Uniform reporting system for health care claims data sets

129 CMR: HEALTH CARE QUALITY AND COST COUNCIL

129 CMR 2.00: UNIFORM REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS

Section

2.01: Authority 2.02: Purpose and Scope 2.03: Effective Date 2.04: Definitions 2.05: Reporting Requirements for All Licensed Carriers 2.06: Protection of Confidentiality 2.07: Data Filing and Penalties 2.08: Compliance with Data Standards 2.09: Coding and Claims Submission Rules 2.10: Registration and Transmission Requirements 2.11: Health Care Claims Data Filing Format 2.12: Source Codes 2.13: Administrative and Technical Bulletins and Severability

2.01: Authority

.00 is promulgated in accordance with the authority granted to the Health Care Quality and Cost Council by M.G.L. c. 6A, § 16L.

2.02: Purpose and Scope

.02 contains the provisions for submission of health care claims data sets from third- party payers, third-party administrators, and carriers thatprovide onlyadministrative services for a plan sponsor.

2.03: Effective Date

.00 is effective July 17, 2009.

2.04: Definitions

Unless the context indicates otherwise, the following words and phrases shall have the following meanings.

Address. Street address, post office box numbers, apartment numbers, e-mail addresses, web universal resource locator (URL) and internet protocol (IP) address number.

Bank Account. Any checking, savings, certificate of deposit, or any account utilized for the payment of third parties.

Capitated Services. Services rendered by a provider through a contract in which payment are based upon a fixed dollar amount for each member on a monthly basis.

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Carrier. Any entity subject to the insurance laws and rules of Massachusetts, or subject to the jurisdiction of the commissioner of insurance that contracts or offers to provide, deliver, arrange for, pay for or reimburse any of the costs of health services, and includes an insurance company, a health maintenance organization, a nonprofit hospital services corporation, a medicalservice corporation, third party administrator or any other entity arranging for or providing insured health coverage.

Clinical Data. Health care claims and information about health care claims for services delivered in hospitals or other setting.

Co-insurance. The percentage a member pays toward the cost of a covered service.

Confidential Agency Data. Data collected or produced by the Council that: (a) Has not been released publicly; (b) Is not a public record pursuant to M.G.L. c. 4, § 7(26) and St.2006, c. 58, § 136; and (c) Shall not, in the opinion of the Council, be released.

Confidential Clinical Data. Data provided to the Council that: (a) Has not been revealed to the general public; and (b) Relates to provision of medical or other services to a specific individual.

Confidential Financial Data. Data provided to the Council that: (a) Has not been revealed to the general public; and (b) Would directly result in the data provider being placed at a competitive economic disadvantage.

Consumer Assessment of HealthCare Providers and Systems (CAHPS®). A family of survey tools that measure patients' experiences with ambulatory and facility-level care and with health plans.

Co-payment. The fixed dollar amount a member pays to a health care provider at the time a covered service is provided or the full cost of a service when that is less than the fixed dollar amount.

Council. The Health Care Quality and Cost Council, established by M.G.L. c. 6A, § 16K.

Designee. An entity with which the Council has entered into an arrangement pursuant to which the entity performs data management and collecting functions, and under which the entity is strictly prohibited from using or releasing the information and data obtained in such a capacityfor anypurposes other than those specified in the agreement.

Direct Patient Identifier. Any information, other than case or code numbers used to create anonymous or encrypted data, that plainly discloses the identity of an individual, including: (a) Names; (b) Postal address information other than town or city, state and zip code; (c) Telephone and fax numbers; (d) Electronic mail addresses; (e) Social security numbers; (f) Vehicle identifiers and serial numbers; (g) Personal internet ID addresses and URLs; (h) Biometric identifiers, including finger and voice prints; and (i) Personal photographic images.

Disclosure. The act of communicating information to a person not already in possession of that information or to using information for a purpose not originally authorized.

Encryption. A method by which the true value of data has been disguised in order to prevent the identification of persons or groups, and which does not provide the means for recovering the true value of the data.

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Family. Spouse, children, parents, siblings, and legal guardians.

Financial Data. Information collected that includes, but is not limited to: (a) Costs of operation; (b) Revenues; (c) Assets; (d) Liabilities; (e) Fund balances; (f) Other income; (g) Rates; (h) Charges; and (i) Units of services.

Health Care Claims Data. Information consisting of, or derived directly from, member eligibility, medical claims, and pharmacy claims. Health Care Claims Data does not include analysis, reports, or studies containing information from health care claims data sets, if those analyses, reports, or studies have already been released in response to another request for information or as part of a general distribution of public information by the Council.

Health Care Claims Processor. A third-party payer, third-party administrator, or carrier that provides administrative services for a plan sponsor.

Health Care Practitioner. Physicians and all others certified, registered or licensed in the healing arts, including, but not limited to: (a) Nurses; (b) Podiatrists; (c) Optometrists; (d) Pharmacists; (e) Chiropractors; (f) Physical therapists; (g) Dentists; (h) Psychologists; and (i) Physicians' assistants.

Healthcare Effectiveness Data and Information Set (HEDIS®). The set of performance measures in the managed care industry that were developed and are maintained by the National Committee for Quality Assurance (NCQA) covering various areas of measurement from general health plan information to utilization rates.

Hospital. A licensed acute or specialty care institution.

Insured. An individual in whose name an insurance policy is carried.

Medical Claims File. A data file composed of service level remittance information for all non-denied adjudicated claims for each billed service including, but not limited to: (a) Member demographics; (b) Provider information; (c) Charge/payment information; and (d) Clinical diagnosis/procedure codes.

Member. The subscriber and any spouse and/or dependent who is covered by the subscriber's policy.

Member Eligibility File. A data file containing demographic information for each individual member eligible for medical or pharmacy benefits for one or more days of coverage at any time during the reporting month.

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National Committee for Quality Assurance (NCQA). The private, not-for-profit organization that assesses and reports on the quality of the nation's managed care plans through an accreditation and performance measurement program, including quality of care, member satisfaction, access and customer service.

Non-hospital Provider. A provider of health care services other than a hospital.

Pharmacy Claims File. A data file containing service level remittance information from all non-denied adjudicated claims for each prescription including, but not limited to: (a) Member demographics; (b) Provider information; (c) Charge/payment information; and (d) National drug codes.

Plan Sponsor. Any persons, other than an insurer, who establishes or maintains a plan covering residents of Massachusetts, including, but not limited to, plans established or maintained by employers or jointly by one or more employers and one or more employee organizations, committee, joint board of trustees or other similar group of representatives of the parties that establish or maintain the plan.

Prepaid Amount. The fee for the service equivalent that would have been paid by the health care claims processor for a specific service if the service had not been capitated.

Privileged Medical Information. Information other than hospital, non-hospital health care facility, or health care claims data that identifies individual patients and that is derived from communications that were: (a) Made for the purpose of diagnosis or treatment among a provider or health care, persons assisting the provider or patient, and a patient; (b) Made for the purpose of payment of health care services among a provider of health care, a health care claims processor, and a patient; (c) Not intended to be disclosed except to persons necessary to transmit or record the communication and persons participating in the diagnosis, treatment or payment; and (d) Not previously disclosed to the general public.

Provider. A health care facility, health care practitioner, health product manufacturer, health product vendor or pharmacy.

Release. To make data or information available for inspection and copying to persons other than the data provider.

Subscriber. The certificate-holder.

Third Party Administrator. Any persons, that, on behalf of a plan sponsor, health care services plan, nonprofit hospital or medical service organization, health maintenance organization or insurer, receives or collects charges, contributions or premiums for, or adjusts or settles claims on residents of the state.

Third Party Payer. A state agency or a health insurer, nonprofithospital, medical services organization, or managed care organization licensed in the Commonwealth of Massachusetts that pays for healthcare services.

2.05: Reporting Requirements for All Licensed Carriers

(1) HEDIS Reporting Requirements. Each carrier that collects data for use in calculating health plan employer data and information set managed care measures shall report those data that are collected and that pertain to Massachusetts resident members or subscribers who receive their benefits under a policy or plan issued in Massachusetts. The carrier shall use the NCQA tool for submission of HEDIS data.

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(2) CAHPS Reporting Requirements. Each carrier that collects CAHPS survey data shall report those data collected that are collected and that pertain to Massachusetts resident members or subscribers who receive their benefits under a policy or plan issued in Massachusetts. The carrier shall use the NCQA format for submission of the CAHPS survey data.

(3) Health Claims Dataset. Each carrier shall submit to the Council, or its designee, a completed health care claims data set for all Massachusetts resident members who receive services under a policy issued in Massachusetts. Each carrier shall also submit all health care claims processed by any sub­ contractor on its behalf. The health care claims data set shall include a member eligibility file, a medical claims file, and a pharmacy claims file.

(4) Health care claims processors may submit all of the data submissions required of carriers under .00, in accordance with the specifications in .05(1) through (4), to the extent permitted by law and contractual requirements.

(5) Exceptions to Reporting Requirements. (a) Third party payers that write less than $250,000 in insured accident and health premiums in Massachusetts on an annual basis shall not be required to submit their health care claims data set, their HEDIS data, or their CAHPS survey data. (b) Third party administrators that administer insured health insurance plans covering fewer than 200 Massachusetts lives in total shall not be required to submit their health claims data. (c) Carriers shall not be required to submit claims for stand-alone insurance policies that cover only one or more of the types of services listed in .05(5)(c)1. through 8.; however claims for these types of services shall be included in the medical claims file submission if they are covered by a comprehensive medical insurance policy. 1. Specific Disease; 2. Accident; 3. Injury; 4. Hospital Indemnity; 5. Disability; 6. Long-term Care; 7. Vision Coverage; or 8. Durable Medical Equipment. (d) In instances where more than one entity is involved in the administration of a policy, the health carrier shall be responsible for submitting the claims data on policies that it has written, and the third party administrator shall be responsible for submitting claims data on self-insured plans that it administers.

2.06: Protection of Confidentiality

The Council shall institute appropriate administrative procedures and mechanisms to ensure that it is in compliance with the provisions of M.G.L. c. 66A, the Fair Information Practices Act, to the extent that the data collected thereunder are "personal data" within the meaning of that statute. In addition, the Council shall ensure that any contract entered into with other parties for the purposes of processing and analysis of data collected under .00 shall contain assurances such other parties shall also comply with the provisions of M.G.L. c. 66A.

2.07: Data Filing and Penalties

(1) Filing Periods. The filing period for each claims data file listed shall be determined by the total number of covered lives who are Massachusetts residents for whomclaims are being paid or processed by each carrier or health claims processor. For those carriers having 2,000 or more Massachusetts covered lives, data shall be submitted monthly. For those carriers or health care claims processors having fewer than 2,000 Massachusetts covered lives, data shall be submitted quarterly.

(2) Testing of Files. At least 30 days prior to the initial submission of the files, each carrier shall submit to the Council, or its designee, a data set for determining compliance with the standards for data submission. The size, based upona calendar period of one month, or quarter of the data files submitted shall correspond to the filing period established for that carrier.

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(3) Rejection of Files. Failure to conform to the requirements for submission shall result in the rejection and return of the applicable data file(s). All rejected and returned files shall be resubmitted in the appropriate, corrected form to the Council, or its designee, within ten days.

(4) Replacement of Data Files. No carrier shall replace a complete data file submission more than one year after the end of the month in which the file was submitted unless it can establish exceptional circumstances for the replacement. Any replacements after this period shall be approved by the Council. Individual adjustment records shall be submitted with a monthly data file submission.

(5) Penalties. If any carrier fails to submit required data to the council on a timely basis, or fails to correct submissions rejected because of excessive errors, the council or its designee shall provide written notice to the carrier or health care claims processor. Pursuant to M.G.L. c. 6A, § 16L(d), if the carrier or health care claims processor fails, without just cause, to provide the required information within two weeks following receipt of said written notice, the Council may require the carrier to pay a penalty of $1,000 for each week of delay; provided, however, that the maximumpenalty under 129 CMR 2.07 shall be $50,000 per year. The Statistical Plan developed pursuant to 129 CMR2.08 shall include the standards the Council or its designee will use to assess penalties for failure to submit required data, and shall define “just cause” for delays in providing required data.

2.08: Compliance with Data Standards

(1) Statistical Plan. The Council shall approve and publish a Statistical Plan. (a) The Statistical Plan shall include the methodology to be used by carriers to create unique member identification numbers. (b) The Statistical Plan shall include the edit specifications that the Council or its designee will use to verify the accuracy of data submissions, as well as the standards that the Council or its designee will use to reject submissions because of excessive errors. The Statistical Plan will specify the format of an edit report displaying detail for allerrors found in a submission, as well as a summary report containing certain aggregate data for review and verification. The Council or its designee shall provide these reports to each carrier. (c) The Statistical Plan shall include a method for carriers to submit a limited number of late claims paid during a prior submission period. The Statistical Plan shall include rules for submitting denied claims. The Statistical Plan shall include rules for submitting claims for medical services that include pharmacy codes. (d) The Statistical Plan shall list the HEDIS and CAHPS measures that carriers are required to report. (e) The Council will establish compliance standards for submission of race, ethnicity and language data by Administrative Bulletin. (f) Race, ethnicity and language data submitted by carriers shall be based on data self-reported by the member. Carriers may report race, ethnicity and language data acquired from a third party provided that: 1. such data is self-reported by members or guardians; and 2. the carrier submits a technical plan to the Council or its designee that specifies how the date was collected by the third party and obtained by the third party.

(2) Compliance. The Council, or its designee, shall evaluate each member eligibility file, medical claims file and pharmacy claims file to determine compliance with the Statistical Plan and the data reporting requirements in .08(2)(a) through (d): (a) The applicable code for each data element shall be included within the eligible values for the element; (b) Coding values indicating “data not available”, “data unknown”, or the equivalent shall not be used for individual data elements unless specified as an eligible value for the element, or determined allowable in the Statistical Plan; (c) Member sex, diagnosis and procedure codes, and date of birth and all other data fields shall be consistent within an individual record; and (d) Member identifiers shall be consistent across files.

(3) Notification. Upon completion of the evaluation, the Council, or its designee shall promptly notify each carrier whose data submissions do not satisfy the standards. This notification shall identify the specific file and the data elements that do not satisfy the standards.

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(4) Response. Each carrier notified of a non-compliant data submission shall respond within 60 days of the notification by making the changes necessary to satisfy the standards.

2.09: Coding and Claims Submission Rules

Carriers shall file claims data in compliance with .09.

(1) Adjustment Records. Carriers and health care claims processors shall report adjustment records with the appropriate positive or negative fields with the medical and pharmacy file submissions. Negative values shall contain the negative sign before the value. No sign shall appear before a positive value.

(2) Capitated Services Claims. Claims for capitated services shall be reported with all medicaland pharmacy file submissions.

(3) Data Fields. Carriers shall make every effort to report the data fields outlined in these requirements. However, if a field is not used for medical or pharmacy claim adjudication, is not captured on the carrier's transaction system (nor on that of its subcontractors), or cannot be derived reliably from other information available on the carrier's transaction system, the health plan shall notify the Council, or its designee, and shallidentify the field that cannot be provided. After notification, the carrier shall not be required to populate that data field in its reports. The carrier shall report on an annual basis its efforts to populate this field, and the expected data as of which this field will be available, if there is such data.

(4) Code Sources. Unless otherwise specified, the member eligibility file and medical and pharmacy claims files submissions shall use the code sources listed in .10.

Member Identification Codes. Carriers shall assign, according to a standard algorithm provided by the Council, or its designee, a unique identification code to each of their members using the method developed by the Council or its designee.

(6) Specific/Unique Coding. With the exception of provider codes and provider specialty codes, specific or unique coding systems shall not be permitted as part of the health care claims data set submission.

(7) Rules Governing Claims Submissions. (a) Claimant and Member Records. Claims records and member records for medical and pharmacy claims shall be reported only for Massachusetts resident members who receive their benefits under a policy or plan issued in Massachusetts. (b) Claim Records. Records for medical and pharmacy claims file submissions shall be reported at the visit, service, or prescription level. The submission of the medical, and pharmacy claims shall be based upon the paid dates and not upon the dates of service associated with the claims. (c) Co-insurance/Co-payment. Co-insurance and co-payment are to be reported intwo separate fields in the medical and pharmacy claims file submission. (d) Coordination of Benefit Claims. Claims where multiple parties have financial responsibility shall be included with all medical and pharmacy claims file submissions. (e) Version Number. When more than one version of a fully-processed claim service line is submitted, each version ofa claimservice line shall be enumerated sequentially with a higher version number (MC005A) so that the latest version of that service line is the record with the highest version number (MC005A) and the same claim number + line counter. (f) Fully-processed Claim Lines. Only fully-processed claim service lines that have gone through an accounts payable run and been booked to the health plan ledger shall be included on medical and pharmacy claims data submissions. (g) Subsequent Incremental Claims. Subsequent incrementalclaims submissions shall include all reversal and adjustment/restated versions of previously submitted claim service lines and all new, fully-processed service lines associated with the claim, provided that they have paid dates in the reporting period:

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1. Each version of a claim service line shall be enumerated sequentially with a higher line version number (MC005A); and 2. Reversal versions of a claim service line shall be indicated by a claim status code = '22' (Field MC038). (h) Eligibility Records. Records for the member eligibility submission shall be reported at the individual member level so that: 1. Members without medical and/or pharmacy coverage during the month reported shall be excluded; 2. If a member is covered as both a subscriber and a dependent on two different policies during the same month, two records shall be submitted; and 3. If a member has two contract numbers for two different coverage types, two member eligibility records shall be submitted. (i) Retroactive Changes. For the purpose of capturing retroactive changes, carriers shallnot be: 1. Required to resend eligibility data for a prior reporting period; and 2. Considered errors in the submitted eligibility data. (j) Quarterly Submission of Data. Carriers that submit data quarterly shall: 1. Include one member record for each calendar month in which a member was covered; and

2. Submit one record for each reporting month in which the member was eligible for medical or pharmacy benefits for one or more days. (k) Behavioral or Mental Health Claims. All claims related to behavioral, mental health, or substance abuse shall be included in the medical claims file. (l) Medicare, Tricare or Other Supplemental Health Insurance. Claims related to Medicare, Tricare, or other supplemental health insurance policies are to be excluded unless the policies are for health care services entirely excluded by the Medicare, Tricare, or other program. (m) Prepaid Amount. Any prepaid amounts shall be reported in a separate field in the medical and pharmacy claims file submissions. (n) Detailed File Specifications. All carriers shall use the following file specifications in their submissions: 1. Filled Fields. All fields shall be filled where applicable. Non-applicable text and data fields shallbe set to null. Non-applicable integer and decimal fields shall be filled with one zero and shall not include decimal points. 2. Position. All text fields shall be left justified. All integer and decimal fields shall be right justified. 3. Signs. All signs (+ or -) shall appear in the left-most position of all integer and decimal fields. Over-punched signed integers or decimals shall not be utilized. 4. Individual Elements and Mapping. Individual data elements, data types, field lengths, field description/code assignments, and mapping locators (UB92, HCFA 1500, ANSI X12N 270/271, 835, 837) for each file type shall conform to the file specification described in 129 CMR 2.10.

2.10: Registration and Transmission Requirements

(1) Registration Form. (a) Each health care claims processor and each carrier shall submit a registration form to the Council, or its designee. The Council shall develop and publish the registration form, and may make changes from year to year. The form shall contain the information listed in 129 CMR 2.10(1)(a)1. through 6.: 1. Company name; 2. NAIC code; 3. Mailing address; 4. Information about whether the company conducts health insurance related business; 5. Number of Massachusetts members covered; and 6. Name, e-mail address and address of the person completing the form. (b) Carriers shall submit a registration form by October 1, 2007, and annually thereafter on a date specified in the Statistical Plan developed pursuant to .08.

(2) File Organization. The member eligibility files, medical claims file, and the pharmacy claims file shall be:

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(a) Submitted to the Council or its designee as separate ASCII files; and (b) Each record terminated with a carriage return (ASCII 13), or a carriage return line feed (ASCII 13, ASCII 10).

(3) Filing Media. (a) Data files shall be submitted utilizing one of the media listed in .10(3)(a)1. through 4.: 1. CD-ROM; 2. DVD-ROM; 3. Secure SSL web upload interface; or 4. Electronic transmission through a file-transfer program. (b) E-mail attachments shall not be acceptable. (c) Space permitting, multiple data files may be submitted utilizing the same media. If this is the case, the external label shall identify the multiple files.

(4) Transmittal Sheet. (a) All data file submissions on physical media shall be accompanied by a hard copy transmittal sheet containing the information listed in .10(4)(a)1. through 7.: 1. Identification of the carrier; 2. File name; 3. Type of file; 4. Data period(s); 5. Date sent; 6. Record count(s) for the file(s); and 7. Contact person with telephone number and e-mail address. (b) The information on the transmittal sheet shall: 1. Match the information on the header and trailer records; and 2. Conform to the following layout:

Health Care Quality and Cost Council Data Transmission Form

Carrier: ________________________________________________________________________

Council Submitter Code: _________________________

Contact Person Name: ________________________________________________________________

Address: ___________________________________________________________________________

___________________________________________________________________________

Telephone: ____________________________ E-Mail: _______________________________

Eligibility Medical Prescription Drugs File Name

Period Beginning Date Period Ending Date Record Count Date Processed Original Submission Resubmission

(c) In addition to the transmittal sheet, carriers submitting data on physical media shall affix an external label to CD-ROM or DVD on which data are sent that includes: 1. Health plan name; 2. Council submitted code; 3. Contact person name;

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4. Contact person address; 5. Contact person telephone number; 6. Contact person e-mail address; 7. Shipping date; 8. Unique tracking identifier number for each file; 9. Period beginning date; 10. Period ending date; 11. Record count; 12. Date proposed; 13. Submission date; and 14. Any date of resubmission.

2.11: Health Care Claims Data Filing Format

(1) File Format. Each data file submission shall be an ASCII file, variable field length, and asterisk delimited. When asterisks are used in any field values, they shall be enclosed in double quotes.

(2) Header and Trailer Records. Each member eligibility file and each medical claims file, and pharmacy claims file that is submitted shallcontain a header record and a trailer record. The "Header record" means the first record of each separate file that is submitted and the "Trailer record" means the last record of each submitted file. The header and trailer record format shall conform to the record specifications in .11(2)(a): (a) Record Specifications. Carriers shall use the record specifications in .11(2)(a) through (d) in submitting their claims records. The file header record layout shall be submitted using the data elements in .11(2)(a)1. through 8.: 1. HD001. This element is named "record type". The data type of this element is text. Its length is 2. 2. HD002. This element is named "payer". The data type of this element is text. Its length is 6. Carriers shall code according to payer submitting payments, Council submitter code. 3. HD003. This element is named "National Plan ID". The data type of this element is text. Its length is 30. Carriers shall code according to CMS National Plan ID. 4. HD004. This element is named "type of file". The data type of this element is text. Its length is 2. Carriers shall code according to ME member eligibility, MC medical claims, PC pharmacy claims. 5. HD005. This element is named "period beginning date". The data type of this element is integer. Its length is 6. Carriers shall code according to CCYYMM, beginning of paid period for claims, beginning of month covered for eligibility. 6. HD006. This element is named "period ending date". The data type of this element is integer. Its length is 6. Carriers shall code according to CCYYMM, end of paid period for claims, end of month covered for eligibility. 7. HD007. This element is named "record count". The data type of this element is integer. Its length is 10. Carriers shall code according to total number of records submitted in this file, with the header and trailer record excluded from the count. 8. HD008. This element is named "comments". The data type of this element is text. Its length is 80. Carriers shall code according to their own option.

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(b) The file header record layout shall conform to the following Table 1:

Table 1: File Header Record Layout

Maximum Data Element # Element Type Description/Codes/Sources Length

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 filename, system source, etc.

(c) The trailer header record layout shall be submitted using the data elements in 129 CMR 2.11(2)(a)3.a. through g.: 1. TR001. This element is named "record type". The data type of this element is text. Its length is 2. 2. TR002. This element is named "payer". The data type of this element is text. Its length is 6. Carriers shall code according to payer submitting payments, Council submitter code. 3. TR003. This element is named "National Plan ID". The data type of this element is text. Its length is 30. Carriers shall code according to CMS National Plan ID. 4. TR004. This element is named "type of file". The data type of this element is text. Its length is 2. Carriers shall code according to ME member eligibility, MC medical claims, PC pharmacy claims. 5. TR005. This element is named "period beginning date". The data type of this element is integer. Its length is 6. Carriers shall code according to CCYYMM, beginning of paid period for claims, beginning of month covered for eligibility. 6. TR006. This element is named "period ending date". The data type of this element is integer. Its length is 6. Carriers shall code according to CCYYMM, end of paid period for claims, end of month covered for eligibility. 7. TR007. This element is named "date processed". The data type of this element is date. Its length is 8. Carriers shall code according to CCYYMMDD, the date the file was created.

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(d) The trailer record layout shall conform to the following Table 2:

Table 2: Trailer Record Layout

Maximum Data Element # Element Type Description/Codes/Sources Length

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

(3) Member Eligibility File. (a) The specifications for the member eligibility file are listed in .11(3)(a)1. and 2. 1. ME001. This element is named "payer". The data type of this element is text. Its length is 6. Carriers shall code according to payer submitting payments, Council submitter code. 2. ME002. This element is named "National Plan ID". The data type of this element is text. Its length is 30. Carriers shall code according to CMS National Plan ID.

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3. ME003. This element is named "insurance type code/product". The data type of this element is text. Its length is 2. Carriers shall code according to the following Table 3:

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

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4. ME004. This element is named "year". The data type of this element is integer. Its length is 4. Carriers shall code according to the year for which eligibility is reported in this submission. 5. ME005. This element is named "month". The data type of this element is integer. Its length is 2. Carriers shall code according to the month for which eligibility is reported in this submission. 6. ME006. This element is named "insured group or policy number". The data type of this element is text. Its length is 30. Carriers shall code according to the group or policy number and not the number that uniquely identifies the subscriber. 7. ME007. This element is named "coverage level code". The data type of this element is text. Its length is 3. Carriers shall code according to the benefit coverage level: a. CHD Children Only; b. DEP Dependents Only; c. ECH Employee and Children; d. EMP Employee Only; e. ESP Employee and Spouse; f. FAM Family; g. IND Individual; h. SPC Spouse and Children; and i. SPO Spouse Only. 8. ME008. This element is named "encrypted subscriber unique identification number". The data type of this element is text. Its length is 30. Carriers shall code according to the encryption method developed by the Council or its designee. Carriers shall set as null if unavailable. 9. ME009. This element is named "plan specific contract number". The data type of this element is text. Its length is 30. Carriers shallcode according to the encrypted plan assigned contract number. Carriers and health care claims processors shall set as nullifcontract number is the same as the subscriber's social security number. 10. ME010. This element is named "member suffix or sequence number". The data type of this element is integer. Its length is 2. Carriers shall code according to the unique number of the member within the contract. 11. ME011. This element is named "member identification code". The data type of this element is text. Its length is 30. Carriers shall code according to the encryption method developed by the Council or its designee, and carriers shall set as null if unavailable. 12. ME012. This element is named "individual relationship code". The data type of this element is integer. Its length is 2. Carriers shall code according to the member's relationship to the subscriber as shown on the following Table 4:

Table 4: Individual Relationship Code

Code Description 01 Spouse 18 Self/Employee 19 Child 21 Unknown 34 Other Adult

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13. ME013. This element is named "member gender". The data type of this element is text. Its length is1. Carriers shall code according to: a. M = Male; b. F = Female; and c. U = Unknown. 14. ME014. This element is named "member date of birth". The data type of this element is date. Its length is 8. Carriers shall code according to CCYYMMDD. 15. ME015. This element is named "member city name". The data type of this element is text. Its length is 30. Carriers shall code according to the city location of the member’s residence. 16. ME016. This element is named "member state or province". The data type of this element is text. Its length is 2. Carriers shall code the state in which the member resides using the standard abbreviations established by the U.S. Postal Service. 17. ME017. This element is named "member zip code". The data type of this element is text. Its length is 11. Carriers shall code according to ZIP code of member’s residence, which may include non-US codes. Carriers and health care claims processors shall not include the dash in the coding. 18. ME018. This element is named "medical coverage". The data type of this element is text. Its length is 1. Carriers shall code according to: a. Y = Yes; and b. N = No. 19. ME019. This element is named "prescription drug coverage". The data type of this element is text. Its length is 1. Coverage for limited supplies only, such as diabetic test-strips, syringes, and birth control, shall be coded as “No”. Carriers shall code according to: a. Y = Yes; and b. N = No. 20. ME020. This element is named “race 1”. The data type of this element is text. Its length is 6. Carriers shall code according to the Race Code below. 21. ME021. This element is named “race 2”. The data type of this element is text. Its length is 6. Carriers shall code according to the Race Code below. If none, set as null.

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

22. ME022. This element is named “other race”. The data type of this element is text. Its length is 15. Carriers shall enter patient race, if ME020 Race 1 or ME021 Race 2 is coded as R9 Other Race. 23. ME023. This element is named “Hispanic indicator”. The data type of this element is text. Its length is 1. Carriers shall code according to: a. Y = Yes Patient is Hispanic/Latino/Spanish;

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b. N = No Patient is not Hispanic/Latino/Spanish; and c. U = Unknown. 24. ME024. This element is named “ethnicity 1”. The data type of this element is text. Its length is 6. Carriers shall code according to the Ethnicity Code below. 24. ME025. This element is named “ethnicity 2”. The data type of this element is text. Its length is 6. Carriers shall code according to the Ethnicity Code in Table 6.

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

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26. ME026. This element is named “other ethnicity”. The data type of this element is text. Its length is 20. Carriers shall enter patient ethnicity, if ME024 Ethnicity 1 or ME025 Ethnicity 2 is coded as OTHER Other Ethnicity. 27. MEO27. This element is named "language." The data type of this element is text. Its length is 20. Carriers shall code according to the language code as follows in Table 7.

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

28. ME028. This element is named "record type". The data type of this element is text. Its length is 2. Its value is literally "ME". (b) The specifications for the member eligibility file shall be submitted using the following Table 8:

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Table 8: Member Eligibility File Layout

Data Max. Element Type Description/Codes/Sources Element # Length ME001 Payer Text 6 Payer submitting payments Council Submitter Code ME002 National Plan ID Text 30 CMS National Plan ID ME003 Insurance Type Text 2 12 Medicare Secondary Working Aged Beneficiary or Spouse Code/Product w ith Employer Group Health Plan 13 Medicare Secondary End-Stage Renal Disease Beneficiary in the 12-month coordination period w ith 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 w ith 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 Maintenance 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

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Data Max. Element Type Description/Codes/Sources Element # Length 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 Text 30 Group or policy number (not the number that uniquely Policy Number identifies the subscriber) ME007 Coverage Level Code Text 3 Benefit Coverage Level CHD 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 Text 30 Encrypted subscriber's unique identification number (set as Unique Identification null if unavailable) Number ME009 Plan Specific Contract Text 30 Encrypted plan assigned contract number (set as null if Number contract number = subscriber's social security number) ME010 Member Suffice or Integer 2 Uniquely numbers the member within the contract Sequence Number ME011 Member Identification Text 30 Encrypted member's unique identification number (set as null Code if unavailable) ME012 Individual Relationship Integer 2 Member's relationship to insured Code 01 Spouse 18 Self/Employee

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Data Max. Element Type Description/Codes/Sources Element # Length 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 Text 2 As defined by the US Postal Service Province 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 Text 1 Y Yes Coverage 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

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Data Max. Element Type Description/Codes/Sources Element # Length 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)

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Data Max. Element Type Description/Codes/Sources Element # Length 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

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Data Max. Element Type Description/Codes/Sources Element # Length 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

(c) The member eligibility file shall be mapped to a nationalstandard format that conforms to the following Table 9:

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Table 9: Member Eligibility File Mapping

Data HIPAA Reference Transaction Element Element # 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 271/2100C/NM1/MI/09 Identification Number 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

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(4) Medical Claim File. (a) Medical claim file shallbe submitted using the data elements in .11(4)(a)1. through 69.: 1. MC001. This element is named "payer". The data type of this element is text. Its length is 6. Carriers shall code according to the payer submitting payments, Council submitter code. 2. MC002. This element is named "national plan ID". The data type of this element is text. Its length is 30. Carriers shall code according to the CMS national plan ID. 3. MC003. This element is named "insurance type/product code". The data type of this element is text. Its length is 2. Carriers shall code according to the following Table 10:

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

4. MC004. This element is named "payer claim control number". The data type of this element is text. Its length is 35. Carriers shall code according to the entire claim and be unique within the payer's system. 5. MC005. This element is named "line counter". The data type of this element is integer. Its length is 4. Carriers shall code according to line number for this service. The line counter shall begin with one and shall be incremented by one for each additional line of a claim. 6. MC005A. This element is named "version number". The data type of this element is integer. Its length is 4. Carriers shall code according to version number of this claim service line. The version number begins with zero, and is incremented by one for each subsequent version of that service line. 7. MC006. This element is named "insured group or policy number". The data type of this element is text. Its length is 30. Carriers shall code according to the group or policy number, not the number that uniquely identifies the subscriber. 8. MC007. This element is named "encrypted subscriber unique identification number". The data type of this element is text. Its length is 30. Carriers shall code according to the encryption method developed by the Council or its designee. Carriers shall set as null if unavailable. 9. MC008. This element is named "plan specific contract number". The data type of this element is text. Its length is 30. Carriers shall code according to the encrypted plan assigned contract number. Carriers shall set as null if the contract number is the same as the subscriber's social security number.

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10. MC009. This element is named "member suffix or sequence number". The data type of this element is integer. Its length is 2. Carriers shall code according to the unique number of the member within the contract. 11. MC010. This element is named "member identification code". The data type of this element is text. Its length is 30. Carriers shall code according to the encryption method developed by the Council or its designee. Carriers shall set as null if unavailable. 12. MC011. This element is named "individual relationship code". The data type of this element is integer. Its length is 2. Carriers shall code according to member's relationship to subscriber shown as follows in Table 11:

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

13. MC012. This element is named "member gender". The data type of this element is text. Its length is 1. Carriers shall code according to: a. M Male; b. F Female; and c. U Unknown. 14. MC013. This element is named "member date of birth". The data type of this element is date. Its length is 8. Carriers shall code according to CCYYMMDD.

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15. MC014. This element is named "member city name". The data type of this element is text. Its length is 30. Carriers shall code according to the city name of the member’s residence. 16. MC015. This element is named "member state or province". The data type of this element is text. Its length is 2. Carriers shall code the state in which the member resides using the standard abbreviations established by the U.S. Postal Service. 17. MC016. This element is named "member ZIP code". The data type of this element is text. Its length is 11. Carriers shall code according to ZIP Code of member’s residence. This may include non-US codes. Carriers shall not use the dash in coding. 18. MC017. This element is named "date service approved" (AP Date). This field is designed to capture the paid date, also called the Accounts Payable date. The data type of this element is date. Its length is 8. Carriers shall code this date in CCYYMMDD format. 19. MC018. This element is named "admission date". The data type of this element is date. Its length is 12. Carriers shall code for all inpatient claims using CCYYMMDD. 20. MC019. This element is named "admission hour". The data type of this element is integer. Its length is 4. Carriers shall code for all inpatient claims, and shall express time in military time, and may report the hour as HH or as HHMM. 21. MC020. This element is named "admission type". The data type of this element is text. Its length is 1. Carriers shall code using an integer shown as follows in Table 12:

Table 12: Admission Type

Code Description 1 Emergency 2 Urgent 3 Elective 4 Newborn 5 Trauma Center 9 Information Not Available

22. MC021. This element is named "admission source". The data type of this element is text. Its length is 1. Carriers shall code using text shown as follows in Table 13:

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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

23. MC022. This element is named "discharge hour". The data type of this element is integer. Its length is 4. Carriers shall code using military time and may report the hour as HH or as HHMM. 24. MC022A. This element is named "discharge date". The data type of this element is date. Its length is 8. Carriers shall code for all inpatient claims using CCYYMMDD. 24. MC023. This element is named “discharge status". The data type of this element is integer. Its length is 2. Carriers shall code shown as follows in Table 14:

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) Discharged/transferred to another type of institution for inpatient care or referred for outpatient 05 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

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25. MC024. This element is named "service provider number". The data type of this element is text. Its length is 30. Carriers shall code using the payer assigned provider number. 26. MC025. This element is named "service provider tax ID number". The data type of this element is text. Its length is 10. Carriers shall code using the federal taxpayer's identification number. 27. MC026. This element is named "national service provider ID". The data type of this element is text. Its length is 20. Carriers shall code if national provider ID is mandated for use under HIPAA. 28. MC027. This element is named "service provider entity type qualifier". The data type of this element is text. Its length is 1. 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 a "person", and these shall be coded as a person. Carriers shall code according to: a. 1 = Person; and b. 2 = Non-person entity 29. MC028. This element is named "service provider first name". The data type of this element is text. Its length is 25. Carriers shall code according to the individual's first name, and set to null if the provider is a facility or organization. 30. MC029. This element is named "service provider middle name". The data type of this element is text. Its length is 25. Carriers shall code according to the entity's middle name or initial, and shall set to null if provider is a facility or organization. 31. MC030. This element is named "service provider last name or organization name". The data type of this element is text. Its length is 50. Carriers shall code using the full name of the provider organization or last name of individual provider. 32. MC031. This element is named "service provider suffix". The data type of this element is text. Its length is 10. Carriers shall code according to the suffix to the individualname, and set to nullif the provider is a facility or organization. The service provider suffix shall be used to capture the generation of individual clinician (e.g., Jr., Sr., III.), if applicable, rather than the clinician's degree (e.g., MD, LICSW). 33. MC032. This element is named "service provider specialty". The data type of this element is text. Its length is 10. Carriers shall code as defined by the payer dictionary for specialty code value, which shall be supplied during testing. 34. MC033. This element is named "service provider city name". The data type of this element is text. Its length is 30. Carriers shall code according to the city name of provider, and preferably the practice location. 35. MC034. This element is named "service provider state". The data type of this element is text. Its length is 2. Carriers shall code as defined by the US Postal Service. 36. MC035. This element is named "service provider ZIP Code". The data type of this element is text. The length is 11. Carriers shall code according to ZIP code of provider, which may include non-US codes. Carriers shall not use the dash in coding. 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. 37. MC036. This element is named "type of bill on Facility Claims". The data type of this element is integer. Its length is 2. Carriers shall use this coding on facility claims, including those submitted using UB92 forms, shown as follows in Table 15:

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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 Bill Classification Digit = 1 through 6 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 Bill Classification 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 Second Digit if First Bill Classification Digit = 8 1 Hospice, Non-hospital based 2 Hospital, Hospital based 3 Ambulatory Surgery Center 4 Free Standing Birthing Center 9 Other

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38. MC037. This element is named "site of service on NSF/CMS 1500 claims". The data type of this element is text. Its length is 2. Carriers shall use this coding on professional claims, including those submitted using NSF CMS 1500 forms, shown as follows in Table 16:

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

39. MC038. This element is named "claim status". The data type of this element is integer. Its length is 2. This code describes the payment status of the specific service line record. Carriers shall code according to .11(4)(a)39.a. through h.: a. 01 Processed as primary; b. 02 Processed as secondary; c. 03 Processed as tertiary; d. 04 Denied;

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e. 19 Processed as primary, forwarded to additional payer(s); f. 20 Processed as secondary, forwarded to additional payer(s); g. 21 Processed as tertiary, forwarded to additional payer(s); and h. 22 Reversal of previous payment. 40. MC039. This element is named "admitting diagnosis". The data type of this element is text. Its length is 5. Carriers shall code according to all inpatient admission claims and encounters using the ICD-9-CM without the decimal point. 41. MC040. This element is named "E-code". The data type of this element is text. Its length is 5. Carriers shall use this code to describe an injury, poisoning or adverse effect, ICD­ 9-CM without coding decimal points. 42. MC041. This element is named "principal diagnosis". The data type of this element is text. Its length is 5. Carriers shall code the principal diagnosis given on the claim header using CD-9-CM without coding decimal points. 43. MC042. This element is named "other diagnosis – 1". The data type of this element is text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points. 44. MC043. This element is named "other diagnosis – 2". The data type of this element is text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points. 45. MC044. This element is named "other diagnosis – 3". The data type of this element is text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points. 46. MC045. This element is named "other diagnosis – 4". The data type of this element is text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points. 47. MC046. This element is named "other diagnosis – 5". The data type of this element is text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points. 48. MC047. This element is named "other diagnosis – 6". The data type of this element is text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points. 49. MC048. This element is named "other diagnosis – 7". The data type of this element is text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points. 50. MC049. This element is named "other diagnosis – 8". The data type of this element is text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points. 51. MC050. This element is named "other diagnosis – 9". The data type of this element is text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points. 52. MC051. This element is named "other diagnosis – 10". The data type of this element is text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points. 53. MC052. This element is named "other diagnosis – 11". The data type of this element is text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points. 54. MC053. This element is named "other diagnosis – 12". The data type of this element is text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points. 55. MC054. This element is named "revenue code". The data type of this element is text. Its length is 4. Carriers shall code using national uniform billing committee codes. Carriers shall code using leading zeroes, left-justified, and four digits. 56. MC055. This element is named "procedure code". The data type of this element is text. Its length is 5. Carriers shallcode according to the Health Care Common Procedural Coding System (HCPCS). This includes the CPT codes of the American Medical Association.

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57. MC056. This element is named "procedure modifier – 1". The data type of this element is text. Its length is 2. Carriers shall code using a procedure modifier when a modifier clarifies or improves the reporting accuracy of the associated procedure code. 58. MC057. This element is named "procedure modifier – 2". The data type of this element is text. Its length is 2. Carriers shall code using a procedure modifier required when a modifier clarifies or improves the reporting accuracy of the associated procedure code. 59. MC058. This element is named "ICD-9-CM procedure code". The data type of this element is text. Its length is 4. Carriers shall code using the primary ICD-9-CM code given on the claim header without coding decimal points. 60. MC059. This element is named "date of service – from". The data type of this element is date. Its length is 8. Carriers shall code using the first date of service for this service line, CCYYMMDD. 61. MC060. This element is named "date of service – through". The data type of this element is date. Its length is 8. Carriers shall code using the last date of service for this service line, CCYYMMDD. 62. MC061. This element is named "quantity". The data type of this element is integer. Its length is 3. Carriers shall code according to the count of services performed, which shall be set equal to one on all observation bed service lines and should be set equal to zero on all other room and board service lines, regardless of the length of stay. 63. MC062. This element is named "charge amount". The data type of this element is decimal. Its length is 10. Carriers shall code according to the charge without coding decimal points. 64. MC063. This element is named "paid amount". The data type of this element is decimal. Its length is 10. Carriers shall code including withhold amounts without coding decimal points. 65. MC064. This element is named "prepaid amount". The data type of this element is decimal. Its length is 10. Carriers shall code using for capitated services, the fee for service equivalent amount without coding decimal points. 66. MC065. This element is named "co-pay amount". The data type of this element is decimal. Its length is 10. Carriers shall code using the preset, fixed dollar amount for which the individual is responsible without coding decimal points. 67. MC066. This element is named "coinsurance amount". The data type of this element is decimal. Its length is 10. Carriers shall code using the dollar amount of the coinsurance without coding decimal points. 68. MC067. This element is named "deductible amount". The data type of this element is decimal. Its length is 10. Carriers shall code using the dollar amount of the deductible without coding decimal points. 69. MC068. This element is named "record type". The data type of this element is text. Its length is 2.

(b) The file specification for the medical claim file shall conform to the following Table 17:

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Table 17: Medical Claims File Layout

Data Max. Element Data Element Name Type Description/Codes/Sources Length #

MC001 Payer Text 6 Payer submitting payments Council Submitter Code MC002 National Plan ID Text 30 CMS National Plan ID MC003 Insurance Type/ Text 2 12 Preferred Provider Organization (PPO) Product Code 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 Text 35 Must apply to the entire claim and be unique w ithin the Number payer's system MC005 Line Counter Integer 4 Line number for this service The line counter begins w ith 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 w ith 0 and is incremented by 1 for each subsequent version of that service line MC006 Insured Group or Text 30 Group or policy number (not the number that uniquely Policy Number identifies the subscriber) MC007 Encrypted Text 30 Encrypted subscriber’s Unique Identification number Set as Subscriber Unique null if unavailable Identification Number MC008 Plan Specific Text 30 Encrypted plan assigned Set as null if contract number = Contract Number subscriber’s social security number MC009 Member Suffix or Integer 2 Uniquely numbers the member w ithin the contract Sequence Number MC010 Member Text 30 Encrypted member’s Unique Identification number Set as Identification Code null if unavailable MC011 Individual Integer 2 Member's relationship to subscriber Relationship Code 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

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Table 17: Medical Claims File Layout (continued)

Data Max. Element Data Element Name Type Description/Codes/Sources Length # 21 Unknow n 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 Unknow n MC013 Member Date of Date 8 CCYYMMDD Birth MC014 Member City Name Text 30 City name of member MC015 Member State or Text 2 As defined by the US Postal Service Province MC016 Member ZIP Code Text 11 ZIP Code of member - may include non-US codes MC017 Date Service Date 8 CCYYMMDD Approved (AP Date) (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

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Table 17: Medical Claims File Layout (continued)

Data Max. Element Data Element Name Type Description/Codes/Sources Length # 09 Admitted as an inpatient to this hospital 20 Expired 30 Still patient or expected to return for outpatient services MC024 Service Provider Text 30 Payer assigned provider number Number MC025 Service Provider Tax Text 10 Federal taxpayer's identification number ID Number MC026 National Service Text 20 Required if National Provider ID is mandated for use under Provider ID HIPAA MC027 Service Provider Text 1 1 Person Entity Type Qualifier 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 Provider Text 25 Individual first name First Name Set to null if provider is a facility or organization MC029 Service Provider Text 25 Individual middle name or initial Middle Name Set to null if provider is a facility or organization MC030 Service Provider Text 50 Full name of provider organization or last name of individual Last Name or provider Organization Name MC031 Service Provider Text 10 Suffix to individual name Suffix 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 Text 10 As defined by payer Specialty Dictionary for specialty code values must be supplied during testing MC033 Service Provider Text 30 City name of provider - preferably practice location City Name MC034 Service Provider Text 2 As defined by the US Postal Service State MC035 Service Provider ZIP Text 11 ZIP Code of provider - may include non-US codes Do not Code include dash MC035A Service Provider Text 30 Country name of provider - preferably practice location Country Name

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Table 17: Medical Claims File Layout (continued)

Data Max. Element Data Element Name Type Description/Codes/Sources Length #

MC036 Type of Bill – on Integer 2 Type of Facility - First Digit Facility Claims (Should be coded on 1 Hospital facility claim s, such as those subm itted using on UB92 form s) 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 Sw ing 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 Text 2 11 Office NSF/CMS 1500 Claims (Should be coded on 12 Home professional claim s, such as those subm itted using NSF [CMS 1500 form s]) 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room – Hospital

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Table 17: Medical Claims File Layout (continued)

Data Max. Element Data Element Name Type Description/Codes/Sources Length # 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 02 Processed as secondary the paym ent status of the specific service line record) 03 Processed as tertiary 04 Denied 19 Processed as primary, forw arded to additional payer(s) 20 Processed as secondary, forw arded to additional payer(s) 21 Processed as tertiary, forw arded 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

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Table 17: Medical Claims File Layout (continued)

Data Max. Element Data Element Name Type Description/Codes/Sources Length #

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 Text 2 Procedure modifier required w hen a modifier clarifies/ Modifier – 1 improves the reporting accuracy of the associated procedure code MC057 Procedure 1 Text 2 Procedure modifier required w hen a modifier clarifies/ Modifier – 2 improves the reporting accuracy of the associated procedure code MC058 ICD-9-CM Text 4 Primary ICD-9-CM code given on the claim header. Do not Procedure 1 Code code decimal point MC059 Date of Service – Date 8 First date of service for this service line From CCYYMMDD MC060 Date of Service – Date 8 Last date of service for this service line Through 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 w ithhold 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 w hich 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

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(c) The mapping for medical claims file shall conform to the following national standard in Table 18:

Table 18: Medical Claims File Mapping

UB-92 HIPAA Reference UB-92 (Version HCFA NSF (National Transaction Form 6.0) Record 1500 Standard Format) Set/Loop/Segment/ Type/ Qualifier/

Data Data Element Name Locator Field # # Locator Data Element 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 N/A 30/4 N/A N/A 835/2100/CLP/ /06 Indicator Code MC004 Payer Claim Control N/A N/A N/A FA0-02.0, FB0-02.0, 835/2100/CLP/ /07 Number FB1-02.0, GA0-02.0, GC0-02.0, GX0-02.0, GX2-02.0, HA0-02.0, FB2-02.0, GU0-02.0 MC005 Line Counter N/A N/A N/A N/A 837/2400/LX/ /01 MC006 Insured Group or Policy 62 (A-C) 30/10 11C DA0-10.0 837/2000B/SBR/ /03 Number MC007 Encrypted Subscriber N/A N/A N/A N/A 835/2100/NM1/34/08 Unique Identification Number MC008 Plan Specific Contract N/A N/A N/A N/A 835/2100/NM1/HN/08 Number MC009 Member Suffix or N/A N/A N/A N/A N/A Sequence Number MC010 Member Identification N/A N/A N/A N/A 835/2100/NM1/34/08 Code MC011 Individual Relationship 59 (A-C) 30/18 6 DA0-17.0 837/2000B/SBR/ /02, Code 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 5 10/4-5 25 BA0-09.0, CA0-28.0, 835/2100/NM1/FI/09 Number 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

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Table 18: Medical Claims File Mapping (continued)

UB-92 HIPAA Reference UB-92 (Version HCFA NSF (National Transaction Form 6.0) Record 1500 Standard Format) Set/Loop/Segment/ Type/ Qualifier/

Data Data Element Name Locator Field # # Locator Data Element Element # MC026 National Service Provider N/A 10/6 N/A N/A 835/2100/NM1/XX/09 ID MC027 Service Provider Entity N/A N/A N/A N/A 835/2100/NM1/82/02 Type Qualifier MC028 Service Provider First 1 10/12 33 BA0-20.0 835/2100/NM1/82/04 Name MC029 Service Provider Middle 1 10/12 33 BA0-21.0 835/2100/NM1/82/05 Name MC030 Service Provider Last 1 10/12 33 BA0-18.0, BA0-19.0 835/2100/NM1/82/03 Name or Organization Name 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 1 10/14 N/A BA1-09.0, 15.0 837/2010A/N4/ /01 Name MC034 Service Provider State or 1 10/15 N/A BA1-10.0, 16.0 837/2010A/N4/ /02 Province MC035 Service Provider ZIP 1 10/16 N/A BA1-11.0, 17.0 837/2010A/N4/ /03 Code MC036 Type of Bill – on Facility 4 Positions N/A N/A 837/2300/CLM/ /05-1 Claims 1-2: 40/4 MC037 Site of Service – on N/A N/A N/A FA0-07.0, GU0-0.50 835/2100/CLP/ /08 NSF/CMS 1500 Claims 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 21.1 EA0-32.0, GX0-31.0, 837/2300/HI/BK/01-2 GU0-12.0 MC042 Other Diagnosis – 1 68 70/5 21.2 EA0-33.0, GX0-32.0, 837/2300/HI/BF/02-1 GU0-13.0 MC043 Other Diagnosis – 2 69 70/6 21.3 EA0-33.0, GX0-32.0, 837/2300/HI/BF/02-2 GU0-13.0 MC044 Other Diagnosis – 3 70 70/7 21.4 EA0-33.0, GX0-32.0, 837/2300/HI/BF/02-3 GU0-13.0 MC045 Other Diagnosis – 4 71 70/8 N/A EA0-35.0, GX0-34.0, 837/2300/HI/BF/02-4 GU0-15.0 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, N/A N/A 835/2110/SVC/RB/01-2, 60/5,15-16, 835/2110/SVC/NU/01-2 61/5,15-16

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Table 18: Medical Claims File Mapping (continued)

UB-92 HIPAA Reference UB-92 (Version HCFA NSF (National Transaction Form 6.0) Record 1500 Standard Format) Set/Loop/Segment/ Type/ Qualifier/

Data Data Element Name Locator Field # # Locator Data Element Element # MC055 Procedure Code 44 60/6,15-16, 24.1-6 FA0-09.0, FB0-15.0, 835/2110/SVC/HC/01-2 61/6,15-16 D GU0-07.0 MC056 Procedure Modifier – 1 44 60/7,15-16, 24.1-6 FA0-10.0, GU0-08.0 835/2110/SVC/HC/01-3 61/7, 15-16 D MC057 Procedure Modifier – 2 44 60/8,15-16, 24.1-6 FA0-11.0 835/2110/SVC/HC/01-3 61/8,15-16 D MC058 ICD-9-CM Procedure 80, 70/13, 15, N/A N/A 835/2110/SVC/ID/01-2 Code 81(A-E) 17, 19, 21, 23 MC059 Date of Service – From 45 61/13, 15­ 24.1-6 N/A 835/2110/DTM/150/02 16, 61/13, A 15-16 MC060 Date of Service – Thru N/A N/A 24.1-6 FA0-05.0, FA0-06.0 835/2110/DTM/151/02 A MC061 Quantity 46 50/7, 11-13, 24.1-6 FA0-19.0, FB0-16.0 835/2110/SVC/ /05 60/9,15-16, G 61/9,15-16 MC062 Charge Amount 47 50/8, 11-13, 24.1-6F FA0-13.0 835/2110/SVC/ /02 60/10, 16­ 16, 61/11, 15-16 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

(5) Pharmacy Claims File. (a) The pharmacy claimfile layout shall be submitted using the format in .11(5)(a)1. through 44.: 1. PC001. This element is named "payer". The data type of this element is text. Its length is 6. Carriers shall code using the payer submitting payments, Council submitter code. 2. PC002. This element is named "plan ID". The data type of this element is text. Its length is 30. Carriers shall code using the CMS national plan ID. 3. PC003. This element is named "insurance type/product code". The data type of this element is text. Its length is 2. Carriers shall code as follows in Table 19:

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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

4. PC004. This element is named "payer claim control number". The data type of this element is text. Its length is 35. Carriers shall code using the entire claim, which shall be unique within the payer's system. 5. PC005. This element is named "line counter". The data type of this element is integer. Its length is 4. Carriers shall code according to line number for this service. The line counter shall begin with one and be incrementally increased by one for eachadditionalservice line of a claim. 6. PC006. This element is named "insured group number". The data type of this element is text. Its length is 30. Carriers shall code according to group or policy number and not the number that uniquely identifies the subscriber. 7. PC007. This element is named "encrypted subscriber Unique Identification number". The data type of this element is text. Its length is 30. Carriers shall code according to the encryption method developed by the Council or its designee. Carriers shall set as null if unavailable. 8. PC008. This element is named "plan specific contract number. The data type of this element is text. Its length is 30. Carriers shallcode according to the encrypted plan assigned contract number. Carriers shall set as null if contract number is the same as subscriber's social security number. 9. PC009. This element is named "member suffix or sequence number". The data type of this element is integer. Its length is 2. Carriers shall code according to the unique number that identifies the member within the contract. 10. PC010. This element is named "member identification code". The data type of this element is text. Its length is 30. Carriers shall code according to the encryption method developed by the Council or its designee. Carriers shall set as null if unavailable. 11. PC011. This element is named "individual relationship code". The data type of this element is integer. Its length is 2. Carriers shall code according to member's relationship to subscriber as follows in Table 20:

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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

12. PC012. This element is named "member gender". The data type of this element is integer. Its length is 1. Carriers shall code as follows in Table 21:

Table 21: Member Gender

Code Description

1 Male 2 Female 3 Unknown

13. PC013. This element is named "member date of birth". The data type of this element is date. Its length is 8. Carriers shall code according to CCYYMMDD. 14. PC014. This element is named "member city name of residence. The data type of this element is text. Its length is 30. Carriers shall code according to the city name of member's residence. 15. PC015. This element is named "member state". The data type of this element is text. Its length is 2. Carriers shall code the state in which the member resides using the standard abbreviations established by the US Postal Service. 16. PC016. This element is named "member ZIP code". The data type of this element is text. Its length is 9. Carriers shall code according to the ZIP Code of member's residence, which may include non-US codes. Carriers shall not include dash. 17. PC017. This element is named "date service approved" (AP Date). The data type of this element is date. Its length is 8. Carriers shall code according to CCYYMMDD. This date is generally the same as the paid date or the pharmacy benefits manager's billing date.

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18. PC018. This element is named "pharmacy number". The data type of this element is text. Its length is 30. Carriers shall code according to assigned pharmacy number (NCPDP or NABP). 19. PC019. This element is named "pharmacy tax ID number". The data type of this element is text. Its length is 10. Carriers shall code according to Federal taxpayer's identification number. Carriers shall provide the pharmacy chain's federal tax identification number, if the individual retail pharmacy's tax ID# is not available. 20. PC020. This element is named "pharmacy name". The data type of this element is text. Its length is 30. Carriers shall code according to the name of pharmacy. 21. PC021. This element is named "national pharmacy ID number. The data type of this element is text. Its length is 20. Carriers shall code according to the national provider ID, if that is mandated for use under HIPAA. 22. PC022. This element is named "pharmacy location city". The data type of this element is text. Its length is 30. Carriers shall code according to the city name of pharmacy. 23. PC023. This element is named "pharmacy location state". The data type of this element is text. Its length is 2. Carriers shall code as defined by the US Postal Service. 24. PC024. This element is named "pharmacy ZIP code". The data type of this element is text. Its length is 10. Carriers shall code according to ZIP code of pharmacy, which may include non-US codes. Carriers shall not include the dash in their codes. 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. 25. PC025. This element is named "claim status". The data type of this element is integer. Its length is 2. Carriers shall code according to: a. 01 Processed as primary; b. 02 Processed as secondary; c. 03 Processed as tertiary; d. 04 Denied; e. 19 Processed as primary, forwarded to additional payer(s); f. 20 Processed as secondary, forwarded to additional payer(s); g. 21 Processed as tertiary, forwarded to additional payer(s); and h. 22 Reversal of previous payment. 26. PC026. This element is named "drug code". The data type of this element is text. Its length is 11. Carriers shall code according to NDC Code. 27. PC027. This element is named "drug name". The data type of this element is text. Its length is 80. Carriers shall code according to text name of drug. 28. PC028. This element is named "new prescription". The data type of this element is text. Its length is 1. Carriers shall code according to: a. N = new prescription; and b. R = refill prescription. 29. PCO28A. This element is named "refill number". The data type of this element is integer. Its length is 2. Carriers shallcode according to 01-99 Number of refill. If the refill number is unknown then code as 01. 30. PC029. This element is named "generic drug indicator". The data type of this element is text. Its length is 1. Carriers shall code according to: a. N = No, branded drug; and b. Y = Yes, generic drug.

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31. PC030. This element is named "dispense as written code". The data type of this element is integer. Its length is 1. Carriers shall code according to: a. 0 = Not dispensed as written; b. 1 = Physician dispense as written; c. 2 = Member dispense as written; d. 3 = Pharmacy dispense as written; e. 4 = No generic available; f. 5 = Brand dispensed as generic; g. 6 = Override; h. 7 = Substitution not allowed, brand drug mandated by law; i. 8 = Substitution allowed, generic drug not available in marketplace; and j. 9 = Other. 32. PC031. This element is named "compound drug indicator". The data type of this element is text. Its length is 1. Carriers shall code according to: a. N = Non-compound drug; b. Y = Compound drug; and c. U = Non-specified drug compound. 33. PC032. This element is named "date prescription filled". The data type of this element is date. Its length is 8. Carriers shall code according to CCYYMMDD. 34. PC033. This element is named "quantity dispensed". The data type of this element is integer. Its length is 5. Carriers shall code according to the number of metric units of medication dispensed. 35. PC034. This element is named "days supply". The data type of this element is integer. Its length is 3. Carriers shall code according to estimated number of days the prescription will last. 36. PC035. This element is named "charge amount". The data type of this element is decimal. Its length is 10. Carriers shallcode according to the charge, without coding decimal points. 37. PC036. This element is named "paid amount". The data type of this element is decimal. Its length is 10. Carriers shall code according to "includes all health plan payments and excludes all member payments", without coding decimal points. 38. PC037. This element is named "ingredient cost/list price". The data type of this element is decimal. Its length is 10. Carriers shall code according to Average Wholesale Price (AWP) of the drug dispensed, without coding decimal points. 39. PC038. This element is named "postage amount claimed". The data type of this element is decimal. Its length is 10. Carriers shall not code decimal points. 40. PC039. This element is named "dispensing fee". The data type of this element is decimal. Its length is 10. Carriers shall code according to the fee, without coding decimal points. 41. PC040. This element is named "co-pay amount". The data type of this element is decimal. Its length is 10. Carriers shall code according to the preset, fixed dollar amount for which the individual is responsible, without coding decimal points. 42. PC041. This element is named "coinsurance amount". The data type of this element is decimal. Its length is 10. Carriers shall code not code decimal points. 43. PC042. This element is named "deductible amount". The data type of this element is decimal. Its length is 10. Carriers shall not code decimal points. 44. PC043. This element is named "record type". The data type of this element is text. Its length is 2.

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(b) The specifications for the pharmacy claims file layout shall conform to the following Table 22:

Table 22: Pharmacy Claims File Layout

Data Max. Description/Codes/Sources Element Element Type Length #

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 w ithin the payer's system PC005 Line Counter Integer 4 Line number for this service The line counter begins w ith 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 Text 30 Encrypted subscriber’s Unique Identification Identification Number 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 Integer 2 Uniquely numbers the member w ithin the contract Number 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

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Table 22: Pharmacy Claims File Layout (continued)

Data Max. Description/Codes/Sources Element Element Type Length # 20 Employee/Self 21 Unknow n 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 Unknow n PC013 Member Date of Birth Date 8 CCYYMMDD PC014 Member City Name of Text 30 City name of member Residence 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 8 CCYYMMDD Date) (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

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Table 22: Pharmacy Claims File Layout (continued)

Data Max. Description/Codes/Sources Element Element Type Length # 19 Processed as primary, forw arded to additional payer(s) 20 Processed as secondary, forw arded to additional payer(s) 21 Processed as tertiary, forw arded 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 w ritten 1 Physician dispense as w ritten 2 Member dispense as w ritten 3 Pharmacy dispense as w ritten 4 No generic available 5 Brand dispensed as generic 6 Override 7 Substitution not allow ed - brand drug mandated by law 8 Substitution allow ed - 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 w ill 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 Decimal 10 Cost of the drug dispensed (AWP) 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 w hich the individual is responsible Do not code decimal point

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Table 22: Pharmacy Claims File Layout (continued)

Data Max. Description/Codes/Sources Element Element Type Length # PC041 Coinsurance Amount Decimal 10 Do not code decimal point PC042 Deductible Amount Decimal 10 Do not code decimal point PC043 Record Type Text 2 PC

(c) The pharmacy claims file shall be mapped to a national standard as follows in Table 23:

Table 23: Pharmacy Claims File Mapping

Data National Council for Prescription Element Element 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

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Table 23: Pharmacy Claims File Mapping (continued)

Data National Council for Prescription Element Element Drug Programs # Field # 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

2.12: Source Codes

(1) Admission Source Code (Data Element: MC021)

SOURCE: National Uniform Billing Data Element Specifications

AVAILABLE FROM: National Uniform Billing Committee American Hospital Association 840 Lake Shore Drive Chicago, IL 60697

ABSTRACT: A variety of codes explaining who recommended admission to a medical facility.

(2) Admission Type Code (Data Element: MC020)

SOURCE: National Uniform Billing Data Element Specifications

AVAILABLE FROM: National Uniform Billing Committee American Hospital Association 840 Lake Shore Drive Chicago, IL 60697

ABSTRACT: A variety of codes explaining the priority of the admission to a medical facility.

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(3) Current Procedural Terminology (CPT) Codes (Data Element: MC055)

SOURCE: Physicians' Current Procedural Terminology (CPT) Manual

AVAILABLE FROM: Order Department American Medical Association 515 North State Street Chicago, IL 60610

ABSTRACT: A listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians.

(4) Health Care Common Procedural Coding System (Data Element: MC055)

SOURCE: Health Care Common Procedural Coding System

AVAILABLE FROM: www.cms.gov/medicare/hcpcs.htm Centers for Medicare and Medicaid Services Center for Health Plans and Providers CCPP/DCPC C5-08-27 7500 Security Boulevard Baltimore, MD 21244-1850

ABSTRACT: HCPCS is the Centers for Medicare and Medicaid Services (CMS) coding scheme to group procedures performed for payment to providers.

(5) Centers for Medicare and Medicaid Services National Plan ID (Data Elements: DC002, HD003, MC002, ME002, PC002, TR003)

SOURCE: Plan ID Database

AVAILABLE FROM: Centers for Medicare and Medicaid Services Centers for Beneficiary Services Administration Group Division of Membership Operations SI-05-06 7500 Security Boulevard Baltimore, MD 21244-1850

ABSTRACT: The Centers for Medicare and Medicaid Services is developing the Plan ID, which will be proposed as the standard unique identifier for each health plan under the Health Insurance Portability and Accountability Act of 1996.

(6) Centers for Medicare and Medicaid Services National Provider Identifier (Data Elements: DC020, MC026)

SOURCE: National Provider System AVAILABLE FROM: Centers for Medicare and Medicaid Services Office of Information Services Security and Standards Group Director, Division of Health Care Information Systems 7500 Security Boulevard Baltimore, MD 21244-1850

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ABSTRACT: The Centers for Medicare and Medicaid Services is developing the National Provider Identifiers, which is proposed as the standard unique identifier for each health care provider under the Health Insurance Portability and Accountability Act of 1996.

(7) International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure (Data Elements: MC040, MC041, MC043, MC044, MC045, MC046, MC047, MC048, MC049, MC050, MC051, MC052, MC053, MC058)

SOURCE: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9­ CM)

AVAILABLE FROM: U.S. National Center for Health Statistics Commission of Professional and Hospital Activities 1968 Green Road Ann Arbor, MI 48105

ABSTRACT: The International Classification of Diseases, 9th Revision, Clinical Modification, describes the classification of morbidity and mortality information for statistical purposes and for the indexing of hospital records by disease and operations.

(8) National Association of Boards of Pharmacy Number (Data Element: PC021)

SOURCE: National Association of Boards of Pharmacy Database and Listings

AVAILABLE FROM: National Council for Prescription Drug Program 4201 North 24th Street Suite 365 Phoenix, AZ 85016

ABSTRACT: A unique number assigned in the U.S. and its territories to individual clinic, hospital, chain, and independent pharmacy locations that conduct business at retailbybilling third-party drug benefit payers. The National Council for Prescription Drug Programs (NCPDP) maintains this database under contract from the National Association of Boards of Pharmacy. The National Association of Boards of Pharmacy is a seven-digit numeric number with the following format SSNNNNC, where SS=NCPDP assigned state code number, NNNN=NCPDP assigned pharmacy location number, and C=check digit calculated by algorithm from previous six digits.

(9) National Association of Insurance Commissioners (NAIC) Code (Data Elements: DC001, HD002, MC001, ME001, PC001, TR002)

SOURCE: National Association of Insurance Commissioners Company Code List Manual

AVAILABLE FROM: National Association of Insurance Commissioners Publications Department 12th Street, Suite 1100 Kansas City, MO 64105-1925

ABSTRACT: Codes that uniquely identify each insurance company.

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(10) National Drug Code (Data Element: PC026)

SOURCE: Blue Book, Price Alert, National Drug Data File

AVAILABLE FROM: First Databank, The Hearst Corporation 1111 Bayhill Drive San Bruno, CA 94066

ABSTRACT: The National Drug Code is a coding convention established by the Food and Drug Administration to identify the labeler, product number, and package sizes of FDA-approved prescription drugs. There are over 170,000 National Drug Codes on file.

(11) National Uniform Billing Committee (NUBC) Codes (Data Element: MC054)

SOURCE: National Uniform Billing Data Element Specifications

AVAILABLE FROM: National Uniform Billing Committee American Hospital Association 840 Lake Shore Drive Chicago, IL 60697

ABSTRACT: Revenue codes are a classification of hospital charges in a standard grouping that is controlled by the National Uniform Billing Committee. Place of service codes specify the type of location where a service is provided.

(12) Discharge Status Code (Data Element: MC023)

SOURCE: National Uniform Billing Data Element Specifications

AVAILABLE FROM: National Uniform Billing Committee American Hospital Association 840 Lake Shore Drive Chicago, IL 60697

ABSTRACT: A variety of codes indicating member status as of the date of service-thru field.

(13) States and Outlying Areas of the U.S. (Data Elements: DC015, DC028, MC015, MC034, ME016, PC015, PC023)

SOURCE: National Zip Code and Post Office Directory

AVAILABLE FROM: U.S. Postal Service National Information Data Center P.O. Box 2977 Washington, DC 20013

ABSTRACT: Provides names, abbreviations, and codes for the 50 states, the District of Columbia, and the outlying areas of the U.S. The entities listed are considered to be the first order divisions of the U.S. Microfiche.

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(14) Uniform Billing Claim Form Bill Type (Data Element: MC036)

SOURCE: National Uniform Billing Data Element Specifications Type of Bill Positions 1 and 2

AVAILABLE FROM: National Uniform Billing Committee American Hospital Association 840 Lake Shore Drive Chicago, IL 60697

ABSTRACT: A variety of codes describing the type of medical facility.

(15) X12 Directories

SOURCE: X12.3 Data Element Directory; X12.22 Segment Directory

AVAILABLE FROM: Data Interchange Standards Association, Inc. (DISA) Suite 200 1800 Diagonal Road Alexandria, VA 22314-2852

ABSTRACT: The data element directory contains the format and descriptions of data elements used to construct X12 segments. It also contains code lists associated with these data elements. The segment director contains the format and definitions of the data segments used to construct the X12 transaction sets.

(16) ZIP Code (Data Elements: DC016, DC029, MC016, MC035, ME017, PC016, PC024)

SOURCE: National Zip Code and Post Office Directory, Publication 65, The USPS Domestic Mail Manual

AVAILABLE FROM: U.S. Postal Service Washington, DC 20260

New Orders Superintendent of Documents P.O. Box 371954 Pittsburgh, PA 15250-7954

ABSTRACT: The ZIP Code is a geographic identifier of areas within the United States and its territories for purposes of expediting mail distribution by the U.S. PostalService. It is five or nine numeric digits. The ZIP Code structure divides the U.S. into ten large groups of states. The leftmost digit identifies one of these groups. The next two digits identify a smaller geographic area within the large group. The two right-most digits identify a local delivery area. In the nine digit ZIP Code, the four digits that follow the hyphen further subdivide the delivery service area. The two leftmost digits identify a sector that may consist of several large buildings, blocks or groups of streets. The rightmost digits divide the sector into segments such as a street, a block, a floor of a building, or a cluster of mailboxes. The USPS Domestics Mail Manual includes information on the use of the new 11-digit ZIP code.

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(17) Race and Ethnicity Codes (Data Elements: ME020, ME021, ME022, ME023, ME024, ME025 and ME026)

Source: Massachusetts Division of Health Care Finance and Policy Hospital Inpatient Discharge Data Electronic Records Submission Specification, September 2006

And Hierarchy for Reporting Ethnicity, September 14, 2006

Available from: Massachusetts Division of Health Care Finance and Policy 2 Boylston Street Boston, MA 02116

ABSTRACT: This document provides the technical and data specifications, including edit specifications, required for the Massachusetts Hospital Inpatient Discharge Data.

(18) Language Codes (Data Element: ME027)

SOURCE: Guidelines for the Implementation, Interpretation and Enforcement of the Boston Public Health Commission's Standardized Data Collection Regulation

AVAILABLE FROM: Boston Public Health Commission 1010 Massachusetts Avenue Boston, MA 02118

ABSTRACT: This document provides technicaland data specifications for acute hospitals to report race, ethnicityand language data for all inpatient, outpatientobservation, and outpatient emergency department visits. .

2.13: Administrative and Technical Bulletins and Severability

(1) Administrative and Technical Information Bulletins The Council may revise the specifications or other administrative requirements from time to time by notice or administrative bulletin.

(2) Severability. The provisions of .00 are declared to be severable and if any such provisions or the application of such provisions to any carrier or circumstances are held invalid or unconstitutional, such invalidity or unconstitutionality shall not be construed to affect the validity or unconstitutionality of any of the remaining provisions of129 CMR2.00 or of such provisions to carriers or circumstances other than those as to which it is held invalid.

REGULATORY AUTHORITY

.00: M.G.L. c. 6A, § 16L.