United States Health Information Knowledgebase

 

Pennsylvania



Name:Pennsylvania
Abbreviation:PA
Websitehttp://www.phc4.org/ Exit Disclaimer [www.phc4.org]
Who Maintains the SystemPHC4 (Pennsylvania Health Care Cost Containment Council)
Versions:June 2011

File Specification for Medical Claims File Submission - June 2011

Data Element ID Data Element Description Type Format Length
1 Payer Payer submitting payments. Alphanumeric 128
2 National Plan ID CMS National Plan Identification Number Alphanumeric 30
3 Insurance Type/Product Code Not Provided Alphanumeric 2
4 Payer Claim Control Number Payer Claim Control Identification. A unique identifier within the payer's system that applies to the entire claim. Alphanumeric 35
5 Line Counter Line number for this service Numeric 4
5a Version Number The version number of this claim service line. Numeric 4
6 Insured Group or Policy Number Group or policy number, not the number that uniquely identifies the subscriber. Alphanumeric 30
7 Subscriber Social Security Number Subscriber's Social Security Number Numeric 9
8 Plan Specific Contract Number Plan-assigned contract number Alphanumeric 30
9 Member Suffix or Sequence Number Uniquely numbers the member within the contract. Numeric 20
10 Member Identification Code Patient's/Member's Social Security Number. Numeric 9
11 Individual Relationship Code Patient's/Member's relationship to insured. Numeric 2
12 Member Gender Patient/Member Gender Alphanumeric 1
13 Member Date of Birth Not Provided Numeric MMDDCCYY 8
14 Member City Name City name associated with member Alphanumeric 30
15 Member State As defined by the US Postal Service Alphanumeric 2
16 Member ZIP Code Zip code of member Numeric 9
17 Date Service Approved/Accounts Payable Date/Actual Paid Date Date Service Approved. Numeric MMDDCCYY 8
18 Admission Date Required for all inpatient claims. Numeric MMDDCCYY 8
19 Admission Hour Required for all inpatient claims. Numeric HHMM 4
20 Admission Type Required for all inpatient claims Numeric 1
21 Admission Source Required for all inpatient claims. The point of patient origin for admission or visit. Alphanumeric 1
22 Discharge Hour Required for all inpatient claims. Numeric HHMM 4
23 Discharge Status Required for all inpatient claims Numeric 2
24 Service Provider Number As assigned by payer. To capture the provider that rendered the service. Alphanumeric 30
25 Service Provider Tax ID Number Federal taxpayer's identification number Alphanumeric 10
26 National Service Provider ID National Provider ID. This data element pertains to the entity or individual directly providing the service. Alphanumeric 20
27 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 a "person", and these shall be coded as a person Alphanumeric 1
28 Service Provider First Name Individual first name. Alphanumeric 25
29 Service Provider Middle Name Individual middle name or initial. Alphanumeric 25
30 Service Provider Last Name or Organization Name Full name of provider organization or last name of individual provider. Alphanumeric 60
31 Service Provider Suffix Suffix to individual name. The service provider suffix shall 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, LCSW). Alphanumeric 10
32 Service Provider Specialty As defined by payer. Alphanumeric 10
33 Service Provider City Name City name of provider, preferably practice location. Alphanumeric 30
34 Service Provider State or Province As defined by US Postal Service Alphanumeric 2
35 Service Provider ZIP Code ZIP code of provider Numeric 9
36 Type of Bill - Institutional Required for institutional claims. Numeric 2
37 Facility Type - Professional Required for professional claims. Alphanumeric 2
38 Claim Status Describes the payment status of the specific service line record. Numeric 2
39 Admitting Diagnosis Required on all inpatient admission claims. Alphanumeric 7
40 E-Code Describes an injury, poisoning or adverse effect. Alphanumeric 7
41 Principal Diagnosis Not Provided Alphanumeric 7
42 Other Diagnosis - 1 Not Provided Alphanumeric 7
43 Other Diagnosis - 2 Not Provided Alphanumeric 7
44 Other Diagnosis - 3 Not Provided Alphanumeric 7
45 Other Diagnosis - 4 Not Provided Alphanumeric 7
46 Other Diagnosis - 5 Not Provided Alphanumeric 7
47 Other Diagnosis - 6 Not Provided Alphanumeric 7
48 Other Diagnosis - 7 Not Provided Alphanumeric 7
49 Other Diagnosis - 8 Not Provided Alphanumeric 7
50 Other Diagnosis - 9 Not Provided Alphanumeric 7
51 Other Diagnosis - 10 Not Provided Alphanumeric 7
52 Other Diagnosis - 11 Not Provided Alphanumeric 7
53 Other Diagnosis - 12 Not Provided Alphanumeric 7
54 Revenue Code Not Provided Numeric 10
55 Procedure Code Not Provided Alphanumeric 10
56 Procedure Modifier - 1 Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code. Alphanumeric 2
57 Procedure Modifier - 2 Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code. Alphanumeric 2
58 ICD-9-CM Procedure Code Primary procedure code for this line of service. Alphanumeric 7
59 Date of Service - From First date of service for this service line. Numeric MMDDCCYY 8
60 Date of Service - Thru Last date of service for this service line. Numeric MMDDCCYY 8
61 Quantity Count of services/units performed. Numeric 3
62 Charge Amount Not Provided Numeric DDDDCC 10
63 Paid Amount Not Provided Numeric DDDDCC 10
64 Prepaid Amount For capitated services, the fee-for-service equivalent amount. Numeric DDDDCC 10
65 Co-pay Amount The preset, fixed-dollar amount for which the individual is responsible. Numeric DDDDCC 10
66 Coinsurance Amount The specific dollar amount for which the individual is responsible on a percentage basis. Numeric DDDDCC 10
67 Deductible Amount Not Provided Numeric DDDDCC 10
68 Patient Account/Control Number Number assigned by hospital/provider Alphanumeric 24
69 Discharge Date Date patient was discharged. Numeric MMDDCCYY 8
70 Service Provider Country Name Not Provided Alphanumeric 30
71 DRG Not Provided Alphanumeric 10
72 DRG Version Version number of the grouper used. Numeric 2
73 APC Not Provided Alphanumeric 4
74 APC Version Version number of the grouper used. Alphanumeric 2
75 Drug Code An NDC code used only when a medication is paid for as part of a medical claim. Alphanumeric 11
76 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. Alphanumeric 30
77 National Billing Provider ID National Provider ID Alphanumeric 20
78 Billing Provider Last Name or Organization Name Full name of provider billing organization or last name of individual billing provider. Alphanumeric 60
79 Subscriber Last Name Not Provided Alphanumeric 128
80 Subscriber First Name Not Provided Alphanumeric 128
81 Subscriber Middle Initial Not Provided Alphanumeric 1
82 Member Last Name Not Provided Alphanumeric 128
83 Member First Name Not Provided Alphanumeric 128
84 Member Middle Initial Not Provided Alphanumeric 1
85 Capitated Services Indicator Indicates whether payment for this service or care is covered under a capitated arrangement. Numeric 1
86 Record Type Indicates the type of record being submitted, in this case, Medical Claims. Alphanumeric 2

File Specification for Medical Eligibility File Submission - June 2011

Data Element ID Data Element Description Type Format Length
1 Payer Payer submitting payments. Alphanumeric 128
2 National Plan ID CMS National Plan Identification Number Alphanumeric 30
3 Insurance Type Code/Product These codes differ from the codes for this data element in the Medical Claims file. Alphanumeric 2
4 Year Year for which eligibility is reported in this submission Use CCYY as year format. Numeric CCYY 4
5 Month Month for which eligibility is reported in this submission Use MM as month format. Numeric MM 2
6 Insured Group or Policy Number Group or policy number, not the number that uniquely identifies the subscriber. Alphanumeric 30
7 Coverage Level Code Benefit coverage level Alphanumeric 3
8 Subscriber Social Security Number Subscriber's Social Security Number Numeric 9
9 Plan Specific Contract Number Plan assigned subscriber's contract number Alphanumeric 30
10 Member Suffix or Sequence Number Uniquely numbers the member within the contract. Numeric 20
11 Member Identification Code Member's SSN. Numeric 9
12 Individual Relationship Code Member's relationship to insured. Numeric 2
13 Member Gender Member Gender Alphanumeric 1
14 Member Date of Birth Not Provided Numeric MMDDCCYY 8
15 Member City Name City name associated with member Alphanumeric 30
16 Member State or Province As defined by the US Postal Service Alphanumeric 2
17 Member ZIP Code Zip code of member Numeric 9
18 Medical Coverage Does the member have medical coverage? Alphanumeric 1
19 Prescription Drug Coverage Does the member have prescription drug coverage? Alphanumeric 1
20a Patient Race Patient's/Member's racial background. Alphanumeric 1
20b Patient Hispanic/Latino Origin or Descent Hispanic/Latino origin refers to people whose origins are from Spain, Mexico, or the Spanish speaking countries of Central or South America. Origin can be viewed as the ancestry, nationality lineage, or country in which the person or his/her ancestors were born before their arrival in the United States. Alphanumeric 1
21 Primary Insurance Indicator Indicates whether coverage under member's plan or policy is primary. Alphanumeric 1
22 Coverage Type Not Provided Alphanumeric 3
23 Market Category Code The market the policy is sold into. Alphanumeric 4
24 Special Coverage Future element reserved for assignment. character field 3
25 Group Name Group name. Alphanumeric 128
26 Health Care Home Assigned Flag Future element reserved for assignment. Alphanumeric 1
27 Health Care Home Number Future element reserved for assignment. Alphanumeric 10
28 Health Care Home Tax ID Number Future element reserved for assignment. Alphanumeric 20
29 Health Care Home National Provider ID Future element reserved for assignment. Alphanumeric 60
30 Health Care Home Name Future element reserved for assignment. Alphanumeric 128
31 Subscriber Last Name Not Provided Alphanumeric 128
32 Subscriber First Name Not Provided Alphanumeric 128
33 Subscriber Middle Initial Not Provided Alphanumeric 1
34 Member Last Name Not Provided Alphanumeric 128
35 Member First Name Not Provided Alphanumeric 128
36 Member Middle Initial Not Provided Alphanumeric 1
37 Record Type Indicates the type of record being submitted, in this case, Member Eligibility. Alphanumeric 2

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