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Medical File Submission

Tennessee

Versions: Medical Claims File Submission• Medical File SubmissionCompare Versions


Name:Medical File Submission
State:Tennessee
Definition:Not Provided
VersionJanuary 31, 2014 - v1.0

File Specification for Medical File Submission

Data Element ID Data Element Description Type Format Length
ADJ_TYP_CD Adjustment Type Code Client-specific code for the type of adjustment for the claim. The corresponding Medstat Advantage Suite standard field is Adjustment Type Code Medstat. Char 1
ADMDX_POA Admitting Diagnosis Present on Admission Indicator The Diagnosis Present on Admission Indicator is is tied to a specific diagnosis and indicates that the condition identified by the related diagnosis was present at the time of admission. Char 1
ADMIT_DATE Admission Date This field contains the date of the inpatient admission as reported by the payer. In ASCII-formatted extracts, this field is presented in a CCYYMMDD format. Date CCYYMMDD 8
ADMIT_DX Admitting Diagnosis This payer-supplied field contains the ICD-9 diagnosis code indicating the reason for the inpatient admission. Char 8
ADMIT_HOUR Admission Hour This payer-supplied field indicates the hour and minutes, using military-time format, of the inpatient's admission to the hospital. Valid codes are 0000 - 2359. Numeric 4
ADMIT_SOURCE Admission Source This payer-supplied field records the source of admission for all inpatient hospital bills. Char 2
ADMIT_TYPE Admission Type This payer-supplied field records the type of admission for all inpatient hospital bills. Numeric 5
APC APC Submitted by Payer This field contains the APC submitted by the payer for this claim. The CMS methodology is preferred for grouping. Text 5
APC_VERSION Version of APC Grouper Used This payer-supplied field contains the version number of the grouper used to assign the APC. Text 2
BILL_TYPE Type of Bill - Institutional This payer-supplied field, which is required for institutional claims and is not to be used for professional claims, contains the Type of Bill code as reported per the National Uniform Billing Committee's official UB-04 specifications manual. Text 4
BILLING_PRVIDN Billing Provider Number This field contains the Billing Provider ID Number. Numeric 20
CHARGE Charge Amount This field contains the total charges for the service as reported by the payer. This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
CLAIM Payer Claim Control Number This field contains the Payer Claim Control Number used by the payer to internally track the claim. In general, the claim number is associated with all service lines of the bill. Multiple medical records therefore may share the same claim number. This number must apply to the entire claim and be unique within the payer's system. Text 35
CLAIM_STATUS Claim Status This field contains the status of the claim as reported by the payer. Numeric 2
CLAIM_TYPE Claim Type This is a value-added field that sorts medical claims into type-of-setting or type-of-provider buckets. Numeric 2
COINSURANCE Coinsurance Amount This payer-supplied field contains the dollar amount that a member must pay toward the cost of a covered service (often stipulated as a cost-sharing ratio). In many health insurance plans, the member's coinsurance responsibility is capped after a certain dollar amount of eligible expenses has been incurred. Not all carriers can distinguish between the mutually exclusive fields of Copay Amount (COPAY) and Coinsurance Amount. To determine the total out-of-pocket/member responsibility for this service, you must sum these two fields with the Deductible Amount (DEDUCTIBLE). This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
COPAY Copay Amount This payer-supplied field contains the preset, fixed dollar amount payable by a member, often on a per-visit/-service basis. Not all carriers can distinguish between the mutually exclusive fields of Copay Amount and Coinsurance Amount (COINSURANCE). To determine the total out-of-pocket/member responsibility for this service, you must sum these two fields with the Deductible Amount (DEDUCTIBLE). This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
CPT CPT Procedure Code This payer-supplied field contains the HCPCS or CPT code for the performed procedure. Char 10
CPT_MOD1 Procedure Modifier 1 This payer-supplied field identifies a CPT procedure modifier, which is used to indicate that a service or procedure has been altered by some specific circumstance but has not changed in its definition or code. Modifiers may be used to indicate that a service or procedure has both a professional and a technical component, that only part of a service was performed, that a bilateral procedure was performed, or that a service or procedure was provided more than once. A procedure modifier is required when a modifier clarifies or improves the reporting accuracy of the associated procedure code. Char 2
CPT_MOD2 Procedure Modifier 2 This payer-supplied field identifies a CPT procedure modifier, which is used to indicate that a service or procedure has been altered by some specific circumstance but has not changed in its definition or code. Modifiers may be used to indicate that a service or procedure has both a professional and a technical component, that only part of a service was performed, that a bilateral procedure was performed, or that a service or procedure was provided more than once. A procedure modifier is required when a modifier clarifies or improves the reporting accuracy of the associated procedure code. Char 2
DEDUCTIBLE Deductible Amount This payer-supplied field contains the dollar amount that a member must pay before health plan benefits will begin to reimburse for services. It is usually an annual amount of all healthcare costs that are not covered by the member's insurance plan. To determine the total out-of-pocket/member responsibility for this service, you must sum this field with both Copay Amount (COPAY) and Coinsurance Amount (COINSURANCE). This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
DISCH_HOUR Discharge Hour This payer-supplied field indicates the hour, using military-time format, of the inpatient's discharge from the hospital. Valid codes are 00 - 23. Numeric 4
DISCH_STATUS Discharge Status This field is required for inpatient hospital admissions. It records the status for the patient discharged from the hospital. This field contains the patient discharge status code as reported by the payer. This field is inconsistently reported across data reporters. It may be underreported on inpatient records and sometimes reported on outpatient records. Numeric 2
DRG DRG Submitted by Payer This field contains the DRG submitted by the payer for this claim. When the preferred CMS methodology is used for grouping, this field contains only the DRG. When the All Payer DRG system is used, this field contains three components and uses the format of ADRG-X, where a constant of A is the prefix, followed by the three-digit DRG, followed by a dash and then the severity level (indicated here by X). Text 10
DRG_VERSION Version of DRG Grouper Used This payer-supplied field contains the version number of the grouper used to assign the DRG. Text 2
DX1 Principal Diagnosis This payer-supplied field contains the ICD-9 diagnosis code for the principal diagnosis. Char 8
DX1_POA Primary Diagnosis Present on Admission Indicator The Diagnosis Present on Admission Indicator is is tied to a specific diagnosis and indicates that the condition identified by the related diagnosis was present at the time of admission. Char 1
DX10 Other Diagnosis 9 This payer-supplied field contains the ICD-9 diagnosis code for the ninth secondary diagnosis. Char 8
DX11 Other Diagnosis 10 This payer-supplied field contains the ICD-9 diagnosis code for the tenth secondary diagnosis. Char 8
DX12 Other Diagnosis 11 This payer-supplied field contains the ICD-9 diagnosis code for the eleventh secondary diagnosis. Char 8
DX13 Other Diagnosis 12 This payer-supplied field contains the ICD-9 diagnosis code for the twelth secondary diagnosis. Char 8
DX2 Other Diagnosis 1 This payer-supplied field contains the ICD-9 diagnosis code for the first secondary diagnosis. Char 8
DX2_POA Other Diagnosis 1 Present on Admission Indicator The Diagnosis Present on Admission Indicator is is tied to a specific diagnosis and indicates that the condition identified by the related diagnosis was present at the time of admission. Char 1
DX3 Other Diagnosis 2 This payer-supplied field contains the ICD-9 diagnosis code for the second secondary diagnosis. Char 8
DX3_POA Other Diagnosis 2 Present on Admission Indicator The Diagnosis Present on Admission Indicator is is tied to a specific diagnosis and indicates that the condition identified by the related diagnosis was present at the time of admission. Char 1
DX4 Other Diagnosis 3 This payer-supplied field contains the ICD-9 diagnosis code for the third secondary diagnosis. Char 8
DX4_POA Other Diagnosis 3 Present on Admission Indicator The Diagnosis Present on Admission Indicator is is tied to a specific diagnosis and indicates that the condition identified by the related diagnosis was present at the time of admission. Char 1
DX5 Other Diagnosis 4 This payer-supplied field contains the ICD-9 diagnosis code for the fourth secondary diagnosis. Char 8
DX5_POA Other Diagnosis 4 Present on Admission Indicator The Diagnosis Present on Admission Indicator is is tied to a specific diagnosis and indicates that the condition identified by the related diagnosis was present at the time of admission. Char 1
DX6 Other Diagnosis 5 This payer-supplied field contains the ICD-9 diagnosis code for the fifth secondary diagnosis. Char 8
DX6_POA Other Diagnosis 5 Present on Admission Indicator The Diagnosis Present on Admission Indicator is is tied to a specific diagnosis and indicates that the condition identified by the related diagnosis was present at the time of admission. Char 1
DX7 Other Diagnosis 6 This payer-supplied field contains the ICD-9 diagnosis code for the sixth secondary diagnosis. Char 8
DX7_POA Other Diagnosis 6 Present on Admission Indicator The Diagnosis Present on Admission Indicator is is tied to a specific diagnosis and indicates that the condition identified by the related diagnosis was present at the time of admission. Char 1
DX8 Other Diagnosis 7 This payer-supplied field contains the ICD-9 diagnosis code for the seventh secondary diagnosis. Char 8
DX9 Other Diagnosis 8 This payer-supplied field contains the ICD-9 diagnosis code for the eigth secondary diagnosis. Char 8
ECODE_DX E-Code This payer-supplied field describes an injury, poisoning, or adverse effect using an ICD-9 E-Code diagnosis. Users should search the Other Diagnosis fields to identify all submitted E-Codes. Note that the same E-Code may be reported in this field and in an Other Diagnosis field, depending upon the data reporter. Char 8
ER_FLAG ER Flag This field is used to identify specific emergency room (ER) REV or procedure codes within a claim. This field is assigned as a value-added field and is set only on the specific claim line where an ER REV or procedure code was found. Char 1
FIRST_SVC_DATE Date of Service - From This payer-supplied field contains the first date of service for this service line. In ASCII-formatted extracts, this field is presented in a CCYYMMDD format. Date CCYYMMDD 8
ICD9_OP ICD-9-CM Procedure Code This field contains an ICD-9 procedure code, which is generally available on inpatient claims. The decimal point is not coded. It is not consistently reported by data reporters. Char 8
ICD9_OP1 ICD-9-CM Procedure Code This field contains an ICD-9 procedure code, which is generally available on inpatient claims. The decimal point is not coded. It is not consistently reported by data reporters. Char 8
ICD9_OP2 ICD-9-CM Procedure Code This field contains an ICD-9 procedure code, which is generally available on inpatient claims. The decimal point is not coded. It is not consistently reported by data reporters. Char 8
ICD9_OP3 ICD-9-CM Procedure Code This field contains an ICD-9 procedure code, which is generally available on inpatient claims. The decimal point is not coded. It is not consistently reported by data reporters. Char 8
ICD9_OP4 ICD-9-CM Procedure Code This field contains an ICD-9 procedure code, which is generally available on inpatient claims. The decimal point is not coded. It is not consistently reported by data reporters. Char 8
ICD9_OP5 ICD-9-CM Procedure Code This field contains an ICD-9 procedure code, which is generally available on inpatient claims. The decimal point is not coded. It is not consistently reported by data reporters. Char 8
INPATIENT_CATEGORY Inpatient Category Code This value-added field is based on BILL_TYPE and is used to differentiate categories of inpatient lines (e.g., skilled nursing facilities (SNF), swing beds, etc.). Numeric 1
IPDISCHARGE Inpatient Discharge Identifier This field is a value-added element that associates all claim lines for a given inpatient stay under one coded value. Numeric 20
LAST_SVC_DATE Date of Service - Thru This payer-supplied field contains the last date of service for this service line. In ASCII-formatted extracts, this field is presented in a CCYYMMDD format. Date CCYYMMDD 8
LINE Line Counter This field contains the line number for this service as reported by the payer. The Line Counter begins with 1 and is incremented by 1 for each additional service line of a claim. Numeric 6
MEMBERIDN Member ID Number This field generally represents a unique combination of member fields unique to the payer. This field should not be used to aggregate all records associated with a member. Numeric 15
NDC National Drug Code This field contains the National Drug Code for this claim as reported by the payer. Each drug product listed under Section 510 of the Federal Food, Drug, and Cosmetic Act is assigned a unique 10-digit, three-segment number. This number, known as the National Drug Code (NDC), identifies the labeler/vendor, product, and trade package size. The first segment, the labeler/vendor code, is assigned by the FDA. A labeler is any firm that manufactures, repacks, or distributes a drug product. The second segment, the product code, identifies a specific strength, dosage form, and formulation for a particular firm. The third segment, the package code, identifies package sizes. Both the product and package codes are assigned by the firm. The NDC will be in one of the following configurations: 4-4-2, 5-3-2, or 5-4-1. Numeric 11
ORIG_CLM_ID Original Claim ID number This field is used with adjustments. If the claim id number changes to a different number due to an adjustment then this field will be populated with the original claim id number. Text 53
PAID_MEDICAL Paid Amount (Medical Paid Amount) This payer-supplied field contains the total dollar amount paid to the provider, including all health plan payments and excluding withhold amounts and all member payments. This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
PAYERCODE Payer Code This field contains the data reporter code for the payer or data reporter submitting payments. The first two characters indicate the data collection state and the third character indicates the type of data reporter. A single payer may have multiple data reporter codes because the payer is submitting from more than one system or from more than one location. All data reporter codes associated with a single payer will have the same first seven characters. A suffix in the eighth position may be used to distinguish the location and/or system variations. Char 8
PAYER PAYER This field contains the Payer ID Number. This code is used to identify the data reporter. Its source is the Payer element reported by the payer in the medical claims data. Numeric 8
PID_MED Provider ID Medical Claims This field contains the payer-assigned provider number. Its source is the Service Provider Number element reported by the payer in the medical claims data. Text 40
PLAN_NPI National Plan ID This payer-supplied field contains the National Plan ID for the data reporter. This field is not populated. Text 30
PREPAID Prepaid Amount This payer-supplied field contains the fee for service equivalent that would have been paid by the health care claims processor for a specific service if the service had not been capitated. Capitated services are services rendered by a provider through a contract under which payments are based upon a fixed dollar amount for each member on a monthly basis. Note that the provider did not receive this payment. Any payment for this service was made through capitation, which is not captured in this database. This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
PRODUCT Standardized Product Code This field contains the code identifying the member's type of insurance or insurance product. Text 6
QTY Quantity This field contains a count of services performed as reported by the payer. This field may be negative and should be set equal to 1 on all observation bed service lines for this field. This field must be used with caution because the type of units may vary based upon the service performed. For example, one anesthesia unit may equal 10 minutes, while one ambulance transportation unit may equal one mile. Numeric (signed) 14
REV Revenue Code This payer-supplied field contains the revenue code for hospital claims as reported per the National Uniform Billing Committee's official UB-04 specifications manual. Char 4
SVC_PRVIDN Service Provider Number This field contains the service provider ID number. This field cannot be used to aggregate all claims associated with a provider. Numeric 20
PLACE_OF_SERVICE Service Site (Professional) This payer-supplied field, which is required for professional claims and is not be used for institutional claims, records the site where the service was performed. Numeric 2
TYP_OF_SVC Type of Service This field contains the type of service for this claim. Text 2
VERSION_NUM Claim Version This field indicates the claim version number, which is used if the payer adjudicates claims based on a versioning system. Its source is the Version Number element reported by the payer in the medical claims data. See additional documentation on a detailed explanation of versioning. Numeric 4
FILLER FILLER This field is reserved for additional fields that may be added in the future. Char 500

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Data Element ID Data Element Code Value
ADJ_TYP_CD Adjustment Type Code O Original
R Replacement
V Void
ADMIT_SOURCE Admission Source 1 Non-healthcare Facility Point of Origin
2 Clinic Referral
3 Discontinued
4 Transfer From a Hospital (Different Facility)
5 Transfer from a Skilled Nursing Facility or Intermediate Care Facility
5 Born inside this hospital (ADMISSION_TYPE is 4)
6 Transfer from Another Health Care Facility
6 Born outside this hospital (ADMISSION_TYPE is 4)
7 Emergency Room
8 Court/Law Enforcement
9 Information Not Available
A Reserved
B Transfer from Another HHA C:Readmission to Same HHA
D Transfer from One Distinct Unit of the Hospital to Another Distinct Unit of the Same Hospital Resulting in a Separate Claim to the Payer
E Transfer from Ambulatory Surgery Center
F Transfer from Hospice and is Under a Hospice Plan of Care of Enrolled in a Hospice Program
ADMIT_TYPE Admission Type -1 Payer supplied no value
-2 Payer supplied incorrect value
1 Emergency
2 Urgent
3 Elective
4 Newborn
5 Trauma Center
9 Information Not Available
CLAIM_STATUS 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
25 none
CLAIM_TYPE Claim Type 1 Hospital Inpatient
2 Hospital Outpatient
8 Unknown
PAYERCODE Payer Code TNC Commercial data reporter
TNG Governmental payer
TNT Third-party administrator
PRODUCT Standardized Product Code 12 Medicare Secondary Working Aged Beneficiary or Spouse with an Employer's Group Health Plan
13 Medicare Secondary End-Stage Renal Disease Beneficiary in the 12 month Coordination Period with an Employer's Group Health Plan
14 Medicare Secondary, No-fault Insurance Including Auto is Primary
15 Medicare Secondary Workers Compensation
16 Medicare Secondary Public Health Service or Other Federal Agency
41 Medicare Secondary Black Lung
42 Medicare Secondary Veterans Administration
43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health
47 Medicare Secondary, Other Liability Insurance is Primary
ACA Affordable Care Act
CP Medicare Conditionally Primary
D Disability
DB Disability Benefits
EP Exclusive Provider Organization
HM Health Maintenance Organization (HMO)
HN Health Maintenance Organization (HMO) Medicare Risk / Medicare Part C
HS Special Low Income Medicare Beneficiary
IN Indemnity
MA Medicare Part A
MB Medicare Part B
MCTNCR Tennessee Medicaid (TennCare)
MD Medicare Part D
MH Medigap Part A
MI Medigap Part B
MP Medicare Primary
PR Preferred Provider Organization (PPO)
PS Point of Service (POS)
QM Qualified Medicare Beneficiary
SP Supplemental Policy
WC Worker's Compensation
XXTNAC AccessTN
XXTNCV CoverTN
XXTNKD CoverKids
PLACE_OF_SERVICE Service Site (Professional) 00-10 Unassigned
11 Office
12 Home
13-20 Unassigned
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
27-30 Unassigned
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
35-40 Unassigned
41 Ambulance - Land
42 Ambulance - Air or Water
43-49 Unassigned
50 Federally Qualified Health 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
57-59 Unassigned
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
63-64 Unassigned
65 End-Stage Renal Disease Treatment Facility
66-70 Unassigned
71 State or Local Public Health Clinic
72 Rural Health Clinic
73-80 Unassigned
81 Independent Laboratory
82-98 Unassigned
99 Other Unlisted Facility
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