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Accident Indicator

MC126, Connecticut



Name:Accident Indicator
Data Element ID:MC126
Description:Indicator - Accident Related
State:Connecticut
Data Type:Integer
Format:int[1]
Length:1
Column:127
Threshold:100%
Required:All
Element Submission Guideline:Report the value that defines the element. EXAMPLE: 1 = Yes, Claim Line is Accident related.
PACDR 837I Map:n/a
PACDR 837P Map:Presence of Loop 2300 Segment CLM11-01 = AA or OA set value = 1, else value = 2
Permissible Values: Accident Indicator uses the following permissible values:
Code / Value Meaning
1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
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File Specification for Medical Claims File Submission - December 5, 2013 - v1.2

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

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