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Medical Claims File Submission

Massachusetts

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


Name:Medical Claims File Submission
State:Massachusetts
Definition:A MA APCD File Type for reporting all Paid Medical Claim Lines of a given time period. File accommodates Facility, Professional, Reimbursement Forms and Replacement and Void lines.
VersionDecember 1, 2010 - v2.1

File Specification for Medical Claims File Submission

Data Element ID Data Element Description Type Format Length
Multiple versionsHD001 Record Type Header Record Identifier Text HD 2
Multiple versionsHD002 Payer Header Submitter/Carrier ID Text 8
Multiple versionsHD003 National Plan ID Header CMS National Plan Identification Number (PlanID) Text 30
Multiple versionsHD004 Type of File Header Type of File Text MC 2
Multiple versionsHD005 Period Beginning Date Header Period Start Date Date Period CCYYMM 6
Multiple versionsHD006 Period Ending Date Header Period Ending Date Date Period CCYYMM 6
Multiple versionsHD007 Record Count Header Record Count Integer ####### 10
Multiple versionsHD008 Comments Header Carrier Comments Text Free Text Comments 80
Multiple versionsMC001 Payer Carrier Specific Submitter Code as defined by APCD. Text 8
Multiple versionsMC002 National Plan ID CMS National Plan Identification Number (PlanID) Text 30
Multiple versionsMC003 Insurance Type Code/Product Type / Product Identification Code Text tlkpClaimInsuranceType 2
Multiple versionsMC004 Payer Claim Control Number Payer Claim Control Identification Text Free Text Control Number 35
Multiple versionsMC005 Line Counter Incremental Line Counter Integer 4
Multiple versionsMC005A Version Number Claim service line version number Integer ####### 4
Multiple versionsMC006 Insured Group or Policy Number Carriers group or policy number Text 30
Multiple versionsMC007 Subscriber SSN Subscriber's Social Security Number Text ######### 9
Multiple versionsMC008 Plan Specific Contract Number Plan Specific Contract Number Text 30
Multiple versionsMC009 Member Suffix or Sequence Number Member/Patient's Contract Sequence Number Text 20
Multiple versionsMC010 Member SSN Member/Patient's Social Security Number Text ######### 9
Multiple versionsMC011 Individual Relationship Code Member/Patient to Subscriber Relationship Code Integer tlkpIndividualRelathionshipCode 2
Multiple versionsMC012 Member Gender Member/Patient's Gender Text tlkpGender 1
Multiple versionsMC013 Member Date of Birth Member/Patient's date of birth Date CCYYMMDD 8
Multiple versionsMC014 Member City Name City name of the Member/Patient Text Free Text Address 30
Multiple versionsMC015 Member State or Province State of the Member/Patient Text External Code Source 2 2
Multiple versionsMC016 Member ZIP Code Zip Code of the Member/Patient Text External Code Source 3 11
Multiple versionsMC017 Date Service Approved (AP Date) Date Service Approved Date CCYYMMDD 8
Multiple versionsMC018 Admission Date Inpatient Admit Date Date CCYYMMDD 8
Multiple versionsMC019 Admission Hour Admission Time Integer HHMM 4
Multiple versionsMC020 Admission Type Admission Type Code Integer External Code Source 10 1
Multiple versionsMC021 Admission Source Admission Source Code Text External Code Source 10 1
Multiple versionsMC022 Discharge Hour Discharge Time Integer HHMM
Multiple versionsMC023 Discharge Status Inpatient Discharge Status Code Integer External Code Source 10 2
Multiple versionsMC024 Service Provider Number Service Provider Identification Number Text 30
Multiple versionsMC025 Service Provider Tax ID Number Service Provider's Tax ID number Text ######### 10
Multiple versionsMC026 National Service Provider ID National Provider Identification (NPI) of the Service Provider Text External Code Source 4 20
Multiple versionsMC027 Service Provider Entity Type Qualifier Service Provider Entity Identifier Code Integer tlkpServProvEntityTypeQualifier 1
Multiple versionsMC028 Service Provider First Name First name of Service Provider Text Free Text Name 25
Multiple versionsMC029 Service Provider Middle Name Middle initial of Service Provider Text Free Text Name 25
Multiple versionsMC030 Servicing Provider Last Name or Organization Name Last name or Organization Name of Service Provider Text Free Text Name 60
Multiple versionsMC031 Service Provider Suffix Provider Name Suffix Text tlkpLastNameSuffix 10
Multiple versionsMC032 Service Provider Specialty Specialty Code Text External Code Source 13 - AND/OR - Carrier Defined Reference Table 50
Multiple versionsMC033 Service Provider City Name City Name of the Provider Text Free Text Address 30
Multiple versionsMC034 Service Provider State State of the Service Provider Text External Code Source 2 2
Multiple versionsMC035 Service Provider ZIP Code Zip Code of the Service Provider Text External Code Source 3 11
Multiple versionsMC036 Type of Bill - on Facility Claims Type of Bills as used on Institutional Claims Integer External Code Source 10 2
Multiple versionsMC037 Site of Service - on NSF/CMS 1500 Claims Place of Service Code as used on Professional Claims Text External Code Source 9 2
Multiple versionsMC038 Claim Status Claim Line Status Integer tlkpClaimStatus 2
Multiple versionsMC039 Admitting Diagnosis Admitting Diagnosis Code Text External Code Source 5 7
Multiple versionsMC040 E-Code ICD Diagnostic External Injury Code Text External Code Source 5 7
Multiple versionsMC041 Principal Diagnosis ICD Primary Diagnosis Code Text External Code Source 5 7
Multiple versionsMC042 Other Diagnosis - 1 ICD Secondary Diagnosis Code Text External Code Source 5 7
Multiple versionsMC043 Other Diagnosis - 2 ICD Other Diagnosis Code Text External Code Source 5 7
Multiple versionsMC044 Other Diagnosis - 3 ICD Other Diagnosis Code Text External Code Source 5 7
Multiple versionsMC045 Other Diagnosis - 4 ICD Other Diagnosis Code Text External Code Source 5 7
Multiple versionsMC046 Other Diagnosis - 5 ICD Other Diagnosis Code Text External Code Source 5 7
Multiple versionsMC047 Other Diagnosis - 6 ICD Other Diagnosis Code Text External Code Source 5 7
Multiple versionsMC048 Other Diagnosis - 7 ICD Other Diagnosis Code Text External Code Source 5 7
Multiple versionsMC049 Other Diagnosis - 8 ICD Other Diagnosis Code Text External Code Source 5 7
Multiple versionsMC050 Other Diagnosis - 9 ICD Other Diagnosis Code Text External Code Source 5 7
Multiple versionsMC051 Other Diagnosis - 10 ICD Other Diagnosis Code Text External Code Source 5 7
Multiple versionsMC052 Other Diagnosis - 11 ICD Other Diagnosis Code Text External Code Source 5 7
Multiple versionsMC053 Other Diagnosis - 12 ICD Other Diagnosis Code Text External Code Source 5 7
Multiple versionsMC054 Revenue Code Revenue Code as defined for use on an Institutional Claim Text External Code Source 10 10
Multiple versionsMC055 Procedure Code HCPCS / CPT Code Text External Code Source 7 10
Multiple versionsMC056 Procedure Modifier - 1 HCPCS / CPT Code Modifier Text External Code Source 7 2
Multiple versionsMC057 Procedure Modifier - 2 HCPCS / CPT Code Modifier Text External Code Source 7 2
Multiple versionsMC058 ICD9-CM Procedure Code ICD Primary Procedure Code Text External Code Source 5 6
Multiple versionsMC059 Date of Service - From Date of Service Date CCYYMMDD 8
Multiple versionsMC060 Date of Service - To Date of Service Date CCYYMMDD 8
Multiple versionsMC061 Quantity Claim line units of service Integer ####### 15
Multiple versionsMC062 Charge Amount Amount of provider charges for the claim line Integer DDDDCC 10
Multiple versionsMC063 Paid Amount Amount paid by the carrier for the claim line Integer DDDDCC 10
Multiple versionsMC064 Prepaid Amount Amount carrier has prepaid towards claim line Integer DDDDCC 10
Multiple versionsMC065 Copay Amount Amount of Copay member/patient is responsible to pay Integer DDDDCC 10
Multiple versionsMC066 Coinsurance Amount Amount of coinsurance member/patient is responsible to pay Integer DDDDCC 10
Multiple versionsMC067 Deductible Amount Amount of deductible member/patient is responsible to pay on the claim line Integer DDDDCC 10
Multiple versionsMC068 Patient Control Number Patient Control Number Text Free Text Control Number 20
Multiple versionsMC069 Discharge Date Discharge Date Date CCYYMMDD 8
Multiple versionsMC070 Service Provider Country Code Country name of the Provider Text External Code Source 1 3
Multiple versionsMC071 DRG Diagnostic Related Group (DRG) Code Text External Code Source 11 10
Multiple versionsMC072 DRG Version Diagnostic Related Group (DRG) Code Version Number Text External Code Source 11 2
Multiple versionsMC073 APC Ambulatory Payment Classification (APC) Number Text External Code Source 16 4
Multiple versionsMC074 APC Version Ambulatory Payment Classification (APC) Version Text External Code Source 16 2
Multiple versionsMC075 Drug Code National Drug Code (NDC) Text 5-4-2 standard. Do not include hyphens 11
Multiple versionsMC076 Billing Provider Number Billing Provider Number Text 30
Multiple versionsMC077 National Billing Provider ID National Provider Identification (NPI) of the Billing Provider Text External Code Source 4 20
Multiple versionsMC078 Billing Provider Last Name or Organization Name Last name or Organization Name of Billing Provider Text Free Text Name 60
Multiple versionsMC079 Product ID Number Product Identification Number Text ID PR001 20
Multiple versionsMC080 Reason for Adjustment Reason for Adjustment Code Text External Code Source 14 4
Multiple versionsMC081 Capitated Encounter Flag Indicates if the service is covered under a capitation arrangement. Integer tlkpFlagIndicators 1
Multiple versionsMC082 Member Street Address Street address of the Member/Patient Text Free Text Address 50
Multiple versionsMC083 Other ICD-9-CM Procedure Code - 1 ICD Secondary Procedure Code Text External Code Source 5 6
Multiple versionsMC084 Other ICD-9-CM Procedure Code - 2 ICD Other Procedure Code Text External Code Source 5 6
Multiple versionsMC085 Other ICD-9-CM Procedure Code - 3 ICD Other Procedure Code Text External Code Source 5 6
Multiple versionsMC086 Other ICD-9-CM Procedure Code - 4 ICD Other Procedure Code Text External Code Source 5 6
Multiple versionsMC087 Other ICD-9-CM Procedure Code - 5 ICD Other Procedure Code Text External Code Source 5 6
Multiple versionsMC088 Other ICD-9-CM Procedure Code - 6 ICD Other Procedure Code Text External Code Source 5 6
Multiple versionsMC089 Paid Date Paid date of the claim line Date CCYYMMDD 8
Multiple versionsMC090 LOINC Code Logical Observation Identifiers, Names and Codes (LOINC) Code Text 7
Multiple versionsMC091 Filler The APCD will reserve this field for possible future use. Please fill with null values in the format described. Filler Filler 20
Multiple versionsMC092 Covered Days Covered Inpatient Days Integer ### 3
Multiple versionsMC093 Non Covered Days Noncovered Inpatient Days Integer ### 3
Multiple versionsMC094 Type of Claim Type of Claim Indicator Text tlkpTypeOfClaim 3
Multiple versionsMC095 Coordination of Benefits/TPL Liability Amount Amount due from a Secondary Carrier when known Integer DDDDCC 10
Multiple versionsMC096 Other Insurance Paid Amount Amount paid by a Primary Carrier Integer DDDDCC 10
Multiple versionsMC097 Medicare Paid Amount Amount Medicare paid on claim Integer DDDDCC 10
Multiple versionsMC098 Allowed amount Allowed Amount Integer DDDDCC 10
Multiple versionsMC099 Non-Covered Amount Amount of claim line charge not covered Integer DDDDCC 10
Multiple versionsMC100 Delegated Benefit Administrator Organization ID DHCFP assigned Org ID for Benefit Administrator Integer ########## 10
Multiple versionsMC101 Subscriber Last Name Last name of Subscriber Text Free Text Name 60
Multiple versionsMC102 Subscriber First Name First name of the Subscriber Text Free Text Name 25
Multiple versionsMC103 Subscriber Middle Initial Middle initial of Subscriber Text Free Text Name 1
Multiple versionsMC104 Member Last Name Last name of Member/Patient Text Free Text Name 60
Multiple versionsMC105 Member First Name First name of Member/Patient Text Free Text Name 25
Multiple versionsMC106 Member Middle Initial Middle initial of Member/Patient Text Free Text Name 1
Multiple versionsMC107 Filler The APCD will reserve this field for possible future use. Please fill with null values in the format described. Filler Filler 5
Multiple versionsMC108 Procedure Modifier - 3 HCPCS / CPT Code Modifier Text External Code Source 7 2
Multiple versionsMC109 Procedure Modifier - 4 HCPCS / CPT Code Modifier Text External Code Source 7 2
Multiple versionsMC110 Claim Processed Date Claim Processed Date Date CCYYMMDD 8
Multiple versionsMC111 Diagnostic Pointer Diagnostic Pointer Number Text # 1
Multiple versionsMC112 Referring Provider ID Referring Provider Number Text 28
Multiple versionsMC113 Payment Arrangement Type Payment Arrangement Code Text tlkpPaymentArrangementType 2
Multiple versionsMC114 Excluded Expenses Amount not covered at the claim line due to benefit/plan limitation Integer DDDDCC 10
Multiple versionsMC115 Medicare Indicator Medicare Payment Indicator Text tlkpFlagIndicators 1
Multiple versionsMC116 Withhold Amount Amount to be paid to the provider upon guarantee of performance Integer DDDDCC 10
Multiple versionsMC117 Authorization Needed Indicates if the service required a pre-authorization number for payment. Integer tlkpFlagIndicators 1
Multiple versionsMC118 Referral Indicator Referral Required Indicator Text tlkpFlagIndicators 1
Multiple versionsMC119 PCP Indicator PCP Service Performance Indicator Text tlkpFlagIndicators 1
Multiple versionsMC120 DRG Level Diagnostic Related Group (DRG) Code Level Text External Code Source 11 3
Multiple versionsMC121 Filler The APCD will reserve this field for possible future use. Please fill with null values in the format described. Filler Filler 5
Multiple versionsMC122 Global Payment Flag Global Payment Method Indicator Text tlkpFlagIndicators 1
Multiple versionsMC123 Denied Flag Denied Claim Line Indicator Text tlkpFlagIndicators 1
Multiple versionsMC124 Denial Reason Denial Reason Code Text Carrier Defined Reference Table 10
Multiple versionsMC125 Attending Provider Attending Provider ID number found in the Provider File (PV002). This number is defined in the carrier's systems and may be equal to any other identifier, i.e., NPI, State License Number Text 28
Multiple versionsMC126 Accident Indicator Service is related to an accident Text tlkpFlagIndicators 1
Multiple versionsMC127 Family Planning Indicator Service is related to Family Planning Text tlklpFamilyPlanning 1
Multiple versionsMC128 Employment Related Indicator Service related to Employment Injury Text tlkpFlagIndicators 1
Multiple versionsMC129 EPSDT Indicator Service related to Early Periodic Screening, Diagnosis and Treatment (EPSDT) Text tlkpEPSDTIndicator 1
Multiple versionsMC130 Procedure Code Type Claim line Procedure Code Type Identifier Text tlkpProcedureCodeType 1
Multiple versionsMC131 InNetwork Indicator Network rates applied identifier Text tlkpFlagIndicators 1
Multiple versionsMC132 Service Class Service Class Code Text Carrier Defined Reference Table 2
Multiple versionsMC133 Filler The APCD will reserve this field for possible future use. Please fill with null values in the format described. Filler Filler 2
Multiple versionsMC134 Plan Rendering Provider Identifier Plan Rendering Number Text 28
Multiple versionsMC135 Provider Location Location of Provider Text 28
Multiple versionsMC136 Discharge Diagnosis ICD Discharge Diagnosis Code Text External Code Source 5 7
Multiple versionsMC137 CarrierSpecificUniqueMemberID Member/Patient Carrier Unique Identification Text 20
Multiple versionsMC138 Claim Line Type Claim Line Activity Type Code Text tlkpClaimLineType 10
Multiple versionsMC139 Former Claim Number Previous Claim Number Text ID 35
Multiple versionsMC140 Member Address 2 Secondary Street Address of the Member/Patient Text Free Text Address 50
Multiple versionsMC141 CarrierSpecificUniqueSubscriberID Subscriber Carrier Unique Identification Text 20
Multiple versionsMC899 Record Type File Type Identifier Text MC 2
Multiple versionsTR001 Record Type Trailer Record Identifier Text TR 2
Multiple versionsTR002 Payer Carrier Specific Submitter Code as defined by APCD. This must match the Submitter Code reported in HD002 Text 8
Multiple versionsTR003 National Plan ID CMS National Plan Identification Number (PlanID) Text 30
Multiple versionsTR004 Type of File This is an indicator that defines the type of file and the data contained within the file. This must match the File Type reported in HD004. Text MC 2
Multiple versionsTR005 Period Beginning Date Trailer Period Start Date Date Period CCYYMM 6
Multiple versionsTR006 Period Ending Date Trailer Period Ending Date Date Period CCYYMM 6
Multiple versionsTR007 Date Processed Trailer Processed Date Date CCYYMMDD 8

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Data Element ID Data Element Code Value
HD001 Record Type HD
HD004 Type of File MC
MC003 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
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
TV Title V
VA Veterans Administration Plan
WC Workers' Compensation
MC011 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
MC012 Member Gender F Female
M Male
O Other
U Unknown
MC027 Service Provider Entity Type Qualifier 1 Person
2 Non-person entity
MC031 Service Provider Suffix 0 Unknown / Not Applicable
1 I.
2 II.
3 III.
4 Jr.
5 Sr.
MC038 Claim Status 01 Processed as primary
02 Processed as secondary
03 Processed as tertiary
04 Denied
19 Processed as primary, forwarded to additional payer(s)
20 Processed as secondary, forwarded to additional payer(s)
21 Processed as tertiary, forwarded to additional payer(s)
22 Reversal of previous payment
MC081 Capitated Encounter Flag 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
MC094 Type of Claim 001 Professional
002 Hospital
003 Reimbursement Form
MC113 Payment Arrangement Type 01 Capitation
02 Fee for Service
03 Percent of Charges
04 DRG
05 Pay for Performance
06 Global Payment
07 Other
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 0 Unknown / Not Applicable / Not Avail
1 Family planning services provided
2 Abortion services provided
3 Sterilization services provided
4 No family planning services provided
MC128 Employment Related Indicator 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
MC129 EPSDT Indicator 0 Unknown / Not Applicable / Not Avail
1 EPSDT Screen
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
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
MC899 Record Type MC
TR001 Record Type TR
TR004 Type of File MC
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