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Medical Claims File Submission

Colorado

Versions: Medical Claims File Submission• Medical Claims File Submission• Medical Claims File SubmissionCompare Versions


Name:Medical Claims File Submission
State:Colorado
Definition:Not Provided
VersionMarch 2014 - v6

File Specification for Medical Claims File Submission

Data Element ID Data Element Description Type Format Length
Multiple versionsHD001 Record Type Not Provided char 2
Multiple versionsHD002 Payer Code Distributed by CIVHC varchar 8
Multiple versionsHD003 Payer Name Distributed by CIVHC varchar 75
Multiple versionsHD004 Beginning Month Not Provided date CCYYMM 6
Multiple versionsHD005 Ending Month Not Provided date CCYYMM 6
Multiple versionsHD006 Record count Total number of records submitted in the medical claims file, excluding header and trailer records int 10
Multiple versionsMC001 Payer Code Distributed by CIVHC varchar 8
Multiple versionsMC002 Payer Name Distributed by CIVHC varchar 30
Multiple versionsMC003 Insurance Type/Product Code Not Provided char 2
Multiple versionsMC004 Payer Claim Control Number Must apply to the entire claim and be unique within the payer's system. No partial claims. Only paid (or partially paid) claims varchar 35
Multiple versionsMC005 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. All claims must contain a line 1. int 4
Multiple versionsMC005A Version Number The version number of this claim service line. The original claim will have a version number of 0, with the next version being assigned a 1, and each subsequent version being incremented by 1 for that service line. Plans that cannot increment this column may opt to use YYMM as the version number. int 4
Multiple versionsMC006 Insured Group or Policy Number Group or policy number - not the number that uniquely identifies the subscriber. varchar 30
Multiple versionsMC007 Subscriber Social Security Number Subscriber's social security number; Set as null if unavailable varchar 9
Multiple versionsMC008 Plan Specific Contract Number Plan assigned subscriber's contract number; Set as null if contract number = subscriber's social security number or use an alternate unique identifier such as Medicaid ID. Must be an identifier that is unique to the subscriber. varchar 128
Multiple versionsMC009 Member Suffix or Sequence Number Unique number of the member within the contract. Must be an identifier that is unique to the member. varchar 20
Multiple versionsMC010 Member Identification Code (patient) Member's social security number; Set as null if contract number = subscriber's social security number or use an alternate unique identifier such as Medicaid ID. Must be an identifier that is unique to the member. varchar 9
Multiple versionsMC011 Individual Relationship Code Member's relationship to insured char 2
Multiple versionsMC012 Member Gender Not Provided char 1
Multiple versionsMC013 Member Date of Birth Not Provided char YYYYMMDD 8
Multiple versionsMC014 Member City Name City name of member varchar 30
Multiple versionsMC107 Member Street Address Physical street address of the covered member Varchar 50
Multiple versionsMC015 Member State or Province As defined by the US Postal Service char 2
Multiple versionsMC016 Member ZIP Code ZIP Code of member - may include non- US codes. Plus 4 optional but desired. varchar 11
Multiple versionsMC017 Date Service Approved/Accounts Payable Date/Actual Paid Date Not Provided char YYYYMMDD 8
Multiple versionsMC018 Admission Date Required for all inpatient claims. char YYYYMMDD 8
Multiple versionsMC019 Admission Hour Required for all inpatient claims. Time is expressed in military time char HHMM 4
Multiple versionsMC020 Admission Type Required for all inpatient claims (SOURCE: National Uniform Billing Data Element Specifications) int 1
Multiple versionsMC021 Admission Source Required for all inpatient claims (SOURCE: National Uniform Billing Data Element Specifications) char 1
Multiple versionsMC022 Discharge Hour Time expressed in military time int HHMM 4
Multiple versionsMC023 Discharge Status Required for all inpatient claims. char 2
Multiple versionsMC024 Service Provider Number Payer assigned service provider number. Submit facility for institutional claims; physician or healthcare professional for professional claims. varchar 30
Multiple versionsMC025 Service Provider Tax ID Number Federal taxpayer's identification number varchar 10
Multiple versionsMC026 Service National Provider ID National Provider ID. This data element pertains to the entity or individual directly providing the service. varchar 20
Multiple versionsMC027 Service Provider Entity Type Qualifier HIPAA provider taxonomy classifies provider groups (clinicians who bill as a group practice or under a corporate name, even if that group is composed of one provider) as a "person", and these shall be coded as a person. char 1
Multiple versionsMC028 Service Provider First Name Individual first name. Set to null if provider is a facility or organization. varchar 25
Multiple versionsMC029 Service Provider Middle Name Individual middle name or initial. Set to null if provider is a facility or organization. varchar 25
Multiple versionsMC030 Service Provider Last Name or Organization Name Full name of provider organization or last name of individual provider varchar 60
Multiple versionsMC031 Service Provider Suffix Suffix to individual name. Set to null if provider is a facility or organization. The service provider suffix shall be used to capture the generation of the individual clinician (e.g., Jr., Sr., III), if applicable, rather than the clinician's degree (e.g., MD, LCSW). varchar 10
Multiple versionsMC032 Service Provider Specialty As defined by payer. Dictionary for specialty code values must be supplied during testing. varchar 10
Multiple versionsMC108 Service Provider Street Address Physical practice location street address of the provider administering the services Varchar 50
Multiple versionsMC033 Service Provider City Name City name of provider - preferably practice location varchar 30
Multiple versionsMC034 Service Provider State or Province As defined by the US Postal Service char 2
Multiple versionsMC035 Service Provider ZIP Code ZIP Code of provider - may include non- US codes; do not include dash. Plus 4 optional but desired. varchar 11
Multiple versionsMC036 Type of Bill - Institutional Required for institutional claims; Not to be used for professional claims char 3
Multiple versionsMC037 Place of Service Required for professional claims. Not to be used for institutional claims. Map where you can and default to "99" for all others. char 2
Multiple versionsMC038 Claim Status Not Provided char 2
Multiple versionsMC039 Admitting Diagnosis Required on all inpatient admission claims and encounters. ICD-9-CM or ICD-10-CM. Do not code decimal point. varchar 7
Multiple versionsMC898 ICD-9 / ICD-10 Flag The purpose of this field is to identify which code set is being utilized. char 1
Multiple versionsMC040 E-Code Describes an injury, poisoning or adverse effect. ICD-9-CM or ICD-10-CM. Do not code decimal point. varchar 7
Multiple versionsMC041 Principal Diagnosis ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC042 Other Diagnosis - 1 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC043 Other Diagnosis - 2 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC044 Other Diagnosis - 3 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC045 Other Diagnosis - 4 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC046 Other Diagnosis - 5 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC047 Other Diagnosis - 6 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC048 Other Diagnosis - 7 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC049 Other Diagnosis - 8 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC050 Other Diagnosis - 9 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC051 Other Diagnosis - 10 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC052 Other Diagnosis - 11 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC053 Other Diagnosis - 12 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC054 Revenue Code National Uniform Billing Committee Codes. Code using leading zeroes, left justified, and four digits. char 10
Multiple versionsMC055 Outpatient Procedure Code Health Care Common Procedural Coding System (HCPCS); this includes the CPT codes of the American Medical Association. Required for Outpatient and Professional claims only. varchar 10
Multiple versionsMC056 Procedure Modifier - 1 Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code. Required for Outpatient and Professional claims only. char 2
Multiple versionsMC057 Procedure Modifier - 2 Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code. Required for Outpatient and Professional claims only. char 2
Multiple versionsMC058 ICD-9-CM or ICD-10 Procedure Code Primary procedure code for this line of service. Do not code decimal point. Default to Blank char 7
Multiple versionsMC059 Date of Service - From First date of service for this service line. Date YYYYMMDD 8
Multiple versionsMC060 Date of Service - Thru Last date of service for this service line. Date YYYYMMDD 8
Multiple versionsMC061 Quantity Count of services performed, which shall be set equal to one on all observation bed service lines and should be set equal to zero on all other room and board service lines, regardless of the length of stay. int 3
Multiple versionsMC062 Charge Amount Do not code decimal point or provide any punctuation where $1,000.00 converted to 100000 Same for all financial data that follows. int 10
Multiple versionsMC063 Paid Amount Includes any withhold amounts. Do not code decimal point. For capitated claims set to zero. int 10
Multiple versionsMC064 Prepaid Amount For capitated services, the fee for service equivalent amount. Do not code decimal point. int 10
Multiple versionsMC065 Co-pay Amount The preset, fixed dollar amount for which the individual is responsible. Do not code decimal point. int 10
Multiple versionsMC066 Coinsurance Amount The dollar amount an individual is responsible for - not the percentage. Do not code decimal point. int 10
Multiple versionsMC067 Deductible Amount Do not code decimal point. int 10
Multiple versionsMC068 Patient Account/Control Number Number assigned by hospital varchar 20
Multiple versionsMC069 Discharge Date Date patient discharged. Required for all inpatient claims. Date YYYYMMDD 8
Multiple versionsMC070 Service Provider Country Name Code US for United States. varchar 30
Multiple versionsMC071 DRG Insurers and health care 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 DRG system is used, the insurer 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). varchar 10
Multiple versionsMC072 DRG Version Version number of the grouper used char 2
Multiple versionsMC073 APC Insurers and health care claims processors shall code using the CMS methodology when available. Precedence shall be given to APCs transmitted from the health care provider. char 4
Multiple versionsMC074 APC Version Version number of the grouper used char 2
Multiple versionsMC075 Drug Code An NDC code used only when a medication is paid for as part of a medical claim. varchar 11
Multiple versionsMC076 Billing Provider Number Payer assigned billing provider number. This number should be the identifier used by the payer for internal identification purposes, and does not routinely change. varchar 30
Multiple versionsMC077 National Billing Provider ID National Provider ID varchar 20
Multiple versionsMC078 Billing Provider Last Name or Organization Name Full name of provider billing organization or last name of individual billing provider. varchar 60
Multiple versionsMC101 Subscriber Last Name Subscriber last name varchar 128
Multiple versionsMC102 Subscriber First Name Subscriber first name varchar 128
Multiple versionsMC103 Subscriber Middle Initial Subscriber middle initial char 1
Multiple versionsMC104 Member Last Name Not Provided varchar 128
Multiple versionsMC105 Member First Name Not Provided varchar 128
Multiple versionsMC106 Member Middle Initial Not Provided char 1
Multiple versionsMC201A Present on Admission - PDX Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201B Present on Admission - DX1 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201C Present on Admission - DX2 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201D Present on Admission - DX3 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201E Present on Admission - DX4 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201F Present on Admission - DX5 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201G Present on Admission - DX6 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201H Present on Admission - DX7 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201I Present on Admission - DX8 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201J Present on Admission - DX9 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201K Present on Admission - DX10 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201L Present on Admission - DX11 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201M Present on Admission - DX12 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC202 Tooth Number Tooth Number or Letter Identification Char 20
Multiple versionsMC203 Dental Quadrant Dental Quadrant Char 1
Multiple versionsMC204 Tooth Surface Tooth Surface Identification Char 10
Multiple versionsMC205 ICD-9-CM or ICD-10-CM Procedure Date Date MC058 was performed Date 8
Multiple versionsMC058A ICD-9-CM Procedure Code or ICD-10-CM Procedure code Secondary procedure code for this line of service. Do not code decimal point. char 7
Multiple versionsMC205A ICD-9-CM or ICD-10-CM Procedure Date Date MC058A was performed Date 8
Multiple versionsMC058B ICD-9-CM Procedure Code or ICD-10-CM Procedure code Secondary procedure code for this line of service. Do not code decimal point. char 7
Multiple versionsMC205B ICD-9-CM or ICD-10-CM Procedure Date Date MC058B was performed Date 8
Multiple versionsMC058C ICD-9-CM Procedure Code or ICD-10-CM Procedure code Secondary procedure code for this line of service. Do not code decimal point. char 7
Multiple versionsMC205C ICD-9-CM or ICD-10-CM Procedure Date Date MC058C was performed Date 8
Multiple versionsMC058D ICD-9-CM Procedure Code or ICD-10-CM Procedure code Secondary procedure code for this line of service. Do not code decimal point. char 7
Multiple versionsMC205D ICD-9-CM or ICD-10-CM Procedure Date Date MC058E was performed Date 8
Multiple versionsMC058E ICD-9-CM Procedure Code or ICD-10-CM Procedure code Secondary procedure code for this line of service. Do not code decimal point. char 7
Multiple versionsMC205E ICD-9-CM or ICD-10-CM Procedure Date Date MC058E was performed Date 8
Multiple versionsMC206 Capitated Service Indicator Not Provided Char 1
Multiple versionsMC899 Record Type Not Provided char 2
Multiple versionsTR001 Record Type Not Provided char 2
Multiple versionsTR002 Payer Code Distributed by CIVHC varchar 8
Multiple versionsTR003 Payer Name Distributed by CIVHC varchar 75
Multiple versionsTR004 Beginning Month Not Provided date CCYYMM 6
Multiple versionsTR005 Ending Month Not Provided date CCYYMM 6
Multiple versionsTR006 Extraction Date Not Provided date YYYYMMDD 8

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Data Element ID Data Element Code Value
HD001 Record Type MC
MC003 Insurance Type/Product Code 12 Preferred Provider Organization (PPO)
13 Point of Service (POS)
15 Indemnity Insurance
16 Health Maintenance Organization (HMO) Medicare Advantage
17 Dental Maintenance Organization (DMO)
99 Other
CI Commercial Insurance Company
DN Dental
HM Health Maintenance Organization
HN HMO Medicare Risk/ Medicare Part C
MA Medicare Part A
MB Medicare Part B
MC Medicaid
MD Medicare Part D
MP Medicare Primary
QM Qualified Medicare Beneficiary
SP Supplemental Policy
SP Medicare Supplemental (Medi-gap) plan
TV Title V
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
MC020 Admission Type 1 Emergency
2 Urgent
3 Elective
4 Newborn
5 Trauma Center
9 Information not available
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 - Institutional 111 Hospital Inpatient (Including Medicare Part A) Admit Through Discharge
112 Hospital Inpatient (Including Medicare Part A) Interim-First Claim Used for the
113 Hospital Inpatient (Including Medicare Part A) Interim-Continuing Claims
114 Hospital Inpatient (Including Medicare Part A) Interim-Last Claim
115 Hospital Inpatient (Including Medicare Part A) Late Charge Only
117 Hospital Inpatient (Including Medicare Part A) Replacement of Prior Claim
118 Hospital Inpatient (Including Medicare Part A) Void/Cancel of a Prior Claim
119 Hospital Inpatient (Including Medicare Part A) Final Claim for a Home
121 Hospital Inpatient (Medicare Part B Only) Admit Through Discharge
122 Hospital Inpatient (Medicare Part B Only) Interim-First Claim Used for the
123 Hospital Inpatient (Medicare Part B Only) Interim-Continuing Claims
124 Hospital Inpatient (Medicare Part B Only) Interim-Last Claim
125 Hospital Inpatient (Medicare Part B Only) Late Charge Only
127 Hospital Inpatient (Medicare Part B Only) Replacement of Prior Claim
128 Hospital Inpatient (Medicare Part B Only) Void/Cancel of a Prior Claim
129 Hospital Inpatient (Medicare Part B Only) Final Claim for a Home
131 Hospital Outpatient Admit Through Discharge
132 Hospital Outpatient Interim-First Claim Used for the
133 Hospital Outpatient Interim-Continuing Claims
134 Hospital Outpatient Interim-Last Claim
135 Hospital Outpatient Late Charge Only
137 Hospital Outpatient Replacement of Prior Claim
138 Hospital Outpatient Void/Cancel of a Prior Claim
139 Hospital Outpatient Final Claim for a Home
141 Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Admit Through Discharge
142 Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-First Claim Used for the
143 Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Continuing Claims
144 Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Last Claim
145 Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Late Charge Only
147 Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Replacement of Prior Claim
148 Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Void/Cancel of a Prior Claim
149 Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Final Claim for a Home
151 Hospital Nursing Facility Level I Admit Through Discharge
152 Hospital Nursing Facility Level I Interim-First Claim Used for the
153 Hospital Nursing Facility Level I Interim-Continuing Claims
154 Hospital Nursing Facility Level I Interim-Last Claim
155 Hospital Nursing Facility Level I Late Charge Only
157 Hospital Nursing Facility Level I Replacement of Prior Claim
158 Hospital Nursing Facility Level I Void/Cancel of a Prior Claim
159 Hospital Nursing Facility Level I Final Claim for a Home
161 Hospital Nursing Facility Level II Admit Through Discharge
162 Hospital Nursing Facility Level II Interim-First Claim Used for the
163 Hospital Nursing Facility Level II Interim-Continuing Claims
164 Hospital Nursing Facility Level II Interim-Last Claim
165 Hospital Nursing Facility Level II Late Charge Only
167 Hospital Nursing Facility Level II Replacement of Prior Claim
168 Hospital Nursing Facility Level II Void/Cancel of a Prior Claim
169 Hospital Nursing Facility Level II Final Claim for a Home
171 Hospital Intermediate Care Level III Nursing Facility Admit Through Discharge
172 Hospital Intermediate Care Level III Nursing Facility Interim-First Claim Used for the
173 Hospital Intermediate Care Level III Nursing Facility Interim-Continuing Claims
174 Hospital Intermediate Care Level III Nursing Facility Interim-Last Claim
175 Hospital Intermediate Care Level III Nursing Facility Late Charge Only
177 Hospital Intermediate Care Level III Nursing Facility Replacement of Prior Claim
178 Hospital Intermediate Care Level III Nursing Facility Void/Cancel of a Prior Claim
179 Hospital Intermediate Care Level III Nursing Facility Final Claim for a Home
181 Hospital Swing Beds Admit Through Discharge
182 Hospital Swing Beds Interim-First Claim Used for the
183 Hospital Swing Beds Interim-Continuing Claims
184 Hospital Swing Beds Interim-Last Claim
185 Hospital Swing Beds Late Charge Only
187 Hospital Swing Beds Replacement of Prior Claim
188 Hospital Swing Beds Void/Cancel of a Prior Claim
189 Hospital Swing Beds Final Claim for a Home
211 Skilled Nursing Inpatient (Including Medicare Part A) Admit Through Discharge
212 Skilled Nursing Inpatient (Including Medicare Part A) Interim-First Claim Used for the
213 Skilled Nursing Inpatient (Including Medicare Part A) Interim-Continuing Claims
214 Skilled Nursing Inpatient (Including Medicare Part A) Interim-Last Claim
215 Skilled Nursing Inpatient (Including Medicare Part A) Late Charge Only
217 Skilled Nursing Inpatient (Including Medicare Part A) Replacement of Prior Claim
218 Skilled Nursing Inpatient (Including Medicare Part A) Void/Cancel of a Prior Claim
219 Skilled Nursing Inpatient (Including Medicare Part A) Final Claim for a Home
221 Skilled Nursing Inpatient (Medicare Part B Only) Admit Through Discharge
222 Skilled Nursing Inpatient (Medicare Part B Only) Interim-First Claim Used for the
223 Skilled Nursing Inpatient (Medicare Part B Only) Interim-Continuing Claims
224 Skilled Nursing Inpatient (Medicare Part B Only) Interim-Last Claim
225 Skilled Nursing Inpatient (Medicare Part B Only) Late Charge Only
227 Skilled Nursing Inpatient (Medicare Part B Only) Replacement of Prior Claim
228 Skilled Nursing Inpatient (Medicare Part B Only) Void/Cancel of a Prior Claim
229 Skilled Nursing Inpatient (Medicare Part B Only) Final Claim for a Home
231 Skilled Nursing Outpatient Admit Through Discharge
232 Skilled Nursing Outpatient Interim-First Claim Used for the
233 Skilled Nursing Outpatient Interim-Continuing Claims
234 Skilled Nursing Outpatient Interim-Last Claim
235 Skilled Nursing Outpatient Late Charge Only
237 Skilled Nursing Outpatient Replacement of Prior Claim
238 Skilled Nursing Outpatient Void/Cancel of a Prior Claim
239 Skilled Nursing Outpatient Final Claim for a Home
241 Skilled Nursing Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Admit Through Discharge
242 Skilled Nursing Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-First Claim Used for the
243 Skilled Nursing Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Continuing Claims
244 Skilled Nursing Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Last Claim
245 Skilled Nursing Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Late Charge Only
247 Skilled Nursing Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Replacement of Prior Claim
248 Skilled Nursing Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Void/Cancel of a Prior Claim
249 Skilled Nursing Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Final Claim for a Home
251 Skilled Nursing Nursing Facility Level I Admit Through Discharge
252 Skilled Nursing Nursing Facility Level I Interim-First Claim Used for the
253 Skilled Nursing Nursing Facility Level I Interim-Continuing Claims
254 Skilled Nursing Nursing Facility Level I Interim-Last Claim
255 Skilled Nursing Nursing Facility Level I Late Charge Only
257 Skilled Nursing Nursing Facility Level I Replacement of Prior Claim
258 Skilled Nursing Nursing Facility Level I Void/Cancel of a Prior Claim
259 Skilled Nursing Nursing Facility Level I Final Claim for a Home
261 Skilled Nursing Nursing Facility Level II Admit Through Discharge
262 Skilled Nursing Nursing Facility Level II Interim-First Claim Used for the
263 Skilled Nursing Nursing Facility Level II Interim-Continuing Claims
264 Skilled Nursing Nursing Facility Level II Interim-Last Claim
265 Skilled Nursing Nursing Facility Level II Late Charge Only
267 Skilled Nursing Nursing Facility Level II Replacement of Prior Claim
268 Skilled Nursing Nursing Facility Level II Void/Cancel of a Prior Claim
269 Skilled Nursing Nursing Facility Level II Final Claim for a Home
271 Skilled Nursing Intermediate Care Level III Nursing Facility Admit Through Discharge
272 Skilled Nursing Intermediate Care Level III Nursing Facility Interim-First Claim Used for the
273 Skilled Nursing Intermediate Care Level III Nursing Facility Interim-Continuing Claims
274 Skilled Nursing Intermediate Care Level III Nursing Facility Interim-Last Claim
275 Skilled Nursing Intermediate Care Level III Nursing Facility Late Charge Only
277 Skilled Nursing Intermediate Care Level III Nursing Facility Replacement of Prior Claim
278 Skilled Nursing Intermediate Care Level III Nursing Facility Void/Cancel of a Prior Claim
279 Skilled Nursing Intermediate Care Level III Nursing Facility Final Claim for a Home
281 Skilled Nursing Swing Beds Admit Through Discharge
282 Skilled Nursing Swing Beds Interim-First Claim Used for the
283 Skilled Nursing Swing Beds Interim-Continuing Claims
284 Skilled Nursing Swing Beds Interim-Last Claim
285 Skilled Nursing Swing Beds Late Charge Only
287 Skilled Nursing Swing Beds Replacement of Prior Claim
288 Skilled Nursing Swing Beds Void/Cancel of a Prior Claim
289 Skilled Nursing Swing Beds Final Claim for a Home
311 Home Health Inpatient (Including Medicare Part A) Admit Through Discharge
312 Home Health Inpatient (Including Medicare Part A) Interim-First Claim Used for the
313 Home Health Inpatient (Including Medicare Part A) Interim-Continuing Claims
314 Home Health Inpatient (Including Medicare Part A) Interim-Last Claim
315 Home Health Inpatient (Including Medicare Part A) Late Charge Only
317 Home Health Inpatient (Including Medicare Part A) Replacement of Prior Claim
318 Home Health Inpatient (Including Medicare Part A) Void/Cancel of a Prior Claim
319 Home Health Inpatient (Including Medicare Part A) Final Claim for a Home
321 Home Health Inpatient (Medicare Part B Only) Admit Through Discharge
322 Home Health Inpatient (Medicare Part B Only) Interim-First Claim Used for the
323 Home Health Inpatient (Medicare Part B Only) Interim-Continuing Claims
324 Home Health Inpatient (Medicare Part B Only) Interim-Last Claim
325 Home Health Inpatient (Medicare Part B Only) Late Charge Only
327 Home Health Inpatient (Medicare Part B Only) Replacement of Prior Claim
328 Home Health Inpatient (Medicare Part B Only) Void/Cancel of a Prior Claim
329 Home Health Inpatient (Medicare Part B Only) Final Claim for a Home
331 Home Health Outpatient Admit Through Discharge
332 Home Health Outpatient Interim-First Claim Used for the
333 Home Health Outpatient Interim-Continuing Claims
334 Home Health Outpatient Interim-Last Claim
335 Home Health Outpatient Late Charge Only
337 Home Health Outpatient Replacement of Prior Claim
338 Home Health Outpatient Void/Cancel of a Prior Claim
339 Home Health Outpatient Final Claim for a Home
341 Home Health Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Admit Through Discharge
342 Home Health Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-First Claim Used for the
343 Home Health Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Continuing Claims
344 Home Health Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Last Claim
345 Home Health Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Late Charge Only
347 Home Health Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Replacement of Prior Claim
348 Home Health Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Void/Cancel of a Prior Claim
349 Home Health Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Final Claim for a Home
351 Home Health Nursing Facility Level I Admit Through Discharge
352 Home Health Nursing Facility Level I Interim-First Claim Used for the
353 Home Health Nursing Facility Level I Interim-Continuing Claims
354 Home Health Nursing Facility Level I Interim-Last Claim
355 Home Health Nursing Facility Level I Late Charge Only
357 Home Health Nursing Facility Level I Replacement of Prior Claim
358 Home Health Nursing Facility Level I Void/Cancel of a Prior Claim
359 Home Health Nursing Facility Level I Final Claim for a Home
361 Home Health Nursing Facility Level II Admit Through Discharge
362 Home Health Nursing Facility Level II Interim-First Claim Used for the
363 Home Health Nursing Facility Level II Interim-Continuing Claims
364 Home Health Nursing Facility Level II Interim-Last Claim
365 Home Health Nursing Facility Level II Late Charge Only
367 Home Health Nursing Facility Level II Replacement of Prior Claim
368 Home Health Nursing Facility Level II Void/Cancel of a Prior Claim
369 Home Health Nursing Facility Level II Final Claim for a Home
371 Home Health Intermediate Care Level III Nursing Facility Admit Through Discharge
372 Home Health Intermediate Care Level III Nursing Facility Interim-First Claim Used for the
373 Home Health Intermediate Care Level III Nursing Facility Interim-Continuing Claims
374 Home Health Intermediate Care Level III Nursing Facility Interim-Last Claim
375 Home Health Intermediate Care Level III Nursing Facility Late Charge Only
377 Home Health Intermediate Care Level III Nursing Facility Replacement of Prior Claim
378 Home Health Intermediate Care Level III Nursing Facility Void/Cancel of a Prior Claim
379 Home Health Intermediate Care Level III Nursing Facility Final Claim for a Home
381 Home Health Swing Beds Admit Through Discharge
382 Home Health Swing Beds Interim-First Claim Used for the
383 Home Health Swing Beds Interim-Continuing Claims
384 Home Health Swing Beds Interim-Last Claim
385 Home Health Swing Beds Late Charge Only
387 Home Health Swing Beds Replacement of Prior Claim
388 Home Health Swing Beds Void/Cancel of a Prior Claim
389 Home Health Swing Beds Final Claim for a Home
411 Christian Science Hospital Inpatient (Including Medicare Part A) Admit Through Discharge
412 Christian Science Hospital Inpatient (Including Medicare Part A) Interim-First Claim Used for the
413 Christian Science Hospital Inpatient (Including Medicare Part A) Interim-Continuing Claims
414 Christian Science Hospital Inpatient (Including Medicare Part A) Interim-Last Claim
415 Christian Science Hospital Inpatient (Including Medicare Part A) Late Charge Only
417 Christian Science Hospital Inpatient (Including Medicare Part A) Replacement of Prior Claim
418 Christian Science Hospital Inpatient (Including Medicare Part A) Void/Cancel of a Prior Claim
419 Christian Science Hospital Inpatient (Including Medicare Part A) Final Claim for a Home
421 Christian Science Hospital Inpatient (Medicare Part B Only) Admit Through Discharge
422 Christian Science Hospital Inpatient (Medicare Part B Only) Interim-First Claim Used for the
423 Christian Science Hospital Inpatient (Medicare Part B Only) Interim-Continuing Claims
424 Christian Science Hospital Inpatient (Medicare Part B Only) Interim-Last Claim
425 Christian Science Hospital Inpatient (Medicare Part B Only) Late Charge Only
427 Christian Science Hospital Inpatient (Medicare Part B Only) Replacement of Prior Claim
428 Christian Science Hospital Inpatient (Medicare Part B Only) Void/Cancel of a Prior Claim
429 Christian Science Hospital Inpatient (Medicare Part B Only) Final Claim for a Home
431 Christian Science Hospital Outpatient Admit Through Discharge
432 Christian Science Hospital Outpatient Interim-First Claim Used for the
433 Christian Science Hospital Outpatient Interim-Continuing Claims
434 Christian Science Hospital Outpatient Interim-Last Claim
435 Christian Science Hospital Outpatient Late Charge Only
437 Christian Science Hospital Outpatient Replacement of Prior Claim
438 Christian Science Hospital Outpatient Void/Cancel of a Prior Claim
439 Christian Science Hospital Outpatient Final Claim for a Home
441 Christian Science Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Admit Through Discharge
442 Christian Science Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-First Claim Used for the
443 Christian Science Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Continuing Claims
444 Christian Science Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Last Claim
445 Christian Science Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Late Charge Only
447 Christian Science Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Replacement of Prior Claim
448 Christian Science Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Void/Cancel of a Prior Claim
449 Christian Science Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Final Claim for a Home
451 Christian Science Hospital Nursing Facility Level I Admit Through Discharge
452 Christian Science Hospital Nursing Facility Level I Interim-First Claim Used for the
453 Christian Science Hospital Nursing Facility Level I Interim-Continuing Claims
454 Christian Science Hospital Nursing Facility Level I Interim-Last Claim
455 Christian Science Hospital Nursing Facility Level I Late Charge Only
457 Christian Science Hospital Nursing Facility Level I Replacement of Prior Claim
458 Christian Science Hospital Nursing Facility Level I Void/Cancel of a Prior Claim
459 Christian Science Hospital Nursing Facility Level I Final Claim for a Home
461 Christian Science Hospital Nursing Facility Level II Admit Through Discharge
462 Christian Science Hospital Nursing Facility Level II Interim-First Claim Used for the
463 Christian Science Hospital Nursing Facility Level II Interim-Continuing Claims
464 Christian Science Hospital Nursing Facility Level II Interim-Last Claim
465 Christian Science Hospital Nursing Facility Level II Late Charge Only
467 Christian Science Hospital Nursing Facility Level II Replacement of Prior Claim
468 Christian Science Hospital Nursing Facility Level II Void/Cancel of a Prior Claim
469 Christian Science Hospital Nursing Facility Level II Final Claim for a Home
471 Christian Science Hospital Intermediate Care Level III Nursing Facility Admit Through Discharge
472 Christian Science Hospital Intermediate Care Level III Nursing Facility Interim-First Claim Used for the
473 Christian Science Hospital Intermediate Care Level III Nursing Facility Interim-Continuing Claims
474 Christian Science Hospital Intermediate Care Level III Nursing Facility Interim-Last Claim
475 Christian Science Hospital Intermediate Care Level III Nursing Facility Late Charge Only
477 Christian Science Hospital Intermediate Care Level III Nursing Facility Replacement of Prior Claim
478 Christian Science Hospital Intermediate Care Level III Nursing Facility Void/Cancel of a Prior Claim
479 Christian Science Hospital Intermediate Care Level III Nursing Facility Final Claim for a Home
481 Christian Science Hospital Swing Beds Admit Through Discharge
482 Christian Science Hospital Swing Beds Interim-First Claim Used for the
483 Christian Science Hospital Swing Beds Interim-Continuing Claims
484 Christian Science Hospital Swing Beds Interim-Last Claim
485 Christian Science Hospital Swing Beds Late Charge Only
487 Christian Science Hospital Swing Beds Replacement of Prior Claim
488 Christian Science Hospital Swing Beds Void/Cancel of a Prior Claim
489 Christian Science Hospital Swing Beds Final Claim for a Home
511 Christian Science Extended Care Inpatient (Including Medicare Part A) Admit Through Discharge
512 Christian Science Extended Care Inpatient (Including Medicare Part A) Interim-First Claim Used for the
513 Christian Science Extended Care Inpatient (Including Medicare Part A) Interim-Continuing Claims
514 Christian Science Extended Care Inpatient (Including Medicare Part A) Interim-Last Claim
515 Christian Science Extended Care Inpatient (Including Medicare Part A) Late Charge Only
517 Christian Science Extended Care Inpatient (Including Medicare Part A) Replacement of Prior Claim
518 Christian Science Extended Care Inpatient (Including Medicare Part A) Void/Cancel of a Prior Claim
519 Christian Science Extended Care Inpatient (Including Medicare Part A) Final Claim for a Home
521 Christian Science Extended Care Inpatient (Medicare Part B Only) Admit Through Discharge
522 Christian Science Extended Care Inpatient (Medicare Part B Only) Interim-First Claim Used for the
523 Christian Science Extended Care Inpatient (Medicare Part B Only) Interim-Continuing Claims
524 Christian Science Extended Care Inpatient (Medicare Part B Only) Interim-Last Claim
525 Christian Science Extended Care Inpatient (Medicare Part B Only) Late Charge Only
527 Christian Science Extended Care Inpatient (Medicare Part B Only) Replacement of Prior Claim
528 Christian Science Extended Care Inpatient (Medicare Part B Only) Void/Cancel of a Prior Claim
529 Christian Science Extended Care Inpatient (Medicare Part B Only) Final Claim for a Home
531 Christian Science Extended Care Outpatient Admit Through Discharge
532 Christian Science Extended Care Outpatient Interim-First Claim Used for the
533 Christian Science Extended Care Outpatient Interim-Continuing Claims
534 Christian Science Extended Care Outpatient Interim-Last Claim
535 Christian Science Extended Care Outpatient Late Charge Only
537 Christian Science Extended Care Outpatient Replacement of Prior Claim
538 Christian Science Extended Care Outpatient Void/Cancel of a Prior Claim
539 Christian Science Extended Care Outpatient Final Claim for a Home
541 Christian Science Extended Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Admit Through Discharge
542 Christian Science Extended Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-First Claim Used for the
543 Christian Science Extended Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Continuing Claims
544 Christian Science Extended Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Last Claim
545 Christian Science Extended Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Late Charge Only
547 Christian Science Extended Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Replacement of Prior Claim
548 Christian Science Extended Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Void/Cancel of a Prior Claim
549 Christian Science Extended Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Final Claim for a Home
551 Christian Science Extended Care Nursing Facility Level I Admit Through Discharge
552 Christian Science Extended Care Nursing Facility Level I Interim-First Claim Used for the
553 Christian Science Extended Care Nursing Facility Level I Interim-Continuing Claims
554 Christian Science Extended Care Nursing Facility Level I Interim-Last Claim
555 Christian Science Extended Care Nursing Facility Level I Late Charge Only
557 Christian Science Extended Care Nursing Facility Level I Replacement of Prior Claim
558 Christian Science Extended Care Nursing Facility Level I Void/Cancel of a Prior Claim
559 Christian Science Extended Care Nursing Facility Level I Final Claim for a Home
561 Christian Science Extended Care Nursing Facility Level II Admit Through Discharge
562 Christian Science Extended Care Nursing Facility Level II Interim-First Claim Used for the
563 Christian Science Extended Care Nursing Facility Level II Interim-Continuing Claims
564 Christian Science Extended Care Nursing Facility Level II Interim-Last Claim
565 Christian Science Extended Care Nursing Facility Level II Late Charge Only
567 Christian Science Extended Care Nursing Facility Level II Replacement of Prior Claim
568 Christian Science Extended Care Nursing Facility Level II Void/Cancel of a Prior Claim
569 Christian Science Extended Care Nursing Facility Level II Final Claim for a Home
571 Christian Science Extended Care Intermediate Care Level III Nursing Facility Admit Through Discharge
572 Christian Science Extended Care Intermediate Care Level III Nursing Facility Interim-First Claim Used for the
573 Christian Science Extended Care Intermediate Care Level III Nursing Facility Interim-Continuing Claims
574 Christian Science Extended Care Intermediate Care Level III Nursing Facility Interim-Last Claim
575 Christian Science Extended Care Intermediate Care Level III Nursing Facility Late Charge Only
577 Christian Science Extended Care Intermediate Care Level III Nursing Facility Replacement of Prior Claim
578 Christian Science Extended Care Intermediate Care Level III Nursing Facility Void/Cancel of a Prior Claim
579 Christian Science Extended Care Intermediate Care Level III Nursing Facility Final Claim for a Home
581 Christian Science Extended Care Swing Beds Admit Through Discharge
582 Christian Science Extended Care Swing Beds Interim-First Claim Used for the
583 Christian Science Extended Care Swing Beds Interim-Continuing Claims
584 Christian Science Extended Care Swing Beds Interim-Last Claim
585 Christian Science Extended Care Swing Beds Late Charge Only
587 Christian Science Extended Care Swing Beds Replacement of Prior Claim
588 Christian Science Extended Care Swing Beds Void/Cancel of a Prior Claim
589 Christian Science Extended Care Swing Beds Final Claim for a Home
611 Intermediate Care Inpatient (Including Medicare Part A) Admit Through Discharge
612 Intermediate Care Inpatient (Including Medicare Part A) Interim-First Claim Used for the
613 Intermediate Care Inpatient (Including Medicare Part A) Interim-Continuing Claims
614 Intermediate Care Inpatient (Including Medicare Part A) Interim-Last Claim
615 Intermediate Care Inpatient (Including Medicare Part A) Late Charge Only
617 Intermediate Care Inpatient (Including Medicare Part A) Replacement of Prior Claim
618 Intermediate Care Inpatient (Including Medicare Part A) Void/Cancel of a Prior Claim
619 Intermediate Care Inpatient (Including Medicare Part A) Final Claim for a Home
621 Intermediate Care Inpatient (Medicare Part B Only) Admit Through Discharge
622 Intermediate Care Inpatient (Medicare Part B Only) Interim-First Claim Used for the
623 Intermediate Care Inpatient (Medicare Part B Only) Interim-Continuing Claims
624 Intermediate Care Inpatient (Medicare Part B Only) Interim-Last Claim
625 Intermediate Care Inpatient (Medicare Part B Only) Late Charge Only
627 Intermediate Care Inpatient (Medicare Part B Only) Replacement of Prior Claim
628 Intermediate Care Inpatient (Medicare Part B Only) Void/Cancel of a Prior Claim
629 Intermediate Care Inpatient (Medicare Part B Only) Final Claim for a Home
631 Intermediate Care Outpatient Admit Through Discharge
632 Intermediate Care Outpatient Interim-First Claim Used for the
633 Intermediate Care Outpatient Interim-Continuing Claims
634 Intermediate Care Outpatient Interim-Last Claim
635 Intermediate Care Outpatient Late Charge Only
637 Intermediate Care Outpatient Replacement of Prior Claim
638 Intermediate Care Outpatient Void/Cancel of a Prior Claim
639 Intermediate Care Outpatient Final Claim for a Home
641 Intermediate Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Admit Through Discharge
642 Intermediate Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-First Claim Used for the
643 Intermediate Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Continuing Claims
644 Intermediate Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Interim-Last Claim
645 Intermediate Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Late Charge Only
647 Intermediate Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Replacement of Prior Claim
648 Intermediate Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Void/Cancel of a Prior Claim
649 Intermediate Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment) Final Claim for a Home
651 Intermediate Care Nursing Facility Level I Admit Through Discharge
652 Intermediate Care Nursing Facility Level I Interim-First Claim Used for the
653 Intermediate Care Nursing Facility Level I Interim-Continuing Claims
654 Intermediate Care Nursing Facility Level I Interim-Last Claim
655 Intermediate Care Nursing Facility Level I Late Charge Only
657 Intermediate Care Nursing Facility Level I Replacement of Prior Claim
658 Intermediate Care Nursing Facility Level I Void/Cancel of a Prior Claim
659 Intermediate Care Nursing Facility Level I Final Claim for a Home
661 Intermediate Care Nursing Facility Level II Admit Through Discharge
662 Intermediate Care Nursing Facility Level II Interim-First Claim Used for the
663 Intermediate Care Nursing Facility Level II Interim-Continuing Claims
664 Intermediate Care Nursing Facility Level II Interim-Last Claim
665 Intermediate Care Nursing Facility Level II Late Charge Only
667 Intermediate Care Nursing Facility Level II Replacement of Prior Claim
668 Intermediate Care Nursing Facility Level II Void/Cancel of a Prior Claim
669 Intermediate Care Nursing Facility Level II Final Claim for a Home
671 Intermediate Care Intermediate Care Level III Nursing Facility Admit Through Discharge
672 Intermediate Care Intermediate Care Level III Nursing Facility Interim-First Claim Used for the
673 Intermediate Care Intermediate Care Level III Nursing Facility Interim-Continuing Claims
674 Intermediate Care Intermediate Care Level III Nursing Facility Interim-Last Claim
675 Intermediate Care Intermediate Care Level III Nursing Facility Late Charge Only
677 Intermediate Care Intermediate Care Level III Nursing Facility Replacement of Prior Claim
678 Intermediate Care Intermediate Care Level III Nursing Facility Void/Cancel of a Prior Claim
679 Intermediate Care Intermediate Care Level III Nursing Facility Final Claim for a Home
681 Intermediate Care Swing Beds Admit Through Discharge
682 Intermediate Care Swing Beds Interim-First Claim Used for the
683 Intermediate Care Swing Beds Interim-Continuing Claims
684 Intermediate Care Swing Beds Interim-Last Claim
685 Intermediate Care Swing Beds Late Charge Only
687 Intermediate Care Swing Beds Replacement of Prior Claim
688 Intermediate Care Swing Beds Void/Cancel of a Prior Claim
689 Intermediate Care Swing Beds Final Claim for a Home
711 Clinic Rural HealthAdmit Through Discharge
712 Clinic Rural HealthInterim-First Claim Used for the
713 Clinic Rural HealthInterim-Continuing Claims
714 Clinic Rural HealthInterim-Last Claim
715 Clinic Rural HealthLate Charge Only
717 Clinic Rural HealthReplacement of Prior Claim
718 Clinic Rural HealthVoid/Cancel of a Prior Claim
719 Clinic Rural HealthFinal Claim for a Home
721 Clinic Hospital Based or Independent Renal Dialysis CenterAdmit Through Discharge
722 Clinic Hospital Based or Independent Renal Dialysis CenterInterim-First Claim Used for the
723 Clinic Hospital Based or Independent Renal Dialysis CenterInterim-Continuing Claims
724 Clinic Hospital Based or Independent Renal Dialysis CenterInterim-Last Claim
725 Clinic Hospital Based or Independent Renal Dialysis CenterLate Charge Only
727 Clinic Hospital Based or Independent Renal Dialysis CenterReplacement of Prior Claim
728 Clinic Hospital Based or Independent Renal Dialysis CenterVoid/Cancel of a Prior Claim
729 Clinic Hospital Based or Independent Renal Dialysis CenterFinal Claim for a Home
731 Clinic Free Standing Outpatient Rehabilitation Facility (ORF)Admit Through Discharge
732 Clinic Free Standing Outpatient Rehabilitation Facility (ORF)Interim-First Claim Used for the
733 Clinic Free Standing Outpatient Rehabilitation Facility (ORF)Interim-Continuing Claims
734 Clinic Free Standing Outpatient Rehabilitation Facility (ORF)Interim-Last Claim
735 Clinic Free Standing Outpatient Rehabilitation Facility (ORF)Late Charge Only
737 Clinic Free Standing Outpatient Rehabilitation Facility (ORF)Replacement of Prior Claim
738 Clinic Free Standing Outpatient Rehabilitation Facility (ORF)Void/Cancel of a Prior Claim
739 Clinic Free Standing Outpatient Rehabilitation Facility (ORF)Final Claim for a Home
751 Clinic Comprehensive Outpatient Rehabilitation Facilities (CORFs)Admit Through Discharge
752 Clinic Comprehensive Outpatient Rehabilitation Facilities (CORFs)Interim-First Claim Used for the
753 Clinic Comprehensive Outpatient Rehabilitation Facilities (CORFs)Interim-Continuing Claims
754 Clinic Comprehensive Outpatient Rehabilitation Facilities (CORFs)Interim-Last Claim
755 Clinic Comprehensive Outpatient Rehabilitation Facilities (CORFs)Late Charge Only
757 Clinic Comprehensive Outpatient Rehabilitation Facilities (CORFs)Replacement of Prior Claim
758 Clinic Comprehensive Outpatient Rehabilitation Facilities (CORFs)Void/Cancel of a Prior Claim
759 Clinic Comprehensive Outpatient Rehabilitation Facilities (CORFs)Final Claim for a Home
761 Clinic Community Mental Health CenterAdmit Through Discharge
762 Clinic Community Mental Health CenterInterim-First Claim Used for the
763 Clinic Community Mental Health CenterInterim-Continuing Claims
764 Clinic Community Mental Health CenterInterim-Last Claim
765 Clinic Community Mental Health CenterLate Charge Only
767 Clinic Community Mental Health CenterReplacement of Prior Claim
768 Clinic Community Mental Health CenterVoid/Cancel of a Prior Claim
769 Clinic Community Mental Health CenterFinal Claim for a Home
791 Clinic OtherAdmit Through Discharge
792 Clinic OtherInterim-First Claim Used for the
793 Clinic OtherInterim-Continuing Claims
794 Clinic OtherInterim-Last Claim
795 Clinic OtherLate Charge Only
797 Clinic OtherReplacement of Prior Claim
798 Clinic OtherVoid/Cancel of a Prior Claim
799 Clinic OtherFinal Claim for a Home
811 Special Facility Hospice (Non Hospital Based)Admit Through Discharge
812 Special Facility Hospice (Non Hospital Based)Interim-First Claim Used for the
813 Special Facility Hospice (Non Hospital Based)Interim-Continuing Claims
814 Special Facility Hospice (Non Hospital Based)Interim-Last Claim
815 Special Facility Hospice (Non Hospital Based)Late Charge Only
817 Special Facility Hospice (Non Hospital Based)Replacement of Prior Claim
818 Special Facility Hospice (Non Hospital Based)Void/Cancel of a Prior Claim
819 Special Facility Hospice (Non Hospital Based)Final Claim for a Home
821 Special Facility Hospice (Hospital-Based)Admit Through Discharge
822 Special Facility Hospice (Hospital-Based)Interim-First Claim Used for the
823 Special Facility Hospice (Hospital-Based)Interim-Continuing Claims
824 Special Facility Hospice (Hospital-Based)Interim-Last Claim
825 Special Facility Hospice (Hospital-Based)Late Charge Only
827 Special Facility Hospice (Hospital-Based)Replacement of Prior Claim
828 Special Facility Hospice (Hospital-Based)Void/Cancel of a Prior Claim
829 Special Facility Hospice (Hospital-Based)Final Claim for a Home
831 Special Facility Ambulatory Surgery CenterAdmit Through Discharge
832 Special Facility Ambulatory Surgery CenterInterim-First Claim Used for the
833 Special Facility Ambulatory Surgery CenterInterim-Continuing Claims
834 Special Facility Ambulatory Surgery CenterInterim-Last Claim
835 Special Facility Ambulatory Surgery CenterLate Charge Only
837 Special Facility Ambulatory Surgery CenterReplacement of Prior Claim
838 Special Facility Ambulatory Surgery CenterVoid/Cancel of a Prior Claim
839 Special Facility Ambulatory Surgery CenterFinal Claim for a Home
841 Special Facility Free Standing Birthing CenterAdmit Through Discharge
842 Special Facility Free Standing Birthing CenterInterim-First Claim Used for the
843 Special Facility Free Standing Birthing CenterInterim-Continuing Claims
844 Special Facility Free Standing Birthing CenterInterim-Last Claim
845 Special Facility Free Standing Birthing CenterLate Charge Only
847 Special Facility Free Standing Birthing CenterReplacement of Prior Claim
848 Special Facility Free Standing Birthing CenterVoid/Cancel of a Prior Claim
849 Special Facility Free Standing Birthing CenterFinal Claim for a Home
891 Special Facility OtherAdmit Through Discharge
892 Special Facility OtherInterim-First Claim Used for the
893 Special Facility OtherInterim-Continuing Claims
894 Special Facility OtherInterim-Last Claim
895 Special Facility OtherLate Charge Only
897 Special Facility OtherReplacement of Prior Claim
898 Special Facility OtherVoid/Cancel of a Prior Claim
899 Special Facility OtherFinal Claim for a Home
MC037 Place of Service 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
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
MC898 ICD-9 / ICD-10 Flag 0 This claim contains ICD-9-CM codes
1 This claim contains ICD-10-CM codes
MC201A Present on Admission - PDX 1 Exempt for POA reporting
3 Unknown
E Exempt for POA reporting
N Diagnosis was not present at time of inpatient admission
U Documentation insufficient to determine if condition was present at time of inpatient admission
W Clinically undetermined
Y Diagnosis was present at time of inpatient admission
MC201B Present on Admission - DX1 1 Exempt for POA reporting
3 Unknown
E Exempt for POA reporting
N Diagnosis was not present at time of inpatient admission
U Documentation insufficient to determine if condition was present at time of inpatient admission
W Clinically undetermined
Y Diagnosis was present at time of inpatient admission
MC201C Present on Admission - DX2 1 Exempt for POA reporting
3 Unknown
E Exempt for POA reporting
N Diagnosis was not present at time of inpatient admission
U Documentation insufficient to determine if condition was present at time of inpatient admission
W Clinically undetermined
Y Diagnosis was present at time of inpatient admission
MC201D Present on Admission - DX3 1 Exempt for POA reporting
3 Unknown
E Exempt for POA reporting
N Diagnosis was not present at time of inpatient admission
U Documentation insufficient to determine if condition was present at time of inpatient admission
W Clinically undetermined
Y Diagnosis was present at time of inpatient admission
MC201E Present on Admission - DX4 1 Exempt for POA reporting
3 Unknown
E Exempt for POA reporting
N Diagnosis was not present at time of inpatient admission
U Documentation insufficient to determine if condition was present at time of inpatient admission
W Clinically undetermined
Y Diagnosis was present at time of inpatient admission
MC201F Present on Admission - DX5 1 Exempt for POA reporting
3 Unknown
E Exempt for POA reporting
N Diagnosis was not present at time of inpatient admission
U Documentation insufficient to determine if condition was present at time of inpatient admission
W Clinically undetermined
Y Diagnosis was present at time of inpatient admission
MC201G Present on Admission - DX6 1 Exempt for POA reporting
3 Unknown
E Exempt for POA reporting
N Diagnosis was not present at time of inpatient admission
U Documentation insufficient to determine if condition was present at time of inpatient admission
W Clinically undetermined
Y Diagnosis was present at time of inpatient admission
MC201H Present on Admission - DX7 1 Exempt for POA reporting
3 Unknown
E Exempt for POA reporting
N Diagnosis was not present at time of inpatient admission
U Documentation insufficient to determine if condition was present at time of inpatient admission
W Clinically undetermined
Y Diagnosis was present at time of inpatient admission
MC201I Present on Admission - DX8 1 Exempt for POA reporting
3 Unknown
E Exempt for POA reporting
N Diagnosis was not present at time of inpatient admission
U Documentation insufficient to determine if condition was present at time of inpatient admission
W Clinically undetermined
Y Diagnosis was present at time of inpatient admission
MC201J Present on Admission - DX9 1 Exempt for POA reporting
3 Unknown
E Exempt for POA reporting
N Diagnosis was not present at time of inpatient admission
U Documentation insufficient to determine if condition was present at time of inpatient admission
W Clinically undetermined
Y Diagnosis was present at time of inpatient admission
MC201K Present on Admission - DX10 1 Exempt for POA reporting
3 Unknown
E Exempt for POA reporting
N Diagnosis was not present at time of inpatient admission
U Documentation insufficient to determine if condition was present at time of inpatient admission
W Clinically undetermined
Y Diagnosis was present at time of inpatient admission
MC201L Present on Admission - DX11 1 Exempt for POA reporting
3 Unknown
E Exempt for POA reporting
N Diagnosis was not present at time of inpatient admission
U Documentation insufficient to determine if condition was present at time of inpatient admission
W Clinically undetermined
Y Diagnosis was present at time of inpatient admission
MC201M Present on Admission - DX12 1 Exempt for POA reporting
3 Unknown
E Exempt for POA reporting
N Diagnosis was not present at time of inpatient admission
U Documentation insufficient to determine if condition was present at time of inpatient admission
W Clinically undetermined
Y Diagnosis was present at time of inpatient admission
MC206 Capitated Service Indicator N services are not paid under a capitated arrangement
U unknown
Y services are paid under a capitated arrangement
MC899 Record Type MC
TR001 Record Type MC
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