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Dental Services Fixed Format File Submission

Maryland



Name:Dental Services Fixed Format File Submission
State:Maryland
Definition:Not provided
VersionJanuary 9, 2014

File Specification for Dental Services Fixed Format File Submission

Data Element ID Data Element Description Type Format Length
1 Record Identifier The value is 6 numeric 1
2 Patient IdentifierP (payer encrypted) Patient's unique identification number assigned by payer and encrypted. alphanumeric 12
3 Patient IdentifierU (UUID encrypted) Patient's universally unique identification (UUID) number generated using an encryption algorithm provided by MHCC. alphanumeric 12
4 Patient Year and Month of Birth Date of patient's birth using 00 instead of day. numeric CCYYMM00 8
5 Patient Sex Sex of the patient. numeric 1
6 Patient Zip Code+4digit add-on code Zip code of patient's residence. numeric 10
7 Patient Covered by Other Insurance Indicator Indicates whether patient has additional insurance coverage. numeric 1
8 Coverage Type Modified! Patient's type of insurance coverage. alphanumeric 1
9 Source Company Defines the payer company that holds the beneficiary's contract; for use in characterizing contract requirements under Maryland law. numeric 1
10 Claim Related Condition Describes connection, if any, between patient's condition and employment, automobile accident, or other accident. numeric 1
11 Practitioner Federal Tax ID (TIN) Employer Tax ID of the practitioner, practice or office facility receiving payment for services. alphanumeric 9
12 Participating Provider Flag Indicates if the service was provided by a provider that participates in the payer's network. numeric 1
13 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
14 Claim Control Number Internal payer claim number used for tracking. alphanumeric 23
15 Claim Paid Date The date a claim was authorized for payment. numeric CCYYMMDD 8
16 Number of Line Items If using Variable Format, the # of line items completed in the variable portion 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
17 Service From Date First date of service for a procedure in this line item. numeric CCYYMMDD 8
18 Service Thru Date Last date of service for this line item. numeric CCYYMMDD 8
19 Place of Service Two-digit numeric code that describes where a service was rendered. numeric 2
20 Service Location Zip Code Zip code for location where service described was provided. alphanumeric 10
21 Procedure Code Describes the health care service provided (i.e., CDT). alphanumeric 5
22 Servicing Practitioner ID Payer-specific identifier for the practitioner rendering health care service(s). alphanumeric 11
23 Billed Charge A practitioner's billed charges rounded to whole dollars. DO NOT USE DECIMALS numeric 9
24 Allowed Amount Total patient and payer liability. DO NOT USE DECIMALS numeric 9
25 Reimbursement Amount Amount paid to Employer Tax ID # of rendering physician as listed on claim. DO NOT USE DECIMALS numeric 9
26 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 81) numeric CCYYMMDD 8
27 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 81) numeric CCYYMMDD 8
28 Patient Deductible The fixed amount that the patient must pay for covered medical services before benefits are payable. DO NOT USE DECIMALS numeric 9
29 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
30 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 payer reimbursement), non-covered services, or penalties. DO NOT USE DECIMALS numeric 9
31 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
32 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
33 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
34 Payer ID Number Payer assigned submission identification number. alphanumeric 4
35 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 15, please be sure to list the source system that corresponds with the letter assigned.) For payers with all data coming from one system only, leave the field blank. alphanumeric 1
36 Encrypted Contract or Group Number (payer encrypted) Payer assigned contract or group number for the plan sponsor using an encryption algorithm generated by the payer. alphanumeric 20
37 Relationship to Policyholder Member's relationship to subscriber/insured. numeric 1
38 Tooth Number/Letter - 1 Report the tooth identifier(s) when Current Dental Terminology Code is within given range. alphanumeric 2
39 Tooth - 1 Surface - 1 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
40 Tooth - 1 Surface - 2 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
41 Tooth - 1 Surface - 3 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
42 Tooth - 1 Surface - 4 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
43 Tooth - 1 Surface - 5 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
44 Tooth - 1 Surface - 6 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
45 Tooth Number/Letter - 2 Report the tooth identifier(s) when Current Dental Terminology Code is within given range. alphanumeric 2
46 Tooth - 2 Surface - 1 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
47 Tooth - 2 Surface - 2 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
48 Tooth - 2 Surface - 3 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
49 Tooth - 2 Surface - 4 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
50 Tooth - 2 Surface - 5 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
51 Tooth - 2 Surface - 6 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
52 Tooth Number/Letter - 3 Report the tooth identifier(s) when Current Dental Terminology Code is within given range. alphanumeric 2
53 Tooth - 3 Surface - 1 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
54 Tooth - 3 Surface - 2 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
55 Tooth - 3 Surface - 3 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
56 Tooth - 3 Surface - 4 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
57 Tooth - 3 Surface - 5 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
58 Tooth - 3 Surface - 6 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
59 Tooth Number/Letter - 4 Report the tooth identifier(s) when Current Dental Terminology Code is within given range. alphanumeric 2
60 Tooth - 4 Surface - 1 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
61 Tooth - 4 Surface - 2 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
62 Tooth - 4 Surface - 3 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
63 Tooth - 4 Surface - 4 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
64 Tooth - 4 Surface - 5 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
65 Tooth - 4 Surface - 6 Report the tooth surface(s) that this service relates to. Provides further detail on procedure(s). Required when Tooth Number/Letter is populated. alphanumeric 5
66 Dental Quadrant - 1 Report the standard quadrant identifier when CDT indicates procedures of 3 or more consecutive teeth. Provides further detail on procedure(s). alphanumeric 2
67 Dental Quadrant - 2 Report the standard quadrant identifier when CDT indicates procedures of 3 or more consecutive teeth. Provides further detail on procedure(s). alphanumeric 2
68 Dental Quadrant - 3 Report the standard quadrant identifier when CDT indicates procedures of 3 or more consecutive teeth. Provides further detail on procedure(s). alphanumeric 2
69 Dental Quadrant - 4 Report the standard quadrant identifier when CDT indicates procedures of 3 or more consecutive teeth. Provides further detail on procedure(s). alphanumeric 2
70 Orthodontics Treatment Indicate if the treatment is for Orthodontics. numeric 1
71 Date Appliance Placed If treatment is for Orthodontics, then provide the date the appliance was placed. numeric CCYYMMDD 8
72 Months of Treatment Remaining If treatment is for Orthodontics, then provide the number of months of treatment remaining. numeric 2
73 Prosthesis Replacement Indicate if the treatment is for the replacement of Prosthesis. numeric 1
74 Date Prior Placement If treatment is for replacement of Prosthesis, then provide the prior date of Prosthesis placement. numeric CCYYMMDD 8
75 Reporting Quarter Indicate the quarter number for which the data is being submitted. numeric 1

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Data Element ID Data Element Code Value
1 Record Identifier 6 Dental Services
5 Patient Sex 1 Male
2 Female
3 Unknown
7 Patient Covered by Other Insurance Indicator 0 No
1 Yes, other coverage is primary
2 Yes, other coverage is secondary
9 Unknown
8 Coverage Type Modified! 1 Medicare Supplemental (i.e., Individual, Group, WRAP)
2 Medicare Advantage Plan
3 Individual Market (not MHIP; not sold in MHBE)
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 (not sold in MHBE) [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
B Individual Market sold in MHBE
C Small Business Options Program (SHOP) sold in MHBE
Z Unknown
9 Source Company 1 Health Maintenance Organization
2 Life & Health Insurance Company or Not-for-Profit Health Benefit Plan
3 Third-Party Administrator (TPA) Unit
10 Claim Related Condition 0 Non-accident (default)
1 Work
2 Auto Accident
3 Other Accident
9 Unknown
12 Participating Provider Flag 1 Participating
2 Non-Participating
3 Unknown/Not Coded
9 No Network for this Plan
13 Record Status 1 Final Bill
8 Capitated or Global Contract Services
19 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 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
37 Relationship to Policyholder 1 Self/employee
2 Spouse
3 Child
4 Other Dependent
5 Other Adult
9 Unknown
70 Orthodontics Treatment 0 No
1 Yes
73 Prosthesis Replacement 0 No
1 Yes
75 Reporting Quarter 1 First Quarter = January 1 thru March 31
2 Second Quarter = April 1 thru June 30
3 Third Quarter = July 1 thru September 30
4 Fourth Quarter = October 1 thru December 31
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