United States Health Information Knowledgebase

 

Medical Claims File Submission

New Hampshire



Name:Medical Claims File Submission
State:New Hampshire
Definition:"Medical claims file" means a data file composed of service level remittance information for all non-denied adjudicated claims for each billed service including, but not limited to: (1) Member demographics; (2) Provider information; (3) Charge/payment information; and (4) Clinical diagnosis/procedure codes.
VersionSeptember 10, 2012

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 submitting payments NHID Submitter Code Text 8
HD003 National Plan ID CMS National Plan ID Text 30
HD004 Type of File Not provided Text 2
HD005 Period Beginning Date Beginning of paid period for claims Beginning of month covered for eligibility Integer CCYYMM 6
HD006 Period Ending Date End of paid period for claims End of month covered for eligibility Integer CCYYMM 6
HD007 Record Count Total number of records submitted in this file Integer 10
HD008 Comments Submitted may use to document this submission by assigning a filename, system source, etc. Text 80
MC001 Payer Payer submitting payments NHID Submitter Code Text 8
MC002 National Plan ID CMS National Plan ID Text 30
MC003 Insurance Type/Product Code Not provided Text 2
MC004 Payer Claim Control Number Must apply to the entire claim and be unique within the payer's system Text 35
MC005 Line Counter Line number for this service The line counter begins with 1 and is incremented by 1 for each additional service line of a claim Integer 4
MC005A Version Number Version number of this claim service line The version number begins with 0 and is incremented by 1 for each subsequent version of that service line Integer 4
MC006 Insured Group or Policy Number Group or policy number (not the number that uniquely identifies the subscriber) Text 50
MC007 Subscriber Social Security Number Subscriber's social security number (this data element will be de-identified by the NHpreprocessor application) Set as null if unavailable Text 128
MC008 Plan Specific Contract Number Plan assigned Set as null if contract number = subscriber's social security number (this data element will be de-identified by the NHpreprocessor application) Text 128
MC009 Member Suffix or Sequence Number Uniquely numbers the member within the contract Integer 20
MC010 Member Identification Code Member's social security number Set as null if unavailable (this data element will be de-identified by the NHpreprocessor application) Text 128
MC011 Individual Relationship Code Member's relationship to insured Integer 2
MC012 Member Gender Not provided Text 1
MC013 Member Date of Birth Not provided Date CCYYMMDD 8
MC014 Member City Name City name of member Text 30
MC015 Member State or Province As defined by the US Postal Service Text 2
MC016 Member ZIP Code ZIP Code of member - may include non-US codes Text 11
MC017 Date Service Approved (AP Date) (Generally the same as the paid date) Date CCYYMMDD 8
MC018 Admission Date Required for all inpatient claims Date CCYYMMDD 8
MC019 Admission Hour Required for all inpatient claims Time is expressed in military time - HHMM Integer HHMM 4
MC020 Admission Type Not provided Integer 1
MC021 Admission Source Not provided Text 1
MC022 Discharge Hour Hour in military time Integer 2
MC023 Discharge Status Not provided Integer 2
MC024 Service Provider Number Payer assigned servicing provider number by the payer for internal identification purposes Text 30
MC025 Service Provider Tax ID Number Federal taxpayer's identification number Text 10
MC026 National Service Provider ID Required if National Provider ID is mandated for use under HIPAA Text 20
MC027 Service Provider Entity Type Qualifier HIPAA provider taxonomy classifies provider groups (clinicians who bill as a group practice or under a corporate name, even if that group is composed of one provider) as "Person". Text 1
MC028 Service Provider First Name Individual first name Set to null if provider is a facility or organization Text 25
MC029 Service Provider Middle Name Individual middle name or initial Set to null if provider is a facility or organization Text 25
MC030 Service Provider Last Name or Organization Name Full name of provider organization or last name of individual provider Text 100
MC031 Service Provider Suffix Suffix to individual name Set to null if provider is a facility or organization. Should be used to capture the generation of the individual clinician (e.g., Jr. Sr., III), if applicable, rather than the clinician's degree [ e.g., 'MD', 'LICSW']. Text 10
MC032 Service Provider Specialty As defined by payer Dictionary for specialty code values must be supplied during testing Text 10
MC033 Service Provider City Name City name of provider - preferably practice location Text 30
MC034 Service Provider State As defined by the US Postal Service Text 2
MC035 Service Provider ZIP Code ZIP Code of provider - may include non-US codes Do not include dash Text 11
MC036 Type of Bill - Institutional Type of Facility - First Digit (Should be coded on facility claims, such as those submitted using on UB04 forms) Integer 2
MC037 Facility Type - Professional (Should be coded on professional claims, such as those submitted using on NSF [CMS 1500 forms]) Text 2
MC038 Claim Status (Actually describes the payment status of the specific service line record) Integer 2
MC039 Admitting Diagnosis Required on all inpatient admission claims and encounters ICD-9-CM Do not code decimal point Text 5
MC040 E-Code Describes an injury, poisoning or adverse effect ICD-9-CM Do not include decimal Text 5
MC041 Principal Diagnosis ICD-9-CM Do not code decimal point This should be the principal diagnosis given on the claim header. Text 5
MC042 Other Diagnosis - 1 ICD-9-CM Do not code decimal point Text 5
MC043 Other Diagnosis - 2 ICD-9-CM Do not code decimal point Text 5
MC044 Other Diagnosis - 3 ICD-9-CM Do not code decimal point Text 5
MC045 Other Diagnosis - 4 ICD-9-CM Do not code decimal point Text 5
MC046 Other Diagnosis - 5 ICD-9-CM Do not code decimal point Text 5
MC047 Other Diagnosis - 6 ICD-9-CM Do not code decimal point Text 5
MC048 Other Diagnosis - 7 ICD-9-CM Do not code decimal point Text 5
MC049 Other Diagnosis - 8 ICD-9-CM Do not code decimal point Text 5
MC050 Other Diagnosis - 9 ICD-9-CM Do not code decimal point Text 5
MC051 Other Diagnosis - 10 ICD-9-CM Do not code decimal point Text 5
MC052 Other Diagnosis - 11 ICD-9-CM Do not code decimal point Text 5
MC053 Other Diagnosis - 12 ICD-9-CM Do not code decimal point Text 5
MC054 Revenue Code National Uniform Billing Committee Codes Code using leading zeroes, left-justified, and four digits. Text 4
MC055 Procedure Code Health Care Common Procedural Coding System (HCPCS) This includes the CPT codes of the American Medical Association Text 5
MC056 Procedure Modifier - 1 Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code Text 2
MC057 Procedure Modifier - 2 Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code Text 2
MC058 ICD-9-CM Procedure Code Primary ICD-9-CM code given on the claim header. Do not code decimal point Text 4
MC059 Date of Service - From First date of service for this service line Date CCYYMMDD 8
MC060 Date of Service - Thru Last date of service for this service line Date CCYYMMDD 8
MC061 Quantity Count of services performed Should be set equal to 1 on all Observation bed service lines, for consistency. Integer 3
MC062 Charge Amount Do not code decimal point Decimal 10
MC063 Paid Amount Includes any withhold amounts Do not code decimal point Decimal 10
MC064 Prepaid Amount For capitated services, the fee for service equivalent amount Do not code decimal point Decimal 10
MC065 Copay Amount The preset, fixed dollar amount for which the individual is responsible Do not code decimal point Decimal 10
MC066 Coinsurance Amount Do not code decimal point Decimal 10
MC067 Deductible Amount Do not code decimal point Decimal 10
MC068 Patient Account/Control Number Not provided Text 20
MC069 Discharge Date Required for all inpatient(s) Date 8
MC070 Service Provider Country Name Not provided Text 30
MC071 DRG Carriers and health care claims processors shall code using the CMS methodology when available. Precedence shall be given to DRGs transmitted from the hospital provider. When the CMS methodology for DRGs is not available, but the All payer DRG system is available, than that system shall be used. If the All Payer DRG system is used, the carrier shall format the DRG and the complexity level within the same field with an "A" prefix, and with a hyphen separating the DRG and the complexity level (e.g. AXXX-XX) Text 3
MC072 DRG Version This element is the version number of the grouper used. Text 2
MC073 APC Carriers and health care claims processors shall code using CMS methodology. Precedence shall be given to APCs transmitted from the health care provider Text 4
MC074 APC Version This element is the version number of the grouper used Text 2
MC075 Drug Code NDC Code Text 11
MC076 Billing Provider Number Payer assigned billing provider number. This number should be the identifier used by the payer for internal identification purposes and does not routinely change Text 30
MC077 National Billing Provider Number ID This is the NPI for the billing provider Text 30
MC078 Billing Provider Last Name Not provided Text 128
MC101 Subscriber Last Name (this data element will be de-identified by the NH preprocessor application) Text 128
MC102 Subscriber First Name (this data element will be de-identified by the NH preprocessor application) Text 128
MC103 Subscriber Middle Initial (this data element will be de-identified by the NH preprocessor application) Text 1
MC104 Member Last Name (this data element will be de-identified by the NH preprocessor application) Text 128
MC105 Member First Name (this data element will be de-identified by the NH preprocessor application) Text 128
MC106 Member Middle Initial (this data element will be de-identified by the NH preprocessor application) Text 1
MC899 Record Type Not provided Text 2
TR001 Record Type Not provided Text 2
TR002 Payer Payer submitting payments NHID Submitter Code Text 8
TR003 National Plan ID CMS National Plan ID Text 30
TR004 Type of File Not provided Text 2
TR005 Period Beginning Date Beginning of paid period for claims Beginning of month covered for eligibility Integer CCYYMM 6
TR006 Period Ending Date End of paid period for claims End of month covered for eligibility Integer CCYYMM 6
TR007 Date Processed Not provided Date CCYYMMDD 8

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Data Element ID Data Element Code Value
HD001 Record Type HD
HD004 Type of File MC Medical Claims
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 Advantage
DS Disability
HM Health Maintenance Organization
MA Medicare Part A
MB Medicare Part B
MC Medicaid
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 Where Insured Has No Financial Responsibility
53 Life Partner
76 Dependent
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 1 Physician Referral
2 Clinic Referral
3 HMO Referral
4 Transfer from Hospital
5 Transfer from a Skilled Nursing Facility
6 Transfer from another Health Care Facility
7 Emergency Room
8 Court/Law Enforcement
9 Unknown
A Transfer from a Rural Primary Care Hospital
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
MC027 Service Provider Entity Type Qualifier 1 Person
2 Non-Person Entity
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 Extended Care Swing Beds
51 Christian Science Extended Care Inpatient (Including Medicare Part A)
52 Christian Science Extended Care Inpatient (Medicare Part B Only)
53 Christian Science Extended Care Outpatient
54 Christian Science Extended Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
55 Christian Science Extended Care Nursing Facility Level I
56 Christian Science Extended Care Nursing Facility Level II
57 Christian Science Extended Care Intermediate Care Level III Nursing Facility
58 Christian Science Extended Care Swing Beds
61 Intermediate Care Inpatient (Including Medicare Part A)
62 Intermediate Care Inpatient (Medicare Part B Only)
63 Intermediate Care Outpatient
64 Intermediate Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
65 Intermediate Care Nursing Facility Level I
66 Intermediate Care Nursing Facility Level II
67 Intermediate Care Intermediate Care Level III Nursing Facility
68 Intermediate Care Swing Beds
71 Clinic Rural Health
72 Clinic Hospital Based or Independent Renal Dialysis Center
73 Clinic Free Standing Outpatient Rehabilitation Facility (ORF)
75 Clinic Comprehensive Outpatient Rehabilitation Facilities (CORFs)
76 Clinic Community Mental Health Center
79 Clinic Other
81 Special Facility Hospice (Non Hospital Based)
82 Special Facility Hospice (Hospital-Based)
83 Special Facility Ambulatory Surgery Center
84 Special Facility Free Standing Birthing Center
89 Special Facility 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
MC899 Record Type MC
TR001 Record Type TR
TR004 Type of File MC Medical Claims
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