United States Health Information Knowledgebase

 

Connecticut



Name:Connecticut
Abbreviation:CT
Websitehttp://www.ct.gov/hix/
Who Maintains the SystemAccess Health CT Access Health CT
Versions:December 5, 2013 - v1.2

File Specification for Dental Claims File Submission - December 5, 2013 - v1.2

Data Element ID Data Element Description Type Format Length
HD001 Record Type Header Record Identifier Text char[2] 2
HD002 Submitter Header Submitter / Carrier ID defined by AHCT Integer varchar[6] 6
HD003 National Plan ID Header CMS National Plan Identification Number (PlanID) Integer int[10] 10
HD004 Type of File Defines the file type and data expected. Text char[2] 2
HD005 Period Beginning Date Header Period Start Date Full Date - Integer int[8] YYYYMMDD 8
HD006 Period Ending Date Header Period Ending Date Full Date - Integer int[8] YYYYMMDD 8
HD007 Record Count Header Record Count Integer varchar[10] 10
HD008 Comments Header Carrier Comments Text varchar[80] 80
HD009 APCD Version Number Submission Guide Version Decimal - Numeric char[3] 3
DC001 Submitter CT APCD defined and maintained unique identifier Integer varchar[6] 6
DC002 National Plan ID CMS National Plan Identification Number (PlanID) Text int[10] 10
DC003 Insurance Type Code / Product Type / Product Identification Code Text char[2] 2
DC004 Payer Claim Control Number Payer Claim Control Identification Text varchar[35] 35
DC005 Line Counter Incremental Line Counter Integer varchar[4] 4
DC005A Version Number Claim Service Line Version Number Integer varchar[4] 4
DC006 Insured Group or Policy Number Group / Policy Number Text varchar[30] 30
DC007 Subscriber SSN Subscriber's Social Security Number Numeric char[9] 9
DC008 Plan Specific Contract Number Contract Number Text varchar[30] 30
DC009 Member Suffix or Sequence Number Member/Patient's Contract Sequence Number Text varchar[20] 20
DC010 Member SSN Member/Patient's Social Security Number Numeric char[9] 9
DC011 Individual Relationship Code Patient to Subscriber Relationship Code Text varchar[2] 2
DC012 Member Gender Patient's Gender Text char[1] 1
DC013 Member Date of Birth Member/Patient's date of birth Full Date - Integer int[8] YYYYMMDD 8
DC014 Member City Name City name of the Member/Patient Text varchar[50] 50
DC015 Member State State / Province of the Patient External Code Source - USPS char[2] 2
DC016 Member ZIP Code Zip Code of the Member / Patient External Code Source - USPS varchar[9] 9
DC017 Date Service Approved (AP Date) Date Service Approved by Payer Full Date - Integer int[8] YYYYMMDD 8
DC018 Service Provider Number Service Provider Identification Number Text varchar[30] 30
DC019 Service Provider Tax ID Number Service Provider's Tax ID number Numeric char[9] 9
DC020 National Provider ID - Service National Provider Identification (NPI) of the Service Provider External Code Source - NPPES int[10] 10
DC021 Service Provider Entity Type Qualifier Service Provider Entity Identifier Code integer int[1] 1
DC022 Service Provider First Name First name of Service Provider Text varchar[25] 25
DC023 Service Provider Middle Name Middle initial of Service Provider Text varchar[25] 25
DC024 Service Provider Last Name or Organization Name Last name or Organization Name of Service Provider Text varchar[60] 60
DC025 Carve Out Vendor CT APCD ID CT APCD defined and maintained Org ID for linking across submitters Integer varchar[6] 6
DC026 Service Provider Taxonomy Taxonomy Code External Code Source - WPC varchar[10] 10
DC027 Service Provider City Name City name of the Provider Text varchar[30] 30
DC028 Service Provider State State of the Service Provider External Code Source - USPS char[2] 2
DC029 Service Provider ZIP Code Zip Code of the Service Provider External Code Source - USPS varchar[9] 9
DC030 Facility Type - Professional Place of Service Code External Code Source - CMS char[2] 2
DC031 Claim Status Claim Line Status integer varchar[2] 2
DC032 CDT Code HCPCS / CDT Code External Code Source - ADA char[5] 5
DC033 Procedure Modifier - 1 HCPCS / CPT Code Modifier External Code Source - AMA char[2] 2
DC034 Procedure Modifier - 2 HCPCS / CPT Code Modifier External Code Source - AMA char[2] 2
DC035 Date of Service - From Date of Service Full Date - Integer int[8] YYYYMMDD 8
DC036 Date of Service - To Date of Service Full Date - Integer int[8] YYYYMMDD 8
DC037 Charge Amount Amount of provider charges for the claim line Integer ±varchar[10] 10
DC038 Paid Amount Amount paid by the carrier for the claim line Integer ±varchar[10] 10
DC039 Copay Amount Amount of Copay member/patient is responsible to pay Integer ±varchar[10] 10
DC040 Coinsurance Amount Amount of coinsurance member/patient is responsible to pay Integer ±varchar[10] 10
DC041 Deductible Amount Amount of deductible member/patient is responsible to pay on the claim line Integer ±varchar[10] 10
DC042 Filler Filler Filler char[0] 0
DC043 Member Street Address Street address of the Member/Patient Text varchar[50] 50
DC044 Billing Provider Tax ID Number The Billing Provider's Federal Tax Identification Number (FTIN) Numeric char[9] 9
DC045 Paid Date Paid date of the claim line Integer int[8] YYYYMMDD 8
DC046 Allowed Amount Allowed Amount Integer ±varchar[10] 10
DC047 Tooth Number/Letter Tooth Number or Letter Identification External Code Source - ADA varchar[2] 2
DC048 Dental Quadrant Dental Quadrant External Code Source - ADA char[10] 10
DC049 Tooth Surface Tooth Service Identification External Code Source - ADA varchar[5] 5
DC050 Subscriber Last Name Last name of Subscriber Text varchar[60] 60
DC051 Subscriber First Name First name of Subscriber Text varchar[25] 25
DC052 Subscriber Middle Initial Middle initial of Subscriber Text char[1] 1
DC053 Member Last Name Last name of Member/Patient Text varchar[60] 60
DC054 Member First Name First name of Member/Patient Text varchar[25] 25
DC055 Member Middle Initial Middle initial of the Member/Patient Text char[1] 1
DC056 Carrier Specific Unique Member ID Member's Unique ID Text varchar[50] 50
DC057 Carrier Specific Unique Subscriber ID Subscriber's Unique ID Text varchar[50] 50
DC058 Member Street Address 2 Secondary Street Address of the Member/Patient Text varchar[50] 50
DC059 Claim Line Type Claim Line Activity Type Code Text char[1] 1
DC060 Former Claim Number Previous Claim Number Text varchar[35] 35
DC061 Diagnosis Code ICD Diagnosis Code External Code Source - ICD varchar[7] 7
DC062 ICD Indicator International Classification of Diseases version Integer int[1] 1
DC063 Denied Flag Denied Claim Line Indicator Integer int[1] 1
DC064 Denial Reason Denial Reason Code External Code Source - HIPAA - OR- Carrier Lookup Table varchar[20] 20
DC065 Payment Arrangement Type Payment Arrangement Type Value Numeric char[2] 2
DC066 Filler Filler Filler char[0] 0
DC067 APCD ID Code Member Enrollment Type Integer int[1] 1
DC068 Bill Frequency Code Bill Frequency External Code Source - NUBC char[1] 1
DC899 Record Type File Type Identifier Text char[2] 2
TR001 Record Type Trailer Record Identifier Text char[2] 2
TR002 Submitter Trailer Submitter / Carrier ID defined by AHCT Integer varchar[6] 6
TR003 National Plan ID CMS National Plan Identification Number (PlanID) Integer int[10] 10
TR004 Type of File Validates the file type defined in HD004. Text char[2] 2
TR005 Period Beginning Date Trailer Period Start Date Full Date - Integer int[8] YYYYMMDD 8
TR006 Period Ending Date Trailer Period Ending Date Full Date - Integer int[8] YYYYMMDD 8
TR007 Date Processed Trailer Processed Date Full Date - Integer int[8] YYYYMMDD 8

File Specification for Medical Claims File Submission - December 5, 2013 - v1.2

Data Element ID Data Element Description Type Format Length
HD001 Record Type Header Record Identifier Text char[2] 2
HD002 Submitter Header Submitter / Carrier ID defined by AHCT Integer varchar[6] 6
HD003 National Plan ID Header CMS National Plan Identification Number (PlanID) Integer int[10] 10
HD004 Type of File Defines the file type and data expected. Text char[2] 2
HD005 Period Beginning Date Header Period Start Date Full Date - Integer int[8] YYYYMMDD 8
HD006 Period Ending Date Header Period Ending Date Full Date - Integer int[8] YYYYMMDD 8
HD007 Record Count Header Record Count Integer varchar[10] 10
HD008 Comments Header Carrier Comments Text varchar[80] 80
HD009 APCD Version Number Submission Guide Version Decimal - Numeric char[3] 3
MC001 Submitter CT APCD defined and maintained unique identifier Integer varchar[6] 6
MC002 National Plan ID CMS National Plan Identification Number (PlanID) Integer int[10] 10
MC003 Insurance Type Code/Product Type / Product Identification Code Text char[2] 2
MC004 Payer Claim Control Number Payer Claim Control Identification Text varchar[35] 35
MC005 Line Counter Incremental Line Counter Integer varchar[4] 4
MC005A Version Number Claim Service Line Version Number Integer varchar[4] 4
MC006 Insured Group or Policy Number Group / Policy Number Text varchar[30] 30
MC007 Subscriber SSN Subscriber's Social Security Number Numeric char[9] 9
MC008 Plan Specific Contract Number Contract Number Text varchar[30] 30
MC009 Member Suffix or Sequence Number Member/Patient's Contract Sequence Number Text varchar[20] 20
MC010 Member SSN Member/Patient's Social Security Number Numeric char[9] 9
MC011 Individual Relationship Code Patient to Subscriber Relationship Code Text varchar[2] 2
MC012 Member Gender Patient's Gender Text char[1] 1
MC013 Member Date of Birth Member/Patient's date of birth Full Date - Integer int[8] YYYYMMDD 8
MC014 Member City Name City name of the Member/Patient Text varchar[30] 30
MC015 Member State State / Province of the Patient External Code Source - USPS char[2] 2
MC016 Member ZIP Code Zip Code of the Member / Patient External Code Source - USPS varchar[9] 9
MC017 Date Service Approved (AP Date) Date Service Approved by Payer Full Date - Integer int[8] YYYYMMDD 8
MC018 Admission Date Inpatient Admit Date Full Date - Integer int[8] YYYYMMDD 8
MC019 Admission Hour Admission Time Numeric char[4] HHMM 4
MC020 Admission Type Admission Type Code External Code Source - NUBC int[1] 1
MC021 Admission Source Admission Source Code External Code Source - NUBC char[1] 1
MC022 Discharge Hour Discharge Time Numeric char[4] HHMM 4
MC023 Discharge Status Inpatient Discharge Status Code External Code Source - NUBC char[2] 2
MC024 Service Provider Number Service Provider Identification Number Text varchar[30] 30
MC025 Service Provider Tax ID Number Service Provider's Tax ID number Numeric char[9] 9
MC026 National Provider ID - Service National Provider Identification (NPI) of the Service Provider External Code Source - NPPES int[10] 10
MC027 Service Provider Entity Type Qualifier Service Provider Entity Identifier Code integer int[1] 1
MC028 Service Provider First Name First name of Service Provider Text varchar[25] 25
MC029 Service Provider Middle Name Middle initial of Service Provider Text varchar[25] 25
MC030 Servicing Provider Last Name or Organization Name Last name or Organization Name of Service Provider Text varchar[60] 60
MC031 Filler Filler Filler char[0] 0
MC032 Service Provider Taxonomy Taxonomy Code External Code Source - WPC varchar[10] 10
MC033 Service Provider City Name City Name of the Provider Text varchar[30] 30
MC034 Service Provider State State of the Service Provider External Code Source - USPS char[2] 2
MC035 Service Provider ZIP Code Zip Code of the Service Provider External Code Source - USPS varchar[9] 9
MC036 Type of Bill - on Facility Claims Type of Bill External Code Source - NUBC char[3] 3
MC037 Site of Service - on NSF/CMS 1500 Claims Place of Service Code External Code Source - CMS char[2] 2
MC038 Claim Status Claim Line Status integer varchar[2] 2
MC039 Admitting Diagnosis Admitting Diagnosis Code External Code Source - ICD varchar[7] 7
MC040 E-Code ICD Diagnostic External Injury Code External Code Source - ICD varchar[7] 7
MC041 Principal Diagnosis ICD Primary Diagnosis Code External Code Source - ICD varchar[7] 7
MC042 Other Diagnosis - 1 ICD Secondary Diagnosis Code External Code Source - ICD varchar[7] 7
MC043 Other Diagnosis - 2 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC044 Other Diagnosis - 3 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC045 Other Diagnosis - 4 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC046 Other Diagnosis - 5 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC047 Other Diagnosis - 6 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC048 Other Diagnosis - 7 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC049 Other Diagnosis - 8 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC050 Other Diagnosis - 9 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC051 Other Diagnosis - 10 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC052 Other Diagnosis - 11 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC053 Other Diagnosis - 12 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC054 Revenue Code Revenue Code External Code Source - NUBC char[4] 4
MC055 Procedure Code HCPCS / CPT Code External Code Source - AMA - OR - Carrier Defined Table varchar[10] 10
MC056 Procedure Modifier - 1 HCPCS / CPT Code Modifier External Code Source - AMA char[2] 2
MC057 Procedure Modifier - 2 HCPCS / CPT Code Modifier External Code Source - AMA char[2] 2
MC058 ICD Primary Procedure Code ICD Primary Procedure Code External Code Source - ICD varchar[7] 7
MC059 Date of Service - From Date of Service Full Date - Integer int[8] YYYYMMDD 8
MC060 Date of Service - To Date of Service Full Date - Integer int[8] YYYYMMDD 8
MC061 Quantity Claim line units of service Quantity - Integer ±varchar[15] 15
MC062 Charge Amount Amount of provider charges for the claim line Integer ±varchar[10] 10
MC063 Paid Amount Amount paid by the carrier for the claim line Integer ±varchar[10] 10
MC064 Prepaid Amount Amount carrier has prepaid towards the claim line Integer ±varchar[10] 10
MC065 Copay Amount Amount of Copay member/patient is responsible to pay Integer ±varchar[10] 10
MC066 Coinsurance Amount Amount of coinsurance member/patient is responsible to pay Integer ±varchar[10] 10
MC067 Deductible Amount Amount of deductible member/patient is responsible to pay on the claim line Integer ±varchar[10] 10
MC068 Patient Control Number Patient Control Number Text varchar[20] 20
MC069 Discharge Date Discharge Date Full Date - Integer int[8] YYYYMMDD 8
MC070 Service Provider Country Code Country name of the Service Provider External Code Source - ANSI char[3] 3
MC071 DRG Diagnostic Related Group Code External Code Source - CMS varchar[7] 7
MC072 DRG Version Diagnostic Related Group Version Number External Code Source - CMS char[2] 2
MC073 APC Ambulatory Payment Classification Number External Code Source - CMS char[4] 4
MC074 APC Version Ambulatory Payment Classification Version External Code Source - CMS char[2] 2
MC075 Drug Code National Drug Code (NDC) External Code Source - FDA char[11] 11
MC076 Billing Provider Number Billing Provider Number Text varchar[30] 30
MC077 National Provider ID - Billing National Provider Identification (NPI) of the Billing Provider External Code Source - NPPES int[10] 10
MC078 Billing Provider Last Name or Organization Name Last name or Organization Name of Billing Provider Text varchar[60] 60
MC079 Filler Filler Filler char[0] 0
MC080 Payment Reason Payment Reason Code External Code Source - HIPPA - OR - Carrier Defined Table varchar[10] 10
MC081 Capitated Encounter Flag Indicator - Capitation Payment Integer int[1] 1
MC082 Member Street Address Street address of the Member/Patient Text varchar[50] 50
MC083 Other ICD Procedure Code - 1 ICD Secondary Procedure Code External Code Source - ICD varchar[7] 7
MC084 Other ICD Procedure Code - 2 ICD Other Procedure Code External Code Source - ICD varchar[7] 7
MC085 Other ICD Procedure Code - 3 ICD Other Procedure Code External Code Source - ICD varchar[7] 7
MC086 Other ICD Procedure Code - 4 ICD Other Procedure Code External Code Source - ICD varchar[7] 7
MC087 Other ICD Procedure Code - 5 ICD Other Procedure Code External Code Source - ICD varchar[7] 7
MC088 Other ICD Procedure Code - 6 ICD Other Procedure Code External Code Source - ICD varchar[7] 7
MC089 Paid Date Paid date of the claim line Integer int[8] 8
MC090 Filler Filler Filler char[0] 0
MC091 Filler Filler Filler char[0] 0
MC092 Filler Filler Filler char[0] 0
MC093 Filler Filler Filler char[0] 0
MC094 Type of Claim Type of Claim Indicator Text char[3] 3
MC095 COB / TPL Amount Amount due from a secondary carrier Integer ±varchar[10] 10
MC096 Other Insurance Paid Amount Amount already paid by primary carrier Integer ±varchar[10] 10
MC097 Medicare Paid Amount Any amount Medicare Paid towards claim line Integer ±varchar[10] 10
MC098 Allowed amount Allowed Amount Integer ±varchar[10] 10
MC099 Non-Covered Amount Amount of claim line charge not covered Integer ±varchar[10] 10
MC100 Carve Out Vendor CT APCD ID CT APCD defined and maintained Org ID for linking across submitters Integer varchar[6] 6
MC101 Subscriber Last Name Last name of Subscriber Text varchar[60] 60
MC102 Subscriber First Name First name of Subscriber Text varchar[25] 25
MC103 Subscriber Middle Initial Middle initial of Subscriber Text char[1] 1
MC104 Member Last Name Last name of Member/Patient Text varchar[60] 60
MC105 Member First Name First name of Member/Patient Text varchar[25] 25
MC106 Member Middle Initial Middle initial of Member/Patient Text char[1] 1
MC107 ICD Indicator International Classification of Diseases version Integer int[1] 1
MC108 Procedure Modifier - 3 HCPCS / CPT Code Modifier External Code Source - AMA char[2] 2
MC109 Procedure Modifier - 4 HCPCS / CPT Code Modifier External Code Source - AMA char[2] 2
MC110 Claim Processed Date Claim Processed Date Full Date - Integer int[8] YYYYMMDD 8
MC111 Diagnostic Pointer Diagnostic Pointer Number Integer varchar[4] 4
MC112 Referring Provider ID Referring Provider ID Text varchar[30] 30
MC113 Payment Arrangement Type Payment Arrangement Type Value Integer int[1] 1
MC114 Excluded Expenses Amount not covered at the claim line due to benefit/plan limitation Integer ±varchar[10] 10
MC115 Medicare Indicator Indicator - Medicare Payment Applied Integer int[1] 1
MC116 Filler Filler Filler char[0] 0
MC117 Authorization Needed Indicator - Authorization Needed Integer int[1] 1
MC118 Referral Indicator Indicator - Referral Needed Integer int[1] 1
MC119 PCP Indicator Indicator - PCP Rendered Service Integer int[1] 1
MC120 DRG Level Diagnostic Related Group Code Severity Level External Code Source - CMS int[1] 1
MC121 Patient Total Out of Pocket Amount Total amount patent / member must pay for this claim line Integer int[10] 10
MC122 Global Payment Flag Indicator - Global Payment Integer int[1] 1
MC123 Denied Flag Denied Claim Line Indicator Integer int[1] 1
MC124 Denial Reason Denial Reason Code External Code Source - HIPAA -OR- Carrier Lookup Table varchar[15] 15
MC125 Attending Provider Attending Provider ID Text varchar[30] 30
MC126 Accident Indicator Indicator - Accident Related Integer int[1] 1
MC127 Family Planning Indicator Indicator - Accident Related Integer int[1] 1
MC128 Employment Related Indicator Indicator - Accident Related Integer int[1] 1
MC129 EPSDT Indicator Indicator - Accident Related Integer int[1] 1
MC130 Procedure Code Type Claim line Procedure Code Type Identifier Integer int[1] 1
MC131 InNetwork Indicator Indicator - Network Rate Applied Integer int[1] 1
MC132 Filler Filler Filler char[0] 0
MC133 Bill Frequency Code Bill Frequency External Code Source - NUBC char[1] 1
MC134 Plan Rendering Provider Identifier Plan Rendering Number Text varchar[30] 30
MC135 Provider Location Location of Provider Text varchar[30] 30
MC136 Filler Filler Filler char[0] 0
MC137 Carrier Specific Unique Member ID Member's Unique ID Text varchar[50] 50
MC138 Claim Line Type Claim Line Activity Type Code Text char[1] 1
MC139 Former Claim Number Previous Claim Number Text varchar[35] 35
MC140 Member Street Address 2 Secondary Street Address of the Member/Patient Text varchar[50] 50
MC141 Carrier Specific Unique Subscriber ID Subscriber's Unique ID Text varchar[50] 50
MC142 Other Diagnosis - 13 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC143 Other Diagnosis - 14 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC144 Other Diagnosis - 15 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC145 Other Diagnosis - 16 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC146 Other Diagnosis - 17 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC147 Other Diagnosis - 18 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC148 Other Diagnosis - 19 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC149 Other Diagnosis - 20 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC150 Other Diagnosis - 21 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC151 Other Diagnosis - 22 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC152 Other Diagnosis - 23 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC153 Other Diagnosis - 24 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC154 Present on Admission Code (POA) - 01 POA code for Principal Diagnosis External Code Source - CMS char[1] 1
MC155 Present on Admission Code (POA) - 02 POA code for Other Diagnosis - 1 External Code Source - CMS char[1] 1
MC156 Present on Admission Code (POA) - 03 POA code for Other Diagnosis - 2 External Code Source - CMS char[1] 1
MC157 Present on Admission Code (POA) - 04 POA code for Other Diagnosis - 3 External Code Source - CMS char[1] 1
MC158 Present on Admission Code (POA) - 05 POA code for Other Diagnosis - 4 External Code Source - CMS char[1] 1
MC159 Present on Admission Code (POA) - 06 POA code for Other Diagnosis - 5 External Code Source - CMS char[1] 1
MC160 Present on Admission Code (POA) - 07 POA code for Other Diagnosis - 6 External Code Source - CMS char[1] 1
MC161 Present on Admission Code (POA) - 08 POA code for Other Diagnosis - 7 External Code Source - CMS char[1] 1
MC162 Present on Admission Code (POA) - 09 POA code for Other Diagnosis - 8 External Code Source - CMS char[1] 1
MC163 Present on Admission Code (POA) - 10 POA code for Other Diagnosis - 9 External Code Source - CMS char[1] 1
MC164 Present on Admission Code (POA) - 11 POA code for Other Diagnosis - 10 External Code Source - CMS char[1] 1
MC165 Present on Admission Code (POA) - 12 POA code for Other Diagnosis - 11 External Code Source - CMS char[1] 1
MC166 Present on Admission Code (POA) - 13 POA code for Other Diagnosis - 12 External Code Source - CMS char[1] 1
MC167 Present on Admission Code (POA) - 14 POA code for Other Diagnosis - 13 External Code Source - CMS char[1] 1
MC168 Present on Admission Code (POA) - 15 POA code for Other Diagnosis - 14 External Code Source - CMS char[1] 1
MC169 Present on Admission Code (POA) - 16 POA code for Other Diagnosis - 15 External Code Source - CMS char[1] 1
MC170 Present on Admission Code (POA) - 17 POA code for Other Diagnosis - 16 External Code Source - CMS char[1] 1
MC171 Present on Admission Code (POA) - 18 POA code for Other Diagnosis - 17 External Code Source - CMS char[1] 1
MC172 Present on Admission Code (POA) - 19 POA code for Other Diagnosis - 18 External Code Source - CMS char[1] 1
MC173 Present on Admission Code (POA) - 20 POA code for Other Diagnosis - 19 External Code Source - CMS char[1] 1
MC174 Present on Admission Code (POA) - 21 POA code for Other Diagnosis - 20 External Code Source - CMS char[1] 1
MC175 Present on Admission Code (POA) - 22 POA code for Other Diagnosis - 21 External Code Source - CMS char[1] 1
MC176 Present on Admission Code (POA) - 23 POA code for Other Diagnosis - 22 External Code Source - CMS char[1] 1
MC177 Present on Admission Code (POA) - 24 POA code for Other Diagnosis - 23 External Code Source - CMS char[1] 1
MC178 Present on Admission Code (POA) - 25 POA code for Other Diagnosis - 24 External Code Source - CMS char[1] 1
MC179 Condition Code - 1 Condition Code External Code Source - NUBC char[2] 2
MC180 Condition Code - 2 Condition Code External Code Source - NUBC char[2] 2
MC181 Condition Code - 3 Condition Code External Code Source - NUBC char[2] 2
MC182 Filler Filler Filler char[0] 0
MC183 Filler Filler Filler char[0] 0
MC184 Filler Filler Filler char[0] 0
MC185 Filler Filler Filler char[0] 0
MC186 Filler Filler Filler char[0] 0
MC187 Filler Filler Filler char[0] 0
MC188 Filler Filler Filler char[0] 0
MC189 Filler Filler Filler char[0] 0
MC190 Filler Filler Filler char[0] 0
MC191 Value Code - 1 Value Code External Code Source - NUBC char[2] 2
MC192 Value Amount - 1 Amount that corresponds to Value Code - 1 Integer ±varchar[10] 10
MC193 Value Code - 2 Value Code External Code Source - NUBC char[2] 2
MC194 Value Amount - 2 Amount that corresponds to Value Code - 2 Integer ±varchar[10] 10
MC195 Value Code - 3 Value Code External Code Source - NUBC char[2] 2
MC196 Value Amount - 3 Amount that corresponds to Value Code - 3 Integer ±varchar[10] 10
MC197 Filler Filler Filler char[0] 0
MC198 Filler Filler Filler char[0] 0
MC199 Filler Filler Filler char[0] 0
MC200 Filler Filler Filler char[0] 0
MC201 Filler Filler Filler char[0] 0
MC202 Filler Filler Filler char[0] 0
MC203 Filler Filler Filler char[0] 0
MC204 Filler Filler Filler char[0] 0
MC205 Filler Filler Filler char[0] 0
MC206 Filler Filler Filler char[0] 0
MC207 Filler Filler Filler char[0] 0
MC208 Filler Filler Filler char[0] 0
MC209 Filler Filler Filler char[0] 0
MC210 Filler Filler Filler char[0] 0
MC211 Filler Filler Filler char[0] 0
MC212 Filler Filler Filler char[0] 0
MC213 Filler Filler Filler char[0] 0
MC214 Filler Filler Filler char[0] 0
MC215 Occurrence Code - 1 Occurrence Code External Code Source - NUBC char[2] 2
MC216 Occurrence Date - 1 Date that corresponds to Occurrence Code - 1 Integer int[8] YYYYMMDD 8
MC217 Occurrence Code - 2 Occurrence Code External Code Source - NUBC char[2] 2
MC218 Occurrence Date - 2 Date that corresponds to Occurrence Code - 1 Integer int[8] YYYYMMDD 8
MC219 Occurrence Code - 3 Occurrence Code External Code Source - NUBC char[2] 2
MC220 Occurrence Date - 3 Date that corresponds to Occurrence Code - 1 Integer int[8] YYYYMMDD 8
MC221 Filler Filler Filler char[0] 0
MC222 Filler Filler Filler char[0] 0
MC223 Filler Filler Filler char[0] 0
MC224 Filler Filler Filler char[0] 0
MC225 Occurrence Span Code - 1 Occurrence Span Code External Code Source - NUBC char[2] 2
MC226 Occurrence Span Start Date - 1 Start Date that corresponds to Occurrence Span Code - Integer int[8] YYYYMMDD 8
MC227 Occurrence Span End Date - 1 End Date that corresponds to Occurrence Span Code - Integer int[8] YYYYMMDD 8
MC228 Occurrence Span Code - 2 Occurrence Span Code External Code Source - NUBC char[2] 2
MC229 Occurrence Span Start Date - 2 Start Date that corresponds to Occurrence Span Code - Integer int[8] YYYYMMDD 8
MC230 Occurrence Span End Date - 2 End Date that corresponds to Occurrence Span Code - Integer int[8] YYYYMMDD 8
MC231 Filler Filler Filler char[0] 0
MC232 Filler Filler Filler char[0] 0
MC233 Filler Filler Filler char[0] 0
MC234 Filler Filler Filler char[0] 0
MC235 Filler Filler Filler char[0] 0
MC236 Filler Filler Filler char[0] 0
MC237 Filler Filler Filler char[0] 0
MC238 Filler Filler Filler char[0] 0
MC239 Filler Filler Filler char[0] 0
MC240 Filler Filler Filler char[0] 0
MC241 APCD ID Code Member Enrollment Type Integer int[1] 1
MC899 Record Type File Type Identifier Text char[2] 2
TR001 Record Type Trailer Record Identifier Text char[2] 2
TR002 Submitter Trailer Submitter / Carrier ID defined by AHCT Integer varchar[6] 6
TR003 National Plan ID CMS National Plan Identification Number (PlanID) Integer int[10] 10
TR004 Type of File Validates the file type defined in HD004. Text char[2] 2
TR005 Period Beginning Date Trailer Period Start Date Full Date - Integer int[8] YYYYMMDD 8
TR006 Period Ending Date Trailer Period Ending Date Full Date - Integer int[8] YYYYMMDD 8
TR007 Date Processed Trailer Processed Date Full Date - Integer int[8] YYYYMMDD 8

File Specification for Medical Eligibility File Submission - December 5, 2013 - v1.2

Data Element ID Data Element Description Type Format Length
HD001 Record Type Header Record Identifier Text char[2] 2
HD002 Submitter Header Submitter / Carrier ID defined by AHCT Integer varchar[6] 6
HD003 National Plan ID Header CMS National Plan Identification Number (PlanID) Integer int[10] 10
HD004 Type of File Defines the file type and data expected. Text char[2] 2
HD005 Period Beginning Date Header Period Start Date Full Date - Integer int[8] YYYYMMDD 8
HD006 Period Ending Date Header Period Ending Date Full Date - Integer int[8] YYYYMMDD 8
HD007 Record Count Header Record Count Integer varchar[10] 10
HD008 Comments Header Carrier Comments Text varchar[80] 80
HD009 APCD Version Number Submission Guide Version Decimal - Numeric char[3] 3
ME001 Submitter CT APCD defined and maintained unique identifier Integer varchar[6] 6
ME002 National Plan ID CMS National Plan Identification Number (PlanID) Integer int[10] 10
ME003 Insurance Type Code/Product Type / Product Identification Code Text char[2] 2
ME004 Year Eligibility year reported in this submission. Date Period - Integer int[4] YYYY 4
ME005 Month Reporting Month of Eligibility Date Period - Numeric char[2] MM 2
ME006 Insured Group or Policy Number Group / Policy Number Text varchar[30] 30
ME007 Coverage Level Code Benefit Coverage Level Code Text char[3] 3
ME008 Subscriber SSN Subscriber's Social Security Number Numeric char[9] 9
ME009 Plan Specific Contract Number Contract Number Text varchar[30] 30
ME010 Member Suffix or Sequence Number Member's Contract Sequence Number Text varchar[20] 20
ME011 Member SSN Member's Social Security Number Numeric char[9] 9
ME012 Individual Relationship Code Member to Subscriber Relationship Code Text varchar[2] 2
ME013 Member Gender Member's Gender Text char[1] 1
ME014 Member Date of Birth Member's date of birth Full Date - Integer int[8] YYYYMMDD 8
ME015 Member City Name City name of the Member Text varchar[30] 30
ME016 Member State State / Province of the Member External Code Source 2 - Text char[2] 2
ME017 Member ZIP Code Zip Code of the Member External Code Source 2 - Text varchar[9] 9
ME018 Medical Coverage Indicator - Medical Option Integer int[1] 1
ME019 Prescription Drug Coverage Indicator - Pharmacy Option Integer int[1] 1
ME020 Dental Coverage Indicator - Dental Option Integer int[1] 1
ME021 Race 1 Member's self-disclosed Primary Race Text char[2] 2
ME022 Race 2 Member's self-disclosed Secondary Race Text char[2] 2
ME023 Other Race Member's Other Race Text varchar[15] 15
ME024 Hispanic Indicator Indicator - Hispanic Status Integer int[1] 1
ME025 Ethnicity 1 Member's Primary Ethnicity External Code Source - CDC char[6] 6
ME026 Ethnicity 2 Member's Secondary Ethnicity External Code Source - CDC char[6] 6
ME027 Other Ethnicity Member's Other Ethnicity Text varchar[20] 20
ME028 Primary Insurance Indicator Indicator - Primary Insurance Coverage Integer int[1] 1
ME029 Coverage Type Type of Coverage Code Text char[3] 3
ME030 Group Size Group Size Code Integer varchar[4] 4
ME031 Filler Filler Filler char[0] 0
ME032 Filler Filler Filler char[0] 0
ME033 Member language preference Member's self-disclosed verbal language preference External Code Source - Census int[3] 3
ME034 Member language preference -Other Member's Other Language Preference Text varchar[20] 20
ME035 Medical Home Flag Medical Home indicator Integer int[1] 1
ME036 Medical Home Number Health Care Home ID Text varchar[30] 30
ME037 Medical Home Tax ID Number Health Care Home EIN Numeric char[9] 9
ME038 Medical Home National Provider ID - National Provider Identification (NPI) of the Health Care Home Provider External Code Source - NPPES int[10] 10
ME039 Health Care Home Name Name of Health Care Home Text varchar[60] 60
ME040 Product ID Number Product Identification Filler varchar[30] 30
ME041 Enrollment Start Date Start Date Integer int[8] YYYYMMDD 8
ME042 Enrollment End Date End Date Integer int[8] YYYYMMDD 8
ME043 Member Street Address Street address of the Member Text varchar[50] 50
ME044 Member Street Address 2 Secondary Street Address of the Member Text varchar[50] 50
ME045 Purchased through Access Health CT Flag Indicator - Access Health CT Integer int[1] 1
ME046 Member PCP ID Member's PCP ID Text varchar[30] 30
ME047 Filler Filler Filler char[0] 0
ME048 Filler Filler Filler char[0] 0
ME049 Member Deductible Annual maximum out-of- pocket Member Deductible across all benefit types Integer varchar[10] 10
ME050 Filler Filler Filler char[0] 0
ME051 Behavioral Health Benefit Flag Indicator - Behavioral Health Option Integer int[1] 1
ME052 Filler Filler Filler char[0] 0
ME053 Disease Management Enrollee Flag Chronic Illness Management indicator Integer int[1] 1
ME054 Filler Filler Filler char[0] 0
ME055 Business Type Code Business Type Integer int[1] 1
ME056 Filler Filler Filler char[0] 0
ME057 Date of Death Member's Date of Death Full Date - Integer int[8] YYYYMMDD 8
ME058 Subscriber Street Address Street address of the Subscriber Text varchar[50] 50
ME059 Disability Indicator Indicator - Disability Integer int[1] 1
ME060 Employment Status Employment Status Code Text char[1] 1
ME061 Student Status Indicator - Student Status Integer int[1] 1
ME062 Marital Status Marital Status Code Text char[1] 1
ME063 Benefit Status Benefit Status Code Text char[1] 1
ME064 Employee Type Employee Type Code Text char[1] 1
ME065 Date of Retirement Employee's Date of Retirement Integer int[8] YYYYMMDD 8
ME066 COBRA Status Indicator - COBRA Usage Integer int[1] 1
ME067 Filler Filler Filler char[0] 0
ME068 Filler Filler Filler char[0] 0
ME069 Filler Filler Filler char[0] 0
ME070 Filler Filler Filler char[0] 0
ME071 Pool Indicator Indicator - Pool Grouping Integer int[1] 1
ME072 Family Size Family Size as Contracted Integer varchar[2] 2
ME073 Fully Insured member Fully Insured identifier Integer int[1] 1
ME074 Interpreter Indicator - Interpreter Need Integer int[1] 1
ME075 Filler Filler Filler char[0] 0
ME076 Filler Filler Filler char[0] 0
ME077 Member's North American Industry Code (NAICS) Member's Standard NAICS Code External Code Source - NAICS varchar[6] 6
ME078 Employer Zip Code Zip Code of the Employer Numeric char[5] 5
ME079 Filler Filler Filler char[0] 0
ME080 Filler Filler Filler char[0] 0
ME081 Medicare Code Indicator - Medicare Plan Integer int[1] 1
ME082 Employer Name Member's Employer Name Text varchar[60] 60
ME083 Employer EIN Member's Employer EIN Numeric char[9] 9
ME101 Subscriber Last Name Last name of Subscriber Text varchar[60] 60
ME102 Subscriber First Name First name of Subscriber Text varchar[25] 25
ME103 Subscriber Middle Initial Middle initial of Subscriber Text char[1] 1
ME104 Member Last Name Last name of Member Text varchar[60] 60
ME105 Member First Name First name of Member Text varchar[25] 25
ME106 Member Middle Initial Middle initial of Member Text char[1] 1
ME107 Carrier Specific Unique Member ID Member's Unique ID Text varchar[50] 50
ME108 Subscriber City Name City name of the Subscriber Text varchar[30] 30
ME109 Subscriber State or Province State of the Subscriber External Code Source 2 - Text char[2] 2
ME110 Subscriber ZIP Code Zip Code of the Subscriber External Code Source 2 - Text varchar[9] 9
ME111 Filler Filler Filler char[0] 0
ME112 Filler Filler Filler char[0] 0
ME113 Filler Filler Filler char[0] 0
ME114 Filler Filler Filler char[0] 0
ME115 Dental Deductible Maximum out-of-pocket amount of member's deductible applied to Dental Benefits Integer varchar[10] 10
ME116 Vision Deductible Maximum out-of-pocket amount of member's deductible applied to Vision Benefits Integer varchar[10] 10
ME117 Carrier Specific Unique Subscriber ID Subscriber's Unique ID Text varchar[50] 50
ME118 Vision Benefit Indicator - Vision Option Integer int[1] 1
ME119 Filler Filler Filler char[0] 0
ME120 Actuarial Value Not Provided Decimal - Numeric varchar[6] 6
ME121 Metal Level Standardized plan level in metal reference Integer int[1] 1
ME122 Filler Filler Filler char[0] 0
ME123 Filler Filler Filler char[0] 0
ME124 Filler Filler Filler char[0] 0
ME125 Filler Filler Filler char[0] 0
ME126 Risk Adjustment Covered Plan (RACP) Subscriber / Member enrolled in a Risk Adjustment Plan Integer int[1] 1
ME127 Billable Member Indicator - Billable Member Integer int[1] 1
ME128 Filler Filler Filler char[0] 0
ME129 Filler Filler Filler char[0] 0
ME130 Filler Filler Filler char[0] 0
ME131 Filler Filler Filler char[0] 0
ME132 Total Monthly Premium Combined contribution of Employer + Subscriber Integer varchar[10] 10
ME133 Filler Filler Filler char[0] 0
ME134 APCD ID Code Member Enrollment Type Integer int[1] 1
ME899 Record Type Tile Type Identifier Text char[2] 2
TR001 Record Type Trailer Record Identifier Text char[2] 2
TR002 Submitter Trailer Submitter / Carrier ID defined by AHCT Integer varchar[6] 6
TR003 National Plan ID CMS National Plan Identification Number (PlanID) Integer int[10] 10
TR004 Type of File Validates the file type defined in HD004. Text char[2] 2
TR005 Period Beginning Date Trailer Period Start Date Full Date - Integer int[8] YYYYMMDD 8
TR006 Period Ending Date Trailer Period Ending Date Full Date - Integer int[8] YYYYMMDD 8
TR007 Date Processed Trailer Processed Date Full Date - Integer int[8] YYYYMMDD 8

File Specification for Pharmacy Claims File Submission - December 5, 2013 - v1.2

Data Element ID Data Element Description Type Format Length
HD001 Record Type Header Record Identifier Text char[2] 2
HD002 Submitter Header Submitter / Carrier ID defined by AHCT Integer varchar[6] 6
HD003 National Plan ID Header CMS National Plan Identification Number (PlanID) Integer int[10] 10
HD004 Type of File Defines the file type and data expected. Text char[2] 2
HD005 Period Beginning Date Header Period Start Date Full Date - Integer int[8] YYYYMMDD 8
HD006 Period Ending Date Header Period Ending Date Full Date - Integer int[8] YYYYMMDD 8
HD007 Record Count Header Record Count Integer varchar[10] 10
HD008 Comments Header Carrier Comments Text varchar[80] 80
HD009 APCD Version Number Submission Guide Version Decimal - Numeric char[3] 3
PC001 Submitter CT APCD defined and maintained unique identifier Integer varchar[6] 6
PC002 National Plan ID CMS National Plan Identification Number (PlanID) Integer int[10] 10
PC003 Insurance Type Code / Product Type / Product Identification Code Text char[2] 2
PC004 Payer Claim Control Number Payer Claim Control Identification Text varchar[35] 35
PC005 Line Counter Incremental Line Counter Numeric varchar[4] 4
PC005A Version Number Claim Service Line Version Number Numeric varchar[4] 4
PC006 Insured Group or Policy Number Group / Policy Number Text varchar[30] 30
PC007 Subscriber SSN Subscriber's Social Security Number Numeric char[9] 9
PC008 Plan Specific Contract Number Contract Number Text varchar[30] 30
PC009 Member Suffix or Sequence Number Member/Patient's Contract Sequence Number Text varchar[20] 20
PC010 Member SSN Member/Patient's Social Security Number Numeric char[9] 9
PC011 Individual Relationship Code Patient to Subscriber Relationship Code Text varchar[2] 2
PC012 Member Gender Patient's Gender Text char[1] 1
PC013 Member Date of Birth Member/Patient's date of birth Full Date - Integer int[8] YYYYMMDD 8
PC014 Member City Name of Residence City name of the Member/Patient Text varchar[50] 50
PC015 Member State State / Province of the Patient External Code Source - USPS char[2] 2
PC016 Member ZIP Code Zip code of the Member / Patient External Code Source - USPS varchar[9] 9
PC017 Date Service Approved (AP Date) Date Service Approved by Payer Full Date - Integer int[8] YYYYMMDD 8
PC018 Pharmacy Number Pharmacy Number Text varchar[30] 30
PC019 Pharmacy Tax ID Number Pharmacy Tax Identification Number Numeric char[9] 9
PC020 Pharmacy Name Name of Pharmacy Text varchar[100] 100
PC021 National Provider ID - Pharmacy National Provider Identification (NPI) of the Pharmacy External Code Source - NPPES int[10] 10
PC022 Pharmacy Location City City name of the Pharmacy Text varchar[30] 30
PC023 Pharmacy Location State State of the Pharmacy External Code Source - USPS char[2] 2
PC024 Pharmacy ZIP Code Zip code of the Pharmacy External Code Source - USPS varchar[9] 9
PC024A Pharmacy Country Code Country Code of the Pharmacy External Code Source - ANSI char[3] 3
PC025 Claim Status Claim Line Status integer varchar[2] 2
PC026 Drug Code National Drug Code (NDC) External Code Source - FDA char[11] 11
PC027 Drug Name Name of the drug as supplied External Code Source - FDA varchar[80] 80
PC028 New Prescription or Refill Prescription Status Indicator Numeric char[2] 2
PC029 Generic Drug Indicator Generic Drug Indicator Integer int[1] 1
PC030 Dispense as Written Code Prescription Dispensing Activity Code Integer int[1] 1
PC031 Compound Drug Indicator Compound Drug Indicator Integer int[1] 1
PC032 Date Prescription Filled Prescription filled date Full Date - Integer int[8] YYYYMMDD 8
PC033 Quantity Dispensed Claim line units dispensed Quantity - Integer ±varchar[10] 10
PC034 Days' Supply Prescription Supply Days Quantity - Integer ±varchar[3] 3
PC035 Charge Amount Amount of provider charges for the claim line Integer ±varchar[10] 10
PC036 Paid Amount Amount paid by the carrier for the claim line Integer ±varchar[10] 10
PC037 Ingredient Cost/List Price Amount defined as the List Price or Ingredient Cost Integer ±varchar[10] 10
PC038 Postage Amount Claimed Amount of postage claimed on the claim line Integer ±varchar[10] 10
PC039 Dispensing Fee Amount of dispensing fee for the claim line Integer ±varchar[10] 10
PC040 Copay Amount Amount of Copay member/patient is responsible to pay Integer ±varchar[10] 10
PC041 Coinsurance Amount Amount of coinsurance member/patient is responsible to pay Integer ±varchar[10] 10
PC042 Deductible Amount Amount of deductible member/patient is responsible to pay on the claim line Integer ±varchar[10] 10
PC043 Prescribing ProviderID Prescribing Provider Identification Text varchar[30] 30
PC044 Prescribing Physician First Name First name of Prescribing Physician Text varchar[25] 25
PC045 Prescribing Physician Middle Name Middle initial of Prescribing Physician Text varchar[25] 25
PC046 Prescribing Physician Last Name Last name of Prescribing Physician Text varchar[60] 60
PC047 Prescribing Physician DEA Prescriber DEA Text char[9] 9
PC048 National Provider ID - Prescribing National Provider Identification (NPI) of the Prescriber External Code Source - NPPES int[10] 10
PC049 Prescribing Physician Plan Number Carrier-assigned Provider Plan ID Text varchar[30] 30
PC050 Prescribing Physician License Number Prescribing Physician License Number Text varchar[30] 30
PC051 Prescribing Physician Street Address Street address of the Prescribing Physician Text varchar[50] 50
PC052 Prescribing Physician Street Address 2 Secondary street address of the Prescribing Physician Text varchar[50] 50
PC053 Prescribing Physician City City name of the Prescribing Physician Text varchar[30] 30
PC054 Prescribing Physician State State of the Prescribing Physician External Code Source - USPS char[2] 2
PC055 Prescribing Physician Zip Code Zip code of the Prescribing Physician External Code Source - USPS varchar[9] 9
PC056 Filler Filler Filler char[0] 0
PC057 Mail Order pharmacy Indicator - Mail Order Option Integer int[1] 1
PC058 Script number Prescription Number Text varchar[20] 20
PC059 Filler Filler Filler char[0] 0
PC060 Single / Multiple Source Indicator Indicator - Drug Source Integer int[1] 1
PC061 Member Street Address Street address of the Member/Patient Text varchar[50] 50
PC062 Billing Provider Tax ID Number The Billing Provider's Federal Tax Identification Number (FTIN) Numeric char[9] 9
PC063 Paid Date Paid date of the claim line Integer int[8] YYYYMMDD 8
PC064 Date Prescription Written Date prescription was prescribed Full Date - Integer int[8] YYYYMMDD 8
PC065 COB / TPL Amount Amount due from a secondary carrier Integer ±varchar[10] 10
PC066 Other Insurance Paid Amount Amount already paid by primary carrier Integer ±varchar[10] 10
PC067 Medicare Paid Amount Any amount Medicare Paid towards claim line Integer ±varchar[10] 10
PC068 Allowed amount Allowed Amount Integer ±varchar[10] 10
PC069 Member Self Pay Amount Amount member/patient paid out of pocket on the claim line Integer ±varchar[10] 10
PC070 Rebate Indicator Indicator - Rebate Integer int[1] 1
PC071 State Sales Tax Amount of applicable sales tax on the claim line Integer ±varchar[10] 10
PC072 Carve Out Vendor CT APCD ID CT APCD defined and maintained Org ID for linking across submitters Integer varchar[6] 6
PC073 Formulary Code Indicator - Formulary Inclusion Integer int[1] 1
PC074 Route of Administration Route of Administration External Codes Source - NCPDP char[2] 2
PC075 Drug Unit of Measure Units of Measure External Codes Source - NCPDP char[2] 2
PC101 Subscriber Last Name Last name of Subscriber Text varchar[60] 60
PC102 Subscriber First Name First name of Subscriber Text varchar[25] 25
PC103 Subscriber Middle Initial Middle initial of Subscriber Text char[1] 1
PC104 Member Last Name Last name of Member/Patient Text varchar[60] 60
PC105 Member First Name First name of Member/Patient Text varchar[25] 25
PC106 Member Middle Initial Middle initial of the Member/Patient Text char[1] 1
PC107 Carrier Specific Unique Member ID Member's Unique ID Text varchar[50] 50
PC108 Carrier Specific Unique Subscriber ID Subscriber's Unique ID Text varchar[50] 50
PC109 Member Street Address 2 Secondary Street Address of the Member/Patient Text varchar[50] 50
PC110 Claim Line Type Claim Line Activity Type Code Text char[1] 1
PC111 Former Claim Number Previous Claim Number Text varchar[35] 35
PC112 Medicare Indicator Indicator - Medicare Payment Applied Integer int[1] 1
PC113 Pregnancy Indicator Indicator - Pregnancy Integer int[1] 1
PC114 Diagnosis Code ICD Diagnosis Code External Codes Source - ICD varchar[7] 7
PC115 ICD Indicator International Classification of Diseases version Integer int[1] 1
PC116 Denied Flag Indicator - Denied Claim Line Integer int[1] 1
PC117 Denial Reason Denial Reason Code External Code Source - HIPAA -OR- Carrier Lookup Table varchar[30] 30
PC118 Payment Arrangement Type Payment Arrangement Type Value Integer int[1] 1
PC119 Filler Filler Filler char[0] 0
PC120 APCD ID Code Member Enrollment Type Integer int[1] 1
PC899 Record Type File Type Identifier Text char[2] 2
TR001 Record Type Trailer Record Identifier Text char[2] 2
TR002 Submitter Trailer Submitter / Carrier ID defined by AHCT Integer varchar[6] 6
TR003 National Plan ID CMS National Plan Identification Number (PlanID) Integer int[10] 10
TR004 Type of File Validates the file type defined in HD004. Text char[2] 2
TR005 Period Beginning Date Trailer Period Start Date Full Date - Integer int[8] YYYYMMDD 8
TR006 Period Ending Date Trailer Period Ending Date Full Date - Integer int[8] YYYYMMDD 8
TR007 Date Processed Trailer Processed Date Full Date - Integer int[8] YYYYMMDD 8

File Specification for Provider File Submission - December 5, 2013 - v1.2

Data Element ID Data Element Description Type Format Length
HD001 Record Type Header Record Identifier Text char[2] 2
HD002 Submitter Header Submitter / Carrier ID defined by AHCT Integer varchar[6] 6
HD003 National Plan ID Header CMS National Plan Identification Number (PlanID) Integer int[10] 10
HD004 Type of File Defines the file type and data expected. Text char[2] 2
HD005 Period Beginning Date Header Period Start Date Full Date - Integer int[8] YYYYMMDD 8
HD006 Period Ending Date Header Period Ending Date Full Date - Integer int[8] YYYYMMDD 8
HD007 Record Count Header Record Count Integer varchar[10] 10
HD008 Comments Header Carrier Comments Text varchar[80] 80
HD009 APCD Version Number Submission Guide Version Decimal - Numeric char[3] 3
PV001 Submitter CT APCD defined and maintained unique identifier Integer varchar[6] 6
PV002 Plan Provider ID Carrier Unique Provider Code Text varchar[30] 30
PV003 Tax ID Federal Tax ID of non- individual Provider Numeric char[9] 9
PV004 UPIN ID Unique Physician ID Text char[6] 6
PV005 DEA ID Provider DEA Text char[9] 9
PV006 License ID State practice license ID Text varchar[25] 25
PV008 Last Name Last name of the Provider in PV002 Text varchar[50] 50
PV009 First Name First name of the Provider in PV002 Text varchar[50] 50
PV010 Middle Initial Middle initial of the Provider in PV002 Text char[1] 1
PV011 Filler Filler Filler char[0] 0
PV012 Entity Name Group / Facility name Text varchar[100] 100
PV014 Gender Code Gender of Provider identified in PV002 Text char[1] 1
PV015 Provider Date of Birth Birth date of the provider Integer int[8] CCYYMMDD 8
PV016 Provider Street Address 1 Street address of the Provider Text varchar[50] 50
PV017 Provider Street Address 2 Street Address 2 of the Provider Text varchar[50] 50
PV018 City Name City of the Provider Text varchar[35] 35
PV019 State Code State of the Provider External Code Source - USPS char[2] 2
PV020 Country Code Country Code of the Provider External Code Source - USPS char[3] 3
PV021 Zip Code Zip code of the Provider External Code Source - USPS varchar[9] 9
PV022 Taxonomy Taxonomy Code External Code Source - WPC char[10] 10
PV023 Mailing Street Address1 Name Street address of the Provider / Entity Text varchar[50] 50
PV024 Mailing Street Address2 Name Secondary Street address of the Provider / Entity Text varchar[50] 50
PV025 Mailing City Name City name of the Provider / Entity Text varchar[35] 35
PV026 Mailing State Code State name of the Provider / Entity External Code Source - USPS char[2] 2
PV027 Mailing Country Code Country name of the Provider / Entity External Code Source - USPS char[3] 3
PV028 Mailing Zip Code Zip code of the Provider External Code Source - USPS varchar[9] 9
PV030 Primary Specialty Code Specialty Code External Code Source 4 - Integer char[2] 2
PV034 Provider ID Code Provider Identification Code Integer int[1] 1
PV035 SSN Id Provider's Social Security Number Numeric char[9] 9
PV036 Medicare ID Provider's Medicare Number, other than UPIN Text varchar[30] 30
PV037 Start Date Provider Start Date Integer int[8] CCYYMMDD 8
PV038 End Date Provider End Date Integer int[8] CCYYMMDD 8
PV039 National Provider ID National Provider Identification (NPI) of the Provider External Code Source - NPPES int[10] 10
PV040 National Provider ID 2 National Provider Identification (NPI) of the Provider External Code Source - NPPES int[10] 10
PV041 Filler Filler Filler char[0] 0
PV042 Secondary Specialty Code Specialty Code Carrier Defined Table - Text varchar[10] 10
PV043 Other Specialty Code 3 Specialty Code Carrier Defined Table - OR - External Code Source 4 - Integer varchar[10] 10
PV044 Other Specialty Code 4 Specialty Code Carrier Defined Table - OR - External Code Source 4 - Integer varchar[10] 10
PV045 Filler Filler Filler char[0] 0
PV046 Filler Filler Filler char[0] 0
PV047 Uses Electronic Health Records Indicator - EHR Utilization Integer int[1] 1
PV048 Filler Filler Filler char[0] 0
PV049 Filler Filler Filler char[0] 0
PV050 Filler Filler Filler char[0] 0
PV051 Filler Filler Filler char[0] 0
PV052 Has multiple offices Indicator - Multiple Office Provider Integer int[1] 1
PV053 Filler Filler Filler char[0] 0
PV054 Medical / Healthcare Home ID Medical Home Identification Number Text varchar[15] 15
PV055 PCP Flag Indicator - Provider is a PCP Integer int[1] 1
PV056 Provider Affiliation Provider Affiliation Code Text varchar[30] 30
PV057 Provider Telephone Telephone number associated with the provider identified in PV002 Numeric varchar[10] 10
PV058 Delegated Provider Record Flag Indicator - Delegated Record Integer int[1] 1
PV059 Filler Filler Filler char[0] 0
PV060 Filler Filler Filler char[0] 0
PV061 Filler Filler Filler char[0] 0
PV062 Filler Filler Filler char[0] 0
PV063 Filler Filler Filler char[0] 0
PV064 PPO Indicator Indicator - Provider PPO Contract Integer int[1] 1
PV899 Record Type File Type Identifier Text char[2] 2
TR001 Record Type Trailer Record Identifier Text char[2] 2
TR002 Submitter Trailer Submitter / Carrier ID defined by AHCT Integer varchar[6] 6
TR003 National Plan ID CMS National Plan Identification Number (PlanID) Integer int[10] 10
TR004 Type of File Validates the file type defined in HD004. Text char[2] 2
TR005 Period Beginning Date Trailer Period Start Date Full Date - Integer int[8] YYYYMMDD 8
TR006 Period Ending Date Trailer Period Ending Date Full Date - Integer int[8] YYYYMMDD 8
TR007 Date Processed Trailer Processed Date Full Date - Integer int[8] YYYYMMDD 8

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