Appendix A: Medical claims data file layout and dictionary



Appendix A: Medical claims data file layout and dictionaryData elementNameTypeMax. length Required?Description/valid valuesError thresholdMC001 Payer typeText 1 YesSee lookup table MC0010%MC003Product codeText3YesSee lookup table MC0030%MC004 Claim IDText80YesPayer’s unique claim identifier0%MC005 Service line counterNumeric4YesIncrements of 1 for each claim line0%MC010Member IDText30YesPlan-specific unique member identifier0%MC017Payment dateDate8YesCCYYMMDD (example: 20090624). Blanks allowed for denied claims only.0%MC018Admission dateDate8YesCCYYMMDD (example: 20090603). Required only for institutional claims.1.2%MC023Discharge statusText2YesSee lookup table MC023. Required only for institutional claims.1.2%MC024Rendering provider IDText30YesIdentifier for the rendering provider as assigned by the reporting entity1.2%MC036Type of billNumeric3SituationalSee lookup table MC 036. Required only for institutional claims.1.2%MC037Place of serviceText2SituationalSee lookup table MC 037. Required only for professional claims.1.2%MC038Claim statusText1YesWas claim paid, denied, CCO encounter, or MCO encounter only? Valid values: P (paid), D (denied), C (CCO encounter), E (other managed care encounter)0%MC038ACOB statusText1 YesWas claim a COB claim? Valid values: Y (yes), N (no)1.2%MC041Principal diagnosisText8YesICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 01220)1.2%MC041PPOA flag 1Text1YesPresent on admission flag for principal diagnosis. See look-up table MC041P. Required only for institutional claims.1.2%MC042Diagnosis 2Text8YesICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 01220)1.2%MC042PPOA flag 2Text1SituationalPresent on admission flag for diagnosis 2. Required if MC042 is populated. See look-up table MC041P. Required only for institutional claims.1.2%MC043Diagnosis 3Text8YesICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 01220)1.2%MC043PPOA flag 3Text1SituationalPresent on admission flag for diagnosis 3. Required if MC043 is populated. See look-up table MC041P. Required only for institutional claims.1.2%MC044Diagnosis 4Text8YesICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 01220)1.2%MC044PPOA flag 4Text1SituationalPresent on admission flag for diagnosis 4. Required if MC044 is populated. See look-up table MC041P. Required only for institutional claims.1.2%MC045Diagnosis 5Text8YesICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 01220)1.2%MC045PPOA flag 5Text1SituationalPresent on admission flag for diagnosis 5. Required if MC045 is populated. See look-up table MC041P. Required only for institutional claims.1.2%MC046Diagnosis 6Text8YesICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 01220)1.2%MC046PPOA flag 6Text1SituationalPresent on admission flag for diagnosis 6. Required if MC046 is populated. See look-up table MC041P. Required only for institutional claims.1.2%MC047Diagnosis 7Text8YesICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 01220)1.2%MC047PPOA flag 7Text1SituationalPresent on admission flag for diagnosis 7. Required if MC047 is populated. See look-up table MC041P. Required only for institutional claims.1.2%MC048Diagnosis 8Text8YesICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 01220)1.2%MC048PPOA flag 8Text1SituationalPresent on admission flag for diagnosis 8. Required if MC048 is populated. See look-up table MC041P. Required only for institutional claims.1.2%MC049Diagnosis 9Text8YesICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 01220)1.2%MC049PPOA flag 9Text1SituationalPresent on admission flag for diagnosis 9. Required if MC049 is populated. See look-up table MC041P. Required only for institutional claims.1.2%MC050Diagnosis 10Text8YesICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 01220)1.2%MC050PPOA flag 10Text1SituationalPresent on admission flag for diagnosis 10. Required if MC050 is populated. See look-up table MC041P. Required only for institutional claims.1.2%MC051Diagnosis 11Text8YesICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 01220)1.2%MC051PPOA flag 11Text1SituationalPresent on admission flag for diagnosis 11 Required if MC051 is populated. See look-up table MC041P. Required only for institutional claims.1.2%MC052Diagnosis 12Text8YesICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 01220)1.2%MC052PPOA flag 12Text1SituationalPresent on admission flag for diagnosis 12 Required if MC052 is populated. See look-up table MC041P. Required only for institutional claims.1.2%MC053Diagnosis 13Text8YesICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 01220)1.2%MC053PPOA flag 13Text1SituationalPresent on admission flag for diagnosis 13 Required if MC053 is populated. See look-up table MC041P. Required only for institutional claims.1.2%MC054Revenue codeText4YesInclude all digits (example: 0320). Required only for institutional claims.1.2%MC055CPT/CPT II/HCPCS procedure codeText5YesCPT, CPT II or HCPCS code. Include all digits (examples: 29870 or G0289)1.2%MC056Procedure modifier 1Text2YesCPT or HCPCS modifier. Include all digits (examples: 50 or AA)1.2%MC057Procedure modifier 2Text2YesCPT or HCPCS modifier. Include all digits (examples: 50 or AA)1.2%MC057AProcedure modifier 3Text2YesCPT or HCPCS modifier. Include all digits (examples: 50 or AA)1.2%MC057BProcedure modifier 4Text2YesCPT or HCPCS modifier. Include all digits (examples: 50 or AA)1.2%MC058Principal inpatient procedure codeText8YesICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 0085). Required only for institutional claims.1.2%MC058AInpatient procedure code 2Text8YesICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 0085). Required only for institutional claims.1.2%MC058BInpatient procedure code 3Text8YesICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 0085). Required only for institutional claims.1.2%MC058CInpatient procedure code 4 Text8YesICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 0085). Required only for institutional claims.1.2%MC058DInpatient procedure code 5Text8YesICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 0085). Required only for institutional claims.1.2%MC058EInpatient procedure code 6Text8YesICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 0085). Required only for institutional claims.1.2%MC058FInpatient procedure code 7Text8YesICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 0085). Required only for institutional claims.1.2%MC058GInpatient procedure code 8Text8YesICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 0085). Required only for institutional claims.1.2%MC058HInpatient procedure code 9Text8YesICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 0085). Required only for institutional claims.1.2%MC058JInpatient procedure code 10Text8YesICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 0085). Required only for institutional claims.1.2%MC058KInpatient procedure code 11Text8YesICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 0085). Required only for institutional claims.1.2%MC058LInpatient procedure code 12Text8YesICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 0085). Required only for institutional claims.1.2%MC058MInpatient procedure code 13Text8YesICD-10 procedure code for dates of service after 10/01/2014. Include all characters, (example: B245ZZ3). ICD-9 procedure code for dates of service before 10/01/20154. If ICD-9 include all digits and exclude decimal point (example: 0085). Required only for institutional claims.1.2%MC059Date of service – FromDate8YesCCYYMMDD (example: 20090603)0%MC060Date of service – ThruDate8YesCCYYMMDD (example: 20090603)0%MC061QuantityNumeric115YesCount of units sent on claim line.0%MC062ChargesNumeric12YesTwo explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.000%MC062AAllowed amountNumeric12YesTwo explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.000%MC063PaymentNumeric12YesTwo explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.000%MC064Prepaid amountNumeric12YesTwo explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.000%MC065Co-paymentNumeric12YesTwo explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.000%MC066Co-insuranceNumeric12YesTwo explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.000%MC067DeductibleNumeric12YesTwo explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.000%MC067APatient pay amountNumeric12SituationalRequired if any of MC065, MC066, or MC067 are missing. Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.000%MC070Discharge dateDate8SituationalRequired only for institutional claims. Use 99991231 if patient has not discharged. CCYYMMDD (example: 20090605). Required only for institutional claims.1.2%MC076Billing provider IDText30YesIdentifier for the billing provider as assigned by the reporting entity1.2%QC05Prior version claim numberText80SituationalRequired for participants in Q-Corp initiative.N/AQC06Claim received dateDate8SituationalRequired for participants in Q-Corp initiative. CCYYMMDDN/AQC22DRGText3SituationalDRG paid by payer. If not available send billed DRG. Required for participants in Q-Corp initiative. Example: 061N/AQC23DRG typeText1SituationalRequired for participants in Q-Corp initiative. Valid values: C (CMS v.24) or M (MS-DRG)N/AQC37LOINC codeText8NoDo not populate as of 01/01/2017.Placeholder for the Q-Corp initiative. N/AQC38Lab resultText8NoDo not populate as of 01/01/2017.Placeholder for the Q-Corp initiative.N/AQC39Micro/macro albumin resultText1NoDo not populate as of 01/01/2017.Placeholder for the Q-Corp initiative.N/AOHLC1COB allowed amountNumeric12SituationalDo not populate as of 01/01/2017.Required for participants in OHLC high value medical home initiative. Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00N/AOHLC2Risk withhold amountNumeric12SituationalDo not populate as of 01/01/2017.Required for participants in OHLC high value medical home initiative. Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00N/AMC008Plan specific contract numberText30YesPlan specific contract number (aka group number)0%MC201ICD version codeText2YesSpecifies the claim’s ICD version. Valid values: 9 (ICD-9) or 10 (ICD-10)0%TBDMC202NetworkText1YesSee lookup table MC2020%TBDMC203Admission TypeText1SituationalRequired for inpatient claims. Populate this field only if claim is inpatient. Valid values: 1 (Emergency), 2 (Urgent), 3 (Elective), 4 (Newborn), 5 (Trauma Center), 9 (Information Not Available)1.2%TBDMC204Admission SourceText1SituationalRequired for inpatient claims. Populate this field only if claim is inpatient. See lookup table MC2041.2%TBDMC205Admitting DiagnosisText8SituationalRequired for inpatient claims. ICD-10 diagnosis code for dates of service beginning 10/01/2014. Include all characters (example: E10.359). ICD-9 diagnosis code for dates of service before 10/01/2014. If ICD-9 include all digits and exclude decimal point (example: 01220). Populate this field only if claim is inpatient.1.2%TBDMC206Pay to Patient FlagText1YesValid values: Y (patient was directly reimbursed), N (patient was not directly reimbursed). If unknown, default to N.0%TBDMC207Empty fieldFor future implementationN/AMC208Empty fieldFor future implementationN/AMC209Empty fieldFor future implementationN/AMC210Empty fieldFor future implementationN/ALookup Table MC001: Payer typeThis field contains a single letter identifying the payer type.CodeValueCCarrierDMedicaidGOther government agencyPPharmacy benefits managerTThird-party administratorUUnlicensed entityLookup Table MC003: Product codeThis field contains the insurance type or product code that indicates the type of insurance coverage the individual has.CodeValueMDEMedicaid dual eligible HMOMDMedicaid disabled HMOMLIMedicaid low income HMOMRBMedicaid restricted benefit HMOMRMedicare Advantage HMOMPMedicare Advantage PPOMPDMedicare Part D onlyMCMedicare CostPPOCommercial PPOPOSCommercial POSHMOCommercial HMOSN1Special needs plan – chronic conditionSN2Special needs plan – institutionalizedSN3Special needs plan – dual eligibleCHPSpecial Children’s Health Insurance Program (SCHIP)MDFMedicaid fee-for-serviceSIPSelf insured PPOSIFSelf insured POSSIHSelf insured HMOPHPharmacy benefits onlyINCommercial indemnityEPOCommercial EPOSLCommercial stop lossZZUnknownLookup Table MC023: Discharge statusThis field contains the status for the patient discharged from the hospital.CodeValue01Discharged to home or self care02Discharged/transferred to another short term general hospital for inpatient care03Discharged/transferred to skilled nursing facility (SNF)04Discharged/transferred to nursing facility (NF)05Discharged/transferred to a designated cancer center or children’s hospital06Discharged/transferred to home under care of organized home health service organization07Left against medical advice or discontinued care08Discharged/transferred to home under care of a Home IV provider09Admitted as an inpatient to this hospital20Expired21Discharged/transferred to court/law enforcement30Still patient or expected to return for outpatient services40Expired at home41Expired in a medical facility42Expired, place unknown43Discharged/transferred to a Federal hospital50Hospice – home51Hospice – medical facility61Discharged/transferred within this institution to a hospital based Medicare-approved swing bed62Discharged/transferred to an inpatient rehabilitation facility including distinct parts of a hospital63Discharge/transferred to a long-term care hospital64Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare65Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital66Discharged/transferred to a critical access hospital (CAH)70Discharged/transferred to another type of health care institution not defined elsewhere in this code listLookup Table MC036: Type of billThis field is required for institutional claims and must not be populated for professional claims. The values of the second digit are situational depending on the value of the first digit.First digit: type of facilityCodeValue1Hospital2Skilled Nursing3Home Health4Christian Science Hospital5Christian Science Extended Care6Intermediate Care7Clinic8Special FacilitySecond Digit if First Digit = 1-6CodeValue1Inpatient (Including Medicare Part A)2Inpatient (Medicare Part B Only)3Outpatient4Other (for hospital referenced diagnostic services or home health not under a plan of treatment)5Nursing Facility Level I6Nursing Facility Level II7Intermediate Care -Level III Nursing Facility8Swing BedsSecond Digit if First Digit =7CodeValue1Rural Health2Hospital Based or Independent Renal Dialysis Center3Free Standing Outpatient Rehabilitation Facility (ORF)5Comprehensive Outpatient Rehabilitation Facilities (CORFs)6Nursing Facility Level II7Community Mental Health Center9OtherSecond Digit if First Digit = 8CodeValue1Hospice (Non Hospital Based)2Hospice (Hospital-Based)3Ambulatory Surgery Center4Free Standing Birthing Center9OtherThird digit: claim frequencyCodeValue1Admit Through Discharge2Interim-First Claim3Interim-Continuing Claims4Interim-Last Claim5Late Charge Only7Replacement of Prior Claim8Void/Cancel of a Prior Claim9Final Claim for a Home Health EncounterLookup Table MC037: Site of serviceFor professional claims, this field records the type of facility where the service was performed. This field should not be populated for institutional claims.CodeValue00Not supplied01Pharmacy03School 04Homeless Shelter 05Indian Health Service Freestanding Facility 06Indian Health Service Provider-Based Facility 07Tribal 638 Freestanding Facility 08Tribal 638 Provider-Based Facility 09Prison/Correctional Facility11Office 12Home 13Assisted Living Facility 14Group Home 15Mobile Unit 16Temporary Lodging17Walk-in Retail Health Clinic20Urgent Care Facility 21Inpatient Hospital 22Outpatient Hospital 23Emergency Room – Hospital 24Ambulatory Surgical Center 25Birthing Center26Military Treatment Facility 31Skilled Nursing Facility 32Nursing Facility 33Custodial Care Facility 34Hospice 41Ambulance-Land 42Ambulance-Air or Water 49Independent Clinic 50Federally Qualified Health Center 51Inpatient Psychiatric Facility 52Psychiatric Facility-Partial Hospitalization 53Community Mental Health Center 54Intermediate Care Facility/Mentally Retarded 55Residential Substance Abuse Treatment Facility 56Psychiatric Residential Treatment Center 57Non-residential Substance Abuse Treatment Facility 60Mass Immunization Center 61Comprehensive Inpatient Rehabilitation Facility 62Comprehensive Outpatient Rehabilitation Facility 65End-Stage Renal Disease Treatment Facility 71State or Local Public Health Clinic72Rural Health Clinic 81Independent Laboratory 99Other Place of Service Lookup Table MC041P: POA flagThis field contains the inpatient present on admission (POA) flag as reported by the provider. Do not populate if not reported by the provider.CodeValueYYesNNoWClinically undeterminedUInformation not in record1Diagnosis exempt from POA reporting Lookup Table MC202: NetworkThis field contains a single digit indicating whether the provider was paid under a network contract. CodeValue1In-network: The plan has a direct contract with the provider that made the claim.2National network: The plan does not have a direct contract with the provider that made the claim, but paid a contracted rate through participation in a national network or reciprocal agreement with a plan operating in another state.3Out-of-network: The plan did not pay the provider a contracted rate.Lookup Table MC204: Admission SourceThis field contains a single character indicating source of referral for an inpatient admission. Populate this field only for institutional inpatient claims. Do not populate this field for professional claims. Use codes on the next page if MC203 = 4. CodeValue if MC203 <> 40ANOMALY: invalid value, if present, translate to '9'1Non-Health Care Facility Point of Origin (Physician Referral): The patient was admitted to this facility upon an order of a physician.2Clinic referral: The patient was admitted upon the recommendation of this facility's clinic physician.3HMO referral: Reserved for National Assignment. Prior to 3/08, HMO referral: The patient was admitted upon the recommendation of a health maintenance organization (HMO) physician.4Transfer from a hospital (different facility): The patient was admitted to this facility as a hospital transfer from an acute care facility where he or she was an inpatient.5Transfer from a skilled nursing facility (SNF) or Intermediate Care Facility (ICF): The patient was admitted to this facility as a transfer from a SNF or ICF where he or she was a resident.6Transfer from another health care facility: The patient was admitted to this facility as a transfer from another type of health care facility not defined elsewhere in this code list where he or she was an inpatient.7Emergency room: The patient was admitted to this facility after receiving services in this facility's emergency room.8Court/law enforcement: The patient was admitted upon the direction of a court of law or upon the request of a law enforcement agency's representative.9Information not available: The means by which the patient was admitted is not known.AReserved for National Assignment. (eff. 3/08) Prior to 3/08 defined as: Transfer from a Critical Access Hospital: patient was admitted/referred to this facility as a transfer from a Critical Access Hospital.BTransfer from Another Home Health Agency: The patient was admitted to this home health agency as a transfer from another home health agency.(Discontinued July 1,2010- See Condition Code 47)CReadmission to Same Home Health Agency: The patient was readmitted to this home health agency within the same home health episode period. (Discontinued July 1,2010)DTransfer from hospital inpatient in the same facility resulting in a separate claim to the payer: The patient was admitted to this facility as a transfer from hospital inpatient within this facility resulting in a separate claim to the payer.ETransfer from Ambulatory Surgical CenterFTransfer from hospice and is under a hospice plan of care or enrolled in hospice programCodeValue if MC203 = 41Normal delivery - A baby delivered without complications. Invalid for discharges after 12/31/2011.2Premature delivery - A baby delivered with time and/or weight factors qualifying it for premature status. Invalid for discharges after 12/31/2011.3Sick baby - A baby delivered with medical complications, other than those relating to premature status. Invalid for discharges after 12/31/2011.4Extramural birth - A baby delivered in a non-sterile environment. Invalid for discharges after 12/31/2011.5Born inside this hospital.6Born outside this hospital.7 - 8Reserved for national assignment.9Information not available. ................
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