Data Element # | Element | Type | Maximum Length | Description/Codes/Sources |
HD001 | Record Type | Text | 2 | HD |
HD002 | Payer | Text | 6 | Payer submitting payments |
Council Submitter Code | ||||
HD003 | National Plan ID | Text | 30 | CMS National Plan ID |
HD004 | Type of File | Text | 2 | MA Member Eligibility |
MC Medical Claims | ||||
PC Pharmacy Claims | ||||
HD005 | Period Beginning Date | Integer | 6 | CCYYMM |
Beginning of paid period for claims | ||||
Beginning of month covered for eligibility | ||||
HD006 | Period Ending Date | Integer | 6 | CCYYMM |
End of paid period for claims | ||||
End of month covered for eligibility | ||||
HD007 | Record Count | Integer | 10 | Total number of records submitted in this file |
HD008 | Comments | Text | 80 | Submitter may use to document this submission by assigning a file name , system source, etc. |
Table 2: Trailer Record Layout
Data Element # | Element | Type | Maximum Length | Description/Codes/Sources |
TR001 | Record Type | Text | 2 | TR |
TR002 | Payer | Text | 6 | Payer submitting payments |
Council Submitter Code | ||||
TR003 | National Plan ID | Text | 30 | CMS National Plan ID |
TR004 | Type of File | Text | 2 | MA Member Eligibility |
MC Medical Claims | ||||
PC Pharmacy Claims | ||||
TR005 | Period Beginning Date | Integer | 6 | CCYYMM |
Beginning of paid period for claims | ||||
Beginning of month covered for eligibility | ||||
TR006 | Period Ending Date | Integer | 6 | CCYYMM |
End of paid period for claims | ||||
End of month covered for eligibility | ||||
TR007 | Date Processed | Date | 8 | CCYYMMDD |
Date file was created |
Table 3: Insurance Type Code/Product
Code | Description |
12 | Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan |
13 | Medicare Secondary End-Stage Renal Disease Beneficiary in the 12-month coordination period with an Employer Group Health Plan |
14 | Medicare Secondary No-Fault Insurance including Insurance in which 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 Plan (LGHP) |
47 | Medicare Secondary Other Liability Insurance is Primary |
AP | Auto Insurance Policy |
CP | Medicare Conditionally Primary |
D | Disability |
DB | Disability Benefits |
EP | Exclusive Provider Organization (for self- insured risks) |
HM | Health Maintenance Organization (HMO) |
HN | Health Maintenance Organization (HMO) Medicare Advantage |
HS | Special Low Income Medicare Beneficiary |
IN | Indemnity |
LC | Long Term Care |
LD | Long Term Policy |
LI | Life Insurance |
LT | Litigation |
MA | Medicare Part A |
MB | Medicare Part B |
MC | Medicaid |
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 | Workers' Compensation |
Table 4: Individual Relationship Code
Code | Description |
01 | Spouse |
18 | Self/Employee |
19 | Child |
21 | Unknown |
34 | Other Adult |
Table 5: Race Code
Code | Description |
R1 | American Indian/Alaska Native |
R2 | Asian |
R3 | Black/African American |
R4 | Native Hawaiian or other Pacific Islander |
R5 | White |
R9 | Other Race |
UNKNOW | Unknown/not specified |
Table 6: Ethnicity Code
Code | Description |
2182-4 | Cuban |
2184-0 | Dominican |
2148-5 | Mexican, Mexican American, Chicano |
2180-8 | Puerto Rican |
2161-8 | Salvadoran |
2155-0 | Central American (not otherwise specified) |
2165-9 | South American (not otherwise specified) |
2060-2 | African |
2058-6 | African American |
AMERCN | American |
2028-9 | Asian |
2029-7 | Asian Indian |
BRAZIL | Brazilian |
2033-9 | Cambodian |
CVERDN | Cape Verdean |
CARIBI | Caribbean Island |
2034-7 | Chinese |
2169-1 | Columbian |
2108-9 | European |
2036-2 | Filipino |
2157-6 | Guatemalan |
2071-9 | Haitian |
2158-4 | Honduran |
2039-6 | Japanese |
2040-4 | Korean |
2041-2 | Laotian |
2118-8 | Middle Eastern |
PORTUG | Portuguese |
RUSSIA | Russian |
EASTEU | Eastern European |
2047-9 | Vietnamese |
OTHER | Other Ethnicity |
UNKNOW | Unknown/not specified |
Table 7: Language Code
Code | Description |
799 | African Languages (please specify) |
777 | Arabic |
708 | Chinese (please specify) |
601 | Cape Verdean Creole |
600 | English |
620 | French |
607 | German |
637 | Greek |
623 | Haitian Creole |
778 | Hebrew |
663 | Hindi |
619 | Italian |
723 | Japanese |
724 | Korean |
656 | Persian |
645 | Polish |
629 | Portuguese |
639 | Russian |
625 | Spanish |
742 | Tagalog |
671 | Urdu |
728 | Vietnamese |
997 | Other Language (please specify) |
998 | Declined |
999 | Unavailable |
Table 8: Member Eligibility File Layout
Data Element # | Element | Type | Max. Length | Description/Codes/Sources | |
ME001 | Payer | Text | 6 | Payer submitting payments | |
Council Submitter Code | |||||
ME002 | National Plan ID | Text | 30 | CMS National Plan ID | |
ME003 | Insurance Type Code/Product | Text | 2 | 12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan | |
13 Medicare Secondary End-Stage Renal Disease Beneficiary in the 12-month coordination period with an Employer Group Health Plan | |||||
14 Medicare Secondary, No-fault insurance including insurance in which 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 Plan (LGHP) | |||||
47 Medicare Secondary, Other Liability Insurance is Primary | |||||
AP Auto Insurance Policy | |||||
CP Medicare Conditionally Primary | |||||
D Disability | |||||
DB Disability Benefits | |||||
EP Exclusive Provider Organization | |||||
HM Health Maintenance Organization (HMO) | |||||
HN Health Maint enance organization ( HMO) Medicare Risk | |||||
HS Special Low Income Medicare Beneficiary | |||||
IN Indemnity | |||||
LC Long Term Care | |||||
LD Long Term Policy | |||||
LI Life Insurance | |||||
LT Litigation | |||||
MA Medicare Part A | |||||
MB Medicare Part B | |||||
MC Medicaid | |||||
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 Workers' Compensation | |||||
ME004 | Year | Integer | 4 | Year for which eligibility is reported in this submission | |
ME005 | Month | Integer | 2 | Month for which eligibility is reported in this submission | |
ME006 | Insured Group or Policy Number | Text | 30 | Group or policy number (not the number that uniquely identifies the subscriber) | |
ME007 | Coverage Level Code | Text | 3 | Benefit Coverage Level | |
C HD Children Only | |||||
DEP Dependents Only | |||||
ECH Employee and Children | |||||
EMP Employee Only | |||||
ESP Employee and Spouse | |||||
FAM Family | |||||
IND Individual | |||||
SPC Spouse and Children | |||||
SPO Spouse Only | |||||
ME008 | Encrypted Subscriber Unique Identification Number | Text | 30 | Encrypted subscriber's unique identification number (set as null if unavailable) | |
ME009 | Plan Specific Contract Number | Text | 30 | Encrypted plan assigned contract number (set as null if contract number = subscriber's social security number) | |
ME010 | Member Suffice or Sequence Number | Integer | 2 | Uniquely numbers the member within the contract | |
ME011 | Member Identification Code | Text | 30 | Encrypted member's unique identification number (set as null if unavailable) | |
ME012 | Individual Relationship Code | Integer | 2 | Member's relationship to insured | |
01 Spouse | |||||
18 Self/Employee | |||||
19 Child | |||||
21 Unknown | |||||
34 Other Adult | |||||
ME013 | Member Gender | Text | 1 | M Male | |
F Female | |||||
U Unknown | |||||
ME014 | Member Date of Birth | Date | 8 | CCYYMMDD | |
ME015 | Member City Name | Text | 30 | City name of member | |
ME016 | Member State or Province | Text | 2 | As defined by the US Postal Service | |
ME017 | Member ZIP Code | Text | 11 | ZIP Code of member - may include non-US codes. (Do not include dash) | |
ME018 | Medical Coverage | Text | 1 | Y Yes | |
N No | |||||
ME019 | Prescription Drug Coverage | Text | 1 | Y Yes | |
N No | |||||
ME020 | Race 1 | Text | 6 | R1 American Indian/Alaska Native | |
R2 Asian | |||||
R3 Black/African American | |||||
R4 Native Hawaiian or other Pacific Islander | |||||
R5 White | |||||
R9 Other Race | |||||
UNKNOW Unknown/not specified | |||||
ME021 | Race 2 | Text | 6 | R1 American Indian/Alaska Native | |
R2 Asian | |||||
R3 Black/African American | |||||
R4 Native Hawaiian or other Pacific Islander | |||||
R5 White | |||||
R9 Other Race | |||||
UNKNOWN Unknown/not specified | |||||
ME022 | Other Race | Text | 15 | Patient Race, if Race 1 or Race 2 is entered as R9 Other Race (set as null if none) | |
ME023 | Hispanic Indicator | Text | 1 | Y Patient is Hispanic/Latino/Spanish | |
N Patient is not Hispanic/Latino/ Spanish | |||||
U Unknown | |||||
ME024 | Ethnicity 1 | Text | 6 | 2182-4 Cuban | |
2184-0 Dominican | |||||
2148-5 Mexican, Mexican American, Chicano | |||||
2180-8 Puerto Rican | |||||
2161-8 Salvadoran | |||||
2155-0 Central American (not otherwise specified) | |||||
2165-9 South American (not otherwise specified) | |||||
2060-2 African | |||||
2058-6 African American | |||||
AMERCN American | |||||
2028-9 Asian | |||||
2029-7 Asian Indian | |||||
BRAZIL Brazilian | |||||
2033-9 Cambodian | |||||
CVERDN Cape Verdean | |||||
CARIBI Caribbean Island | |||||
2034-7 Chinese | |||||
2169-1 Columbian | |||||
2108-9 European | |||||
2036-2 Filipino | |||||
2157-6 Guatemalan | |||||
2071-9 Haitian | |||||
2158-4 Honduran | |||||
2039-6 Japanese | |||||
2040-4 Korean | |||||
2041-2 Laotian | |||||
2118-8 Middle Eastern | |||||
PORTUG Portuguese | |||||
RUSSIA Russian | |||||
EASTEU Eastern European | |||||
2047-9 Vietnamese | |||||
OTHER Other Ethnicity | |||||
UNKNOW Unknown/not specified | |||||
ME025 | Ethnicity 2 | Text | 6 | 2182-4 Cuban | |
2184-0 Dominican | |||||
2148-5 Mexican, Mexican American, Chicano | |||||
2180-8 Puerto Rican | |||||
2161-8 Salvadoran | |||||
2155-0 Central American (not otherwise specified) | |||||
2165-9 South American (not otherwise specified) | |||||
2060-2 African | |||||
2058-6 African American | |||||
AMERCN American | |||||
2028-9 Asian | |||||
2029-7 Asian Indian | |||||
BRAZIL Brazilian | |||||
2033-9 Cambodian | |||||
CVERDN Cape Verdean | |||||
CARIBI Caribbean Island | |||||
2034-7 Chinese | |||||
2169-1 Columbian | |||||
2108-9 European | |||||
2036-2 Filipino | |||||
2157-6 Guatemalan | |||||
2071-9 Haitian | |||||
2158-4 Honduran | |||||
2039-6 Japanese | |||||
2040-4 Korean | |||||
2041-2 Laotian | |||||
2118-8 Middle Eastern | |||||
PORTUG Portuguese | |||||
RUSSIA Russian | |||||
EASTEU Eastern European | |||||
2047-9 Vietnamese | |||||
OTHER Other Ethnicity | |||||
UNKNOW Unknown/not specified | |||||
ME026 | Other Ethnicity | Text | 20 | Patient Ethnicity if Ethnicity 1 or Ethnicity 2 is entered as OTHER other Ethnicity. (set as null if none) | |
ME027 | Language | Text | 20 | 799 Africian Language (please specify) | |
777 Arabic | |||||
708 Chinese (please specify) | |||||
601 Cape Verdean Creole | |||||
600 English | |||||
620 French | |||||
607 German | |||||
637 Greek | |||||
623 Haitian Creole | |||||
778 Hebrew | |||||
663 Hindi | |||||
619 Italian | |||||
723 Japanese | |||||
724 | Korean | ||||
656 | Persian | ||||
645 | Polish | ||||
629 | Portuguese | ||||
639 | Russian | ||||
625 | Spanish | ||||
742 | Tagalog | ||||
671 | Urdu | ||||
728 | Vietnamese | ||||
997 | Other Language (please specify) | ||||
998 | Declined | ||||
999 | Unavailable | ||||
ME028 | Record Type | Text | 2 |
Table 9: Member Eligibility File Mapping
Data Element # | Element | HIPAA Reference Transaction Set/Loop/Segment/Qualifier/Data Element |
ME001 | Payer | N/A |
ME002 | National Plan ID | 271/2100A/NM1/XV/09 |
ME003 | Insurance Type Code/Product | 271/2110C/EB/ /04, 271/2110D/EB/ /04 |
ME004 | Year | N/A |
ME005 | Month | N/A |
ME006 | Insured Group or Policy Number | 271/2100C/REF/1L/02, 271/2100C/REF/IG/02, 271/2100C/REF/6P/02, 271/2100D/REF/1L/02, 271/2100D/REF/IG/02, 271/2100D/REF/6P/02 |
ME007 | Coverage Level Code | 271/2110C/EB/ /03, 271/2100D/EB/ /03 |
ME008 | Encrypted Subscriber Unique Identification Number | 271/2100C/NM1/MI/09 |
ME009 | Plan Specific Contract Number | 271/2100C/NM1/MI/09 |
ME010 | Member Suffix or Sequence Number | N/A |
ME011 | Member Identification Code | 271/2100C/MN1/MI/09, 271/2100D/NM1/MI/09 |
ME012 | Individual Relationship Code | 271/2100C/INS/Y/02, 271/2100D/INS/N/02 |
ME013 | Member Gender | 271/2100C/DMG/ /03, 271/2100D/DMG/ /03 |
ME014 | Member Date of Birth | 271/2100C/DMG/D8/02, 271/2100D/DMG/D8/02 |
ME015 | Member City Name | 271/2100C/N4/ /01, 271/2100D/N4/ /01 |
ME016 | Member State or Province | 217/2100C/N4/ /02, 271/2100D/N4/ /02 |
ME017 | Member ZIP Code | 271/2100C/N4/ /03, 271/2100D/N4/ /03 |
ME018 | Medical Coverage | N/A |
ME019 | Prescription Drug Coverage | N/A |
ME020 | Race 1 | N/A |
ME021 | Race 2 | N/A |
ME022 | Other Race | N/A |
ME023 | Hispanic Indicator | N/A |
ME024 | Ethnicity 1 | N/A |
ME025 | Ethnicity 2 | N/A |
ME026 | Other Ethnicity | N/A |
ME027 | Language | N/A |
Table 10: Insurance Type/Product Code
Code | Description |
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 |
DS | Disability |
HM | Health Maintenance Organization |
MA | Medicare Part A |
MB | Medicare Part B |
MC | Medicaid |
VA | Veterans Administration Plan |
WC | Workers' Compensation |
Table 11: Individual Relationship Code
Code | Description |
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 | Employer |
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 | Where Insured Has No Financial Responsibility |
53 | Life Partner |
76 | Dependent |
Table 12: Admission Type
Code | Description |
1 | Emergency |
2 | Urgent |
3 | Elective |
4 | Newborn |
5 | Trauma Center |
9 | Information Not Available |
Table 13: Admission Source
Code | Description |
1 | Physician Referral |
2 | Clinic Referral |
3 | HMO Referral |
4 | Transfer from Hospital |
5 | Transfer from a Skilled Nursing Facility |
6 | Transfer from another Health Care Facility |
7 | Emergency Room |
8 | Court/Law Enforcement |
9 | Unknown |
A | Transfer from a Rural Primary Care Hospital |
Table 14: Discharge Status
Code | Description |
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 |
MC035A. This element is named "service provider country name". The data type of this element is text. Its length is 30. Carriers shall code according to the country name of provider, and preferably the practice location.
Table 15: Type of Bill on Facility Claims
First Digit | Type of Facility |
1 | Hospital |
2 | Skilled Nursing |
3 | Home Health |
4 | Christian Science Hospital |
5 | Christian Science Extended Care |
6 | Intermediate Care |
7 | Clinic |
8 | Special Facility |
Second Digit if First Digit = 1 through 6 | Bill Classification |
1 | Inpatient (including Medicare Part A) |
2 | Inpatient (including Medicare Part B Only) |
3 | Outpatient |
4 | Other (for hospital referenced diagnostic services or home health not under a plan of treatment) |
5 | Nursing Facility Level I |
6 | Nursing Facility Level II |
7 | Intermediate Care - Level III Nursing Facility |
8 | Swing Beds |
Second Digit if First Digit = 7 | Bill Classification |
1 | Rural Health |
2 | Hospital Based or Independent Renal |
3 | Dialysis Center |
4 | Free Standing |
5 | Outpatient Rehabilitation Facility (ORF) |
6 | Comprehensive Outpatient Rehabilitation |
7 | Facilities (CORFs) |
9 | Other |
Second Digit if First Digit = 8 | Bill Classification |
1 | Hospice, Non-hospital based |
2 | Hospital, Hospital based |
3 | Ambulatory Surgery Center |
4 | Free Standing Birthing Center |
9 | Other |
Table 16: Site of Service on NSF/CMS 1500 Claims
Code | Facility |
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 |
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 of Local Public Health Clinic |
72 | Rural Health Clinic |
81 | Independent Laboratory |
99 | Other Unlisted Facility |
Table 17: Medical Claims File Layout
Data Element # | Data Element Name | Type | Max. Length | Description/Codes/Sources |
MC001 | Payer | Text | 6 | Payer submitting payments |
Council Submitter Code | ||||
MC002 | National Plan ID | Text | 30 | CMS National Plan ID |
MC003 | Insurance Type / Product Code | Text | 2 | 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 | ||||
DS Disability | ||||
HM Health Maintenance Organization | ||||
MA Medicare Part A | ||||
MB Medicare Part B | ||||
MC Medicaid | ||||
VA Veteran Administration Plan | ||||
WC Worker's Compensation | ||||
MC004 | Payer Claim Control Number | Text | 35 | Must apply to the entire claim and be unique within the payer's system |
MC005 | Line Counter | Integer | 4 | Line number for this service |
The line counter begins with 1 and is incremented by 1 for each additional service line of a claim | ||||
MC005A | Version Number | Integer | 4 | Version number of this claim service line |
The version number begins with 0 and is incremented by 1 for each subsequent version of that service line | ||||
MC006 | Insured Group or Policy Number | Text | 30 | Group or policy number (not the number that uniquely identifies the subscriber) |
MC007 | Encrypted Subscriber Unique Identification Number | Text | 30 | Encrypted subscriber's Unique Identification number Set as null if unavailable |
MC008 | Plan Specific Contract Number | Text | 30 | Encrypted plan assigned Set as null if contract number = subscriber's social security number |
MC009 | Member Suffix or Sequence Number | Integer | 2 | Uniquely numbers the member within the contract |
MC010 | Member Identification Code | Text | 30 | Encrypted member's Unique Identification number Set as null if unavailable |
MC011 | Individual Relationship Code | Integer | 2 | Member's relationship to subscriber |
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 | ||||
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 Where Insured Has No Financial Responsibility | ||||
53 Life Partner | ||||
76 Dependent | ||||
MC012 | Member Gender | Text | 1 | M Male |
F Female | ||||
U Unknown | ||||
MC013 | Member Date of Birth | Date | 8 | CCYYMMDD |
MC014 | Member City Name | Text | 30 | City name of member |
MC015 | Member State or Province | Text | 2 | As defined by the US Postal Service |
MC016 | Member ZIP Code | Text | 11 | ZIP Code of member - may include non-US codes |
MC017 | Date Service Approved (AP Date) | Date | 8 | CCYYMMDD |
(Generally the same as the paid date) | ||||
MC018 | Admission Date | Date | 8 | Required for all inpatient claims |
CCYYMMDD | ||||
MC019 | Admission Hour | Integer | 4 | Required for all inpatient claims |
Time is expressed in military time - HH or HHMM | ||||
MC020 | Admission Type | Integer | 1 | |
MC021 | Admission Source | Text | 1 | |
MC022 | Discharge Hour | Integer | 4 | Hour in military time - HH or HHMM |
MC022A | Discharge Date | Date | 8 | Required for all inpatient claims CCYYMMDD |
MC023 | Discharge Status | Integer | 2 | 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 | ||||
MC024 | Service Provider Number | Text | 30 | Payer assigned provider number |
MC025 | Service Provider Tax ID Number | Text | 10 | Federal taxpayer's identification number |
MC026 | National Service Provider ID | Text | 20 | Required if National Provider ID is mandated for use under HIPAA |
MC027 | Service Provide r Entity Type Qualifier | Text | 1 | 1 Person 2 Non-Person Entity |
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 "Person". | ||||
MC028 | Service Provide r First Name | Text | 25 | Individual first name |
Set to null if provider is a facility or organization | ||||
MC029 | Service Provide r Middle Name | Text | 25 | Individual middle name or initial |
Set to null if provider is a facility or organization | ||||
MC030 | Service Provider Last Name or Organization Name | Text | 50 | Full name of provider organization or last name of individual provider |
MC031 | Service Provider Suffix | Text | 10 | Suffix to individual name |
Set to null if provider is a facility or organization. Should 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', 'LICSW'). | ||||
MC032 | Service Provider Specialty | Text | 10 | As defined by payer |
Dictionary for specialty code values must be supplied during testing | ||||
MC033 | Service Provider City Name | Text | 30 | City name of provider - preferably practice location |
MC034 | Service Provider State | Text | 2 | As defined by the US Postal Service |
MC035 | Service Provider ZIP Code | Text | 11 | ZIP Code of provider - may include non-US codes Do not include dash |
MC035A | Service Provider Country Name | Text | 30 | Country name of provider - preferably practice location |
MC036 | Type of Bill - on Facility Claims | Integer | 2 | Type of Facility - First Digit |
(Should be coded on facility claim s, such as those submitted using on UB92 form s) | 1 Hospital | |||
2 Skilled Nursing | ||||
3 Home Health | ||||
4 Christian Science Hospital | ||||
5 Christian Science Extended Care | ||||
6 Intermediate Care | ||||
7 Clinic | ||||
8 Special Facility | ||||
Bill Classification - Second Digit if First Digit = 1-6 | ||||
1 Inpatient (Including Medicare Part A) | ||||
2 Inpatient (Medicare Part B Only) | ||||
3 Outpatient | ||||
4 Other (for hospital referenced diagnostic services or home health not under a plan of treatment) | ||||
5 Nursing Facility Level I | ||||
6 Nursing Facility Level II | ||||
7 Intermediate Care - Level III Nursing Facility | ||||
8 Swing Beds | ||||
Bill Classification - Second Digit if First Digit = 7 | ||||
1 Rural Health | ||||
2 Hospital Based or Independent Renal | ||||
3 Dialysis Center | ||||
4 Free Standing | ||||
5 Outpatient Rehabilitation Facility (ORF) | ||||
6 Comprehensive Outpatient Rehabilitation | ||||
7 Facilities (CORFs) | ||||
9 Other | ||||
Bill Classification - Second Digit if First Digit = 8 | ||||
1 Hospice (Non Hospital Based) | ||||
2 Hospice (Hospital-Based) | ||||
3 Ambulatory Surgery Center | ||||
4 Free Standing Birthing Center | ||||
9 Other | ||||
MC037 | Site of Service - on NSF/CMS 1500 Claims | Text | 2 | 11 Office |
(Should be coded on professional claim s, such as those submitted using NSF [CMS 1500 form s]) | 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 | ||||
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 | ||||
50 Federally Qualified Center | ||||
60 Mass Immunization Center | ||||
61 Comprehensive Inpatient Rehabilitation Facility | ||||
62 Comprehensive Outpatient Rehabilitation Facility | ||||
65 End Stage Renal Disease Treatment Facility | ||||
71 State of Local Public Health Clinic | ||||
72 Rural Health Clinic | ||||
81 Independent Laboratory | ||||
99 Other Unlisted Facility | ||||
MC038 | Claim Status | Integer | 2 | 01 Processed as primary |
(Actually describes the payment status of the specific service line record) | 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 | ||||
MC039 | Admitting Diagnosis | Text | 5 | Required on all inpatient admission claims and encounters |
ICD-9-CM Do not code decimal point | ||||
MC040 | E-Code | Text | 5 | Describes an injury, poisoning or adverse effect |
ICD-9-CM Do not include decimal | ||||
MC041 | Principal Diagnosis | Text | 5 | ICD-9-CM Do not code decimal point |
This should be the principal diagnosis given on the claim header. | ||||
MC042 | Other Diagnosis - 1 | Text | 5 | ICD-9-CM Do not code decimal point |
MC043 | Other Diagnosis - 2 | Text | 5 | ICD-9-CM Do not code decimal point |
MC044 | Other Diagnosis - 3 | Text | 5 | ICD-9-CM Do not code decimal point |
MC045 | Other Diagnosis - 4 | Text | 5 | ICD-9-CM Do not code decimal point |
MC046 | Other Diagnosis - 5 | Text | 5 | ICD-9-CM Do not code decimal point |
MC047 | Other Diagnosis - 6 | Text | 5 | ICD-9-CM Do not code decimal point |
MC048 | Other Diagnosis - 7 | Text | 5 | ICD-9-CM Do not code decimal point |
MC049 | Other Diagnosis - 8 | Text | 5 | ICD-9-CM Do not code decimal point |
MC050 | Other Diagnosis - 9 | Text | 5 | ICD-9-CM Do not code decimal point |
MC051 | Other Diagnosis - 10 | Text | 5 | ICD-9-CM Do not code decimal point |
MC052 | Other Diagnosis - 11 | Text | 5 | ICD-9-CM Do not code decimal point |
MC053 | Other Diagnosis - 12 | Text | 5 | ICD-9-CM Do not code decimal point |
MC054 | Revenue Code | Text | 4 | National Uniform Billing Committee Codes |
Code using leading zeroes, left-justified, and four digits. | ||||
MC055 | Procedure 1 Code | Text | 5 | Health Care Common Procedural Coding System (HCPCS) |
This includes the CPT codes of the American Medical Association | ||||
MC056 | Procedure 1 Modifier - 1 | Text | 2 | Procedure modifier required when a modifier clarifies/ improves the reporting accuracy of the associated procedure code |
MC057 | Procedure 1 Modifier - 2 | Text | 2 | Procedure modifier required when a modifier clarifies/ improves the reporting accuracy of the associated procedure code |
MC058 | ICD-9-CM Procedure 1 Code | Text | 4 | Primary ICD-9-CM code given on the claim header. Do not code decimal point |
MC059 | Date of Service - From | Date | 8 | First date of service for this service line |
CCYYMMDD | ||||
MC060 | Date of Service - Through | Date | 8 | Last date of service for this service line |
CCYYMMDD | ||||
MC061 | Quantity | Integer | 3 | Count of services performed |
Should be set equal to 1 on all Observation bed service lines, for consistency. | ||||
MC062 | Charge Amount | Decimal | 10 | Do not code decimal point |
MC063 | Paid Amount | Decimal | 10 | Includes any withhold amounts |
Do not code decimal point | ||||
MC064 | Prepaid Amount | Decimal | 10 | For capitated services, the fee for service equivalent amount |
Do not code decimal point | ||||
MC065 | Copay Amount | Decimal | 10 | The preset, fixed dollar amount for which the individual is responsible Do not code decimal point |
MC066 | Coinsurance Amount | Decimal | 10 | Do not code decimal point |
MC067 | Deductible Amount | Decimal | 10 | Do not code decimal point |
MC068 | Record Type | Text | 2 | MC |
Table 18: Medical Claims File Mapping
UB-92 Form | UB-92 (Version 6.0) Record Type/ | HCFA 1500 | NSF (National Standard Format) | HIPAA Reference Transaction Set/Loop/Segment/ Qualifier/ | ||
Data Element # | Data Element Name | Locator | Field # | # | Locator | Data Element |
MC001 | Payer | N/A | N/A | N/A | N/A | N/A |
MC002 | National Plan ID | N/A | N/A | N/A | N/A | 835/1000A/N1/XV/04 |
MC003 | Product/Claim Filing Indicator Code | N/A | 30/4 | N/A | N/A | 835/2100/CLP/ /06 |
MC004 | Payer Claim Control Number | N/A | N/A | N/A | FA0-02.0, FB0-02.0, FB1-02.0, GA0-02.0, GC0-02.0, GX0-02.0, GX2-02.0, HA0-02.0, FB2-02.0, GU0-02.0 | 835/2100/CLP/ /07 |
MC005 | Line Counter | N/A | N/A | N/A | N/A | 837/2400/LX/ /01 |
MC006 | Insured Group or Policy Number | 62 (A-C) | 30/10 | 11C | DA0-10.0 | 837/2000B/SBR/ /03 |
MC007 | Encrypted Subscriber Unique Identification Number | N/A | N/A | N/A | N/A | 835/2100/NM1/34/08 |
MC008 | Plan Specific Contract Number | N/A | N/A | N/A | N/A | 835/2100/NM1/HN/08 |
MC009 | Member Suffix or Sequence Number | N/A | N/A | N/A | N/A | N/A |
MC010 | Member Identification Code | N/A | N/A | N/A | N/A | 835/2100/NM1/34/08 |
MC011 | Individual Relationship Code | 59 (A-C) | 30/18 | 6 | DA0-17.0 | 837/2000B/SBR/ /02, 837/2000C/PAT/ /01 |
MC012 | Member Gender | 15 | 20/7 | 3 | CA0-09.0 | 837/2010CA/DMG/03 |
MC013 | Member Date of Birth | 14 | 20/8 | 3 | CA0-08.0 | 837/2010CA/DMG/D8/02 |
MC014 | Member City Name | 13 | 20/14 | 5 | CA0-13.0 | 837/2010CA/N4/ /01 |
MC015 | Member State or Province | 13 | 20/15 | 5 | CA0-14.0 | 837/2010CA/N4/ /02 |
MC016 | Member ZIP Code | 13 | 20/16 | 5 | CA0-15.0 | 837/2010CA/N4/ /03 |
MC017 | Date Service Approved | N/A | N/A | N/A | N/A | N/A |
MC018 | Admission Date | 17 | 20/17 | N/A | N/A | 837/2300/DTP/435/03 |
MC019 | Admission Hour | 18 | 20/18 | N/A | N/A | 837/2300/DTP/435/03 |
MC020 | Admission Type | 19 | 20/10 | N/A | N/A | 837/2300/CL1/ /01 |
MC021 | Admission Source | 20 | 20/11 | N/A | 837/2300/CL1/ /02 | |
MC022 | Discharge Hour | 21 | 20/22 | N/A | 837/2300/DTP/096/03 | |
MC023 | Discharge Status | 22 | 20/21 | N/A | N/A | 837/2300/CL1/ /03 |
MC024 | Service Provider Number | N/A | N/A | N/A | N/A | N/A |
MC025 | Service Provider Tax ID Number | 5 | 10/4-5 | 25 | BA0-09.0, CA0-28.0, BA0-02.0, BA1-02.0, YA0-02.0,BA0-06.0, BA0-10.0, BA0-12.0, BA0-13.0, BA0-14.0, BA0-15.0, BA0-16.0, BA0-17.0, BA0-24.0, YA0-06.0 | 835/2100/NM1/FI/09 |
MC026 | National Service Provider ID | N/A | 10/6 | N/A | N/A | 835/2100/NM1/XX/09 |
MC027 | Service Provider Entity Type Qualifier | N/A | N/A | N/A | N/A | 835/2100/NM1/82/02 |
MC028 | Service Provider First Name | 1 | 10/12 | 33 | BA0-20.0 | 835/2100/NM1/82/04 |
MC029 | Service Provider Middle Name | 1 | 10/12 | 33 | BA0-21.0 | 835/2100/NM1/82/05 |
MC030 | Service Provider Last Name or Organization Name | 1 | 10/12 | 33 | BA0-18.0, BA0-19.0 | 835/2100/NM1/82/03 |
MC031 | Service Provider Suffix | 1 | 10/12 | 33 | BA0-22.0 | 835/2100/NM1/82/07 |
MC032 | Service Provider Specialty | N/A | N/A | N/A | N/A | 837/2000A/PRV/ZZ/03 |
MC033 | Service Provider City Name | 1 | 10/14 | N/A | BA1-09.0, 15.0 | 837/2010A/N4/ /01 |
MC034 | Service Provider State or Province | 1 | 10/15 | N/A | BA1-10.0, 16.0 | 837/2010A/N4/ /02 |
MC035 | Service Provider ZIP Code | 1 | 10/16 | N/A | BA1-11.0, 17.0 | 837/2010A/N4/ /03 |
MC036 | Type of Bill - on Facility Claims | 4 | Positions 1-2: 40/4 | N/A | N/A | 837/2300/CLM/ /05-1 |
MC037 | Site of Service - on NSF/CMS 1500 Claims | N/A | N/A | N/A | FA0-07.0, GU0-0.50 | 835/2100/CLP/ /08 |
MC038 | Claim Status | N/A | N/A | N/A | N/A | 835/2100/CLP/ /02 |
MC039 | Admitting Diagnosis | 76 | 70/25 | N/A | N/A | 837/2300/HI/BJ/02-2 |
MC040 | E-Code | 77 | 70/26 | N/A | N/A | 837/2300/HI/BN/03-2 |
MC041 | Principal Diagnosis | 67 | 70/4 | EA0-32.0, GX0-31.0, GU0-12.0 | 837/2300/HI/BK/01-2 | |
MC042 | Other Diagnosis - 1 | 68 | 70/5 | 21.2 | EA0-33.0, GX0-32.0, GU0-13.0 | 837/2300/HI/BF/02-1 |
MC043 | Other Diagnosis - 2 | 69 | 70/6 | 21.3 | EA0-33.0, GX0-32.0, GU0-13.0 | 837/2300/HI/BF/02-2 |
MC044 | Other Diagnosis - 3 | 70 | 70/7 | 21.4 | EA0-33.0, GX0-32.0, GU0-13.0 | 837/2300/HI/BF/02-3 |
MC045 | Other Diagnosis - 4 | 71 | 70/8 | N/A | EA0-35.0, GX0-34.0, GU0-15.0 | 837/2300/HI/BF/02-4 |
MC046 | Other Diagnosis - 5 | 72 | 70/9 | N/A | N/A | 837/2300/HI/BF/02-5 |
MC047 | Other Diagnosis - 6 | 73 | 70/10 | N/A | N/A | 837/2300/HI/BF/02-6 |
MC048 | Other Diagnosis - 7 | 74 | 70/11 | N/A | N/A | 837/2300/HI/BF/02-7 |
MC049 | Other Diagnosis - 8 | 75 | 70/12 | N/A | N/A | 837/2300/HI/BF/02-8 |
MC050 | Other Diagnosis - 9 | N/A | N/A | N/A | N/A | 837/2300/HI/BF/02-9 |
MC051 | Other Diagnosis -10 | N/A | N/A | N/A | N/A | 837/2300/HI/BF/02-10 |
MC052 | Other Diagnosis -11 | N/A | N/A | N/A | N/A | 837/2300/HI/BF/02-11 |
MC053 | Other Diagnosis -12 | N/A | N/A | N/A | N/A | 837/2300/HI/BF/02-12 |
MC054 | Revenue Code | 42 | 50/5,11-13, 60/5,15-16, 61/5,15-16 | N/A | N/A | 835/2110/SVC/RB/01-2, 835/2110/SVC/NU/01-2 |
MC055 | Procedure Code | 44 | 60/6,15-16, 61/6,15-16 | 24.1-6 D | FA0-09.0, FB0-15.0, GU0-07.0 | 835/2110/SVC/HC/01-2 |
MC056 | Procedure Modifier - 1 | 44 | 60/7,15-16, 61/7, 15-16 | 24.1-6 D | FA0-10.0, GU0-08.0 | 835/2110/SVC/HC/01-3 |
MC057 | Procedure Modifier - 2 | 44 | 60/8,15-16, 61/8,15-16 | 24.1-6 D | FA0-11.0 | 835/2110/SVC/HC/01-3 |
MC058 | ICD-9-CM Procedure Code | 80, 81(A-E) | 70/13, 15, 17, 19, 21, 23 | N/A | N/A | 835/2110/SVC/ID/01-2 |
MC059 | Date of Service - From | 45 | 61/13, 15-16, 61/13, 15-16 | 24.1-6 A | N/A | 835/2110/DTM/150/02 |
MC060 | Date of Service - Thru | N/A | N/A | 24.1-6 A | FA0-05.0, FA0-06.0 | 835/2110/DTM/151/02 |
MC061 | Quantity | 46 | 50/7, 11-13, 60/9,15-16, 61/9,15-16 | 24.1-6 G | FA0-19.0, FB0-16.0 | 835/2110/SVC/ /05 |
MC062 | Charge Amount | 47 | 50/8, 11-13, 60/10, 16-16, 61/11, 15-16 | 24.1-6F | FA0-13.0 | 835/2110/SVC/ /02 |
MC063 | Paid Amount | 48 | N/A | N/A | N/A | 835/2110/SVC/ /03 |
MC064 | Prepaid Amount | N/A | N/A | N/A | N/A | N/A |
MC065 | Co-pay Amount | N/A | N/A | N/A | N/A | N/A |
MC066 | Coinsurance Amount | N/A | N/A | N/A | N/A | N/A |
MC067 | Deductible Amount | N/A | N/A | N/A | N/A | N/A |
MC068 | Record Type | N/A | N/A | N/A | N/A | N/A |
Table 19: Pharmacy Insurance Type/Product Code
Code | Description |
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 |
DS | Disability |
HM | Health Maintenance Organization |
LI | Liability |
LM | Liability Medical |
MA | Medicare Part A |
MB | Medicare Party B |
MC | Medicaid |
OF | Other Federal Program (e.g. Black Lung) |
TV | Title V |
VA | Veterans Administration Plan |
WC | Workers' Compensation |
Table 20: Individual Relationship Code
Code | Description |
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 |
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 |
Table 21: Member Gender
Code | Description |
1 | Male |
2 | Female |
3 | Unknown |
PC024A. This element is named "pharmacy country name". The data type of this element is text. Its length is 30. Carriers shall code according to the country name of pharmacy.
Table 22: Table 22: Pharmacy Claims File Layout
Data Element # | Element | Type | Max. Length | Description/Codes/Sources |
PC001 | Payer | Text | 6 | Payer submitting payments |
Council Submitter Code | ||||
PC002 | Plan ID | Text | 30 | CMS National Plan ID |
PC003 | Insurance Type /Product Code | Text | 2 | 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 | ||||
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 (e.g. Black Lung) | ||||
TV Title V | ||||
VA Veteran Administration Plan | ||||
WC Worker's Compensation | ||||
PC004 | Payer Claim Control Number | Text | 35 | Must apply to the entire claim and be unique within the payer's system |
PC005 | Line Counter | Integer | 4 | Line number for this service |
The line counter begins with 1 and is incremented by 1 for each additional service line of a claim | ||||
PC006 | Insured Group Number | Text | 30 | Group or policy number - not the number that uniquely identifies the subscriber |
PC007 | Encrypted Subscriber Unique Identification Number | Text | 30 | Encrypted subscriber's Unique Identification number Set as null if unavailable |
PC008 | Plan Specific Contract Number | Text | 30 | Encrypted plan assigned contract number |
Set as null if contract number = subscriber's social security number | ||||
PC009 | Member Suffix or Sequence Number | Integer | 2 | Uniquely numbers the member within the contract |
PC010 | Member Identification Code | Text | 30 | Encrypted member's Unique Identification number Set as null if unavailable |
PC011 | Individual Relationship Code | Integer | 2 | Member's relationship to subscriber |
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 | ||||
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 | ||||
PC012 | Member Gender | Integer | 1 | 1 Male |
2 Female | ||||
3 Unknown | ||||
PC013 | Member Date of Birth | Date | 8 | CCYYMMDD |
PC014 | Member City Name of Residence | Text | 30 | City name of member |
PC015 | Member State | Text | 2 | As defined by the US Postal Service |
PC016 | Member ZIP Code | Text | 9 | ZIP Code of member - may include non-US codes Do not include dash |
PC017 | Date Service Approved (AP Date) | Date | 8 | CCYYMMDD (Generally the same as the paid date or the Pharmacy Benefits Manager's billing date) |
PC018 | Pharmacy Number | Text | 30 | pharmacy number (NCPDP or NABP) |
PC019 | Pharmacy Tax ID Number | Text | 10 | Federal taxpayer's identification number (Please provide the pharmacy chain's federal tax identification number, if the individual retail pharmacy's tax ID# is not available.) |
PC020 | Pharmacy Name | Text | 30 | Name of pharmacy |
PC021 | National Pharmacy ID Number | Text | 20 | Required if National Provider ID is mandated for use under HIPAA |
PC022 | Pharmacy Location City | Text | 30 | City name of pharmacy - preferably pharmacy location |
PC023 | Pharmacy Location State | Text | 2 | As defined by the US Postal Service |
PC024 | Pharmacy ZIP Code | Text | 10 | ZIP Code of pharmacy - may include non-US codes Do not include dash |
PC024A | Pharmacy Country Name | Text | 30 | Country name of pharmacy |
PC025 | Claim Status | Integer | 2 | 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 | ||||
PC026 | Drug Code | Text | 11 | NDC Code |
PC027 | Drug Name | Text | 80 | Text name of drug |
PC028 | New Prescription | Integer | 2 | 00 New prescription |
PC028A | Refill Number | Integer | 2 | 01-99 Number of refill |
('01' should be used for all refills, if the specific number of the prescription refill is not available.) | ||||
PC029 | Generic Drug Indicator | Text | 1 | N No, branded drug |
Y Yes, generic drug | ||||
PC030 | Dispense as Written Code | Integer | 1 | 0 Not dispensed as written |
1 Physician dispense as written | ||||
2 Member dispense as written | ||||
3 Pharmacy dispense as written | ||||
4 No generic available | ||||
5 Brand dispensed as generic | ||||
6 Override | ||||
7 Substitution not allowed - brand drug mandated by law | ||||
8 Substitution allowed - generic drug not available in marketplace | ||||
9 Other | ||||
PC031 | Compound Drug Indicator | Text | 1 | N Non-compound drug |
Y Compound drug | ||||
U Non-specified drug compound | ||||
PC032 | Date Prescription Filled | Date | 8 | CCYYMMDD |
PC033 | Quantity Dispensed | Integer | 5 | Number of metric units of medication dispensed |
PC034 | Days Supply | Integer | 3 | Estimated number of days the prescription will last |
PC035 | Charge Amount | Decimal | 10 | Do not code decimal point |
PC036 | Paid Amount | Decimal | 10 | Includes all health plan payments and excludes all member payments |
Do not code decimal point | ||||
PC037 | Average Wholesale Price (AWP) | Decimal | 10 | Cost of the drug dispensed |
Do not code decimal point | ||||
PC038 | Postage Amount Claimed | Decimal | 10 | Do not code decimal point |
PC039 | Dispensing Fee | Decimal | 10 | Do not code decimal point |
PC040 | Copay Amount | Decimal | 10 | The preset, fixed dollar amount for which the individual is responsible |
Do not code decimal point | ||||
PC041 | Coinsurance Amount | Decimal | 10 | Do not code decimal point |
PC042 | Deductible Amount | Decimal | 10 | Do not code decimal point |
PC043 | Re cord Type | Text | 2 | PC |
Table 23: Pharmacy Claims File Mapping
Data Element # | Element | National Council for Prescription Drug Programs Field # |
PC001 | Payer | N/A |
PC002 | Plan ID | N/A |
PC003 | Insurance Type/Product Code | N/A |
PC004 | Payer Claim Control Number | N/A |
PC005 | Line Counter | N/A |
PC006 | Insured Group Number | 301-C1 |
PC007 | Encrypted Subscriber Unique Identification Number | 302-C2 |
PC008 | Plan Specific Contract Number | N/A |
PC009 | Member Suffix or Sequence Number | N/A |
PC010 | Member Identification Code | 302-CY |
PC011 | Individual Relationship Code | 306-C6 |
PC012 | Member Gender | 305-C5 |
PC013 | Member Date of Birth | 304-C4 |
PC014 | Member City Name of Residence | 323-CN |
PC015 | Member State or Province | 324-CO |
PC016 | Member ZIP Code | 325-CP |
PC017 | Date Service Approved (AP Date) | N/A |
PC018 | Pharmacy Number | 202-B2 |
PC019 | Pharmacy Tax ID Number | N/A |
PC020 | Pharmacy Name | 833-5P |
PC021 | National Pharmacy ID Number | N/A |
PC022 | Pharmacy Location City | 831-5N |
PC023 | Pharmacy Location State | 832-6F |
PC024 | Pharmacy ZIP Code | 835-5R |
PC025 | Claim Status | N/A |
PC026 | Drug Code | 407-D7 |
PC027 | Drug Name | 516-FG |
PC028 | New Prescription | 403-D3 |
PC029 | Generic Drug Indicator | N/A |
PC030 | Dispense as Written Code | 408-D8 |
PC031 | Compound Drug Indicator | 406-D6 |
PC032 | Date Prescription Filled | 401-D1 |
PC033 | Quantity Dispensed | 442-E7 |
PC034 | Days Supply | 405-D5 |
PC035 | Charge Amount | 804-5B |
PC036 | Paid Amount | 509-F9 |
PC037 | Ingredient Cost/List Price | 506-F6 |
PC038 | Postage Amount Claimed | 428-DS |
PC039 | Dispensing Fee | 507-F7 |
PC040 | Copay Amount | 518-FI |
PC041 | Coinsurance Amount | 518-FI |
PC042 | Deductible Amount | 505-F5 |
PC043 | Record Type | N/A |
129 CMR 2.11