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Dental Claims File Submission

Connecticut



Name:Dental Claims File Submission
State:Connecticut
Definition:Not provided
VersionDecember 5, 2013 - v1.2

File Specification for Dental Claims File Submission

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
DC001 Submitter CT APCD defined and maintained unique identifier Integer varchar[6] 6
DC002 National Plan ID CMS National Plan Identification Number (PlanID) Text int[10] 10
DC003 Insurance Type Code / Product Type / Product Identification Code Text char[2] 2
DC004 Payer Claim Control Number Payer Claim Control Identification Text varchar[35] 35
DC005 Line Counter Incremental Line Counter Integer varchar[4] 4
DC005A Version Number Claim Service Line Version Number Integer varchar[4] 4
DC006 Insured Group or Policy Number Group / Policy Number Text varchar[30] 30
DC007 Subscriber SSN Subscriber's Social Security Number Numeric char[9] 9
DC008 Plan Specific Contract Number Contract Number Text varchar[30] 30
DC009 Member Suffix or Sequence Number Member/Patient's Contract Sequence Number Text varchar[20] 20
DC010 Member SSN Member/Patient's Social Security Number Numeric char[9] 9
DC011 Individual Relationship Code Patient to Subscriber Relationship Code Text varchar[2] 2
DC012 Member Gender Patient's Gender Text char[1] 1
DC013 Member Date of Birth Member/Patient's date of birth Full Date - Integer int[8] YYYYMMDD 8
DC014 Member City Name City name of the Member/Patient Text varchar[50] 50
DC015 Member State State / Province of the Patient External Code Source - USPS char[2] 2
DC016 Member ZIP Code Zip Code of the Member / Patient External Code Source - USPS varchar[9] 9
DC017 Date Service Approved (AP Date) Date Service Approved by Payer Full Date - Integer int[8] YYYYMMDD 8
DC018 Service Provider Number Service Provider Identification Number Text varchar[30] 30
DC019 Service Provider Tax ID Number Service Provider's Tax ID number Numeric char[9] 9
DC020 National Provider ID - Service National Provider Identification (NPI) of the Service Provider External Code Source - NPPES int[10] 10
DC021 Service Provider Entity Type Qualifier Service Provider Entity Identifier Code integer int[1] 1
DC022 Service Provider First Name First name of Service Provider Text varchar[25] 25
DC023 Service Provider Middle Name Middle initial of Service Provider Text varchar[25] 25
DC024 Service Provider Last Name or Organization Name Last name or Organization Name of Service Provider Text varchar[60] 60
DC025 Carve Out Vendor CT APCD ID CT APCD defined and maintained Org ID for linking across submitters Integer varchar[6] 6
DC026 Service Provider Taxonomy Taxonomy Code External Code Source - WPC varchar[10] 10
DC027 Service Provider City Name City name of the Provider Text varchar[30] 30
DC028 Service Provider State State of the Service Provider External Code Source - USPS char[2] 2
DC029 Service Provider ZIP Code Zip Code of the Service Provider External Code Source - USPS varchar[9] 9
DC030 Facility Type - Professional Place of Service Code External Code Source - CMS char[2] 2
DC031 Claim Status Claim Line Status integer varchar[2] 2
DC032 CDT Code HCPCS / CDT Code External Code Source - ADA char[5] 5
DC033 Procedure Modifier - 1 HCPCS / CPT Code Modifier External Code Source - AMA char[2] 2
DC034 Procedure Modifier - 2 HCPCS / CPT Code Modifier External Code Source - AMA char[2] 2
DC035 Date of Service - From Date of Service Full Date - Integer int[8] YYYYMMDD 8
DC036 Date of Service - To Date of Service Full Date - Integer int[8] YYYYMMDD 8
DC037 Charge Amount Amount of provider charges for the claim line Integer ±varchar[10] 10
DC038 Paid Amount Amount paid by the carrier for the claim line Integer ±varchar[10] 10
DC039 Copay Amount Amount of Copay member/patient is responsible to pay Integer ±varchar[10] 10
DC040 Coinsurance Amount Amount of coinsurance member/patient is responsible to pay Integer ±varchar[10] 10
DC041 Deductible Amount Amount of deductible member/patient is responsible to pay on the claim line Integer ±varchar[10] 10
DC042 Filler Filler Filler char[0] 0
DC043 Member Street Address Street address of the Member/Patient Text varchar[50] 50
DC044 Billing Provider Tax ID Number The Billing Provider's Federal Tax Identification Number (FTIN) Numeric char[9] 9
DC045 Paid Date Paid date of the claim line Integer int[8] YYYYMMDD 8
DC046 Allowed Amount Allowed Amount Integer ±varchar[10] 10
DC047 Tooth Number/Letter Tooth Number or Letter Identification External Code Source - ADA varchar[2] 2
DC048 Dental Quadrant Dental Quadrant External Code Source - ADA char[10] 10
DC049 Tooth Surface Tooth Service Identification External Code Source - ADA varchar[5] 5
DC050 Subscriber Last Name Last name of Subscriber Text varchar[60] 60
DC051 Subscriber First Name First name of Subscriber Text varchar[25] 25
DC052 Subscriber Middle Initial Middle initial of Subscriber Text char[1] 1
DC053 Member Last Name Last name of Member/Patient Text varchar[60] 60
DC054 Member First Name First name of Member/Patient Text varchar[25] 25
DC055 Member Middle Initial Middle initial of the Member/Patient Text char[1] 1
DC056 Carrier Specific Unique Member ID Member's Unique ID Text varchar[50] 50
DC057 Carrier Specific Unique Subscriber ID Subscriber's Unique ID Text varchar[50] 50
DC058 Member Street Address 2 Secondary Street Address of the Member/Patient Text varchar[50] 50
DC059 Claim Line Type Claim Line Activity Type Code Text char[1] 1
DC060 Former Claim Number Previous Claim Number Text varchar[35] 35
DC061 Diagnosis Code ICD Diagnosis Code External Code Source - ICD varchar[7] 7
DC062 ICD Indicator International Classification of Diseases version Integer int[1] 1
DC063 Denied Flag Denied Claim Line Indicator Integer int[1] 1
DC064 Denial Reason Denial Reason Code External Code Source - HIPAA - OR- Carrier Lookup Table varchar[20] 20
DC065 Payment Arrangement Type Payment Arrangement Type Value Numeric char[2] 2
DC066 Filler Filler Filler char[0] 0
DC067 APCD ID Code Member Enrollment Type Integer int[1] 1
DC068 Bill Frequency Code Bill Frequency External Code Source - NUBC char[1] 1
DC899 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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Data Element ID Data Element Code Value
HD001 Record Type HD Header Elements
HD004 Type of File DC DENTAL CLAIM
HD009 APCD Version Number 1 Current Version; required for reporting periods as of October 2013
DC003 Insurance Type Code / Product 9 Self-pay
11 Other Non-Federal Programs(use of this value requires disclosure to Data Manager prior to submission)
12 Preferred Provider Organization (PPO)
13 Point of Service (POS)
14 Exclusive Provider Organization (EPO)
15 Indemnity Insurance
16 Health Maintenance Organization (HMO) Medicare Risk
17 Dental Maintenance Organization (DMO)
96 Husky Health A
97 Husky Health B
98 Husky Health C
99 Husky Health D
AM Automobile Medical
CH Champus (now TRICARE)
CI CommercialInsurance
DS Disability
HM Health Maintenance Organization
LM Liability Medical
MA Medicare Part A
MB Medicare Part B
MC Medicaid
OF Other Federal Program(use of this value requires disclosure to Data Manager prior to submission)
TV Title V
VA Veterans Affairs Plan
WC Workers' Compensation
ZZ Mutually Defined(use of this value requires disclosure to Data Manager prior to submission)
DC011 Individual Relationship Code 1 Spouse
4 Grandfather or Grandmother
5 Grandson or Granddaughter
7 Nephew or Niece
10 Foster Child
12 Other Adult
15 Ward
17 Stepson or Stepdaughter
19 Child
20 Self / Employee
21 Unknown
22 HandicappedDependent
23 SponsoredDependent
24 Dependent of a Minor Dependent
29 Significant Other
32 Mother
33 Father
34 Other Adult
36 EmancipatedMinor
39 Organ Donor
40 Cadaver Donor
41 Injured Plaintiff
43 Child Where Insured Has No Financial Responsibility
53 Life Partner
76 Dependent
DC012 Member Gender F Female
M Male
O Other
U Unknown
DC021 Service Provider Entity Type Qualifier 1 Person
2 Non-person entity
DC031 Claim Status 1 Processed as primary
2 Processed as secondary
3 Processed as tertiary
4 Denied
19 Processed as primary, forwarded to additional payer(s)
20 Processed as secondary, forwarded to additional payer(s)
21 Processed as tertiary, forwarded to additional payer(s)
22 Reversal of previous payment
23 Not our claim, forwarded to additional payer(s)
25 Predetermination Pricing Only - no payment
DC059 Claim Line Type A Amendment
B Back Out
O Original
R Replacement
V Void
DC062 ICD Indicator 0 ICD-10
9 ICD-9
DC063 Denied Flag 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
DC065 Payment Arrangement Type 1 Capitation
2 Fee for Service
3 Percent of Charges
4 DRG
5 Pay for Performance
6 Global Payment
7 Other
8 Bundled Payment
DC067 APCD ID Code 0 Unknown / Not Applicable
1 FIG - Fully-Insured Commercial Group Enrollee
2 SIG - Self-Insured Group Enrollee
3 State or Federal Employer Enrollee
4 Individual - Non-Group Enrollee
5 Supplemental Policy Enrollee
6 ICO - Integrated Care Organization
DC899 Record Type DC
TR001 Record Type TR end of the data file
TR004 Type of File DC
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