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Professional Services Fixed Format File Submission


Versions: Professional Services Fixed Format File Submission• Professional Services Fixed Format File Submission• Professional Services Fixed Format File SubmissionCompare Versions

Name:Professional Services Fixed Format File Submission
Definition:Not provided
VersionSeptember 13, 2013

File Specification for Professional Services Fixed Format File Submission

Data Element ID Data Element Description Type Format Length
Multiple versions1 Record Identifier The value is 1 numeric 1
Multiple versions2 Patient IdentifierP (payor encrypted) Patient's unique identification number assigned by payor and encrypted. alphanumeric 12
Multiple versions3 Patient IdentifierU (UUID encrypted) Patient's universally unique identification (UUID) number generated using an encryption algorithm provided by MHCC. alphanumeric 12
Multiple versions4 Patient Year and Month of Birth Date of patient's birth using 00 instead of day. numeric CCYYMM00 8
Multiple versions5 Patient Sex Sex of the patient. numeric 1
Multiple versions6 Consumer Directed Health Plan (CDHP) with HSA or HRA Indicator Consumer Directed Health Plan (CDHP) with Health Savings Account (HSA) or Health Resources Account (HRA) numeric 1
Multiple versions7 Patient Zip Code+4digit add-on code Zip code of patient's residence. numeric 10
Multiple versions8 Patient Covered by Other Insurance Indicator Indicates whether patient has additional insurance coverage. numeric 1
Multiple versions9 Coverage Type Patient's type of insurance coverage. alphanumeric 1
Multiple versions10 Source Company Defines the payor company that holds the beneficiary's contract; for use in characterizing contract requirements under Maryland law. numeric 1
Multiple versions11 Claim Related Condition Describes connection, if any, between patient's condition and employment, automobile accident, or other accident. numeric 1
Multiple versions12 Practitioner Federal Tax ID Employer Tax ID of the practitioner, practice or office facility receiving payment for services. alphanumeric 9
Multiple versions13 Participating Provider Status Indicates if the service was provided by a provider that participates in the payor's network. numeric 1
Multiple versions14 Record Status Describes payment and adjustment status of a claim. Adjustments include paying a claim more than once, paying additional services that may have been denied, or crediting a provider due to overpayment or paying the wrong provider. alphanumeric 1
Multiple versions15 Claim Control Number Internal payor claim number used for tracking. alphanumeric 23
Multiple versions16 Claim Paid Date The date a claim was authorized for payment. numeric CCYYMMDD 8
Multiple versions17 Number of Diagnosis Codes The number of diagnosis codes, up to ten. numeric 2
Multiple versions18 Number of Line Items If using Variable Format, the # of line items completed in the variable portion (data elements 20-40, 44-50)must match the value entered for this data element, maximum value for this data and # of line items is 26. If using Fixed Format, the number of line items is always equal to one (1) because only one service is written per row. numeric 2
Multiple versions19 Diagnosis Code 1 The primary ICD-9-CM or ICD-10-CM Diagnosis Code followed by a secondary diagnosis (up to 10 codes), if applicable at time of service. Remove embedded decimal point. alphanumeric 7
Multiple versions20 Diagnosis Code 2 Not Provided alphanumeric 7
Multiple versions21 Diagnosis Code 3 Not Provided alphanumeric 7
Multiple versions22 Diagnosis Code 4 Not Provided alphanumeric 7
Multiple versions23 Diagnosis Code 5 Not Provided alphanumeric 7
Multiple versions24 Diagnosis Code 6 Not Provided alphanumeric 7
Multiple versions25 Diagnosis Code 7 Not Provided alphanumeric 7
Multiple versions26 Diagnosis Code 8 Not Provided alphanumeric 7
Multiple versions27 Diagnosis Code 9 Not Provided alphanumeric 7
Multiple versions28 Diagnosis Code 10 Not Provided alphanumeric 7
Multiple versions29 Service From Date First date of service for a procedure in this line item. numeric CCYYMMDD 8
Multiple versions30 Service Thru Date Last date of service for this line item. numeric CCYYMMDD 8
Multiple versions31 Place of Service Two-digit numeric code that describes where a service was rendered. numeric 2
Multiple versions32 Service Location Zip Code +4digit add-on code Zip code for location where service described was provided. alphanumeric 10
Multiple versions33 Service Unit Indicator Category of service as it corresponds to Units data element. numeric 1
Multiple versions34 Units of Service Quantity of services or number of units for a service or minutes of anesthesia. numeric 3
Multiple versions35 Procedure Code Describes the health care service provided (i.e., CPT-4, HCPCS, ICD-9-CM, ICD-10-CM) alphanumeric 6
Multiple versions36 Modifier I Discriminate code used by practitioners to distinguish that a health care service has been altered [by a specific condition] but not changed in definition or code. A modifier is added as a suffix to a procedure code field. alphanumeric 2
Multiple versions37 Modifier II Specific to Modifier I. alphanumeric 2
Multiple versions38 Servicing Practitioner ID Payor-specific identifier for the practitioner rendering health care service(s). alphanumeric 11
Multiple versions39 Billed Charge A practitioner's billed charges rounded to whole dollars. DO NOT USE DECIMALS numeric 9
Multiple versions40 Allowed Amount Total patient and payor liability. DO NOT USE DECIMALS numeric 9
Multiple versions41 Reimbursement Amount Amount paid to Employer Tax ID # of rendering physician as listed on claim. DO NOT USE DECIMALS numeric 9
Multiple versions42 Date of Enrollment The start date of enrollment for the patient in this delivery system(in this data submission time period). (see Source Company on page 70) numeric CCYYMMDD 8
Multiple versions43 Date of Disenrollment The end date of enrollment for the patient in this delivery system (in this data submission time period).(see Source Company on page 70) numeric CCYYMMDD 8
Multiple versions44 Patient Deductible The fixed amount that the patient must pay for covered medical services before benefits are payable. DO NOT USE DECIMALS numeric 9
Multiple versions45 Patient Coinsurance or Patient Co-payment The specified amount or percentage the patient is required to contribute towards covered medical services after any applicable deductible. DO NOT USE DECIMALS numeric 9
Multiple versions46 Other Patient Obligations Any patient obligations other than the deductible or coinsurance/co-payment. This could include obligations for out-of-network care (balance billing net of patient deductible, patient coinsurance/co-payment and payor reimbursement), non-covered services, or penalties. DO NOT USE DECIMALS numeric 9
Multiple versions47 Plan Liability Indicates if insurer is at risk for the patient's service use or the insurer is simply paying claims as Administrative Services Only (ASO) numeric 1
Multiple versions48 Servicing Practitioner Individual National Provider Identifier (NPI) number Federal identifier assigned by the federal government for use in all HIPAA transactions to an individual practitioner. alphanumeric 10
Multiple versions49 Practitioner National Provider Identifier (NPI) number used for Billing Federal identifier assigned by the federal government for use in all HIPAA transactions to an individual practitioner or an organization for billing purposes. alphanumeric 10
Multiple versions50 Product Type Classifies the benefit plan by key product characteristics (scope of coverage, size of network, coverage for out-of-network benefits).(Please code based on how the product is primarily marketed, and most importantly be consistent from year to year. If not sure, send an e-mail describing the product to Larry Monroe at larry.monroe@maryland.gov) numeric 1
Multiple versions51 Payor ID Number Payor assigned submission identification number (see Appendix A on page 38). alphanumeric 4
Multiple versions52 Source System Identify the source system (platforms or business units) from which the data was obtained by using an alphabet letter (A, B, C, D, etc...) (Note: In your documentation on page 14, please be sure to list the source system that corresponds with the letter assigned.) For payors with all data coming from one system only, leave the field blank. alphanumeric 1
Multiple versions53 Assignment of Benefits For out-of-network services please provide information on whether or not the patient assigned benefits to the servicing physician for an out-of-network service. alphanumeric 1
Multiple versions54 Diagnosis Code Indicator Indicates the volume of the International Classification of Diseases, Clinical Modification system used in assigning codes to diagnoses. numeric 1
Multiple versions55 CPT Category II Code 1 Provide any applicable CPT Category II codes. alphanumeric 5
Multiple versions56 Other CPT Category II Code 2 Not Provided alphanumeric 5
Multiple versions57 Other CPT Category II Code 3 Not Provided alphanumeric 5
Multiple versions58 Other CPT Category II Code 4 Not Provided alphanumeric 5
Multiple versions59 Other CPT Category II Code 5 Not Provided alphanumeric 5

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Data Element ID Data Element Code Value
1 Record Identifier 1 Professional Services
5 Patient Sex 1 Male
2 Female
3 Unknown
6 Consumer Directed Health Plan (CDHP) with HSA or HRA Indicator 0 No
1 Yes
8 Patient Covered by Other Insurance Indicator 0 No
1 Yes, other coverage is primary
2 Yes, other coverage is secondary
9 Unknown
9 Coverage Type 1 Medicare Supplemental (i.e., Individual, Group, WRAP)
2 Medicare Advantage Plan
3 Individual Market (not MHIP)
4 Maryland Health Insurance Plan (MHIP)
5 Private Employer Sponsored or Other Group (i.e. union or association plans)
6 Public Employee - Federal (FEHBP)
7 Public Employee - Other (state, county, local/municipal government and public school systems)
8 Comprehensive Standard Health Benefit Plan [a self employed individual or small businesses (public or private employers) with 2- 50 eligible employees]
9 Health Insurance Partnership (HIP)
A Student Health Plan
Z Unknown
10 Source Company 1 Health Maintenance Organization
2 Life & Health Insurance Company or Not-for-Profit Health Benefit Plan
3 Third-Party Administrator (TPA) Unit
11 Claim Related Condition 0 Non-accident (default)
1 Work
2 Auto Accident
3 Other Accident
9 Unknown
13 Participating Provider Status 1 Participating
2 Non-Participating
3 Unknown/Not Coded
9 No Network for this Plan
14 Record Status 1 Final Bill
8 Capitated or Global Contract Services
31 Place of Service 11 Provider's Office
12 Patient's Home
13 Assisted Living Facility
17 Walk-in Retail Health Clinic
18 Place of Employment - Worksite
20 Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
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 Non-residential Substance Abuse Treatment Facility
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 & Imaging
99 Other Place of Service
33 Service Unit Indicator 0 Values reported as zero (no allowed services)
1 Transportation (ambulance air or ground) Miles
2 Anesthesia Time Units
3 Services
4 Oxygen Units
5 Units of Blood
6 Allergy Tests
7 Lab Tests
8 Minutes of Anesthesia (waiver required)
36 Modifier I QX Nurse Anesthetist service; under supervision of a doctor
QZ Nurse Anesthetist service; w/o the supervision of a doctor
47 Plan Liability 1 Risk (under Maryland contract)
2 Risk (under non-Maryland contract)
3 ASO (employer self-insured)
50 Product Type 1 Exclusive Provider Organization (in any form)
2 Health Maintenance Organization
3 Indemnity
4 Point of Service (POS)
5 Preferred Provider Organization (PPO)
6 Limited Benefit Plan (Mini-Meds)
7 Student Health Plan
8 Catastrophic
51 Payor ID Number P020 Aetna Life Insurance Co.
P030 Aetna Health, Inc.
P130 CareFirst BlueChoice, Inc.
P131 CareFirst of Maryland, Inc.
P132 Group Hospitalization & Medical Services, Inc. (GHMSI)
P160 Cigna Health and Life Insurance Co., Inc.
P180 Connecticut General Life Insurance Co.
P220 Corporate Health Insurance Co.
P280 Assurant Health/Time Insurance Co.
P320 Golden Rule Insurance Co.
P480 Kaiser Permanente Mid-Atlantic States
P500 MAMSI Life and Health Insurance Co.
P520 MD-Individual Practice Association, Inc.
P530 MEGA Life and Health Insurance Co.
P620 Optimum Choice, Inc.
P680 Coventry Healthcare of Delaware, Inc.
P760 State Farm Mutual Automobile Insurance Co.
P820 United Healthcare Insurance Co.
P870 United Healthcare of the Mid-Atlantic, Inc.
53 Assignment of Benefits 0 No, Assignment of Benefits not accepted and Practitioner Not inNetwork
1 Yes, Assignment of Benefits Accepted and Practitioner Not in Network
2 N/A, Practitioner is In Network
9 Unknown
54 Diagnosis Code Indicator 1 ICD-9-CM
2 ICD-10-CM
3 Missing/Unknown
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