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Dental Claims File Submission

Massachusetts

Versions: December 1, 2010 - v2.1 • June 7, 2013 - v3.1• October 1, 2014 - v4.0Compare Versions


Name:Dental Claims File Submission
State:Massachusetts
Definition:A MA APCD File Type for reporting all Paid Dental Claim Lines of a given time period. File accommodates Replacement and Void lines.
VersionDecember 1, 2010 - v2.1

File Specification for Dental Claims File Submission

Data Element ID Data Element Description Type Format Length
Multiple versionsHD001 Record Type Header Record Identifier Text HD 2
Multiple versionsHD002 Payer Header Submitter/Carrier ID Text 8
Multiple versionsHD003 National Plan ID Header CMS National Plan Identification Number (PlanID) Text 30
Multiple versionsHD004 Type of File Header Type of File Text DC 2
Multiple versionsHD005 Period Beginning Date Header Period Start Date Date Period CCYYMM 6
Multiple versionsHD006 Period Ending Date Header Period Ending Date Date Period CCYYMM 6
Multiple versionsHD007 Record Count Header Record Count Integer ####### 10
Multiple versionsHD008 Comments Header Carrier Comments Text Free Text Comments 80
Multiple versionsDC001 Payer Carrier Specific Submitter Code as defined by APCD. This must match the Submitter Code reported in HD002 Text 8
Multiple versionsDC002 National Plan ID CMS National Plan Identification Number (PlanID) Text 30
Multiple versionsDC003 Dental Insurance Type Code/Product Dental Product/Type Identifier Text tlkpClaimInsuranceType 2
Multiple versionsDC004 Payer Claim Control Number Payer Claim Control Identification Text Free Text Control Number 35
Multiple versionsDC005 Line Counter Incremental Line Counter Integer #### 4
Multiple versionsDC005A Version Number Claim Service Line Version Number Integer #### 4
Multiple versionsDC006 Insured Group or Policy Number Carriers group or policy number Text 30
Multiple versionsDC007 Subscriber SSN Subscriber's Social Security Number Text ######### 9
Multiple versionsDC008 Plan Specific Contract Number Plan Specific Contract Number Text 30
Multiple versionsDC009 Member Suffix or Sequence Number Member/Patient's Contract Sequence Number Text 20
Multiple versionsDC010 Member Identification Code Member/Patient's Social Security Number Text ######### 9
Multiple versionsDC011 Individual Relationship Code Member/Patient to Subscriber Relationship Code Integer tlkpIndividualRelathionshipCode 2
Multiple versionsDC012 Member Gender Member/Patient's Gender Text tlkpGender 1
Multiple versionsDC013 Member Date of Birth Member/Patient's date of birth Date CCYYMMDD 8
Multiple versionsDC014 Member City Name City name of the Member/Patient Text Free Text Address 50
Multiple versionsDC015 Member State or Province State of the Member/Patient Text External Code Source 2 2
Multiple versionsDC016 Member ZIP Code State of the Member/Patient Text External Code Source 3 11
Multiple versionsDC017 Date Service Approved (AP Date) The date the claim or service was approved for payment. Date CCYYMMDD 8
Multiple versionsDC018 Service Provider Number Service Provider Identification Number Text 30
Multiple versionsDC019 Service Provider Tax ID Number Service Provider's Tax ID number Text ######### 10
Multiple versionsDC020 National Service Provider ID National Provider Identification (NPI) of the National Service Provider Text External Code Source 4 20
Multiple versionsDC021 Service Provider Entity Type Qualifier Service Provider Entity Identifier Code Integer tlkpServProvEntityTypeQualifier 1
Multiple versionsDC022 Service Provider First Name First name of Service Provider Text Free Text Name 25
Multiple versionsDC023 Service Provider Middle Name Middle initial of Service Provider Text Free Text Name 25
Multiple versionsDC024 Service Provider Last Name or Organization Name Last name or Organization Name of Service Provider Text Free Text Name 60
Multiple versionsDC025 Delegated Benefit Administrator Organization ID DHCFP assigned Org ID for Benefit Administrator Integer ########## 10
Multiple versionsDC026 Service Provider Specialty Specialty Code Text External Code Source 13 - AND/OR - Carrier Defined Reference Table 10
Multiple versionsDC027 Service Provider City Name City name of the Provider Text Free Text Address 30
Multiple versionsDC028 Service Provider State State of the Service Provider Text External Code Source 2 2
Multiple versionsDC029 Service Provider ZIP Code Zip Code of the Service Provider Text External Code Source 3 11
Multiple versionsDC030 Facility Type - Professional Place of Service Code as used on Professional Claims Text External Code Source 9 2
Multiple versionsDC031 Claim Status Claim Line Status Integer tlkpClaimStatus 2
Multiple versionsDC032 CDT Code HCPCS / CDT Code Text External Code Source 8 5
Multiple versionsDC033 Procedure Modifier - 1 HCPCS / CPT Code Modifier Text External Code Source 8 2
Multiple versionsDC034 Procedure Modifier - 2 HCPCS / CPT Code Modifier Text External Code Source 8 2
Multiple versionsDC035 Date of Service - From Date of Service Date CCYYMMDD 8
Multiple versionsDC036 Date of Service - Thru Last date of service for this service line. Date CCYYMMDD 8
Multiple versionsDC037 Charge Amount Amount of provider charges for the claim line Integer DDDDCC 10
Multiple versionsDC038 Paid Amount Amount paid by the carrier for the claim line Integer DDDDCC 10
Multiple versionsDC039 Copay Amount Amount of Copay member/patient is responsible to pay Integer DDDDCC 10
Multiple versionsDC040 Coinsurance Amount Amount of coinsurance member/patient is responsible to pay Integer DDDDCC 10
Multiple versionsDC041 Deductible Amount Amount of deductible member/patient is responsible to pay on the claim line Integer DDDDCC 10
Multiple versionsDC042 Product ID Number Product Identification Number Text ID PR001 20
Multiple versionsDC043 Member Street Address Street address of the Member/Patient Text Free Text Address 30
Multiple versionsDC044 Billing Provider Tax ID Number The Billing Provider's Federal Tax Identification Number (FTIN) Text ######### 9
Multiple versionsDC045 Paid Date Paid date of the claim line Date CCYYMMDD 8
Multiple versionsDC046 Allowed Amount Allowed Amount Integer DDDDCC 10
Multiple versionsDC047 Tooth Number/Letter Tooth Number or Letter Identification Text External Code Source 8 20
Multiple versionsDC048 Dental Quadrant Dental Quadrant Text External Code Source 8 1
Multiple versionsDC049 Tooth Surface Tooth Service Identification Text External Code Source 8 10
Multiple versionsDC050 Subscriber Last Name Last name of Subscriber Text Free Text Name 60
Multiple versionsDC051 Subscriber First Name First name should exclude all punctuation, including hyphens and apostrophes, and be reported in upper case. Name should be contracted where punctuation is removed, do not report spaces. Example: Anne-Marie becomes ANNEMARIE. Text Free Text Name 25
Multiple versionsDC052 Subscriber Middle Initial Middle initial of Subscriber Text Free Text Name 1
Multiple versionsDC053 Member Last Name Last name of Member/Patient Text Free Text Name 60
Multiple versionsDC054 Member First Name First name of Member/Patient Text Free Text Name 25
Multiple versionsDC055 Member Middle Initial Middle initial of the Member/Patient Text Free Text Name 1
Multiple versionsDC056 CarrierSpecificUniqueMemberID Member/Patient Carrier Unique Identification Text 50
Multiple versionsDC057 CarrierSpecificUniqueSubscriberID Subscriber Carrier Unique Identification Text 50
Multiple versionsDC058 Member Address 2 Secondary Street Address of the Member/Patient Text Free Text Address 30
Multiple versionsDC059 Claim Line Type Claim Line Activity Type Code Text tlkpClaimLineType 10
Multiple versionsDC060 Former Claim Number Previous Claim Number Text ID 35
Multiple versionsDC899 Record Type File Type Identifier Text DC 2
Multiple versionsTR001 Record Type Trailer Record Identifier Text TR 2
Multiple versionsTR002 Payer Carrier Specific Submitter Code as defined by APCD. This must match the Submitter Code reported in HD002 Text 8
Multiple versionsTR003 National Plan ID CMS National Plan Identification Number (PlanID) Text 30
Multiple versionsTR004 Type of File This is an indicator that defines the type of file and the data contained within the file. This must match the File Type reported in HD004. Text DC 2
Multiple versionsTR005 Period Beginning Date Trailer Period Start Date Date Period CCYYMM 6
Multiple versionsTR006 Period Ending Date Trailer Period Ending Date Date Period CCYYMM 6
Multiple versionsTR007 Date Processed Trailer Processed Date Date CCYYMMDD 8

Downloads
 
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Data Element ID Data Element Code Value
HD001 Record Type HD
HD004 Type of File DC
DC003 Dental Insurance Type Code/Product 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
DC011 Individual Relationship Code 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 Member Gender F Female
M Male
O Other
U Unknown
DC021 Service Provider Entity Type Qualifier 1 Person
2 Non-person entity
DC031 Claim Status 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
DC059 Claim Line Type A Amendment
B Back Out
O Original
R Replacement
V Void
DC899 Record Type DC
TR001 Record Type TR
TR004 Type of File DC
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