24	Dependent of a Minor Dependent
29	Significant Other
32	Mother
33	Father
36	Emancipated Minor
39	Organ Donor
40	Cadaver Donor
41	Injured Plaintiff
43	Child Where Insured Has No Financial Responsibility
53	Life Partner
76	Dependent

DC012

Name:	Member Gender
Type:	varchar
Length:	1
Codes:

Name:	Member Gender
Type:	CHAR
Length:	1
Codes:
F	Female
M	Male
U	Unknown

DC013

Name:	Member Date of Birth
Type:	date
Length:	Not Provided

Name:	Member Date of Birth
Type:	DATE
Length:	8

DC014

Name:	Member City Name of Residence
Type:	varchar
Length:	50

Name:	Member City Name of Residence
Type:	CHAR
Length:	50

DC015

Name:	Member State or Province
Type:	varchar
Length:	2

Name:	Member State or Province
Type:	CHAR
Length:	2

DC016

Name:	Member ZIP Code
Type:	varchar
Length:	11

Name:	Member ZIP Code
Type:	CHAR
Length:	11

DC017

Name:	Date Service Approved (AP Date)
Type:	date
Length:	Not Provided

Name:	Date Service Approved (AP Date)
Type:	DATE
Length:	8

DC030

Name:	Facility Type - Professional
Type:	varchar
Length:	2
Codes:

Name:	Facility Type - Professional
Type:	CHAR
Length:	2
Codes:
11	Office
12	Home
21	Inpatient Hospital
22	Outpatient Hospital
31	Skilled Nursing Facility
35	Adult Living Care Facility

DC031

Name:	Claim Status
Type:	integer
Length:	2
Codes:

Name:	Claim Status
Type:	NUMBER
Length:	2
Codes:
01	Processed as primary
02	Processed as secondary
03	Processed as tertiary
04	Denied
19	Processed as primary, forwarded to additional payer(s)
20	Processed as secondary, forwarded to additional payer(s)
21	Processed as tertiary, forwarded to additional payer(s)
22	Reversal of previous payment

DC032

Name:	CDT Code
Type:	varchar
Length:	5

Name:	CDT Code
Type:	CHAR
Length:	5

DC033

Name:	Procedure Modifier - 1
Type:	varchar
Length:	2

Name:	Procedure Modifier - 1
Type:	CHAR
Length:	2

DC034

Name:	Procedure Modifier - 2
Type:	varchar
Length:	2

Name:	Procedure Modifier - 2
Type:	CHAR
Length:	2

DC035

Name:	Date of Service From
Type:	date
Length:	Not Provided

Name:	Date of Service From
Type:	DATE
Length:	8

DC036

Name:	Date of Service Thru
Type:	date
Length:	Not Provided

Name:	Date of Service Thru
Type:	DATE
Length:	8

DC037

Name:	Charge Amount
Type:	decimal
Length:	10

Name:	Charge Amount
Type:	NUMBER
Length:	10

DC038

Name:	Paid Amount
Type:	decimal
Length:	10

Name:	Paid Amount
Type:	NUMBER
Length:	10

DC039

Name:	Copay Amount
Type:	decimal
Length:	10

Name:	Copay Amount
Type:	NUMBER
Length:	10

DC040

Name:	Coinsurance Amount
Type:	decimal
Length:	10

Name:	Coinsurance Amount
Type:	NUMBER
Length:	10

DC041

Name:	Deductible Amount
Type:	decimal
Length:	10

Name:	Deductible Amount
Type:	NUMBER
Length:	10

DC042

Name:	Billing Provider Number
Type:	varchar
Length:	30
Codes:

Name:	Record Type
Type:	CHAR
Length:	2
Codes:
DC	Dental Claims

DC043

Name:	National Billing Provider Identifier
Type:	varchar
Length:	20

Data Element: DC043
not present in this file submission.

DC044

Name:	Billing Provider Last Name or Organization Name
Type:	varchar
Length:	60

Data Element: DC044
not present in this file submission.

DC101

Name:	Encryped Subscriber Last Name
Type:	varchar
Length:	128

Data Element: DC101
not present in this file submission.

DC102

Name:	Encryped Subscriber First Name
Type:	varchar
Length:	128

Data Element: DC102
not present in this file submission.

DC103

Name:	Encryped Subscriber Middle Initial
Type:	varchar
Length:	1

Data Element: DC103
not present in this file submission.

DC104

Name:	Encryped Member Last Name
Type:	varchar
Length:	128

Data Element: DC104
not present in this file submission.

DC105

Name:	Encryped Member First Name
Type:	varchar
Length:	128

Data Element: DC105
not present in this file submission.

DC106

Name:	Encryped Member Middle Initial
Type:	varchar
Length:	1

Data Element: DC106
not present in this file submission.

DC899

Name:	Record Type
Type:	varchar
Length:	2
Codes:
DC

Data Element: DC899
not present in this file submission.

DC901

Name:	Member Age
Type:	integer
Length:	3

Name:	Member Age
Type:	NUMBER
Length:	3

DC902

Name:	Record ID#
Type:	integer
Length:	Not Provided

Name:	Record ID #
Type:	NUMBER
Length:	12

DC903

Name:	Date of Transfer to MHDO
Type:	date
Length:	Not Provided

Name:	MHDO Extract Date
Type:	DATE
Length:	8

DC904

Name:	Encrypted Member ID# (longer of ESSN or Contract) + DOB
Type:	varchar
Length:	71

Name:	Unique Member ID
Type:	CHAR
Length:	71

DC905

Name:	Submission ID#
Type:	integer
Length:	Not Provided

Name:	Submission Id #
Type:	NUMBER
Length:	12

DC906

Name:	Double Encrypted Payer Claim Control Number
Type:	varchar
Length:	100

Name:	Double Encrypted Payer Control Claim Number
Type:	CHAR
Length:	100

DC907

Name:	Double Encrypted Subscriber Social Security Number
Type:	varchar
Length:	64

Name:	Double Encrypted Subscriber Social Security Number
Type:	CHAR
Length:	64

DC908

Name:	Double Encrypted Plan Specific Contract Number
Type:	varchar
Length:	128

Name:	Double Encrypted Contract Number
Type:	CHAR
Length:	128

DC909

Name:	Double Encrypted Member Identification Code
Type:	varchar
Length:	128

Name:	Double Encrypted Member Identification Code
Type:	CHAR
Length:	128

DC910

Name:	Double Encrypted Member ID# (longer of MHDO_ESSN or
Type:	varchar
Length:	135

Name:	Double Encrypted Member ID #
Type:	CHAR
Length:	135

DC911

Name:	Provider ID#
Type:	integer
Length:	Not Provided

Name:	Provider ID #
Type:	INTEGER
Length:	12

DC912

Name:	Standardized Insurance Type/Product Code
Type:	varchar
Length:	2
Codes:

Name:	Standardized Insurance Type/Product Code
Type:	CHAR
Length:	2
Codes:
11	Other non Federal program
12	Medicare secondary working aged beneficiary or spouse with employer group health plan
13	Medicare secondary end-stage renal disease beneficiary in the 12 month coordination period with an employer's group health plan
14	Medicare secondary, no-fault insurance including auto is primary
15	Medicare secondary public health service (PHS) or other federal agency
41	Medicare secondary black lung
42	Medicare secondary veteran's administration
43	Medicare secondary disabled beneficiary under age 65 with large group health plan (LGHP)
47	Medicare secondary, other liability insurance is primary
AM	Auto insurance policy
CP	Medicare conditionally primary
DB	Disability benefits
DS	Disability
EP	Exclusive Provider Organization (EPO)
HM	Health Maintenance Organization (HMO)
HN	Health Maintenance Organization (HMO) Medicare risk
HS	Special low income Medicare beneficiary
IN	Indemnity Insurance
LC	Long term care
LD	Long term policy
LI	Life insurance
LM	Liability medical
LT	Litigation
MA	Medicare part A
MB	Medicare part B
MC	Medicaid
MH	Medigap part A
MI	Medigap part B
MP	Medicare primary
OF	Other federal program (e.g. black lung)
OT	Other
PE	Property Insurance - Personal
PR	Preferred Provider Organization (PPO)
PS	Point of Service (POS)
QM	Qualified Medicare beneficiary
SP	Supplemental policy
TV	Title V
VA	Veteran administration plan
WC	Workers' compensation

DC913

Name:	PAID_YR
Type:	integer
Length:	Not Provided

Name:	Year Paid
Type:	Number
Length:	4

DC914

Name:	PAID_MON
Type:	integer
Length:	Not Provided

Name:	Month Paid
Type:	Number
Length:	2

DC915

Name:	INCURRED_YR
Type:	integer
Length:	Not Provided

Name:	Year of Service
Type:	Number
Length:	4

DC916

Name:	INCURRED_MON
Type:	integer
Length:	Not Provided

Name:	Month of Service
Type:	Number
Length:	2

DC917

Name:	Quarter
Type:	integer
Length:	Not Provided
Codes:

Name:	Payment Quarter
Type:	Number
Length:	1
Codes:
1	January - March
2	April - June
3	July - September
4	October - December

DC918

Name:	Quarter
Type:	integer
Length:	Not Provided
Codes:

Name:	Quarter Service Performed
Type:	Number
Length:	1
Codes:
1	January - March
2	April - June
3	July - September
4	October - December

United States Health Information Knowledgebase

File Submission Comparison

Identifying Attributes

Data Elements & Codes