| Name: | Dental Services Fixed Format File Submission |
|---|---|
| State: | Maryland |
| Definition: | Not provided |
| Version | January 9, 2014 |
| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| 1 | Record Identifier | The value is 6 | numeric | 1 | |
| 2 | Patient IdentifierP (payer encrypted) | Patient's unique identification number assigned by payer and encrypted. | alphanumeric | 12 | |
| 3 | Patient IdentifierU (UUID encrypted) | Patient's universally unique identification (UUID) number generated using an encryption algorithm provided by MHCC. | alphanumeric | 12 | |
| 4 | Patient Year and Month of Birth | Date of patient's birth using 00 instead of day. | numeric | CCYYMM00 | 8 |
| 5 | Patient Sex | Sex of the patient. | numeric | 1 | |
| 6 | Patient Zip Code+4digit add-on code | Zip code of patient's residence. | numeric | 10 | |
| 7 | Patient Covered by Other Insurance Indicator | Indicates whether patient has additional insurance coverage. | numeric | 1 | |
| 8 | Coverage Type Modified! | Patient's type of insurance coverage. | alphanumeric | 1 | |
| 9 | Source Company | Defines the payer company that holds the beneficiary's contract; for use in characterizing contract requirements under Maryland law. | numeric | 1 | |
| 10 | Claim Related Condition | Describes connection, if any, between patient's condition and employment, automobile accident, or other accident. | numeric | 1 | |
| 11 | Practitioner Federal Tax ID (TIN) | Employer Tax ID of the practitioner, practice or office facility receiving payment for services. | alphanumeric | 9 | |
| 12 | Participating Provider Flag | Indicates if the service was provided by a provider that participates in the payer's network. | numeric | 1 | |
| 13 | Record Status | Describes payment and adjustment status of a claim. Adjustments include paying a claim more than once, paying additional services that may have been denied, or crediting a provider due to overpayment or paying the wrong provider. | alphanumeric | 1 | |
| 14 | Claim Control Number | Internal payer claim number used for tracking. | alphanumeric | 23 | |
| 15 | Claim Paid Date | The date a claim was authorized for payment. | numeric | CCYYMMDD | 8 |
| 16 | Number of Line Items | If using Variable Format, the # of line items completed in the variable portion must match the value entered for this data element, maximum value for this data and # of line items is 26. If using Fixed Format, the number of line items is always equal to one (1) because only one service is written per row. | numeric | 2 | |
| 17 | Service From Date | First date of service for a procedure in this line item. | numeric | CCYYMMDD | 8 |
| 18 | Service Thru Date | Last date of service for this line item. | numeric | CCYYMMDD | 8 |
| 19 | Place of Service | Two-digit numeric code that describes where a service was rendered. | numeric | 2 | |
| 20 | Service Location Zip Code | Zip code for location where service described was provided. | alphanumeric | 10 | |
| 21 | Procedure Code | Describes the health care service provided (i.e., CDT). | alphanumeric | 5 | |
| 22 | Servicing Practitioner ID | Payer-specific identifier for the practitioner rendering health care service(s). | alphanumeric | 11 | |
| 23 | Billed Charge | A practitioner's billed charges rounded to whole dollars. DO NOT USE DECIMALS | numeric | 9 | |
| 24 | Allowed Amount | Total patient and payer liability. DO NOT USE DECIMALS | numeric | 9 | |
| 25 | Reimbursement Amount | Amount paid to Employer Tax ID # of rendering physician as listed on claim. DO NOT USE DECIMALS | numeric | 9 | |
| 26 | Date of Enrollment | The start date of enrollment for the patient in this delivery system (in this data submission time period). (see Source Company on page 81) | numeric | CCYYMMDD | 8 |
| 27 | Date of Disenrollment | The end date of enrollment for the patient in this delivery system (in this data submission time period). (see Source Company on page 81) | numeric | CCYYMMDD | 8 |
| 28 | Patient Deductible | The fixed amount that the patient must pay for covered medical services before benefits are payable. DO NOT USE DECIMALS | numeric | 9 | |
| 29 | Patient Coinsurance or Patient Co-payment | The specified amount or percentage the patient is required to contribute towards covered medical services after any applicable deductible. DO NOT USE DECIMALS | numeric | 9 | |
| 30 | Other Patient Obligations | Any patient obligations other than the deductible or coinsurance/co-payment. This could include obligations for out-of-network care (balance billing net of patient deductible, patient coinsurance/co-payment and payer reimbursement), non-covered services, or penalties. DO NOT USE DECIMALS | numeric | 9 | |
| 31 | Servicing Practitioner Individual National Provider Identifier (NPI) number | Federal identifier assigned by the federal government for use in all HIPAA transactions to an individual practitioner. | alphanumeric | 10 | |
| 32 | Practitioner National Provider Identifier (NPI) number used for Billing. | Federal identifier assigned by the federal government for use in all HIPAA transactions to an individual practitioner or an organization for billing purposes. | alphanumeric | 10 | |
| 33 | Product Type | Classifies the benefit plan by key product characteristics (scope of coverage, size of network, coverage for out-of-network benefits). (Please code based on how the product is primarily marketed, and most importantly be consistent from year to year. If not sure, send an e-mail describing the product to Larry Monroe at larry.monroe@maryland.gov) | numeric | 1 | |
| 34 | Payer ID Number | Payer assigned submission identification number. | alphanumeric | 4 | |
| 35 | Source System | Identify the source system (platforms or business units) from which the data was obtained by using an alphabet letter (A, B, C, D, etc...) (Note: In your documentation on page 15, please be sure to list the source system that corresponds with the letter assigned.) For payers with all data coming from one system only, leave the field blank. | alphanumeric | 1 | |
| 36 | Encrypted Contract or Group Number (payer encrypted) | Payer assigned contract or group number for the plan sponsor using an encryption algorithm generated by the payer. | alphanumeric | 20 | |
| 37 | Relationship to Policyholder | Member's relationship to subscriber/insured. | numeric | 1 | |
| 38 | Tooth Number/Letter - 1 | Report the tooth identifier(s) when Current Dental Terminology Code is within given range. | alphanumeric | 2 | |
| 39 | Tooth - 1 Surface - 1 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 40 | Tooth - 1 Surface - 2 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 41 | Tooth - 1 Surface - 3 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 42 | Tooth - 1 Surface - 4 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 43 | Tooth - 1 Surface - 5 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 44 | Tooth - 1 Surface - 6 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 45 | Tooth Number/Letter - 2 | Report the tooth identifier(s) when Current Dental Terminology Code is within given range. | alphanumeric | 2 | |
| 46 | Tooth - 2 Surface - 1 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 47 | Tooth - 2 Surface - 2 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 48 | Tooth - 2 Surface - 3 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 49 | Tooth - 2 Surface - 4 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 50 | Tooth - 2 Surface - 5 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 51 | Tooth - 2 Surface - 6 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 52 | Tooth Number/Letter - 3 | Report the tooth identifier(s) when Current Dental Terminology Code is within given range. | alphanumeric | 2 | |
| 53 | Tooth - 3 Surface - 1 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 54 | Tooth - 3 Surface - 2 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 55 | Tooth - 3 Surface - 3 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 56 | Tooth - 3 Surface - 4 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 57 | Tooth - 3 Surface - 5 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 58 | Tooth - 3 Surface - 6 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 59 | Tooth Number/Letter - 4 | Report the tooth identifier(s) when Current Dental Terminology Code is within given range. | alphanumeric | 2 | |
| 60 | Tooth - 4 Surface - 1 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 61 | Tooth - 4 Surface - 2 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 62 | Tooth - 4 Surface - 3 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 63 | Tooth - 4 Surface - 4 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 64 | Tooth - 4 Surface - 5 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 65 | Tooth - 4 Surface - 6 | Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. | alphanumeric | 5 | |
| 66 | Dental Quadrant - 1 | Report the standard quadrant identifier when CDT indicates procedures of 3 or more consecutive teeth. Provides further detail on procedure(s). | alphanumeric | 2 | |
| 67 | Dental Quadrant - 2 | Report the standard quadrant identifier when CDT indicates procedures of 3 or more consecutive teeth. Provides further detail on procedure(s). | alphanumeric | 2 | |
| 68 | Dental Quadrant - 3 | Report the standard quadrant identifier when CDT indicates procedures of 3 or more consecutive teeth. Provides further detail on procedure(s). | alphanumeric | 2 | |
| 69 | Dental Quadrant - 4 | Report the standard quadrant identifier when CDT indicates procedures of 3 or more consecutive teeth. Provides further detail on procedure(s). | alphanumeric | 2 | |
| 70 | Orthodontics Treatment | Indicate if the treatment is for Orthodontics. | numeric | 1 | |
| 71 | Date Appliance Placed | If treatment is for Orthodontics, then provide the date the appliance was placed. | numeric | CCYYMMDD | 8 |
| 72 | Months of Treatment Remaining | If treatment is for Orthodontics, then provide the number of months of treatment remaining. | numeric | 2 | |
| 73 | Prosthesis Replacement | Indicate if the treatment is for the replacement of Prosthesis. | numeric | 1 | |
| 74 | Date Prior Placement | If treatment is for replacement of Prosthesis, then provide the prior date of Prosthesis placement. | numeric | CCYYMMDD | 8 |
| 75 | Reporting Quarter | Indicate the quarter number for which the data is being submitted. | numeric | 1 |
| Data Element ID | Data Element | Code | Value |
|---|---|---|---|
| 1 | Record Identifier | 6 | Dental Services |
| 5 | Patient Sex | 1 | Male |
| 2 | Female | ||
| 3 | Unknown | ||
| 7 | Patient Covered by Other Insurance Indicator | 0 | No |
| 1 | Yes, other coverage is primary | ||
| 2 | Yes, other coverage is secondary | ||
| 9 | Unknown | ||
| 8 | Coverage Type Modified! | 1 | Medicare Supplemental (i.e., Individual, Group, WRAP) |
| 2 | Medicare Advantage Plan | ||
| 3 | Individual Market (not MHIP; not sold in MHBE) | ||
| 4 | Maryland Health Insurance Plan (MHIP) | ||
| 5 | Private Employer Sponsored or Other Group (i.e. union or association plans) | ||
| 6 | Public Employee - Federal (FEHBP) | ||
| 7 | Public Employee - Other (state, county, local/municipal government and public school systems) | ||
| 8 | Comprehensive Standard Health Benefit Plan (not sold in MHBE) [a self employed individual or small businesses (public or private employers) with 2-50 eligible employees] | ||
| 9 | Health Insurance Partnership (HIP) | ||
| A | Student Health Plan | ||
| B | Individual Market sold in MHBE | ||
| C | Small Business Options Program (SHOP) sold in MHBE | ||
| Z | Unknown | ||
| 9 | Source Company | 1 | Health Maintenance Organization |
| 2 | Life & Health Insurance Company or Not-for-Profit Health Benefit Plan | ||
| 3 | Third-Party Administrator (TPA) Unit | ||
| 10 | Claim Related Condition | 0 | Non-accident (default) |
| 1 | Work | ||
| 2 | Auto Accident | ||
| 3 | Other Accident | ||
| 9 | Unknown | ||
| 12 | Participating Provider Flag | 1 | Participating |
| 2 | Non-Participating | ||
| 3 | Unknown/Not Coded | ||
| 9 | No Network for this Plan | ||
| 13 | Record Status | 1 | Final Bill |
| 8 | Capitated or Global Contract Services | ||
| 19 | Place of Service | 11 | Provider's Office |
| 12 | Patient's Home | ||
| 13 | Assisted Living Facility | ||
| 17 | Walk-in Retail Health Clinic | ||
| 18 | Place of Employment - Worksite | ||
| 20 | Urgent Care Facility | ||
| 21 | Inpatient Hospital | ||
| 22 | Outpatient Hospital | ||
| 23 | Emergency Room - Hospital | ||
| 24 | Ambulatory Surgical 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 | ||
| 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 | ||
| 57 | Non-residential Substance Abuse Treatment Facility | ||
| 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 & Imaging | ||
| 99 | Other Place of Service | ||
| 33 | Product Type | 1 | Exclusive Provider Organization (in any form) |
| 2 | Health Maintenance Organization | ||
| 3 | Indemnity | ||
| 4 | Point of Service (POS) | ||
| 5 | Preferred Provider Organization (PPO) | ||
| 6 | Limited Benefit Plan (Mini-Meds) | ||
| 7 | Student Health Plan | ||
| 8 | Catastrophic | ||
| 37 | Relationship to Policyholder | 1 | Self/employee |
| 2 | Spouse | ||
| 3 | Child | ||
| 4 | Other Dependent | ||
| 5 | Other Adult | ||
| 9 | Unknown | ||
| 70 | Orthodontics Treatment | 0 | No |
| 1 | Yes | ||
| 73 | Prosthesis Replacement | 0 | No |
| 1 | Yes | ||
| 75 | Reporting Quarter | 1 | First Quarter = January 1 thru March 31 |
| 2 | Second Quarter = April 1 thru June 30 | ||
| 3 | Third Quarter = July 1 thru September 30 | ||
| 4 | Fourth Quarter = October 1 thru December 31 |
Agency for Healthcare Research and Quality • 5600 Fishers Lane, Rockville, MD 20857 • Telephone: (301) 427-1364
