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Medical Claims File Submission

Maine

Versions: 2010-03-16• v1.2Compare Versions


Name:Medical Claims File Submission
State:Maine
Definition:"Medical claims file" means a data file composed of service level remittance information including, but not limited to, member demographics, provider information, charge/payment information, and clinical diagnosis/procedure codes from all non-denied adjudicated claims for each billed service.
Versionv1.2

File Specification for Medical Claims File Submission

Data Element ID Data Element Description Type Format Length
Multiple versionsMC001 Payer This field contains the MHDO submitter code for the payer submitting payments. The first character of the submitter code indicates the type of submitter. This field is primarily used for tracking compliance by Payer. CHAR 6
Multiple versionsMC002 National Plan ID CMS National Plan ID CHAR 30
Multiple versionsMC003 Insurance Type/Product Code The insurance type or product code indicates the type of Insurance coverage the individual has. TEXT 2
Multiple versionsMC004 Payer Claim Control Number This field contains the claim number used by the payer to internally track the claim. CHAR 35
Multiple versionsMC005 Line Counter This field contains the line number for this service NUMBER 30
Multiple versionsMC006 Insured Group or Policy Number The group or policy number is associated with the entity that has purchased the insurance. For self insured individuals this relates to the purchaser. For the majority of eligibility and claims data the group relates to the employer. CHAR 30
Multiple versionsMC007 Encrypted Subscriber Social Security Number This field contains the Encrypted Social Security Number for the subscriber. If the social security number was not available from the payer this field will be null and the Contract field will be populated. This field has been encrypted using the same algorithm across all payers. If this field is populated, it forms the core of the unique member identification code (MEMBERID). CHAR 32
Multiple versionsMC008 Plan Specific Contract Number This field contains the payer assigned contract number for the subscriber. If the Encrypted Social Security Number is null, this field forms the core of the unique member number (MEMBERID). CHAR 64
Multiple versionsMC009 Member Suffix or Sequence Number This payer supplied code uniquely identifies the member within the context of the subscriber Encrypted Social Security Number or Contract. CHAR 20
Multiple versionsMC010 Member Identification Code This field is used to record the member's social security number when available. If the member is the subscriber, this field should contain the same value as the Encrypted Social Security Number. If the member is not the subscriber, this field will not equal the Encrypted Social Security Number. CHAR 64
Multiple versionsMC011 Individual Relationship Code This field contains the member's relationship to the subscriber or the insured. CHAR 2
Multiple versionsMC012 Member Gender This field contains the gender of the member. CHAR 1
Multiple versionsMC013 Member Date of Birth This field contains the member's data of birth with a format of CCYYMMDD. This field is used to calculate age as of the from date of service (MC059). DATE CCYYMMDD 8
Multiple versionsMC014 Member City Name This field contains the member's city of residence and was not required reporting until 2004. CHAR 30
Multiple versionsMC015 Member State or Province The Member State or Province contains the 2 character abbreviation code used by the US Postal Service and was not required reporting until 2004. Since this database has been built for Maine residents the code will generally be ME for Maine. CHAR 2
Multiple versionsMC016 Member ZIP Code This field contains ZIP Code of the member. Payers are encouraged to provide a full 9 character zip code. CHAR 11
Multiple versionsMC017 Date Service Approved (AP Date) This field contains the date the record was approved for payment. This is generally referred to as the Paid Date with a CCYYMMDD format. DATE CCYYMMDD 8
Multiple versionsMC018 Admission Date This field contains the date of the inpatient admission with a CCYYMMDD format. DATE CCYYMMDD 8
Multiple versionsMC019 Admission Hour This field contains the hour the inpatient was admitted to the hospital in military time. NUMBER 4
Multiple versionsMC020 Admission Type This field is used to record the type of admission for all inpatient hospital bills. NUMBER 2
Multiple versionsMC021 Admission Source This field is required for inpatient hospital bills. It records the source of admission. For newborns (ADMSR = 4) CHAR 1
Multiple versionsMC022 Discharge Hour This field contains the hour the inpatient was discharged from the hospital in military time. NUMBER 2
Multiple versionsMC023 Member Status This field contains the status for the patient discharged from the hospital. NUMBER 2
Multiple versionsMC036 Type of Bill - Institutional Not Provided NUMBER 2
Multiple versionsMC037 Facility Type - Professional For professional claims, this field records the type of facility where the service was performed. CHAR 2
Multiple versionsMC038 Claim Status This field contains the status of the claim as reported by the payer. NUMBER 2
Multiple versionsMC039 Admitting Diagnosis This field contains the ICD-9 diagnosis code indicating the reason for the inpatient admission. CHAR 5
Multiple versionsMC040 E-Code This field describes an injury, poisoning or adverse effect using an ICD-9 E-code diagnosis. CHAR 5
Multiple versionsMC041 Principal Diagnosis This field contains the ICD-9 diagnosis code for the principal diagnosis. CHAR 5
Multiple versionsMC042 Other Diagnosis 1 This field contains the ICD-9 diagnosis code for the first secondary diagnosis . This was not required reporting until 2004. CHAR 5
Multiple versionsMC043 Other Diagnosis 2 This field contains the ICD-9 diagnosis code for the second secondary diagnosis and was not required reporting until CHAR 5
Multiple versionsMC044 Other Diagnosis 3 This field contains the ICD-9 diagnosis code for the third secondary diagnosis and was not required reporting until 2004. CHAR 5
Multiple versionsMC045 Other Diagnosis 4 This field contains the ICD-9 diagnosis code for the fourth secondary diagnosis and was not required reporting until 2004. CHAR 5
Multiple versionsMC046 Other Diagnosis 5 This field contains the ICD-9 diagnosis code for the fifth secondary diagnosis and was not required reporting until 2004. CHAR 5
Multiple versionsMC047 Other Diagnosis 6 This field contains the ICD-9 diagnosis code for the sixth secondary diagnosis and was not required reporting until 2004. CHAR 5
Multiple versionsMC048 Other Diagnosis 7 This field contains the ICD-9 diagnosis code for the seventh secondary diagnosis and was not required reporting until 2004. CHAR 5
Multiple versionsMC049 Other Diagnosis 8 This field contains the ICD-9 diagnosis code for the eighth secondary diagnosis and was not required reporting until 2004. CHAR 5
Multiple versionsMC050 Other Diagnosis 9 This field contains the ICD-9 diagnosis code for the ninth secondary diagnosis and was not required reporting until 2004. CHAR 5
Multiple versionsMC051 Other Diagnosis 10 This field contains the ICD-9 diagnosis code for the tenth secondary diagnosis and was not required reporting until 2004. CHAR 5
Multiple versionsMC052 Other Diagnosis 11 This field contains the ICD-9 diagnosis code for the eleventh secondary diagnosis and was not required reporting until 2004. CHAR 5
Multiple versionsMC053 Other Diagnosis 12 This field contains the ICD-9 diagnosis code for the twelfth secondary diagnosis and was not required reporting until 2004. CHAR 5
Multiple versionsMC054 Revenue Code This field is used to report the revenue code for hospital claims. It is one of three fields used to report type of service. National Uniform Billing Committee codes are used in this field. CHAR 10
Multiple versionsMC055 Procedure Code This field contains the HCPC or CPT code for the procedure performed. It is one of three fields used to report the service. CHAR 10
Multiple versionsMC056 Procedure Modifier 1 A modifier is used to indicate that a service or procedure has been altered by some specific circumstance but not changed in its definition or code. Modifiers may be used to indicate a service or procedure that has both a professional and a technical component, only part of a service was performed, a bilateral procedure was performed, or a service or procedure was provided more than once. CHAR 2
Multiple versionsMC057 Procedure Modifier 2 A modifier is used to indicate that a service or procedure has been altered by some specific circumstance but not changed in its definition or code. Modifiers may be used to indicate a service or procedure that has both a professional and a technical component, only part of a service was performed, a bilateral procedure was performed, or a service or procedure was provided more than once. CHAR 2
Multiple versionsMC058 ICD-9-CM Procedure Code This is used to report the ICD-9 procedure code. The decimal point is not coded. This is one of three fields used to report type of service. CHAR 4
Multiple versionsMC059 Date of Service From This field contains the first date of service for this service line in a CCYYMMDD format. DATE CCYYMMDD 8
Multiple versionsMC060 Date of Service Thru This field contains the last date of service for this service line in a CCYYMMDD format. DATE CCYYMMDD 8
Multiple versionsMC061 Quantity This field contains a count of services performed. This field may be negative. NUMBER 3
Multiple versionsMC062 Charge Amount This field contains the total charges for the service as reported by the provider. This is a money field Containing dollars and cents with an implied decimal Point. This field may contain a negative value. NUMBER 10
Multiple versionsMC063 Paid Amount This field includes all health plan payments, including withhold amounts, and excludes all member payments. This is a money field containing dollars and cents with an Implied decimal point. This field may contain a negative Value. NUMBER 10
Multiple versionsMC064 Prepaid Amount This field contains the fee for service equivalent that would have been paid by the health care claims processor for a specific service if the service had not been capitated. "Capitated services" means services rendered by a provider through a contract where payments are based upon a fixed dollar amount for each member on a monthly basis. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. NUMBER 10
Multiple versionsMC065 Copay Amount This field contains the pre-set, fixed dollar amount Payable by a member, often on a per visit/service basis. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. NUMBER 10
Multiple versionsMC066 Coinsurance Amount This amount is paid by the member and reflects the percent a member must pay toward the cost of a covered service. In many health insurance plans the coinsurance a member is responsible for is capped after a certain dollar amount of eligible expenses have been incurred. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. NUMBER 10
Multiple versionsMC067 Deductible Amount This is an amount that is required to be paid by a member before health plan benefits will begin to reimburse for services. It is usually an annual amount of all health care costs that is not covered by the member's insurance plan. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. NUMBER 10
Multiple versionsMC068 Record Type This field indicates the type of record. CHAR 2
Multiple versionsMC069 Patient Account/Control Number This field is used by hospitals to identify a patient. CHAR 38
MC070 Discharge Date This field contains the date the patient was discharged from the hospital. The format is CCYYMMDD. DATE CCYYMMDD 8
Multiple versionsMC901 Member Age This field contains the age of the member in years as of the from date of service (MC059). Children under the age of 1 have an age of zero. If no date of birth is available, this field is null. NUMBER 3
Multiple versionsMC902 Record ID # This field contains a Data Processing Center assigned record number that is unique across all data types. This field is used for tracking purposes. NUMBER 12
Multiple versionsMC903 MHDO Extract Date This is the date the record was extracted by the Data Processing Center for inclusion in the MHDO Data Warehouse. The format is CCYYMMDD. DATE CCYYMMDD 8
Multiple versionsMC904 Encrypted Member ID # The MEMBERID is a combination of fields which generally represent a unique individual. For those members with a value in the Encrypted Subscriber Social Security Number, the Memberid is comprised of Encrypted Subscriber Social Security Number + Year and Month of birth + Gender + Individual Relationship Code. If the Encrypted Subscriber Social Security Number is blank, the Memberid is comprised of the Plan Specific Contract Number + Year and Month of Birth + Gender + Individual Relationship Code. CHAR 71
Multiple versionsMC905 Medicare Coverage This field indicates whether the claim is for a member who also has Medicare coverage. It is derived from the insurance type/product code field (MC003). CHAR 1
Multiple versionsMC906 Submission ID # This field contains a unique submission number assigned by the Data Processing Center for tracking purposes. Each payer submission receives a submission number that is unique across all data types. NUMBER 12
Multiple versionsMC907 Double Encrypted Payer Claim Control Number This field contains the encrypted version of the Payer Claim Control Number reported in DC004. The claim number used by the payer to internally track the claim. In general the claim number is associated with all service lines of the bill. Therefore, multiple medical records may share the same claim number. CHAR 100
Multiple versionsMC908 Double Encrypted Subscriber Social Security Number This field contains an encryption of the information originally submitted by the payer in field DC007 - the Encrypted Social Security Number for the subscriber. If the social security number was not available from the payer this field will be null and the CONTRACT field will be populated. This field has been encrypted using the same algorithm across all payers. If this field is populated, it forms the core of the unique member identification code(MHDO_MEMBERID). CHAR 64
Multiple versionsMC909 Double Encrypted Plan Specific Contract Number This field contains an encryption of the information originally submitted by the payer in field DC008 - the payer assigned contract number for the subscriber. If the Encrypted Subscriber Social Security Number is null, this field forms the core of the unique member number (MHDO_MEMBERID). This field has been encrypted using the same algorithm across all payers. CHAR 128
Multiple versionsMC910 Double Encrypted Member Social Security Number This field is used to record the member's social security number when available. If the member is the subscriber, this field should contain the same value as the Encrypted Social Security Number. If the member is not the subscriber, this field will not equal the Encrypted Social Security Number. CHAR 128
Multiple versionsMC911 Double Encrypted Member ID # The Double Encrypted Member ID is a combination of fields which generally represent a unique individual. For those members with a value in the Encrypted Subscriber Social Security Number, the Double Encrypted Memberid is comprised of Double Encrypted Subscriber Social CHAR 135
Multiple versionsMC912 Provider ID # This is the provider identification number that links to the Medical Service Provider file using MCSP001. INTEGER 12
Multiple versionsMC913 Standardized Insurance Type/Product Code The insurance type or product code indicates the type of insurance coverage the individual has. CHAR 2
Multiple versionsMC914 Abortion Flag This field flags all records associated with a possible abortion claim. INTEGER 1
Multiple versionsMC915 Year Paid This field is derived from Date Service Approved (MC017) and contains the year of payment (YYYY format). Number YYYY 4
Multiple versionsMC916 Month Paid This field is derived from Date Service Approved (MC017) and contains the month of payment (MM format). Number MM 2
Multiple versionsMC917 Year of Service This field is derived from the From Date of Service (MC059) and contains the year the service was performed (YYYY format). Number YYYY 4
Multiple versionsMC918 Month of Service This field is derived from the From Date of Service (MC059) and contains the month the service was performed (MM format). Number MM 2
Multiple versionsMC919 Payment Quarter This field is derived from Date Service Approved (MC017) and contains the quarter of payment. Number 1
Multiple versionsMC920 Quarter Service Performed This field is derived from the From Date of Service (MC059) and contains the quarter of service. Number 1

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Data Element ID Data Element Code Value
MC001 Payer C Commercial carrier
T Third Party Administrator
U Unlicensed entity
MC003 Insurance Type/Product Code 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
AM Automobile Medical
DS Disability
HM Health Maintenance Organization
LI Liability
LM Liability Medical
MA Medicare Part A
MB Medicare Part B
MC Medicaid
OF Other Federal Program (e.g. Black Lung)
TV Title V
VA Veteran Administration Plan
WC Worker's Compensation
MC011 Individual Relationship Code 01 Spouse
04 Grandfather or Grandmother
05 Grandson or Granddaughter
07 Nephew or Niece
10 Foster Child
15 Ward
17 Stepson or Stepdaughter
19 Child
20 Employee
21 Unknown
22 Handicapped Dependent
23 Sponsored Dependent
24 Dependent of a Minor Dependent
29 Significant Other
32 Mother
33 Father
36 Emancipated Minor
39 Organ Donor
40 Cadaver Donor
41 Injured Plaintiff
43 Child Where Insured Has No Financial Responsibility
53 Life Partner
76 Dependent
MC012 Member Gender F Female
M Male
U Unknown
MC019 Admission Hour 0-23 are valid codes
00 Midnight
12 Noon
MC020 Admission Type 1 Emergency
2 Urgent
3 Elective
4 Newborn
5 Trauma Center
6 Reserved for National Assignment
7 Reserved for National Assignment
8 Reserved for National Assignment
9 Information not Available
MC021 Admission Source 1 Normal delivery
1 Physician referral
2 Premature delivery
2 Clinic referral
3 Sick baby
3 HMO referral
4 Extramural birth
4 Transfer from a hospital
5 Transfer from a skilled nursing facility
6 Transfer from another health care facility
7 Emergency Room
8 Court/Law enforcement
9 Information not available
9 Information not available
Admissions other than newborn
For newborns (ADMSR = 4)
MC022 Discharge Hour 0-23 are valid codes
00 Midnight
12 Noon
MC023 Member Status 01 Discharged to home or self care
02 Discharged/transferred to another short term general hospital for inpatient care
03 Discharged/transferred to skilled nursing facility (SNF)
04 Discharged/transferred to nursing facility (NF)
05 Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution
06 Discharged/transferred to home under care of organized home health service organization
07 Left against medical advice or discontinued care
08 Discharged/transferred to home under care of a Home IV provider
09 Admitted as an inpatient to this hospital
20 Expired
30 Still patient or expected to return for outpatient services
MC036 Type of Bill - Institutional 11 Hospital Inpatient (Including Medicare Part A)
12 Hospital Inpatient (Medicare Part B Only)
13 Hospital Outpatient
14 Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
15 Hospital Nursing Facility Level I
16 Hospital Nursing Facility Level II
17 Hospital Intermediate Care Level III Nursing Facility
18 Hospital Swing Beds
21 Skilled Nursing Inpatient (Including Medicare Part A)
22 Skilled Nursing Inpatient (Medicare Part B Only)
23 Skilled Nursing Outpatient
24 Skilled Nursing Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
25 Skilled Nursing Nursing Facility Level I
26 Skilled Nursing Nursing Facility Level II
27 Skilled Nursing Intermediate Care Level III Nursing Facility
28 Skilled Nursing Swing Beds
31 Home Health Inpatient (Including Medicare Part A)
32 Home Health Inpatient (Medicare Part B Only)
33 Home Health Outpatient
34 Home Health Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
35 Home Health Nursing Facility Level I
36 Home Health Nursing Facility Level II
37 Home Health Intermediate Care Level III Nursing Facility
38 Home Health Swing Beds
41 Christian Science Hospital Inpatient (Including Medicare Part A)
42 Christian Science Hospital Inpatient (Medicare Part B Only)
43 Christian Science Hospital Outpatient
44 Christian Science Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
45 Christian Science Hospital Nursing Facility Level I
46 Christian Science Hospital Nursing Facility Level II
47 Christian Science Hospital Intermediate Care Level III Nursing Facility
48 Christian Science Hospital Swing Beds
51 Nursing Facility Level I Inpatient (Including Medicare Part A)
52 Nursing Facility Level I Inpatient (Medicare Part B Only)
53 Nursing Facility Level I Outpatient
54 Nursing Facility Level I Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
55 Nursing Facility Level I Nursing Facility Level I
56 Nursing Facility Level I Nursing Facility Level II
57 Nursing Facility Level I Intermediate Care Level III Nursing Facility
58 Nursing Facility Level I Swing Beds
61 Nursing Facility Level II Inpatient (Including Medicare Part A)
62 Nursing Facility Level II Inpatient (Medicare Part B Only)
63 Nursing Facility Level II Outpatient
64 Nursing Facility Level II Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
65 Nursing Facility Level II Nursing Facility Level I
66 Nursing Facility Level II Nursing Facility Level II
67 Nursing Facility Level II Intermediate Care Level III Nursing Facility
68 Nursing Facility Level II Swing Beds
71 Intermediate Care Level III Nursing Facility Rural Health
72 Intermediate Care Level III Nursing Facility Hospital Based or Independent Renal
73 Intermediate Care Level III Nursing Facility Dialysis Center
74 Intermediate Care Level III Nursing Facility Free Standing
75 Intermediate Care Level III Nursing Facility Outpatient Rehabilitation Facility (ORF)
76 Intermediate Care Level III Nursing Facility Comprehensive Outpatient Rehabilitation
77 Intermediate Care Level III Nursing Facility Facilities (CORFs)
79 Intermediate Care Level III Nursing Facility Other
81 Swing Beds Hospice (Non Hospital Based
82 Swing Beds Hospice (Hospital-Based)
83 Swing Beds Ambulatory Surgery Center
84 Swing Beds Free Standing Birthing Center
89 Swing Beds Other
MC037 Facility Type - Professional 11 Office
12 Home
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room Hospital
24 Ambulatory Surgery Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance Land
42 Ambulance Air or Water
50 Federally Qualified Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End Stage Renal Disease Treatment Facility
71 State of Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Unlisted Facility
MC038 Claim Status 01 Processed as primary
02 Processed as secondary
03 Processed as tertiary
04 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
MC068 Record Type MC Medical Claims
MC905 Medicare Coverage 1 Yes
2 No
MC913 Standardized Insurance Type/Product Code 11 Other non Federal program
12 Medicare secondary working aged beneficiary or spouse with employer group health plan
13 Medicare secondary end-stage renal disease beneficiary in the 12 month coordination period with an employer's group health plan
14 Medicare secondary, no-fault insurance including auto is primary
15 Medicare secondary worker's compensation
15 Medicare secondary public health service (PHS) or other federal agency
41 Medicare secondary black lung
42 Medicare secondary veteran's administration
43 Medicare secondary disabled beneficiary under age 65 with large group health plan (LGHP)
47 Medicare secondary, other liability insurance is primary
AM Auto insurance policy
CP Medicare conditionally primary
DB Disability benefits
DS Disability
EP Exclusive Provider Organization (EPO)
HM Health Maintenance Organization (HMO)
HN Health Maintenance Organization (HMO) Medicare risk
HS Special low income Medicare beneficiary
IN Indemnity Insurance
LC Long term care
LD Long term policy
LI Life insurance
LM Liability medical
LT Litigation
MA Medicare part A
MB Medicare part B
MC Medicaid
MH Medigap part A
MI Medigap part B
MP Medicare primary
OF Other federal program (e.g. black lung)
OT Other
PE Property Insurance Personal
PR Preferred Provider Organization (PPO)
PS Point of Service (POS)
QM Qualified Medicare beneficiary
SP Supplemental policy
TV Title V
VA Veteran administration plan
WC Workers' compensation
MC914 Abortion Flag 0 Release
1 Withhold
MC919 Payment Quarter 1 January - March
2 April - June
3 July - September
4 October - December
MC920 Quarter Service Performed 1 January - March
2 April - June
3 July - September
4 October - December
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