Data Element # | Data Element Name |
ME003 | Insurance Type |
ME004 | Year of Reported Eligibility |
ME005 | Month of Reported Eligibility |
ME007 | Coverage Level Code |
ME012 | Individual Relationship Code |
ME013 | Member Gender |
ME016 | Member State or Province |
ME018 | Medical Coverage -Yes/No |
ME019 | Prescription Drug Coverage -Yes/No |
ME020 | Race 1 |
ME021 | Race 2 |
ME022 | Other Race |
ME023 | Hispanic Indicator -Yes/No |
ME024 | Ethnicity 1 |
ME025 | Ethnicity 2 |
ME026 | Other Ethnicity |
MC003 | Insurance Type/Product Code |
MC011 | Individual Relationship Code |
MC012 | Member Gender |
MC019 | Admission Hour |
MC020 | Admission Type |
MC021 | Admission Source |
MC022 | Discharge Hour |
MC023 | Discharge Status Length of Stay (LOS) |
MC027 | Service Provider Entity Type Qualifier |
MC031 | Service Provider Suffix |
MC034 | Service Provider State |
MC035A | Service Provider Country Name |
MC036 | Type of Bill -on Facility Claims |
MC037 | Site of Service -on NSF/CMS 1500 Claims |
MC038 | Claim Status |
MC039 | Admitting Diagnosis |
MC040 | E-Code |
MC041 | Principal Diagnosis |
MC042 | Other Diagnosis -1 |
MC043 | Other Diagnosis -2 |
MC044 | Other Diagnosis -3 |
MC045 | Other Diagnosis -4 |
MC046 | Other Diagnosis -5 |
MC047 | Other Diagnosis -6 |
MC048 | Other Diagnosis -7 |
MC049 | Other Diagnosis -8 |
MC050 | Other Diagnosis -9 |
MC051 | Other Diagnosis -10 |
MC052 | Other Diagnosis -11 |
MC053 | Other Diagnosis -12 |
MC054 | Revenue Code |
MC055 | Procedure 1 Code |
MC056 | Procedure 1 Modifier- 1 |
MC057 | Procedure 1 Modifier -2 |
MC058 | ICD-9-CM Procedure 1 Code |
MC061 | Quantity |
MC065 | Copay Amount |
MC067 | Deductible Amount |
PC003 | Insurance Type/Product Code |
PC011 | Individual Relationship Code |
PC012 | Member Gender |
PC017 | Date Service Approved (AP Date) |
PC024A | Pharmacy Country Name |
PC025 | Claim Status |
PC026 | Drug Code |
PC027 | Drug Name |
PC028 | New Prescription |
PC028A | Refill Number |
PC029 | Generic Drug Indicator |
PC030 | Dispense as Written Code |
PC031 | Compound Drug Indicator |
PC033 | Quantity Dispensed |
PC034 | Days Supply |
PC037 | Average Wholesale Price (AWP) |
PC038 | Postage Amount Claimed |
PC039 | Dispensing Fee |
PC040 | Copay Amount |
PC042 | Deductible Amount |
Data Element # | Data Element Name |
ME001 | Payer |
ME002 | National Plan ID |
ME008 | Encrypted Subscriber Unique Identification Number |
ME009 | Plan Specific Contract Number |
ME010 | Member Suffice or Sequence Number |
ME011 | Member Identification Code |
Member Age in Years | |
Member Age in Months | |
ME015 | Member City Name |
ME017 | Member ZIP Code |
MC001 | Payer |
MC002 | National Plan ID |
MC004 | Payer Claim Control Number |
MC005 | Line Counter |
MC005A | Version Number |
MC007 | Encrypted Subscriber Unique Identification Number |
MC008 | Plan Specific Contract Number |
MC009 | Member Suffix or Sequence Number |
MC010 | Member Identification Code |
MC014 | Member City Name |
MC015 | Member State or Province |
MC016 | Member ZIP Code |
MC017 | Date Service Approved (AP Date) |
MC018 | Admission Date |
MC022A | Discharge Date |
Member Age in Years at Discharge | |
Member Age in Months at Discharge | |
MC024 | Service Provider Number |
MC025 | Service Provider Tax ID Number |
MC026 | National Service Provider ID |
MC028 | Service Provider First Name |
MC029 | Service Provider Middle Name |
MC030 | Service Provider Last Name or Organization Name |
MC032 | Service Provider Specialty |
MC033 | Service Provider City Name |
MC035 | Service Provider ZIP Code |
MC059 | Date of Service -From |
MC060 | Date of Service -Thru |
MC062 | Charge Amount |
MC063 | Paid Amount |
MC064 | Prepaid Amount |
MC066 | Coinsurance Amount |
Data Element # | Data Element Name |
ME006 | Insured Group or Policy Number |
ME014 | Member Date of Birth |
MC006 | Insured Group or Policy Number |
MC013 | Member Date of Birth |
PC006 | Insured Group Number |
PC013 | Member Date of Birth |
129 CMR 3.03