United States Health Information Knowledgebase

 

Medical Claims File Submission

Vermont



Name:Medical Claims File Submission
State:Vermont
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 member demographics, provider information, charge/payment information, and clinical diagnosis and procedure codes, and shall include all claims related to behavioral or mental health.
VersionOctober 2008

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; Text 8
HD003 National Plan Id CMS National Plan ID; This is not yet available. Code as null 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 the file Integer 10
HD008 Comments Payer comments Text 80
MC001 Payer Payer submitting payments; Text 8
MC002 National Plan ID CMS National Plan ID; This is not yet available. Code as null Text 30
MC003 Insurance Type/Product Code Type of Insurance Product Text 2
MC004 Payer Claim Control Number Unique claim identifier Text 35
MC005 Line Counter Claim line number for service rendered Integer 4
MC005A Version Number Version number of this claim service line Integer 4
MC006 Insured Group or Policy Number Group number or Policy Number Text 30
MC007 Encrypted Subscriber Unique Identification Number Subscriber's social security number; used to create unique member ID Text 128
MC008 Plan Specific Contract Number Do not include values in this field that will distinguish one member of the family from another. If submitted, this should be the contract or certificate number for the subscriber and all of his/her dependents Text 128
MC009 Member Suffix or Sequence Number The unique number of the member within the contract. Integer 20
MC010 Member Identification Code Member's social security number; used to create unique member ID Text 128
MC011 Individual Relationship Code Member's relationship to insured Integer 2
MC012 Member Gender Member's gender Text 1
MC013 Member Date of Birth Not provided Date CCYYMMDD 8
MC014 Member City Name The city location of the 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) Not provided Date CCYYMMDD 8
MC018 Admission Date Not provided Date CCYYMMDD 8
MC019 Admission Hour HHMM: If only the hour is known, code the minutes as 00. 4 PM would be reported as 1600 Integer HHMM 4
MC020 Admission Type Type of Admission Integer 1
MC021 Admission Source Source of Admission Text 1
MC022 Discharge Hour HHMM: If only the hour is known, code the minutes as 00. 4 PM would be reported as 1600 Integer HHMM 4
MC023 Discharge Status Status of Discharge Integer 2
MC024 Service Provider Number Payer assigned number for provider of service Text 30
MC025 Service Provider Tax ID Number Federal tax id for provider of service Text 10
MC026 National Service Provider ID If available NPI for provider of service Text 20
MC027 Service Provider Entity Type Qualifier Person or non-person qualifier of provider of service Text 1
MC028 Service Provider First Name First name of provider of service Text 25
MC029 Service Provider Middle Name Middle name of provider of service Text 25
MC030 Service Provider Last Name or Organization Name Last name of provider of service Text 60
MC031 Service Provider Suffix Any sufficx of provider of service Text 10
MC032 Service Provider Specialty Specialty code of provider of service as defined by payer Text 50
MC033 Service Provider City Name The city location of the provider of service Text 30
MC034 Service Provider State or Province As defined by the US Postal Service state or province of provider of service Text 2
MC035 Service Provider ZIP Code ZIP Code of member - may include non-US codes. Text 11
MC036 Type of Bill - on Facility Claims Institutional claim type of bill Integer 2
MC037 Site of Service - on NSF/CMS 1500 Claims Site of service on professional claim Text 2
MC038 Claim Status Status of claim Integer 2
MC039 Admitting Diagnosis ICD-9-CM Do not code decimal point Text 5
MC040 E-Code Describes an injury, poisoning or adverse effect Text 5
MC041 Principal Diagnosis ICD-9-CM Do not code decimal point 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 Text 4
MC055 Procedure 1 Code This includes the CPT codes of the American Medical Association Text 5
MC056 Procedure 1 Modifier - 1 Procedure modifier required when a modifier clarifies/improves the Text 2
MC057 Procedure 1 Modifier - 2 Procedure modifier required when a modifier clarifies/improves the Text 2
MC058 ICD9-CM Procedure 1 Code Procedure code for this line of service. Do not code decimal point Text 4
MC059 Date of Service - From Not provided Date CCYYMMDD 8
MC060 Date of Service - Thru Not provided Date CCYYMMDD 8
MC061 Quantity Count of services performed Integer 3
MC062 Charge Amount Do not code decimal point Decimal 10
MC063 Paid Amount Includes any withhold amounts Decimal 10
MC064 Prepaid Amount For capitated services, the fee for service equivalent amount Decimal 10
MC065 Copay Amount The preset, fixed dollar amount for which the individual is responsible Decimal 10
MC066 Coinsurance Amount The dollar amount an individual is responsible for not the percentage Decimal 10
MC067 Deductible Amount Do not code decimal point Decimal 10
MC068 Patient Account/Control Number Number assigned by hospital Text 20
MC069 Discharge Date Date patient discharged. Required for all inpatient claims. Date CCYYMMDD 8
MC070 Service Provider Country Name Code US for United States Text 30
MC071 DRG Carriers and health care claims processors shall code using the CMS methodology. Precedence shall be given to DRGs transmitted from the hospital provider. Text 7
MC072 DRG Version Version of DRG (inpatient) grouper used Text 2
MC073 APC Carriers and health care claims processors shall code using the CMS methodology. Precedence shall be given to APCs transmitted from the health care provider. Text 4
MC074 APC Version Version of APC (outpatient) grouper used Text 2
MC075 Drug Code NDC Code Text 11
MC076 Billing Provider Number Payer assigned provider number Text 30
MC077 National Billing Provider ID National Provider ID mandated for use under HIPAA Text 20
MC078 Billing Provider Last Name Full name of billing organization or last name of individual billing or Organization Name Text 60
MC101 Encrypted Subscriber Last Name Encrypted subscriber last name, used to create unique member ID Text 128
MC102 Encrypted Subscriber First Name Encrypted subscriber first name, used to create unique member ID Text 128
MC103 Encrypted Subscriber Middle Initial Encrypted subscriber middle initial, used to create unique member ID Text 1
MC104 Encrypted Member Last Name Encrypted member last name, used to create unique member ID Text 128
MC105 Encrypted Member First Name Encrypted member first name, used to create unique member ID Text 128
MC106 Encrypted Member Middle Initial Encrypted member middle initial, used to create unique member ID Text 1
MC899 Record Type Not provided Text 2
TR001 Record Type Not provided Text 2
TR002 Payer Payer Code Text 8
TR003 National Plan ID CMS National Plan ID; This is not yet available. Code as null 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 YYYYMM 6
TR006 Period Ending Date End of paid period for Claims End of month covered for Eligibility 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
HD004 Type of File MC Medical Claims
MC003 Insurance Type/Product Code * Indicates that code is not to be included in Vermont submissions. Included in data set for harmonization with other New England states data collection rules.
*WC Workers Compensation
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
MA Medicare Part A
MB Medicare Part B
MC Medicaid
MD Medicare Part D
OF Other Federal Program (e.g. Black Lung)
TV Title V
VA Veteran Administration Plan
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/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
MC012 Member Gender F Female
M Male
U Unknown
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 Discharged/transferred to a long term care hospital
64 Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare
MC027 Service Provider Entity Type Qualifier 1 Person
2 Non-Person Entity
MC036 Type of Bill - on Facility Claims 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 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
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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