United States Health Information Knowledgebase

 

Utah



Name:Utah
Abbreviation:UT
Title of SystemUtah All-Payer Claims Database
Websitehttp://health.utah.gov/hda/apd/index.php
Who Maintains the SystemUtah Department of Health, Office of Health Care Statistics
Versions:December 5, 2013 - v2.0
August 12, 2009 - v1.3

File Specification for Medical Claims File Submission - December 5, 2013 - v2.0

Data Element ID Data Element Description Type Format Length
MC001 Payer Code Distributed by OHCS varchar 8
MC002 Payer Name Distributed by OHCS varchar 30
MC003 Insurance Type/Product Code Not Provided char 2
MC004 Payer Claim Control Number Must apply to the entire claim and be unique within the payer's system. No partial claims. Only paid (or partially paid) claims varchar 35
MC005 Line Counter Line number for this service. The line counter begins with 1 and is incremented by 1 for each additional service line of a claim. All claims must contain a line 1. int 4
MC005A Version Number The version number of this claim service line. The original claim will have a version number of 0, with the next version being assigned a 1, and each subsequent version being incremented by 1 for that service line. Plans that cannot increment this column may opt to use YYMM as the version number. int 4
MC006 Insured Group or Policy Number Group or policy number - not the number that uniquely identifies the subscriber. varchar 30
MC007 Subscriber Social Security Number Subscriber's social security number; Set as null if unavailable varchar 9
MC008 Plan Specific Contract Number Plan assigned subscriber's contract number; Set as null if contract number = subscriber's social security number or use an alternate unique identifier such as Medicaid ID. Must be an identifier that is unique to the subscriber. varchar 128
MC009 Member Suffix or Sequence Number Unique number of the member within the contract. Must be an identifier that is unique to the member. Must match ME010. varchar 128
MC010 Member Identification Code (patient) Member's social security number; Set as blank if unavailable. varchar 9
MC011 Individual Relationship Code Member's relationship to insured - payers will map their available codes to those listed in Lookup Table B-1.B char 2
MC012 Member Gender Not Provided char 1
MC013 Member Date of Birth Not Provided char YYYYMMDD 8
MC014 Member City Name City name of member varchar 30
MC107 Member Street Address Physical street address of the covered member Varchar 50
MC015 Member State or Province As defined by the US Postal Service char 2
MC016 Member ZIP Code ZIP Code of member - may include non- US codes. Plus 4 optional but desired. varchar 11
MC017 Date Service Approved/Accounts Payable Date/Actual Paid Date Not Provided char YYYYMMDD 8
MC018 Admission Date Required for all inpatient claims. char YYYYMMDD 8
MC019 Admission Hour Required for all inpatient claims. Time is expressed in military time char HHMM 4
MC020 Admission Type Required for all inpatient claims (SOURCE: National Uniform Billing Data Element Specifications) int 1
MC021 Admission Source Required for all inpatient claims (SOURCE: National Uniform Billing Data Element Specifications) Need Values from Treo char 1
MC022 Discharge Hour Time expressed in military time int HHMM 4
MC023 Discharge Status Required for all inpatient claims. char 2
MC024 Service Provider Number Payer assigned service provider number. Submit facility for institutional claims; physician or healthcare professional for professional claims. Must match MP001. varchar 30
MC025 Service Provider Tax ID Number Federal taxpayer's identification number varchar 10
MC026 Service National Provider ID National Provider ID. This data element pertains to the entity or individual directly providing the service. varchar 20
MC027 Service Provider Entity Type Qualifier HIPAA provider taxonomy classifies provider groups (clinicians who bill as a group practice or under a corporate name, even if that group is composed of one provider) as a "person", and these shall be coded as a person. char 1
MC028 Service Provider First Name Individual first name. Set to null if provider is a facility or organization. varchar 25
MC029 Service Provider Middle Name Individual middle name or initial. Set to null if provider is a facility or organization. varchar 25
MC030 Service Provider Last Name or Organization Name Full name of provider organization or last name of individual provider varchar 60
MC031 Service Provider Suffix Suffix to individual name. Set to null if provider is a facility or organization. The service provider suffix shall be used to capture the generation of the individual clinician (e.g., Jr., Sr., III), if applicable, rather than the clinician's degree (e.g., MD, LCSW). varchar 10
MC032 Service Provider Specialty Report the HIPAA-compliant health care provider taxonomy code. Code set is freely available at the National Uniform Claims Committee's web site at http://www.nucc.org/ varchar 50
MC108 Service Provider Street Address Physical practice location street address of the provider administering the services Varchar 50
MC033 Service Provider City Name City name of provider - preferably practice location varchar 30
MC034 Service Provider State or Province As defined by the US Postal Service char 2
MC035 Service Provider ZIP Code ZIP Code of provider - may include non- US codes; do not include dash. Plus 4 optional but desired. varchar 11
MC036 Type of Bill - Institutional Required for institutional claims; Not to be used for professional claims char 3
MC037 Facility Type - Professional Required for professional claims. Not to be used for institutional claims. Map where you can and default to "99" for all others. char 2
MC038 Claim Status Not Provided char 2
MC039 Admitting Diagnosis Required on all inpatient admission claims and encounters. ICD-9-CM or ICD-10-CM. Do not code decimal point. varchar 7
MC898 ICD-9 / ICD-10 Flag The purpose of this field is to identify which code set is being utilized. char 1
MC040 E-Code Describes an injury, poisoning or adverse effect. ICD-9-CM or ICD-10-CM. Do not code decimal point. varchar 7
MC041 Principal Diagnosis ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
MC042 Other Diagnosis - 1 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
MC043 Other Diagnosis - 2 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
MC044 Other Diagnosis - 3 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
MC045 Other Diagnosis - 4 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
MC046 Other Diagnosis - 5 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
MC047 Other Diagnosis - 6 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
MC048 Other Diagnosis - 7 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
MC049 Other Diagnosis - 8 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
MC050 Other Diagnosis - 9 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
MC051 Other Diagnosis - 10 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
MC052 Other Diagnosis - 11 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
MC053 Other Diagnosis - 12 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
MC054 Revenue Code National Uniform Billing Committee Codes. Code using leading zeroes, left justified, and four digits. char 10
MC055 Outpatient Procedure Code Health Care Common Procedural Coding System (HCPCS); this includes the CPT codes of the American Medical Association. Required for Outpatient and Professional claims only. varchar 10
MC056 Procedure Modifier - 1 Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code. Required for Outpatient and Professional claims only. char 2
MC057 Procedure Modifier - 2 Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code. Required for Outpatient and Professional claims only. char 2
MC058 ICD-9-CM Procedure Code Primary procedure code for this line of service. Do not code decimal point. char 4
MC059 Date of Service - From First date of service for this service line. Date YYYYMMDD 8
MC060 Date of Service - Thru Last date of service for this service line. Date YYYYMMDD 8
MC061 Quantity Count of services performed, which shall be set equal to one on all observation bed service lines and should be set equal to zero on all other room and board service lines, regardless of the length of stay. int 3
MC062 Charge Amount Do not code decimal point or provide any punctuation where $1,000.00 converted to 100000 Same for all financial data that follows. int 10
MC063 Paid Amount Includes any withhold amounts. Treo? Do not code decimal point. For capitated claims set to zero. int 10
MC064 Prepaid Amount For capitated services, the fee for service equivalent amount. Do not code decimal point. int 10
MC065 Co-pay Amount The preset, fixed dollar amount for which the individual is responsible. Do not code decimal point. int 10
MC066 Coinsurance Amount The dollar amount an individual is responsible for - not the percentage. Do not code decimal point. int 10
MC067 Deductible Amount Do not code decimal point. int 10
MC068 Patient Account/Control Number Number assigned by hospital varchar 20
MC069 Discharge Date Date patient discharged. Required for all inpatient claims. Date YYYYMMDD 8
MC070 Service Provider Country Name Code US for United States. Non US? varchar 30
MC071 DRG Insurers and health care claims processors shall code using the CMS methodology when available. Precedence shall be given to DRGs transmitted from the hospital provider. When the CMS methodology for DRGs is not available, but the DRG system is used, the insurer shall format the DRG and the complexity level within the same field with an "A" prefix, and with a hyphen separating the DRG and the complexity level (e.g. AXXX-XX). varchar 10
MC072 DRG Version Version number of the grouper used char 2
MC073 APC Insurers and health care claims processors shall code using the CMS methodology when available. Precedence shall be given to APCs transmitted from the health care provider. char 4
MC074 APC Version Version number of the grouper used char 2
MC075 Drug Code An NDC code used only when a medication is paid for as part of a medical claim. varchar 11
MC076 Billing Provider Number Payer assigned billing provider number. This number should be the identifier used by the payer for internal identification purposes, and does not routinely change. varchar 30
MC077 National Billing Provider ID National Provider ID varchar 20
MC078 Billing Provider Last Name or Organization Name Full name of provider billing organization or last name of individual billing provider. varchar 60
MC101 Subscriber Last Name Subscriber last name varchar 128
MC102 Subscriber First Name Subscriber first name varchar 128
MC103 Subscriber Middle Initial Subscriber middle initial char 1
MC104 Member Last Name Not Provided varchar 128
MC105 Member First Name Not Provided varchar 128
MC106 Member Middle Initial Not Provided char 1
MC201A Present on Admission - PDX Code indicating the presence of diagnosis at the time of admission. Varchar 1
MC201B Present on Admission - DX1 Code indicating the presence of diagnosis at the time of admission for MC201. Varchar 1
MC201C Present on Admission - DX2 Code indicating the presence of diagnosis at the time of admission. Varchar 1
MC201D Present on Admission - DX3 Code indicating the presence of diagnosis at the time of admission. Varchar 1
MC201E Present on Admission - DX4 Code indicating the presence of diagnosis at the time of admission. Varchar 1
MC201F Present on Admission - DX5 Code indicating the presence of diagnosis at the time of admission. Varchar 1
MC201G Present on Admission - DX6 Code indicating the presence of diagnosis at the time of admission. Varchar 1
MC201H Present on Admission - DX7 Code indicating the presence of diagnosis at the time of admission. Varchar 1
MC201I Present on Admission - DX8 Code indicating the presence of diagnosis at the time of admission. Varchar 1
MC201J Present on Admission - DX9 Code indicating the presence of diagnosis at the time of admission. Varchar 1
MC201K Present on Admission - DX10 Code indicating the presence of diagnosis at the time of admission. Varchar 1
MC201L Present on Admission - DX11 Code indicating the presence of diagnosis at the time of admission. Varchar 1
MC201M Present on Admission - DX12 Code indicating the presence of diagnosis at the time of admission. Varchar 1
MC202 Tooth Number Tooth Number or Letter Identification Char 20
MC203 Dental Quadrant Dental Quandrant Char 1
MC204 Tooth Surface Tooth Surface Identification Char 10
MC205 ICD-9-CM Procedure Date Date MC058 was performed Date 8
MC058A ICD-9-CM Procedure Code Secondary procedure code for this line of service. Do not code decimal point. char 4
MC205A ICD-9-CM Procedure Date Date MC058A was performed Date 8
MC058B ICD-9-CM Procedure Code Secondary procedure code for this line of service. Do not code decimal point. char 4
MC205B ICD-9-CM Procedure Date Date MC058B was performed Date 8
MC058C ICD-9-CM Procedure Code Secondary procedure code for this line of service. Do not code decimal point. char 4
MC205C ICD-9-CM Procedure Date Date MC058C was performed Date 8
MC058D ICD-9-CM Procedure Code Secondary procedure code for this line of service. Do not code decimal point. char 4
MC205D ICD-9-CM Procedure Date Date MC058E was performed Date 8
MC058E ICD-9-CM Procedure Code Secondary procedure code for this line of service. Do not code decimal point. char 4
MC205E ICD-9-CM Procedure Date Date MC058E was performed Date 8
MC206 Capitated Service Indicator Not Provided Char 1
MC899 Record Type Not Provided char 2

File Specification for Medical Claims File Submission 837I - August 12, 2009 - v1.3

Data Element ID Data Element Description Type Format Length
1 BHT01 Hierarchical Structure Code BHT06 Transaction Type Code O ID 2/2 Code specifying the type of transaction INDUSTRY: Claim or Encounter Identifier ALIAS: Claim or Encounter Indicator 1808 Use RP when the entire ST-SE envelope contains encounter transmissions. Use RP when the transmission is being sent to an entity (usually not a payer or a normal provider-payer transmission itermediary) for purposes other than adjudication of a claim. Such an entity could be a state health agency which is using the 837 for health data reporting purposes. ID 2/2
2 Functional Group Header GS08 Version / Release / Industry Identifier Code M AN 1/12 Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed AN 1/12
3 Functional Group Header GS01 Code identifying a group of application related transaction sets AN 2/2
4 Submitter Name 1000A NM103 Individual last name or organizational name INDUSTRY: Submitter Last or Organization Name ALIAS: Submitter Name AN 2/80
5 Submitter Identifier 1000A NM109 Code identifying a party or other code INDUSTRY: Submitter Identifier ALIAS: Submitter Primary Identification Number SYNTAX: P0809 AN 2/80
6 Submitter EDI Contact Information 1000A PER01- 05 Code identifying the major duty or responsibility of the person or group named AN 2/80
7 Receiver Name 1000B NM103 Name Last or Organization Name Individual last name or organizational name INDUSTRY: Receiver Name AN 2/80
8 Receiver Identifier 1000B NM109 Not Provided AN 2/80
9 Billing Provider Name 2010AA NM103 Individual last name or organizational name INDUSTRY: Billing Provider Last or Organizational Name ALIAS: Billing Provider Name AN 2/80
10 Billing Provider ID 2010AA NM109 Individual last name or organizational name INDUSTRY: Billing Provider Last or Organizational Name ALIAS: Billing Provider Name AN 2/80
11 Billing Provider Secondary Identification 2010AA REF02 Tax Identifiing information of the Provider that was paid AN 1/30
12 Individual Relationship Code 2000B SBR02 Code indicating the relationship between two individuals or entities ALIAS: Patients Relationship to Insured SEMANTIC: SBR02 specifies the relationship to the person insured. ID 2/2
13 Insured Group or Policy Number 2000B SBR03 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Insured Group or Policy Number ALIAS: Group Number SEMANTIC: SBR03 is policy or group number. AN 1/30
14 Payer Name 2010BC NM103 Individual last name or organizational name AN 1/30
15 Subscriber Lname 2010BA NM103 Individual last name or organizational name INDUSTRY: Subscriber Last Name AN 1/35
16 Subscriber Fname 2010BA NM104 Individual first name INDUSTRY: Subscriber First Name AN 1/25
17 Subscriber Middle Name 2010BA NM105 Individual middle name or initial INDUSTRY: Subscriber Middle Name ALIAS: Subscriber's Middle Initial AN 1/25
18 Subscriber Primary Identifier 2010BA NM109 Code identifying a party or other code INDUSTRY: Subscriber Primary Identifier SYNTAX: P0809 AN 2/80
19 Subscriber Address1 2010BA N301 Address information INDUSTRY: Subscriber Address Line AN 1/55
20 Subscriber Address2 2010BA N302 Address information INDUSTRY: Subscriber Address Line AN 1/55
21 Subscriber City Name 2010BA N401 Free-form text for city name INDUSTRY: Subscriber City Name COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. AN 2/30
22 Subscriber State 2010BA N402 Code (Standard State/Province) as defined by appropriate government agency INDUSTRY: Subscriber State Code COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada. CODE SOURCE 22: States and Outlying Areas of the U.S. ID 2/2
23 Subscriber Zip Code 2010BA N403 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) INDUSTRY: Subscriber Postal Zone or ZIP Code CODE SOURCE 51: ZIP Code ID 3/15
24 Subscriber Date of Birth 2010BA DMG02 Expression of a date, a time, or range of dates, times or dates and times INDUSTRY: Subscriber Birth Date ALIAS: Date of Birth - Patient SYNTAX: P0102 SEMANTIC: DMG02 is the date of birth. AN CCYYMMDD 1/35
25 Subscriber Gender 2010BA DMG03 Code indicating the sex of the individual INDUSTRY: Subscriber Gender Code ALIAS: Gender - Patient AN 1/1
26 Subscriber Secondary Identification Qualifier 2010BA REF01 Code qualifying the Reference Identification ID 2/3
27 Subscriber Secondary Identification 2010BA REF02 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Subscriber Supplemental Identifier SYNTAX: R0203 AN 1/30
28 Patients Relationship to Insured 2000C PAT01 Code indicating the relationship between two individuals or entities ALIAS: Patients Relationship to Insured ID 2/2
29 Patient Lname 2010CA NM103 Individual last name or organizational name INDUSTRY: Patient Last Name AN 1/35
30 Patient Fname 2010CA NM104 Name First O AN 1/25 Individual first name INDUSTRY: Patient First Name AN 1/25
31 Patient Middle Name 2010CA NM105 Individual middle name or initial INDUSTRY: Patient Middle Name AN 1/25
32 Patient Primary Identifier 2010CA NM109 Code identifying a party or other code INDUSTRY: Patient Primary Identifier SYNTAX: P0809 AN 2/80
33 Patient Address1 2010BA/2010CA N301 Address information INDUSTRY: Patient Address Line AN 1/55
34 Patient Address2 2010CA N302 Address information INDUSTRY: Patient Address Line AN 1/55
35 Patient City Name 2010CA N401 Free-form text for city name INDUSTRY: Patient City Name COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. AN 2/30
36 Patient State 2010CA N402 Code (Standard State/Province) as defined by appropriate government agency INDUSTRY: Patient State Code COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada. CODE SOURCE 22: States and Outlying Areas of the U.S. ID 2/2
37 Patient Zip Code 2010CA N403 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) INDUSTRY: Patient Postal Zone or ZIP Code CODE SOURCE 51: ZIP Code ID 3/15
38 Patient Date of Birth 2010CA DMG02 Expression of a date, a time, or range of dates, times or dates and times INDUSTRY: Patient Birth Date ALIAS: Patient's Date of Birth SYNTAX: P0102 SEMANTIC: DMG02 is the date of birth. AN 1/35
39 Patient Gender 2010CA DMG03 Code indicating the sex of the individual INDUSTRY: Patient Gender Code AN 1/1
40 Patient Secondary Identification Qualifier 2010CA REF01 Code qualifying the Reference Identification ID 2/3
41 Patient Secondary Identification 2010CA REF02 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Patient Secondary Identifier SYNTAX: R0203 AN 1/30
42 Facility Type Code (Type of Bill, Positions 1-3) 2300 CLM05-1 Code identifying the type of facility where services were performed; the first through third positions of the Uniform Bill Type code or the Place of Service code from the Electronic Media Claims National Standard Format INDUSTRY: Facility Type Code AN 1/3
45 Claim Frequency Type Code (Type of Bill, Position 4) 2300 CLM05-3 Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type INDUSTRY: Claim Frequency Code CODE SOURCE 235: Claim Frequency Type Code ID 1/1
46 Original Reference Number 2300 REF02 When REF01=F8 Code qualifying the Reference Identification A/N 1/30
47 Admission Date/Hour 2300 DTP03 When DTP01=435 Expression of a date, a time, or range of dates, times or dates and times INDUSTRY: Discharge Hour AN 1/35
48 Institutional Claim Code 2300 CL101 Admission Type Code indicating the priority of this admission CODE SOURCE 231: Admission Type Code ID 1/1
49 Institutional Claim Code 2300 CL102 Admission Source Code indicating the source of this admission CODE SOURCE 230: Admission Source Code ID 1/1
50 Institutional Claim Code 2300 CL103 Patient Status Code Code indicating the source of this admission CODE SOURCE 230: Patient Status Code ID 1/2
51 Diagnosis Related Group (DRG) 2300 HI01-2 When HI01- 1=DR Code indicating a code from a specific industry code list AN 1/30
52 Statement Date 2300 DTP03 when DTP01=434 Expression of a date, a time, or range of dates, times or dates and times INDUSTRY: Discharge Date AN CCYYMMDD 1/35
54 Discharge Hour 2300 DTP03 When DTP01=096 Expression of a date, a time, or range of dates, times or dates and times INDUSTRY: Discharge Hour AN HHMM 1/25
55 Patient Account Number 2300 CLM01 Claim Submitter's Identifier Identifier used to track a claim from creation by the health care provider through payment INDUSTRY: Patient Account Number ALIAS: Patient Control Number AN 1/20
56 Medical Record Number 2300 REF02 When REF01=EA Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Medical Record Number AN 1/30
57 Total Claim Charge Amount 2300 CLM02 Monetary amount INDUSTRY: Total Claim Charge Amount ALIAS: Total Claim Charges SEMANTIC: CLM02 is the total amount of all submitted charges of service segments for this claim. R 1/18
58 Patient Paid Amount 2300 AMT02 When AMT01=F5 Monetary amount INDUSTRY: Patient Amount Paid R 1/18
59 Payer Prior Payment 2320 AMT02 WHEN AMT01=C4 Monetary amount INDUSTRY: Other Payer Patient Paid Amount Prior Payments -Payers R 1/18
60 Service Facility Name 2310E NM103 Individual last name or organizational name INDUSTRY: Laboratory or Facility Name ALIAS: Laboratory/Facility Name AN 1/35
61 Service Facility ID Code 2310E NM109 Code identifying a party or other code INDUSTRY: Laboratory or Facility Primary Identifier ALIAS: Laboratory/Facility Primary Identifier SYNTAX: P0809 AN 2/80
62 Claim Adjudication Date 2330B DTP03 WHEN DTP01=573 Expression of a date, a time, or range of dates, times or dates and times INDUSTRY: Adjudication or Payment Date AN 1/35
63 Coordination of Benefits Total Allowed Amount 2320 AMT02 When AMT01=B6 Monetary amount INDUSTRY: Allowed Amount R 1/18
64 Claim Adjustment Group Code 2320 CAS01 Claim Adjustment Group Code Code identifying the general category of payment adjustment ID 1/2
65 Claim Adjustment Reason Code 2320 CAS02 Claim Adjustment reason Code Code identifying the detailed reason the adjustment was made INDUSTRY: Adjustment Reason Code ID 1/5
66 Claim Level Adjustment Amount 2320 CAS03 Monetary Amount Monetary amount INDUSTRY: Adjustment Amount SEMANTIC: CAS03 is the amount of adjustment. COMMENT: When the submitted charges are paid in full, the value for CAS03 should be zero. R 1/18
67 Laboratory or Facility Primary Identifier 2310E NM109 Code identifying a party or other code INDUSTRY: Laboratory or Facility Primary Identifier ALIAS: Laboratory/Facility Primary Identifier SYNTAX: P0809 AN 2/80
68 Principal, Admitting, E- Code and Patient Reason for Visit Diagnosis Information 2300 HI02-2 When HI02- 1=ZZ PAT Reason for Visit 1 Code indicating a code from a specific industry code list INDUSTRY: Patient's Reason for Visit AN 1/30
69 Principal, Admitting, E- Code and Patient Reason for Visit Diagnosis Information 2300 HI02-2 When HI02- 1=ZZ PAT Reason for Visit 2 Code indicating a code from a specific industry code list INDUSTRY: Patient's Reason for Visit AN 1/30
70 Principal, Admitting, E- Code and Patient Reason for Visit Diagnosis Information 2300 HI02-2 When HI02- 1=ZZ PAT Reason for Visit 3 Code indicating a code from a specific industry code list INDUSTRY: Patient's Reason for Visit AN 1/30
71 Principal, Admitting, E- Code and Patient Reason for Visit Diagnosis Information 2300 HI02-2 When HI02- 1=BJ Admitting DX Code indicating a code from a specific industry code list INDUSTRY: Admitting Diagnosis AN 1/30
72 Principal, Admitting, E- Code and Patient Reason for Visit Diagnosis Information 2300 HI01-2 When HI01- 1=BK Principal DX Code indicating a code from a specific industry code list INDUSTRY: Principal Diagnosis Code AN 99 1/30
73 Present on Admission Indicator 2300 K3 Data in fixed format agreed upon by sender and receiver AN 1/80
74 Other Diagnosis Information 2300 HI01-2 When HI01- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
75 Other Diagnosis Information 2300 HI02-2 When HI02- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
76 Other Diagnosis Information 2300 HI03-2 When HI03- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
77 Other Diagnosis Information 2300 HI04-2 When HI04- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
78 Other Diagnosis Information 2300 HI05-2 When HI05- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
79 Other Diagnosis Information 2300 HI06-2 When HI06- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
80 Other Diagnosis Information 2300 HI07-2 When HI07- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
81 Other Diagnosis Information 2300 HI08-2 When HI08- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
82 Other Diagnosis Information 2300 HI09-2 When HI09- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
83 Other Diagnosis Information 2300 HI10-2 When HI10- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
84 Other Diagnosis Information 2300 HI11-2 When HI11- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
85 Other Diagnosis Information 2300 HI12-2 When HI12- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
86 Principal, Admitting, E- Code and Patient Reason for Visit Diagnosis Information 2300 HI03-2 When HI03- 1=BN E-Code 1 Code indicating a code from a specific industry code list INDUSTRY: External Cause of Injury Code (E- code)] AN 1/30
87 Principal, Admitting, E- Code and Patient Reason for Visit Diagnosis Information 2300 HI03-2 When HI03- 1=BN E-Code 2 Code indicating a code from a specific industry code list INDUSTRY: External Cause of Injury Code (E- code)] AN 1/30
88 Principal, Admitting, E- Code and Patient Reason for Visit Diagnosis Information 2300 HI03-2 When HI03- 1=BN E-Code 3 Code indicating a code from a specific industry code list INDUSTRY: External Cause of Injury Code (E- code)] AN 1/30
89 Principal Procedure Code 2300 HI01-2 When HI01- 1=BR Principal Procedure Code indicating a code from a specific industry code list INDUSTRY: Primary Procedure AN 1/30
90 Principal Procedure Date 2300 HI01-4 When HI01- 1=BR Principal Procedure Date Date Time Period AN CCYYMMDD 1/35
91 Other Procedure Code 2300 HI01-2 When HI01- 1=BQ Code indicating a code from a specific industry code list INDUSTRY: Other Procedure AN 1/30
92 Other Procedure Date 2300 HI01-4 When HI01- 1=BQ Date Time Period AN CCYYMMDD 1/35
93 Other Procedure Code 2300 HI02-2 When HI02- 1=BQ Code indicating a code from a specific industry code list INDUSTRY: Other Procedure AN 1/30
94 Other Procedure Date 2300 HI02-4 When HI02- 1=BQ Date Time Period AN CCYYMMDD 1/35
95 Other Procedure Code 2300 HI03-2 When HI03- 1=BQ Code indicating a code from a specific industry code list INDUSTRY: Other Procedure AN 1/30
96 Other Procedure Date 2300 HI03-4 When HI03- 1=BQ Date Time Period AN CCYYMMDD 1/35
97 Other Procedure Code 2300 HI04-2 When HI04- 1=BQ Code indicating a code from a specific industry code list INDUSTRY: Other Procedure AN 1/30
98 Other Procedure Date 2300 HI04-4 When HI04- 1=BQ Date Time Period AN CCYYMMDD 1/35
99 Other Procedure Code 2300 HI05-2 When HI05- 1=BQ Code indicating a code from a specific industry code list INDUSTRY: Other Procedure AN 1/30
100 Other Procedure Date 2300 HI05-4 When HI05- 1=BQ Date Time Period AN CCYYMMDD 1/35
101 Attending Physician Specialty Information 2000A or 2310A PRV03 Reference Identification Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Provider Taxonomy Code ALIAS: Provider Specialty Code Text 10
102 Attending Physician LName 2310A NM103 Individual last name or organizational name INDUSTRY: Attending Physician Last Name AN 1/35
103 Attending Physician FName 2310A NM104 Individual first name INDUSTRY: Attending Physician First Name AN 1/35
104 Attending Physician Name Middle 2310A NM105 Individual middle name or initial INDUSTRY: Attending Physician Middle Name AN 1/25
105 Attending Physician Name Suffix 2310A NM107 Suffix to individual name INDUSTRY: Attending Physician Name Suffix AN 1/10
106 Attending Physician Primary Identifier 2310A NM109 Code identifying a party or other code INDUSTRY: Attending Physician Primary Identifier SYNTAX: P0809 AN 2/80
107 Attending Physician Secondary Identification 2310A REF02 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Attending Physician Secondary Identifier SYNTAX: R0203 AN 1/30
108 Line Counter 2400 LX01 Number assigned for differentiation within a transaction set ALIAS: Line Counter This is the service line number. Begin with 1 and increment by 1 for each new LX segment within a claim. AN 1/48
109 Date(s) of Service 2400 DTP03 WHEN DTP01=472 Code specifying type of date or time, or both date and time INDUSTRY: Date Time Qualifier AN CCYYMMDD or range: CCYYMMDD-CCYYMMDD 1/35
110 Institutional Service Line Product/Service ID 2400 SV202-2 Identifying number for a product or service INDUSTRY: Procedure Code ALIAS: HCPCS Procedure Code AN 1/48
111 Institutional Service Line Procedure Modifier - 1 2400 SV202-3 This identifies special circumstances related to the performance of the service, as defined by trading partners ALIAS: HCPCS Modifier 1 AN 2/2
112 Institutional Service Line Procedure Modifier - 2 2400 SV202-4 This identifies special circumstances related to the performance of the service, as defined by trading partners ALIAS: HCPCS Modifier 2 AN 2/2
113 Institutional Service Line Procedure Modifier - 3 2400 SV202-5 This identifies special circumstances related to the performance of the service, as defined by trading partners ALIAS: HCPCS Modifier 3 AN 2/2
114 Institutional Service Line Procedure Modifier - 4 2400 SV202-6 This identifies special circumstances related to the performance of the service, as defined by trading partners ALIAS: HCPCS Modifier 4 AN 2/2
115 Institutional Service Line (Revenue Codes) 2400 SV201 Identifying number for a product or service INDUSTRY: Service Line Revenue Code SYNTAX: R0102 SEMANTIC: SV201 is the revenue code. AN 1/48
116 Service Units 2400 SV205 Numeric value of quantity INDUSTRY: Service Unit Count ALIAS: Service Line Units SYNTAX: P0405 R 1/15
117 Line Item Charge Amount 2400 SV203 Monetary amount INDUSTRY: Line Item Charge Amount ALIAS: Service Line Charge Amount SEMANTIC: SV203 is a submitted charge amount. R 1/18
119 Drug Identification 2410 LIN03 Code identifying the type/source of the descriptive number used in Product/Service ID (234) COMMENT: LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU. AN 1/48
120 Prescription Number 2410 REF02 when REF01=XZ Code qualifying the Reference Identification ALIAS: Code Qualifier AN 1/30
121 Drug Units Qualifier 2410 CTP05-1 Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken ALIAS: Code Qualifier R 1/15
122 Drug Number of Units 2410 CTP04 Numeric value of quantity ALIAS: National Drug Unit Count SYNTAX: P0405 R 1/15
123 Drug Cost or Unit Price 2410 CTP03 Price per unit of product, service, commodity, etc. ALIAS: Drug Unit Price SYNTAX: C1103 R 1/15
124 Line Adjustment Group Code 2430 CAS01 Claim Adjustment Group Code Code identifying the general category of payment adjustment ID 1/2
125 Line Level Adjustment Reason Code 2430 CAS02 Claim Adjustment reason Code Code identifying the detailed reason the adjustment was made INDUSTRY: Adjustment Reason Code ID 1/5
126 Line Level Adjustment Amount 2430 CAS03 Code identifying the general category of payment adjustment/Code identifying the detailed reason the adjustment was made INDUSTRY: Adjustment Reason Code CODE SOURCE 139: Claim Adjustment Reason Code/Monetary amount INDUSTRY: Adjustment Amount SEMANTIC: CAS03 is the amount of adjustment. COMMENT: When the submitted charges are paid in full, the value for CAS03 should be zero. R 1/18

File Specification for Medical Claims File Submission 837P - August 12, 2009 - v1.3

Data Element ID Data Element Description Type Format Length
1 BHT Beginning of Hierarchical Transaction BHT06 To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time RP Reporting Use RP when the entire ST-SE envelope contains encounters. Use RP when the transaction is being sent to an entity (usually not a payer or a normal provider payer transmission intermediary) for purposes other than adjudication of a claim. Such an entity could be a state health data agency which is using the 837 for health data reporting purposes. ID 2/2
2 Functional Group Header GS08 Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed AN 1/12
3 Functional Group Header GS01 Code identifying a group of application related transaction sets AN 2/2
4 Submitter Name 1000A NM103 Individual last name or organizational name INDUSTRY: Submitter Last or Organization Name ALIAS: Submitter Name AN 2/80
5 Submitter Identifier 1000A NM109 Code identifying a party or other code INDUSTRY: Submitter Identifier ALIAS: Submitter Primary Identification Number SYNTAX: P0809 AN 2/80
6 Submitter EDI Contact Information 1000A PER01- 05 Code identifying the major duty or responsibility of the person or group named AN 2/80
7 Receiver Name 1000B NM103 Name Last or Organization Name Individual last name or organizational name INDUSTRY: Receiver Name AN 2/80
8 Receiver Identifier 1000B NM109 Not Provided AN 2/80
9 Billing Provider Name 2010AA NM103 Individual last name or organizational name INDUSTRY: Billing Provider Last or Organizational Name ALIAS: Billing Provider Name AN 2/80
10 Billing Provider ID 2010AA NM109 Individual last name or organizational name INDUSTRY: Billing Provider Last or Organizational Name ALIAS: Billing Provider Name AN 2/80
11 Billing Provider Secondary Identification 2010AA REF02 Tax Identifiing information of the Provider that was paid AN 1/30
12 Individual Relationship Code 2000B SBR02 Code indicating the relationship between two individuals or entities ALIAS: Relationship Code SEMANTIC: SBR02 specifies the relationship to the person insured. ID 2/2
13 Insured Group or Policy Number 2000B SBR03 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Insured Group or Policy Number ALIAS: Group or Policy Number SEMANTIC: SBR03 is policy or group number. AN 1/30
14 Payer Name 2010BB NM103 Individual last name or organizational name AN 1/30
15 Subscriber Lname 2010BA NM103 Individual last name or organizational name INDUSTRY: Subscriber Last Name AN 1/35
16 Subscriber Fname 2010BA NM104 Individual first name INDUSTRY: Subscriber First Name AN 1/25
17 Subscriber Middle Name 2010BA NM105 Individual middle name or initial INDUSTRY: Subscriber Middle Name AN 1/25
18 Subscriber Primary Identifier 2010BA NM109 Code identifying a party or other code INDUSTRY: Subscriber Primary Identifier SYNTAX: P0809 AN 2/80
19 Subscriber Address1 2010BA N301 Address information INDUSTRY: Subscriber Address Line ALIAS: Subscriber Address 1 AN 1/55
20 Subscriber Address2 2010BA N302 Address information INDUSTRY: Subscriber Address Line ALIAS: Subscriber Address 2 AN 1/55
21 Subscriber City Name 2010BA N401 Free-form text for city name INDUSTRY: Subscriber City Name COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. AN 2/30
22 Subscriber State 2010BA N402 Code (Standard State/Province) as defined by appropriate government agency INDUSTRY: Subscriber State Code COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada. CODE SOURCE 22: States and Outlying Areas of the U.S. ID 2/2
23 Subscriber Zip Code 2010BA N403 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) INDUSTRY: Subscriber Postal Zone or ZIP Code ALIAS: Subscriber Zip Code CODE SOURCE 51: ZIP Code ID 3/15
24 Subscriber Date of Birth 2010BA DMG02 Expression of a date, a time, or range of dates, times or dates and times INDUSTRY: Subscriber Birth Date ALIAS: Date of Birth - Patient SYNTAX: P0102 SEMANTIC: DMG02 is the date of birth. AN CCYYMMDD 1/35
25 Subscriber Gender 2010BA DMG03 Code indicating the sex of the individual INDUSTRY: Subscriber Gender Code ALIAS: Gender - Patient AN 1/1
26 Subscriber Secondary Identification Qualifier 2010BA REF01 Code qualifying the Reference Identification ID 2/3
27 Subscriber Secondary Identification 2010BA REF02 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Subscriber Supplemental Identifier SYNTAX: R0203 AN 1/30
28 Patients Relationship to Insured 2000C PAT01 Code indicating the relationship between two individuals or entities ALIAS: Patients Relationship to Insured ID 2/2
29 Patient Lname 2010CA NM103 Individual last name or organizational name INDUSTRY: Patient Last Name AN 1/35
30 Patient Fname 2010CA NM104 Individual first name INDUSTRY: Patient First Name AN 1/25
31 Patient Middle Name 2010CA NM105 Individual middle name or initial INDUSTRY: Patient Middle Name ALIAS: Patient Middle Initial AN 1/25
32 Patient Primary Identifier 2010CA NM109 Code identifying a party or other code INDUSTRY: Patient Primary Identifier ALIAS: Patient's Primary Identification Number SYNTAX: P0809 AN 2/80
33 Patient Address1 2010BA/2010CA N301 Address information INDUSTRY: Patient Address Line ALIAS: Patient Address 1 AN 1/55
34 Patient Address2 2010CA N302 Address information INDUSTRY: Patient Address Line ALIAS: Patient Address 2 AN 1/55
35 Patient City Name 2010CA N401 Free-form text for city name INDUSTRY: Patient City Name COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. AN 2/30
36 Patient State 2010CA N402 Code (Standard State/Province) as defined by appropriate government agency INDUSTRY: Patient State Code COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada. CODE SOURCE 22: States and Outlying Areas of the U.S. ID 2/2
37 Patient Zip Code 2010CA N403 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) INDUSTRY: Patient Postal Zone or ZIP Code ALIAS: Patient Zip Code CODE SOURCE 51: ZIP Code ID 3/15
38 Patient Date of Birth 2010CA DMG02 Expression of a date, a time, or range of dates, times or dates and times INDUSTRY: Patient Birth Date ALIAS: Date of Birth SYNTAX: P0102 SEMANTIC: DMG02 is the date of birth. AN 1/35
39 Patient Gender 2010CA DMG03 Code indicating the sex of the individual INDUSTRY: Patient Gender Code ALIAS: Gender - Patient AN 1/1
40 Patient Secondary Identification Qualifier 2010CA REF01 Code qualifying the Reference Identification ID 2/3
41 Patient Secondary Identification 2010CA REF02 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Patient Secondary Identifier SYNTAX: R0203 AN 1/30
43 Facility Type Code 2300 CLM05-1 Code identifying the type of facility where services were performed; the first and second positions of the Uniform Bill Type code or the Place of Service code from the Electronic Media Claims National Standard Format INDUSTRY: Facility Type Code AN 1/2
44 Claim Frequency Type Code (Type of Bill, Position 4) 2300 CLM05-3 Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type INDUSTRY: Claim Frequency Code ALIAS: Claim Submission Reason Code CODE SOURCE 235: Claim Frequency Type Code ID 1/1
46 Original Reference Number 2300 REF02 When REF01=F8 Code qualifying the Reference Identification AN 1/30
47 Admissio Date 2300 DTP03 When DTP01=435 Not Provided AN 1/35
53 Discharge Date 2300 DTP03 WHEN DTP01=096 Not Provided AN CCYYMMDD 1/35
55 Patient Account Number 2300 CLM01 Claim Submitter's Identifier Identifier used to track a claim from creation by the health care provider through payment INDUSTRY: Patient Account Number ALIAS: Patient Control Number AN 1/20
56 Medical Record Number 2300 REF02 When REF01=EA Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Medical Record Number AN 1/30
57 Total Claim Charge Amount 2300 CLM02 Monetary amount INDUSTRY: Total Claim Charge Amount ALIAS: Total Submitted Charges SEMANTIC: CLM02 is the total amount of all submitted charges of service segments for this claim. R 1/18
58 Patient Paid Amount 2300 AMT02 When AMT01=F5 Monetary amount INDUSTRY: Patient Amount Paid R 1/18
59 Coordination Of Benefits Payer Paid Amount 2320 AMT02 WHEN AMT01 = D Monetary amount INDUSTRY: Payer Paid Amount R 1/18
60 Service Facility Name 2310D NM103 Individual last name or organizational name INDUSTRY: Laboratory or Facility Name ALIAS: Laboratory/Facility Name AN 1/35
61 Service Facility ID Code 2310D NM109 Code identifying a party or other code INDUSTRY: Laboratory or Facility Primary Identifier ALIAS: Laboratory/Facility Primary Identifier SYNTAX: P0809 AN 2/80
62 Claim Adjudication Date 2330B DTP03 WHEN DTP01=573 Expression of a date, a time, or range of dates, times or dates and times INDUSTRY: Adjudication or Payment Date AN 1/35
63 Coordination of Benefits Allowed Amount 2320 AMT02 when AMT01 = B6 Monetary amount INDUSTRY: Allowed Amount R 1/18
64 Claim Adjustment Group Code 2320 CAS01 Claim Adjustment Group Code Code identifying the general category of payment adjustment ID 1/2
65 Claim Adjustment Reason Code 2320 CAS02 Claim Adjustment reason Code Code identifying the detailed reason the adjustment was made INDUSTRY: Adjustment Reason Code ALIAS: Adjustment Reason Code - Claim Level ID 1/5
66 Claim Level Adjustment Amount 2320 CAS03 Monetary amount INDUSTRY: Adjustment Amount ALIAS: Adjusted Amount - Claim Level SEMANTIC: CAS03 is the amount of adjustment. COMMENT: When the submitted charges are paid in full, the value for CAS03 should be zero. R 1/18
67 Laboratory or Facility Primary Identifier 2310D NM109 Code identifying a party or other code INDUSTRY: Laboratory or Facility Primary Identifier ALIAS: Laboratory/Facility Primary Identifier SYNTAX: P0809 AN 2/80
72 Principal Diagnosis 2300 HI01 -2 Code indicating a code from a specific industry code list INDUSTRY: Diagnosis Code AN 1/30
74 Diagnosis 2300 HI02 -2 Code indicating a code from a specific industry code list INDUSTRY: Diagnosis Code AN 1/30
75 Diagnosis 2300 HI03 -2 Code indicating a code from a specific industry code list INDUSTRY: Diagnosis Code AN 1/30
76 Diagnosis 2300 HI04 -2 Code indicating a code from a specific industry code list INDUSTRY: Diagnosis Code AN 1/30
77 Diagnosis 2300 HI05 -2 Code indicating a code from a specific industry code list INDUSTRY: Diagnosis Code AN 1/30
78 Diagnosis 2300 HI06 -2 Code indicating a code from a specific industry code list INDUSTRY: Diagnosis Code AN 1/30
79 Diagnosis 2300 HI07 -2 Code indicating a code from a specific industry code list INDUSTRY: Diagnosis Code AN 1/30
80 Diagnosis 2300 HI08 -2 Code indicating a code from a specific industry code list INDUSTRY: Diagnosis Code AN 1/30
81 Not Provided NOT USED HI09 C022 HEALTH CARE CODE INFORMATION AN 1/30
82 Not Provided NOT USED HI10 C022 HEALTH CARE CODE INFORMATION AN 1/30
83 Not Provided NOT USED HI11 C022 HEALTH CARE CODE INFORMATION AN CCYYMMDD or range: CCYYMMDD-CCYYMMDD 1/30
84 Not Provided NOT USED HI12 C022 HEALTH CARE CODE INFORMATION AN 1/30
101 Rendering Provider Specialty 2310B PRV03 or 2000A Reference Identification Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Provider Taxonomy Code ALIAS: Provider Specialty Code Text 10
102 Rendering Provider LName 2310B NM103 Individual last name or organizational name INDUSTRY: Rendering Provider Last or Organization Name ALIAS: Rendering Provider Last Name AN 1/35
103 Rendering Provider FName 2310B NM104 Individual first name INDUSTRY: Rendering Provider First Name AN 1/25
104 Rendering Provider Name Middle 2310B NM105 Individual middle name or initial INDUSTRY: Rendering Provider Middle Name AN 1/25
105 Rendering Provider Name Suffix 2310B NM107 Suffix to individual name INDUSTRY: Rendering Provider Name Suffix ALIAS: Rendering Provider Generation AN 1/10
106 Rendering Provider Primary Identifier 2310B NM109 Code identifying a party or other code INDUSTRY: Rendering Provider Identifier ALIAS: Rendering Provider Primary Identifier SYNTAX: P0809 AN 2/80
107 Rendering Provider Secondary Identification 2310B REF02 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Rendering Provider Secondary Identifier SYNTAX: R0203 AN 1/30
108 Line Counter 2400 LX01 Number assigned for differentiation within a transaction set ALIAS: Line Counter This is the service line number. Begin with 1 and increment by 1 for each new LX segment within a claim. NO 1/6
109 Date(s) of Service 2400 DTP03 WHEN DTP01=472 Code specifying type of date or time, or both date and time INDUSTRY: Date Time Qualifier AN CCYYMMDD or range: CCYYMMDD-CCYYMMDD 1/35
110 Procedure Code 2400 SV101-2 Identifying number for a product or service INDUSTRY: Procedure Code AN 1/48
111 Procedure Modifier - 1 2400 SV101-3 This identifies special circumstances related to the performance of the service, as defined by trading partners ALIAS: Procedure Modifier 1 AN 2/2
112 Procedure Modifier - 2 2400 SV101-4 This identifies special circumstances related to the performance of the service, as defined by trading partners ALIAS: Procedure Modifier 2 AN 2/2
113 Procedure Modifier - 3 2400 SV101-5 This identifies special circumstances related to the performance of the service, as defined by trading partners ALIAS: Procedure Modifier 3 AN 2/2
114 Procedure Modifier - 4 2400 SV101-6 This identifies special circumstances related to the performance of the service, as defined by trading partners ALIAS: Procedure Modifier 4 AN 2/2
116 Days or Units 2400 SV104 Numeric value of quantity INDUSTRY: Service Unit Count ALIAS: Units or Minutes SYNTAX: P0304 1/15
117 Line Item Charge Amount 2400 SV102 Monetary amount INDUSTRY: Line Item Charge Amount ALIAS: Submitted charge amount SEMANTIC: SV102 is the submitted charge amount. R 1/18
118 Allowed Amount 2400 AMT02 Monetary Amount INDUSTRY: Approved Amount R 1/18
119 Drug Identification 2410 LIN03 Code identifying the type/source of the descriptive number used in Product/Service ID (234) COMMENT: LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU. INDUSTRY: Product or Service ID Qualifier AN 1/48
120 Prescription Number 2410 REF02 when REF01=XZ Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Prescription Number ALIAS: Prescription Number SYNTAX: R0203 AN 1/30
121 Drug Units Qualifier 2410 CTP05-1 Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken ALIAS: Code qualifier R 1/15
122 Drug Number of Units 2410 CTP04 Numeric value of quantity INDUSTRY: National Drug Unit Count ALIAS: National Drug Unit Count SYNTAX: P0405 R 1/15
123 Drug Cost or Unit Price 2410 CTP03 Price per unit of product, service, commodity, etc. INDUSTRY: Drug Unit Price ALIAS: Drug Unit Price SYNTAX: C1103 R 1/15
124 Line Adjustment Group Code 2430 CAS01 Claim Adjustment Group Code Code identifying the general category of payment adjustment ID 1/2
125 Line Adjustment Reason Code 2430 CAS02 Claim Adjustment reason Code Code identifying the detailed reason the adjustment was made INDUSTRY: Adjustment Reason Code ALIAS: Adjustment Reason Code - Line Level ID 1/5
126 Line Level Adjustment Amount 2430 CAS03 Monetary amount INDUSTRY: Adjustment Amount ALIAS: Adjusted Amount - Line Level SEMANTIC: CAS03 is the amount of adjustment. COMMENT: When the submitted charges are paid in full, the value for CAS03 should be zero. R 1/18

File Specification for Multiple versionsMedical Eligibility File Submission - December 5, 2013 - v2.0

Data Element ID Data Element Description Type Format Length
ME001 Payer Code Distributed by OHCS varchar 8
ME002 Payer Name Distributed by OHCS varchar 30
ME003 Insurance Type Code/Product Not Provided char 2
ME004 Year 4 digit Year for which eligibility is reported in this submission int 4
ME005 Month Month for which eligibility is reported in this submission expressed numerical from 01 to 12. char 2
ME006 Insured Group or Policy Number Group or policy number - not the number that uniquely identifies the subscriber varchar 30
ME007 Coverage Level Code Benefit coverage level char 3
ME008 Subscriber Social Security Number Subscriber's social security number; Set as blank if unavailable varchar 9
ME009 Plan Specific Contract Number Plan assigned subscriber's contract number; Set as null if contract number = subscriber's social security number or use an alternate unique identifier such as Medicaid ID. Must be an identifier that is unique to the subscriber. varchar 128
ME010 Member Suffix or Sequence Number Unique number of the member. This column is the unique identifying column for membership and related medical and pharmacy claims. Only one record per eligibility month. Must match MC009 and PC009. varchar 128
ME011 Member Identification Code Member's social security number; Set as blank if unavailable. varchar 9
ME012 Individual Relationship Code Member's relationship to insured char 2
ME013 Member Gender Not Provided char 1
ME014 Member Date of Birth Not Provided char YYYYMMDD 8
ME015 Member City Name City location of member varchar 30
ME016 Member State or Province As defined by the US Postal Service char 2
ME017 Member ZIP Code ZIP Code of member - may include non-US codes. Do not include dash. Plus 4 optional but desired. varchar 11
ME018 Medical Coverage Not Provided char 1
ME019 Prescription Drug Coverage Not Provided char 1
ME020 Dental Coverage Not Provided char 1
ME021 Race 1 Not Provided varchar 6
ME022 Race 2 Not Provided varchar 6
ME023 Other Race List race if MC021or MC022 are coded as R9. varchar 15
ME024 Hispanic Indicator Not Provided char 1
ME025 Ethnicity 1 Not Provided varchar 6
ME026 Ethnicity 2 Not Provided varchar 6
ME027 Other Ethnicity List ethnicity if MC025 or MC026 are coded as OTHER. varchar 20
ME028 Primary Insurance Indicator Not Provided char 1
ME029 Coverage Type Not Provided char 3
ME030 Market Category Code Not Provided varchar 4
ME032 Group Name Group name or IND for individual policies varchar 128
ME043 Member Street Address Street address of member varchar 50
ME044 Employer Name Name of the Employer, or if same as Group Name, null varchar 50
ME101 Subscriber Last Name The subscriber last name varchar 128
ME102 Subscriber First Name The subscriber first name varchar 128
ME103 Subscriber Middle Initial The subscriber middle initial char 1
ME104 Member Last Name The member last name varchar 128
ME105 Member First Name The member first name varchar 128
ME897 Plan Effective Date Date eligibility started for this member under this plan type. The purpose of this data element is to maintain eligibility span for each member. char YYYYMMDD 8
ME045 Exchange Offering Identifies whether or not a policy was purchased through the Utah Health Benefits Exchange (UBHE). char 1
ME106 Group Size Code indicating Group Size consistent with Utah Insurance Law and Regulation Required only for plans sold in the commercial large, small and non-group markets. The following plan/products do not need to report this value: Student plans Medicare supplemental Medicaid-funded plans Stand-alone behavioral health, dental and vision char 2
ME107 Risk Basis Not Provided char 1
ME108 High Deductible/ Health Savings Account Plan Not Provided char 1
ME120 Actuarial Value Report value as calculated in the most recent version of the HHS Actuarial Value Calculator available at http://cciio.cms.gov/resources/regulations/index.html Size includes decimal point. Required as of January 1, 2014 for small group and non-group (individual) plans sold inside or outside the Exchange. decimal 6
ME121 Metallic Value Metal Level (percentage of Actuarial Value) per federal regulations. Required as of January 1, 2014 for small group and non group (individual) plans sold inside or outside the Exchange. Use values provided in the most recent version of the HHS Actuarial Value Calculator available at : http://cciio.cms.gov/resources/regulations/index.html int 1
ME122 Grandfather Status See definition of "grandfathered plans" in HHS rules CFR 147.140 Required as of January 1, 2014 for small group and non group (individual) plans sold inside or outside the Exchange. Char 1
ME899 Record Type Not Provided char 2

File Specification for Multiple versionsPharmacy Claims File Submission - December 5, 2013 - v2.0

Data Element ID Data Element Description Type Format Length
PC001 Payer Code Distributed by OHCS varchar 8
PC002 Payer Name Distributed by OHCS varchar 30
PC003 Insurance Type/Product Code Not Provided char 2
PC004 Payer Claim Control Number Must apply to the entire claim and be unique within the payer's system. varchar 35
PC005 Line Counter Line number for this service. The line counter begins with 1 and is incremented by 1 for each additional service line of a claim. int 4
PC006 Insured Group Number Group or policy number - not the number that uniquely identifies the subscriber varchar 30
PC007 Subscriber Social Security Number Subscriber's social security number; Set as null if unavailable varchar 9
PC008 Plan Specific Contract Number Plan assigned subscriber's contract number; Set as null if contract number = subscriber's social security number or use an alternate unique identifier such as Medicaid ID. Must be an identifier that is unique to the subscriber. varchar 128
PC009 Member Suffix or Sequence Number Unique number of the member within the contract. Must be an identifier that is unique to the member. Must match ME010. varchar 20
PC010 Member Identification Code Member's social security number; Set as null if contract number = subscriber's social security number or use an alternate unique identifier such as Medicaid ID. Must be an identifier that is unique to the member. varchar 128
PC011 Individual Relationship Code Member's relationship to insured char 2
PC012 Member Gender Not Provided char 1
PC013 Member Date of Birth Not Provided Date YYYYMMDD 8
PC014 Member City Name of Residence City name of member varchar 50
PC015 Member State or Province As defined by the US Postal Service char 2
PC016 Member ZIP Code ZIP Code of member - may include non-US codes; Do not include dash. Plus 4 optional but desired. varchar 11
PC017 Date Service Approved (AP Date) date claim paid if available, otherwise set to Date Prescription Filled Date YYYYMMDD 8
PC018 Pharmacy Number Payer assigned pharmacy number. AHFS number is acceptable. varchar 30
PC019 Pharmacy Tax ID Number Federal taxpayer's identification number coded with no punctuation (carriers that contract with outside PBM's will not have this) varchar 10
PC020 Pharmacy Name Name of pharmacy varchar 50
PC021 National Provider ID Number National Provider ID. This data element pertains to the entity or individual directly providing the service. varchar 20
PC048 Pharmacy Location Street Address Street address of pharmacy Varchar 30
PC022 Pharmacy Location City City name of pharmacy - preferably pharmacy location (if mail order null) varchar 30
PC023 Pharmacy Location State As defined by the US Postal Service (if mail order null) char 2
PC024 Pharmacy ZIP Code ZIP Code of pharmacy - may include non-US codes. Do not include dash. Plus 4 optional but desired (if mail order null) varchar 10
PC024d Pharmacy Country Name Code US for United States varchar 30
PC025 Claim Status Not Provided char 2
PC026 Drug Code NDC Code varchar 11
PC027 Drug Name Text name of drug varchar 80
PC028 New Prescription or Refill Older systems provide only an "N" for new or an "R" for refill, otherwise provide refill # varchar 2
PC029 Generic Drug Indicator Not Provided char 2
PC030 Dispense as Written Code Not Provided char 1
PC031 Compound Drug Indicator Not Provided char 1
PC032 Date Prescription Filled Not Provided Date YYYYMMDD 8
PC033 Quantity Dispensed Number of metric units of medication dispensed int 5
PC034 Days Supply Estimated number of days the prescription will last int 3
PC035 Charge Amount Do not code decimal point or provide any punctuation where $1,000.00 converted to 100000 Same for all financial data that follows. int 10
PC036 Paid Amount Includes all health plan payments and excludes all member payments. Do not code decimal point. int 10
PC037 Ingredient Cost/List Price Cost of the drug dispensed. Do not code decimal point. int 10
PC038 Postage Amount Claimed Do not code decimal point. Not typically captured. int 10
PC039 Dispensing Fee Do not code decimal point. int 10
PC040 Co-pay Amount The preset, fixed dollar amount for which the individual is responsible. Do not code decimal point. int 10
PC041 Coinsurance Amount The dollar amount an individual is responsible for - not the percentage. Do not code decimal point. int 10
PC042 Deductible Amount Do not code decimal point. int 10
PC043 Unassigned Reserved for assignment (future use) Not Supplied Not Supplied Not Supplied
PC044 Prescribing Physician First Name Physician first name. varchar 25
PC045 Prescribing Physician Middle Name Physician middle name or initial. varchar 25
PC046 Prescribing Physician Last Name Physician last name. varchar 60
PC047 Prescribing Physician NPI NPI number for prescribing physician varchar 20
PC049 Member Street Address Street address of member varchar 50
PC101 Subscriber Last Name Subscriber Last Name varchar 128
PC102 Subscriber First Name Subscriber First Name varchar 128
PC103 Subscriber Middle Initial Subscriber Middle Initial char 1
PC104 Member Last Name Member Last Name varchar 128
PC105 Member First Name Member First Name varchar 128
PC106 Member Middle Initial Member Middle Initial char 1
PC201 Version Number The version number of this claim service line. The original claim will have a version number of 0, with the next version being assigned a 1, and each subsequent version being incremented by 1 for that service line. int 4
PC202 Prescription Written Date Date Prescription was written Date 8
PC047a Prescribing Physician Provider ID Provider ID for the prescribing physician varchar 30
PC047b Prescribing Physician DEA DEA number for prescribing physician varchar 20
PC899 Record Type Not Provided char 2

File Specification for Provider File Submission - December 5, 2013 - v2.0

Data Element ID Data Element Description Type Format Length
MP001 Provider ID Unique identified for the provider as assigned by the reporting entity Must match MC024. varchar 30
MP002 Provider Tax ID Tax ID of the provider. Do not code punctuation. varchar 10
MP003 Provider Entity Not Provided char 1
MP004 Provider First Name Individual first name. Set to null if provider is a facility or organization. varchar 25
MP005 Provider Middle Name or Initial Provider Middle Name or Initial varchar 25
PM006 Provider Last Name or Organization Name Full name of provider organization or last name of individual provider varchar 60
MP007 Provider Suffix Example: Jr;null if provider is an organization. Do not use credentials such as MD or PhD varchar 10
MP008 Provider Specialty Report the HIPAA-compliant health care provider taxonomy code. Code set is freely available at the National Uniform Claims Committee's web site at http://www.nucc.org/ varchar 50
MP009 Provider Office Street Address Physical address - address where provider delivers health care services varchar 50
MP010 Provider Office City Physical address - address where provider delivers health care services varchar 30
MP011 Provider Office State Physical address - address where provider delivers health care services. Use postal service standard 2 letter abbreviations. char 2
MP012 Provider Office Zip Physical address - address where provider delivers health care services. Minimum 5 digit code. varchar 11
MP013 Provider DEA Number Provider DEA Number varchar 12
MP014 Provider NPI Provider NPI varchar 20
MP015 Provider State License Number Prefix with two-character state of licensure with no punctuation. Example UTLL12345 varchar 20
MP899 Record Type Not Provided char 2

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