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Medical Claims File Submission

Pennsylvania



Name:Medical Claims File Submission
State:Pennsylvania
Definition:Not provided
VersionJune 2011

File Specification for Medical Claims File Submission

Data Element ID Data Element Description Type Format Length
1 Payer Payer submitting payments. Alphanumeric 128
2 National Plan ID CMS National Plan Identification Number Alphanumeric 30
3 Insurance Type/Product Code Not Provided Alphanumeric 2
4 Payer Claim Control Number Payer Claim Control Identification. A unique identifier within the payer's system that applies to the entire claim. Alphanumeric 35
5 Line Counter Line number for this service Numeric 4
5a Version Number The version number of this claim service line. Numeric 4
6 Insured Group or Policy Number Group or policy number, not the number that uniquely identifies the subscriber. Alphanumeric 30
7 Subscriber Social Security Number Subscriber's Social Security Number Numeric 9
8 Plan Specific Contract Number Plan-assigned contract number Alphanumeric 30
9 Member Suffix or Sequence Number Uniquely numbers the member within the contract. Numeric 20
10 Member Identification Code Patient's/Member's Social Security Number. Numeric 9
11 Individual Relationship Code Patient's/Member's relationship to insured. Numeric 2
12 Member Gender Patient/Member Gender Alphanumeric 1
13 Member Date of Birth Not Provided Numeric MMDDCCYY 8
14 Member City Name City name associated with member Alphanumeric 30
15 Member State As defined by the US Postal Service Alphanumeric 2
16 Member ZIP Code Zip code of member Numeric 9
17 Date Service Approved/Accounts Payable Date/Actual Paid Date Date Service Approved. Numeric MMDDCCYY 8
18 Admission Date Required for all inpatient claims. Numeric MMDDCCYY 8
19 Admission Hour Required for all inpatient claims. Numeric HHMM 4
20 Admission Type Required for all inpatient claims Numeric 1
21 Admission Source Required for all inpatient claims. The point of patient origin for admission or visit. Alphanumeric 1
22 Discharge Hour Required for all inpatient claims. Numeric HHMM 4
23 Discharge Status Required for all inpatient claims Numeric 2
24 Service Provider Number As assigned by payer. To capture the provider that rendered the service. Alphanumeric 30
25 Service Provider Tax ID Number Federal taxpayer's identification number Alphanumeric 10
26 National Service Provider ID National Provider ID. This data element pertains to the entity or individual directly providing the service. Alphanumeric 20
27 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 Alphanumeric 1
28 Service Provider First Name Individual first name. Alphanumeric 25
29 Service Provider Middle Name Individual middle name or initial. Alphanumeric 25
30 Service Provider Last Name or Organization Name Full name of provider organization or last name of individual provider. Alphanumeric 60
31 Service Provider Suffix Suffix to individual name. 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). Alphanumeric 10
32 Service Provider Specialty As defined by payer. Alphanumeric 10
33 Service Provider City Name City name of provider, preferably practice location. Alphanumeric 30
34 Service Provider State or Province As defined by US Postal Service Alphanumeric 2
35 Service Provider ZIP Code ZIP code of provider Numeric 9
36 Type of Bill - Institutional Required for institutional claims. Numeric 2
37 Facility Type - Professional Required for professional claims. Alphanumeric 2
38 Claim Status Describes the payment status of the specific service line record. Numeric 2
39 Admitting Diagnosis Required on all inpatient admission claims. Alphanumeric 7
40 E-Code Describes an injury, poisoning or adverse effect. Alphanumeric 7
41 Principal Diagnosis Not Provided Alphanumeric 7
42 Other Diagnosis - 1 Not Provided Alphanumeric 7
43 Other Diagnosis - 2 Not Provided Alphanumeric 7
44 Other Diagnosis - 3 Not Provided Alphanumeric 7
45 Other Diagnosis - 4 Not Provided Alphanumeric 7
46 Other Diagnosis - 5 Not Provided Alphanumeric 7
47 Other Diagnosis - 6 Not Provided Alphanumeric 7
48 Other Diagnosis - 7 Not Provided Alphanumeric 7
49 Other Diagnosis - 8 Not Provided Alphanumeric 7
50 Other Diagnosis - 9 Not Provided Alphanumeric 7
51 Other Diagnosis - 10 Not Provided Alphanumeric 7
52 Other Diagnosis - 11 Not Provided Alphanumeric 7
53 Other Diagnosis - 12 Not Provided Alphanumeric 7
54 Revenue Code Not Provided Numeric 10
55 Procedure Code Not Provided Alphanumeric 10
56 Procedure Modifier - 1 Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code. Alphanumeric 2
57 Procedure Modifier - 2 Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code. Alphanumeric 2
58 ICD-9-CM Procedure Code Primary procedure code for this line of service. Alphanumeric 7
59 Date of Service - From First date of service for this service line. Numeric MMDDCCYY 8
60 Date of Service - Thru Last date of service for this service line. Numeric MMDDCCYY 8
61 Quantity Count of services/units performed. Numeric 3
62 Charge Amount Not Provided Numeric DDDDCC 10
63 Paid Amount Not Provided Numeric DDDDCC 10
64 Prepaid Amount For capitated services, the fee-for-service equivalent amount. Numeric DDDDCC 10
65 Co-pay Amount The preset, fixed-dollar amount for which the individual is responsible. Numeric DDDDCC 10
66 Coinsurance Amount The specific dollar amount for which the individual is responsible on a percentage basis. Numeric DDDDCC 10
67 Deductible Amount Not Provided Numeric DDDDCC 10
68 Patient Account/Control Number Number assigned by hospital/provider Alphanumeric 24
69 Discharge Date Date patient was discharged. Numeric MMDDCCYY 8
70 Service Provider Country Name Not Provided Alphanumeric 30
71 DRG Not Provided Alphanumeric 10
72 DRG Version Version number of the grouper used. Numeric 2
73 APC Not Provided Alphanumeric 4
74 APC Version Version number of the grouper used. Alphanumeric 2
75 Drug Code An NDC code used only when a medication is paid for as part of a medical claim. Alphanumeric 11
76 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. Alphanumeric 30
77 National Billing Provider ID National Provider ID Alphanumeric 20
78 Billing Provider Last Name or Organization Name Full name of provider billing organization or last name of individual billing provider. Alphanumeric 60
79 Subscriber Last Name Not Provided Alphanumeric 128
80 Subscriber First Name Not Provided Alphanumeric 128
81 Subscriber Middle Initial Not Provided Alphanumeric 1
82 Member Last Name Not Provided Alphanumeric 128
83 Member First Name Not Provided Alphanumeric 128
84 Member Middle Initial Not Provided Alphanumeric 1
85 Capitated Services Indicator Indicates whether payment for this service or care is covered under a capitated arrangement. Numeric 1
86 Record Type Indicates the type of record being submitted, in this case, Medical Claims. Alphanumeric 2

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Data Element ID Data Element Code Value
3 Insurance Type/Product Code 12 Preferred Provider Organization (PPO)
13 Point of Service (POS)
14 Exclusive Provider Organization (EPO)
15 Indemnity Insurance
16 Health Maintenance Organization (HMO) Medicare Advantage
DS Disability
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
OF Other Federal Program (e.g. Black Lung)
PR Preferred Provider Organization (PPO)
PS Point of Service
QM Qualified Medicare Beneficiary
SP Supplemental Policy
TV Title V
VA Veteran Administration Plan
WC Workers' Compensation
XX non-medical assistance public program
11 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
34 Other Adult
43 Child Where Insured Has No Financial Responsibility
53 Life Partner
76 Dependent
12 Member Gender F Female
M Male
U Unknown
20 Admission Type 1 Emergency
2 Urgent
3 Elective
4 Newborn
5 Trauma Center
9 Information not available
23 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
27 Service Provider Entity Type Qualifier 1 Person
2 Non-Person Entity
36 Type of Bill - Institutional 11 Hospital Inpatient (Including Medicare Part A)
12 Hospital Inpatient (Medicare Part B Only)
13 Hospital Outpatient
14 Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
15 Hospital Nursing Facility Level I
16 Hospital Nursing Facility Level II
17 Hospital Intermediate Care - Level III Nursing Facility
18 Hospital Swing Beds
21 Skilled Nursing Inpatient (Including Medicare Part A)
22 Skilled Nursing Inpatient (Medicare Part B Only)
23 Skilled Nursing Outpatient
24 Skilled Nursing Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
25 Skilled Nursing Nursing Facility Level I
26 Skilled Nursing Nursing Facility Level II
27 Skilled Nursing Intermediate Care - Level III Nursing Facility
28 Skilled Nursing Swing Beds
31 Home Health Inpatient (Including Medicare Part A)
32 Home Health Inpatient (Medicare Part B Only)
33 Home Health Outpatient
34 Home Health Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
35 Home Health Nursing Facility Level I
36 Home Health Nursing Facility Level II
37 Home Health Intermediate Care - Level III Nursing Facility
38 Home Health Swing Beds
41 Christian Science Hospital Inpatient (Including Medicare Part A)
42 Christian Science Hospital Inpatient (Medicare Part B Only)
43 Christian Science Hospital Outpatient
44 Christian Science Hospital Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
45 Christian Science Hospital Nursing Facility Level I
46 Christian Science Hospital Nursing Facility Level II
47 Christian Science Hospital Intermediate Care - Level III Nursing Facility
48 Christian Science Hospital Swing Beds
51 Christian Science Extended Care Inpatient (Including Medicare Part A)
52 Christian Science Extended Care Inpatient (Medicare Part B Only)
53 Christian Science Extended Care Outpatient
54 Christian Science Extended Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
55 Christian Science Extended Care Nursing Facility Level I
56 Christian Science Extended Care Nursing Facility Level II
57 Christian Science Extended Care Intermediate Care - Level III Nursing Facility
58 Christian Science Extended Care Swing Beds
61 Intermediate Care Inpatient (Including Medicare Part A)
62 Intermediate Care Inpatient (Medicare Part B Only)
63 Intermediate Care Outpatient
64 Intermediate Care Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
65 Intermediate Care Nursing Facility Level I
66 Intermediate Care Nursing Facility Level II
67 Intermediate Care Intermediate Care - Level III Nursing Facility
68 Intermediate Care Swing Beds
71 Clinic Rural Health
72 Clinic Hospital Based or Independent Renal Dialysis Center
73 Clinic Free Standing Outpatient Rehabilitation Facility (ORF)
75 Clinic Comprehensive Outpatient Rehabilitation Facilities (CORFs)
76 Clinic Community Mental Health Center
79 Clinic Other
81 Special Facility Hospice (Non-Hospital Based)
82 Special Facility Hospice (Hospital-Based)
83 Special Facility Ambulatory Surgery Center
84 Special Facility Free Standing Birthing Center
89 Special Facility Other
37 Facility Type - Professional 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
38 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
85 Capitated Services Indicator 1 Yes, service is covered under capitated arrangement
2 No
86 Record Type MC
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