Statutes, codes, and regulations
New Hampshire Administrative Code
Title Ins - Commissioner, Insurance DepartmentChapter Ins 4000 - UNIFORM REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS
Part Ins 4010 - DATA TABLES
Section Ins 4010.07 - Mapping and Format Information Tables

N.H. Admin. Code § Ins 4010.07

Download
PDF
Current through Register No. 50, December 12, 2024
Section Ins 4010.07 - Mapping and Format Information Tables
(a) Member Eligibility File Mapping and Format Information

Table 4010.07 (a) Member Eligibility File Mapping and Format Information

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

Subscriber Social Security 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 Social Security Number

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

Dental Coverage

N/A

ME021

Race 1

N/A

ME022

Race 2

N/A

ME023

Place holder

N/A

ME024

Hispanic Indicator

N/A

ME025

Ethnicity 1

N/A

ME026

Ethnicity 2

N/A

ME027

Place holder

N/A

ME028

Primary Insurance Indicator

N/A

ME029

Coverage Type

N/A

ME030

Market Category

N/A

ME031

NH Health Protection Program

N/A

ME032

Group Name

N/A

ME101

Subscriber Last Name

270/2100C/NM1/IL/1/3

ME102

Subscriber First Name

270/2100C/NM1/IL/1/4

ME103

Subscriber Middle Initial

270/2100C/NM1/IL/1/5

ME104

Member Last Name

270/2100D/NM1/QC/1/3

ME105

Member First Name

270/2100D/NM1/QC/1/4

ME106

Member Middle Initial

270/2100D/NM1/QC/1/5

271/2100/N3//01, 02

271/2100D/N3/ /01, 02

ME203

Member's Assigned PCP

Loop 2000B SBR02 = 18 - ELSE - Loop

ME204

HIOS Plan ID

N/A

ME205

Plan Effective Date

N/A

ME206

Minimum Value

2010CA Segment N301

ME207

Exchange Indicator

N/A

ME208

High Deductible Health Plan

N/A

ME209

Active Enrollment

N/A

ME210

New Coverage

N/A

ME211

N/A

ME899

Record Type

N/A

ME900

Plan State

N/A

ME901

Premium Tax Credit

N/A

ME902

NAIC Number

N/A

ME903

Grandfather Plan Indicator

N/A

(b) Medical Claims File Mapping and Format Information

Table 4010.07 (b) Medical Claims File Mapping and Format Information

Data Element #

Data Element Name

UB-92 Form Locator

UB-92 (Version 6.0) Record Type/ Field #

HCFA 1500 #

NSF (National Standard Format) Locator

HIPAA Reference Transaction Set/Loop/Segment/Qualifier/ 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

MC005A

Version Number

N/A

N/A

N/A

N/A

N/A

MC006

Insured Group or Policy Number

62 (A-C)

30/10

11C

DA0-10.0

837/2000B/SBR/ /03

MC007

Subscriber Social Security 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 Social Security Number

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

8 37/2000B/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

Paid Date (AP Date)

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 - Institutional

4

Positions 1-2: 40/4

N/A

N/A

837/2300/CLM/ /05-1

MC037

Facility Type - Professional

N/A

N/A

N/A

FA0-07.0, GU0-0.50

835/2100/CLP/ /08

MC038

Service Line Status

N/A

N/A

N/A

N/A

835/2100/CLP/ /02

MC039

Admitting Diagnosis

76

70/25

N/A

N/A

837/2300/HI/BJ/02-2

MC040

E-Code

77

70/26

N/A

N/A

837/2300/HI/BN/03-2

MC041

Principal Diagnosis

67

70/4

21.1

EA0-32.0, GX0-31.0, 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

Fee for Service Equivalent

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

Patient Account/Control Number

3

N/A

N/A

837/2300/CLM/1

MC069

Discharge Date

MC070

Service Provider Country Name

N/A

N/A

N/A

N/A

N/A

MC071

DRG

N/A

N/A

N/A

N/A

837/2300/HI/DR/2

MC072

DRG Version

N/A

N/A

N/A

N/A

N/A

MC073

APC

N/A

N/A

N/A

N/A

N/A

MC074

APC Version

N/A

N/A

N/A

N/A

N/A

MC075

Drug Code

N/A

837/2400/SV2/N1/2

837/2400/SV2/N2/2

837/2400/SV2/N3/2

837/2400/SV2/N4/2

837/2400/SV2/ND/2

MC076

Billing Provider Number

N/A

N/A

N/A

N/A

N/A

MC077

National Billing Provider Number ID

N/A

N/A

N/A

N/A

N/A

MC078

Billing Provider Organization or Last Name

N/A

N/A

N/A

N/A

N/A

MC101

Encrypted Subscriber Last Name

N/A

N/A

N/A

N/A

837/2110BA/NM1/IL/1/3

MC102

Encrypted Subscriber First Name

N/A

N/A

N/A

N/A

837/2110BA/NM1/IL/1/4

MC103

Encrypted Subscriber Middle Initial

N/A

N/A

N/A

N/A

837/2110BA/NM1/IL/1/5

MC104

Encrypted Member Last Name

N/A

N/A

N/A

N/A

837/2110CA/NM1/QC/1/3

MC105

Encrypted Member First Name

N/A

N/A

N/A

N/A

837/2110CA/NM1/QC/1/4

MC106

Encrypted Member Middle Initial

N/A

N/A

N/A

N/A

837/2110CA/NM1/QC/1/5

MC200

ICD Indicator

N/A

N/A

N/A

N/A

Set value here based upon Loop 2300 Segment H101-01 starting with the letter A

MC202

Other ICD-CM Procedure code - 2

N/A

N/A

N/A

N/A

837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)

MC203

Other ICD-CM Procedure code - 3

N/A

N/A

N/A

N/A

837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)

MC204

Other ICD-CM Procedure code - 4

N/A

N/A

N/A

N/A

837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)

MC205

Other ICD-CM Procedure code - 5

N/A

N/A

N/A

N/A

837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)

MC206

Other ICD-CM Procedure code - 6

N/A

N/A

N/A

N/A

837/2300 H102-1=BQ (ICD-9) or = BBQ (ICD-10)

MC207

Carrier Associated with Claim

N/A

N/A

N/A

N/A

N/A

MC208

Carrier Plan Specific contract Number or Subscriber/Member Social Security Number

N/A

N/A

N/A

N/A

N/A

MC209

Practitioner Group Practice

N/A

N/A

N/A

N/A

N/A

MC210

Coordination of Benefits/Third Party Liability Amount

N/A

N/A

N/A

N/A

835/2320 AMT02

MC211

Cross Reference Claims ID

N/A

N/A

N/A

N/A

N/A

MC212

Allowed Amount

N/A

N/A

N/A

N/A

837/2300 HCP02

MC215

Service Line Type

N/A

N/A

N/A

N/A

N/A

MC216

Payment Arrangement Type

N/A

N/A

N/A

N/A

Loop 2400 Segment HCP01

MC217

Pay for Performance Flag

N/A

N/A

N/A

N/A

N/A

MC218

Claim Processing Level Indicator

N/A

N/A

N/A

N/A

N/A

MC219

Denied Claim Indicator

N/A

N/A

N/A

N/A

Loop 2430 CAS identification

MC220

Denial Reason

N/A

N/A

N/A

N/A

Loop 2430 CAS identification

MC221

Procedure Modifier - 3

N/A

N/A

N/A

N/A

837/2430 SVD03-05

MC222

Procedure Modifier - 4

N/A

N/A

N/A

N/A

837/2430 SVD03-06

MC899

Record Type

N/A

N/A

N/A

N/A

N/A

MC900

In Network Indicator

N/A

N/A

N/A

N/A

N/A

MC901

Unit of Measure

N/A

N/A

N/A

N/A

(c) Pharmacy Claims File Mapping and Format Information

Table 4010.07 (c) Pharmacy Claims File Mapping and Format Information

Data Element

Element

National Council for Prescription Drug Programs Field #

PC001

Payer

879

PC002

Plan ID

879

PC003

Insurance Type/Product Code

N/A

PC004

Payer Claim Control Number

993-A7

PC005

Line Counter

N/A

PC006

Insured Group Number

301-C1

PC007

Subscriber Social Security 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

Paid Date (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

PC024A

Pharmacy Country Name

N/A

PC025

Service Line Status

N/A

PC026

Drug Code

407-D7

PC027

Drug Name

516-FG

PV028

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

Placeholder

N/A

PC044

Prescribing Physician First Name

717

PC045

Prescribing Physician Middle Name

N/A

PC046

Prescribing Physician Last Name

716

PC047

Prescribing Physician Number

411-DB

PC101

Subscriber Last Name

716

PC102

Subscriber First Name

717

PC103

Subscriber Middle Initial

718

PC104

Member Last Name

716

PC105

Member First Name

717

PC106

Member Middle Initial

718

PC203

Carrier Associated with Claim

N/A

PC204

Carrier Plan Specific Contract Number or Subscriber/Member Social Security Number

N/A

PC211

Cross Reference Claims ID

N/A

PC212

Allowed Amount

N/A

PC213

HIOS Plan ID

N/A

PC214

Claim Processing Level Indicator

N/A

PC215

Service Line Type

N/A

PC216

Denied Claim Indicator

N/A

PC217

Denial Reason

N/A

PC899

Record Type

N/A

PC900

Mail Order Pharmacy Indicator

N/A

PC901

In Network Indicator

N/A

PC902

Version Number

N/A

(d) Dental Claims File Mapping and Format Information

Table 4010.07 (d) Dental Claims File Mapping and Format Information

Data Element #

Data Element Name

NSF (National Standard Format) Locator

HIPAA Reference Transaction Set/Loop/Segment/Qualifier/Data Element

DC001

Payer

N/A

N/A

DC002

National Plan Id

N/A

N/A

DC003

Insurance Type/Product Code

N/A

835/2100/CLP/ /06

DC004

Payer Claim Control Number

N/A

835/2100/CLP/ /07

DC005

Line Counter

FA0-02.0, FB0-02.0, FB1-02.0, GA0-02.0, GC0-02.0, GX0-02.0, GX2-02.0, HA0-02.0, FB2-02.0GU0-02.0

837/2400/LX/ /01

DC006

Insured Group or Policy Number

DA0-10.0

837/2000B/SBR/ /03

DC007

Subscriber Social Security Number

N/A

837/2010BA/REF/SY/02

DC008

Plan Specific Contract Number

N/A

835/2100/NM1/MI/08

DC009

Member Suffix or Sequence Number

N/A

N/A

DC010

Member Social Security Number

N/A

835/2100/NM1/34/09

DC011

Individual Relationship Code

DA0-17.0

837/2000B/SBR/ /02, 837/20000C/PAT/ /01

DC012

Member Gender

CA0-09.0

837/2010BA/DMB/ /03, 837/2010CA/DMB/ /03

DC013

Member Date of Birth

CA0-08.0

837/2010BA/DMB/D8/02, 837/2010CA/DMB/D8/02

DC014

Member City Name of Residence

CA0-13.0

837/2010BA/N4/ /01, 837/2010CA/N4/ /01

DC015

Member State or Province

CA0-14.0

837/2010BA/N4/ /02, 837/2010CA/N4/ /02

DC016

Member ZIP Code of Residence

CA0-15.0

837/2010BA/N4/ /03, 837/2010CA/N4/ /03

DC017

Date Service Approved

N/A

835/Header Financial Information/BPR/ /16

DC018

Service Provider Number

N/A

835/21000/REF/1A/02, 835/2100/REF/1B/02, 835/2100/REF/1C/02, 835/2100/REF/1D/02, 835/2100/REF/G2/02, 835/2100/NM1/BD/09, 835/2100/NM1/BS/09, 835/2100/NM1/MC/09, 835/2100/NM1/PC/09

DC019

Service Provider Tax ID Number

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

DC020

National Service Provider ID

N/A

837/2310B/NM1/XX/09

DC021

Service Provider Entity Type Qualifier

N/A

837/2310B/NM1/82/02

DC022

Service Provider First Name

BA0-20.0

837/2310B/NM1/82/04

DC023

Service Provider Middle Name

BA0-21.0

837/2310B/NM1/82/05

DC024

Service Provider Last Name or Organization Name

BA0-18.0, BA0-19.0

837/2310B/NM1/82/03

DC025

Service Provider Suffix

BA0-22.0

837/2310B/NM1/82/07

DC026

Service Provider Specialty

N/A

837/2310B/PRV/PXC/03

DC027

Service Provider City name

BA1-09.0, 15.0

837/2310C/N4/ /01

DC028

Service Provider State or Province

BA1-10.0, 16.0

837/2310C /N4/ /02

DC029

Service Provider ZIP Code

BA1-11.0, 17.0

837/2310C /N4/ /03

DC030

Facility Type - Professional

FA0-07.0, GU0-0.50

837/2300/CLM/05-1

DC031

Claim Status

835/2100/CLP/ /02

DC032

CDT Code

FA0-09.0, FB0-15.0, GU0-07.0

837/2400/SV3/AD/01-2

DC033

Procedure Modifier - 1

FA0-10.0, GU0-08.0

837/2400/SV3/AD/01-3

DC034

Procedure Modifier - 2

FA0-11.0

837/2400/SV3/AD/01-4

DC035

Date of Service - From

N/A

837/2400/DTP/472/D8/03, 837/2300/DTP/472/D8/03

DC036

Date of Service - Thru

FA0-05.0, FA0-06.0

837/2400/DTP/472/D8/03, 837/2300/DTP/472/D8/03

DC037

Charge Amount

FA0-13.0

837/2400/SV3/ /02

DC038

Paid Amount

N/A

835/2110/SVC/ /03

DC039

Copay Amount

N/A

835/2110/CAS/PR/3-03

DC040

Coinsurance Amount

N/A

835/2110/CAS/PR/2-03

DC041

Deductible Amount

N/A

835/2110/CAS/PR/1-03

DC042

Billing Provider Number

N/A

837/2010BB/REF/G2/02

DC044

National Billing Provider ID

N/A

837/2010AA/NM1/XX/09

DC044

Billing Provider Last Name

N/A

837/2010AA/NM1/ /03

DC101

Subscriber Last Name

N/A

837/2010BA/NM1/ /03

DC102

Subscriber First Name

N/A

837/2010BA/NM1/ /04

DC103

Subscriber Middle Initial

N/A

837/2010BA/NM1/ /05

DC104

Member Last Name

N/A

837/2010BA/NM1/ /03, 837/2010CA/NM1/ /03

DC105

Member First Name

N/A

837/2010BA/NM1/ /04, 837/2010CA/NM1/ /04

DC106

Member Middle Initial

N/A

837/2010BA/NM1/ /05, 837/2010CA/NM1/ /05

DC201

Carrier Associated with Claim

N/A

N/A

DC202

Carrier Plan Specific Contract Number or Subscriber/Member Social Security Number

N/A

N/A

DC203

Practitioner Group Practice

N/A

N/A

DC204

Tooth Number/Letter

N/A

837/2400 TOO02

DC205

Dental Quadrant

N/A

N/A

DC206

Tooth Surface

837/2400 TOO03

DC207

Claim Version

N/A

N/A

DC208

Diagnosis Code

N/A

837/2300 H101-2

DC209

ICD Indicator

N/A

N/A

DC211

Cross Reference Claims ID

N/A

N/A

DC212

Allowed Amount

N/A

837/2300 HCP02

DC213

HIOS Plan ID

N/A

N/A

DC215

Service Line Type

N/A

N/A

DC218

Claim Processing Level Indicator

N/A

N/A

DC219

Denied Claim Indicator

N/A

N/A

DC220

Denial Reason

N/A

N/A

DC899

Record Type

N/A

N/A

DC900

In Network Indicator

N/A

N/A

DC901

Quantity

N/A

N/A

N.H. Admin. Code § Ins 4010.07

Derived From Volume XXXV Number 32, Filed August 13, 2015, Proposed by #10877, Effective 7/10/2015, Expires7/10/2025.
Amended by Volume XL Number 50, Filed December 10, 2020, Proposed by #13136, Effective 11/24/2020, Expires 11/24/2030