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Medical Claims File Submission

Connecticut



Name:Medical Claims File Submission
State:Connecticut
Definition:Not provided
VersionDecember 5, 2013 - v1.2

File Specification for Medical Claims File Submission

Data Element ID Data Element Description Type Format Length
HD001 Record Type Header Record Identifier Text char[2] 2
HD002 Submitter Header Submitter / Carrier ID defined by AHCT Integer varchar[6] 6
HD003 National Plan ID Header CMS National Plan Identification Number (PlanID) Integer int[10] 10
HD004 Type of File Defines the file type and data expected. Text char[2] 2
HD005 Period Beginning Date Header Period Start Date Full Date - Integer int[8] YYYYMMDD 8
HD006 Period Ending Date Header Period Ending Date Full Date - Integer int[8] YYYYMMDD 8
HD007 Record Count Header Record Count Integer varchar[10] 10
HD008 Comments Header Carrier Comments Text varchar[80] 80
HD009 APCD Version Number Submission Guide Version Decimal - Numeric char[3] 3
MC001 Submitter CT APCD defined and maintained unique identifier Integer varchar[6] 6
MC002 National Plan ID CMS National Plan Identification Number (PlanID) Integer int[10] 10
MC003 Insurance Type Code/Product Type / Product Identification Code Text char[2] 2
MC004 Payer Claim Control Number Payer Claim Control Identification Text varchar[35] 35
MC005 Line Counter Incremental Line Counter Integer varchar[4] 4
MC005A Version Number Claim Service Line Version Number Integer varchar[4] 4
MC006 Insured Group or Policy Number Group / Policy Number Text varchar[30] 30
MC007 Subscriber SSN Subscriber's Social Security Number Numeric char[9] 9
MC008 Plan Specific Contract Number Contract Number Text varchar[30] 30
MC009 Member Suffix or Sequence Number Member/Patient's Contract Sequence Number Text varchar[20] 20
MC010 Member SSN Member/Patient's Social Security Number Numeric char[9] 9
MC011 Individual Relationship Code Patient to Subscriber Relationship Code Text varchar[2] 2
MC012 Member Gender Patient's Gender Text char[1] 1
MC013 Member Date of Birth Member/Patient's date of birth Full Date - Integer int[8] YYYYMMDD 8
MC014 Member City Name City name of the Member/Patient Text varchar[30] 30
MC015 Member State State / Province of the Patient External Code Source - USPS char[2] 2
MC016 Member ZIP Code Zip Code of the Member / Patient External Code Source - USPS varchar[9] 9
MC017 Date Service Approved (AP Date) Date Service Approved by Payer Full Date - Integer int[8] YYYYMMDD 8
MC018 Admission Date Inpatient Admit Date Full Date - Integer int[8] YYYYMMDD 8
MC019 Admission Hour Admission Time Numeric char[4] HHMM 4
MC020 Admission Type Admission Type Code External Code Source - NUBC int[1] 1
MC021 Admission Source Admission Source Code External Code Source - NUBC char[1] 1
MC022 Discharge Hour Discharge Time Numeric char[4] HHMM 4
MC023 Discharge Status Inpatient Discharge Status Code External Code Source - NUBC char[2] 2
MC024 Service Provider Number Service Provider Identification Number Text varchar[30] 30
MC025 Service Provider Tax ID Number Service Provider's Tax ID number Numeric char[9] 9
MC026 National Provider ID - Service National Provider Identification (NPI) of the Service Provider External Code Source - NPPES int[10] 10
MC027 Service Provider Entity Type Qualifier Service Provider Entity Identifier Code integer int[1] 1
MC028 Service Provider First Name First name of Service Provider Text varchar[25] 25
MC029 Service Provider Middle Name Middle initial of Service Provider Text varchar[25] 25
MC030 Servicing Provider Last Name or Organization Name Last name or Organization Name of Service Provider Text varchar[60] 60
MC031 Filler Filler Filler char[0] 0
MC032 Service Provider Taxonomy Taxonomy Code External Code Source - WPC varchar[10] 10
MC033 Service Provider City Name City Name of the Provider Text varchar[30] 30
MC034 Service Provider State State of the Service Provider External Code Source - USPS char[2] 2
MC035 Service Provider ZIP Code Zip Code of the Service Provider External Code Source - USPS varchar[9] 9
MC036 Type of Bill - on Facility Claims Type of Bill External Code Source - NUBC char[3] 3
MC037 Site of Service - on NSF/CMS 1500 Claims Place of Service Code External Code Source - CMS char[2] 2
MC038 Claim Status Claim Line Status integer varchar[2] 2
MC039 Admitting Diagnosis Admitting Diagnosis Code External Code Source - ICD varchar[7] 7
MC040 E-Code ICD Diagnostic External Injury Code External Code Source - ICD varchar[7] 7
MC041 Principal Diagnosis ICD Primary Diagnosis Code External Code Source - ICD varchar[7] 7
MC042 Other Diagnosis - 1 ICD Secondary Diagnosis Code External Code Source - ICD varchar[7] 7
MC043 Other Diagnosis - 2 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC044 Other Diagnosis - 3 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC045 Other Diagnosis - 4 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC046 Other Diagnosis - 5 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC047 Other Diagnosis - 6 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC048 Other Diagnosis - 7 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC049 Other Diagnosis - 8 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC050 Other Diagnosis - 9 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC051 Other Diagnosis - 10 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC052 Other Diagnosis - 11 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC053 Other Diagnosis - 12 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC054 Revenue Code Revenue Code External Code Source - NUBC char[4] 4
MC055 Procedure Code HCPCS / CPT Code External Code Source - AMA - OR - Carrier Defined Table varchar[10] 10
MC056 Procedure Modifier - 1 HCPCS / CPT Code Modifier External Code Source - AMA char[2] 2
MC057 Procedure Modifier - 2 HCPCS / CPT Code Modifier External Code Source - AMA char[2] 2
MC058 ICD Primary Procedure Code ICD Primary Procedure Code External Code Source - ICD varchar[7] 7
MC059 Date of Service - From Date of Service Full Date - Integer int[8] YYYYMMDD 8
MC060 Date of Service - To Date of Service Full Date - Integer int[8] YYYYMMDD 8
MC061 Quantity Claim line units of service Quantity - Integer ±varchar[15] 15
MC062 Charge Amount Amount of provider charges for the claim line Integer ±varchar[10] 10
MC063 Paid Amount Amount paid by the carrier for the claim line Integer ±varchar[10] 10
MC064 Prepaid Amount Amount carrier has prepaid towards the claim line Integer ±varchar[10] 10
MC065 Copay Amount Amount of Copay member/patient is responsible to pay Integer ±varchar[10] 10
MC066 Coinsurance Amount Amount of coinsurance member/patient is responsible to pay Integer ±varchar[10] 10
MC067 Deductible Amount Amount of deductible member/patient is responsible to pay on the claim line Integer ±varchar[10] 10
MC068 Patient Control Number Patient Control Number Text varchar[20] 20
MC069 Discharge Date Discharge Date Full Date - Integer int[8] YYYYMMDD 8
MC070 Service Provider Country Code Country name of the Service Provider External Code Source - ANSI char[3] 3
MC071 DRG Diagnostic Related Group Code External Code Source - CMS varchar[7] 7
MC072 DRG Version Diagnostic Related Group Version Number External Code Source - CMS char[2] 2
MC073 APC Ambulatory Payment Classification Number External Code Source - CMS char[4] 4
MC074 APC Version Ambulatory Payment Classification Version External Code Source - CMS char[2] 2
MC075 Drug Code National Drug Code (NDC) External Code Source - FDA char[11] 11
MC076 Billing Provider Number Billing Provider Number Text varchar[30] 30
MC077 National Provider ID - Billing National Provider Identification (NPI) of the Billing Provider External Code Source - NPPES int[10] 10
MC078 Billing Provider Last Name or Organization Name Last name or Organization Name of Billing Provider Text varchar[60] 60
MC079 Filler Filler Filler char[0] 0
MC080 Payment Reason Payment Reason Code External Code Source - HIPPA - OR - Carrier Defined Table varchar[10] 10
MC081 Capitated Encounter Flag Indicator - Capitation Payment Integer int[1] 1
MC082 Member Street Address Street address of the Member/Patient Text varchar[50] 50
MC083 Other ICD Procedure Code - 1 ICD Secondary Procedure Code External Code Source - ICD varchar[7] 7
MC084 Other ICD Procedure Code - 2 ICD Other Procedure Code External Code Source - ICD varchar[7] 7
MC085 Other ICD Procedure Code - 3 ICD Other Procedure Code External Code Source - ICD varchar[7] 7
MC086 Other ICD Procedure Code - 4 ICD Other Procedure Code External Code Source - ICD varchar[7] 7
MC087 Other ICD Procedure Code - 5 ICD Other Procedure Code External Code Source - ICD varchar[7] 7
MC088 Other ICD Procedure Code - 6 ICD Other Procedure Code External Code Source - ICD varchar[7] 7
MC089 Paid Date Paid date of the claim line Integer int[8] 8
MC090 Filler Filler Filler char[0] 0
MC091 Filler Filler Filler char[0] 0
MC092 Filler Filler Filler char[0] 0
MC093 Filler Filler Filler char[0] 0
MC094 Type of Claim Type of Claim Indicator Text char[3] 3
MC095 COB / TPL Amount Amount due from a secondary carrier Integer ±varchar[10] 10
MC096 Other Insurance Paid Amount Amount already paid by primary carrier Integer ±varchar[10] 10
MC097 Medicare Paid Amount Any amount Medicare Paid towards claim line Integer ±varchar[10] 10
MC098 Allowed amount Allowed Amount Integer ±varchar[10] 10
MC099 Non-Covered Amount Amount of claim line charge not covered Integer ±varchar[10] 10
MC100 Carve Out Vendor CT APCD ID CT APCD defined and maintained Org ID for linking across submitters Integer varchar[6] 6
MC101 Subscriber Last Name Last name of Subscriber Text varchar[60] 60
MC102 Subscriber First Name First name of Subscriber Text varchar[25] 25
MC103 Subscriber Middle Initial Middle initial of Subscriber Text char[1] 1
MC104 Member Last Name Last name of Member/Patient Text varchar[60] 60
MC105 Member First Name First name of Member/Patient Text varchar[25] 25
MC106 Member Middle Initial Middle initial of Member/Patient Text char[1] 1
MC107 ICD Indicator International Classification of Diseases version Integer int[1] 1
MC108 Procedure Modifier - 3 HCPCS / CPT Code Modifier External Code Source - AMA char[2] 2
MC109 Procedure Modifier - 4 HCPCS / CPT Code Modifier External Code Source - AMA char[2] 2
MC110 Claim Processed Date Claim Processed Date Full Date - Integer int[8] YYYYMMDD 8
MC111 Diagnostic Pointer Diagnostic Pointer Number Integer varchar[4] 4
MC112 Referring Provider ID Referring Provider ID Text varchar[30] 30
MC113 Payment Arrangement Type Payment Arrangement Type Value Integer int[1] 1
MC114 Excluded Expenses Amount not covered at the claim line due to benefit/plan limitation Integer ±varchar[10] 10
MC115 Medicare Indicator Indicator - Medicare Payment Applied Integer int[1] 1
MC116 Filler Filler Filler char[0] 0
MC117 Authorization Needed Indicator - Authorization Needed Integer int[1] 1
MC118 Referral Indicator Indicator - Referral Needed Integer int[1] 1
MC119 PCP Indicator Indicator - PCP Rendered Service Integer int[1] 1
MC120 DRG Level Diagnostic Related Group Code Severity Level External Code Source - CMS int[1] 1
MC121 Patient Total Out of Pocket Amount Total amount patent / member must pay for this claim line Integer int[10] 10
MC122 Global Payment Flag Indicator - Global Payment Integer int[1] 1
MC123 Denied Flag Denied Claim Line Indicator Integer int[1] 1
MC124 Denial Reason Denial Reason Code External Code Source - HIPAA -OR- Carrier Lookup Table varchar[15] 15
MC125 Attending Provider Attending Provider ID Text varchar[30] 30
MC126 Accident Indicator Indicator - Accident Related Integer int[1] 1
MC127 Family Planning Indicator Indicator - Accident Related Integer int[1] 1
MC128 Employment Related Indicator Indicator - Accident Related Integer int[1] 1
MC129 EPSDT Indicator Indicator - Accident Related Integer int[1] 1
MC130 Procedure Code Type Claim line Procedure Code Type Identifier Integer int[1] 1
MC131 InNetwork Indicator Indicator - Network Rate Applied Integer int[1] 1
MC132 Filler Filler Filler char[0] 0
MC133 Bill Frequency Code Bill Frequency External Code Source - NUBC char[1] 1
MC134 Plan Rendering Provider Identifier Plan Rendering Number Text varchar[30] 30
MC135 Provider Location Location of Provider Text varchar[30] 30
MC136 Filler Filler Filler char[0] 0
MC137 Carrier Specific Unique Member ID Member's Unique ID Text varchar[50] 50
MC138 Claim Line Type Claim Line Activity Type Code Text char[1] 1
MC139 Former Claim Number Previous Claim Number Text varchar[35] 35
MC140 Member Street Address 2 Secondary Street Address of the Member/Patient Text varchar[50] 50
MC141 Carrier Specific Unique Subscriber ID Subscriber's Unique ID Text varchar[50] 50
MC142 Other Diagnosis - 13 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC143 Other Diagnosis - 14 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC144 Other Diagnosis - 15 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC145 Other Diagnosis - 16 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC146 Other Diagnosis - 17 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC147 Other Diagnosis - 18 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC148 Other Diagnosis - 19 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC149 Other Diagnosis - 20 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC150 Other Diagnosis - 21 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC151 Other Diagnosis - 22 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC152 Other Diagnosis - 23 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC153 Other Diagnosis - 24 ICD Other Diagnosis Code External Code Source - ICD varchar[7] 7
MC154 Present on Admission Code (POA) - 01 POA code for Principal Diagnosis External Code Source - CMS char[1] 1
MC155 Present on Admission Code (POA) - 02 POA code for Other Diagnosis - 1 External Code Source - CMS char[1] 1
MC156 Present on Admission Code (POA) - 03 POA code for Other Diagnosis - 2 External Code Source - CMS char[1] 1
MC157 Present on Admission Code (POA) - 04 POA code for Other Diagnosis - 3 External Code Source - CMS char[1] 1
MC158 Present on Admission Code (POA) - 05 POA code for Other Diagnosis - 4 External Code Source - CMS char[1] 1
MC159 Present on Admission Code (POA) - 06 POA code for Other Diagnosis - 5 External Code Source - CMS char[1] 1
MC160 Present on Admission Code (POA) - 07 POA code for Other Diagnosis - 6 External Code Source - CMS char[1] 1
MC161 Present on Admission Code (POA) - 08 POA code for Other Diagnosis - 7 External Code Source - CMS char[1] 1
MC162 Present on Admission Code (POA) - 09 POA code for Other Diagnosis - 8 External Code Source - CMS char[1] 1
MC163 Present on Admission Code (POA) - 10 POA code for Other Diagnosis - 9 External Code Source - CMS char[1] 1
MC164 Present on Admission Code (POA) - 11 POA code for Other Diagnosis - 10 External Code Source - CMS char[1] 1
MC165 Present on Admission Code (POA) - 12 POA code for Other Diagnosis - 11 External Code Source - CMS char[1] 1
MC166 Present on Admission Code (POA) - 13 POA code for Other Diagnosis - 12 External Code Source - CMS char[1] 1
MC167 Present on Admission Code (POA) - 14 POA code for Other Diagnosis - 13 External Code Source - CMS char[1] 1
MC168 Present on Admission Code (POA) - 15 POA code for Other Diagnosis - 14 External Code Source - CMS char[1] 1
MC169 Present on Admission Code (POA) - 16 POA code for Other Diagnosis - 15 External Code Source - CMS char[1] 1
MC170 Present on Admission Code (POA) - 17 POA code for Other Diagnosis - 16 External Code Source - CMS char[1] 1
MC171 Present on Admission Code (POA) - 18 POA code for Other Diagnosis - 17 External Code Source - CMS char[1] 1
MC172 Present on Admission Code (POA) - 19 POA code for Other Diagnosis - 18 External Code Source - CMS char[1] 1
MC173 Present on Admission Code (POA) - 20 POA code for Other Diagnosis - 19 External Code Source - CMS char[1] 1
MC174 Present on Admission Code (POA) - 21 POA code for Other Diagnosis - 20 External Code Source - CMS char[1] 1
MC175 Present on Admission Code (POA) - 22 POA code for Other Diagnosis - 21 External Code Source - CMS char[1] 1
MC176 Present on Admission Code (POA) - 23 POA code for Other Diagnosis - 22 External Code Source - CMS char[1] 1
MC177 Present on Admission Code (POA) - 24 POA code for Other Diagnosis - 23 External Code Source - CMS char[1] 1
MC178 Present on Admission Code (POA) - 25 POA code for Other Diagnosis - 24 External Code Source - CMS char[1] 1
MC179 Condition Code - 1 Condition Code External Code Source - NUBC char[2] 2
MC180 Condition Code - 2 Condition Code External Code Source - NUBC char[2] 2
MC181 Condition Code - 3 Condition Code External Code Source - NUBC char[2] 2
MC182 Filler Filler Filler char[0] 0
MC183 Filler Filler Filler char[0] 0
MC184 Filler Filler Filler char[0] 0
MC185 Filler Filler Filler char[0] 0
MC186 Filler Filler Filler char[0] 0
MC187 Filler Filler Filler char[0] 0
MC188 Filler Filler Filler char[0] 0
MC189 Filler Filler Filler char[0] 0
MC190 Filler Filler Filler char[0] 0
MC191 Value Code - 1 Value Code External Code Source - NUBC char[2] 2
MC192 Value Amount - 1 Amount that corresponds to Value Code - 1 Integer ±varchar[10] 10
MC193 Value Code - 2 Value Code External Code Source - NUBC char[2] 2
MC194 Value Amount - 2 Amount that corresponds to Value Code - 2 Integer ±varchar[10] 10
MC195 Value Code - 3 Value Code External Code Source - NUBC char[2] 2
MC196 Value Amount - 3 Amount that corresponds to Value Code - 3 Integer ±varchar[10] 10
MC197 Filler Filler Filler char[0] 0
MC198 Filler Filler Filler char[0] 0
MC199 Filler Filler Filler char[0] 0
MC200 Filler Filler Filler char[0] 0
MC201 Filler Filler Filler char[0] 0
MC202 Filler Filler Filler char[0] 0
MC203 Filler Filler Filler char[0] 0
MC204 Filler Filler Filler char[0] 0
MC205 Filler Filler Filler char[0] 0
MC206 Filler Filler Filler char[0] 0
MC207 Filler Filler Filler char[0] 0
MC208 Filler Filler Filler char[0] 0
MC209 Filler Filler Filler char[0] 0
MC210 Filler Filler Filler char[0] 0
MC211 Filler Filler Filler char[0] 0
MC212 Filler Filler Filler char[0] 0
MC213 Filler Filler Filler char[0] 0
MC214 Filler Filler Filler char[0] 0
MC215 Occurrence Code - 1 Occurrence Code External Code Source - NUBC char[2] 2
MC216 Occurrence Date - 1 Date that corresponds to Occurrence Code - 1 Integer int[8] YYYYMMDD 8
MC217 Occurrence Code - 2 Occurrence Code External Code Source - NUBC char[2] 2
MC218 Occurrence Date - 2 Date that corresponds to Occurrence Code - 1 Integer int[8] YYYYMMDD 8
MC219 Occurrence Code - 3 Occurrence Code External Code Source - NUBC char[2] 2
MC220 Occurrence Date - 3 Date that corresponds to Occurrence Code - 1 Integer int[8] YYYYMMDD 8
MC221 Filler Filler Filler char[0] 0
MC222 Filler Filler Filler char[0] 0
MC223 Filler Filler Filler char[0] 0
MC224 Filler Filler Filler char[0] 0
MC225 Occurrence Span Code - 1 Occurrence Span Code External Code Source - NUBC char[2] 2
MC226 Occurrence Span Start Date - 1 Start Date that corresponds to Occurrence Span Code - Integer int[8] YYYYMMDD 8
MC227 Occurrence Span End Date - 1 End Date that corresponds to Occurrence Span Code - Integer int[8] YYYYMMDD 8
MC228 Occurrence Span Code - 2 Occurrence Span Code External Code Source - NUBC char[2] 2
MC229 Occurrence Span Start Date - 2 Start Date that corresponds to Occurrence Span Code - Integer int[8] YYYYMMDD 8
MC230 Occurrence Span End Date - 2 End Date that corresponds to Occurrence Span Code - Integer int[8] YYYYMMDD 8
MC231 Filler Filler Filler char[0] 0
MC232 Filler Filler Filler char[0] 0
MC233 Filler Filler Filler char[0] 0
MC234 Filler Filler Filler char[0] 0
MC235 Filler Filler Filler char[0] 0
MC236 Filler Filler Filler char[0] 0
MC237 Filler Filler Filler char[0] 0
MC238 Filler Filler Filler char[0] 0
MC239 Filler Filler Filler char[0] 0
MC240 Filler Filler Filler char[0] 0
MC241 APCD ID Code Member Enrollment Type Integer int[1] 1
MC899 Record Type File Type Identifier Text char[2] 2
TR001 Record Type Trailer Record Identifier Text char[2] 2
TR002 Submitter Trailer Submitter / Carrier ID defined by AHCT Integer varchar[6] 6
TR003 National Plan ID CMS National Plan Identification Number (PlanID) Integer int[10] 10
TR004 Type of File Validates the file type defined in HD004. Text char[2] 2
TR005 Period Beginning Date Trailer Period Start Date Full Date - Integer int[8] YYYYMMDD 8
TR006 Period Ending Date Trailer Period Ending Date Full Date - Integer int[8] YYYYMMDD 8
TR007 Date Processed Trailer Processed Date Full Date - Integer int[8] YYYYMMDD 8

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Data Element ID Data Element Code Value
HD001 Record Type HD Header Elements
HD004 Type of File MC MEDICAL CLAIM
HD009 APCD Version Number 1 Current Version; required for reporting periods as of October 2013
MC003 Insurance Type Code/Product 9 Self-pay
11 Other Non-Federal Programs (use of this value requires disclosure to Data Manager prior to submission)
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)
96 Husky Health A
97 Husky Health B
98 Husky Health C
99 Husky Health D
AM Automobile Medical
CH Champus (now TRICARE)
CI Commercial Insurance
DS Disability
HM Health Maintenance Organization
LM Liability Medical
MA Medicare Part A
MB Medicare Part B
MC Medicaid
OF Other Federal Program (use of this value requires disclosure to Data Manager prior to submission)
TV Title V
VA Veterans Affairs Plan
WC Workers' Compensation
ZZ Mutually Defined (use of this value requires disclosure to Data Manager prior to submission)
MC011 Individual Relationship Code 1 Spouse
4 Grandfather or Grandmother
5 Grandson or Granddaughter
7 Nephew or Niece
10 Foster Child
12 Other Adult
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
34 Other Adult
36 Emancipated Minor
39 Organ Donor
40 Cadaver Donor
41 Injured Plaintiff
43 Child Where Insured Has No Financial Responsibility
53 Life Partner
76 Dependent
MC012 Member Gender F Female
M Male
U Unknown
MC027 Service Provider Entity Type Qualifier 1 Person
2 Non-person entity
MC038 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
MC081 Capitated Encounter Flag 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
MC094 Type of Claim 001 Professional
002 Facility
003 Reimbursement Form
MC107 ICD Indicator 0 ICD-10
9 ICD-9
MC113 Payment Arrangement Type 1 Capitation
2 Fee for Service
3 Percent of Charges
4 DRG
5 Pay for Performance
6 Global Payment
7 Other
8 Bundled Payment
MC115 Medicare Indicator 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
MC117 Authorization Needed 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
MC118 Referral Indicator 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
MC119 PCP Indicator 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
MC122 Global Payment Flag 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
MC123 Denied Flag 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
MC126 Accident Indicator 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
MC127 Family Planning Indicator 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
MC128 Employment Related Indicator 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
MC129 EPSDT Indicator 0 Unknown / Not Applicable
1 EPSDT Screening
2 EPSDT Treatment
3 EPSDT Referral
MC130 Procedure Code Type 1 CPT or HCPCS Level 1 Code
2 HCPCS Level II Code
3 HCPCS Level III Code (State Medicare code).
4 American Dental Association (ADA) Procedure Code (Also referred to as CDT code.)
5 State defined Procedure Code
6 CPT Category II
7 Custom Code - Submitter must send in a lookup table of values for MC055
MC131 InNetwork Indicator 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
MC138 Claim Line Type A Amendment
B Back Out
O Original
R Replacement
V Void
MC241 APCD ID Code 0 Unknown / Not Applicable
1 FIG - Fully-Insured Commercial Group Enrollee
2 SIG - Self-Insured Group Enrollee
3 State or Federal Employer Enrollee
4 Individual - Non-Group Enrollee
5 Supplemental Policy Enrollee
6 ICO - Integrated Care Organization
MC899 Record Type MC
TR001 Record Type TR end of the data file
TR004 Type of File MC
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