Name: | New Hampshire |
---|---|
Abbreviation: | NH |
Title of System | New Hampshire Comprehensive Health Care Information System |
Website | https://nhchis.com/ ![]() |
Who Maintains the System | NHCHIS reflects a partnership between NH Insurance Department and NH Department of Health and Human Services |
Versions: | September 10, 2012 |
Data Element ID | Data Element | Description | Type | Format | Length |
---|---|---|---|---|---|
HD001 | Record Type | Not provided | Text | 2 | |
HD002 | Payer | Payer submitting payments NHID Submitter Code | Text | 8 | |
HD003 | National Plan ID | CMS National Plan ID | Text | 30 | |
HD004 | Type of File | Not provided | Text | 2 | |
HD005 | Period Beginning Date | Beginning of paid period for claims Beginning of month covered for eligibility | Integer | CCYYMM | 6 |
HD006 | Period Ending Date | End of paid period for claims End of month covered for eligibility | Integer | CCYYMM | 6 |
HD007 | Record Count | Total number of records submitted in this file | Integer | 10 | |
HD008 | Comments | Submitted may use to document this submission by assigning a filename, system source, etc. | Text | 80 | |
DC001 | Payer | Payer submitting payments | Text | 8 | |
DC002 | National Plan ID | CMS National Plan ID | Text | 30 | |
DC003 | Insurance Type/Product Code | Not provided | Text | 2 | |
DC004 | Payer Claim Control Number | Must apply to entire claim and be unique within payer's system | Text | 35 | |
DC005 | Line Counter | Line number for this service The line counter begins with 1 and is incremented by 1 for each additional service line of a claim | Integer | 4 | |
DC006 | Insured Group or Policy Number | Group or policy number - not the number that uniquely identifies the subscriber | Text | 50 | |
DC007 | Subscriber Social Security Number | subscriber's social security number (this data element will be de-identified by the NHpreprocessor application) Set as null if unavailable | Text | 32 | |
DC008 | Plan Specific Contract Number | plan assigned contract number (this data element will be de-identified by the NHpreprocessor application) Set as null if contract number = subscriber's social security number | Text | 64 | |
DC009 | Member Suffix or Sequence Number | Uniquely numbers the member within the contract | Integer | 20 | |
DC010 | Member Identification Code | member's social security number (this data element will be de-identified by the NHpreprocessor application) Set as null if unavailable | Text | 30 | |
DC011 | Individual Relationship Code | Member's relationship to insured | Integer | 2 | |
DC012 | Member Gender | Not provided | Text | 1 | |
DC013 | Member Date of Birth | Not provided | Date | CCYYMMDD | 8 |
DC014 | Member City Name of Residence | City name of member | Text | 50 | |
DC015 | Member State or Province | As defined by the U.S. Postal Service | Text | 2 | |
DC016 | Member ZIP Code | ZIP Code of member - may include non-US codes Do not include dash | Text | 11 | |
DC017 | Date Service Approved (AP Date) | Not provided | Date | CCYYMMDD | 8 |
DC018 | Service Provider Number | Payer assigned provider number | Text | 30 | |
DC019 | Service Provider Tax ID Number | Federal Taxpayer's identification number | Text | 10 | |
DC020 | National Service Provider ID | Required if National Provider ID is mandated for use under HIPAA | Text | 20 | |
DC021 | Service Provider Entity Type Qualifier | Not provided | Text | 1 | |
DC022 | Service Provider First Name | Individual first name Set as null if provider is a facility or organization | Text | 25 | |
DC023 | Service Provider Middle Name | Individual middle name or initial Set as null if provider is a facility or organization | Text | 25 | |
DC024 | Service Provider Last Name or Organization Name | Full name of provider organization or last name of individual provider | Text | 60 | |
DC025 | Service Provider Suffix | Suffix to individual name Set as null if provider is a facility or organization | Text | 10 | |
DC026 | Service Provider Specialty | As defined by payer Dictionary for specialty code values must be supplied during testing | Text | 10 | |
DC027 | Service Provider City Name | City name of provider - preferably precise location | Text | 30 | |
DC028 | Service Provider State or Province | As defined by the U.S. Postal Service | Text | 2 | |
DC029 | Service Provider ZIP Code | ZIP Code of provider - may include non-US codes Do not include dash | Text | 11 | |
DC030 | Facility Type - Professional | Not provided | Text | 2 | |
DC031 | Claim Status | Not provided | Integer | 2 | |
DC032 | CDT Code | Common Dental Terminology code | Text | 5 | |
DC033 | Procedure Modifier - 1 | Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code | Text | 2 | |
DC034 | Procedure Modifier - 2 | Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code | Text | 2 | |
DC035 | Date of Service - From | First date of service for this service line | Date | CCYYMMDD | 8 |
DC036 | Date of Service - Thru | Last date of service for this service line | Date | CCYYMMDD | 8 |
DC037 | Charge Amount | Do not code decimal point | Decimal | 10 | |
DC038 | Paid Amount | Do not code decimal point | Decimal | 10 | |
DC039 | Copay Amount | The present, fixed dollar amount for which the individual is responsible Do not code decimal point | Decimal | 10 | |
DC040 | Coinsurance Amount | The dollar amount an individual is responsible for - not the percentage Do not code decimal point | Decimal | 10 | |
DC041 | Deductible Amount | Do not code decimal point | Decimal | 10 | |
DC042 | Billing Provider Number | Carriers and dental claims processors shall code using the payer assigned billing provider number. This number should be the identifier used by the payer for internal identification purposes, and does not routinely change | Text | 30 | |
DC043 | National Billing Provider Number ID | This is the NPI for the billing provider | Text | 30 | |
DC044 | Billing Provider Last Name | Full name of provider billing organization or last name of individual billing provider | Text | 128 | |
DC101 | Subscriber Last Name | (this data element will be de-identified by the NHpreprocessor application) | Text | 128 | |
DC102 | Subscriber First Name (this data element will be de-identified by the NHpreprocessor application) | (this data element will be de-identified by the NHpreprocessor application) | Text | 128 | |
DC103 | Subscriber Middle Initial (this data element will be de-identified by the NHpreprocessor application) | (this data element will be de-identified by the NHpreprocessor application) | Text | 1 | |
DC104 | Member Last Name (this data element will be de-identified by the NHpreprocessor application) | (this data element will be de-identified by the NHpreprocessor application) | Text | 128 | |
DC105 | Member First Name (this data element will be de-identified by the NHpreprocessor application) | (this data element will be de-identified by the NHpreprocessor application) | Text | 128 | |
DC106 | Member Middle Initial (this data element will be de-identified by the NHpreprocessor application) | (this data element will be de-identified by the NHpreprocessor application) | Text | 1 | |
DC899 | Record Type | Not provided | Text | 2 | |
TR001 | Record Type | Not provided | Text | 2 | |
TR002 | Payer | Payer submitting payments NHID Submitter Code | Text | 8 | |
TR003 | National Plan ID | CMS National Plan ID | Text | 30 | |
TR004 | Type of File | Not provided | Text | 2 | |
TR005 | Period Beginning Date | Beginning of paid period for claims Beginning of month covered for eligibility | Integer | CCYYMM | 6 |
TR006 | Period Ending Date | End of paid period for claims End of month covered for eligibility | Integer | CCYYMM | 6 |
TR007 | Date Processed | Not provided | Date | CCYYMMDD | 8 |
Data Element ID | Data Element | Description | Type | Format | Length |
---|---|---|---|---|---|
HD001 | Record Type | Not provided | Text | 2 | |
HD002 | Payer | Payer submitting payments NHID Submitter Code | Text | 8 | |
HD003 | National Plan ID | CMS National Plan ID | Text | 30 | |
HD004 | Type of File | Not provided | Text | 2 | |
HD005 | Period Beginning Date | Beginning of paid period for claims Beginning of month covered for eligibility | Integer | CCYYMM | 6 |
HD006 | Period Ending Date | End of paid period for claims End of month covered for eligibility | Integer | CCYYMM | 6 |
HD007 | Record Count | Total number of records submitted in this file | Integer | 10 | |
HD008 | Comments | Submitted may use to document this submission by assigning a filename, system source, etc. | Text | 80 | |
MC001 | Payer | Payer submitting payments NHID Submitter Code | Text | 8 | |
MC002 | National Plan ID | CMS National Plan ID | Text | 30 | |
MC003 | Insurance Type/Product Code | Not provided | Text | 2 | |
MC004 | Payer Claim Control Number | Must apply to the entire claim and be unique within the payer's system | Text | 35 | |
MC005 | Line Counter | Line number for this service The line counter begins with 1 and is incremented by 1 for each additional service line of a claim | Integer | 4 | |
MC005A | Version Number | Version number of this claim service line The version number begins with 0 and is incremented by 1 for each subsequent version of that service line | Integer | 4 | |
MC006 | Insured Group or Policy Number | Group or policy number (not the number that uniquely identifies the subscriber) | Text | 50 | |
MC007 | Subscriber Social Security Number | Subscriber's social security number (this data element will be de-identified by the NHpreprocessor application) Set as null if unavailable | Text | 128 | |
MC008 | Plan Specific Contract Number | Plan assigned Set as null if contract number = subscriber's social security number (this data element will be de-identified by the NHpreprocessor application) | Text | 128 | |
MC009 | Member Suffix or Sequence Number | Uniquely numbers the member within the contract | Integer | 20 | |
MC010 | Member Identification Code | Member's social security number Set as null if unavailable (this data element will be de-identified by the NHpreprocessor application) | Text | 128 | |
MC011 | Individual Relationship Code | Member's relationship to insured | Integer | 2 | |
MC012 | Member Gender | Not provided | Text | 1 | |
MC013 | Member Date of Birth | Not provided | Date | CCYYMMDD | 8 |
MC014 | Member City Name | City name of member | Text | 30 | |
MC015 | Member State or Province | As defined by the US Postal Service | Text | 2 | |
MC016 | Member ZIP Code | ZIP Code of member - may include non-US codes | Text | 11 | |
MC017 | Date Service Approved (AP Date) | (Generally the same as the paid date) | Date | CCYYMMDD | 8 |
MC018 | Admission Date | Required for all inpatient claims | Date | CCYYMMDD | 8 |
MC019 | Admission Hour | Required for all inpatient claims Time is expressed in military time - HHMM | Integer | HHMM | 4 |
MC020 | Admission Type | Not provided | Integer | 1 | |
MC021 | Admission Source | Not provided | Text | 1 | |
MC022 | Discharge Hour | Hour in military time | Integer | 2 | |
MC023 | Discharge Status | Not provided | Integer | 2 | |
MC024 | Service Provider Number | Payer assigned servicing provider number by the payer for internal identification purposes | Text | 30 | |
MC025 | Service Provider Tax ID Number | Federal taxpayer's identification number | Text | 10 | |
MC026 | National Service Provider ID | Required if National Provider ID is mandated for use under HIPAA | Text | 20 | |
MC027 | Service Provider Entity Type Qualifier | HIPAA provider taxonomy classifies provider groups (clinicians who bill as a group practice or under a corporate name, even if that group is composed of one provider) as "Person". | Text | 1 | |
MC028 | Service Provider First Name | Individual first name Set to null if provider is a facility or organization | Text | 25 | |
MC029 | Service Provider Middle Name | Individual middle name or initial Set to null if provider is a facility or organization | Text | 25 | |
MC030 | Service Provider Last Name or Organization Name | Full name of provider organization or last name of individual provider | Text | 100 | |
MC031 | Service Provider Suffix | Suffix to individual name Set to null if provider is a facility or organization. Should be used to capture the generation of the individual clinician (e.g., Jr. Sr., III), if applicable, rather than the clinician's degree [ e.g., 'MD', 'LICSW']. | Text | 10 | |
MC032 | Service Provider Specialty | As defined by payer Dictionary for specialty code values must be supplied during testing | Text | 10 | |
MC033 | Service Provider City Name | City name of provider - preferably practice location | Text | 30 | |
MC034 | Service Provider State | As defined by the US Postal Service | Text | 2 | |
MC035 | Service Provider ZIP Code | ZIP Code of provider - may include non-US codes Do not include dash | Text | 11 | |
MC036 | Type of Bill - Institutional | Type of Facility - First Digit (Should be coded on facility claims, such as those submitted using on UB04 forms) | Integer | 2 | |
MC037 | Facility Type - Professional | (Should be coded on professional claims, such as those submitted using on NSF [CMS 1500 forms]) | Text | 2 | |
MC038 | Claim Status | (Actually describes the payment status of the specific service line record) | Integer | 2 | |
MC039 | Admitting Diagnosis | Required on all inpatient admission claims and encounters ICD-9-CM Do not code decimal point | Text | 5 | |
MC040 | E-Code | Describes an injury, poisoning or adverse effect ICD-9-CM Do not include decimal | Text | 5 | |
MC041 | Principal Diagnosis | ICD-9-CM Do not code decimal point This should be the principal diagnosis given on the claim header. | Text | 5 | |
MC042 | Other Diagnosis - 1 | ICD-9-CM Do not code decimal point | Text | 5 | |
MC043 | Other Diagnosis - 2 | ICD-9-CM Do not code decimal point | Text | 5 | |
MC044 | Other Diagnosis - 3 | ICD-9-CM Do not code decimal point | Text | 5 | |
MC045 | Other Diagnosis - 4 | ICD-9-CM Do not code decimal point | Text | 5 | |
MC046 | Other Diagnosis - 5 | ICD-9-CM Do not code decimal point | Text | 5 | |
MC047 | Other Diagnosis - 6 | ICD-9-CM Do not code decimal point | Text | 5 | |
MC048 | Other Diagnosis - 7 | ICD-9-CM Do not code decimal point | Text | 5 | |
MC049 | Other Diagnosis - 8 | ICD-9-CM Do not code decimal point | Text | 5 | |
MC050 | Other Diagnosis - 9 | ICD-9-CM Do not code decimal point | Text | 5 | |
MC051 | Other Diagnosis - 10 | ICD-9-CM Do not code decimal point | Text | 5 | |
MC052 | Other Diagnosis - 11 | ICD-9-CM Do not code decimal point | Text | 5 | |
MC053 | Other Diagnosis - 12 | ICD-9-CM Do not code decimal point | Text | 5 | |
MC054 | Revenue Code | National Uniform Billing Committee Codes Code using leading zeroes, left-justified, and four digits. | Text | 4 | |
MC055 | Procedure Code | Health Care Common Procedural Coding System (HCPCS) This includes the CPT codes of the American Medical Association | Text | 5 | |
MC056 | Procedure Modifier - 1 | Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code | Text | 2 | |
MC057 | Procedure Modifier - 2 | Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code | Text | 2 | |
MC058 | ICD-9-CM Procedure Code | Primary ICD-9-CM code given on the claim header. Do not code decimal point | Text | 4 | |
MC059 | Date of Service - From | First date of service for this service line | Date | CCYYMMDD | 8 |
MC060 | Date of Service - Thru | Last date of service for this service line | Date | CCYYMMDD | 8 |
MC061 | Quantity | Count of services performed Should be set equal to 1 on all Observation bed service lines, for consistency. | Integer | 3 | |
MC062 | Charge Amount | Do not code decimal point | Decimal | 10 | |
MC063 | Paid Amount | Includes any withhold amounts Do not code decimal point | Decimal | 10 | |
MC064 | Prepaid Amount | For capitated services, the fee for service equivalent amount Do not code decimal point | Decimal | 10 | |
MC065 | Copay Amount | The preset, fixed dollar amount for which the individual is responsible Do not code decimal point | Decimal | 10 | |
MC066 | Coinsurance Amount | Do not code decimal point | Decimal | 10 | |
MC067 | Deductible Amount | Do not code decimal point | Decimal | 10 | |
MC068 | Patient Account/Control Number | Not provided | Text | 20 | |
MC069 | Discharge Date | Required for all inpatient(s) | Date | 8 | |
MC070 | Service Provider Country Name | Not provided | Text | 30 | |
MC071 | DRG | Carriers and health care claims processors shall code using the CMS methodology when available. Precedence shall be given to DRGs transmitted from the hospital provider. When the CMS methodology for DRGs is not available, but the All payer DRG system is available, than that system shall be used. If the All Payer DRG system is used, the carrier shall format the DRG and the complexity level within the same field with an "A" prefix, and with a hyphen separating the DRG and the complexity level (e.g. AXXX-XX) | Text | 3 | |
MC072 | DRG Version | This element is the version number of the grouper used. | Text | 2 | |
MC073 | APC | Carriers and health care claims processors shall code using CMS methodology. Precedence shall be given to APCs transmitted from the health care provider | Text | 4 | |
MC074 | APC Version | This element is the version number of the grouper used | Text | 2 | |
MC075 | Drug Code | NDC Code | Text | 11 | |
MC076 | Billing Provider Number | Payer assigned billing provider number. This number should be the identifier used by the payer for internal identification purposes and does not routinely change | Text | 30 | |
MC077 | National Billing Provider Number ID | This is the NPI for the billing provider | Text | 30 | |
MC078 | Billing Provider Last Name | Not provided | Text | 128 | |
MC101 | Subscriber Last Name | (this data element will be de-identified by the NH preprocessor application) | Text | 128 | |
MC102 | Subscriber First Name | (this data element will be de-identified by the NH preprocessor application) | Text | 128 | |
MC103 | Subscriber Middle Initial | (this data element will be de-identified by the NH preprocessor application) | Text | 1 | |
MC104 | Member Last Name | (this data element will be de-identified by the NH preprocessor application) | Text | 128 | |
MC105 | Member First Name | (this data element will be de-identified by the NH preprocessor application) | Text | 128 | |
MC106 | Member Middle Initial | (this data element will be de-identified by the NH preprocessor application) | Text | 1 | |
MC899 | Record Type | Not provided | Text | 2 | |
TR001 | Record Type | Not provided | Text | 2 | |
TR002 | Payer | Payer submitting payments NHID Submitter Code | Text | 8 | |
TR003 | National Plan ID | CMS National Plan ID | Text | 30 | |
TR004 | Type of File | Not provided | Text | 2 | |
TR005 | Period Beginning Date | Beginning of paid period for claims Beginning of month covered for eligibility | Integer | CCYYMM | 6 |
TR006 | Period Ending Date | End of paid period for claims End of month covered for eligibility | Integer | CCYYMM | 6 |
TR007 | Date Processed | Not provided | Date | CCYYMMDD | 8 |
Data Element ID | Data Element | Description | Type | Format | Length |
---|---|---|---|---|---|
HD001 | Record Type | Not provided | Text | 2 | |
HD002 | Payer | Payer submitting payments NHID Submitter Code | Text | 8 | |
HD003 | National Plan ID | CMS National Plan ID | Text | 30 | |
HD004 | Type of File | Not provided | Text | 2 | |
HD005 | Period Beginning Date | Beginning of paid period for claims Beginning of month covered for eligibility | Integer | CCYYMM | 6 |
HD006 | Period Ending Date | End of paid period for claims End of month covered for eligibility | Integer | CCYYMM | 6 |
HD007 | Record Count | Total number of records submitted in this file | Integer | 10 | |
HD008 | Comments | Submitted may use to document this submission by assigning a filename, system source, etc. | Text | 80 | |
ME001 | Payer | Payer submitting payments NHID Submitter Code | Text | 8 | |
ME002 | National Plan ID | CMS National Plan ID | Text | 30 | |
ME003 | Insurance Type Code/Product | Not provided | Text | 2 | |
ME004 | Year | Year for which eligibility is reported in this submission | Integer | 4 | |
ME005 | Month | Month for which eligibility is reported in this submission | Integer | 2 | |
ME006 | Insured Group or Policy Number | Group or policy number (not the number that uniquely identifies the subscriber) | Text | 50 | |
ME007 | Coverage Level Code | Benefit Coverage Level | Text | 3 | |
ME008 | Subscriber Social Security Number | Subscriber's social security number (set as null if unavailable) (this data element will be de-identified by the NHpreprocessor application) | Text | 128 | |
ME009 | Plan Specific Contract Number | Plan assigned contract number (set as null if contract number = subscriber's social security number) (this data element will be de-identified by the NHpreprocessor application) | Text | 128 | |
ME010 | Member Suffice or Sequence Number | Uniquely numbers the member within the contract | Integer | 2 | |
ME011 | Member Identification Code | Member's social security number (set as null if unavailable) (this data element will be de-identified by the NHpreprocessor application) | Text | 128 | |
ME012 | Individual Relationship Code | Member's relationship to insured | Integer | 2 | |
ME013 | Member Gender | Not provided | Text | 1 | |
ME014 | Member Date of Birth | Not provided | Date | CCYYMMDD | 8 |
ME015 | Member City Name | City name of member | Text | 30 | |
ME016 | Member State or Province | As defined by the US Postal Service | Text | 2 | |
ME017 | Member ZIP Code | ZIP Code of member - may include non-US codes. (Do not include dash) | Text | 11 | |
ME018 | Medical Coverage | Not provided | Text | 1 | |
ME019 | Prescription Drug Coverage | Not provided | Text | 1 | |
ME020 | Dental Coverage | Not provided | Text | 1 | |
ME021 | Race 1 | Not provided | Text | 6 | |
ME022 | Race 2 | Not provided | Text | 6 | |
ME023 | Placeholder | Not provided | Not Supplied | Not Supplied | Not Supplied |
ME024 | Hispanic Indicator | Not provided | Text | 1 | |
ME025 | Ethnicity 1 | Not provided | Text | 6 | |
ME026 | Ethnicity 2 | Not provided | Text | 6 | |
ME027 | Place holder | Not provided | 20 | ||
ME028 | Primary Insurance Indicator | Not provided | Text | 1 | |
ME029 | Coverage Type | Not provided | Text | 3 | |
ME030 | Market Category | Not provided | Text | 4 | |
ME031 | Special Coverage | Not provided | Text | 3 | |
ME032 | Group Name | Name of the group which the member is covered by. If the member is part of a group of one or non-group then this field shall be set as null | Text | 128 | |
ME101 | Subscriber Last Name (this data element will be de-identified by the NHpreprocessor application) | Not provided | Text | 128 | |
ME102 | Subscriber First Name (this data element will be de-identified by the NHpreprocessor application) | Not provided | Text | 128 | |
ME103 | Subscriber Middle Initial (this data element will be de- identified by the NHpreprocessor application) | Not provided | Text | 1 | |
ME104 | Member Last Name (this data element will be de-identified by the NHpreprocessor application) | Not provided | Text | 128 | |
ME105 | Member First Name (this data element will be de-identified by the NHpreprocessor application) | Not provided | Text | 128 | |
ME106 | Member Middle Initial (this data element will be de-identified by the NHpreprocessor application) | Not provided | Text | 1 | |
ME899 | Record Type | Not provided | Text | 2 | |
TR001 | Record Type | Not provided | Text | 2 | |
TR002 | Payer | Payer submitting payments NHID Submitter Code | Text | 8 | |
TR003 | National Plan ID | CMS National Plan ID | Text | 30 | |
TR004 | Type of File | Not provided | Text | 2 | |
TR005 | Period Beginning Date | Beginning of paid period for claims Beginning of month covered for eligibility | Integer | CCYYMM | 6 |
TR006 | Period Ending Date | End of paid period for claims End of month covered for eligibility | Integer | CCYYMM | 6 |
TR007 | Date Processed | Not provided | Date | CCYYMMDD | 8 |
Data Element ID | Data Element | Description | Type | Format | Length |
---|---|---|---|---|---|
HD001 | Record Type | Not provided | Text | 2 | |
HD002 | Payer | Payer submitting payments NHID Submitter Code | Text | 8 | |
HD003 | National Plan ID | CMS National Plan ID | Text | 30 | |
HD004 | Type of File | Not provided | Text | 2 | |
HD005 | Period Beginning Date | Beginning of paid period for claims Beginning of month covered for eligibility | Integer | CCYYMM | 6 |
HD006 | Period Ending Date | End of paid period for claims End of month covered for eligibility | Integer | CCYYMM | 6 |
HD007 | Record Count | Total number of records submitted in this file | Integer | 10 | |
HD008 | Comments | Submitted may use to document this submission by assigning a filename, system source, etc. | Text | 80 | |
PC001 | Payer | Payer submitting payments NHID Submitter Code | Text | 8 | |
PC002 | Plan ID | CMS National Plan ID | Text | 30 | |
PC003 | Insurance Type/Product Code | Not provided | Text | 2 | |
PC004 | Payer Claim Control Number | Must apply to the entire claim and be unique within the payer's system | Text | 35 | |
PC005 | Line Counter | Line number for this service The line counter begins with 1 and is incremented by 1 for each additional service line of a claim | Integer | 4 | |
PC006 | Insured Group Number | Group or policy number - not the number that uniquely identifies the subscriber | Text | 30 | |
PC007 | Subscriber Social Security Number | Subscriber's social security number (this data element will be de-identified by the NHpreprocessor application) Set as null if unavailable | Text | 30 | |
PC008 | Plan Specific Contract Number | Plan assigned contract number (this data element will be de-identified by the NHpreprocessor application) Set as null if contract number = subscriber's social security number | Text | 30 | |
PC009 | Member Suffix or Sequence Number | Uniquely numbers the member within the contract | Integer | 2 | |
PC010 | Member Identification Code | Member's social security number Set as null if unavailable (this data element will be de-identified by the NHpreprocessor application) | Text | 30 | |
PC011 | Individual Relationship Code | Member's relationship to insured | Integer | 2 | |
PC012 | Member Gender | Not provided | Integer | 1 | |
PC013 | Member Date of Birth | Not provided | Date | CCYYMMDD | 8 |
PC014 | Member City Name of Residence | City name of member | Text | 30 | |
PC015 | Member State | As defined by the US Postal Service | Text | 2 | |
PC016 | Member ZIP Code | ZIP Code of member - may include non-US codes Do not include dash | Text | 9 | |
PC017 | Date Service Approved (AP Date) | (Generally the same as the paid date or the Pharmacy Benefits Manager's billing date) | Date | CCYYMMDD | 8 |
PC018 | Pharmacy Number | Payer assigned pharmacy number AHFS number is acceptable | Text | 30 | |
PC019 | Pharmacy Tax ID Number | Federal taxpayer's identification number (Please provide the pharmacy chain's federal tax identification number, if the individual retail pharmacy's tax ID# is not available.) | Text | 10 | |
PC020 | Pharmacy Name | Name of pharmacy | Text | 30 | |
PC021 | National Pharmacy ID Number | Required if National Provider ID is mandated for use under HIPAA | Text | 20 | |
PC022 | Pharmacy Location City | City name of pharmacy - preferably pharmacy location | Text | 30 | |
PC023 | Pharmacy Location State | As defined by the US Postal Service | Text | 2 | |
PC024 | Pharmacy ZIP Code | ZIP Code of pharmacy - may include non- US codes Do not include dash | Text | 10 | |
PC024A | Pharmacy County Name | Not provided | Text | 30 | |
PC025 | Claim Status | Not provided | Integer | 2 | |
PC026 | Drug Code | NDC Code | Text | 11 | |
PC027 | Drug Name | Text name of drug | Text | 80 | |
PC028 | New Prescription | 00 New prescription. 01-99 Number of refill(s) ('01' should be used for all refills, if the specific number of the prescription refill is not available) | Integer | 2 | |
PC029 | Generic Drug Indicator | Not provided | Text | 1 | |
PC030 | Dispense as Written Code | Not provided | Integer | 1 | |
PC031 | Compound Drug Indicator | Not provided | Text | 1 | |
PC032 | Date Prescription Filled | Not provided | Date | CCYYMMDD | 8 |
PC033 | Quantity Dispensed | Number of metric units of medication dispensed | Integer | 5 | |
PC034 | Days Supply | Estimated number of days the prescription will last | Integer | 3 | |
PC035 | Charge Amount | Do not code decimal point | Decimal | 10 | |
PC036 | Paid Amount | Includes all health plan payments and excludes all member payments Do not code decimal point | Decimal | 10 | |
PC037 | Ingredient Cost/List Price | Cost of the drug dispensed Do not code decimal point | Decimal | 10 | |
PC038 | Postage Amount Claimed | Do not code decimal point | Decimal | 10 | |
PC039 | Dispensing Fee | Do not code decimal point | Decimal | 10 | |
PC040 | Copay Amount | The preset, fixed dollar amount for which the individual is responsible Do not code decimal point | Decimal | 10 | |
PC041 | Coinsurance Amount | Do not code decimal point | Decimal | 10 | |
PC042 | Deductible Amount | Do not code decimal point | Decimal | 10 | |
PC043 | Place holder | Not provided | Not Supplied | Not Supplied | Not Supplied |
PC044 | Prescribing Physician First Name | Physician first name | Text | 25 | |
PC045 | Prescribing Physician Middle Name | Physician middle name | Text | 25 | |
PC046 | Prescribing Physician Last Name | Physician last name | Text | 50 | |
PC047 | Prescribing Physician Number | Carriers and health claims processors shall code using the payer assigned provider number. This number should be the identifier used by the payer for internal identification purposes, and does not routinely change. | Text | 30 | |
PC101 | Subscriber Last Name | (this data element will be de-identified by the NH preprocessor application) | Text | 128 | |
PC102 | Subscriber First Name | (this data element will be de-identified by the NH preprocessor application) | Text | 128 | |
TR001 | Record Type | Not provided | Text | 2 | |
TR002 | Payer | Payer submitting payments NHID Submitter Code | Text | 8 | |
TR003 | National Plan ID | CMS National Plan ID | Text | 30 | |
TR004 | Type of File | Not provided | Text | 2 | |
TR005 | Period Beginning Date | Beginning of paid period for claims Beginning of month covered for eligibility | Integer | CCYYMM | 6 |
TR006 | Period Ending Date | End of paid period for claims End of month covered for eligibility | Integer | CCYYMM | 6 |
TR007 | Date Processed | Not provided | Date | CCYYMMDD | 8 |