United States Health Information Knowledgebase

 

Medical Claims File Submission

Minnesota



Name:Medical Claims File Submission
State:Minnesota
Definition:"Health care claims data" means information included in an institutional, professional, or pharmacy drug claim or equivalent encounter information transaction for a covered individual that is required under Minnesota Statutes, section 62J.536.
VersionMay 2009

File Specification for Medical Claims File Submission

Data Element ID Data Element Description Type Format Length
HD001 Record Type Not Provided Text 2
HD002 Payer Payer Code Text 8
HD004 Type of File Not Provided Text 2
HD005 Period Beginning Date Not Provided Integer CCYYMM 6
HD006 Period Ending Date Not Provided Integer CCYYMM 6
HD007 Record Count Total number of records submitted in the file Integer 10
HD008 Comments Payer comments Text 80
MC001 Payer This field contains the NCDMS assigned submitter code for the data submitter. The first two characters of the submitter code indicate Minnesota and the third character designates the type of submitter. A single data submitter may have multiple submitter codes because the data submitter is submitting from more than one system or from more than one location. All submitter codes associated with a single data submitter will have the same first 6 characters. A suffix will be used to distinguish the location and/or system variations. This field contains a constant value and is primarily used for tracking compliance by data submitter. Text 8
MC003 Insurance Type / Product Code This field contains the insurance type or product code that indicates the type of insurance coverage the individual has. Code all but MC and XX as 2 characters; MC and XX must include a valid subcode. Text 6
MC004 Payer Claim Control Number This field contains the claim number used by the data submitter to internally track the claim. In general the claim number is associated with all service lines of the bill. It must apply to the entire claim and be unique within the data submitter's system. Text 35
MC004A Claim Submitter's Identifier This field is used to track a claim from creation by the health care provider through the payment. This field is used in algorithms to determine the final payment for the service. Text 38
MC005 Line Counter This field contains the line number for this service. The line counter begins with 1 and is incremented by 1 for each additional service line of a claim. This field is used in algorithms to determine the final payment for the service. If the data submitter's processing system assigns an internal line counter for the adjudication process, that number may be submitted in place of the line number submitted by the provider. Integer 4
MC005A Version Number This is a voluntary administrative field and is not required to be reported. This field contains the version number of the claim service line. It begins with 0 and is incremented by 1 for each subsequent version of that service line. This field is used in algorithms to determine the final payment for the service Integer 4
MC008 Plan Specific Contract Number This field contains the data submitter assigned contract number for the subscriber. This field is encrypted using the same algorithm across all data submitters and is not available in the analytical data warehouse. When this field is populated, it forms the core of the unique member identification code. Set as null if unavailable. Text 128
MC011 Individual Relationship Code This field contains the member's relationship to the subscriber or the insured. Integer 2
MC012 Member Gender This field contains the gender of the patient. Text 1
MC013 Member Date of Birth This field contains the member's date of birth with a format of CCYYMMDD. During the encryption process, this field is used to calculate age as of the from date of service (MC059). The field is then encrypted. This data element will not be transmitted in unencrypted form. Date CCYYMMDD 8
MC014 Member City Name This field contains the member's city of residence Text 30
MC015 Member State or Province The member state or province contains the 2 character abbreviation code used by the US Postal Service. Text 2
MC016 Member ZIP Code This field contains the ZIP code associated with the member's residence Text 5
MC017 Check Issue or EFT Effective Date This field contains the date the record was approved for payment. This is generally referred to as the paid date and reported with a CCYYMMDD format. When BPR04 is "NON" for non-payment, include remittance data Date CCYYMMDD 8
MC018 Admission Date This field contains the date of the inpatient admission reported with a CCYYMMDD format. Date CCYYMMDD 8
MC020 Admission Type This field is used to record the type of admission for all inpatient hospital claims. Integer 1
MC021 Admission Source This field is required for inpatient hospital claims. It records the source of admission. For newborns (Admission Type = 4) Text 1
MC023 Discharge Status This field contains the status for the patient discharged from the hospital. Integer 2
MC024 Service Provider Number Data submitter assigned or legacy rendering/attending provider number. This field will be used to create a master provider index for Minnesota providers encompassing both medical service providers and prescribing providers. Required if MC026 is not filled. Text 30
MC025 Service Provider Tax ID Number Federal tax payer's identification number for rendering/attending provider. This field will be used to create a master provider index for Minnesota providers encompassing both medical service providers and prescribing providers. Text 10
MC026 National Service Provider ID Record the National Provider Identification (NPI) number for the entity or individual directly providing the service. This field will be used to create a master provider index for Minnesota medical service and prescribing providers. Required if MC024 is not filled. Text 20
MC027 Service Provider Entity Type Qualifier Not Provided Text 1
MC028 Service Provider First Name Report the individual's first name. Set to null if provider is a facility or an organization. This field will be used to create a master provider index for Minnesota providers encompassing both medical service providers and prescribing providers Text 25
MC029 Service Provider Middle Name Report the individual's middle name or initial. Set to null if provider is a facility or an organization. This field will be used to create a master provider index for Minnesota providers encompassing both medical service providers and prescribing providers. Text 25
MC030 Service Provider Last Name or Organization Name Report the last name of the individual practitioner or the full name if the provider is a facility or an organization. This field will be used to create a master provider index for Minnesota providers encompassing both medical service providers and prescribing providers. Text 100
MC031 Service Provider Suffix The service provider suffix is used to capture any generational identifiers associated with an individual clinician's name (e.g. Jr. Sr., III). Do not code the clinician's credentials (e.g. MD, LCSW) in this field. Set to null if the provider is a facility or an organization. This field will be used to create a master provider index for Minnesota providers encompassing both medical service providers and prescribing providers. Text 10
MC033 Service Provider City Name Report the city name of the provider address, preferably the practice location. This field will be used to create a master provider index for Minnesota providers encompassing both medical service providers and prescribing providers. Text 30
MC034 Service Provider State or Province The provider's state or province contains the 2 character abbreviation code used by the US Postal Service. This field will be used to create a master provider index for Minnesota providers encompassing both medical service providers and prescribing providers. Text 2
MC035 Service Provider ZIP Code Report the ZIP code of the servicing provider's address, preferably the practice location. This field will be used to create a master provider index for Minnesota providers encompassing both medical service providers and prescribing providers. Text 15
MC036 Type of Bill - Institutional This field is required for institutional claims and must be set to null for professional claims. Integer 3
MC037 Site of Service - on NSF/CMS 1500 Claims For professional claims, this field records the type of facility where the service was performed. The field should be set to null for institutional claims. Text 2
MC039 Admitting Diagnosis This field contains the ICD-9 diagnosis code indicating the reason for the inpatient admission. Decimal point is not coded. Text 5
MC040 E-Code This field describes an injury, poisoning or adverse effect using an ICD-9 E-code diagnosis. Decimal point is not coded. Additional E-Codes may be reported in other diagnosis fields MC041-MC053 Text 5
MC041 Principal Diagnosis This field contains the ICD-9 diagnosis code for the principal diagnosis. Decimal point is not coded. Text 5
MC042 Other Diagnosis - 1 This field contains the ICD-9 diagnosis code for the first secondary diagnosis. Decimal point is not coded. Text 5
MC043 Other Diagnosis - 2 This field contains the ICD-9 diagnosis code for the second secondary diagnosis. Decimal point is not coded. Text 5
MC044 Other Diagnosis - 3 This field contains the ICD-9 diagnosis code for the third secondary diagnosis. Decimal point is not coded. Text 5
MC045 Other Diagnosis - 4 This field contains the ICD-9 diagnosis code for the fourth secondary diagnosis. Decimal point is not coded. Text 5
MC046 Other Diagnosis - 5 This field contains the ICD-9 diagnosis code for the fifth secondary diagnosis. Decimal point is not coded. Text 5
MC047 Other Diagnosis - 6 This field contains the ICD-9 diagnosis code for the sixth secondary diagnosis. Decimal point is not coded. Text 5
MC048 Other Diagnosis - 7 This field contains the ICD-9 diagnosis code for the seventh secondary diagnosis. Decimal point is not coded. Text 5
MC049 Other Diagnosis - 8 This field contains the ICD-9 diagnosis code for the eighth secondary diagnosis. Decimal point is not coded. Text 5
MC050 Other Diagnosis - 9 This field contains the ICD-9 diagnosis code for the ninth secondary diagnosis. Decimal point is not coded. Text 5
MC051 Other Diagnosis - 10 This field contains the ICD-9 diagnosis code for the tenth secondary diagnosis. Decimal point is not coded. Text 5
MC052 Other Diagnosis - 11 This field contains the ICD-9 diagnosis code for the eleventh secondary diagnosis. Decimal point is not coded. Text 5
MC053 Other Diagnosis - 12 This field contains the ICD-9 diagnosis code for the twelfth secondary diagnosis. Decimal point is not coded. Text 5
MC054 Revenue Code This field is used to report the revenue code for institutional claims. It is one of three fields used to report type of service. National Uniform Billing Committee Codes are accepted. Code using leading zeroes, left justified and four digits. Text 4
MC055 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. Health Care Common Procedural Coding System (HCPCS), including CPT codes of the American Medical Association, are accepted. Text 5
MC056 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 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. Text 2
MC057A 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. Text 2
MC057B Procedure Modifier - 3 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. Text 2
MC057C Procedure Modifier - 4 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. Text 2
MC058 Principal ICD-9-CM Procedure Code This is used to report the principal inpatient ICD-9 procedure code. The decimal point is not coded. The ICD-9 procedure must be repeated for all lines of the claim if necessary. This is one of three fields used to report type of service. Use fields MC058A- E to report other ICD-9-CM procedure codes. Text 4
MC058A Other ICD- 9-CM Procedure Code - 1 This is used to report the second ICD-9 procedure code. The decimal point is not coded. The ICD-9 procedure must be repeated for all lines of the claim if necessary. Text 4
MC058B Other ICD- 9-CM Procedure Code - 2 This is used to report the third ICD-9 procedure code. The decimal point is not coded. The ICD-9 procedure must be repeated for all lines of the claim if necessary. Text 4
MC058C Other ICD- 9-CM Procedure Code - 3 This is used to report the fourth ICD-9 procedure code. The decimal point is not coded. The ICD-9 procedure must be repeated for all lines of the claim if necessary. Text 4
MC058D Other ICD- 9-CM Procedure Code - 4 This is used to report the fifth ICD-9 procedure code. The decimal point is not coded. The ICD-9 procedure must be repeated for all lines of the claim if necessary. Text 4
MC058E Other ICD- 9-CM Procedure Code - 5 This is used to report the sixth ICD-9 procedure code. The decimal point is not coded. The ICD-9 procedure must be repeated for all lines of the claim if necessary. Text 4
MC059 Date of Service - From This field contains the first date of service for this service line in a CCYYMMDD format. Date CCYYMMDD 8
MC060 Date of Service - Thru This field contains the last date of service for this service line in a CCYYMMDD format. Future dates are acceptable. Date CCYYMMDD 8
MC061 Quantity This field contains a count of services performed. This field may be negative. Integer 5
MC062 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. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. Decimal 10
MC063 Paid Amount This field includes all health plan payments , and excludes all member payments and withholds from providers. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. Decimal 10
MC063A Header/ Line Payment Indicator This field is used to indicate whether the payment is reported on the header or line level. Code H for Header or L for Line. If H, populate each line after the first line with "H" and a paid amount of $0. If L, populate each line as necessary. Text 1
MC063C Managed Care Withhold This is an amount withheld from payment to a provider by a managed care organization, which may be paid at a later date. 0$ is acceptable; code "data not available" as 9999999999. Submissions containing 9999999999 will not factor into the calculation of the threshold. Decimal 10
MC064 Prepaid Amount For capitated services, the fee for service equivalent amount. 0$ is acceptable; code "data not available" as 9999999999. Submissions containing 9999999999 will not factor into the calculation of the threshold. Decimal 10
MC065 Copay / Co-insurance Amount This field contains the pre-set, fixed dollar amount of copay and/or ccoinsurance 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. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. Decimal 10
MC067 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. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. Decimal 10
MC076 Billing Provider Number Enter the data submitter assigned billing provider number. This should be the identifier used by the data submitter for internal reasons and does not routinely change. Required if MC077 is not filled. Text 30
MC077 National Billing Provider ID National Provider Identification (NPI) number for the billing provider. Required if MC076 is not filled. Text 10
MC078 Billing Provider Last Name Report the full name of the billing organization or the last name of the individual billing provider. Text 60
MC079 Diagnosis Code Pointer -1 A pointer to the claim diagnosis code in the order of importance to this service. Use this pointer for the first diagnosis code pointer (primary diagnosis for this service line). Integer 1
MC080 Diagnosis Code Pointer -2 A pointer to the claim diagnosis code in the order of importance to this service. Use this pointer for the second diagnosis code pointer if applicable. Integer 1
MC081 Diagnosis Code Pointer -3 A pointer to the claim diagnosis code in the order of importance to this service. Use this pointer for the third diagnosis code pointer if applicable. Integer 1
MC082 Diagnosis Code Pointer -4 A pointer to the claim diagnosis code in the order of importance to this service. Use this pointer for the fourth diagnosis code pointer if applicable. Integer 1
MC101 Subscriber Last Name The subscriber last name is used to create a unique de-identified member ID. It is encrypted at the data submitter's site. This data element will not be available in the data warehouse. Text 128
MC102 Subscriber First Name Subscriber first name, used to create a unique de-identified member ID. It is encrypted at the data submitter's site. This data element will not be available in the data warehouse. Text 128
MC103 Subscriber Middle Initial Subscriber middle initial, used to create a unique de-identified member ID. It is encrypted at the data submitter's site. This data element will not be available in the data warehouse. Text 1
MC104 Member Last Name Member last name, used to create a unique de-identified member ID. It is encrypted at the data submitter's site. This data element will not be available in the data warehouse. Text 128
MC105 Member First Name Member first name, used to create a unique de-identified member ID. It is encrypted at the data submitter's site. This data element will not be available in the data warehouse. Text 128
MC106 Member Middle Initial Member middle initial, used to create unique de-identified member ID. It is encrypted at the data submitter's site. This data element will not be available in the data warehouse. Text 1
MC899 Record Type This field indicates the type of record. MC = Institutional & Professional Claims This is an administrative field required by NCDMS and populated with a constant value. Text 2
TR001 Record Type Not Provided Text 2
TR002 Payer Payer Code Text 8
TR004 Type of File Not Provided Text 2
TR005 Period Beginning Date Not Provided Integer YYYYMM 6
TR006 Period Ending Date Not Provided Integer YYYYMM 6
TR007 Date Processed Date file was created Date CCYYMMDD 8

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Data Element ID Data Element Code Value
HD001 Record Type HD Header Record
HD004 Type of File MC Institutional & Prof'l Claims
MC001 Payer MNC Commercial carrier
MNG Governmental agency
MNT Third Party Administrator
MNU Unlicensed entity
MC003 Insurance Type / Product Code 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
16 Medicare Secondary Public Health Service 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
47 Medicare Secondary, Other Liability Insurance is Primary
CP Medicare Conditionally Primary
D Disability
DB Disability Benefits
EP Exclusive Provider Organization
HM Health Maintenance Organization (HMO)
HN Health Maintenance Organization (HMO) Medicare Risk / Medicare Part C
HS Special Low Income Medicare Beneficiary
IN Indemnity
MA Medicare Part A
MB Medicare Part B
MCFFSM Medical Assistance - Fee-for-service Medical Assistance
MCMDHO Medical Assistance - MN Disability Health Options
MCMISC Medical Assistance - Other managed care program within Medical Assistance
MCMSHO Medical Assistance - MN Senior Health Options
MCPMAP Medical Assistance - Prepaid Medical Assistance Program
MCSNBC Medical Assistance - Special Needs Basic Care
MD Medicare Part D
MH Medigap Part A
MI Medigap Part B
MP Medicare Primary
PR Preferred Provider Organization (PPO)
PS Point of Service (POS)
QM Qualified Medicare Beneficiary
SP Supplemental Policy
XXCDEP Non-Medical-Assistance Public Program - Chemical Dependency
XXGAMC Non-Medical-Assistance Public Program - General Assistance Medical Care
XXHIVA Non-Medical-Assistance Public Program - HIV/AIDS
XXMCHA Non-Medical-Assistance Public Program - Minnesota Comprehensive Health Association
XXMISC Non-Medical-Assistance Public Program - Other non-Medical Assitance public program
XXMNCR Non-Medical-Assistance Public Program - MinnesotaCare
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
18 Self
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
34 Other Adult
36 Emancipated Minor
39 Organ Donor
40 Cadaver Donor
41 Injured Plaintiff
43 Child Where Insured Has No Financial Responsibility
53 Life Partner
MC012 Member Gender F Female
M Male
U Unknown
MC020 Admission Type 1 Emergency
2 Urgent
3 Elective
4 Newborn
5 Trauma Center
9 Information not Available
MC021 Admission Source Admissions other than newborn 1 Physician referral
Admissions other than newborn 2 Clinic referral
Admissions other than newborn 3 HMO referral
Admissions other than newborn 4 Transfer from a hospital
Admissions other than newborn 5 Transfer from a skilled nursing facility
Admissions other than newborn 6 Transfer from another health care facility
Admissions other than newborn 7 Emergency room
Admissions other than newborn 8 Court/Law enforcement
Admissions other than newborn 9 Information not available
For newborns 1 Normal delivery
For newborns 2 Premature delivery
For newborns 3 Sick baby
For newborns 4 Extramural birth
For newborns 9 Information not available
MC023 Discharge 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
40 Expired at home
41 Expired in a medical facility
42 Expired, place unknown
43 Discharged/transferred to a Federal hospital
50 Hospice - home
51 Hospice - medical facility
61 Discharged/transferred within this institution to a hospital based Medicare-approved swing bed
62 Discharged/transferred to an inpatient rehabilitation facility including distinct parts of a hospital
63 Discharge/transferred to a longterm care hospital
64 Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare
MC024 Service Provider Number L Legacy / pre-NPI
M MHCP
O Other
U UMPI
MC027 Service Provider Entity Type Qualifier 1 Person
2 Non-Person Entity
MC036 Type of Bill - Institutional 111 Hospital Inpatient (Including Medicare Part A) Admit Through Discharge
112 Hospital Inpatient (Including Medicare Part A) Interim-First Claim Used for the
113 Hospital Inpatient (Including Medicare Part A) Interim-Continuing Claims
114 Hospital Inpatient (Including Medicare Part A) Interim-Last Claim
115 Hospital Inpatient (Including Medicare Part A) Late Charge Only
117 Hospital Inpatient (Including Medicare Part A) Replacement of Prior Claim
118 Hospital Inpatient (Including Medicare Part A) Void/Cancel of a Prior Claim
119 Hospital Inpatient (Including Medicare Part A) Final Claim for a Home
121 Hospital Inpatient (Medicare Part B Only) Admit Through Discharge
122 Hospital Inpatient (Medicare Part B Only) Interim-First Claim Used for the
123 Hospital Inpatient (Medicare Part B Only) Interim-Continuing Claims
124 Hospital Inpatient (Medicare Part B Only) Interim-Last Claim
125 Hospital Inpatient (Medicare Part B Only) Late Charge Only
127 Hospital Inpatient (Medicare Part B Only) Replacement of Prior Claim
128 Hospital Inpatient (Medicare Part B Only) Void/Cancel of a Prior Claim
129 Hospital Inpatient (Medicare Part B Only) Final Claim for a Home
131 Hospital Outpatient Admit Through Discharge
132 Hospital Outpatient Interim-First Claim Used for the
133 Hospital Outpatient Interim-Continuing Claims
134 Hospital Outpatient Interim-Last Claim
135 Hospital Outpatient Late Charge Only
137 Hospital Outpatient Replacement of Prior Claim
138 Hospital Outpatient Void/Cancel of a Prior Claim
139 Hospital Outpatient Final Claim for a Home
141 Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Admit Through Discharge
142 Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-First Claim Used for the
143 Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Continuing Claims
144 Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Last Claim
145 Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Late Charge Only
147 Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Replacement of Prior Claim
148 Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Void/Cancel of a Prior Claim
149 Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Final Claim for a Home
151 Hospital Nursing Facility Level I Admit Through Discharge
152 Hospital Nursing Facility Level I Interim-First Claim Used for the
153 Hospital Nursing Facility Level I Interim-Continuing Claims
154 Hospital Nursing Facility Level I Interim-Last Claim
155 Hospital Nursing Facility Level I Late Charge Only
157 Hospital Nursing Facility Level I Replacement of Prior Claim
158 Hospital Nursing Facility Level I Void/Cancel of a Prior Claim
159 Hospital Nursing Facility Level I Final Claim for a Home
161 Hospital Nursing Facility Level II Admit Through Discharge
162 Hospital Nursing Facility Level II Interim-First Claim Used for the
163 Hospital Nursing Facility Level II Interim-Continuing Claims
164 Hospital Nursing Facility Level II Interim-Last Claim
165 Hospital Nursing Facility Level II Late Charge Only
167 Hospital Nursing Facility Level II Replacement of Prior Claim
168 Hospital Nursing Facility Level II Void/Cancel of a Prior Claim
169 Hospital Nursing Facility Level II Final Claim for a Home
171 Hospital Intermediate Care Level III Nursing Facility Admit Through Discharge
172 Hospital Intermediate Care Level III Nursing Facility Interim-First Claim Used for the
173 Hospital Intermediate Care Level III Nursing Facility Interim-Continuing Claims
174 Hospital Intermediate Care Level III Nursing Facility Interim-Last Claim
175 Hospital Intermediate Care Level III Nursing Facility Late Charge Only
177 Hospital Intermediate Care Level III Nursing Facility Replacement of Prior Claim
178 Hospital Intermediate Care Level III Nursing Facility Void/Cancel of a Prior Claim
179 Hospital Intermediate Care Level III Nursing Facility Final Claim for a Home
181 Hospital Swing Beds Admit Through Discharge
182 Hospital Swing Beds Interim-First Claim Used for the
183 Hospital Swing Beds Interim-Continuing Claims
184 Hospital Swing Beds Interim-Last Claim
185 Hospital Swing Beds Late Charge Only
187 Hospital Swing Beds Replacement of Prior Claim
188 Hospital Swing Beds Void/Cancel of a Prior Claim
189 Hospital Swing Beds Final Claim for a Home
211 Skilled Nursing Inpatient (Including Medicare Part A) Admit Through Discharge
212 Skilled Nursing Inpatient (Including Medicare Part A) Interim-First Claim Used for the
213 Skilled Nursing Inpatient (Including Medicare Part A) Interim-Continuing Claims
214 Skilled Nursing Inpatient (Including Medicare Part A) Interim-Last Claim
215 Skilled Nursing Inpatient (Including Medicare Part A) Late Charge Only
217 Skilled Nursing Inpatient (Including Medicare Part A) Replacement of Prior Claim
218 Skilled Nursing Inpatient (Including Medicare Part A) Void/Cancel of a Prior Claim
219 Skilled Nursing Inpatient (Including Medicare Part A) Final Claim for a Home
221 Skilled Nursing Inpatient (Medicare Part B Only) Admit Through Discharge
222 Skilled Nursing Inpatient (Medicare Part B Only) Interim-First Claim Used for the
223 Skilled Nursing Inpatient (Medicare Part B Only) Interim-Continuing Claims
224 Skilled Nursing Inpatient (Medicare Part B Only) Interim-Last Claim
225 Skilled Nursing Inpatient (Medicare Part B Only) Late Charge Only
227 Skilled Nursing Inpatient (Medicare Part B Only) Replacement of Prior Claim
228 Skilled Nursing Inpatient (Medicare Part B Only) Void/Cancel of a Prior Claim
229 Skilled Nursing Inpatient (Medicare Part B Only) Final Claim for a Home
231 Skilled Nursing Outpatient Admit Through Discharge
232 Skilled Nursing Outpatient Interim-First Claim Used for the
233 Skilled Nursing Outpatient Interim-Continuing Claims
234 Skilled Nursing Outpatient Interim-Last Claim
235 Skilled Nursing Outpatient Late Charge Only
237 Skilled Nursing Outpatient Replacement of Prior Claim
238 Skilled Nursing Outpatient Void/Cancel of a Prior Claim
239 Skilled Nursing Outpatient Final Claim for a Home
241 Skilled Nursing Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Admit Through Discharge
242 Skilled Nursing Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-First Claim Used for the
243 Skilled Nursing Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Continuing Claims
244 Skilled Nursing Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Last Claim
245 Skilled Nursing Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Late Charge Only
247 Skilled Nursing Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Replacement of Prior Claim
248 Skilled Nursing Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Void/Cancel of a Prior Claim
249 Skilled Nursing Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Final Claim for a Home
251 Skilled Nursing Nursing Facility Level I Admit Through Discharge
252 Skilled Nursing Nursing Facility Level I Interim-First Claim Used for the
253 Skilled Nursing Nursing Facility Level I Interim-Continuing Claims
254 Skilled Nursing Nursing Facility Level I Interim-Last Claim
255 Skilled Nursing Nursing Facility Level I Late Charge Only
257 Skilled Nursing Nursing Facility Level I Replacement of Prior Claim
258 Skilled Nursing Nursing Facility Level I Void/Cancel of a Prior Claim
259 Skilled Nursing Nursing Facility Level I Final Claim for a Home
261 Skilled Nursing Nursing Facility Level II Admit Through Discharge
262 Skilled Nursing Nursing Facility Level II Interim-First Claim Used for the
263 Skilled Nursing Nursing Facility Level II Interim-Continuing Claims
264 Skilled Nursing Nursing Facility Level II Interim-Last Claim
265 Skilled Nursing Nursing Facility Level II Late Charge Only
267 Skilled Nursing Nursing Facility Level II Replacement of Prior Claim
268 Skilled Nursing Nursing Facility Level II Void/Cancel of a Prior Claim
269 Skilled Nursing Nursing Facility Level II Final Claim for a Home
271 Skilled Nursing Intermediate Care Level III Nursing Facility Admit Through Discharge
272 Skilled Nursing Intermediate Care Level III Nursing Facility Interim-First Claim Used for the
273 Skilled Nursing Intermediate Care Level III Nursing Facility Interim-Continuing Claims
274 Skilled Nursing Intermediate Care Level III Nursing Facility Interim-Last Claim
275 Skilled Nursing Intermediate Care Level III Nursing Facility Late Charge Only
277 Skilled Nursing Intermediate Care Level III Nursing Facility Replacement of Prior Claim
278 Skilled Nursing Intermediate Care Level III Nursing Facility Void/Cancel of a Prior Claim
279 Skilled Nursing Intermediate Care Level III Nursing Facility Final Claim for a Home
281 Skilled Nursing Swing Beds Admit Through Discharge
282 Skilled Nursing Swing Beds Interim-First Claim Used for the
283 Skilled Nursing Swing Beds Interim-Continuing Claims
284 Skilled Nursing Swing Beds Interim-Last Claim
285 Skilled Nursing Swing Beds Late Charge Only
287 Skilled Nursing Swing Beds Replacement of Prior Claim
288 Skilled Nursing Swing Beds Void/Cancel of a Prior Claim
289 Skilled Nursing Swing Beds Final Claim for a Home
311 Home Health Inpatient (Including Medicare Part A) Admit Through Discharge
312 Home Health Inpatient (Including Medicare Part A) Interim-First Claim Used for the
313 Home Health Inpatient (Including Medicare Part A) Interim-Continuing Claims
314 Home Health Inpatient (Including Medicare Part A) Interim-Last Claim
315 Home Health Inpatient (Including Medicare Part A) Late Charge Only
317 Home Health Inpatient (Including Medicare Part A) Replacement of Prior Claim
318 Home Health Inpatient (Including Medicare Part A) Void/Cancel of a Prior Claim
319 Home Health Inpatient (Including Medicare Part A) Final Claim for a Home
321 Home Health Inpatient (Medicare Part B Only) Admit Through Discharge
322 Home Health Inpatient (Medicare Part B Only) Interim-First Claim Used for the
323 Home Health Inpatient (Medicare Part B Only) Interim-Continuing Claims
324 Home Health Inpatient (Medicare Part B Only) Interim-Last Claim
325 Home Health Inpatient (Medicare Part B Only) Late Charge Only
327 Home Health Inpatient (Medicare Part B Only) Replacement of Prior Claim
328 Home Health Inpatient (Medicare Part B Only) Void/Cancel of a Prior Claim
329 Home Health Inpatient (Medicare Part B Only) Final Claim for a Home
331 Home Health Outpatient Admit Through Discharge
332 Home Health Outpatient Interim-First Claim Used for the
333 Home Health Outpatient Interim-Continuing Claims
334 Home Health Outpatient Interim-Last Claim
335 Home Health Outpatient Late Charge Only
337 Home Health Outpatient Replacement of Prior Claim
338 Home Health Outpatient Void/Cancel of a Prior Claim
339 Home Health Outpatient Final Claim for a Home
341 Home Health Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Admit Through Discharge
342 Home Health Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-First Claim Used for the
343 Home Health Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Continuing Claims
344 Home Health Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Last Claim
345 Home Health Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Late Charge Only
347 Home Health Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Replacement of Prior Claim
348 Home Health Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Void/Cancel of a Prior Claim
349 Home Health Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Final Claim for a Home
351 Home Health Nursing Facility Level I Admit Through Discharge
352 Home Health Nursing Facility Level I Interim-First Claim Used for the
353 Home Health Nursing Facility Level I Interim-Continuing Claims
354 Home Health Nursing Facility Level I Interim-Last Claim
355 Home Health Nursing Facility Level I Late Charge Only
357 Home Health Nursing Facility Level I Replacement of Prior Claim
358 Home Health Nursing Facility Level I Void/Cancel of a Prior Claim
359 Home Health Nursing Facility Level I Final Claim for a Home
361 Home Health Nursing Facility Level II Admit Through Discharge
362 Home Health Nursing Facility Level II Interim-First Claim Used for the
363 Home Health Nursing Facility Level II Interim-Continuing Claims
364 Home Health Nursing Facility Level II Interim-Last Claim
365 Home Health Nursing Facility Level II Late Charge Only
367 Home Health Nursing Facility Level II Replacement of Prior Claim
368 Home Health Nursing Facility Level II Void/Cancel of a Prior Claim
369 Home Health Nursing Facility Level II Final Claim for a Home
371 Home Health Intermediate Care Level III Nursing Facility Admit Through Discharge
372 Home Health Intermediate Care Level III Nursing Facility Interim-First Claim Used for the
373 Home Health Intermediate Care Level III Nursing Facility Interim-Continuing Claims
374 Home Health Intermediate Care Level III Nursing Facility Interim-Last Claim
375 Home Health Intermediate Care Level III Nursing Facility Late Charge Only
377 Home Health Intermediate Care Level III Nursing Facility Replacement of Prior Claim
378 Home Health Intermediate Care Level III Nursing Facility Void/Cancel of a Prior Claim
379 Home Health Intermediate Care Level III Nursing Facility Final Claim for a Home
381 Home Health Swing Beds Admit Through Discharge
382 Home Health Swing Beds Interim-First Claim Used for the
383 Home Health Swing Beds Interim-Continuing Claims
384 Home Health Swing Beds Interim-Last Claim
385 Home Health Swing Beds Late Charge Only
387 Home Health Swing Beds Replacement of Prior Claim
388 Home Health Swing Beds Void/Cancel of a Prior Claim
389 Home Health Swing Beds Final Claim for a Home
411 Christian Science Hospital Inpatient (Including Medicare Part A) Admit Through Discharge
412 Christian Science Hospital Inpatient (Including Medicare Part A) Interim-First Claim Used for the
413 Christian Science Hospital Inpatient (Including Medicare Part A) Interim-Continuing Claims
414 Christian Science Hospital Inpatient (Including Medicare Part A) Interim-Last Claim
415 Christian Science Hospital Inpatient (Including Medicare Part A) Late Charge Only
417 Christian Science Hospital Inpatient (Including Medicare Part A) Replacement of Prior Claim
418 Christian Science Hospital Inpatient (Including Medicare Part A) Void/Cancel of a Prior Claim
419 Christian Science Hospital Inpatient (Including Medicare Part A) Final Claim for a Home
421 Christian Science Hospital Inpatient (Medicare Part B Only) Admit Through Discharge
422 Christian Science Hospital Inpatient (Medicare Part B Only) Interim-First Claim Used for the
423 Christian Science Hospital Inpatient (Medicare Part B Only) Interim-Continuing Claims
424 Christian Science Hospital Inpatient (Medicare Part B Only) Interim-Last Claim
425 Christian Science Hospital Inpatient (Medicare Part B Only) Late Charge Only
427 Christian Science Hospital Inpatient (Medicare Part B Only) Replacement of Prior Claim
428 Christian Science Hospital Inpatient (Medicare Part B Only) Void/Cancel of a Prior Claim
429 Christian Science Hospital Inpatient (Medicare Part B Only) Final Claim for a Home
431 Christian Science Hospital Outpatient Admit Through Discharge
432 Christian Science Hospital Outpatient Interim-First Claim Used for the
433 Christian Science Hospital Outpatient Interim-Continuing Claims
434 Christian Science Hospital Outpatient Interim-Last Claim
435 Christian Science Hospital Outpatient Late Charge Only
437 Christian Science Hospital Outpatient Replacement of Prior Claim
438 Christian Science Hospital Outpatient Void/Cancel of a Prior Claim
439 Christian Science Hospital Outpatient Final Claim for a Home
441 Christian Science Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Admit Through Discharge
442 Christian Science Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-First Claim Used for the
443 Christian Science Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Continuing Claims
444 Christian Science Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Last Claim
445 Christian Science Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Late Charge Only
447 Christian Science Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Replacement of Prior Claim
448 Christian Science Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Void/Cancel of a Prior Claim
449 Christian Science Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Final Claim for a Home
451 Christian Science Hospital Nursing Facility Level I Admit Through Discharge
452 Christian Science Hospital Nursing Facility Level I Interim-First Claim Used for the
453 Christian Science Hospital Nursing Facility Level I Interim-Continuing Claims
454 Christian Science Hospital Nursing Facility Level I Interim-Last Claim
455 Christian Science Hospital Nursing Facility Level I Late Charge Only
457 Christian Science Hospital Nursing Facility Level I Replacement of Prior Claim
458 Christian Science Hospital Nursing Facility Level I Void/Cancel of a Prior Claim
459 Christian Science Hospital Nursing Facility Level I Final Claim for a Home
461 Christian Science Hospital Nursing Facility Level II Admit Through Discharge
462 Christian Science Hospital Nursing Facility Level II Interim-First Claim Used for the
463 Christian Science Hospital Nursing Facility Level II Interim-Continuing Claims
464 Christian Science Hospital Nursing Facility Level II Interim-Last Claim
465 Christian Science Hospital Nursing Facility Level II Late Charge Only
467 Christian Science Hospital Nursing Facility Level II Replacement of Prior Claim
468 Christian Science Hospital Nursing Facility Level II Void/Cancel of a Prior Claim
469 Christian Science Hospital Nursing Facility Level II Final Claim for a Home
471 Christian Science Hospital Intermediate Care Level III Nursing Facility Admit Through Discharge
472 Christian Science Hospital Intermediate Care Level III Nursing Facility Interim-First Claim Used for the
473 Christian Science Hospital Intermediate Care Level III Nursing Facility Interim-Continuing Claims
474 Christian Science Hospital Intermediate Care Level III Nursing Facility Interim-Last Claim
475 Christian Science Hospital Intermediate Care Level III Nursing Facility Late Charge Only
477 Christian Science Hospital Intermediate Care Level III Nursing Facility Replacement of Prior Claim
478 Christian Science Hospital Intermediate Care Level III Nursing Facility Void/Cancel of a Prior Claim
479 Christian Science Hospital Intermediate Care Level III Nursing Facility Final Claim for a Home
481 Christian Science Hospital Swing Beds Admit Through Discharge
482 Christian Science Hospital Swing Beds Interim-First Claim Used for the
483 Christian Science Hospital Swing Beds Interim-Continuing Claims
484 Christian Science Hospital Swing Beds Interim-Last Claim
485 Christian Science Hospital Swing Beds Late Charge Only
487 Christian Science Hospital Swing Beds Replacement of Prior Claim
488 Christian Science Hospital Swing Beds Void/Cancel of a Prior Claim
489 Christian Science Hospital Swing Beds Final Claim for a Home
511 Christian Science Extended Care Inpatient (Including Medicare Part A) Admit Through Discharge
512 Christian Science Extended Care Inpatient (Including Medicare Part A) Interim-First Claim Used for the
513 Christian Science Extended Care Inpatient (Including Medicare Part A) Interim-Continuing Claims
514 Christian Science Extended Care Inpatient (Including Medicare Part A) Interim-Last Claim
515 Christian Science Extended Care Inpatient (Including Medicare Part A) Late Charge Only
517 Christian Science Extended Care Inpatient (Including Medicare Part A) Replacement of Prior Claim
518 Christian Science Extended Care Inpatient (Including Medicare Part A) Void/Cancel of a Prior Claim
519 Christian Science Extended Care Inpatient (Including Medicare Part A) Final Claim for a Home
521 Christian Science Extended Care Inpatient (Medicare Part B Only) Admit Through Discharge
522 Christian Science Extended Care Inpatient (Medicare Part B Only) Interim-First Claim Used for the
523 Christian Science Extended Care Inpatient (Medicare Part B Only) Interim-Continuing Claims
524 Christian Science Extended Care Inpatient (Medicare Part B Only) Interim-Last Claim
525 Christian Science Extended Care Inpatient (Medicare Part B Only) Late Charge Only
527 Christian Science Extended Care Inpatient (Medicare Part B Only) Replacement of Prior Claim
528 Christian Science Extended Care Inpatient (Medicare Part B Only) Void/Cancel of a Prior Claim
529 Christian Science Extended Care Inpatient (Medicare Part B Only) Final Claim for a Home
531 Christian Science Extended Care Outpatient Admit Through Discharge
532 Christian Science Extended Care Outpatient Interim-First Claim Used for the
533 Christian Science Extended Care Outpatient Interim-Continuing Claims
534 Christian Science Extended Care Outpatient Interim-Last Claim
535 Christian Science Extended Care Outpatient Late Charge Only
537 Christian Science Extended Care Outpatient Replacement of Prior Claim
538 Christian Science Extended Care Outpatient Void/Cancel of a Prior Claim
539 Christian Science Extended Care Outpatient Final Claim for a Home
541 Christian Science Extended Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Admit Through Discharge
542 Christian Science Extended Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-First Claim Used for the
543 Christian Science Extended Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Continuing Claims
544 Christian Science Extended Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Last Claim
545 Christian Science Extended Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Late Charge Only
547 Christian Science Extended Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Replacement of Prior Claim
548 Christian Science Extended Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Void/Cancel of a Prior Claim
549 Christian Science Extended Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Final Claim for a Home
551 Christian Science Extended Care Nursing Facility Level I Admit Through Discharge
552 Christian Science Extended Care Nursing Facility Level I Interim-First Claim Used for the
553 Christian Science Extended Care Nursing Facility Level I Interim-Continuing Claims
554 Christian Science Extended Care Nursing Facility Level I Interim-Last Claim
555 Christian Science Extended Care Nursing Facility Level I Late Charge Only
557 Christian Science Extended Care Nursing Facility Level I Replacement of Prior Claim
558 Christian Science Extended Care Nursing Facility Level I Void/Cancel of a Prior Claim
559 Christian Science Extended Care Nursing Facility Level I Final Claim for a Home
561 Christian Science Extended Care Nursing Facility Level II Admit Through Discharge
562 Christian Science Extended Care Nursing Facility Level II Interim-First Claim Used for the
563 Christian Science Extended Care Nursing Facility Level II Interim-Continuing Claims
564 Christian Science Extended Care Nursing Facility Level II Interim-Last Claim
565 Christian Science Extended Care Nursing Facility Level II Late Charge Only
567 Christian Science Extended Care Nursing Facility Level II Replacement of Prior Claim
568 Christian Science Extended Care Nursing Facility Level II Void/Cancel of a Prior Claim
569 Christian Science Extended Care Nursing Facility Level II Final Claim for a Home
571 Christian Science Extended Care Intermediate Care Level III Nursing Facility Admit Through Discharge
572 Christian Science Extended Care Intermediate Care Level III Nursing Facility Interim-First Claim Used for the
573 Christian Science Extended Care Intermediate Care Level III Nursing Facility Interim-Continuing Claims
574 Christian Science Extended Care Intermediate Care Level III Nursing Facility Interim-Last Claim
575 Christian Science Extended Care Intermediate Care Level III Nursing Facility Late Charge Only
577 Christian Science Extended Care Intermediate Care Level III Nursing Facility Replacement of Prior Claim
578 Christian Science Extended Care Intermediate Care Level III Nursing Facility Void/Cancel of a Prior Claim
579 Christian Science Extended Care Intermediate Care Level III Nursing Facility Final Claim for a Home
581 Christian Science Extended Care Swing Beds Admit Through Discharge
582 Christian Science Extended Care Swing Beds Interim-First Claim Used for the
583 Christian Science Extended Care Swing Beds Interim-Continuing Claims
584 Christian Science Extended Care Swing Beds Interim-Last Claim
585 Christian Science Extended Care Swing Beds Late Charge Only
587 Christian Science Extended Care Swing Beds Replacement of Prior Claim
588 Christian Science Extended Care Swing Beds Void/Cancel of a Prior Claim
589 Christian Science Extended Care Swing Beds Final Claim for a Home
611 Intermediate Care Inpatient (Including Medicare Part A) Admit Through Discharge
612 Intermediate Care Inpatient (Including Medicare Part A) Interim-First Claim Used for the
613 Intermediate Care Inpatient (Including Medicare Part A) Interim-Continuing Claims
614 Intermediate Care Inpatient (Including Medicare Part A) Interim-Last Claim
615 Intermediate Care Inpatient (Including Medicare Part A) Late Charge Only
617 Intermediate Care Inpatient (Including Medicare Part A) Replacement of Prior Claim
618 Intermediate Care Inpatient (Including Medicare Part A) Void/Cancel of a Prior Claim
619 Intermediate Care Inpatient (Including Medicare Part A) Final Claim for a Home
621 Intermediate Care Inpatient (Medicare Part B Only) Admit Through Discharge
622 Intermediate Care Inpatient (Medicare Part B Only) Interim-First Claim Used for the
623 Intermediate Care Inpatient (Medicare Part B Only) Interim-Continuing Claims
624 Intermediate Care Inpatient (Medicare Part B Only) Interim-Last Claim
625 Intermediate Care Inpatient (Medicare Part B Only) Late Charge Only
627 Intermediate Care Inpatient (Medicare Part B Only) Replacement of Prior Claim
628 Intermediate Care Inpatient (Medicare Part B Only) Void/Cancel of a Prior Claim
629 Intermediate Care Inpatient (Medicare Part B Only) Final Claim for a Home
631 Intermediate Care Outpatient Admit Through Discharge
632 Intermediate Care Outpatient Interim-First Claim Used for the
633 Intermediate Care Outpatient Interim-Continuing Claims
634 Intermediate Care Outpatient Interim-Last Claim
635 Intermediate Care Outpatient Late Charge Only
637 Intermediate Care Outpatient Replacement of Prior Claim
638 Intermediate Care Outpatient Void/Cancel of a Prior Claim
639 Intermediate Care Outpatient Final Claim for a Home
641 Intermediate Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Admit Through Discharge
642 Intermediate Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-First Claim Used for the
643 Intermediate Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Continuing Claims
644 Intermediate Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Last Claim
645 Intermediate Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Late Charge Only
647 Intermediate Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Replacement of Prior Claim
648 Intermediate Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Void/Cancel of a Prior Claim
649 Intermediate Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Final Claim for a Home
651 Intermediate Care Nursing Facility Level I Admit Through Discharge
652 Intermediate Care Nursing Facility Level I Interim-First Claim Used for the
653 Intermediate Care Nursing Facility Level I Interim-Continuing Claims
654 Intermediate Care Nursing Facility Level I Interim-Last Claim
655 Intermediate Care Nursing Facility Level I Late Charge Only
657 Intermediate Care Nursing Facility Level I Replacement of Prior Claim
658 Intermediate Care Nursing Facility Level I Void/Cancel of a Prior Claim
659 Intermediate Care Nursing Facility Level I Final Claim for a Home
661 Intermediate Care Nursing Facility Level II Admit Through Discharge
662 Intermediate Care Nursing Facility Level II Interim-First Claim Used for the
663 Intermediate Care Nursing Facility Level II Interim-Continuing Claims
664 Intermediate Care Nursing Facility Level II Interim-Last Claim
665 Intermediate Care Nursing Facility Level II Late Charge Only
667 Intermediate Care Nursing Facility Level II Replacement of Prior Claim
668 Intermediate Care Nursing Facility Level II Void/Cancel of a Prior Claim
669 Intermediate Care Nursing Facility Level II Final Claim for a Home
671 Intermediate Care Intermediate Care Level III Nursing Facility Admit Through Discharge
672 Intermediate Care Intermediate Care Level III Nursing Facility Interim-First Claim Used for the
673 Intermediate Care Intermediate Care Level III Nursing Facility Interim-Continuing Claims
674 Intermediate Care Intermediate Care Level III Nursing Facility Interim-Last Claim
675 Intermediate Care Intermediate Care Level III Nursing Facility Late Charge Only
677 Intermediate Care Intermediate Care Level III Nursing Facility Replacement of Prior Claim
678 Intermediate Care Intermediate Care Level III Nursing Facility Void/Cancel of a Prior Claim
679 Intermediate Care Intermediate Care Level III Nursing Facility Final Claim for a Home
681 Intermediate Care Swing Beds Admit Through Discharge
682 Intermediate Care Swing Beds Interim-First Claim Used for the
683 Intermediate Care Swing Beds Interim-Continuing Claims
684 Intermediate Care Swing Beds Interim-Last Claim
685 Intermediate Care Swing Beds Late Charge Only
687 Intermediate Care Swing Beds Replacement of Prior Claim
688 Intermediate Care Swing Beds Void/Cancel of a Prior Claim
689 Intermediate Care Swing Beds Final Claim for a Home
711 Clinic Rural HealthAdmit Through Discharge
712 Clinic Rural HealthInterim-First Claim Used for the
713 Clinic Rural HealthInterim-Continuing Claims
714 Clinic Rural HealthInterim-Last Claim
715 Clinic Rural HealthLate Charge Only
717 Clinic Rural HealthReplacement of Prior Claim
718 Clinic Rural HealthVoid/Cancel of a Prior Claim
719 Clinic Rural HealthFinal Claim for a Home
721 Clinic Hospital Based or Independent Renal Dialysis CenterAdmit Through Discharge
722 Clinic Hospital Based or Independent Renal Dialysis CenterInterim-First Claim Used for the
723 Clinic Hospital Based or Independent Renal Dialysis CenterInterim-Continuing Claims
724 Clinic Hospital Based or Independent Renal Dialysis CenterInterim-Last Claim
725 Clinic Hospital Based or Independent Renal Dialysis CenterLate Charge Only
727 Clinic Hospital Based or Independent Renal Dialysis CenterReplacement of Prior Claim
728 Clinic Hospital Based or Independent Renal Dialysis CenterVoid/Cancel of a Prior Claim
729 Clinic Hospital Based or Independent Renal Dialysis CenterFinal Claim for a Home
731 Clinic Free Standing Outpatient Rehabilitation Facility (ORF)Admit Through Discharge
732 Clinic Free Standing Outpatient Rehabilitation Facility (ORF)Interim-First Claim Used for the
733 Clinic Free Standing Outpatient Rehabilitation Facility (ORF)Interim-Continuing Claims
734 Clinic Free Standing Outpatient Rehabilitation Facility (ORF)Interim-Last Claim
735 Clinic Free Standing Outpatient Rehabilitation Facility (ORF)Late Charge Only
737 Clinic Free Standing Outpatient Rehabilitation Facility (ORF)Replacement of Prior Claim
738 Clinic Free Standing Outpatient Rehabilitation Facility (ORF)Void/Cancel of a Prior Claim
739 Clinic Free Standing Outpatient Rehabilitation Facility (ORF)Final Claim for a Home
751 Clinic Comprehensive Outpatient Rehabilitation Facilities (CORFs)Admit Through Discharge
752 Clinic Comprehensive Outpatient Rehabilitation Facilities (CORFs)Interim-First Claim Used for the
753 Clinic Comprehensive Outpatient Rehabilitation Facilities (CORFs)Interim-Continuing Claims
754 Clinic Comprehensive Outpatient Rehabilitation Facilities (CORFs)Interim-Last Claim
755 Clinic Comprehensive Outpatient Rehabilitation Facilities (CORFs)Late Charge Only
757 Clinic Comprehensive Outpatient Rehabilitation Facilities (CORFs)Replacement of Prior Claim
758 Clinic Comprehensive Outpatient Rehabilitation Facilities (CORFs)Void/Cancel of a Prior Claim
759 Clinic Comprehensive Outpatient Rehabilitation Facilities (CORFs)Final Claim for a Home
761 Clinic Community Mental Health CenterAdmit Through Discharge
762 Clinic Community Mental Health CenterInterim-First Claim Used for the
763 Clinic Community Mental Health CenterInterim-Continuing Claims
764 Clinic Community Mental Health CenterInterim-Last Claim
765 Clinic Community Mental Health CenterLate Charge Only
767 Clinic Community Mental Health CenterReplacement of Prior Claim
768 Clinic Community Mental Health CenterVoid/Cancel of a Prior Claim
769 Clinic Community Mental Health CenterFinal Claim for a Home
791 Clinic OtherAdmit Through Discharge
792 Clinic OtherInterim-First Claim Used for the
793 Clinic OtherInterim-Continuing Claims
794 Clinic OtherInterim-Last Claim
795 Clinic OtherLate Charge Only
797 Clinic OtherReplacement of Prior Claim
798 Clinic OtherVoid/Cancel of a Prior Claim
799 Clinic OtherFinal Claim for a Home
811 Special Facility Hospice (Non Hospital Based)Admit Through Discharge
812 Special Facility Hospice (Non Hospital Based)Interim-First Claim Used for the
813 Special Facility Hospice (Non Hospital Based)Interim-Continuing Claims
814 Special Facility Hospice (Non Hospital Based)Interim-Last Claim
815 Special Facility Hospice (Non Hospital Based)Late Charge Only
817 Special Facility Hospice (Non Hospital Based)Replacement of Prior Claim
818 Special Facility Hospice (Non Hospital Based)Void/Cancel of a Prior Claim
819 Special Facility Hospice (Non Hospital Based)Final Claim for a Home
821 Special Facility Hospice (Hospital-Based)Admit Through Discharge
822 Special Facility Hospice (Hospital-Based)Interim-First Claim Used for the
823 Special Facility Hospice (Hospital-Based)Interim-Continuing Claims
824 Special Facility Hospice (Hospital-Based)Interim-Last Claim
825 Special Facility Hospice (Hospital-Based)Late Charge Only
827 Special Facility Hospice (Hospital-Based)Replacement of Prior Claim
828 Special Facility Hospice (Hospital-Based)Void/Cancel of a Prior Claim
829 Special Facility Hospice (Hospital-Based)Final Claim for a Home
831 Special Facility Ambulatory Surgery CenterAdmit Through Discharge
832 Special Facility Ambulatory Surgery CenterInterim-First Claim Used for the
833 Special Facility Ambulatory Surgery CenterInterim-Continuing Claims
834 Special Facility Ambulatory Surgery CenterInterim-Last Claim
835 Special Facility Ambulatory Surgery CenterLate Charge Only
837 Special Facility Ambulatory Surgery CenterReplacement of Prior Claim
838 Special Facility Ambulatory Surgery CenterVoid/Cancel of a Prior Claim
839 Special Facility Ambulatory Surgery CenterFinal Claim for a Home
841 Special Facility Free Standing Birthing CenterAdmit Through Discharge
842 Special Facility Free Standing Birthing CenterInterim-First Claim Used for the
843 Special Facility Free Standing Birthing CenterInterim-Continuing Claims
844 Special Facility Free Standing Birthing CenterInterim-Last Claim
845 Special Facility Free Standing Birthing CenterLate Charge Only
847 Special Facility Free Standing Birthing CenterReplacement of Prior Claim
848 Special Facility Free Standing Birthing CenterVoid/Cancel of a Prior Claim
849 Special Facility Free Standing Birthing CenterFinal Claim for a Home
891 Special Facility OtherAdmit Through Discharge
892 Special Facility OtherInterim-First Claim Used for the
893 Special Facility OtherInterim-Continuing Claims
894 Special Facility OtherInterim-Last Claim
895 Special Facility OtherLate Charge Only
897 Special Facility OtherReplacement of Prior Claim
898 Special Facility OtherVoid/Cancel of a Prior Claim
899 Special Facility OtherFinal Claim for a Home
MC037 Site of Service - on NSF/CMS 1500 Claims 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
35 Boarding Home
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 or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Unlisted Facility
MC063A Header/ Line Payment Indicator H Header
L Line
MC076 Billing Provider Number L Legacy / pre-NPI
M MHCP
O Other
U UMPI
MC899 Record Type MC Institutional & Professional Claims
TR001 Record Type TR Trailer Record
TR004 Type of File MC Institutional & Prof'l Claims
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