United States Health Information Knowledgebase

 

Rhode Island



Name:Rhode Island
Abbreviation:RI
Title of SystemRhode Island All Payer Database
Websitehttp://www.health.ri.gov/programs/allpayorclaimsdatabase/
Who Maintains the SystemRhode Island Department of HealthRhode Island Department of Health
Versions:February 2014 - v1.1
June 2014 - v1.3

File Specification for Multiple versionsMedical Claims File Submission - June 2014 - v1.3

Data Element ID Data Element Description Type Format Length
Multiple versionsHD001 Record Type This field must be coded HD to indicate the start of the header record. Text 2
Multiple versionsHD002 Submitter Code This field must contain the submitter code assigned to you by Onpoint Health Data. Text 8
Multiple versionsHD003 Placeholder This field must be coded as null; it is reserved for header consistency across all clients using Onpoint Health Data's APCD services. Text 30
Multiple versionsHD004 Type of File This field must be coded MC to indicate submission of medical claims data. Text 2
Multiple versionsHD005 Period Beginning Date Use this field to report the earliest payment year/month included in the submission in CCYYMM format. Submissions with records containing a Payment Date / Settlement Date (MC017) outside of the date range indicated in this file's header and trailer records will fail. Integer CCYYMM 6
Multiple versionsHD006 Period Ending Date Use this field to report the latest payment year/month included in the submission in CCYYMM format. Submissions with records containing a Payment Date / Settlement Date (MC017) outside of the date range indicated in this file's header and trailer records will fail. Integer CCYYMM 6
Multiple versionsHD007 Record Count Use this field to report the total number of records in the submission, excluding the header and trailer records. If the number of records within the submission does not equal the number reported in this field, the submission will fail. Integer 10
Multiple versionsHD008 Comments This field may be used by the submitter to document a file name, system source, or other administrative device to assist with their internal tracking of the submission. Text 80
Multiple versionsMC001 Submitter Code Use this field to report your Onpoint-assigned submitter code for the data submitter. Note that the first two characters of the submitter code are used to indicate the reporting state and the third character designates the type of submitter. For Rhode Island's APCD collection. Notes: A single data submitter may have multiple submitter codes if they are submitting from more than one system or from more than one location. All submitter codes associated with a single data submitter will have the same first six characters. A suffix will be used to distinguish the location and/or system variations. This field contains a constant value and is primarily used for tracking compliance by data submitter. Text 8
Multiple versionsMC002 NAIC Use this field to report, at a record level, the code as assigned by the NAIC that uniquely identifies the applicable insurance plan. If no NAIC number has been assigned, report as "0". Text 5
Multiple versionsMC003 Insurance Type / Product Code Use this field to report the member's type of insurance or insurance product. Notes: The value reported for this field should be consistent with the value reported in ME003 ("Insurance Type / Product Code") in the eligibility file. To ensure reporting consistency between submitters, all Medicare Advantage plans should use the code "HN" to denote a Health Maintenance Organization (HMO) - Medicare Risk. Valid codes are maintained by the Accredited Standards Committee (ASC) and are available in the ASC X12 transaction set. Text 2
Multiple versionsMC004 Payer Claim Control Number Use this field to report the claim number used by the data submitter to internally track the claim. Notes: In general, the claim number is associated with all service lines of the claim. It must apply to the entire claim and be unique within the data submitter's system. The value reported in this field should remain consistent over time. If reporting multiple versions of the same claim, this number should remain the same; use MC005A (Version Number) to report multiple versions of the same claim subject to subsequent changes/adjustments. Text 50
Multiple versionsMC004A Claim Submitter's Identifier Use this field to report the claim number used by the healthcare provider (e.g., the doctor, hospital, etc.) to track a claim from creation through payment. Text 38
Multiple versionsMC005 Line Counter Use this field to report the line number for this service. Notes: The line counter should begin with 1 and be incremented by 1 for each additional service line of a claim. Integer 4
Multiple versionsMC005A Version Number Use this field to report the version number of the claim service record. Notes: The version number should begin with 0 and be incremented by 1 for each subsequent version of that service line. If versioning is not used to report adjusted claims, report claims with a Version Number of zero (0). Integer 4
Multiple versionsMC006 Insured Group or Policy Number Use this field to report the group or policy number. Notes: This is not the number that uniquely identifies the subscriber. The value reported for this field should be consistent with the value reported in the Insured Group or Policy Number fields across all file types (ME006, MC006, PC006). If a policy is sold to an individual as a non-group policy, then this field should be reported with a value of "IND". This principle pertains to all claim types: commercial, Medicaid, and Medicare. Text 50
Multiple versionsMC007 Subscriber Social Security Number Use this field to report the subscriber's 9-digit Social Security number. Notes: The value reported for this field should be consistent with the value reported in ME008 ("Subscriber Social Security Number") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 9
Multiple versionsMC008 Plan-Specific Contract Number Use this field to report the submitter-assigned contract number for the subscriber. Notes: The value reported for this field should be consistent with the value reported in ME009 ("Plan-Specific Contract Number") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 80
Multiple versionsMC009 Member Suffix or Sequence Number Use this field to report the unique number of the member within the contract. Text 20
Multiple versionsMC010 Member Social Security Number Use this field to report the member's 9-digit Social Security number. Notes: The value reported for this field should be consistent with the value reported in ME011 ("Member Social Security Number") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 9
Multiple versionsMC010A Unique Member Identifier Use this field to report the Unique Member Identifier assigned by the Lockbox Vendor in the Response File's field RF017. Notes: The value reported for this field should be reported identically to the "Unique Member Identifier" field in the eligibility file (ME010A). String 32
Multiple versionsMC011 Member Relationship Use this field to report the member's relationship to the subscriber or the insured. Notes: The value reported for this field should be consistent with the value reported in ME012 ("Member Relationship") in the eligibility file. Valid codes are maintained by the Accredited Standards Committee (ASC) and are available in the ASC X12 transaction set. Text 2
Multiple versionsMC012 Member Gender Use this field to report the member's gender. Notes: The value reported for this field should be consistent with the value reported in ME013 ("Member Gender") in the eligibility file. Text 1
Multiple versionsMC013 Member Date of Birth Use this field to report the member's date of birth using an 8- digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Notes: The value reported for this field should be consistent with the value reported in ME014 ("Member Date of Birth") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Immediately prior to hashing this field, Onpoint's hashing application calculates a member's age in months based on the Member Date of Birth field (ME014, MC013, PC013). The Member Date of Birth field is then hashed and both the hashed value and the value-added Age in Months element are submitted to the APCD - the hashed value to allow for quality assurance review, the de-identified Age in Months to enable analytic use of the APCD. Date 8
Multiple versionsMC014 Member City Use this field to report the name of the member's city of residence. Text 30
Multiple versionsMC015 Member State or Province Use this field to report the member's state or province using the two-character abbreviation code defined by the U.S. Postal Service(for U.S. states) and Canada Post (for Canadian provinces). Text 2
Multiple versionsMC016 Member ZIP/Postal Code Use this field to report the ZIP/postal code associated with the member's residence. Notes: For U.S. ZIP codes, include the ZIP+4 (also referred to as the "plus-four" or "add-on" code). Do not code dashes or spaces within ZIP/postal codes. Text 9
Multiple versionsMC017 Payment Date / Settlement Date Use this field to report the date on which the record was approved for payment using an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Notes: This date generally is referred to as the paid date. When BPR04 is "NON" for nonpayment, report the remittance date instead. Date CCYYMMDD 8
Multiple versionsMC018 Admission Date Use this field to report the date of the inpatient admission using an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC019 Admission Hour Use this field to report the hour - in the format of military time (i.e., 00 through 23) - during which the member was admitted for inpatient care. Text 2
Multiple versionsMC020 Admission Type Use this field to report the type of admission for the inpatient hospital claim. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC021 Admission Source Use this field to report the source of admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC022 Discharge Hour Use this field to report the hour - in the format of military time (i.e., 00 through 23) - during which the member was discharged from inpatient care. Text 2
Multiple versionsMC023 Discharge Status Use this field to report the status for the patient discharged from an inpatient stay. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 2
Multiple versionsMC024 Rendering Provider Plan ID Use this field to report the submitter-assigned or legacy provider plan ID for the rendering provider. Note: The provider data reported in the eligibility, claims, and provider files are used to create a Provider Master Index that is used to match the data across all file types. It is expected that a provider's identifiers (e.g., plan-assigned ID, NPI, etc.) will be reported consistently by a submitter across file types as this is the payer-assigned provider ID (ME051, MC024, PC048A, PV006). Text 50
Multiple versionsMC025 Rendering Provider Tax ID Number Use this field to report the federal taxpayer identification number for the rendering provider. Notes: If the tax ID number is an individual's Social Security number, report this field as null. Text 9
Multiple versionsMC026 Rendering Provider NPI Use this field to report the National Provider Identifier (NPI) for the rendering provider or entity. Text 10
Multiple versionsMC027 Entity Type Qualifier Use this field to report whether the rendering provider was an individual practitioner or a business entity. Notes: Valid codes are maintained by the Accredited Standards Committee (ASC) and are available in the ASC X12 transaction set. Text 1
Multiple versionsMC027A Network Indicator Use this field to report whether the rendering provider was in or out of the network. Text 1
Multiple versionsMC028 Rendering Provider First Name Use this field to report the rendering provider's first name. Notes: Set to null if the provider is a facility or an organization. Text 35
Multiple versionsMC029 Rendering Provider Middle Initial Use this field to report the rendering provider's middle initial. Notes: Set to null if the provider is a facility or an organization. Text 1
Multiple versionsMC030 Rendering Provider Last Name or Organization Name Use this field to report the last name of the rendering provider if an individual or the full name if the provider is a facility or an organization. Text 60
Multiple versionsMC031 Rendering Provider Suffix Use this field to report any generational identifiers associated with the rendering provider's name (e.g., JR, SR, III). Notes: Do not code punctuation and do not code the rendering provider's credentials (e.g., MD, LCSW) in this field. Set to null if the provider is a facility or an organization. Text 10
Multiple versionsMC032 Rendering Provider Taxonomy Code Use this field to report the rendering provider's taxonomy code. Text 10
Multiple versionsMC033 Rendered Service Location - City Use this field to report the city where the service was rendered. Notes: When not available (e.g., ambulance services), report the organization or provider's location city. Text 30
Multiple versionsMC034 Rendered Service Location - State or Province Use this field to report the state or province where the service was rendered using the two-character abbreviation defined by the U.S. Postal Service (for U.S. states) and Canada Post (for Canadian provinces). Notes: When not available (e.g., ambulance services), report the organization or provider's location state or province. Text 2
Multiple versionsMC035 Rendered Service Location - ZIP/Postal Code Use this field to report the ZIP/postal code where the service was rendered. Notes: For U.S. ZIP codes, include the ZIP+4 (also referred to as the "plus-four" or "add-on" code). Do not code dashes or spaces within ZIP/postal codes. When not available (e.g., ambulance services), report the organization or provider's location ZIP/postal code. Text 9
Multiple versionsMC036 Type of Bill Use this field to report the code for the type of bill. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. This field is required for institutional claims and must be set to null for professional claims. Text 3
Multiple versionsMC037 Place of Service Use this field to report the place of service code as reported on a professional claim. Notes: This field is required for professional claims and must be set to null for institutional claims. Text 2
Multiple versionsMC038 Claim Status Use this field to report the status of the claim line - whether paid as primary, paid as secondary, denied, etc. Notes: Valid codes are maintained by the Accredited Standards Committee (ASC) and are available in the ASC X12 transaction set. Text 2
Multiple versionsMC039 Admitting Diagnosis Use this field to report the ICD diagnosis code indicating the reason for the inpatient admission. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC039A ICD Version Indicator Use this field to declare the version of ICD reported on this service line. Notes: The version indicator should be consistent for the entire claim and for all ICD diagnosis and procedure codes. Text 1
Multiple versionsMC040 External Cause of Injury (ECI) Code - 1 Use this field to report the first injury, poisoning, or adverse effect using an ICD diagnosis code. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC040A External Cause of Injury (ECI) Code - 2 Use this field to report the second injury, poisoning, or adverse effect using an ICD diagnosis code. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC040B External Cause of Injury (ECI) Code - 3 Use this field to report the third injury, poisoning, or adverse effect using an ICD diagnosis code. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC041 Principal Diagnosis Use this field to report the ICD diagnosis for the principal diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC042 Other Diagnosis - 1 Use this field to report the ICD diagnosis code for the first secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC043 Other Diagnosis - 2 Use this field to report the ICD diagnosis code for the second secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC044 Other Diagnosis - 3 Use this field to report the ICD diagnosis code for the third secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC045 Other Diagnosis - 4 Use this field to report the ICD diagnosis code for the fourth secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC046 Other Diagnosis - 5 Use this field to report the ICD diagnosis code for the fifth secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC047 Other Diagnosis - 6 Use this field to report the ICD diagnosis code for the sixth secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC048 Other Diagnosis - 7 Use this field to report the ICD diagnosis code for the seventh secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC049 Other Diagnosis - 8 Use this field to report the ICD diagnosis code for the eighth secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC050 Other Diagnosis - 9 Use this field to report the ICD diagnosis code for the ninth secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC051 Other Diagnosis - 10 Use this field to report the ICD diagnosis code for the tenth secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC052 Other Diagnosis - 11 Use this field to report the ICD diagnosis code for the eleventh secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC053 Other Diagnosis - 12 Use this field to report the ICD diagnosis code for the twelfth secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC054 Revenue Code Use this field to report the revenue code for institutional claims. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Code using leading zeroes to ensure a full complement of four digits. Leave this field null for professional claims. Text 4
Multiple versionsMC055 Procedure Code Use this field to report the HCPCS, CPT, or HIPPS code for the service rendered. Text 5
Multiple versionsMC056 Procedure Modifier - 1 Use this field to report the first modifier indicating that a service or procedure has been altered by some specific circumstance but has not been changed in its definition or code. Text 2
Multiple versionsMC057 Procedure Modifier - 2 Use this field to report the second modifier indicating that a service or procedure has been altered by some specific circumstance but has not been changed in its definition or code. Text 2
Multiple versionsMC057A Procedure Modifier - 3 Use this field to report the third modifier indicating that a service or procedure has been altered by some specific circumstance but has not been changed in its definition or code. Text 2
Multiple versionsMC057B Procedure Modifier - 4 Use this field to report the fourth modifier indicating that a service or procedure has been altered by some specific circumstance but has not been changed in its definition or code. Text 2
Multiple versionsMC058 Principal ICD Procedure Code Use this field to report the principal ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058A Other ICD Procedure Code - 1 Use this field to report the second ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058B Other ICD Procedure Code - 2 Use this field to report the third ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058C Other ICD Procedure Code - 3 Use this field to report the fourth ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058D Other ICD Procedure Code - 4 Use this field to report the fifth ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058E Other ICD Procedure Code - 5 Use this field to report the sixth ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058F Other ICD Procedure Code - 6 Use this field to report the seventh ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058G Other ICD Procedure Code - 7 Use this field to report the eighth ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058H Other ICD Procedure Code - 8 Use this field to report the ninth ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058I Other ICD Procedure Code - 9 Use this field to report the tenth ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058J Other ICD Procedure Code - 10 Use this field to report the eleventh ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058K Other ICD Procedure Code - 11 Use this field to report the twelfth ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058L Other ICD Procedure Code - 12 Use this field to report the thirteenth ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058M Other ICD Procedure Code - 13 Use this field to report the fourteenth ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058N Other ICD Procedure Code - 14 Use this field to report the fifteenth ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058O Other ICD Procedure Code - 15 Use this field to report the sixteenth ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058P Other ICD Procedure Code - 16 Use this field to report the seventeenth ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058Q Other ICD Procedure Code - 17 Use this field to report the eighteenth ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058R Other ICD Procedure Code - 18 Use this field to report the nineteenth ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058S Other ICD Procedure Code - 19 Use this field to report the twentieth ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058T Other ICD Procedure Code - 20 Use this field to report the twenty-first ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058U Other ICD Procedure Code - 21 Use this field to report the twenty-second ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058V Other ICD Procedure Code - 22 Use this field to report the twenty-third ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058W Other ICD Procedure Code - 23 Use this field to report the twenty-fourth ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC058X Other ICD Procedure Code - 24 Use this field to report the twenty-fifth ICD procedure code on inpatient claims only. Notes: The ICD procedure must be repeated for all lines of the claim if necessary. This field must be null for professional claims. Do not include the decimal point when coding this field. Text 7
Multiple versionsMC059 Date of Service (From) Use this field to report the first date of service for this service line using an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Notes: Dates subsequent to the Paid Date are not acceptable. Date CCYYMMDD 8
Multiple versionsMC060 Date of Service (Through) Use this field to report the last date of service for this service line using an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Notes: Dates subsequent to the Date of Service (From) and the Paid Date are not acceptable. Date CCYYMMDD 8
Multiple versionsMC061 Quantity Use this field to report a count of services performed. Notes: This field may be negative. When coding this field, always report with two decimal places. If the actual value includes three decimal places, round to two. Do not include the decimal point when coding this field. Decimal 10,2
Multiple versionsMC062 Charge Amount Use this field to report the total charges for the service. Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. Decimal 10,2
Multiple versionsMC063 Paid Amount Use this field to report the total dollar amount paid to the provider, including all health plan payments and excluding all member payments and withholds from providers. Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. Decimal 10,2
Multiple versionsMC063A Payment Indicator Use this field to report whether the payment is reported on the header or line. Notes: If "H," populate all lines included in the global payment with an "H." Note that some claims may have a combination of lines paid at the Header and Line level and so may have both "H" and "L" records reported. If "L," populate each line as necessary. As payers' systems are updated to store this information, it should be reported to the APCD. Text 1
Multiple versionsMC064A Payment Arrangement Indicator Use this field to report the payment arrangement under which this claim has been processed. The actual amount paid should be reported in the Paid Amount field (MC063); the fee-for-service equivalent, if available, should be reported in the Fee-for-Service Equivalent field (MC064B). Text 1
Multiple versionsMC064B Fee-for-Service Equivalent Use this field to report the fee-for-service equivalent that would have been paid by the healthcare claims processor for a specific service if the service had not been capitated or paid under a bundled or managed care withhold payment arrangement. This field should contain the sum of the monies that would have been paid to the provider had funds not been withheld under a managed care withhold arrangement (i.e., the sum of the actual amount paid to the provider (Paid Amount; MC063) plus the amount withheld.) Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. Decimal 10,2
Multiple versionsMC065 Copay Amount Use this field to report the preset, fixed dollar amount payable by a member, often on a per visit/service basis. Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. Decimal 10,2
Multiple versionsMC066 Coinsurance Amount Use this field to report the dollar amount that a member must pay toward the cost of a covered service, which is often a percentage of total cost. Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. Decimal 10,2
Multiple versionsMC067 Deductible Amount Use this field to report the dollar amount that a member must pay before the health plan benefits will begin to reimburse for services. Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. Decimal 10,2
Multiple versionsMC068 Medical Record Number Use this field to report the member's medical record number. Text 20
Multiple versionsMC069 Discharge Date Use this field to report the discharge date of the patient from inpatient care using an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC070 Rendering Provider Country Use this field to report the name of the country where the service was rendered. Notes: Please code only a two-digit response - "US" - to indicate the United States. Text 30
Multiple versionsMC071 DRG Use this field to report the Diagnosis-Related Group (DRG) if available. Text 7
Multiple versionsMC072 DRG Version Use this field to declare the version of Diagnosis-Related Group (DRG) reported in MC071. Text 4
Multiple versionsMC073 APC Use this field to report the Ambulatory Payment Classification (APC) if available. Text 5
Multiple versionsMC074 APC Version Use this field to declare the version of the Ambulatory Payment Classification (APC) reported in MC073. Text 2
Multiple versionsMC075 National Drug Code Use this field to report the National Drug Code (NDC) assigned by the U.S. Food and Drug Administration (FDA). Text 11
Multiple versionsMC076 Billing Provider Plan ID Use this field to report the submitter-assigned billing provider number. Notes: This should be the identifier used by the submitter for internal reasons and should not routinely change. Text 50
Multiple versionsMC077 Billing Provider NPI Use this field to report the National Provider Identifier (NPI) for the billing provider. Text 10
Multiple versionsMC078 Billing Provider Last Name or Organization Name Use this field to report the last name of the billing provider if an individual or the full name if an organization. Text 60
Multiple versionsMC080 Placeholder N/A N/A N/A
Multiple versionsMC081 Placeholder N/A N/A N/A
Multiple versionsMC082 Placeholder N/A N/A N/A
Multiple versionsMC083 Placeholder N/A N/A N/A
Multiple versionsMC084 Placeholder N/A N/A N/A
Multiple versionsMC101 Subscriber Last Name Use this field to report the subscriber's last name. Notes: The value reported for this field should be consistent with the value reported in ME101 ("Subscriber Last Name") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 60
Multiple versionsMC102 Subscriber First Name Use this field to report the subscriber's first name. Notes: The value reported for this field should be consistent with the value reported in ME102 ("Subscriber First Name") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 35
Multiple versionsMC103 Subscriber Middle Initial Use this field to report the subscriber's middle initial. Notes: The value reported for this field should be consistent with the value reported in ME103 ("Subscriber Middle Initial") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 1
Multiple versionsMC104 Member Last Name Use this field to report the member's last name. Notes: If the member is the subscriber, report the subscriber's last name again in this field. The value reported for this field should be consistent with the value reported in ME104 ("Member Last Name") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 60
Multiple versionsMC105 Member First Name Use this field to report the member's first name. Notes: If the member is the subscriber, report the subscriber's first name again in this field. The value reported for this field should be consistent with the value reported in ME105 ("Member First Name") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 35
Multiple versionsMC106 Member Middle Initial Use this field to report the member's middle initial. Notes: If the member is the subscriber, report the subscriber's middle initial again in this field. The value reported for this field should be consistent with the value reported in ME106 ("Member Middle Initial") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 1
Multiple versionsMC201 Aid Category For Medicaid claims only, use this field to report the member's Medicaid aid category based on service date. Text 2
Multiple versionsMC212 Category Of Service For Medicaid claims only, use this field to report the member's Medicaid category of service. Text 4
Multiple versionsMC215 Fund Source Code For Medicaid claims only, use this field to report the Medicaid funding source. Text 2
Multiple versionsMC401 Other Diagnosis - 13 Use this field to report the ICD diagnosis code for the thirteenth secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC402 Other Diagnosis - 14 Use this field to report the ICD diagnosis code for the fourteenth secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC403 Other Diagnosis - 15 Use this field to report the ICD diagnosis code for the fifteenth secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC404 Other Diagnosis - 16 Use this field to report the ICD diagnosis code for the sixteenth secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC405 Other Diagnosis - 17 Use this field to report the ICD diagnosis code for the seventeenth secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC406 Other Diagnosis - 18 Use this field to report the ICD diagnosis code for the eighteenth secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC407 Other Diagnosis - 19 Use this field to report the ICD diagnosis code for the nineteenth secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC408 Other Diagnosis - 20 Use this field to report the ICD diagnosis code for the twentieth secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC409 Other Diagnosis - 21 Use this field to report the ICD diagnosis code for the twenty- first secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC410 Other Diagnosis - 22 Use this field to report the ICD diagnosis code for the twenty- second secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC411 Other Diagnosis - 23 Use this field to report the ICD diagnosis code for the twenty- third secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC412 Other Diagnosis - 24 Use this field to report the ICD diagnosis code for the twenty- fourth secondary diagnosis. Notes: Do not include the decimal point when coding this field. Text 7
Multiple versionsMC413 Present on Admission - ECI Code - 1 Use this field to report whether or not the first external cause of injury code was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC413A Present on Admission - External Cause of Injury (ECI) Code - 2 Use this field to report whether or not the second external cause of injury code was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC413B Present on Admission - External Cause of Injury (ECI) Code - 3 Use this field to report whether or not the third external cause of injury code was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC414 Present on Admission - Principal Diagnosis Code Use this field to report whether or not the primary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC415 Present on Admission - Other Diagnosis - 1 Use this field to report whether or not the first secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC416 Present on Admission - Other Diagnosis - 2 Use this field to report whether or not the second secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC417 Present on Admission - Other Diagnosis - 3 Use this field to report whether or not the third secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC418 Present on Admission - Other Diagnosis - 4 Use this field to report whether or not the fourth secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC419 Present on Admission - Other Diagnosis - 5 Use this field to report whether or not the fifth secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC420 Present on Admission - Other Diagnosis - 6 Use this field to report whether or not the sixth secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC421 Present on Admission - Other Diagnosis - 7 Use this field to report whether or not the seventh secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC422 Present on Admission - Other Diagnosis - 8 Use this field to report whether or not the eighth secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC423 Present on Admission - Other Diagnosis - 9 Use this field to report whether or not the ninth secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC424 Present on Admission - Other Diagnosis - 10 Use this field to report whether or not the tenth secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC425 Present on Admission - Other Diagnosis - 11 Use this field to report whether or not the eleventh secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC426 Present on Admission - Other Diagnosis - 12 Use this field to report whether or not the twelfth secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC427 Present on Admission - Other Diagnosis - 13 Use this field to report whether or not the thirteenth secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC428 Present on Admission - Other Diagnosis - 14 Use this field to report whether or not the fourteenth secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC429 Present on Admission - Other Diagnosis - 15 Use this field to report whether or not the fifteenth secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC430 Present on Admission - Other Diagnosis - 16 Use this field to report whether or not the sixteenth secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC431 Present on Admission - Other Diagnosis - 17 Use this field to report whether or not the seventeenth secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC432 Present on Admission - Other Diagnosis - 18 Use this field to report whether or not the eighteenth secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC433 Present on Admission - Other Diagnosis - 19 Use this field to report whether or not the nineteenth secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC434 Present on Admission - Other Diagnosis - 20 Use this field to report whether or not the twentieth secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC435 Present on Admission - Other Diagnosis - 21 Use this field to report whether or not the twenty-first secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC436 Present on Admission - Other Diagnosis - 22 Use this field to report whether or not the twenty-second secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC437 Present on Admission - Other Diagnosis - 23 Use this field to report whether or not the twenty-third secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC438 Present on Admission - Other Diagnosis - 24 Use this field to report whether or not the twenty-fourth secondary diagnosis was present on admission. Notes: Valid codes are maintained by the National Uniform Billing Committee (NUBC) and are available in the UB-04 Data Specifications Manual. Text 1
Multiple versionsMC439 DRG Outlier Payment Amount For Medicare claims only, use this field to report the additional payment amount approved by the Peer Review Organization due to an outlier situation for a beneficiary's stay under the prospective payment system, which has been classified into a specific diagnosis related group. Notes: When reporting this field, always report with two decimal places. Do not code the decimal point when reporting to Onpoint. Decimal 12,2
Multiple versionsMC440 Payer-Supplied Claim Type For Medicaid and Medicare claims only, use this field to indicate the type of claim using the payer's classification system. Text 2
Multiple versionsMC441 Claim Utilization Day Count For Medicare claims only, use this field to report the number of covered days of care that are chargeable to Medicare facility utilization that includes full days, coinsurance days, and lifetime reserve days. Integer 6
Multiple versionsMC445 Non-Payment Reason Code Use this field to report the reason that no payment was made for services on an institutional claim. Text 2
Multiple versionsMC446 Primary Payer Code For Medicare claims only, use this field to specify a federal non-Medicare program or other source that has primary responsibility for the payment of the Medicare beneficiary's medical bills relating to the line item service on the non- institutional claim. Text 2
Multiple versionsMC447 Line Processing Indicator For a non-institutional Medicare claim only, use this field to report to whom payment was made or if the claim was denied. Text 2
Multiple versionsMC448 Claim Coinsurance Days For Medicare claims only, use this field to report the count of the total number of coinsurance days involved with the beneficiary's stay in a facility. Integer 22
Multiple versionsMC449 Claim Final Bill Code For Medicare claims only, use this field to report the type of claim record being processed with respect to payment (e.g., debit/credit indicator; interim/final indicator; etc.). Integer 22
Multiple versionsMC451 Claim MCO Paid Switch For Medicare claims only, use this field to report whether or not a managed care organization (MCO) has paid the provider for an institutional claim. Text 2
Multiple versionsMC452 Noncovered Charge Amount For Medicare claims only, use this field to report the charge amount related to a revenue center code for services that are not covered by Medicare. Decimal 10,2
Multiple versionsMC454 Type of Service Code Use this field to report the type of service for this line item on a professional claim. Text 2
Multiple versionsMC456 Attending Provider Last Name Use this field to report the last name of the attending provider on an institutional claim. Text 60
Multiple versionsMC457 Attending Provider First Name Use this field to report the first name of the attending provider on an institutional claim. Text 35
Multiple versionsMC458 Attending Provider Middle Initial Use this field to report the middle initial of the attending provider on an institutional claim. Text 1
Multiple versionsMC459 Attending Provider NPI Use this field to report the NPI of the attending provider on an institutional claim. Text 10
Multiple versionsMC460 Operating Provider Last Name Use this field to report the last name of the operating provider on an institutional claim. Text 60
Multiple versionsMC460A Operating Provider First Name Use this field to report the first name of the operating provider on an institutional claim. Text 35
Multiple versionsMC460B Operating Provider Middle Initial Use this field to report the middle initial of the operating provider on an institutional claim. Text 1
Multiple versionsMC461 Operating Provider NPI Use this field to report the NPI of the operating provider on an institutional claim. Text 10
Multiple versionsMC462 Other Provider NPI Use this field to report the NPI of the other provider on an institutional claim. Text 10
Multiple versionsMC463 Ordering Provider NPI Use this field to report the NPI of the ordering provider on an institutional claim. Text 10
Multiple versionsMC464 Referring Provider NPI Use this field to report the NPI of the referring provider. Text 10
Multiple versionsMC465 Date Performed - ICD Primary Procedure Code Use this field to report the date on which the primary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC466 Date Performed - Other ICD Procedure Code - 1 Use this field to report the date on which the first secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC467 Date Performed - Other ICD Procedure Code - 2 Use this field to report the date on which the second secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC468 Date Performed - Other ICD Procedure Code - 3 Use this field to report the date on which the third secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC469 Date Performed - Other ICD Procedure Code - 4 Use this field to report the date on which the fourth secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC470 Date Performed - Other ICD Procedure Code - 5 Use this field to report the date on which the fifth secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC471 Date Performed - Other ICD Procedure Code - 6 Use this field to report the date on which the sixth secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC472 Date Performed - Other ICD Procedure Code - 7 Use this field to report the date on which the seventh secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC473 Date Performed - Other ICD Procedure Code - 8 Use this field to report the date on which the eighth secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC474 Date Performed - Other ICD Procedure Code - 9 Use this field to report the date on which the ninth secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC475 Date Performed - Other ICD Procedure Code - 10 Use this field to report the date on which the tenth secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC476 Date Performed - Other ICD Procedure Code - 11 Use this field to report the date on which the eleventh secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC477 Date Performed - Other ICD Procedure Code - 12 Use this field to report the date on which the twelfth secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC478 Date Performed - Other ICD Procedure Code - 13 Use this field to report the date on which the thirteenth secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC479 Date Performed - Other ICD Procedure Code - 14 Use this field to report the date on which the fourteenth secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC480 Date Performed - Other ICD Procedure Code - 15 Use this field to report the date on which the fifteenth secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC481 Date Performed - Other ICD Procedure Code - 16 Use this field to report the date on which the sixteenth secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC482 Date Performed - Other ICD Procedure Code - 17 Use this field to report the date on which the seventeenth secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC483 Date Performed - Other ICD Procedure Code - 18 Use this field to report the date on which the eighteenth secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC484 Date Performed - Other ICD Procedure Code - 19 Use this field to report the date on which the nineteenth secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC485 Date Performed - Other ICD Procedure Code - 20 Use this field to report the date on which the twentieth secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC486 Date Performed - Other ICD Procedure Code - 21 Use this field to report the date on which the twenty-first secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC487 Date Performed - Other ICD Procedure Code - 22 Use this field to report the date on which the twenty-second secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC488 Date Performed - Other ICD Procedure Code - 23 Use this field to report the date on which the twenty-third secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC489 Date Performed - Other ICD Procedure Code - 24 Use this field to report the date on which the twenty-fourth secondary ICD procedure was performed. Notes: When coding this field, use an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsMC899 Record Type Use this field to report the constant value of "MC" to denote a medical claims record. Text 2
Multiple versionsTR001 Record Type This field must be coded TR to indicate the start of the trailer record. Text 2
Multiple versionsTR002 Submitter Code This field must contain the submitter code assigned to you by Onpoint Health Data. Text 8
Multiple versionsTR003 Placeholder This field must be coded as null; it is reserved for trailer consistency across all clients using Onpoint CDM. Text 30
Multiple versionsTR004 Type of File This field must be coded MC to indicate submission of medical claims data. Text 2
Multiple versionsTR005 Period Beginning Date Use this field to report the earliest payment year/month included in the submission in CCYYMM format. Submissions with records containing a Payment Date / Settlement Date (MC017) outside of the date range indicated in this file's header and trailer records will fail. Integer CCYYMM 6
Multiple versionsTR006 Period Ending Date Use this field to report the latest payment year/month included in the submission in CCYYMM format. Submissions with records containing a Payment Date / Settlement Date (MC017) outside of the date range indicated in this file's header and trailer records will fail. Integer CCYYMM 6
Multiple versionsTR007 Date Processed Use this field to report the date on which the file was created in CCYYMMDD format. Date CCYYMMDD 8

File Specification for Multiple versionsMedical Eligibility File Submission - June 2014 - v1.3

Data Element ID Data Element Description Type Format Length
Multiple versionsHD001 Record Type This field must be coded HD to indicate the start of the header record. Text 2
Multiple versionsHD002 Submitter Code This field must contain the submitter code assigned to you by Onpoint Health Data. Text 8
Multiple versionsHD003 Placeholder This field must be coded as null; it is reserved for header consistency across all clients using Onpoint Health Data's APCD services. Text 30
Multiple versionsHD004 Type of File This field must be coded ME to indicate submission of eligibility data. Text 2
Multiple versionsHD005 Period Beginning Date Use this field to report the earliest eligibility year/month included in the submission in CCYYMM format. Submissions with records containing an eligibility period (ME004, ME005) before this date will fail. Integer 6
Multiple versionsHD006 Period Ending Date Use this field to report the latest eligibility year/month included in the submission in CCYYMM format. Submissions with records containing an eligibility period (ME004, ME005) after this date will fail. Integer CCYYMM 6
Multiple versionsHD007 Record Count Use this field to report the total number of records in the submission, excluding the header and trailer records. If the number of records within the submission does not equal the number reported in this field, the submission will fail. Integer 10
Multiple versionsHD008 Comments This field may be used by the submitter to document a file name, system source, or other administrative device to assist with their internal tracking of the submission. Text 80
Multiple versionsME001 Submitter Code Use this field to report your Onpoint-assigned submitter code for the data submitter. Note that the first two characters of the submitter code are used to indicate the reporting state and the third character designates the type of submitter. Notes: A single data submitter may have multiple submitter codes if they are submitting from more than one system or from more than one location. All submitter codes associated with a single data submitter will have the same first six characters. A suffix will be used to distinguish the location and/or system variations. This field contains a constant value and is primarily used for tracking compliance by data submitter. Text 8
Multiple versionsME002 NAIC Use this field to report, at a record level, the code as assigned by the NAIC that uniquely identifies the applicable insurance plan. If no NAIC number has been assigned, report as "0". Text 5
Multiple versionsME003 Insurance Type / Product Code Use this field to report the member's type of insurance or insurance product. Notes: The value reported for this field should be reported consistently in the "Insurance Type / Product Code" field in both the medical claims (MC003) and pharmacy claims (PC003) data. To ensure reporting consistency between submitters, all Medicare Advantage plans should use the code "HN" to denote a Health Maintenance Organization (HMO) - Medicare Risk. Valid codes are maintained by the Accredited Standards Committee (ASC) and are available in the ASC X12 transaction set. Text 2
Multiple versionsME004 Year Use this field to report the year of eligibility using a 4-digit format of CCYY (e.g., January 1972, would be coded as "1972"). Integer CCYY 4
Multiple versionsME005 Month Use this field to report the month of eligibility using a 2-digit format of MM (e.g., January would be coded as "01"). Text MM 2
Multiple versionsME005A Days Eligible Use this field to report the number of days for which the member was eligible during this reporting period. Integer 3
Multiple versionsME006 Insured Group or Policy Number Use this field to report the group or policy number. Notes: The value reported for this field should be reported consistently in the "Insured Group or Policy Number" field in both the medical claims (MC006) and pharmacy claims (PC006) data. This is not the number that uniquely identifies the subscriber. If a policy is sold to an individual as a non-group policy, then both the Insured Group or Policy Number (ME006) and Group Name (ME037) should be reported with a value of "IND". This principle pertains to all claim types: commercial, Medicaid, and Medicare. Text 50
Multiple versionsME007 Coverage Level Code Use this field to report the benefit level of coverage. Notes: Valid codes are maintained by the Accredited Standards Committee (ASC) and are available in the ASC X12 transaction set. Text 3
Multiple versionsME008 Subscriber Social Security Number Use this field to report the subscriber's 9-digit Social Security number. Notes: The value reported for this field should be reported consistently in the "Subscriber Social Security Number" field in both the medical claims (MC007) and pharmacy claims (PC007) data. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 9
Multiple versionsME009 Plan-Specific Contract Number Use this field to report the submitter-assigned contract number for the subscriber. Notes: The value reported for this field should be reported consistently in the "Plan-Specific Contract Number" field in both the medical claims (MC008) and pharmacy claims (PC008) data. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 80
Multiple versionsME010 Member Suffix or Sequence Number Use this field to report the unique number of the member within the contract. Text 20
Multiple versionsME010A Unique Member Identifier Use this field to report the Unique Member Identifier assigned by the Lockbox Vendor. Notes: The value for this field will be supplied in the Response File from the Lockbox Vendor using the field RF017. The value reported for this field should be reported consistently in the Unique Member Identifier field in both the medical claims (MC010A) and pharmacy claims (PC010A) data. String 32
Multiple versionsME010B Unique Member Identifier (Legacy) Use this field to report the Unique Member Identifier (Legacy) previously assigned by the Lockbox Vendor. Notes: The value for this field will be supplied in the Response File from the Lockbox Vendor using the field RF020. This legacy ID has been replaced by the Unique Member Identifier reported above in ME010A. This change is due to the merging or splitting of the member's previously assigned Unique Member Identifier as identified by the code reported in the Response File from the Lockbox Vendor using the field RF019 (and below in ME010C). String 32
Multiple versionsME010C Unique Member Identifier Merge/Split Indicator Use this field to report a code that indicates whether a legacy ID was created because a member's ID was merged with another ID (for a member identified by the Lockbox Vendor as being reported duplicatively) or split into a different ID (for a member identified by the Lockbox Vendor as incorrectly previously grouped under a single Unique Member ID) Notes: The value for this field will be supplied in the Response File from the Lockbox Vendor using the field RF019. Text 1
Multiple versionsME010D Member Opt-Out Status Use this field to indicate that a member has elected to opt out of having their data submitted to the APCD as provided to you in the Lockbox Vendor's Response File using field RF018. Notes: The value for this field will be supplied in the Response File from the Lockbox Vendor using the field RF018. Even though you may have submitted a value of I for this field to the Lockbox Vendor, indicating inclusion in the APCD, the member may have requested to opt out via another insurer or the Opt- Out Portal, therefore, therefore requiring a value of O to be returned to all insurers providing coverage for the same individual. If the value reported in the Member Opt-Out Status field is O, the only reportable data fields for this record are Submitter Code (ME001), Year (ME004), Month (ME005), Unique Member Identifier (ME010A), and Member Opt-Out Status (ME010D) and Record Type (ME899); all other fields must be reported as null. Text 1
Multiple versionsME011 Member Social Security Number Use this field to report the member's 9-digit Social Security number. Notes: The value reported for this field should be consistently reported in the "Member Social Security Number" field in both the medical claims (MC010) and pharmacy claims (PC010) data. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 9
Multiple versionsME012 Member Relationship Use this field to report the member's relationship to the subscriber or the insured. Notes: The value reported for this field should be consistently reported in the "Member Relationship" field in both the medical claims (MC011) and pharmacy claims (PC011) data. Valid codes are maintained by the Accredited Standards Committee (ASC) and are available in the ASC X12 transaction set. Text 2
Multiple versionsME013 Member Gender Use this field to report the member's gender. Notes: The value reported for this field should be consistently reported in the "Member Gender" field in both the medical claims (MC012) and pharmacy claims (PC012) data. Text 1
Multiple versionsME014 Member Date of Birth Use this field to report the member's date of birth using an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Notes: The value reported for this field should be consistently reported in the "Member Date of Birth" field in both the medical claims (MC013) and pharmacy claims (PC013) data. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Immediately prior to hashing this field, Onpoint's hashing application calculates a member's age in months based on the Member Date of Birth field (ME014, MC013, PC013). The Member Date of Birth field is then hashed and both the hashed value and the value- added Age in Months element are submitted to the APCD - the hashed value to allow for quality assurance review, the de-identified Age in Months to enable analytic use of the APCD. Date CCYYMMDD 8
Multiple versionsME015 Member City Use this field to report the name of the member's city of residence. Text 30
Multiple versionsME016 Member State or Province Use this field to report the member's state or province using the two-character abbreviation code defined by the U.S. Postal Service (for U.S. states) and Canada Post (for Canadian provinces). Text 2
Multiple versionsME017 Member ZIP/Postal Code Use this field to report the ZIP/postal code of the member's residence. Notes: For U.S. ZIP codes, include the ZIP+4 (also referred to as the "plus-four" or "add-on" code). Do not code dashes or spaces within ZIP/postal codes. Text 9
Multiple versionsME018 Medical Coverage Use this field to report whether or not the member had medical coverage during the reported period. Text 1
Multiple versionsME019 Prescription Drug Coverage Use this field to report whether or not the member had prescription drug coverage during the reported period. Y ...................... Yes N...................... No Text 1
Multiple versionsME021 Race - 1 Use this field to report the member's primary race. If data has not been collected, leave as null. Text 6
Multiple versionsME022 Race - 2 Use this field to report the member's secondary race. If data has not been collected, leave as null. Text 6
Multiple versionsME023 Race - Other Use this field to report a member's self-disclosed race when ME021 or ME022 is reported as R9 (Other Race). Notes: Leave null if not applicable. Text 15
Multiple versionsME024 Hispanic Indicator Use this field to report whether or not a member has identified as Hispanic. Notes: If the data has not been collected, leave as null. Text 1
Multiple versionsME025 Ethnicity - 1 Use this field to report the member's primary ethnicity. Notes: The code "UNKNOW" (Unknown / Not specified) should be used only when a member answers unknown or refuses to answer. If data has not been collected, leave as null. Text 6
Multiple versionsME026 Ethnicity - 2 Use this field to report the member's secondary ethnicity. Notes: The code "UNKNOW" (Unknown / Not specified) should be used only when a member answers unknown or refuses to answer. If data has not been collected, leave as null. Text 6
Multiple versionsME027 Ethnicity - Other Use this field to report a member's self-disclosed ethnicity when either ME025 or ME026 is reported as OTHER (Other ethnicity). Notes: Leave null if not applicable. Text 20
Multiple versionsME028 Primary Insurance Indicator Use this field to report whether or not this coverage is primary. Text 1
Multiple versionsME029 Coverage Type Use this field to report the type of coverage, distinguishing self-funded plans from commercially insured plans. Text 3
Multiple versionsME030 Market Category Code Use this field to report the type of policy sold by the insurer. Text 4
Multiple versionsME031 Placeholder N/A N/A N/A
Multiple versionsME032 PCMH Assigned Flag Use this field to report whether or not the member has an approved medical home for this coverage period. Text 1
Multiple versionsME033 PCMH Number Use this field to report the submitter-assigned number for the medical home when ME032 is reported as Y. Notes: Leave null if not applicable. Text 30
Multiple versionsME034 PCMH Tax ID Use this field to report the federal taxpayer's identification number for the medical home when ME032 is reported as Y. Notes: Leave null if not applicable. Text 9
Multiple versionsME035 PCMH NPI Use this field to report the National Provider Identifier (NPI) for the medical home when ME032 is reported as Y. Notes: Leave null if not applicable. Text 10
Multiple versionsME036 PCMH Name Use this field to report the full name of the medical home when ME032 is reported as Y. Notes: If an individual, report in the format of last name, first name, and middle initial with no punctuation (e.g., John J. Doe would be reported as "DOEJOHNJ"). Leave null if not applicable. Text 60
Multiple versionsME037 Group Name Use this field to report the name of the group that covers the member. Notes: If a policy is sold to an individual as a non-group policy, then both the Insured Group or Policy Number (ME006) and Group Name (ME037) should be reported with a value of "IND". This principle pertains to all claim types: commercial, Medicaid, and Medicare. Text 60
Multiple versionsME050 Assigned Primary Care Provider Flag Use this field to report whether or not the member identified a primary care provider at the time of enrollment. Text 1
Multiple versionsME051 Assigned Primary Care Provider Plan ID Use this field to report the submitter-assigned or legacy provider plan ID for the member's primary care provider. Note: The provider data reported in the eligibility, claims, and provider files are used to create a Provider Master Index that is used to match the data across all file types. It is expected that a provider's identifiers (e.g., plan-assigned ID, NPI, etc.) will be reported consistently by a submitter across file types as this is the payer-assigned provider ID (ME051, MC024, PC048A, PV006). Text 50
Multiple versionsME052 Assigned Primary Care Provider NPI Use this field to report the National Provider Identifier (NPI) for the member's assigned primary care provider. Text 10
Multiple versionsME053 Assigned Primary Care Provider Last Name Use this field to report the last name of the member's assigned primary care provider. Text 60
Multiple versionsME054 Assigned Primary Care Provider First Name Use this field to report the first name of the member's assigned primary care provider. Text 35
Multiple versionsME055 Assigned Primary Care Provider Middle Initial Use this field to report the middle initial of the member's assigned primary care provider. Text 1
Multiple versionsME056 Assigned Primary Care Provider Street Address 1 Use this field to report the first line of the street address for the member's assigned primary care provider. Text 55
Multiple versionsME057 Assigned Primary Care Provider Street Address 2 Use this field to report the second line of the street address for the member's assigned primary care provider (if needed). Text 55
Multiple versionsME058 Assigned Primary Care Provider City Use this field to report the city of the member's assigned primary care provider. Text 30
Multiple versionsME059 Assigned Primary Care Provider State or Province Use this field to report the state or province of the member's assigned primary care provider using the two-character abbreviation defined by the U.S. Postal Service (for U.S. states) and Canada Post (for Canadian provinces). Text 2
Multiple versionsME060 Assigned Primary Care Provider ZIP/Postal Code Use this field to report the ZIP/postal code of the member's assigned primary care provider. Notes: For U.S. ZIP codes, include the ZIP+4 (also referred to as the "plus-four" or "add-on" code). Do not code dashes or spaces within ZIP/postal codes. Text 9
Multiple versionsME070 Purchased Through Exchange Indicator Use this field to indicate whether or not the product was purchased through the Rhode Island Health Benefits Exchange. Text 1
Multiple versionsME071 Exchange Market Type Use this field to report the type of policy sold by the insurer through the Exchange. Text 2
Multiple versionsME072 HIOS ID Use this field to report the member's type of insurance or insurance product provided through the Exchange. Text 17
Multiple versionsME073 Exchange Metallic Tier Use this field to report the metallic tier that designates the level of the member's Exchange product. Text 1
Multiple versionsME080 Placeholder N/A N/A N/A
Multiple versionsME081 Placeholder N/A N/A N/A
Multiple versionsME082 Placeholder N/A N/A N/A
Multiple versionsME083 Placeholder N/A N/A N/A
Multiple versionsME084 Placeholder N/A N/A N/A
Multiple versionsME101 Subscriber Last Name Use this field to report the subscriber's last name. Notes: The value reported for this field should be consistently reported in the "Subscriber Last Name" field in both the medical claims (MC101) and pharmacy claims (PC101) data. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 60
Multiple versionsME102 Subscriber First Name Use this field to report the subscriber's first name. Notes: The value reported for this field should be consistently reported in the "Subscriber First Name" field in both the medical claims (MC102) and pharmacy claims (PC102) data. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 35
Multiple versionsME103 Subscriber Middle Initial Use this field to report the subscriber's middle initial. Notes: The value reported for this field should be consistently reported in the "Subscriber Middle Initial" field in both the medical claims (MC103) and pharmacy claims (PC103) data. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 1
Multiple versionsME104 Member Last Name Use this field to report the member's last name. Notes: The value reported for this field should be consistently reported in the "Member Last Name" field in both the medical claims (MC104) and pharmacy claims (PC104) data. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 60
Multiple versionsME105 Member First Name Use this field to report the member's first name. Notes: The value reported for this field should be consistently reported in the "Member First Name" field in both the medical claims (MC105) and pharmacy claims (PC105) data. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 35
Multiple versionsME106 Member Middle Initial Use this field to report the member's middle initial. Notes: The value reported for this field should be consistently reported in the "Member Middle Initial" field in both the medical claims (MC106) and pharmacy claims (PC106) data. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 1
Multiple versionsME201 Aid Category For Medicaid claims only, use this field to report the member's Medicaid aid category based on service date. Text 2
Multiple versionsME202 Dual Eligibility Flag For Medicaid and Medicare claims only, use this field to report whether or not a member had both Medicaid and Medicare coverage (i.e., dual coverage) for the reported membership month. Text 2
Multiple versionsME203 Placeholder N/A N/A N/A
Multiple versionsME205 Long-Term Care (LTC) Coverage Flag For Medicaid claims only, use this field to report the level of care provided to a member who had long-term care coverage for the reported membership month. Text 1
Multiple versionsME206 Attributed Income Level For Medicaid claims only, use this field to report the member's attributed income level for the reported membership month. These codes are based on aid categories and tie back to a member's specific eligibility, which may cause overlap in code values. Notes: Do not include the decimal point when coding this field. Text 1
Multiple versionsME212 Third-Party Liability Flag For Medicaid claims only, use this field to indicate that the member was covered by commercial insurance as well. Text 1
Multiple versionsME213 Medicaid Program Code Use this field to report the Medicaid program in which the member was enrolled for the reported month. Text 2
Multiple versionsME401 Date of Death Use this field to report the member's date of death using an 6-digit format of CCYYMM (e.g., January 1972 would be coded as "197201"). Date CCYYMM 8
Multiple versionsME402 Risk Score For Medicare claims only, use this field to report the member's most recent risk score. Notes: Always report with three decimal places. Do not code the decimal place when reporting this field to Onpoint. Decimal 22,3
Multiple versionsME404 Hospice Status Indicator For Medicare claims only, use this field to report whether or not a patient was enrolled in hospice. Text 2
Multiple versionsME405 Medicare Advantage Indicator For Medicare claims only, use this field to report whether or not the member is a participant in a group health organization (GHO). Text 2
Multiple versionsME406 Medicare Status Indicator For Medicare claims only, use this field to report the member's Medicare status with relationship to Aged, ESRD (End Stage Renal Disease), and Disability. Text 2
Multiple versionsME407 Monthly Reason For Entitlement For Medicare claims only, use this field to report whether the member qualified for Medicare for a specific reported eligibility month as Aged, Disabled, ESRD (End Stage Renal Disease), or Disabled and ESRD. Text 2
Multiple versionsME408 Original Reason For Entitlement For Medicare claims only, use this field to report the reason for the beneficiary's original entitlement to Medicare benefits. Text 2
Multiple versionsME899 Record Type Use this field to report the constant value of "ME" to denote a member eligibility record. Text 2
Multiple versionsTR001 Record Type This field must be coded TR to indicate the start of the trailer record. Text 2
Multiple versionsTR002 Submitter Code This field must contain the submitter code assigned to you by Onpoint Health Data. Text 8
Multiple versionsTR003 Placeholder This field must be coded as null; it is reserved for trailer consistency across all clients using Onpoint CDM. Text 30
Multiple versionsTR004 Type of File This field must be coded ME to indicate submission of eligibility data. Text 2
Multiple versionsTR005 Period Beginning Date Use this field to report the earliest eligibility year/month included in the submission in CCYYMM format. Submissions with records containing an eligibility period (ME004, ME005) before this date will fail. Integer CCYYMM 6
Multiple versionsTR006 Period Ending Date Use this field to report the latest eligibility year/month included in the submission in CCYYMM format. Submissions with records containing an eligibility period (ME004, ME005) after this date will fail. Integer CCYYMM 6
Multiple versionsTR007 Date Processed Use this field to report the date on which the file was created in CCYYMMDD format. Date CCYYMMDD 8

File Specification for Multiple versionsPharmacy Claims File Submission - June 2014 - v1.3

Data Element ID Data Element Description Type Format Length
Multiple versionsHD001 Record Type This field must be coded HD to indicate the start of the header record. Text 2
Multiple versionsHD002 Submitter Code This field must contain the submitter code assigned to you by Onpoint Health Data. Text 8
Multiple versionsHD003 Placeholder This field must be coded as null; it is reserved for header consistency across all clients using Onpoint Health Data's APCD services. Text 30
Multiple versionsHD004 Type of File This field must be coded PC to indicate submission of pharmacy claims data. Text 2
Multiple versionsHD005 Period Beginning Date Use this field to report the earliest date service approved year/month included in the submission in CCYYMM format. Submissions with records containing a Payment Date / Settlement Date value (PC017) outside of the date range indicated in this file's header and trailer records will fail. Integer CCYYMM 6
Multiple versionsHD006 Period Ending Date Use this field to report the latest date service approved year/month included in the submission in CCYYMM format. Submissions with records containing a Payment Date / Settlement Date value (PC017) outside of the date range indicated in this file's header and trailer records will fail. Integer CCYYMM 6
Multiple versionsHD007 Record Count Use this field to report the total number of records in the submission, excluding the header and trailer records. If the number of records within the submission does not equal the number reported in this field, the submission will fail. Integer 10
Multiple versionsHD008 Comments This field may be used by the submitter to document a file name, system source, or other administrative device to assist with their internal tracking of the submission. Text 80
Multiple versionsPC001 Submitter Code Use this field to report your Onpoint-assigned submitter code for the data submitter. Note that the first two characters of the submitter code are used to indicate the reporting state and the third character designates the type of submitter. For Rhode Island's APCD collection, valid prefixes include: Notes: A single data submitter may have multiple submitter codes if they are submitting from more than one system or from more than one location. All submitter codes associated with a single data submitter will have the same first six characters. A suffix will be used to distinguish the location and/or system variations. This field contains a constant value and is primarily used for tracking compliance by data submitter. Text 8
Multiple versionsPC002 NAIC Use this field to report, at a record level, the code as assigned by the NAIC that uniquely identifies the applicable insurance plan. If no NAIC number has been assigned, report as "0". Text 5
Multiple versionsPC003 Insurance Type / Product Code Use this field to report the member's type of insurance or insurance product. Notes: The value reported for this field should be consistent with the value reported in ME003 ("Insurance Type / Product Code") in the eligibility file. To ensure reporting consistency between submitters, all Medicare Advantage plans should use the code "HN" to denote a Health Maintenance Organization (HMO) - Medicare Risk. Valid codes are maintained by the Accredited Standards Committee (ASC) and are available in the ASC X12 transaction set. Text 2
Multiple versionsPC004 Payer Claim Control Number Use this field to report the claim number used by the data submitter to internally track the claim. Notes: In general, the claim number is associated with all service lines of the claim. It must apply to the entire claim and be unique within the data submitter's system. The value reported in this field should remain consistent over time. If reporting multiple versions of the same claim, this number should remain the same; use PC005A (Version Number) to report multiple versions of the same claim subject to subsequent changes/adjustments. Text 50
Multiple versionsPC004A Claim Submitter's Identifier Use this field to report the claim number used by the pharmacy to track a claim from creation through payment. Text 38
Multiple versionsPC005 Line Counter Use this field to report the line number for this service. Notes: The line counter should begin with 1 and be incremented by 1 for each additional service line of a claim. Integer 4
Multiple versionsPC005A Version Number Use this field to report the version number of the claim service record. Notes: The version number should begin with 0 and be incremented by 1 for each subsequent version of that service line. If versioning is not used to report adjusted claims, report claims with a Version Number of zero (0). Integer 4
Multiple versionsPC006 Insured Group or Policy Number Use this field to report the group or policy number. Notes: This is not the number that uniquely identifies the subscriber. The value reported for this field should be consistent with the value reported in the Insured Group or Policy Number fields across all file types (ME006, MC006, PC006). If a policy is sold to an individual as a non-group policy, then this field should be reported with a value of "IND". This principle pertains to all claim types: commercial, Medicaid, and Medicare. Text 50
Multiple versionsPC007 Subscriber Social Security Number Use this field to report the subscriber's 9-digit Social Security number. Notes: The value reported for this field should be consistent with the value reported in ME008 ("Subscriber Social Security Number") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 9
Multiple versionsPC008 Plan-Specific Contract Number Use this field to report the submitter-assigned contract number for the subscriber. Notes: The value reported for this field should be consistent with the value reported in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 80
Multiple versionsPC009 Member Suffix or Sequence Number Use this field to report the unique number of the member within the contract. Text 20
Multiple versionsPC010 Member Social Security Number Use this field to report the member's 9-digit Social Security number. Notes: The value reported for this field should be consistent with the value reported in ME011 ("Member Social Security Number") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 9
Multiple versionsPC010A Unique Member Identifier Use this field to report the Unique Member Identifier assigned by the Lockbox Vendor in the Response File's field RF017. Notes: The value reported for this field should be reported identically to the "Unique Member Identifier" field in the eligibility file (ME010A). String 32
Multiple versionsPC011 Member Relationship Use this field to report the member's relationship to the subscriber or the insured. Notes: The value reported for this field should be consistent with the value reported in ME012 ("Member Relationship") in the eligibility file. Valid codes are maintained by the National Council for Prescription Drug Programs (NCPDP) and are available in the NCPDP standards set. Text 2
Multiple versionsPC012 Member Gender Use this field to report the member's gender. Notes: The value reported for this field should be consistent with the value reported in ME013 ("Member Gender") in the eligibility file. Valid codes are maintained by the National Council for Prescription Drug Programs (NCPDP) and are available in the NCPDP standards set. Please note that an additional gender code has been added for this field to accommodate a non-NCPDP value of O (Other). Text 1
Multiple versionsPC013 Member Date of Birth Use this field to report the member's date of birth using an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Notes: The value reported for this field should be consistent with the value reported in ME014 ("Member Date of Birth") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Immediately prior to hashing this field, Onpoint's hashing application calculates a member's age in months based on the Member Date of Birth field (ME014, MC013, PC013). The Member Date of Birth field is then hashed and both the hashed value and the value- added Age in Months element are submitted to the APCD - the hashed value to allow for quality assurance review, the de-identified Age in Months to enable analytic use of the APCD. Date CCYYMMDD 8
Multiple versionsPC014 Member City Use this field to report the name of the member's city of residence. Text 30
Multiple versionsPC015 Member State or Province Use this field to report the member's state or province using the two-character abbreviation code defined by the U.S. Postal Service(for U.S. states) and Canada Post (for Canadian provinces). Text 2
Multiple versionsPC016 Member ZIP/Postal Code Use this field to report the ZIP/postal code associated with the member's residence. Notes: For U.S. ZIP codes, include the ZIP+4 (also referred to as the "plus-four" or "add-on" code). Do not code dashes or spaces within ZIP/postal codes. Text 9
Multiple versionsPC017 Payment Date / Settlement Date Use this field to report the date on which the record was approved for payment using an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Notes: This is generally referred to as the paid date and reported with a CCYYMMDD format. When BPR04 is "NON" for nonpayment, include remittance date. Date CCYYMMDD 8
Multiple versionsPC018 Pharmacy Number Use this field to report the payer-assigned pharmacy number. Text 30
Multiple versionsPC019 Pharmacy Tax ID Number Use this field to report the pharmacy's federal taxpayer's identification number. Text 9
Multiple versionsPC020 Pharmacy Name Use this field to report the name of the pharmacy. Text 30
Multiple versionsPC020A Mail-Order Pharmacy Use this field to report whether or not this pharmacy is a mail-order pharmacy. Text 1
Multiple versionsPC020B Out-of-Network Indicator Use this field to report whether or not the pharmacy at which the prescription was filled was out of network. Text 1
Multiple versionsPC021 National Pharmacy ID Number Use this field to report the National Provider Identification (NPI) of the pharmacy. Text 10
Multiple versionsPC022 Pharmacy Location City Use this field to report the city where the prescription was filled. Text 30
Multiple versionsPC023 Pharmacy Location State or Province Use this field to report the state or province where the prescription was filled using the two- character abbreviation defined by the U.S. Postal Service (for U.S. states) and Canada Post (for Canadian provinces). Text 2
Multiple versionsPC024 Pharmacy ZIP/Postal Code Use this field to report the ZIP/postal code where the prescription was filled. Notes: For U.S. ZIP codes, include the ZIP+4 (also referred to as the "plus-four" or "add-on" code). Do not code dashes or spaces within ZIP/postal codes. Text 9
Multiple versionsPC024A Pharmacy Country Use this field to report the name of the country where the prescription was filled. Notes: Please code only a two-digit response - "US" - to indicate the United States. Text 30
Multiple versionsPC025 Claim Status Use this field to report the status of the claim - whether paid as primary, paid as secondary, denied, etc. Notes: Valid codes are maintained by the Accredited Standards Committee (ASC) and are available in the ASC X12 transaction set. Text 2
Multiple versionsPC026 National Drug Code Use this field to report the National Drug Code assigned by the U.S. Food and Drug Administration (FDA). Text 11
Multiple versionsPC027 Drug Name Use this field to report the text name of the drug. Notes: Valid codes are maintained by the National Council for Prescription Drug Programs (NCPDP) and are available in the NCPDP standards set. Text 80
Multiple versionsPC028 New Prescription or Refill Use this field to report whether this is a new prescription or refill. Integer 2
Multiple versionsPC029 Generic Drug Indicator Use this field to report whether the drug is a branded drug or a generic drug. Text 1
Multiple versionsPC030 Dispense as Written Code Use this field to report the instructions given to the pharmacist for filling the prescription. Notes: Valid codes are maintained by the National Council for Prescription Drug Programs (NCPDP) and are available in the NCPDP standards set. Integer 1
Multiple versionsPC031 Compound Drug Indicator Use this field to indicate whether or not the drug is a compound drug. Notes: Valid codes are maintained by the National Council for Prescription Drug Programs (NCPDP) and are available in the NCPDP standards set. Text 1
Multiple versionsPC032 Date Prescription Filled Use this field to report the date on which the prescription was filled using an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsPC033 Quantity Dispensed Use this field to report the total unit dosage in metric units. Notes: This field may contain a negative value. When coding this field, always report with two decimal places. If the actual value included three decimal place, round to two. Do not include the decimal point when coding this field. Decimal 10,2
Multiple versionsPC034 Days' Supply Use this field to report the days' supply for the prescription based on the metric quantity dispensed. Notes: This field may contain a negative value. Integer 3
Multiple versionsPC035 Charge Amount Use this field to report total charges for the prescription as reported by the pharmacy. Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. Decimal 10,2
Multiple versionsPC036 Paid Amount Use this field to report the total dollar amount paid to the provider, including all health plan payments and excluding all member payments and withholds from providers. Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. Decimal 10,2
Multiple versionsPC037 Ingredient Cost / List Price Use this field to report the cost of the drug that was dispensed. Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. Decimal 10,2
Multiple versionsPC038 Postage Amount Claimed Use this field to report the cost of postage included in the Paid Amount field (PC036). Notes: Do not include the decimal point when coding this field. Decimal 10,2
Multiple versionsPC039 Dispensing Fee Use this field to report the amount charged for dispensing the prescription. Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. Decimal 10,2
Multiple versionsPC040 Copay Amount Use this field to report the preset, fixed dollar amount payable by a member, often on a per visit/service basis. Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. Decimal 10,2
Multiple versionsPC041 Coinsurance Amount Use this field to report the dollar amount that a member must pay toward the cost of a covered service. Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. Decimal 10,2
Multiple versionsPC042 Deductible Amount Use this field to report the dollar amount that a member must pay before the health plan benefits will begin to reimburse for services. Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. Decimal 10,2
Multiple versionsPC044 Prescribing Provider First Name Use this field to report the first name of the prescribing provider. Text 35
Multiple versionsPC045 Prescribing Provider Middle Initial Use this field to report the middle initial of the prescribing provider. Text 1
Multiple versionsPC046 Prescribing Provider Last Name Use this field to report the last name of the prescribing provider. Text 60
Multiple versionsPC047 Prescribing Provider DEA Number Use this field to report the prescribing provider's Drug Enforcement Agency (DEA) number. Text 9
Multiple versionsPC047A Prescribing Provider State License Number Use this field to report the prescribing provider's state license number. Text 20
Multiple versionsPC047B Prescribing Provider Street Address Use this field to report the prescribing provider's street address. Text 55
Multiple versionsPC047C Prescribing Provider City Use this field to report the prescribing provider's city. Text 30
Multiple versionsPC047D Prescribing Provider State or Province Use this field to report the prescribing provider's state using the two-character abbreviation defined by the U.S. Postal Service (for U.S. states) and Canada Post (for Canadian provinces). Text 2
Multiple versionsPC047E Prescribing Provider ZIP/Postal Code Use this field to report the prescribing provider's ZIP/postal code associated with the prescribing provider's location. Notes: For U.S. ZIP codes, include the ZIP+4 (also referred to as the "plus-four" or "add-on" code). Do not code dashes or spaces within ZIP/postal codes. Text 9
Multiple versionsPC048 Prescribing Provider NPI Use this field to report the prescribing provider's National Provider Identifier (NPI). Text 10
Multiple versionsPC048A Prescribing Provider Plan ID Use this field to report the payer-supplied ID for the prescribing provider. Note: The provider data reported in the eligibility, claims, and provider files are used to create a Provider Master Index that is used to match the data across all file types. It is expected that a provider's identifiers (e.g., plan-assigned ID, NPI, etc.) will be reported consistently by a submitter across file types as this is the payer-assigned provider ID (ME051, MC024, PC048A, PV006). Text 15
Multiple versionsPC080 Placeholder N/A N/A N/A
Multiple versionsPC081 Placeholder N/A N/A N/A
Multiple versionsPC082 Placeholder N/A N/A N/A
Multiple versionsPC083 Placeholder N/A N/A N/A
Multiple versionsPC084 Placeholder N/A N/A N/A
Multiple versionsPC101 Subscriber Last Name Use this field to report the subscriber's last name. Notes: The value reported for this field should be consistent with the value reported in ME101 ("Subscriber Last Name") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 60
Multiple versionsPC102 Subscriber First Name Use this field to report the subscriber's first name. Notes: The value reported for this field should be consistent with the value reported in ME102 ("Subscriber First Name") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 35
Multiple versionsPC103 Subscriber Middle Initial Use this field to report the subscriber's middle initial. Notes: The value reported for this field should be consistent with the value reported in ME103 ("Subscriber Middle Initial") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 1
Multiple versionsPC104 Member Last Name Use this field to report the member's last name. Notes: If the member is the subscriber, report the subscriber's last name again in this field. The value reported for this field should be consistent with the value reported in ME104 ("Member Last Name") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 60
Multiple versionsPC105 Member First Name Use this field to report the member's first name. Notes: If the member is the subscriber, report the subscriber's first name again in this field. The value reported for this field should be consistent with the value reported in ME105 ("Member First Name") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 35
Multiple versionsPC106 Member Middle Initial Use this field to report the member's middle initial. Notes: If the member is the subscriber, report the subscriber's middle initial again in this field. The value reported for this field should be consistent with the value reported in ME106 ("Member Middle Initial") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. Text 1
Multiple versionsPC899 Record Type Use this field to report the constant value of "PC" to denote a pharmacy claims record. Text 2
Multiple versionsTR001 Record Type This field must be coded TR to indicate the start of the trailer record. Text 2
Multiple versionsTR002 Submitter Code This field must contain the submitter code assigned to you by Onpoint Health Data. Text 8
Multiple versionsTR003 Placeholder This field must be coded as null; it is reserved for trailer consistency across all clients using Onpoint CDM. Text 30
Multiple versionsTR004 Type of File This field must be coded PC to indicate submission of pharmacy claims data. Text 2
Multiple versionsTR005 Period Beginning Date Use this field to report the earliest date service approved year/month included in the submission in CCYYMM format. Submissions with records containing a Payment Date / Settlement Date value (PC017) outside of the date range indicated in this file's header and trailer records will fail. Integer CCYYMM 6
Multiple versionsTR006 Period Ending Date Use this field to report the latest date service approved year/month included in the submission in CCYYMM format. Submissions with records containing a Payment Date / Settlement Date value (PC017) outside of the date range indicated in this file's header and trailer records will fail. Integer CCYYMM 6
Multiple versionsTR007 Date Processed Use this field to report the date on which the file was created in CCYYMMDD format. Date CCYYMMDD 8

File Specification for Multiple versionsProvider File Submission - June 2014 - v1.3

Data Element ID Data Element Description Type Format Length
Multiple versionsHD001 Record Type This field must be coded HD to indicate the start of the header record. Text 2
Multiple versionsHD002 Submitter Code This field must contain the submitter code assigned to you by Onpoint Health Data. Text 8
Multiple versionsHD003 Placeholder This field must be coded as null; it is reserved for header consistency across all clients using Onpoint Health Data's APCD services. Text 30
Multiple versionsHD004 Type of File This field must be coded PV to indicate submission of provider data. Text 2
Multiple versionsHD005 Period Beginning Date Use this field to indicate the first month of the reporting period included in the submission in CCYYMM format. Integer CCYYMM 6
Multiple versionsHD006 Period Ending Date Use this field to report the last month of the reporting period included in the submission in CCYYMM format. Integer CCYYMM 6
Multiple versionsHD007 Record Count Use this field to report the total number of records in the submission, excluding the header and trailer records. If the number of records within the submission does not equal the number reported in this field, the submission will fail. Integer 10
Multiple versionsHD008 Comments This field may be used by the submitter to document a file name, system source, or other administrative device to assist with their internal tracking of the submission. Text 80
Multiple versionsPV001 Submitter Code Use this field to report your Onpoint-assigned submitter code for the data submitter. Note that the first two characters of the submitter code are used to indicate the reporting state and the third character designates the type of submitter. For Rhode Island's APCD collection, valid prefixes include: Notes: A single data submitter may have multiple submitter codes if they are submitting from more than one system or from more than one location. All submitter codes associated with a single data submitter will have the same first six characters. A suffix will be used to distinguish the location and/or system variations. This field contains a constant value and is primarily used for tracking compliance by data submitter. Text 8
Multiple versionsPV002 National Plan ID Use this field to report the CMS National Plan ID when implemented by the U.S. Centers for Medicaid & Medicare Services (CMS). Until CMS issues a National Plan ID, report this field as null. Text 30
Multiple versionsPV003 Reporting Period Start Date Use this field to report the first date of the reporting period for this submission using an 8-digit format of CCYYMMDD (e.g., if reporting for the first quarter of 2012, this field would be coded as "20120101"). Date CCYYMMDD 8
Multiple versionsPV004 Reporting Period End Date Use this field to report the last date of the reporting period for this submission using an 8-digit format of CCYYMMDD (e.g., if reporting for the first quarter of 2012, this field would be coded as "20120331"). Date CCYYMMDD 8
Multiple versionsPV005 Entity Type Qualifier Use this field to report the value that defines type of entity associated with the Provider Plan ID reported in PV006. Text 1
Multiple versionsPV006 Provider Plan ID Use this field to report the submitter-assigned internal provider ID (e.g., Medicaid ID, Medicare ID, private carrier ID). Note: The provider data reported in the eligibility, claims, and provider files are used to create a Provider Master Index that is used to match the data across all file types. It is expected that a provider's identifiers (e.g., plan-assigned ID, NPI, etc.) will be reported consistently by a submitter across file types as this is the payer-assigned provider ID (ME051, MC024, PC048A, PV006). Text 50
Multiple versionsPV007 Provider NPI Use this field to report the National Provider Identifier (NPI) for the provider. Text 10
Multiple versionsPV008 Provider Tax ID Use this field to report the federal taxpayer identification number for the provider. Notes: If the tax ID number is an individual's Social Security number, report this field as null. Text 9
Multiple versionsPV010 Provider DEA Number Use this field to report the individual provider's Drug Enforcement Agency (DEA) number. Text 10
Multiple versionsPV011 Provider License ID Use this field to report the provider's state license number. Text 20
Multiple versionsPV013 Provider Taxonomy Code - 1 Use this field to report the taxonomy code for the provider. Text 10
Multiple versionsPV014 Provider Taxonomy Code - 2 Use this field to report an additional taxonomy code for the provider. Text 10
Multiple versionsPV015 Provider Last Name or Organization Name Use this field to report the last name of the provider if an individual or the full name if the provider is a facility or an organization. Text 100
Multiple versionsPV016 Provider First Name Use this field to report the first name of the provider if an individual. Notes: Set to null if the provider is a facility or an organization. Text 35
Multiple versionsPV017 Provider Middle Initial Use this field to report the middle initial of the provider if an individual. Notes: Set to null if the provider is a facility or an organization. Text 1
Multiple versionsPV018 Provider Suffix Use this field to report any generational identifiers associated with the provider's name (e.g., JR, SR, III). Notes: Do not code punctuation and do not code the provider's credentials (e.g., MD, LCSW) in this field. Set to null if the provider is a facility or an organization. Text 10
Multiple versionsPV019 Entity Name Use this field to report the practice or hospital with which the provider is affiliated. Note that a new record should be reported for each affiliation (i.e., if a provider is affiliated with two practices, two records should be reported). If a provider is a sole practitioner and their name is used as the practice name, the provider's name should be reported in this field. If a provider's affiliation is unknown, report with a value of "UNKNOWN". Notes: When reporting this field, omit any punctuation Text 100
Multiple versionsPV020 Entity Code Use this field to report the value that defines the entity provider type. Text 2
Multiple versionsPV021 Practice Affiliation Date (Start) Use this field to report either (a) the first date of the reporting period or (b) the first date of this provider's affiliation with this practice, whichever is later. Notes: When reporting this field, code using an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsPV022 Practice Affiliation Date (End) Use this field to report either (a) the last date of the reporting period or (b) the last date of this provider's affiliation with this practice, whichever is earlier. Notes: When reporting this field, code using an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Date CCYYMMDD 8
Multiple versionsPV023 Provider Gender Use this field to report the gender of the provider if an individual. Notes: Set to null if the provider is a facility or an organization. Text 1
Multiple versionsPV024 Provider Date of Birth Use this field to report the provider's date of birth (if an individual) using an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Notes: Set to null if the provider is a facility or an organization. Date CCYYMMDD 8
Multiple versionsPV025 Provider Physical Location - Street Address 1 Use this field to report the first line of the street address for the physical location where the provider rendered the service (medical claims) or dispensed the prescription (pharmacy claims). Notes: A new record must be reported for each physical location reported in the claims file. Text 55
Multiple versionsPV026 Provider Physical Location - Street Address 2 Use this field to report the second line of the street address for the physical location where the provider rendered the service (medical claims) or dispensed the prescription (pharmacy claims). Notes: A new record must be reported for each physical location reported in the claims file. Text 55
Multiple versionsPV027 Provider Physical Location - City Use this field to report the city for the physical location where the provider rendered the service (medical claims) or dispensed the prescription (pharmacy claims). Notes: A new record must be reported for each physical location reported in the claims file. Text 30
Multiple versionsPV028 Provider Physical Location - State or Province Use this field to report the state or province for the physical location where the provider rendered the service (medical claims) or dispensed the prescription (pharmacy claims) using the two-character abbreviation defined by the U.S. Postal Service (for U.S. states) and Canada Post (for Canadian provinces). Notes: A new record must be reported for each physical location reported in the claims file. Text 2
Multiple versionsPV029 Provider Physical Location - ZIP/Postal Code Use this field to report the ZIP/postal code for the physical location where the provider rendered the service (medical claims) or dispensed the prescription (pharmacy claims). Notes: For U.S. ZIP codes, include the ZIP+4 (also referred to as the "plus-four" or "add-on" code). Do not code dashes or spaces within ZIP/postal codes. A new record must be reported for each physical location reported in the claims file. Text 9
Multiple versionsPV030 Placeholder N/A N/A N/A
Multiple versionsPV031 Placeholder N/A N/A N/A
Multiple versionsPV032 Placeholder N/A N/A N/A
Multiple versionsPV033 Placeholder N/A N/A N/A
Multiple versionsPV034 Placeholder N/A N/A N/A
Multiple versionsPV899 Record Type Use this field to report the constant value of "PV" to denote a provider file record. Text 2
Multiple versionsTR001 Record Type This field must be coded TR to indicate the start of the trailer record. Text 2
Multiple versionsTR002 Submitter Code This field must contain the submitter code assigned to you by Onpoint Health Data. Text 8
Multiple versionsTR003 Placeholder This field must be coded as null; it is reserved for trailer consistency across all clients using Onpoint CDM. Text 30
Multiple versionsTR004 Type of File This field must be coded PV to indicate submission of provider data. Text 2
Multiple versionsTR005 Period Beginning Date Use this field to indicate the first month of the reporting period included in the submission in CCYYMM format. Integer CCYYMM 6
Multiple versionsTR006 Period Ending Date Use this field to report the last month of the reporting period included in the submission in CCYYMM format. Integer CCYYMM 6
Multiple versionsTR007 Date Processed Use this field to report the date on which the file was created in CCYYMMDD format. Date CCYYMMDD 8

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