United States Health Information Knowledgebase

 

File Submission Comparison

Selected Items
Action Item Name Version State Type Organization
Dental Claims File Submission December 1, 2010 - v2.1 Massachusetts File Specification Massachusetts Center for Health Information and Analysis (MCHIA)
Dental Claims File Submission June 7, 2013 - v3.1 Massachusetts File Specification Massachusetts Center for Health Information and Analysis (MCHIA)
Dental Claims File Submission October 1, 2014 - v4.0 Massachusetts File Specification Massachusetts Center for Health Information and Analysis (MCHIA)
File Specification: Dental Claims File Submission - December 1, 2010 - v2.1 (Massachusetts) Dental Claims File Submission - June 7, 2013 - v3.1 (Massachusetts) Dental Claims File Submission - October 1, 2014 - v4.0 (Massachusetts)
[Shared] Responsible Organization:
Massachusetts Center for Health Information and Analysis Massachusetts Center for Health Information and Analysis Massachusetts Center for Health Information and Analysis
[Shared] Definition:
A MA APCD File Type for reporting all Paid Dental Claim Lines of a given time period. File accommodates Replacement and Void lines. A MA APCD File Type for reporting all Paid Dental Claim Lines of a given time period. File accommodates Replacement and Void lines. A MA APCD File Type for reporting all Paid Dental Claim Lines of a given time period. File accommodates Replacement and Void lines.
File Specification: Dental Claims File Submission - December 1, 2010 - v2.1 (Massachusetts) Dental Claims File Submission - June 7, 2013 - v3.1 (Massachusetts) Dental Claims File Submission - October 1, 2014 - v4.0 (Massachusetts)
HD001
[Shared] Name: Record Type
[Shared] Type: Text
[Shared] Length: 2
Codes:
HD
 
[Shared] Name: Record Type
[Shared] Type: Text
[Shared] Length: 2
Codes:
HD
 
[Shared] Name: Record Type
[Shared] Type: Text
[Shared] Length: 2
Codes:
HD
 
HD002
[Unshared] Name: Payer
[Unshared] Type: Text
[Unshared] Length: 8
[Unshared] Name: Submitter
[Unshared] Type: Integer
[Unshared] Length: 6
[Unshared] Name: Submitter
[Unshared] Type: Integer
[Unshared] Length: 6
HD003
[Shared] Name: National Plan ID
[Unshared] Type: Text
[Unshared] Length: 30
[Shared] Name: National Plan ID
[Unshared] Type: Integer
[Unshared] Length: 10
[Shared] Name: National Plan ID
[Unshared] Type: Integer
[Unshared] Length: 10
HD004
[Shared] Name: Type of File
[Shared] Type: Text
[Shared] Length: 2
Codes:
DC
 
[Shared] Name: Type of File
[Shared] Type: Text
[Shared] Length: 2
Codes:
DC
DENTAL CLAIM
[Shared] Name: Type of File
[Shared] Type: Text
[Shared] Length: 2
Codes:
DC
DENTAL CLAIM
HD005
[Shared] Name: Period Beginning Date
[Unshared] Type: Date Period
[Shared] Length: 6
[Shared] Name: Period Beginning Date
[Unshared] Type: Date Period - Integer
[Shared] Length: 6
[Shared] Name: Period Beginning Date
[Unshared] Type: Date Period - Integer
[Shared] Length: 6
HD006
[Shared] Name: Period Ending Date
[Unshared] Type: Date Period
[Shared] Length: 6
[Shared] Name: Period Ending Date
[Unshared] Type: Date Period - Integer
[Shared] Length: 6
[Shared] Name: Period Ending Date
[Unshared] Type: Date Period - Integer
[Shared] Length: 6
HD007
[Shared] Name: Record Count
[Shared] Type: Integer
[Shared] Length: 10
[Shared] Name: Record Count
[Shared] Type: Integer
[Shared] Length: 10
[Shared] Name: Record Count
[Shared] Type: Integer
[Shared] Length: 10
HD008
[Shared] Name: Comments
[Shared] Type: Text
[Shared] Length: 80
[Shared] Name: Comments
[Shared] Type: Text
[Shared] Length: 80
[Shared] Name: Comments
[Shared] Type: Text
[Shared] Length: 80
HD009
Data Element: HD009
not present in this file submission.
[Unshared] Name: APCD Version Number
[Unshared] Type: Decimal - Numeric
[Unshared] Length: 3
Codes:
2.1
Prior Version; valid only for reporting periods prior to October 2013
3.0
Current Version; required for reporting periods as of October 2013
 
 
[Unshared] Name: APCD Version Number
[Unshared] Type: Decimal - Numeric
[Unshared] Length: 3
Codes:
2.1
Prior Version; valid only for reporting periods prior to October 2013
3.0
Version 3.0; required for reporting periods as of October 2013 - No longer valid as of May 2015
4.0
Version 4.0; required for reporting periods October 2013 onwards as of May 2015
DC001
[Unshared] Name: Payer
[Unshared] Type: Text
[Unshared] Length: 8
[Unshared] Name: Submitter
[Unshared] Type: Integer
[Unshared] Length: 6
[Unshared] Name: Submitter
[Unshared] Type: Integer
[Unshared] Length: 6
DC002
[Shared] Name: National Plan ID
[Shared] Type: Text
[Unshared] Length: 30
[Shared] Name: National Plan ID
[Shared] Type: Text
[Unshared] Length: 10
[Shared] Name: National Plan ID
[Shared] Type: Text
[Unshared] Length: 10
DC003
[Unshared] Name: Dental Insurance Type Code/Product
[Unshared] Type: Text
[Shared] Length: 2
Codes:
09
Self-pay
10
Central Certification
11
Other Non-Federal Programs
12
Preferred Provider Organization (PPO)
13
Point of Service (POS)
14
Exclusive Provider Organization (EPO)
15
Indemnity Insurance
16
Health Maintenance Organization (HMO) Medicare Risk
17
Dental Maintenance Organization (DMO)
AM
Automobile Medical
BL
Blue Cross / Blue Shield
CC
Commonwealth Care
CE
Commonwealth Choice
CH
Champus
CI
Commercial Insurance Co.
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
 
 
TV
Title V
VA
Veterans Administration Plan
WC
Workers' Compensation
 
 
[Unshared] Name: Insurance Type Code / Product
[Unshared] Type: Lookup Table - Text
[Shared] Length: 2
Codes:
09
Self-pay
10
Central Certification
11
Other Non-Federal Programs
12
Preferred Provider Organization (PPO)
13
Point of Service (POS)
14
Exclusive Provider Organization (EPO)
15
Indemnity Insurance
16
Health Maintenance Organization (HMO) Medicare Risk
17
Dental Maintenance Organization (DMO)
AM
Automobile Medical
BL
Blue Cross / Blue Shield
CC
Commonwealth Care
CE
Commonwealth Choice
CH
Champus
CI
Commercial Insurance Co.
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
TF
HSN Trust Fund
TV
Title V
VA
Veterans Administration Plan
WC
Workers' Compensation
ZZ
Other
[Unshared] Name: Insurance Type Code / Product
[Unshared] Type: Lookup Table - Text
[Shared] Length: 2
Codes:
09
Self-pay
10
Central Certification
11
Other Non-Federal Programs
12
Preferred Provider Organization (PPO)
13
Point of Service (POS)
14
Exclusive Provider Organization (EPO)
15
Indemnity Insurance
16
Health Maintenance Organization (HMO) Medicare Risk
17
Dental Maintenance Organization (DMO)
AM
Automobile Medical
BL
Blue Cross / Blue Shield
CC
Commonwealth Care
CE
Commonwealth Choice
CH
Champus
CI
Commercial Insurance Co.
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
TF
HSN Trust Fund
TV
Title V
VA
Veterans Administration Plan
WC
Workers' Compensation
ZZ
Other
DC004
[Shared] Name: Payer Claim Control Number
[Shared] Type: Text
[Shared] Length: 35
[Shared] Name: Payer Claim Control Number
[Shared] Type: Text
[Shared] Length: 35
[Shared] Name: Payer Claim Control Number
[Shared] Type: Text
[Shared] Length: 35
DC005
[Shared] Name: Line Counter
[Shared] Type: Integer
[Shared] Length: 4
[Shared] Name: Line Counter
[Shared] Type: Integer
[Shared] Length: 4
[Shared] Name: Line Counter
[Shared] Type: Integer
[Shared] Length: 4
DC005A
[Shared] Name: Version Number
[Shared] Type: Integer
[Shared] Length: 4
[Shared] Name: Version Number
[Shared] Type: Integer
[Shared] Length: 4
[Shared] Name: Version Number
[Shared] Type: Integer
[Shared] Length: 4
DC006
[Shared] Name: Insured Group or Policy Number
[Shared] Type: Text
[Shared] Length: 30
[Shared] Name: Insured Group or Policy Number
[Shared] Type: Text
[Shared] Length: 30
[Shared] Name: Insured Group or Policy Number
[Shared] Type: Text
[Shared] Length: 30
DC007
[Shared] Name: Subscriber SSN
[Unshared] Type: Text
[Shared] Length: 9
[Shared] Name: Subscriber SSN
[Unshared] Type: Numeric
[Shared] Length: 9
[Shared] Name: Subscriber SSN
[Unshared] Type: Numeric
[Shared] Length: 9
DC008
[Shared] Name: Plan Specific Contract Number
[Shared] Type: Text
[Shared] Length: 30
[Shared] Name: Plan Specific Contract Number
[Shared] Type: Text
[Shared] Length: 30
[Shared] Name: Plan Specific Contract Number
[Shared] Type: Text
[Shared] Length: 30
DC009
[Shared] Name: Member Suffix or Sequence Number
[Shared] Type: Text
[Shared] Length: 20
[Shared] Name: Member Suffix or Sequence Number
[Shared] Type: Text
[Shared] Length: 20
[Shared] Name: Member Suffix or Sequence Number
[Shared] Type: Text
[Shared] Length: 20
DC010
[Unshared] Name: Member Identification Code
[Unshared] Type: Text
[Shared] Length: 9
[Unshared] Name: Member SSN
[Unshared] Type: Numeric
[Shared] Length: 9
[Unshared] Name: Member SSN
[Unshared] Type: Numeric
[Shared] Length: 9
DC011
[Shared] Name: Individual Relationship Code
[Unshared] Type: Integer
[Shared] Length: 2
Codes:
1
Spouse
4
Grandfather or Grandmother
5
Grandson or Granddaughter
7
Nephew or Niece
10
Foster Child
15
Ward
17
Stepson or Stepdaughter
19
Child
20
Self/Employee
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
[Shared] Name: Individual Relationship Code
[Unshared] Type: Lookup Table - Numeric
[Shared] Length: 2
Codes:
1
Spouse
4
Grandfather or Grandmother
5
Grandson or Granddaughter
7
Nephew or Niece
10
Foster Child
15
Ward
17
Stepson or Stepdaughter
19
Child
20
Self/Employee
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
[Shared] Name: Individual Relationship Code
[Unshared] Type: Lookup Table - Numeric
[Shared] Length: 2
Codes:
1
Spouse
4
Grandfather or Grandmother
5
Grandson or Granddaughter
7
Nephew or Niece
10
Foster Child
15
Ward
17
Stepson or Stepdaughter
19
Child
20
Self/Employee
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
[Shared] Name: Member Gender
[Unshared] Type: Text
[Shared] Length: 1
Codes:
F
Female
M
Male
O
Other
U
Unknown
[Shared] Name: Member Gender
[Unshared] Type: Lookup Table - Text
[Shared] Length: 1
Codes:
F
Female
M
Male
O
Other
U
Unknown
[Shared] Name: Member Gender
[Unshared] Type: Lookup Table - Text
[Shared] Length: 1
Codes:
F
Female
M
Male
O
Other
U
Unknown
DC013
[Shared] Name: Member Date of Birth
[Unshared] Type: Date
[Shared] Length: 8
[Shared] Name: Member Date of Birth
[Unshared] Type: Full Date - Integer
[Shared] Length: 8
[Shared] Name: Member Date of Birth
[Unshared] Type: Full Date - Integer
[Shared] Length: 8
DC014
[Shared] Name: Member City Name
[Shared] Type: Text
[Shared] Length: 50
[Shared] Name: Member City Name
[Shared] Type: Text
[Shared] Length: 50
[Shared] Name: Member City Name
[Shared] Type: Text
[Shared] Length: 50
DC015
[Unshared] Name: Member State or Province
[Unshared] Type: Text
[Shared] Length: 2
[Unshared] Name: Member State
[Unshared] Type: External Code Source 2 - Text
[Shared] Length: 2
[Unshared] Name: Member State
[Unshared] Type: External Code Source 2 - Text
[Shared] Length: 2
DC016
[Shared] Name: Member ZIP Code
[Unshared] Type: Text
[Unshared] Length: 11
[Shared] Name: Member ZIP Code
[Unshared] Type: External Code Source 2 - Text
[Unshared] Length: 9
[Shared] Name: Member ZIP Code
[Unshared] Type: External Code Source 2 - Text
[Unshared] Length: 9
DC017
[Shared] Name: Date Service Approved (AP Date)
[Unshared] Type: Date
[Shared] Length: 8
[Shared] Name: Date Service Approved (AP Date)
[Unshared] Type: Full Date - Integer
[Shared] Length: 8
[Shared] Name: Date Service Approved (AP Date)
[Unshared] Type: Full Date - Integer
[Shared] Length: 8
DC018
[Shared] Name: Service Provider Number
[Shared] Type: Text
[Shared] Length: 30
[Shared] Name: Service Provider Number
[Shared] Type: Text
[Shared] Length: 30
[Shared] Name: Service Provider Number
[Shared] Type: Text
[Shared] Length: 30
DC019
[Shared] Name: Service Provider Tax ID Number
[Unshared] Type: Text
[Unshared] Length: 10
[Shared] Name: Service Provider Tax ID Number
[Unshared] Type: Numeric
[Unshared] Length: 9
[Shared] Name: Service Provider Tax ID Number
[Unshared] Type: Numeric
[Unshared] Length: 9
DC020
[Unshared] Name: National Service Provider ID
[Unshared] Type: Text
[Unshared] Length: 20
[Unshared] Name: National Provider ID - Service
[Unshared] Type: External Code Source 3 - Integer
[Unshared] Length: 10
[Unshared] Name: National Provider ID - Service
[Unshared] Type: External Code Source 3 - Integer
[Unshared] Length: 10
DC021
[Shared] Name: Service Provider Entity Type Qualifier
[Unshared] Type: Integer
[Shared] Length: 1
Codes:
1
Person
2
Non-person entity
[Shared] Name: Service Provider Entity Type Qualifier
[Unshared] Type: Lookup Table - integer
[Shared] Length: 1
Codes:
1
Person
2
Non-person entity
[Shared] Name: Service Provider Entity Type Qualifier
[Unshared] Type: Lookup Table - integer
[Shared] Length: 1
Codes:
1
Person
2
Non-person entity
DC022
[Shared] Name: Service Provider First Name
[Shared] Type: Text
[Shared] Length: 25
[Shared] Name: Service Provider First Name
[Shared] Type: Text
[Shared] Length: 25
[Shared] Name: Service Provider First Name
[Shared] Type: Text
[Shared] Length: 25
DC023
[Shared] Name: Service Provider Middle Name
[Shared] Type: Text
[Shared] Length: 25
[Shared] Name: Service Provider Middle Name
[Shared] Type: Text
[Shared] Length: 25
[Shared] Name: Service Provider Middle Name
[Shared] Type: Text
[Shared] Length: 25
DC024
[Shared] Name: Service Provider Last Name or Organization Name
[Shared] Type: Text
[Shared] Length: 60
[Shared] Name: Service Provider Last Name or Organization Name
[Shared] Type: Text
[Shared] Length: 60
[Shared] Name: Service Provider Last Name or Organization Name
[Shared] Type: Text
[Shared] Length: 60
DC025
[Shared] Name: Delegated Benefit Administrator Organization ID
[Shared] Type: Integer
[Unshared] Length: 10
[Shared] Name: Delegated Benefit Administrator Organization ID
[Shared] Type: Integer
[Unshared] Length: 6
[Shared] Name: Delegated Benefit Administrator Organization ID
[Shared] Type: Integer
[Unshared] Length: 6
DC026
[Unshared] Name: Service Provider Specialty
[Unshared] Type: Text
[Shared] Length: 10
[Unshared] Name: Service Provider Taxonomy
[Unshared] Type: External Code Source 5 - Text
[Shared] Length: 10
[Unshared] Name: Service Provider Taxonomy
[Unshared] Type: External Code Source 5 - Text
[Shared] Length: 10
DC027
[Shared] Name: Service Provider City Name
[Shared] Type: Text
[Shared] Length: 30
[Shared] Name: Service Provider City Name
[Shared] Type: Text
[Shared] Length: 30
[Shared] Name: Service Provider City Name
[Shared] Type: Text
[Shared] Length: 30
DC028
[Shared] Name: Service Provider State
[Unshared] Type: Text
[Shared] Length: 2
[Shared] Name: Service Provider State
[Unshared] Type: External Code Source 2 - Text
[Shared] Length: 2
[Shared] Name: Service Provider State
[Unshared] Type: External Code Source 2 - Text
[Shared] Length: 2
DC029
[Shared] Name: Service Provider ZIP Code
[Unshared] Type: Text
[Unshared] Length: 11
[Shared] Name: Service Provider ZIP Code
[Unshared] Type: External Code Source 2 - Text
[Unshared] Length: 9
[Shared] Name: Service Provider ZIP Code
[Unshared] Type: External Code Source 2 - Text
[Unshared] Length: 9
DC030
[Shared] Name: Facility Type - Professional
[Unshared] Type: Text
[Shared] Length: 2
[Shared] Name: Facility Type - Professional
[Unshared] Type: External Code Source 13 - Numeric
[Shared] Length: 2
[Shared] Name: Facility Type - Professional
[Unshared] Type: External Code Source 13 - Numeric
[Shared] Length: 2
DC031
[Shared] Name: Claim Status
[Unshared] Type: Integer
[Shared] 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
 
 
 
 
[Shared] Name: Claim Status
[Unshared] Type: Lookup Table - Numeric
[Shared] Length: 2
Codes:
1
Processed as primary
2
Processed as secondary
3
Processed as tertiary
4
Denied
 
 
 
 
 
 
 
 
19
Processed as primary, forwarded to additional payer(s)
20
Processed as secondary, forwarded to additional payer(s)
21
Processed as tertiary, forwarded to additional payer(s)
22
Reversal of previous payment
23
Not our claim, forwarded to additional payer(s)
25
Predetermination Pricing Only - no payment
[Shared] Name: Claim Status
[Unshared] Type: Lookup Table - Numeric
[Shared] Length: 2
Codes:
1
Processed as primary
2
Processed as secondary
3
Processed as tertiary
4
Denied
 
 
 
 
 
 
 
 
19
Processed as primary, forwarded to additional payer(s)
20
Processed as secondary, forwarded to additional payer(s)
21
Processed as tertiary, forwarded to additional payer(s)
22
Reversal of previous payment
23
Not our claim, forwarded to additional payer(s)
25
Predetermination Pricing Only - no payment
DC032
[Shared] Name: CDT Code
[Unshared] Type: Text
[Shared] Length: 5
[Shared] Name: CDT Code
[Unshared] Type: External Code Source 10 - Text
[Shared] Length: 5
[Shared] Name: CDT Code
[Unshared] Type: External Code Source 10 - Text
[Shared] Length: 5
DC033
[Shared] Name: Procedure Modifier - 1
[Unshared] Type: Text
[Shared] Length: 2
[Shared] Name: Procedure Modifier - 1
[Unshared] Type: External Code Source 9 - Text
[Shared] Length: 2
[Shared] Name: Procedure Modifier - 1
[Unshared] Type: External Code Source 9 - Text
[Shared] Length: 2
DC034
[Shared] Name: Procedure Modifier - 2
[Unshared] Type: Text
[Shared] Length: 2
[Shared] Name: Procedure Modifier - 2
[Unshared] Type: External Code Source 9 - Text
[Shared] Length: 2
[Shared] Name: Procedure Modifier - 2
[Unshared] Type: External Code Source 9 - Text
[Shared] Length: 2
DC035
[Shared] Name: Date of Service - From
[Unshared] Type: Date
[Shared] Length: 8
[Shared] Name: Date of Service - From
[Unshared] Type: Full Date - Integer
[Shared] Length: 8
[Shared] Name: Date of Service - From
[Unshared] Type: Full Date - Integer
[Shared] Length: 8
DC036
[Shared] Name: Date of Service - Thru
[Unshared] Type: Date
[Shared] Length: 8
[Shared] Name: Date of Service - Thru
[Unshared] Type: Full Date - Integer
[Shared] Length: 8
[Shared] Name: Date of Service - Thru
[Unshared] Type: Full Date - Integer
[Shared] Length: 8
DC037
[Shared] Name: Charge Amount
[Shared] Type: Integer
[Shared] Length: 10
[Shared] Name: Charge Amount
[Shared] Type: Integer
[Shared] Length: 10
[Shared] Name: Charge Amount
[Shared] Type: Integer
[Shared] Length: 10
DC038
[Shared] Name: Paid Amount
[Shared] Type: Integer
[Shared] Length: 10
[Shared] Name: Paid Amount
[Shared] Type: Integer
[Shared] Length: 10
[Shared] Name: Paid Amount
[Shared] Type: Integer
[Shared] Length: 10
DC039
[Shared] Name: Copay Amount
[Shared] Type: Integer
[Shared] Length: 10
[Shared] Name: Copay Amount
[Shared] Type: Integer
[Shared] Length: 10
[Shared] Name: Copay Amount
[Shared] Type: Integer
[Shared] Length: 10
DC040
[Shared] Name: Coinsurance Amount
[Shared] Type: Integer
[Shared] Length: 10
[Shared] Name: Coinsurance Amount
[Shared] Type: Integer
[Shared] Length: 10
[Shared] Name: Coinsurance Amount
[Shared] Type: Integer
[Shared] Length: 10
DC041
[Shared] Name: Deductible Amount
[Shared] Type: Integer
[Shared] Length: 10
[Shared] Name: Deductible Amount
[Shared] Type: Integer
[Shared] Length: 10
[Shared] Name: Deductible Amount
[Shared] Type: Integer
[Shared] Length: 10
DC042
[Shared] Name: Product ID Number
[Shared] Type: Text
[Unshared] Length: 20
[Shared] Name: Product ID Number
[Shared] Type: Text
[Unshared] Length: 30
[Shared] Name: Product ID Number
[Shared] Type: Text
[Unshared] Length: 30
DC043
[Shared] Name: Member Street Address
[Shared] Type: Text
[Unshared] Length: 30
[Shared] Name: Member Street Address
[Shared] Type: Text
[Unshared] Length: 50
[Shared] Name: Member Street Address
[Shared] Type: Text
[Unshared] Length: 50
DC044
[Shared] Name: Billing Provider Tax ID Number
[Unshared] Type: Text
[Shared] Length: 9
[Shared] Name: Billing Provider Tax ID Number
[Unshared] Type: Numeric
[Shared] Length: 9
[Shared] Name: Billing Provider Tax ID Number
[Unshared] Type: Numeric
[Shared] Length: 9
DC045
[Shared] Name: Paid Date
[Unshared] Type: Date
[Shared] Length: 8
[Shared] Name: Paid Date
[Unshared] Type: Full Date - Integer
[Shared] Length: 8
[Shared] Name: Paid Date
[Unshared] Type: Full Date - Integer
[Shared] Length: 8
DC046
[Shared] Name: Allowed Amount
[Shared] Type: Integer
[Shared] Length: 10
[Shared] Name: Allowed Amount
[Shared] Type: Integer
[Shared] Length: 10
[Shared] Name: Allowed Amount
[Shared] Type: Integer
[Shared] Length: 10
DC047
[Shared] Name: Tooth Number/Letter
[Unshared] Type: Text
[Unshared] Length: 20
[Shared] Name: Tooth Number/Letter
[Unshared] Type: External Code Source 10 - Text
[Unshared] Length: 20
[Shared] Name: Tooth Number/Letter
[Unshared] Type: External Code Source 10 - Text
[Unshared] Length: 2
DC048
[Shared] Name: Dental Quadrant
[Unshared] Type: Text
[Unshared] Length: 1
[Shared] Name: Dental Quadrant
[Unshared] Type: External Code Source 10 - Numeric
[Unshared] Length: 2
[Shared] Name: Dental Quadrant
[Unshared] Type: External Code Source 10 - Numeric
[Unshared] Length: 2
DC049
[Shared] Name: Tooth Surface
[Unshared] Type: Text
[Unshared] Length: 10
[Shared] Name: Tooth Surface
[Unshared] Type: External Code Source 10 - Text
[Unshared] Length: 10
[Shared] Name: Tooth Surface
[Unshared] Type: External Code Source 10 - Text
[Unshared] Length: 5
DC050
[Shared] Name: Subscriber Last Name
[Shared] Type: Text
[Shared] Length: 60
[Shared] Name: Subscriber Last Name
[Shared] Type: Text
[Shared] Length: 60
[Shared] Name: Subscriber Last Name
[Shared] Type: Text
[Shared] Length: 60
DC051
[Shared] Name: Subscriber First Name
[Shared] Type: Text
[Shared] Length: 25
[Shared] Name: Subscriber First Name
[Shared] Type: Text
[Shared] Length: 25
[Shared] Name: Subscriber First Name
[Shared] Type: Text
[Shared] Length: 25
DC052
[Shared] Name: Subscriber Middle Initial
[Shared] Type: Text
[Shared] Length: 1
[Shared] Name: Subscriber Middle Initial
[Shared] Type: Text
[Shared] Length: 1
[Shared] Name: Subscriber Middle Initial
[Shared] Type: Text
[Shared] Length: 1
DC053
[Shared] Name: Member Last Name
[Shared] Type: Text
[Shared] Length: 60
[Shared] Name: Member Last Name
[Shared] Type: Text
[Shared] Length: 60
[Shared] Name: Member Last Name
[Shared] Type: Text
[Shared] Length: 60
DC054
[Shared] Name: Member First Name
[Shared] Type: Text
[Shared] Length: 25
[Shared] Name: Member First Name
[Shared] Type: Text
[Shared] Length: 25
[Shared] Name: Member First Name
[Shared] Type: Text
[Shared] Length: 25
DC055
[Shared] Name: Member Middle Initial
[Shared] Type: Text
[Shared] Length: 1
[Shared] Name: Member Middle Initial
[Shared] Type: Text
[Shared] Length: 1
[Shared] Name: Member Middle Initial
[Shared] Type: Text
[Shared] Length: 1
DC056
[Unshared] Name: CarrierSpecificUniqueMemberID
[Shared] Type: Text
[Shared] Length: 50
[Unshared] Name: Carrier Specific Unique Member ID
[Shared] Type: Text
[Shared] Length: 50
[Unshared] Name: Carrier Specific Unique Member ID
[Shared] Type: Text
[Shared] Length: 50
DC057
[Unshared] Name: CarrierSpecificUniqueSubscriberID
[Shared] Type: Text
[Shared] Length: 50
[Unshared] Name: Carrier Specific Unique Subscriber ID
[Shared] Type: Text
[Shared] Length: 50
[Unshared] Name: Carrier Specific Unique Subscriber ID
[Shared] Type: Text
[Shared] Length: 50
DC058
[Unshared] Name: Member Address 2
[Shared] Type: Text
[Unshared] Length: 30
[Unshared] Name: Member Street Address 2
[Shared] Type: Text
[Unshared] Length: 50
[Unshared] Name: Member Street Address 2
[Shared] Type: Text
[Unshared] Length: 50
DC059
[Shared] Name: Claim Line Type
[Unshared] Type: Text
[Unshared] Length: 10
Codes:
A
Amendment
B
Back Out
O
Original
R
Replacement
V
Void
[Shared] Name: Claim Line Type
[Unshared] Type: Lookup Table - Text
[Unshared] Length: 1
Codes:
A
Amendment
B
Back Out
O
Original
R
Replacement
V
Void
[Shared] Name: Claim Line Type
[Unshared] Type: Lookup Table - Text
[Unshared] Length: 1
Codes:
A
Amendment
B
Back Out
O
Original
R
Replacement
V
Void
DC060
[Shared] Name: Former Claim Number
[Shared] Type: Text
[Shared] Length: 35
[Shared] Name: Former Claim Number
[Shared] Type: Text
[Shared] Length: 35
[Shared] Name: Former Claim Number
[Shared] Type: Text
[Shared] Length: 35
DC061
Data Element: DC061
not present in this file submission.
[Unshared] Name: Diagnosis Code
[Unshared] Type: External Code Source 8 - Text
[Unshared] Length: 7
[Unshared] Name: Diagnosis Code
[Unshared] Type: External Code Source 8 - Text
[Unshared] Length: 7
DC062
Data Element: DC062
not present in this file submission.
[Unshared] Name: ICD Indicator
[Unshared] Type: Lookup Table - Integer
[Unshared] Length: 1
Codes:
0
ICD-10
9
ICD-9
[Unshared] Name: ICD Indicator
[Unshared] Type: Lookup Table - Integer
[Unshared] Length: 1
Codes:
0
ICD-10
9
ICD-9
DC063
Data Element: DC063
not present in this file submission.
[Unshared] Name: Denied Flag
[Unshared] Type: Lookup Table - Integer
[Unshared] Length: 1
Codes:
1
Yes
2
No
3
Unknown
4
Other
5
Not Applicable
[Unshared] Name: Denied Flag
[Unshared] Type: Lookup Table - Integer
[Unshared] Length: 1
Codes:
1
Yes
2
No
3
Unknown
4
Other
5
Not Applicable
DC064
Data Element: DC064
not present in this file submission.
[Unshared] Name: Denial Reason
[Unshared] Type: Carrier Defined Table - OR - External Code Source 16
[Unshared] Length: 20
[Unshared] Name: Denial Reason
[Unshared] Type: Carrier Defined Table - OR - External Code Source 16
[Unshared] Length: 20
DC065
Data Element: DC065
not present in this file submission.
[Unshared] Name: Payment Arrangement Type
[Unshared] Type: Lookup Table - Numeric
[Unshared] Length: 2
Codes:
01
Capitation
02
Fee for Service
03
Percent of Charges
04
DRG
05
Pay for Performance
06
Global Payment
07
Other
08
Bundled Payment
09
Payment Amount Per Episode (PAPE) (MassHealth)
[Unshared] Name: Payment Arrangement Type
[Unshared] Type: Lookup Table - Numeric
[Unshared] Length: 2
Codes:
01
Capitation
02
Fee for Service
03
Percent of Charges
04
DRG
05
Pay for Performance
06
Global Payment
07
Other
08
Bundled Payment
09
Payment Amount Per Episode (PAPE) (MassHealth)
DC066
Data Element: DC066
not present in this file submission.
[Unshared] Name: GIC ID
[Unshared] Type: Text
[Unshared] Length: 9
[Unshared] Name: GIC ID
[Unshared] Type: Text
[Unshared] Length: 9
DC067
Data Element: DC067
not present in this file submission.
[Unshared] Name: APCD ID Code
[Unshared] Type: Lookup Table - Integer
[Unshared] Length: 1
Codes:
0
Unknown / Not Applicable
1
FIG - Fully-Insured Commercial Group Enrollee
2
SIG - Self-Insured Group Enrollee
3
GIC - Group Insurance Commission Enrollee
4
MCO - MassHealth Managed Care Organization Enrollee
5
Supplemental Policy Enrollee
6
ICO - Integrated Care Organization
[Unshared] Name: APCD ID Code
[Unshared] Type: Lookup Table - Integer
[Unshared] Length: 1
Codes:
0
Unknown / Not Applicable
1
FIG - Fully-Insured Commercial Group Enrollee
2
SIG - Self-Insured Group Enrollee
3
GIC - Group Insurance Commission Enrollee
4
MCO - MassHealth Managed Care Organization Enrollee
5
Supplemental Policy Enrollee
6
ICO - Integrated Care Organization or SCO - Senior Care Option
DC068
Data Element: DC068
not present in this file submission.
Data Element: DC068
not present in this file submission.
[Unshared] Name: Claim Line Paid Flag
[Unshared] Type: Lookup Table - Integer
[Unshared] Length: 1
Codes:
1
Yes
2
No
3
Unknown
4
Other
5
Not Applicable
DC899
[Shared] Name: Record Type
[Shared] Type: Text
[Shared] Length: 2
Codes:
DC
 
[Shared] Name: Record Type
[Shared] Type: Text
[Shared] Length: 2
Codes:
DC
 
[Shared] Name: Record Type
[Shared] Type: Text
[Shared] Length: 2
Codes:
DC
 
TR001
[Shared] Name: Record Type
[Shared] Type: Text
[Shared] Length: 2
Codes:
TR
 
[Shared] Name: Record Type
[Shared] Type: Text
[Shared] Length: 2
Codes:
TR
 
[Shared] Name: Record Type
[Shared] Type: Text
[Shared] Length: 2
Codes:
TR
 
TR002
[Unshared] Name: Payer
[Unshared] Type: Text
[Unshared] Length: 8
[Unshared] Name: Submitter
[Unshared] Type: Integer
[Unshared] Length: 6
[Unshared] Name: Submitter
[Unshared] Type: Integer
[Unshared] Length: 6
TR003
[Shared] Name: National Plan ID
[Unshared] Type: Text
[Unshared] Length: 30
[Shared] Name: National Plan ID
[Unshared] Type: Integer
[Unshared] Length: 10
[Shared] Name: National Plan ID
[Unshared]