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Dental Claims File Submission

New Hampshire



Name:Dental Claims File Submission
State:New Hampshire
Definition:Not Provided
VersionSeptember 10, 2012

File Specification for Dental 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
DC001 Payer Payer submitting payments Text 8
DC002 National Plan ID CMS National Plan ID Text 30
DC003 Insurance Type/Product Code Not provided Text 2
DC004 Payer Claim Control Number Must apply to entire claim and be unique within payer's system Text 35
DC005 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
DC006 Insured Group or Policy Number Group or policy number - not the number that uniquely identifies the subscriber Text 50
DC007 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 32
DC008 Plan Specific Contract Number plan assigned contract number (this data element will be de-identified by the NHpreprocessor application) Set as null if contract number = subscriber's social security number Text 64
DC009 Member Suffix or Sequence Number Uniquely numbers the member within the contract Integer 20
DC010 Member Identification Code member's social security number (this data element will be de-identified by the NHpreprocessor application) Set as null if unavailable Text 30
DC011 Individual Relationship Code Member's relationship to insured Integer 2
DC012 Member Gender Not provided Text 1
DC013 Member Date of Birth Not provided Date CCYYMMDD 8
DC014 Member City Name of Residence City name of member Text 50
DC015 Member State or Province As defined by the U.S. Postal Service Text 2
DC016 Member ZIP Code ZIP Code of member - may include non-US codes Do not include dash Text 11
DC017 Date Service Approved (AP Date) Not provided Date CCYYMMDD 8
DC018 Service Provider Number Payer assigned provider number Text 30
DC019 Service Provider Tax ID Number Federal Taxpayer's identification number Text 10
DC020 National Service Provider ID Required if National Provider ID is mandated for use under HIPAA Text 20
DC021 Service Provider Entity Type Qualifier Not provided Text 1
DC022 Service Provider First Name Individual first name Set as null if provider is a facility or organization Text 25
DC023 Service Provider Middle Name Individual middle name or initial Set as null if provider is a facility or organization Text 25
DC024 Service Provider Last Name or Organization Name Full name of provider organization or last name of individual provider Text 60
DC025 Service Provider Suffix Suffix to individual name Set as null if provider is a facility or organization Text 10
DC026 Service Provider Specialty As defined by payer Dictionary for specialty code values must be supplied during testing Text 10
DC027 Service Provider City Name City name of provider - preferably precise location Text 30
DC028 Service Provider State or Province As defined by the U.S. Postal Service Text 2
DC029 Service Provider ZIP Code ZIP Code of provider - may include non-US codes Do not include dash Text 11
DC030 Facility Type - Professional Not provided Text 2
DC031 Claim Status Not provided Integer 2
DC032 CDT Code Common Dental Terminology code Text 5
DC033 Procedure Modifier - 1 Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code Text 2
DC034 Procedure Modifier - 2 Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code Text 2
DC035 Date of Service - From First date of service for this service line Date CCYYMMDD 8
DC036 Date of Service - Thru Last date of service for this service line Date CCYYMMDD 8
DC037 Charge Amount Do not code decimal point Decimal 10
DC038 Paid Amount Do not code decimal point Decimal 10
DC039 Copay Amount The present, fixed dollar amount for which the individual is responsible Do not code decimal point Decimal 10
DC040 Coinsurance Amount The dollar amount an individual is responsible for - not the percentage Do not code decimal point Decimal 10
DC041 Deductible Amount Do not code decimal point Decimal 10
DC042 Billing Provider Number Carriers and dental claims processors shall code using the 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
DC043 National Billing Provider Number ID This is the NPI for the billing provider Text 30
DC044 Billing Provider Last Name Full name of provider billing organization or last name of individual billing provider Text 128
DC101 Subscriber Last Name (this data element will be de-identified by the NHpreprocessor application) Text 128
DC102 Subscriber First Name (this data element will be de-identified by the NHpreprocessor application) (this data element will be de-identified by the NHpreprocessor application) Text 128
DC103 Subscriber Middle Initial (this data element will be de-identified by the NHpreprocessor application) (this data element will be de-identified by the NHpreprocessor application) Text 1
DC104 Member Last Name (this data element will be de-identified by the NHpreprocessor application) (this data element will be de-identified by the NHpreprocessor application) Text 128
DC105 Member First Name (this data element will be de-identified by the NHpreprocessor application) (this data element will be de-identified by the NHpreprocessor application) Text 128
DC106 Member Middle Initial (this data element will be de-identified by the NHpreprocessor application) (this data element will be de-identified by the NHpreprocessor application) Text 1
DC899 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 DC Dental Claims
DC001 Payer 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
HM Health Maintenance Organization
MC Medicaid
OF Other Federal Program (e.g. Black Lung)
TV Title V
VA Veteran Administration Plan
DC003 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
HM Health Maintenance Organization
MC Medicaid
OF Other Federal Program (e.g. Black Lung)
TV Title V
VA Veteran Administration Plan
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
DC021 Service Provider Entity Type Qualifier 1 Person
2 Non-Person Entity
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
TR001 Record Type TR
TR004 Type of File DC Dental Claims
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