| Name: | Medical Claims File Submission |
|---|---|
| State: | Tennessee |
| 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: (a) Member demographics; (b) Provider information; (c) Charge/payment information; and (d) Clinical diagnosis/procedure codes. |
| Version | March 18, 2010 |
| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| HD001 | Record Type | Must be coded HD to indicate Header record. | Text | 2 | |
| HD002 | Payer | Payer or submitter code assigned by Onpoint CDM | Text | 8 | |
| HD003 | National Plan ID | Code according to CMS National Plan ID | Text | 30 | |
| HD004 | Type of File | Must be coded ME to indicate submission of eligibility data. | Text | 2 | |
| HD005 | Period Beginning Date | Code the earliest payment year/month included in the submission in CCYYMM format. Submissions with records containing a check issue or effective date (MC017) before this date will fail. | Integer | CCYYMM | 6 |
| HD006 | Period Ending Date | Code the latest payment year/month included in the submission in CCYYMM format. Submissions with records containing a check issue or effective date (MC017) after this date will fail. | Integer | CCYYMM | 6 |
| HD007 | Record Count | Report the total number of records in the submission, excluding the header and trailer records. If the number of records within the submission does not equal the number reported in this field, the submission will fail. | Integer | 10 | |
| HD008 | Comments | Submitter comments | Text | 80 | |
| MC001 | Payer | This field contains the Onpoint CDM-assigned submitter code for the data submitter. The first two characters of the submitter code indicate Tennessee 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 six 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 | |
| MC002 | National Plan ID | Code according to CMS National Plan ID | Text | 30 | |
| MC003 | Insurance Type/Product Code | This field contains the insurance type or product code that indicates the type of insurance coverage the individual has: | 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 | |
| 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 | |
| MC006 | Insured Group Or Policy Number | Group number or policy number | Text | 30 | |
| MC007 | Encrypted Subscriber Index Number | Carriers, healthcare claims processors, and pharmacy benefit managers shall input subscriber's Social Security number. During transformation and encryption: o All but one digit of the Social Security number shall be combined with a seed value o This modified subscriber index number then is encrypted by an application on the processors desktop o The original input Social Security number is deleted and replaced with the modified and encrypted output Carriers, healthcare claims processors, and pharmacy benefit managers shall set the input field null if unavailable. This or MC008 must be populated. | Text | 128 | |
| MC008 | Encrypted Plan Specific Contract Index Number | Carriers and healthcare claims processors shall input a plan-assigned subscriber index number that uniquely identifies members in a contract. This must not be the original contract number, but must be consistent in all fields requiring the plan-specific contract index number and must be consistent in all file submission types (eligibility, medical, and pharmacy claims) submitted by the submitter. This plan-assigned contract index number shall be combined with a seed value and then encrypted. Carriers and healthcare claims processors shall set as null if unavailable. This or MC007 must be populated. | Text | 128 | |
| MC009 | Member Suffix Number | Code a number to designate a member within the contract. | Integer | 20 | |
| MC010 | Encrypted Member Index Number | Carriers, healthcare claims processors, and pharmacy benefit managers shall input member's Social Security number. During transformation and encryption: o All but one digit of the Social Security number shall be combined with a seed value o This modified member index number then is encrypted by an application on the processors desktop o The original input Social Security number is deleted and replaced with the modified and encrypted output Carriers, healthcare claims processors, and pharmacy benefit managers shall set the input field 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 Year of Birth | Carriers, healthcare claims processors, and pharmacy benefit managers shall input member's date of birth as CCYYMMDD. During transformation: o Age in months will be calculated for member using first day of the month for the eligibility file o The age in months value will be added to the end of the record by an application on the processor's desktop o The original input date of birth is deleted and replaced with the year of birth only in the output | Date | CCYYMMDD | 4 |
| 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 two-character abbreviation code used by the U.S. Postal Service. | Text | 2 | |
| MC016 | Member ZIP Code | This field contains the ZIP code associated with the member's residence. | Text | 5 | |
| MC017 | Paid Date | This field contains the date the record was paid. It generally is referred to as the paid date and reported with a CCYYMMDD format. When BPR04 is "NON" for nonpayment, 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 |
| MC019 | Admission Hour | If only the hour is known, code the minutes as 00. 4 P.M. would be reported as 1600. | Integer | HHMM | 4 |
| MC020 | Admission Type | This field is used to record the type of admission for all inpatient hospital claims: | Integer | 1 | |
| MC021 | Point of Origin for Admission or Visit | This field is required for inpatient hospital admissions. It records the source of admission. Reference standard is the National Uniform Billing Committee official UB-04 specifications manual. Currently this data element is form locator 15. | Text | 1 | |
| MC022 | Discharge Hour | HHMM: If only the hour is known, code the minutes as 00. 4 P.M. would be reported as 1600. | Integer | HHMM | 4 |
| MC023 | Discharge Status | This field is required for inpatient hospital admissions. It records the status for the patient discharged from the hospital. Reference standard is the National Uniform Billing Committee official UB-04 specifications manual. Currently this data element is form locator 17. | 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 Tennessee providers encompassing both medical service providers and prescribing providers. Required if MC026 is not filled. One of the following prefixes must precede the submitted number: | Text | 30 | |
| MC025 | Service Provider Tax ID Number | Federal taxpayer's identification number for rendering/attending provider. This field will be used to create a master provider index for Tennessee 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 Tennessee 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 Tennessee 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 Tennessee 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 Tennessee 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 Tennessee providers encompassing both medical service providers and prescribing providers. | Text | 10 | |
| MC032 | Service Provider Specialty | Service provider specialty code as defined by payer. Dictionary for specialty code values must be supplied during testing. | Text | 50 | |
| 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 Tennessee 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 two- character abbreviation code used by the U.S. Postal Service. This field will be used to create a master provider index for Tennessee 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 Tennessee providers encompassing both medical service providers and prescribing providers. | Text | 11 | |
| MC036 | Type of Bill - Institutional | This field is required for all UB-04 submissions. It records the type of bill. Reference standard is the National Uniform Billing Committee official UB-04 specifications manual. Currently this data element is form locator 4. | Text | 4 | |
| MC037 | Place 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. Current valid codes are maintained by National Standards Format (NSF) FA0- 07.0 for use on the HCFA 1500 form. | Text | 2 | |
| MC038 | Claim Status | Claim status: | Integer | 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. Healthcare 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 | |
| MC057 | 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 | |
| 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 | |
| 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. Submissions containing 9999999999 will not factor into the calculation of the threshold. | 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. 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. Only 1% of submissions can contain 9999999999. Submissions containing 9999999999 will not factor into the calculation of the threshold. | Decimal | 10 | |
| MC065 | Copay | This field contains the pre-set, fixed dollar amount of copay 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. Submissions containing 9999999999 will not factor into the calculation of the threshold. | Decimal | 10 | |
| MC066 | Coinsurance Amount | This field contains the dollar amount of coinsurance 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 is not a percentage. This field may contain a negative value. 0 is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. Submissions containing 9999999999 will not factor into the calculation of the threshold. | 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 healthcare 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. Submissions containing 9999999999 will not factor into the calculation of the threshold. | Decimal | 10 | |
| MC068 | Placeholder | Placeholder | N/A | N/A | |
| MC069 | Placeholder | Placeholder | N/A | N/A | |
| MC070 | Service Provider Country | Name of the country for the provider of services. Code as US for United States | Text | 30 | |
| MC071 | DRG | Carriers and healthcare 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, then 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 | AXXX- XX | 10 |
| MC072 | DRG Version | This element is the version number of the grouper used. | Text | 2 | |
| MC073 | APC | Carriers and healthcare claims processors shall code using CMS methodology. Precedence shall be given to APCs transmitted from the healthcare 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 | 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. One of the following prefixes should precede the submitted number: | 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 or Organization Name | Report the full name of the billing organization or the last name of the individual billing provider. | Text | 60 | |
| MC079 | 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 | |
| MC080 | 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 | |
| MC081 | 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 | |
| MC082 | 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 | |
| MC083 | 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 | |
| MC084 | Present on Admission | Present on Admission flag - Admitting Diagnosis. Indicator for MC039 data element. Must equal Onset of Diagnosis Indicator | Text | 1 | |
| MC085 | Present on Admission | Present on Admission flag - Primary Diagnosis. Indicator for MC041 data element. Must equal Onset of Diagnosis Indicator | Text | 1 | |
| MC086 | Present on Admission | Present on Admission flag - First Secondary Diagnosis. Indicator for MC042 data element. Must equal Onset of Diagnosis Indicator | Text | 1 | |
| MC087 | Present on Admission | Present on Admission flag - Second Secondary Diagnosis. Indicator for MC043 data element. Must equal Onset of Diagnosis Indicator | Text | 1 | |
| MC088 | Present on Admission | Present on Admission flag - Third Secondary Diagnosis. Indicator for MC044 data element. Must equal Onset of Diagnosis Indicator | Text | 1 | |
| MC089 | Present on Admission | Present on Admission flag - Fourth Secondary Diagnosis. Indicator for MC045 data element. Must equal Onset of Diagnosis Indicator | Text | 1 | |
| MC090 | Present on Admission | Present on Admission flag - Fifth Secondary Diagnosis. Indicator for MC046 data element. Must equal Onset of Diagnosis Indicator | Text | 1 | |
| MC091 | Present on Admission | Present on Admission flag - Sixth Secondary Diagnosis. Indicator for MC047 data element. Must equal Onset of Diagnosis Indicator | Text | 1 | |
| MC101 | Placeholder | Placeholder | N/A | N/A | |
| MC102 | Placeholder | Placeholder | N/A | N/A | |
| MC103 | Placeholder | Placeholder | N/A | N/A | |
| MC104 | Encrypted Index Number, Member Last Name | Carriers, healthcare claims processors, and pharmacy benefit managers shall input member's last name. During transformation and encryption: o The first character of the last name is combined with a numeric name ID o This modified member last name field then is encrypted by an application on the processor's desktop o The original input member last name is deleted and replaced with the modified and encrypted output | Text | 128 | |
| MC105 | Encrypted Index Number, Member First Name | Carriers, healthcare claims processors, and pharmacy benefit managers shall input member's first initial. During transformation and encryption: o This first character of the first name is combined with a seed value o This modified member first initial then is encrypted by an application on the processor's desktop o The original input member first initial is deleted and replaced with the modified and encrypted output | Text | 128 | |
| MC106 | Placeholder | Placeholder | N/A | N/A | |
| MC899 | Record Type | This field indicates the type of record: This is an administrative field required by Onpoint CDM and populated with a constant value. | Text | 2 | |
| TR001 | Record Type | Must be coded TR to indicate the Trailer record | Text | 2 | |
| TR002 | Payer | Payer or submitter code assigned by Onpoint CDM | Text | 8 | |
| TR003 | National Plan ID | Code according to CMS National Plan ID | Text | 30 | |
| TR004 | Type of File | Must be coded MC to indicate submission of professional and institutional claims data. | Text | 2 | |
| TR005 | Period Beginning Date | Code the earliest payment year/month included in the submission in CCYYMM format. Submissions with records containing a check issue or effective date (MC017) before this date will fail. | Integer | CCYYMM | 6 |
| TR006 | Period Ending Date | Code the latest payment year/month included in the submission in CCYYMM format. Submissions with records containing a check issue or effective date (MC017) after this date will fail. | Integer | CCYYMM | 6 |
| TR007 | Date Processed | Date that the file was created in CCYYMMDD format | Date | CCYYMMDD | 8 |
| Data Element ID | Data Element | Code | Value |
|---|---|---|---|
| HD001 | Record Type | HD | Header Record |
| HD004 | Type of File | MC | professional and institutional claims |
| MC001 | Payer | TNC | Commercial Carrier |
| TNG | Governmental Agency | ||
| TNT | Third-Party Administrator | ||
| TNU | Unlicensed Entity | ||
| MC003 | Insurance Type/Product Code | 12 | Preferred Provider Organization (PPO) |
| 13 | Point of Service (POS) | ||
| 14 | Exclusive Provider Organization (EPO) | ||
| 15 | Indemnity Insurance | ||
| 16 | Health Maintenance Organization (HMO) Medicare Advantage | ||
| DS | Disability | ||
| HM | Health Maintenance Organization | ||
| MA | Medicare Part A | ||
| MB | Medicare Part B | ||
| MCTNCR | Tennessee Medicaid (TennCare) | ||
| MD | Medicare Part D | ||
| OF | Other Federal Program (eg, Black Lung) | ||
| TV | Title V | ||
| VA | Veteran Administration Plan | ||
| WC | Workers' Compensation | ||
| XXTNAC | AccessTN | ||
| XXTNCV | CoverTN | ||
| XXTNKD | CoverKids | ||
| 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 | ||
| MC024 | Service Provider Number | L | Legacy/pre-NPI |
| O | Other | ||
| MC027 | Service Provider Entity Type Qualifier | 1 | Person |
| 2 | Non-Person Entity | ||
| 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 | ||
| MC076 | Billing Provider Number | L | Legacy/pre-NPI |
| O | Other | ||
| MC084 | Present on Admission | 1 | Diagnosis code exempt from POA reporting |
| N | No | ||
| U | Unknown/No information on the Record | ||
| W | Clinically Undetermined | ||
| Y | Yes | ||
| MC085 | Present on Admission | 1 | Diagnosis code exempt from POA reporting |
| N | No | ||
| U | Unknown/No information on the Record | ||
| W | Clinically Undetermined | ||
| Y | Yes | ||
| MC086 | Present on Admission | 1 | Diagnosis code exempt from POA reporting |
| N | No | ||
| U | Unknown/No information on the Record | ||
| W | Clinically Undetermined | ||
| Y | Yes | ||
| MC087 | Present on Admission | 1 | Diagnosis code exempt from POA reporting |
| N | No | ||
| U | Unknown/No information on the Record | ||
| W | Clinically Undetermined | ||
| Y | Yes | ||
| MC088 | Present on Admission | 1 | Diagnosis code exempt from POA reporting |
| N | No | ||
| U | Unknown/No information on the Record | ||
| W | Clinically Undetermined | ||
| Y | Yes | ||
| MC089 | Present on Admission | 1 | Diagnosis code exempt from POA reporting |
| N | No | ||
| U | Unknown/No information on the Record | ||
| W | Clinically Undetermined | ||
| Y | Yes | ||
| MC090 | Present on Admission | 1 | Diagnosis code exempt from POA reporting |
| N | No | ||
| U | Unknown/No information on the Record | ||
| W | Clinically Undetermined | ||
| Y | Yes | ||
| MC091 | Present on Admission | 1 | Diagnosis code exempt from POA reporting |
| N | No | ||
| U | Unknown/No information on the Record | ||
| W | Clinically Undetermined | ||
| Y | Yes | ||
| MC899 | Record Type | MC | Medical Claims |
| TR001 | Record Type | TR | Trailer Record |
| TR004 | Type of File | MC | Medical Claims |
Agency for Healthcare Research and Quality • 5600 Fishers Lane, Rockville, MD 20857 • Telephone: (301) 427-1364
