129 CMR, § 2.11

Current through Register 1538, January 3, 2025

Section 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 shall contain 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 129 CMR 2.11(2)(a):

(a)Record Specifications. Carriers shall use the record specifications in 129 CMR 2.11(2)(a) through (d) in submitting their claims records. The file header record layout shall be submitted using the data elements in 129 CMR 2.11(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.

(b) The file header record layout shall conform to the following Table 1: ____________________Table 1: File Header Record Layout

Data Element #	Element	Type	Maximum Length	Description/Codes/Sources
HD001	Record Type	Text	2	HD
HD002	Payer	Text	6	Payer submitting payments
Council Submitter Code
HD003	National Plan ID	Text	30	CMS National Plan ID
HD004	Type of File	Text	2	MA Member Eligibility
MC Medical Claims
PC Pharmacy Claims
HD005	Period Beginning Date	Integer	6	CCYYMM
Beginning of paid period for claims
Beginning of month covered for eligibility
HD006	Period Ending Date	Integer	6	CCYYMM
End of paid period for claims
End of month covered for eligibility
HD007	Record Count	Integer	10	Total number of records submitted in this file
HD008	Comments	Text	80	Submitter may use to document this submission by assigning a file name , system source, etc.

(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.

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

Table 2: Trailer Record Layout

Data Element #	Element	Type	Maximum Length	Description/Codes/Sources
TR001	Record Type	Text	2	TR
TR002	Payer	Text	6	Payer submitting payments
Council Submitter Code
TR003	National Plan ID	Text	30	CMS National Plan ID
TR004	Type of File	Text	2	MA Member Eligibility
MC Medical Claims
PC Pharmacy Claims
TR005	Period Beginning Date	Integer	6	CCYYMM
				Beginning of paid period for claims
				Beginning of month covered for eligibility
TR006	Period Ending Date	Integer	6	CCYYMM
End of paid period for claims
End of month covered for eligibility
TR007	Date Processed	Date	8	CCYYMMDD
Date file was created

(3)Member Eligibility File.

(a) The specifications for the member eligibility file are listed in 129 CMR 2.11(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.

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

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. F AM 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 shall code according to the encrypted plan assigned contract number. Carriers and health care claims processors shall set as null if contract 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

13.ME013. 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.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;

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

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:

Table 8: Member Eligibility File Layout

Data Element #	Element	Type	Max. Length	Description/Codes/Sources
ME001	Payer	Text	6	Payer submitting payments
Council Submitter Code
ME002	National Plan ID	Text	30	CMS National Plan ID
ME003	Insurance Type Code/Product	Text	2	12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
				13 Medicare Secondary End-Stage Renal Disease Beneficiary in the 12-month coordination period with an Employer Group Health Plan
				14 Medicare Secondary, No-fault insurance including insurance in which auto is primary
				15 Medicare Secondary Workers' Compensation
				16 Medicare Secondary Public Health Service or Other Federal Agency
				41 Medicare Secondary Black Lung
				42 Medicare Secondary Veterans Administration
				43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
				47 Medicare Secondary, Other Liability Insurance is Primary
				AP Auto Insurance Policy
				CP Medicare Conditionally Primary
				D Disability
				DB Disability Benefits
				EP Exclusive Provider Organization
				HM Health Maintenance Organization (HMO)
				HN Health Maint enance organization ( HMO) Medicare Risk
				HS Special Low Income Medicare Beneficiary
				IN Indemnity
				LC Long Term Care
				LD Long Term Policy
				LI Life Insurance
				LT Litigation
				MA Medicare Part A
				MB Medicare Part B
				MC Medicaid
				MH Medigap Part A
				MI Medigap Part B
				MP Medicare Primary
				PR Preferred Provider Organization (PPO)
				PS Point of Service (POS)
				QM Qualified Medicare Beneficiary
				SP Supplemental Policy
				WC Workers' Compensation
ME004	Year	Integer	4	Year for which eligibility is reported in this submission
ME005	Month	Integer	2	Month for which eligibility is reported in this submission
ME006	Insured Group or Policy Number	Text	30	Group or policy number (not the number that uniquely identifies the subscriber)
ME007	Coverage Level Code	Text	3	Benefit Coverage Level
				C HD Children Only
				DEP Dependents Only
				ECH Employee and Children
				EMP Employee Only
				ESP Employee and Spouse
				FAM Family
				IND Individual
				SPC Spouse and Children
				SPO Spouse Only
ME008	Encrypted Subscriber Unique Identification Number	Text	30	Encrypted subscriber's unique identification number (set as null if unavailable)
ME009	Plan Specific Contract Number	Text	30	Encrypted plan assigned contract number (set as null if contract number = subscriber's social security number)
ME010	Member Suffice or Sequence Number	Integer	2	Uniquely numbers the member within the contract
ME011	Member Identification Code	Text	30	Encrypted member's unique identification number (set as null if unavailable)
ME012	Individual Relationship Code	Integer	2	Member's relationship to insured
				01 Spouse
				18 Self/Employee
				19 Child
				21 Unknown
				34 Other Adult
ME013	Member Gender	Text	1	M Male
F Female
U Unknown
ME014	Member Date of Birth	Date	8	CCYYMMDD
ME015	Member City Name	Text	30	City name of member
ME016	Member State or Province	Text	2	As defined by the US Postal Service
ME017	Member ZIP Code	Text	11	ZIP Code of member - may include non-US codes. (Do not include dash)
ME018	Medical Coverage	Text	1	Y Yes
N No
ME019	Prescription Drug Coverage	Text	1	Y Yes
N No
ME020	Race 1	Text	6	R1 American Indian/Alaska Native
				R2 Asian
				R3 Black/African American
				R4 Native Hawaiian or other Pacific Islander
				R5 White
				R9 Other Race
				UNKNOW Unknown/not specified
ME021	Race 2	Text	6	R1 American Indian/Alaska Native
				R2 Asian
				R3 Black/African American
				R4 Native Hawaiian or other Pacific Islander
				R5 White
				R9 Other Race
				UNKNOWN Unknown/not specified
ME022	Other Race	Text	15	Patient Race, if Race 1 or Race 2 is entered as R9 Other Race (set as null if none)
ME023	Hispanic Indicator	Text	1	Y Patient is Hispanic/Latino/Spanish
N Patient is not Hispanic/Latino/ Spanish
U Unknown
ME024	Ethnicity 1	Text	6	2182-4 Cuban
2184-0 Dominican
				2148-5 Mexican, Mexican American, Chicano
				2180-8 Puerto Rican
				2161-8 Salvadoran
				2155-0 Central American (not otherwise specified)
				2165-9 South American (not otherwise specified)
				2060-2 African
				2058-6 African American
				AMERCN American
				2028-9 Asian
				2029-7 Asian Indian
				BRAZIL Brazilian
				2033-9 Cambodian
				CVERDN Cape Verdean
				CARIBI Caribbean Island
				2034-7 Chinese
				2169-1 Columbian
				2108-9 European
				2036-2 Filipino
				2157-6 Guatemalan
				2071-9 Haitian
				2158-4 Honduran
				2039-6 Japanese
				2040-4 Korean
				2041-2 Laotian
				2118-8 Middle Eastern
				PORTUG Portuguese
				RUSSIA Russian
				EASTEU Eastern European
				2047-9 Vietnamese
				OTHER Other Ethnicity
				UNKNOW Unknown/not specified
ME025	Ethnicity 2	Text	6	2182-4 Cuban
				2184-0 Dominican
				2148-5 Mexican, Mexican American, Chicano
				2180-8 Puerto Rican
				2161-8 Salvadoran
				2155-0 Central American (not otherwise specified)
				2165-9 South American (not otherwise specified)
2060-2 African
2058-6 African American
AMERCN American
2028-9 Asian
2029-7 Asian Indian
BRAZIL Brazilian
2033-9 Cambodian
CVERDN Cape Verdean
CARIBI Caribbean Island
2034-7 Chinese
2169-1 Columbian
2108-9 European
2036-2 Filipino
2157-6 Guatemalan
2071-9 Haitian
2158-4 Honduran
2039-6 Japanese
2040-4 Korean
2041-2 Laotian
2118-8 Middle Eastern
PORTUG Portuguese
RUSSIA Russian
EASTEU Eastern European
2047-9 Vietnamese
OTHER Other Ethnicity
UNKNOW Unknown/not specified
ME026	Other Ethnicity	Text	20	Patient Ethnicity if Ethnicity 1 or Ethnicity 2 is entered as OTHER other Ethnicity. (set as null if none)
ME027	Language	Text	20	799 Africian Language (please specify)
777 Arabic
708 Chinese (please specify)
601 Cape Verdean Creole
600 English
620 French
607 German
637 Greek
623 Haitian Creole
778 Hebrew
663 Hindi
619 Italian
723 Japanese
724	Korean
656	Persian
645	Polish
629	Portuguese
639	Russian
625	Spanish
742	Tagalog
671	Urdu
728	Vietnamese
997	Other Language (please specify)
998	Declined
999	Unavailable
ME028	Record Type	Text	2

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

Table 9: Member Eligibility File Mapping

Data Element #	Element	HIPAA Reference Transaction Set/Loop/Segment/Qualifier/Data Element
ME001	Payer	N/A
ME002	National Plan ID	271/2100A/NM1/XV/09
ME003	Insurance Type Code/Product	271/2110C/EB/ /04, 271/2110D/EB/ /04
ME004	Year	N/A
ME005	Month	N/A
ME006	Insured Group or Policy Number	271/2100C/REF/1L/02, 271/2100C/REF/IG/02, 271/2100C/REF/6P/02, 271/2100D/REF/1L/02, 271/2100D/REF/IG/02, 271/2100D/REF/6P/02
ME007	Coverage Level Code	271/2110C/EB/ /03, 271/2100D/EB/ /03
ME008	Encrypted Subscriber Unique Identification Number	271/2100C/NM1/MI/09
ME009	Plan Specific Contract Number	271/2100C/NM1/MI/09
ME010	Member Suffix or Sequence Number	N/A
ME011	Member Identification Code	271/2100C/MN1/MI/09, 271/2100D/NM1/MI/09
ME012	Individual Relationship Code	271/2100C/INS/Y/02, 271/2100D/INS/N/02
ME013	Member Gender	271/2100C/DMG/ /03, 271/2100D/DMG/ /03
ME014	Member Date of Birth	271/2100C/DMG/D8/02, 271/2100D/DMG/D8/02
ME015	Member City Name	271/2100C/N4/ /01, 271/2100D/N4/ /01
ME016	Member State or Province	217/2100C/N4/ /02, 271/2100D/N4/ /02
ME017	Member ZIP Code	271/2100C/N4/ /03, 271/2100D/N4/ /03
ME018	Medical Coverage	N/A
ME019	Prescription Drug Coverage	N/A
ME020	Race 1	N/A
ME021	Race 2	N/A
ME022	Other Race	N/A
ME023	Hispanic Indicator	N/A
ME024	Ethnicity 1	N/A
ME025	Ethnicity 2	N/A
ME026	Other Ethnicity	N/A
ME027	Language	N/A

(4)Medical Claim File.

(a) Medical claim file shall be submitted using the data elements in 129 CMR 2.11(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.

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.

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 C ode 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:

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)
05	Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution
06	Discharged/transferred to home under care of organized home health service organization
07	Left against medical advice or discontinued care
08	Discharged/transferred to home under care of a Home IV provider
09	Admitted as an inpatient to this hospital
20	Expired
30	Still patient or expected to return for outpatient services
40	Expired at home
41	Expired in a medical facility
42	Expired, place unknown
43	Discharged/transferred to a Federal Hospital
50	Hospice - home
51	Hospice - medical facility
61	Discharged/transferred within this institution to a hospital-based Medicare-approved swing bed
62	Discharged/transferred to an inpatient rehabilitation facility including distinct parts of a hospital
63	Discharged/transferred to a long term care hospital
64	Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare

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 individual name, and set to null if 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:

Table 15: Type of Bill on Facility Claims

First Digit	Type of Facility
1	Hospital
2	Skilled Nursing
3	Home Health
4	Christian Science Hospital
5	Christian Science Extended Care
6	Intermediate Care
7	Clinic
8	Special Facility
Second Digit if First Digit = 1 through 6	Bill Classification
1	Inpatient (including Medicare Part A)
2	Inpatient (including Medicare Part B Only)
3	Outpatient
4	Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
5	Nursing Facility Level I
6	Nursing Facility Level II
7	Intermediate Care - Level III Nursing Facility
8	Swing Beds
Second Digit if First Digit = 7	Bill Classification
1	Rural Health
2	Hospital Based or Independent Renal
3	Dialysis Center
4	Free Standing
5	Outpatient Rehabilitation Facility (ORF)
6	Comprehensive Outpatient Rehabilitation
7	Facilities (CORFs)
9	Other
Second Digit if First Digit = 8	Bill Classification
1	Hospice, Non-hospital based
2	Hospital, Hospital based
3	Ambulatory Surgery Center
4	Free Standing Birthing Center
9	Other

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 129 CMR 2.11(4)(a)39.a. through h.:

a. 01 Processed as primary;

b. 02 Processed as secondary;

c. 03 Processed as tertiary;

d. 04 Denied;

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 leng this 5. Carriers shall code according to the Health Care Common Procedural Coding System (HCPCS). This includes the CPT codes of the American Medical Association.

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:

Table 17: Medical Claims File Layout

Data Element #	Data Element Name	Type	Max. Length	Description/Codes/Sources
MC001	Payer	Text	6	Payer submitting payments
Council Submitter Code
MC002	National Plan ID	Text	30	CMS National Plan ID
MC003	Insurance Type / Product Code	Text	2	12 Preferred Provider Organization (PPO)
				13 Point of Service (POS)
				14 Exclusive Provider Organization (EPO)
				15 Indemnity Insurance
				16 Health Maintenance Organization ( HMO) Medicare Risk
				DS Disability
				HM Health Maintenance Organization
				MA Medicare Part A
				MB Medicare Part B
				MC Medicaid
				VA Veteran Administration Plan
				WC Worker's Compensation
MC004	Payer Claim Control Number	Text	35	Must apply to the entire claim and be unique within the payer's system
MC005	Line Counter	Integer	4	Line number for this service
The line counter begins with 1 and is incremented by 1 for each additional service line of a claim
MC005A	Version Number	Integer	4	Version number of this claim service line
The version number begins with 0 and is incremented by 1 for each subsequent version of that service line
MC006	Insured Group or Policy Number	Text	30	Group or policy number (not the number that uniquely identifies the subscriber)
MC007	Encrypted Subscriber Unique Identification Number	Text	30	Encrypted subscriber's Unique Identification number Set as null if unavailable
MC008	Plan Specific Contract Number	Text	30	Encrypted plan assigned Set as null if contract number = subscriber's social security number
MC009	Member Suffix or Sequence Number	Integer	2	Uniquely numbers the member within the contract
MC010	Member Identification Code	Text	30	Encrypted member's Unique Identification number Set as null if unavailable
MC011	Individual Relationship Code	Integer	2	Member's relationship to subscriber
				01 Spouse
				04 Grandfather or Grandmother
				05 Grandson or Granddaughter
				07 Nephew or Niece
				10 Foster Child
				15 Ward
				17 Stepson or Stepdaughter
				19 Child
				20 Employee
				21 Unknown
				22 Handicapped Dependent
				23 Sponsored Dependent
				24 Dependent of a Minor Dependent
				29 Significant Other
				32 Mother
				33 Father
				36 Emancipated Minor
				39 Organ Donor
				40 Cadaver Donor
				41 Injured Plaintiff
				43 Where Insured Has No Financial Responsibility
				53 Life Partner
				76 Dependent
MC012	Member Gender	Text	1	M Male
				F Female
				U Unknown
MC013	Member Date of Birth	Date	8	CCYYMMDD
MC014	Member City Name	Text	30	City name of member
MC015	Member State or Province	Text	2	As defined by the US Postal Service
MC016	Member ZIP Code	Text	11	ZIP Code of member - may include non-US codes
MC017	Date Service Approved (AP Date)	Date	8	CCYYMMDD
(Generally the same as the paid date)
MC018	Admission Date	Date	8	Required for all inpatient claims
CCYYMMDD
MC019	Admission Hour	Integer	4	Required for all inpatient claims
Time is expressed in military time - HH or HHMM
MC020	Admission Type	Integer	1
MC021	Admission Source	Text	1
MC022	Discharge Hour	Integer	4	Hour in military time - HH or HHMM
MC022A	Discharge Date	Date	8	Required for all inpatient claims CCYYMMDD
MC023	Discharge Status	Integer	2	01 Discharged to home or self care
				02 Discharged/transferred to another short-term general hospital for inpatient care
				03 Discharged/transferred to skilled nursing facility (SNF)
				04 Discharged/transferred to nursing facility (NF)
				05 Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution
				06 Discharged/transferred to home under care of organized home health service organization
				07 Left against medical advice or discontinued care
				08 Discharged/transferred to home under care of a Home IV provider
				09 Admitted as an inpatient to this hospital
				20 Expired
				30 Still patient or expected to return for outpatient services
MC024	Service Provider Number	Text	30	Payer assigned provider number
MC025	Service Provider Tax ID Number	Text	10	Federal taxpayer's identification number
MC026	National Service Provider ID	Text	20	Required if National Provider ID is mandated for use under HIPAA
MC027	Service Provide r Entity Type Qualifier	Text	1	1 Person 2 Non-Person Entity
HIPAA provider taxonomy classifies provider groups (clinicians who bill as a group practice or under a corporate name, even if that group is composed of one provider) as "Person".
MC028	Service Provide r First Name	Text	25	Individual first name
Set to null if provider is a facility or organization
MC029	Service Provide r Middle Name	Text	25	Individual middle name or initial
Set to null if provider is a facility or organization
MC030	Service Provider Last Name or Organization Name	Text	50	Full name of provider organization or last name of individual provider
MC031	Service Provider Suffix	Text	10	Suffix to individual name
Set to null if provider is a facility or organization. Should be used to capture the generation of the individual clinician (e.g., Jr. Sr., III), if applicable, rather than the clinician's degree (e.g., 'MD', 'LICSW').
MC032	Service Provider Specialty	Text	10	As defined by payer
Dictionary for specialty code values must be supplied during testing
MC033	Service Provider City Name	Text	30	City name of provider - preferably practice location
MC034	Service Provider State	Text	2	As defined by the US Postal Service
MC035	Service Provider ZIP Code	Text	11	ZIP Code of provider - may include non-US codes Do not include dash
MC035A	Service Provider Country Name	Text	30	Country name of provider - preferably practice location
MC036	Type of Bill - on Facility Claims	Integer	2	Type of Facility - First Digit
	(Should be coded on facility claim s, such as those submitted using on UB92 form s)			1 Hospital
				2 Skilled Nursing
				3 Home Health
				4 Christian Science Hospital
				5 Christian Science Extended Care
				6 Intermediate Care
				7 Clinic
				8 Special Facility
Bill Classification - Second Digit if First Digit = 1-6
				1 Inpatient (Including Medicare Part A)
				2 Inpatient (Medicare Part B Only)
				3 Outpatient
				4 Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
				5 Nursing Facility Level I
				6 Nursing Facility Level II
				7 Intermediate Care - Level III Nursing Facility
				8 Swing Beds
Bill Classification - Second Digit if First Digit = 7
				1 Rural Health
				2 Hospital Based or Independent Renal
				3 Dialysis Center
				4 Free Standing
				5 Outpatient Rehabilitation Facility (ORF)
				6 Comprehensive Outpatient Rehabilitation
				7 Facilities (CORFs)
				9 Other
Bill Classification - Second Digit if First Digit = 8
				1 Hospice (Non Hospital Based)
				2 Hospice (Hospital-Based)
				3 Ambulatory Surgery Center
				4 Free Standing Birthing Center
				9 Other
MC037	Site of Service - on NSF/CMS 1500 Claims	Text	2	11 Office
	(Should be coded on professional claim s, such as those submitted using NSF [CMS 1500 form s])			12 Home
				21 Inpatient Hospital
				22 Outpatient Hospital
				23 Emergency Room - Hospital
				24 Ambulatory Surgery Center
				25 Birthing Center
				26 Military Treatment Facility
				31 Skilled Nursing Facility
				32 Nursing Facility
				33 Custodial Care Facility
				34 Hospice
				41 Ambulance - Land
				42 Ambulance - Air or Water
				51 Inpatient Psychiatric Facility
				52 Psychiatric Facility Partial Hospitalization
				53 Community Mental Health Center
				54 Intermediate Care Facility/Mentally Retarded
				55 Residential Substance Abuse Treatment Facility
				56 Psychiatric Residential Treatment Center
				50 Federally Qualified Center
				60 Mass Immunization Center
				61 Comprehensive Inpatient Rehabilitation Facility
				62 Comprehensive Outpatient Rehabilitation Facility
				65 End Stage Renal Disease Treatment Facility
				71 State of Local Public Health Clinic
				72 Rural Health Clinic
				81 Independent Laboratory
				99 Other Unlisted Facility
MC038	Claim Status	Integer	2	01 Processed as primary
	(Actually describes the payment status of the specific service line record)			02 Processed as secondary
				03 Processed as tertiary
				04 Denied
				19 Processed as primary, forwarded to additional payer(s)
				20 Processed as secondary, forwarded to additional payer(s)
				21 Processed as tertiary, forwarded to additional payer(s)
				22 Reversal of previous payment
MC039	Admitting Diagnosis	Text	5	Required on all inpatient admission claims and encounters
ICD-9-CM Do not code decimal point
MC040	E-Code	Text	5	Describes an injury, poisoning or adverse effect
ICD-9-CM Do not include decimal
MC041	Principal Diagnosis	Text	5	ICD-9-CM Do not code decimal point
This should be the principal diagnosis given on the claim header.
MC042	Other Diagnosis - 1	Text	5	ICD-9-CM Do not code decimal point
MC043	Other Diagnosis - 2	Text	5	ICD-9-CM Do not code decimal point
MC044	Other Diagnosis - 3	Text	5	ICD-9-CM Do not code decimal point
MC045	Other Diagnosis - 4	Text	5	ICD-9-CM Do not code decimal point
MC046	Other Diagnosis - 5	Text	5	ICD-9-CM Do not code decimal point
MC047	Other Diagnosis - 6	Text	5	ICD-9-CM Do not code decimal point
MC048	Other Diagnosis - 7	Text	5	ICD-9-CM Do not code decimal point
MC049	Other Diagnosis - 8	Text	5	ICD-9-CM Do not code decimal point
MC050	Other Diagnosis - 9	Text	5	ICD-9-CM Do not code decimal point
MC051	Other Diagnosis - 10	Text	5	ICD-9-CM Do not code decimal point
MC052	Other Diagnosis - 11	Text	5	ICD-9-CM Do not code decimal point
MC053	Other Diagnosis - 12	Text	5	ICD-9-CM Do not code decimal point
MC054	Revenue Code	Text	4	National Uniform Billing Committee Codes
Code using leading zeroes, left-justified, and four digits.
MC055	Procedure 1 Code	Text	5	Health Care Common Procedural Coding System (HCPCS)
This includes the CPT codes of the American Medical Association
MC056	Procedure 1 Modifier - 1	Text	2	Procedure modifier required when a modifier clarifies/ improves the reporting accuracy of the associated procedure code
MC057	Procedure 1 Modifier - 2	Text	2	Procedure modifier required when a modifier clarifies/ improves the reporting accuracy of the associated procedure code
MC058	ICD-9-CM Procedure 1 Code	Text	4	Primary ICD-9-CM code given on the claim header. Do not code decimal point
MC059	Date of Service - From	Date	8	First date of service for this service line
CCYYMMDD
MC060	Date of Service - Through	Date	8	Last date of service for this service line
CCYYMMDD
MC061	Quantity	Integer	3	Count of services performed
Should be set equal to 1 on all Observation bed service lines, for consistency.
MC062	Charge Amount	Decimal	10	Do not code decimal point
MC063	Paid Amount	Decimal	10	Includes any withhold amounts
Do not code decimal point
MC064	Prepaid Amount	Decimal	10	For capitated services, the fee for service equivalent amount
Do not code decimal point
MC065	Copay Amount	Decimal	10	The preset, fixed dollar amount for which the individual is responsible Do not code decimal point
MC066	Coinsurance Amount	Decimal	10	Do not code decimal point
MC067	Deductible Amount	Decimal	10	Do not code decimal point
MC068	Record Type	Text	2	MC

(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 Form	UB-92 (Version 6.0) Record Type/	HCFA 1500	NSF (National Standard Format)	HIPAA Reference Transaction Set/Loop/Segment/ Qualifier/
Data Element #	Data Element Name	Locator	Field #	#	Locator	Data Element
MC001	Payer	N/A	N/A	N/A	N/A	N/A
MC002	National Plan ID	N/A	N/A	N/A	N/A	835/1000A/N1/XV/04
MC003	Product/Claim Filing Indicator Code	N/A	30/4	N/A	N/A	835/2100/CLP/ /06
MC004	Payer Claim Control Number	N/A	N/A	N/A	FA0-02.0, FB0-02.0, FB1-02.0, GA0-02.0, GC0-02.0, GX0-02.0, GX2-02.0, HA0-02.0, FB2-02.0, GU0-02.0	835/2100/CLP/ /07
MC005	Line Counter	N/A	N/A	N/A	N/A	837/2400/LX/ /01
MC006	Insured Group or Policy Number	62 (A-C)	30/10	11C	DA0-10.0	837/2000B/SBR/ /03
MC007	Encrypted Subscriber Unique Identification Number	N/A	N/A	N/A	N/A	835/2100/NM1/34/08
MC008	Plan Specific Contract Number	N/A	N/A	N/A	N/A	835/2100/NM1/HN/08
MC009	Member Suffix or Sequence Number	N/A	N/A	N/A	N/A	N/A
MC010	Member Identification Code	N/A	N/A	N/A	N/A	835/2100/NM1/34/08
MC011	Individual Relationship Code	59 (A-C)	30/18	6	DA0-17.0	837/2000B/SBR/ /02, 837/2000C/PAT/ /01
MC012	Member Gender	15	20/7	3	CA0-09.0	837/2010CA/DMG/03
MC013	Member Date of Birth	14	20/8	3	CA0-08.0	837/2010CA/DMG/D8/02
MC014	Member City Name	13	20/14	5	CA0-13.0	837/2010CA/N4/ /01
MC015	Member State or Province	13	20/15	5	CA0-14.0	837/2010CA/N4/ /02
MC016	Member ZIP Code	13	20/16	5	CA0-15.0	837/2010CA/N4/ /03
MC017	Date Service Approved	N/A	N/A	N/A	N/A	N/A
MC018	Admission Date	17	20/17	N/A	N/A	837/2300/DTP/435/03
MC019	Admission Hour	18	20/18	N/A	N/A	837/2300/DTP/435/03
MC020	Admission Type	19	20/10	N/A	N/A	837/2300/CL1/ /01
MC021	Admission Source	20	20/11	N/A	837/2300/CL1/ /02
MC022	Discharge Hour	21	20/22	N/A	837/2300/DTP/096/03
MC023	Discharge Status	22	20/21	N/A	N/A	837/2300/CL1/ /03
MC024	Service Provider Number	N/A	N/A	N/A	N/A	N/A
MC025	Service Provider Tax ID Number	5	10/4-5	25	BA0-09.0, CA0-28.0, BA0-02.0, BA1-02.0, YA0-02.0,BA0-06.0, BA0-10.0, BA0-12.0, BA0-13.0, BA0-14.0, BA0-15.0, BA0-16.0, BA0-17.0, BA0-24.0, YA0-06.0	835/2100/NM1/FI/09
MC026	National Service Provider ID	N/A	10/6	N/A	N/A	835/2100/NM1/XX/09
MC027	Service Provider Entity Type Qualifier	N/A	N/A	N/A	N/A	835/2100/NM1/82/02
MC028	Service Provider First Name	1	10/12	33	BA0-20.0	835/2100/NM1/82/04
MC029	Service Provider Middle Name	1	10/12	33	BA0-21.0	835/2100/NM1/82/05
MC030	Service Provider Last Name or Organization Name	1	10/12	33	BA0-18.0, BA0-19.0	835/2100/NM1/82/03
MC031	Service Provider Suffix	1	10/12	33	BA0-22.0	835/2100/NM1/82/07
MC032	Service Provider Specialty	N/A	N/A	N/A	N/A	837/2000A/PRV/ZZ/03
MC033	Service Provider City Name	1	10/14	N/A	BA1-09.0, 15.0	837/2010A/N4/ /01
MC034	Service Provider State or Province	1	10/15	N/A	BA1-10.0, 16.0	837/2010A/N4/ /02
MC035	Service Provider ZIP Code	1	10/16	N/A	BA1-11.0, 17.0	837/2010A/N4/ /03
MC036	Type of Bill - on Facility Claims	4	Positions 1-2: 40/4	N/A	N/A	837/2300/CLM/ /05-1
MC037	Site of Service - on NSF/CMS 1500 Claims	N/A	N/A	N/A	FA0-07.0, GU0-0.50	835/2100/CLP/ /08
MC038	Claim Status	N/A	N/A	N/A	N/A	835/2100/CLP/ /02
MC039	Admitting Diagnosis	76	70/25	N/A	N/A	837/2300/HI/BJ/02-2
MC040	E-Code	77	70/26	N/A	N/A	837/2300/HI/BN/03-2
MC041	Principal Diagnosis	67	70/4	EA0-32.0, GX0-31.0, GU0-12.0	837/2300/HI/BK/01-2
MC042	Other Diagnosis - 1	68	70/5	21.2	EA0-33.0, GX0-32.0, GU0-13.0	837/2300/HI/BF/02-1
MC043	Other Diagnosis - 2	69	70/6	21.3	EA0-33.0, GX0-32.0, GU0-13.0	837/2300/HI/BF/02-2
MC044	Other Diagnosis - 3	70	70/7	21.4	EA0-33.0, GX0-32.0, GU0-13.0	837/2300/HI/BF/02-3
MC045	Other Diagnosis - 4	71	70/8	N/A	EA0-35.0, GX0-34.0, GU0-15.0	837/2300/HI/BF/02-4
MC046	Other Diagnosis - 5	72	70/9	N/A	N/A	837/2300/HI/BF/02-5
MC047	Other Diagnosis - 6	73	70/10	N/A	N/A	837/2300/HI/BF/02-6
MC048	Other Diagnosis - 7	74	70/11	N/A	N/A	837/2300/HI/BF/02-7
MC049	Other Diagnosis - 8	75	70/12	N/A	N/A	837/2300/HI/BF/02-8
MC050	Other Diagnosis - 9	N/A	N/A	N/A	N/A	837/2300/HI/BF/02-9
MC051	Other Diagnosis -10	N/A	N/A	N/A	N/A	837/2300/HI/BF/02-10
MC052	Other Diagnosis -11	N/A	N/A	N/A	N/A	837/2300/HI/BF/02-11
MC053	Other Diagnosis -12	N/A	N/A	N/A	N/A	837/2300/HI/BF/02-12
MC054	Revenue Code	42	50/5,11-13, 60/5,15-16, 61/5,15-16	N/A	N/A	835/2110/SVC/RB/01-2, 835/2110/SVC/NU/01-2
MC055	Procedure Code	44	60/6,15-16, 61/6,15-16	24.1-6 D	FA0-09.0, FB0-15.0, GU0-07.0	835/2110/SVC/HC/01-2
MC056	Procedure Modifier - 1	44	60/7,15-16, 61/7, 15-16	24.1-6 D	FA0-10.0, GU0-08.0	835/2110/SVC/HC/01-3
MC057	Procedure Modifier - 2	44	60/8,15-16, 61/8,15-16	24.1-6 D	FA0-11.0	835/2110/SVC/HC/01-3
MC058	ICD-9-CM Procedure Code	80, 81(A-E)	70/13, 15, 17, 19, 21, 23	N/A	N/A	835/2110/SVC/ID/01-2
MC059	Date of Service - From	45	61/13, 15-16, 61/13, 15-16	24.1-6 A	N/A	835/2110/DTM/150/02
MC060	Date of Service - Thru	N/A	N/A	24.1-6 A	FA0-05.0, FA0-06.0	835/2110/DTM/151/02
MC061	Quantity	46	50/7, 11-13, 60/9,15-16, 61/9,15-16	24.1-6 G	FA0-19.0, FB0-16.0	835/2110/SVC/ /05
MC062	Charge Amount	47	50/8, 11-13, 60/10, 16-16, 61/11, 15-16	24.1-6F	FA0-13.0	835/2110/SVC/ /02
MC063	Paid Amount	48	N/A	N/A	N/A	835/2110/SVC/ /03
MC064	Prepaid Amount	N/A	N/A	N/A	N/A	N/A
MC065	Co-pay Amount	N/A	N/A	N/A	N/A	N/A
MC066	Coinsurance Amount	N/A	N/A	N/A	N/A	N/A
MC067	Deductible Amount	N/A	N/A	N/A	N/A	N/A
MC068	Record Type	N/A	N/A	N/A	N/A	N/A

(5)Pharmacy Claims File.

(a) The pharmacy claim file layout shall be submitted using the format in 129 CMR 2.11(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:

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 each additional service 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 shall code 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 o f 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:

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.

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 shall code according to 01-99 N umber 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.

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 shall code 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.

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

Table 22: Table 22: Pharmacy Claims File Layout

Data Element #	Element	Type	Max. Length	Description/Codes/Sources
PC001	Payer	Text	6	Payer submitting payments
Council Submitter Code
PC002	Plan ID	Text	30	CMS National Plan ID
PC003	Insurance Type /Product Code	Text	2	12 Preferred Provider Organization (PPO)
				13 Point of Service (POS)
				14 Exclusive Provider Organization (EPO)
				15 Indemnity Insurance
				16 Health Maintenance Organization (HMO) Medicare Risk
				AM Automobile Medical
				DS Disability
				HM Health Maintenance Organization
				LI Liability
				LM Liability Medical
				MA Medicare Part A
				MB Medicare Part B
				MC Medicaid
				OF Other Federal Program (e.g. Black Lung)
				TV Title V
				VA Veteran Administration Plan
				WC Worker's Compensation
PC004	Payer Claim Control Number	Text	35	Must apply to the entire claim and be unique within the payer's system
PC005	Line Counter	Integer	4	Line number for this service
The line counter begins with 1 and is incremented by 1 for each additional service line of a claim
PC006	Insured Group Number	Text	30	Group or policy number - not the number that uniquely identifies the subscriber
PC007	Encrypted Subscriber Unique Identification Number	Text	30	Encrypted subscriber's Unique Identification number Set as null if unavailable
PC008	Plan Specific Contract Number	Text	30	Encrypted plan assigned contract number
Set as null if contract number = subscriber's social security number
PC009	Member Suffix or Sequence Number	Integer	2	Uniquely numbers the member within the contract
PC010	Member Identification Code	Text	30	Encrypted member's Unique Identification number Set as null if unavailable
PC011	Individual Relationship Code	Integer	2	Member's relationship to subscriber
				01 Spouse
				04 Grandfather or Grandmother
				05 Grandson or Granddaughter
				07 Nephew or Niece
				10 Foster Child
				15 Ward
				17 Stepson or Stepdaughter
				19 Child
				20 Employee/Self
				21 Unknown
				22 Handicapped Dependent
				23 Sponsored Dependent
				24 Dependent of a Minor Dependent
				29 Significant Other
				32 Mother
				33 Father
				36 Emancipated Minor
				39 Organ Donor
				40 Cadaver Donor
				41 Injured Plaintiff
				43 Child Where Insured Has No Financial Responsibility
				53 Life Partner
				76 Dependent
PC012	Member Gender	Integer	1	1 Male
2 Female
3 Unknown
PC013	Member Date of Birth	Date	8	CCYYMMDD
PC014	Member City Name of Residence	Text	30	City name of member
PC015	Member State	Text	2	As defined by the US Postal Service
PC016	Member ZIP Code	Text	9	ZIP Code of member - may include non-US codes Do not include dash
PC017	Date Service Approved (AP Date)	Date	8	CCYYMMDD (Generally the same as the paid date or the Pharmacy Benefits Manager's billing date)
PC018	Pharmacy Number	Text	30	pharmacy number (NCPDP or NABP)
PC019	Pharmacy Tax ID Number	Text	10	Federal taxpayer's identification number (Please provide the pharmacy chain's federal tax identification number, if the individual retail pharmacy's tax ID# is not available.)
PC020	Pharmacy Name	Text	30	Name of pharmacy
PC021	National Pharmacy ID Number	Text	20	Required if National Provider ID is mandated for use under HIPAA
PC022	Pharmacy Location City	Text	30	City name of pharmacy - preferably pharmacy location
PC023	Pharmacy Location State	Text	2	As defined by the US Postal Service
PC024	Pharmacy ZIP Code	Text	10	ZIP Code of pharmacy - may include non-US codes Do not include dash
PC024A	Pharmacy Country Name	Text	30	Country name of pharmacy
PC025	Claim Status	Integer	2	01 Processed as primary
				02 Processed as secondary
				03 Processed as tertiary
				04 Denied
				19 Processed as primary, forwarded to additional payer(s)
				20 Processed as secondary, forwarded to additional payer(s)
				21 Processed as tertiary, forwarded to additional payer(s)
				22 Reversal of previous payment
PC026	Drug Code	Text	11	NDC Code
PC027	Drug Name	Text	80	Text name of drug
PC028	New Prescription	Integer	2	00 New prescription
PC028A	Refill Number	Integer	2	01-99 Number of refill
('01' should be used for all refills, if the specific number of the prescription refill is not available.)
PC029	Generic Drug Indicator	Text	1	N No, branded drug
Y Yes, generic drug
PC030	Dispense as Written Code	Integer	1	0 Not dispensed as written
				1 Physician dispense as written
				2 Member dispense as written
				3 Pharmacy dispense as written
				4 No generic available
				5 Brand dispensed as generic
				6 Override
				7 Substitution not allowed - brand drug mandated by law
				8 Substitution allowed - generic drug not available in marketplace
				9 Other
PC031	Compound Drug Indicator	Text	1	N Non-compound drug
Y Compound drug
U Non-specified drug compound
PC032	Date Prescription Filled	Date	8	CCYYMMDD
PC033	Quantity Dispensed	Integer	5	Number of metric units of medication dispensed
PC034	Days Supply	Integer	3	Estimated number of days the prescription will last
PC035	Charge Amount	Decimal	10	Do not code decimal point
PC036	Paid Amount	Decimal	10	Includes all health plan payments and excludes all member payments
Do not code decimal point
PC037	Average Wholesale Price (AWP)	Decimal	10	Cost of the drug dispensed
Do not code decimal point
PC038	Postage Amount Claimed	Decimal	10	Do not code decimal point
PC039	Dispensing Fee	Decimal	10	Do not code decimal point
PC040	Copay Amount	Decimal	10	The preset, fixed dollar amount for which the individual is responsible
Do not code decimal point
PC041	Coinsurance Amount	Decimal	10	Do not code decimal point
PC042	Deductible Amount	Decimal	10	Do not code decimal point
PC043	Re cord Type	Text	2	PC

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

Table 23: Pharmacy Claims File Mapping

Data Element #	Element	National Council for Prescription Drug Programs Field #
PC001	Payer	N/A
PC002	Plan ID	N/A
PC003	Insurance Type/Product Code	N/A
PC004	Payer Claim Control Number	N/A
PC005	Line Counter	N/A
PC006	Insured Group Number	301-C1
PC007	Encrypted Subscriber Unique Identification Number	302-C2
PC008	Plan Specific Contract Number	N/A
PC009	Member Suffix or Sequence Number	N/A
PC010	Member Identification Code	302-CY
PC011	Individual Relationship Code	306-C6
PC012	Member Gender	305-C5
PC013	Member Date of Birth	304-C4
PC014	Member City Name of Residence	323-CN
PC015	Member State or Province	324-CO
PC016	Member ZIP Code	325-CP
PC017	Date Service Approved (AP Date)	N/A
PC018	Pharmacy Number	202-B2
PC019	Pharmacy Tax ID Number	N/A
PC020	Pharmacy Name	833-5P
PC021	National Pharmacy ID Number	N/A
PC022	Pharmacy Location City	831-5N
PC023	Pharmacy Location State	832-6F
PC024	Pharmacy ZIP Code	835-5R
PC025	Claim Status	N/A
PC026	Drug Code	407-D7
PC027	Drug Name	516-FG
PC028	New Prescription	403-D3
PC029	Generic Drug Indicator	N/A
PC030	Dispense as Written Code	408-D8
PC031	Compound Drug Indicator	406-D6
PC032	Date Prescription Filled	401-D1
PC033	Quantity Dispensed	442-E7
PC034	Days Supply	405-D5
PC035	Charge Amount	804-5B
PC036	Paid Amount	509-F9
PC037	Ingredient Cost/List Price	506-F6
PC038	Postage Amount Claimed	428-DS
PC039	Dispensing Fee	507-F7
PC040	Copay Amount	518-FI
PC041	Coinsurance Amount	518-FI
PC042	Deductible Amount	505-F5
PC043	Record Type	N/A

129 CMR, § 2.11