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Dental Claims File Submission

Maine

Versions: 2010-03-16• v1.1Compare Versions


Name:Dental Claims File Submission
State:Maine
Definition:"Dental 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 current dental terminology codes from all non-denied adjudicated claims for each billed service.
Versionv1.1

File Specification for Dental Claims File Submission

Data Element ID Data Element Description Type Format Length
Multiple versionsDC001 Payer This field contains the MHDO submitter code for the payer submitting claims. 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 versionsDC002 National Plan ID CMS National Plan ID CHAR 30
Multiple versionsDC003 Insurance Type/Product Code - Original The insurance type or product code indicates the type of Insurance coverage the individual has. CHAR 2
Multiple versionsDC004 Payer Claim Control Number Original This field contains the claim number used by the payer to Internally track the claim. CHAR 35
Multiple versionsDC005 Line Counter This field is the line number of the service NUMBER 4
Multiple versionsDC006 Insured Group or Policy Number This field contains the group or policy number associated with the entity which 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 versionsDC007 Encrypted Subscriber Social Security Number Original 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 versionsDC008 Plan Specific Contract Number Original This field contains 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 (MEMBERID). CHAR 64
Multiple versionsDC009 Member Suffix or Sequence Number This payer supplied code uniquely identifies the member within the context of the subscriber Encrypted Social Security Number or the Contract. CHAR 20
Multiple versionsDC010 Member Identification Code Original 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 30
Multiple versionsDC011 Individual Relationship Code This field contains the member's relationship to the subscriber or the insured. CHAR 2
Multiple versionsDC012 Member Gender This field contains the gender of the member. CHAR 1
Multiple versionsDC013 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. DATE CCYYMMDD 8
Multiple versionsDC014 Member City Name of Residence This field contains the member's city of residence. CHAR 50
Multiple versionsDC015 Member State or Province The Member State or Province contains the 2 character abbreviation code used by the US Postal Service. CHAR 2
Multiple versionsDC016 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 versionsDC017 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. In the CCYYMMDD format. DATE 8
Multiple versionsDC030 Facility Type - Professional For professional claims, this field records the type of facility where the service was performed. CHAR 2
Multiple versionsDC031 Claim Status This field contains the status of the claim as reported by the payer. NUMBER 2
Multiple versionsDC032 CDT Code This field is used to report the procedure performed. Common Dental Terminology (CDT) coding is required. CHAR 5
Multiple versionsDC033 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 versionsDC034 Procedure Modifier - 2 Procedure modifier required when a modifier clarifies/improves CHAR 2
Multiple versionsDC035 Date of Service From This field contains the first date of service for this service line in a CCYYMMDD format. DATE CCYYMMDD 8
Multiple versionsDC036 Date of Service Thru This field contains the thru date of service for this service line in a CCYYMMDD format. DATE CCYYMMDD 8
Multiple versionsDC037 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 versionsDC038 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 versionsDC039 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 versionsDC040 Coinsurance Amount This amount is paid by the member and reflects the Percentage 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 versionsDC041 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 versionsDC042 Record Type This field indicates the type of record. CHAR 2
Multiple versionsDC901 Member Age This field contains the age of the member in years as of the first day of service. 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 versionsDC902 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 versionsDC903 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 versionsDC904 Unique 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 versionsDC905 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 versionsDC906 Double Encrypted Payer Control Claim 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 versionsDC907 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 versionsDC908 Double Encrypted 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 versionsDC909 Double Encrypted 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 128
Multiple versionsDC910 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 Member ID is comprised of Double Encrypted Subscriber Social Security Number + Year and Month of Birth + Gender + Individual Relationship Code. If the Double Encrypted Subscriber Social Security Number is blank, the Double Encrypted MEMBERID is comprised of the Encrypted Plan Specific Contract Number + Year and Month of Birth + Gender + Individual Relationship Code. CHAR 135
Multiple versionsDC911 Provider ID # This is the provider identification number that links to the Dental Service Provider file using DCSPC001. INTEGER 12
Multiple versionsDC912 Standardized Insurance Type/Product Code The insurance type or product code indicates the type of insurance coverage the individual has. CHAR 2
Multiple versionsDC913 Year Paid This field is derived from Date Service Approved (DC017) and contains the year of payment (YYYY format). Number 4
Multiple versionsDC914 Month Paid This field is derived from Date Service Approved (DC017) and contains the month of payment (MM format). Number 2
Multiple versionsDC915 Year of Service This field is derived from the From Date of Service (DC035) and contains the year the service was performed (YYYY format). Number YYYY 4
Multiple versionsDC916 Month of Service This field is derived from the From Date of Service (DC035) and contains the month the service was performed (MM format). Number MM 2
Multiple versionsDC917 Payment Quarter This field is derived from Date Service Approved (DC017) and contains the quarter of payment. Number 1
Multiple versionsDC918 Quarter Service Performed This field is derived from the From Date of Service (DC035) and contains the quarter of service. Number 1

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Data Element ID Data Element Code Value
DC001 Payer C Commercial carrier
T Third Party Administrator
U Unlicensed entity
DC003 Insurance Type/Product Code - Original 12 Preferred Provider Organization (PPO)
13 Point of Service
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 Workers' Compensation
DC011 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/Self
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
DC012 Member Gender F Female
M Male
U Unknown
DC030 Facility Type - Professional 11 Office
12 Home
21 Inpatient Hospital
22 Outpatient Hospital
31 Skilled Nursing Facility
35 Adult Living Care Facility
DC031 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
DC042 Record Type DC Dental Claims
DC912 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
DC917 Payment Quarter 1 January - March
2 April - June
3 July - September
4 October - December
DC918 Quarter Service Performed 1 January - March
2 April - June
3 July - September
4 October - December
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