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Dental Claims File Submission

Massachusetts

Versions: December 1, 2010 - v2.1 • June 7, 2013 - v3.1• October 1, 2014 - v4.0Compare Versions


Name:Dental Claims File Submission
State:Massachusetts
Definition:A MA APCD File Type for reporting all Paid Dental Claim Lines of a given time period. File accommodates Replacement and Void lines.
VersionOctober 1, 2014 - v4.0

File Specification for Dental Claims File Submission

Data Element ID Data Element Description Type Format Length
Multiple versionsHD001 Record Type Header Record Identifier Text char[2] 2
Multiple versionsHD002 Submitter Header Submitter / Carrier ID defined by CHIA Integer varchar[6] 6
Multiple versionsHD003 National Plan ID Header CMS National Plan Identification Number (PlanID) Integer int[10] 10
Multiple versionsHD004 Type of File Defines the file type and data expected. Text char[2] 2
Multiple versionsHD005 Period Beginning Date Header Period Start Date Date Period - Integer int[6] CCYYMM 6
Multiple versionsHD006 Period Ending Date Header Period Ending Date Date Period - Integer int[6] CCYYMM 6
Multiple versionsHD007 Record Count Header Record Count Integer varchar[10] 10
Multiple versionsHD008 Comments Header Carrier Comments Text varchar[80] 80
Multiple versionsHD009 APCD Version Number Submission Guide Version Decimal - Numeric char[3] 3
Multiple versionsDC001 Submitter CHIA defined and maintained unique identifier Integer varchar[6] 6
Multiple versionsDC002 National Plan ID CMS National Plan Identification Number (PlanID) Text int[10] 10
Multiple versionsDC003 Insurance Type Code / Product Type / Product Identification Code Lookup Table - Text char[2] 2
Multiple versionsDC004 Payer Claim Control Number Payer Claim Control Identification Text varchar[35] 35
Multiple versionsDC005 Line Counter Incremental Line Counter Integer varchar[4] 4
Multiple versionsDC005A Version Number Claim Service Line Version Number Integer varchar[4] 4
Multiple versionsDC006 Insured Group or Policy Number Group / Policy Number Text varchar[30] 30
Multiple versionsDC007 Subscriber SSN Subscriber's Social Security Number Numeric char[9] 9
Multiple versionsDC008 Plan Specific Contract Number Contract Number Text varchar[30] 30
Multiple versionsDC009 Member Suffix or Sequence Number Member/Patient's Contract Sequence Number Text varchar[20] 20
Multiple versionsDC010 Member SSN Member/Patient's Social Security Number Numeric char[9] 9
Multiple versionsDC011 Individual Relationship Code Patient to Subscriber Relationship Code Lookup Table - Numeric varchar[2] 2
Multiple versionsDC012 Member Gender Patient's Gender Lookup Table - Text char[1] 1
Multiple versionsDC013 Member Date of Birth Member/Patient's date of birth Full Date - Integer int[8] CCYYMMDD 8
Multiple versionsDC014 Member City Name City name of the Member/Patient Text varchar[50] 50
Multiple versionsDC015 Member State State / Province of the Patient External Code Source 2 - Text char[2] 2
Multiple versionsDC016 Member ZIP Code Zip Code of the Member / Patient External Code Source 2 - Text varchar[9] 9
Multiple versionsDC017 Date Service Approved (AP Date) Date Service Approved by Payer Full Date - Integer int[8] 8
Multiple versionsDC018 Service Provider Number Service Provider Identification Number Text varchar[30] 30
Multiple versionsDC019 Service Provider Tax ID Number Service Provider's Tax ID number Numeric char[9] 9
Multiple versionsDC020 National Provider ID - Service National Provider Identification (NPI) of the Service Provider External Code Source 3 - Integer int[10] 10
Multiple versionsDC021 Service Provider Entity Type Qualifier Service Provider Entity Identifier Code Lookup Table - integer int[1] 1
Multiple versionsDC022 Service Provider First Name First name of Service Provider Text varchar[25] 25
Multiple versionsDC023 Service Provider Middle Name Middle initial of Service Provider Text varchar[25] 25
Multiple versionsDC024 Service Provider Last Name or Organization Name Last name or Organization Name of Service Provider Text varchar[60] 60
Multiple versionsDC025 Delegated Benefit Administrator Organization ID CHIA defined and maintained Org ID for linking across submitters Integer varchar[6] 6
Multiple versionsDC026 Service Provider Taxonomy Taxonomy Code External Code Source 5 - Text varchar[10] 10
Multiple versionsDC027 Service Provider City Name City name of the Provider Text varchar[30] 30
Multiple versionsDC028 Service Provider State State of the Service Provider External Code Source 2 - Text char[2] 2
Multiple versionsDC029 Service Provider ZIP Code Zip Code of the Service Provider External Code Source 2 - Text varchar[9] 9
Multiple versionsDC030 Facility Type - Professional Place of Service Code External Code Source 13 - Numeric char[2] 2
Multiple versionsDC031 Claim Status Claim Line Status Lookup Table - Numeric varchar[2] 2
Multiple versionsDC032 CDT Code HCPCS / CDT Code External Code Source 10 - Text char[5] 5
Multiple versionsDC033 Procedure Modifier - 1 HCPCS / CPT Code Modifier External Code Source 9 - Text char[2] 2
Multiple versionsDC034 Procedure Modifier - 2 HCPCS / CPT Code Modifier External Code Source 9 - Text char[2] 2
Multiple versionsDC035 Date of Service - From Date of Service Full Date - Integer int[8] CCYYMMDD 8
Multiple versionsDC036 Date of Service - Thru Last date of service for this service line. Full Date - Integer int[8] CCYYMMDD 8
Multiple versionsDC037 Charge Amount Amount of provider charges for the claim line Integer ±varchar[10] 10
Multiple versionsDC038 Paid Amount Amount paid by the carrier for the claim line Integer ±varchar[10] 10
Multiple versionsDC039 Copay Amount Amount of Copay member/patient is responsible to pay Integer ±varchar[10] 10
Multiple versionsDC040 Coinsurance Amount Amount of coinsurance member/patient is responsible to pay Integer ±varchar[10] 10
Multiple versionsDC041 Deductible Amount Amount of deductible member/patient is responsible to pay on the claim line Integer ±varchar[10] 10
Multiple versionsDC042 Product ID Number Product Identification Text varchar[30] 30
Multiple versionsDC043 Member Street Address Street address of the Member/Patient Text varchar[50] 50
Multiple versionsDC044 Billing Provider Tax ID Number The Billing Provider's Federal Tax Identification Number (FTIN) Numeric char[9] 9
Multiple versionsDC045 Paid Date Paid date of the claim line Full Date - Integer int[8] CCYYMMDD 8
Multiple versionsDC046 Allowed Amount Allowed Amount Integer ±varchar[10] 10
Multiple versionsDC047 Tooth Number/Letter Tooth Number or Letter Identification External Code Source 10 - Text varchar[2] 2
Multiple versionsDC048 Dental Quadrant Dental Quadrant External Code Source 10 - Numeric char[2] 2
Multiple versionsDC049 Tooth Surface Tooth Service Identification External Code Source 10 - Text varchar[5] 5
Multiple versionsDC050 Subscriber Last Name Last name of Subscriber Text varchar[60] 60
Multiple versionsDC051 Subscriber First Name First name of Subscriber Text varchar[25] 25
Multiple versionsDC052 Subscriber Middle Initial Middle initial of Subscriber Text char[1] 1
Multiple versionsDC053 Member Last Name Last name of Member/Patient Text varchar[60] 60
Multiple versionsDC054 Member First Name First name of Member/Patient Text varchar[25] 25
Multiple versionsDC055 Member Middle Initial Middle initial of the Member/Patient Text char[1] 1
Multiple versionsDC056 Carrier Specific Unique Member ID Member's Unique ID Text varchar[50] 50
Multiple versionsDC057 Carrier Specific Unique Subscriber ID Subscriber's Unique ID Text varchar[50] 50
Multiple versionsDC058 Member Street Address 2 Secondary Street Address of the Member/Patient Text varchar[50] 50
Multiple versionsDC059 Claim Line Type Claim Line Activity Type Code Lookup Table - Text char[1] 1
Multiple versionsDC060 Former Claim Number Previous Claim Number Text varchar[35] 35
Multiple versionsDC061 Diagnosis Code ICD Diagnosis Code External Code Source 8 - Text varchar[7] 7
Multiple versionsDC062 ICD Indicator International Classification of Diseases version Lookup Table - Integer int[1] 1
Multiple versionsDC063 Denied Flag Denied Claim Line Indicator Lookup Table - Integer int[1] 1
Multiple versionsDC064 Denial Reason Denial Reason Code Carrier Defined Table - OR - External Code Source 16 varchar[20] 20
Multiple versionsDC065 Payment Arrangement Type Payment Arrangement Type Value Lookup Table - Numeric char[2] 2
Multiple versionsDC066 GIC ID GIC Member ID Text varchar[9] 9
Multiple versionsDC067 APCD ID Code Member Enrollment Type Lookup Table - Integer int[1] 1
DC068 Claim Line Paid Flag Claim Line Paid Indicator Lookup Table - Integer int[1] 1
Multiple versionsDC899 Record Type File Type Identifier Text char[2] 2
Multiple versionsTR001 Record Type Trailer Record Identifier Text char[2] 2
Multiple versionsTR002 Submitter Trailer Submitter / Carrier ID defined by CHIA Integer varchar[6] 6
Multiple versionsTR003 National Plan ID CMS National Plan Identification Number (PlanID) Integer int[10] 10
Multiple versionsTR004 Type of File Validates the file type defined in HD004. Text char[2] 2
Multiple versionsTR005 Period Beginning Date Trailer Period Start Date Date Period - Integer int[6] CCYYMM 6
Multiple versionsTR006 Period Ending Date Trailer Period Ending Date Date Period - Integer int[6] CCYYMM 6
Multiple versionsTR007 Date Processed Trailer Processed Date Full Date - Integer int[8] CCYYMMDD 8

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Data Element ID Data Element Code Value
HD001 Record Type HD
HD004 Type of File DC DENTAL CLAIM
HD009 APCD Version Number 2.1 Prior Version; valid only for reporting periods prior to October 2013
3.0 Version 3.0; required for reporting periods as of October 2013 - No longer valid as of May 2015
4.0 Version 4.0; required for reporting periods October 2013 onwards as of May 2015
DC003 Insurance Type Code / Product 09 Self-pay
10 Central Certification
11 Other Non-Federal Programs
12 Preferred Provider Organization (PPO)
13 Point of Service (POS)
14 Exclusive Provider Organization (EPO)
15 Indemnity Insurance
16 Health Maintenance Organization (HMO) Medicare Risk
17 Dental Maintenance Organization (DMO)
AM Automobile Medical
BL Blue Cross / Blue Shield
CC Commonwealth Care
CE Commonwealth Choice
CH Champus
CI Commercial Insurance Co.
DS Disability
HM Health Maintenance Organization
LI Liability
LM Liability Medical
MA Medicare Part A
MB Medicare Part B
MC Medicaid
OF Other Federal Program
TF HSN Trust Fund
TV Title V
VA Veterans Administration Plan
WC Workers' Compensation
ZZ Other
DC011 Individual Relationship Code 1 Spouse
4 Grandfather or Grandmother
5 Grandson or Granddaughter
7 Nephew or Niece
10 Foster Child
15 Ward
17 Stepson or Stepdaughter
19 Child
20 Self/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 Child Where Insured Has No Financial Responsibility
53 Life Partner
76 Dependent
DC012 Member Gender F Female
M Male
O Other
U Unknown
DC021 Service Provider Entity Type Qualifier 1 Person
2 Non-person entity
DC031 Claim Status 1 Processed as primary
2 Processed as secondary
3 Processed as tertiary
4 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
23 Not our claim, forwarded to additional payer(s)
25 Predetermination Pricing Only - no payment
DC059 Claim Line Type A Amendment
B Back Out
O Original
R Replacement
V Void
DC062 ICD Indicator 0 ICD-10
9 ICD-9
DC063 Denied Flag 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
DC065 Payment Arrangement Type 01 Capitation
02 Fee for Service
03 Percent of Charges
04 DRG
05 Pay for Performance
06 Global Payment
07 Other
08 Bundled Payment
09 Payment Amount Per Episode (PAPE) (MassHealth)
DC067 APCD ID Code 0 Unknown / Not Applicable
1 FIG - Fully-Insured Commercial Group Enrollee
2 SIG - Self-Insured Group Enrollee
3 GIC - Group Insurance Commission Enrollee
4 MCO - MassHealth Managed Care Organization Enrollee
5 Supplemental Policy Enrollee
6 ICO - Integrated Care Organization or SCO - Senior Care Option
DC068 Claim Line Paid Flag 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
DC899 Record Type DC
TR001 Record Type TR
TR004 Type of File DC
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