Encounter Claims Extract

Transcription

1 Encounter Claims Extract The Weekly Encounter Claims Extract files contain information about approved and denied encounters processed during the previous week. The information is split into sixteen separate files. Claim Type Physical Health Behavioral Health CCR Dental Approved and Denied Institutional Approved and Denied Approved and Denied Approved and Denied Pharmacy Approved and Denied Professional Approved and Denied Approved and Denied Approved and Denied Each encounter has a Common Claim Header Record and one or more details of the appropriate type. Institutional claims have an additional record of data called the Institutional Claim Header Record that supplements the institutional encounter data in the corresponding Common Claim Header Record. The first four fields of each Common Claim Header Record are used to sort the file. This keeps the encounters for each MCO separate, and presents the encounters and their details in the proper order. The character set and sort are assumed to be ASCII. File Header Record Field Name Data Length Description Type File Type Character 1 A - Approved D - Denied Record Type Character 1 (blank) File Name Character 24 ENCOUNTER CLAIMS EXTRACT Behavioral/Physical Indicator Character 1 Identifies if the file is for Behavioral Health, Physical Health, or CCR. Valid values are B, P, or C. File Creation Date Character 8 Date the file is created. CCYYMMDD Filler Character 336 Blanks Total 371 EOR not included. EOR (End of Record) Character 2 Carriage Return/Line Feed(Hexadecimal 0d/0a)

2 Common Claim Header Record Field Name Data Type Length Description Table Name Column Name MCO Code Character 2 Code assigned by DHS to the MCO to identify the MCO ICN Character 13 Claim s internal control number (ICN). t_pmp_svc_loc t_pd_phys_hdr t_pd_dntl_hdr t_deny_dntl_hdr Record Type Character 1 B N/A N/A plan_cde num_icn Detail Number Character 4 0 (zero) N/A N/A Claim Error Status cde_clm_status Code Disposition Character 1 Indicates the status of a claim. The complete list of valid values is "P"- Paid, "D"-Denied. Claim Type Character 1 Code that specifies the type of claim record. Valid values are found in the table s manual. t_pd_phys_hdr t_pd_dntl_hdr t_deny_dntl_hdr t_pd_phys_hdr t_pd_dntl_hdr t_deny_dntl_hdr cde_clm_type

3 Approved/ Rejected Indicator Character 1 1 Rejected, claim submitted after filing deadline (Claim Adjustment Reason Code 29, The time limit for filing has expired) 2 Rejected, service not covered (Adjustment Reason Code 96, Noncovered charge(s)) 3 Rejected, service not referred/authorized (Adjustment Reason Code 62, Payment denied/reduced for absence of, or exceeded pre-certification / authorization, or Adjustment Reason Code 15, Payment Adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider) 4 Rejected, other coverage (Adjustment Reason Code 22, Payment Adjusted because this care may be covered by another payer per coordination of benefits, or 24, Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan) 9 Encounter/Claim was Approved/Accepted (The presence of an adjudication date, the absence of Coordination of Benefits Total Denied Amount. t_pd_phys_hdr t_pd_dntl_hdr t_deny_dntl_hdr ind_carrier_denied

4 Billing Provider Character 9 MA Provider number that uniquely identifies the provider of services. Billing Provider Service Location Code Character 4 Provider Service Location used by PROMISe. t_dental_hdr_keys t_phrm_hdr_keys t_phys_hdr_key t_ub92_hdr_ext_key t_dental_hdr_keys t_phys_hdr_key t_phrm_hdr_keys t_ub92_hdr_ext_key id_provider svc_loc_id_provider cde_service_loc Performing Provider Performing Provider Service Location Code License Number of Practitioner Character 9 Performing Provider ID. t_phys_hdr_key UB92 t_dental_hdr_keys PHARM Character 4 Performing provider service location. t_pd_phys_hdr UB92 Character 10 License number of the performing/prescribing provider. Place of Service Character 2 A code to indicate where the service was provided. Valid values may be obtained from the appropriate HIPAA implementation guide. t_pd_dntl_hdr t_deny_dntl_hdr PHARM t_pr_type t_pr_type (DNTL) t_pd_phys_hdr UB92 t_pd_dntl_hdr t_deny_dntl_hdr id_perf_prov Space id_perf_prov Spaces cde_perf_svc_loc Spaces cde_perf_svc_loc Spaces num_prov_lic id_prov_other num_prov_lic id_prov_prescrb cde_place_of_service Space cde_pos

5 Category of Provider Provider County Code Character 1 1- The performing/rendering/attending provider is the client's assigned PCP. 2- The performing/rendering/attending provider is not their PCP. Character 2 County code for a provider where the license is valid. t_re_pmp_assign t_pd_phys_hdr t_pd_dntl_hdr t_deny_dntl_hdr patient_residence sak_prov_pcp cde_county Provider Type Character 2 Provider type for which a provider is licensed. t_pd_phys_hdr t_pd_dntl_hdr t_deny_dntl_hdr cde_prov_type

6 Provider Zip Code Character 15 Zip code for a provider where the license is valid. Begin Date of Service End Date of Service Character 8 Date on which services were first performed for a recipient. Format: CCYYMMDD Character 8 Date on which services were last performed for a recipient. Format: CCYYMMDD t_pr_adr t_pd_phys_hdr t_pd_dntl_hdr t_deny_dntl_hdr t_pd_phys_hdr t_pd_dntl_hdr t_deny_dntl_hdr adr_mail_zip dte_first_svc dte_first_svc dte_first_svc dte_dispense dte_last_svc dte_last_svc dte_last_svc dte_dispense MCO Payment Adjudication Date Character 8 Date the MCO finalized the claim in there system. Format: CCYYMMDD t_pd_phys_hdr t_pd_dntl_hdr t_deny_dntl_hdr mco_adjud_dte

7 Original ICN Character 13 Original ICN used for the claim being adjusted. MCO ICN Character 20 The Managed Care Organization's (MCO) claim reference number for the claim or encounter that is being submitted. Adjustment Code Character 1 The claim frequency code that specifies the frequency of the claim. MCO Paid Amount Character 10 Amount the MCO or MCO contractor paid to the provider for the service. Other Insurance Paid Character 10 Amount paid by other insurers, excluding Medicare, for the service. via t_adj_phys_xref via t_adj_ub92_xref via t_adj_dntl_xref via t_adj_phrm_xref t_phys_hdr_key t_ub92_hdr_ext_key t_dental_hdr_keys t_phrm_hdr_keys t_pd_phys_hdr t_pd_prof_hdr t_pd_phys_hdr t_pd_dntl_hdr t_deny_dntl_hdr t_pd_phys_hdr t_pd_phys_hdr.num_i cn.num_i cn t_pd_dntl_hdr.num_ic n.num _icn num_crn_mco cde_claim_frequency cde_claim_frequency cde_claim_frequency Space mco_pd_amt tpl_amt tpl_amt

8 Medicare Approved Amount Medicare Paid Amount Deductible Amount Co-Insurance Amount Character 9 Amount approved by Medicare for the service. Character 9 Amount paid by Medicare for the service. Character 9 Medicare Deductible Amount for the service as reported by Medicare. Character 9 Medicare Coinsurance Amount for the service as reported by Medicare. t_pd_dntl_hdr t_deny_dntl_hdr professional institutional tpl_amt tpl_amt 0: see detail 0: see detail t_final_dntl_xover amt_apprvd_mcare pharmacy 0 professional institutional t_final_dntl_xover 0: see detail 0: see detail amt_paid_mcare pharmacy 0 t_final_phys_xover amt_deduct t_final_ub92_xover amt_deduct t_final_dntl_xover amt_deduct pharmacy 0 t_final_phys_xover t_final_ub92_xover t_final_dntl_xover pharmacy 0 Billed Amount Character 11 Billed amount. t_pd_phys_hdr t_pd_dntl_hdr t_deny_dntl_hdr amt_coinsurance amt_coinsurance amt_coinsurance amt_billed amt_billed_ub92 amt_billed amt_billed

9 COB Flag Character 1 1 Benefits are being coordinated through Medicare and payment was not received when the encounter data was submitted. Presence of Medicare as a payer in Loop Absence of adjudication data from Medicare. t_phys_hdr_key t_ub92_hdr_ext_key t_dental_hdr_keys t_phrm_hdr_keys COB_Flag 2 Payment is being sought from a health insurance but payment was not received when the encounter data was submitted. Presence of another payer, not Medicare, in Loop Absence of adjudication data from that payer. 3 Both Medicare and health insurance (Medigap) are being pursued for payment of the claim but payment was not received from either carrier when the encounter data was submitted. Presence of Medicare and Medigap as payers in Loop Absence of adjudication data from both payers. 4 A third party resource is active but the claim was denied by the third party. Presence of a third-party resource as payer in Loop Adjudication data available. Payment is zero. Claim Adjustment Reason Code is one of many that deny claim and the adjustment amount is equal to the billed amount. 5 A third party resource is active but the current benefits are

10 RID Number Character 9 Unique nine-digit number that identifies an individual on CIS. Primary/Principle Character 7 Code describing the principle diagnosis condition that affects the recipient. t_phys_hdr_key t_ub92_hdr_ext_key t_dental_hdr_keys t_phrm_hdr_keys (DNTL) t_phrm_diagnosis (PHRM) id_medicaid cde_diag_seq = 1 or 01) Phrm: cde_diag (where cde_diag_order = 01) Primary/Principle Type Primary/Principle POA Indicator (DNTL) t_phrm_diagnosis (PHRM) Character 1 Present on admission indicator. cde_diag_seq = 1 or 01) cde_diag_seq = 1 or 01)

11 2 Character 7 Code describing the secondary diagnosis condition that affects the recipient. Type 2 POA Indicator 2 (DNTL) t_phrm_diagnosis (PHRM) (DNTL) t_phrm_diagnosis (PHRM) Character 1 Present on admission indicator. cde_diag_seq = 2 or 02) Phrm only: cde_diag (where cde_diag_order = 02) cde_diag_seq = 2 or 02) cde_diag_seq = 2 or 02) 3 Character 7 Code describing the third diagnosis condition that affects the recipient. (DNTL) t_phrm_diagnosis (PHRM) cde_diag_seq = 3 or 03) Phrm only: cde_diag (where cde_diag_order = 03)

12 Type 3 POA Indicator 3 (DNTL) t_phrm_diagnosis (PHRM) Character 1 Present on admission indicator. cde_diag_seq = 3 or 03) cde_diag_seq = 3 or 03) 4 Character 7 Code describing the fourth diagnosis condition that affects the recipient. Type 4 POA Indicator 4 (DNTL) t_phrm_diagnosis (PHRM) (DNTL) t_phrm_diagnosis (PHRM) Character 1 Present on admission indicator. cde_diag_seq = 4 or 04) Phrm only: cde_diag (where cde_diag_order = 04) cde_diag_seq = 4 or 04) cde_diag_seq = 4 or 04)

13 5 Character 7 Code describing the fifth diagnosis condition that affects the recipient. Type 5 POA Indicator 5 (DNTL) t_phrm_diagnosis (PHRM) (DNTL) t_phrm_diagnosis (PHRM) Character 1 Present on admission indicator. cde_diag_seq = 5 or 05) Phrm only: cde_diag (where cde_diag_order = 05) cde_diag_seq = 5 or 05) cde_diag_seq = 5 or 05) 6 Character 7 Code describing the sixth diagnosis condition that affects the recipient. (DNTL) t_phrm_diagnosis (PHRM) cde_diag_seq = 6 or 06) Phrm only: cde_diag (where cde_diag_order = 06)

14 Type 6 POA Indicator 6 (DNTL) t_phrm_diagnosis (PHRM) Character 1 Present on admission indicator. cde_diag_seq = 6 or 06) cde_diag_seq = 6 or 06) 7 Character 7 Code describing the eighth diagnosis condition that affects the recipient. Type 7 POA Indicator 7 (DNTL) t_phrm_diagnosis (PHRM) (DNTL) t_phrm_diagnosis (PHRM) Character 1 Present on admission indicator. cde_diag_seq = 7 or 07) Phrm only: cde_diag (where cde_diag_order = 07) cde_diag_seq = 7 or 07) cde_diag_seq = 7 or 07)

15 8 Character 7 Code describing the eighth diagnosis condition that affects the recipient. Type 8 POA Indicator 8 (DNTL) t_phrm_diagnosis (PHRM) (DNTL) t_phrm_diagnosis (PHRM) Character 1 Present on admission indicator. cde_diag_seq = 8 or 08) Phrm only: cde_diag (where cde_diag_order = 08) cde_diag_seq = 8 or 08) cde_diag_seq = 8 or 08) 9 Character 7 Code describing the ninth diagnosis condition that affects the recipient. (DNTL) t_phrm_diagnosis (PHRM) cde_diag_seq = 9 or 09) Phrm only: cde_diag (where cde_diag_order = 09)

16 Type 9 POA Indicator 9 (DNTL) t_phrm_diagnosis (PHRM) Character 1 Present on admission indicator. cde_diag_seq = 9 or 09) cde_diag_seq = 9 or 09) Admission Date Character 8 Date of admission to the Facility or Hospital. Format: CCYYMMDD Discharge Date Character 8 Date the recipient is discharged from the Facility or Hospital. Format: CCYYMMDD Pregnancy Indicator PROMISe Suspense Date t_pd_phys_hdr dental 0 pharmacy 0 t_pd_phys_hdr ub92 0 dental 0 pharmacy 0 dte_from_hosp dte_admission dte_to_hosp Character 1 Indicates if the recipient is pregnant. t_phys_hdr_key ind_pregnancy Character 8 Date that the encounter claim was first suspended by the PROMISe. Format: CCYYMMDD ub92 t_dental_hdr_keys t_claim_locat Space ind_pregnancy ind_pregnancy dte_clm_locat, earliest date where cde location not = 66, 97, 98 or 99; else 0

17 PROMISe Accepted Date Character 8 Date that the encounter claim was accepted by the PROMISe system. Format CCYYMMDD t_claim_locat dte_clm_locat, where cde_location = 99, else Spaces Recipient Case Character 9 Recipient s case number. The case number assigned to the recipient by the caseworker. Recipient Category of Assistance Recipient Grant group Recipient Validation Digit Recipient Line Number Character 3 Code that identifies the program and type of benefits received by the recipient. Character 1 If applicable, the numeric grant group that distinguishes when there is more than one budget in the same category. Character 1 Numeric value determined by using Luhn Formula Modulus 10 Double- Add-Double and the Recipient Individual Number. Character 2 Two-digit line number assigned to each recipient to distinguish each individual in the case. t_re_cis_elig_svc_pg m t_clm_pgm_xref t_re_cis_elig_svc_pg m t_re_cis_base t_re_cis_elig_svc_pg m num_case cde_cat_of_assist cde_grant_grp check_digit cde_line Recipient SSN Character 9 Recipient s Social Security Number t_re_cis_base num_ssn Recipient Age Character 4 Recipient s age, which is calculated t_clm_pgm_xref recip_age from the birth date to the current date. Recipient DOB Character 8 Date recipient was born t_re_cis_base dte_birth Recipient Gender Character 1 Recipient s Gender: M Male, F - Female t_re_cis_base cde_sex Recipient Race Code 1 Character 1 Recipient s First Race Code. t_re_cis_base cde_race

18 Recipient Race Code 2 Recipient Race Code 3 Recipient Race Code 4 Recipient Race Code 5 Recipient Ethnicity Code Recipient Program Status Code Recipient Deprivation Qualifying Code Recipient Lock In Indicator Recipient Case Child Under 21 Recipient District Code Recipient Employment Status Recipient SSI Medicare Part A Character 1 Recipient s Second Race Code. t_re_cis_base cde_race_2 Character 1 Recipient s Third Race Code. t_re_cis_base cde_race_3 Character 1 Recipient s Fourth Race Code. t_re_cis_base cde_race_4 Character 1 Recipient s Fifth Race Code. t_re_cis_base cde_race_5 Character 1 Recipient s Ethnicity Code t_re_cis_base cde_ethnic Character 2 Recipient code that identifies the budget category for their characteristics. Character 2 Code that determines eligibility for a certain category of assistance. Character 1 Indicator that denotes if the recipient is/was locked-in to a specific provider to prevent utilization abuse by the recipient. Character 1 Indicator used to identify a case where at least one member is under the age of 21. Calculated fields based on the recipient age. Character 1 One-digit code that indicates the district within the county where the case record is maintained. Character 2 Value used to describe the recipient s employment status. Character 1 Code used to identify SSI eligible recipients with Medicare Part A as an active resource. t_clm_pgm_xref t_clm_pgm_xref t_re_lockin_period t_re_cis_case_mem ber t_re_cis_case t_re_cis_base t_re_cis_tpl_insuran ce cde_pgm_stat cde_dep_qual ind_restrict t_re_cis_base.dte_birt h for each id_medicaid cde_district cde_empl_status cde_ins_type

19 Number of Details Character 4 Total number of details associated with the claim. t_pd_phys_hdr t_pd_dntl_hdr t_deny_dntl_hdr num_dtl_total Provider Specialty Code Patient Account Number Character 3 Provider Specialty Code t_pd_phys_hdr t_pd_dntl_hdr t_deny_dntl_hdr Character 38 Identification for a recipient assigned by a provider and used in their system. t_pd_phys_hdr t_pd_dntl_hdr t_deny_dntl_hdr cde_prov_spec num_pat_acct

20 MCO Copay Amount Character 9 This is the claim level copay amount reported by MCOs for encounter data. Claim Note Character 3 Code identifying the functional area or purpose for which the note applies. t_pd_phys_hdr t_pd_dntl_hdr t_deny_dntl_hdr t_clm_nte mco_copay_amt cde_note Claim Note Description Billing Provider NPI ID Billing Provider Taxonomy Code Billing Provider Address Zip Performing Provider NPI ID Performing Provider Taxonomy Code Performing Provider Address Zip Character 80 Free-form description to clarify the related data elements and their content. t_clm_nte dsc_note Character 10 NPI id of the billing provider t_npi_data id_npi Character 10 Taxonomy Code of the billing provider t_npi_data cde_taxonomy Character 9 Address zip code of the billing t_npi_data adr_zip provider Character 10 NPI id of the performing provider. t_npi_data id_npi Character 10 Taxonomy code of the performing provider Character 9 Address zip code of the performing provider t_npi_data t_npi_data cde_taxonomy adr_zip

21 Contract Type Character 2 Contract Type Code. Code identifying a contract type. Only applies to professional claims on the Common Claim HDR. Dispense Fee Character 8 Amount that the provider receives for dispensing a prescription drug. Ingredient Cost Character 8 The product component cost of the dispensed prescription. Prior Authorization Number Basis of Cost Determination Submission Clarification Code 1 Submission Clarification Code 2 Submission Clarification Code 3 Other Coverage Code Character 11 The MCO Prior Authorization number submitted with the claim. Per DHS request, this is only be added for pharmacy claims. Character 2 Code indicating the method Ingredient Cost was submitted. Character 3 The code indicating that the pharmacist is clarifying the submission. Character 3 The code indicating that the pharmacist is clarifying the submission. Character 3 The code indicating that the pharmacist is clarifying the submission. Character 2 Code indicating whether or not the patient has other insurance coverage. 10 Character 7 Code describing the tenth diagnosis condition that affects the recipient. t_clm_cn1 t_phrm_hdr_keys t_phrm_sub_clar t_phrm_sub_clar t_phrm_sub_clar cde_contract_type (Professional only, all others spaces) dispensing_fee_submi tted ingred_cost mco_num_pa basis_of_cost sub_clar_cde (where sub_clar_order = 01) sub_clar_cde (where sub_clar_order = 02) sub_clar_cde (where sub_clar_order = 03) other_cov_ind cde_diag_seq = 10) Type 10 cde_diag_seq = 10)

22 11 Character 7 Code describing the eleventh diagnosis condition that affects the recipient. cde_diag_seq = 11) Type Character 7 Code describing the twelfth diagnosis condition that affects the recipient. cde_diag_seq = 11) cde_diag_seq = 12) Type 12 cde_diag_seq = 12) Patient Reason for Visit Diagnosis 1 Character 7 Code describing the Reason for Visit diagnosis that affects the recipient. cde_diag_seq = R1) Patient Reason for Visit Diagnosis Code Type 1 cde_diag_seq = R1) Patient Reason for Visit Diagnosis 2 Character 7 Code describing the Reason for Visit diagnosis that affects the recipient. cde_diag_seq = R2)

23 Patient Reason for Visit Diagnosis Code Type 2 cde_diag_seq = R2) Patient Reason for Visit Diagnosis 3 Character 7 Code describing the Reason for Visit diagnosis that affects the recipient. cde_diag_seq = R3) Patient Reason for Visit Diagnosis Code Type 3 cde_diag_seq = R3) Total 684 EOR not included. EOR (End of Record) Character 2 Carriage Return/Line Feed (Hexadecimal 0d/0a) N/A N/A

24 Professional Claim Detail Record Field Name Data Type Length Description Table Name Column Name MCO Code Character 2 Code assigned by DHS to the MCO to identify the MCO ICN Character 13 Claim s internal control number (ICN). t_pmp_svc_loc t_pd_phys_hdr Record Type Character 1 "D" N/A N/A Detail Number Character 4 Number of the detail on the claim. t_pd_phys_dtl t_deny_phys_dtl Quantity Character 6 Number of units of service that were provided. Emergency Indicator Character 1 Indicates whether the service was provided as result of emergency situation. NDC Character 11 National Drug Code prescribed/dispensed to a recipient Procedure Code Character 6 HCPCS code identifying a unit of medical services provided to a patient by a provider. Procedure Code Modifier 1 Procedure Code Modifier 2 Procedure Code Modifier 3 Procedure Code Modifier 4 Character 2 First of two codes that may be used to further define the Procedure Code. Character 2 Second of two codes that may be used to further define the Procedure Code. Character 2 Third of two codes that may be used to further define the Procedure Code. Character 2 Fourth of two codes that may be used to further define the Procedure Code. t_pd_phys_dtl t_deny_phys_dtl t_pd_phys_dtl t_deny_phys_dtl Initialized, but not populated t_phys_dext_key t_pd_phys_dtl t_deny_phys_dtl t_pd_phys_dtl t_deny_phys_dtl t_pd_phys_dtl t_deny_phys_dtl t_pd_phys_dtl t_deny_phys_dtl plan_cde num_icn num_dtl qty_billed ind_emergency cde_proc cde_proc_mod cde_modifier_2 cde_modifier_3 cde_modifier_4

25 Begin Date of Service End Date of Service Character 8 Date on which services were first performed for a recipient. Format: CCYYMMDD Character 8 Date on which services were last performed for a recipient. Format: CCYYMMDD t_pd_phys_dtl t_deny_phys_dtl t_pd_phys_dtl t_deny_phys_dtl EPSDT Indicator Character 1 EPSDT or Family Planning code. t_pd_phys_dtl t_deny_phys_dtl MCO Paid Amount Detail Medicare Approved Amount Medicare Paid Amount Character 10 Amount the MCO or MCO contractor paid to the provider for the service. Character 9 Amount approved by Medicare for the service. Character 9 Amount paid by Medicare for the service. Place of Service Character 2 A code to indicate where the service was provided. Valid values may be obtained from the appropriate HIPAA implementation guide. Claim Note Character 3 Code identifying the functional area or purpose for which the note applies. Claim Note Description Capitation FFS Indicator Character 80 Free-form description to clarify the related data elements and their content. Character 2 Code to indicate the type of payment arrangement applicable to the encounter. Valid values are: 05-Capitated 06-Percent Contract Amount Character 9 Subcapitation contract amount(behavioral Health only) t_pd_phys_dtl t_deny_phys_dtl t_final_phys_xover t_final_phys_xover t_pd_phys_dtl t_deny_phys_dtl t_clm_nte t_clm_nte t_clm_cn1 t_clm_cn1 dte_first_svc dte_last_svc cde_epsdt_fp mco_pd_amt_dtl amt_apprvd_mcare amt_paid_mcare cde_pos cde_note dsc_note cde_contract_type amt_contract

26 Contract Percent Character 9 Contract percentage, expressed as a percent. Also known as allowance or charge percent. (Behavioral Health only) Contract ID Character 50 Contract reference ID. Required if the provider is required by contract to supply this information on the claim(behavioral Health only) Terms Discount Percentage Character 9 Terms Discount Percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount due Date(Behavioral Health only) Contract version Character 30 Contract Version Identifier(Behavioral Health only) Approved/Rejecte d Indicator Provider Specialty Code Character 1 The codes are derived from the accompanying Claim Adjustment Segment (CAS). t_clm_cn1 t_clm_cn1 t_clm_cn1 t_clm_cn1 t_pd_phys_dtl t_deny_phys_dtl Character 3 Provider Specialty Code t_pd_phys_dtl t_deny_phys_dtl Units Paid Character 6 Number of units of service that will be paid for. Quantity Qualifier Character 2 Quantity Qualifier. Code specifying the type of quantity. Diagnosis Pointer Character 11 Indicates which diagnosis (or diagnoses) for which services were provided. MCO Copay Amount Character 9 This is the service line level copay amount reported by MCOs for encounter data. Allowed Quantity Character 6 Number of units of service that will be paid for. t_pd_phys_dtl t_deny_phys_dtl t_clm_qty t_pd_phys_dtl t_deny_phys_dtl t_pd_phys_dtl t_deny_phys_dtl t_pd_phys_dtl t_deny_phys_dtl num_contract_percent cde_contract_id num_terms_disc_pcnt cde_contract_version ind_carrier_denied cde_prov_spec qty_allowed qlf_quantity cde_diag_treat_ind mco_copay_amt_dtl qty_allowed

27 Claim Status Character 1 Indicates the status of a claim. The complete list of valid values is "P"- Paid, "S"-Suspended, "D"-Denied, "X"-Super-Suspend, "R"-Resubmit, "L"-Pay and List, "I"-Inactive, and "B"-Batch Error. Allowed Amount Character 9 Amount allowed by the specific program (Medicaid, 590, etc.) for the procedure. t_pd_phys_dtl t_deny_phys_dtl t_pd_phys_dtl t_deny_phys_dtl cde_clm_status amt_alwd Filler Character 72 Blanks Filler Character Total 411 EOR not included. EOR (End of Record) Character 2 Carriage Return/Line Feed (Hexadecimal 0d/0a) N/A N/A

28 Institutional Claim Header Record Field Name Data Type Length Description Table Name Column Name MCO Code Character 2 Code assigned by DHS to the MCO to identify the MCO ICN Character 13 Claim s internal control number (ICN). t_pmp_svc_loc Record Type Character 1 E N/A N/A Detail Number Character 4 0 (zero) N/A N/A Type Of Admission Character 1 UB92 code which indicates the priority of the admission for inpatient or outpatient care. Hospital Admission Hour Hospital Discharge Hour Diagnosis Related Group Number Lifetime Reserve Days Hospital Certified Days Hospital Non Certified Days Co-Insurance Days Character 4 Hour during which the recipient was admitted to the hospital. Character 4 Hour during which the recipient was discharged from the hospital. Character 4 Diagnosis Related Group for the hospital admission calculated by PROMISe. Character 6 Number of Medicare lifetime reserve days used during the service period. Character 4 Indicates the number of days covered for the statement period of the claim. Character 4 Indicates the number of days not covered for the statement period of the claim. Character 3 Number of Medicare Coinsurance days in the service. t_ub92_hdr_ext_key t_drg (dos < 7/1/10) t_ref_apr_drg (dos >= 7/1/10) t_clm_mia t_final_ub92_xover plan_cde num_icn cde_admit_type cde_admit_hour time_discharge cde_drg (t_drg) or cde_drg_apr (t_ref_apr_drg), from t_ub92_hdr_inp cnt_mia_life_reserve num_days_covd num_days_nocvd num_co_ins_days

29 Principle Procedure Code Principle Procedure Date Character 7 Code to indicate the principle medical, surgical, or obstetrical procedure performed. It is the procedure mostly related to the principle diagnosis code. Character 8 Date the principle procedure was performed. Format: CCYYMMDD Procedure Code 2 Character 7 Code to indicate when applicable the secondary medical, surgical, or obstetrical procedure performed. It is the procedure mostly related to the principle diagnosis code. Procedure Date 2 Character 8 Date the secondary procedure was performed. Format: CCYYMMDD Procedure Code 3 Character 7 Code to indicate when applicable the tertiary medical, surgical, or obstetrical procedure performed. It is the procedure mostly related to the principle diagnosis code. Procedure Date 3 Character 8 Date the tertiary procedure was performed. Format: CCYYMMDD Occurrence Span Code 1 Occurrence Span From Date 1 Occurrence Span To Date 1 Occurrence Span Code 2 Character 2 Code that identifies an event that relates to the payment of the claim. Character 8 Effective start date associated with an Occurrence Span Code. Format: CCYYMMDD Character 8 Effective end date associated with an Occurrence Span Code. Format: CCYYMMDD Character 2 Code that identifies an event that relates to the payment of the claim. t_ub92_hdr_icd9cm t_ub92_hdr_icd9cm t_ub92_hdr_icd9cm t_ub92_hdr_icd9cm t_ub92_hdr_icd9cm t_ub92_hdr_icd9cm t_ub92_hdr_occ t_ub92_hdr_occ t_ub92_hdr_occ t_ub92_hdr_occ cde_proc_icd9 where num_seq=1 dte_icd_9_cm_proc where num_seq=1 cde_proc_icd9 where num_seq=2 dte_icd_9_cm_proc where num_seq=2 cde_proc_icd9 where num_seq=3 dte_icd_9_cm_proc where num_seq=3 cde_occurrence, where num_seq = 1 dte_occurrence, where num_seq = 1 dte_occ_to, where num_seq = 1 cde_occurrence, where num_seq = 2

30 Occurrence Span From Date 2 Occurrence Span To Date 2 Occurrence Span Code 3 Occurrence Span From Date 3 Occurrence Span To Date 3 Character 8 Effective start date associated with an Occurrence Span Code. Format: CCYYMMDD Character 8 Effective end date associated with an Occurrence Span Code. Format: CCYYMMDD Character 2 Code that identifies an event that relates to the payment of the claim. Character 8 Effective start date associated with an Occurrence Span Code. Format: CCYYMMDD Character 8 Effective end date associated with an Occurrence Span Code. Format: CCYYMMDD Value Code 1 Character 2 Code structure to relate amounts or values to identified data elements necessary to process the claim as qualified by the payer organization Value Amount 1 Character 10 Value Amount associated with the Value Code Value Code 2 Character 2 Code structure to relate amounts or values to identified data elements necessary to process the claim as qualified by the payer organization. Value Amount 2 Character 10 Value Amount associated with the Value Code. Value Code 3 Character 2 Code structure to relate amounts or values to identified data elements necessary to process the claim as qualified by the payer organization. Value Amount 3 Character 10 Value Amount associated with the Value Code. t_ub92_hdr_occ t_ub92_hdr_occ t_ub92_hdr_occ t_ub92_hdr_occ t_ub92_hdr_occ t_ub92_hdr_value t_ub92_hdr_value t_ub92_hdr_value t_ub92_hdr_value t_ub92_hdr_value t_ub92_hdr_value dte_occurrence, where num_seq = 2 dte_occ_to, where num_seq = 2 cde_occurrence, where num_seq = 3 dte_occurrence, where num_seq = 3 dte_occ_to, where num_seq = 3 cde_value, where num_seq = 1. amt_value, where num_seq = 1. cde_value, where num_seq = 2 amt_value, where num_seq = 2 cde_value, where num_seq = 3 amt_value, where num_seq = 3

31 Patient Status Code Capitation FFS Indicator Character 2 Patient Status Character 2 Code to indicate the type of payment t_clm_cn1 arrangement applicable to the encounter. Valid values are: 05-Capitated 06-Percent Contract Amount Character 9 Subcapitation contract amount(behavioral Health only) Contract Percent Character 9 Contract percentage, expressed as a percent. Also known as allowance or charge percent. (Behavioral Health only) Contract ID Character 50 Contract reference ID. Required if the provider is required by contract to supply this information on the claim(behavioral Health only) Terms Discount Percentage Character 9 Terms Discount Percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount due Date(Behavioral Health only) Contract version Character 30 Contract Version Identifier(Behavioral Health only) MCO DRG code Character 4 The Diagnosis Related Group (DRG) submitted by the MCO on the claim. Type of Bill Character 3 Code which indicates the specific type of facility that is billing for services on the institutional claims. 10 Character 7 Code describing the tenth diagnosis condition that affects the recipient. t_clm_cn1 t_clm_cn1 t_clm_cn1 t_clm_cn1 t_clm_cn1 t_ub92_hdr_inp cde_patient_status cde_contract_type amt_contract num_contract_percent cde_contract_id num_terms_disc_pcnt cde_contract_version cde_drg_submitted cde_type_of_bill cde_diag_seq = 10)

32 Type 10 cde_diag_seq = 10) POA Indicator 10 Character 1 Present on admission indicator. 11 Character 7 Code describing the eleventh diagnosis condition that affects the recipient. Type 11 cde_diag_seq = 10) cde_diag_seq = 11) cde_diag_seq = 11) POA Indicator 11 Character 1 Present on admission indicator. 12 Character 7 Code describing the twelfth diagnosis condition that affects the recipient. Type 12 cde_diag_seq = 11) cde_diag_seq = 12) cde_diag_seq = 12) POA Indicator 12 Character 1 Present on admission indicator. 13 Character 7 Code describing the thirteenth diagnosis condition that affects the recipient. Type 13 cde_diag_seq = 12) cde_diag_seq = 13) cde_diag_seq = 13) POA Indicator 13 Character 1 Present on admission indicator. cde_diag_seq = 13)

33 14 Character 7 Code describing the fourteenth diagnosis condition that affects the recipient. Type 14 cde_diag_seq = 14) cde_diag_seq = 14) POA Indicator 14 Character 1 Present on admission indicator. 15 Character 7 Code describing the fifteenth diagnosis condition that affects the recipient. Type 15 cde_diag_seq = 14) cde_diag_seq = 15) cde_diag_seq = 15) POA Indicator 15 Character 1 Present on admission indicator. 16 Character 7 Code describing the sixteenth diagnosis condition that affects the recipient. Type 16 cde_diag_seq = 15) cde_diag_seq = 16) cde_diag_seq = 16) POA Indicator 16 Character 1 Present on admission indicator. 17 Character 7 Code describing the seventeenth diagnosis condition that affects the recipient. cde_diag_seq = 16) cde_diag_seq = 17)

34 Type 17 cde_diag_seq = 17) POA Indicator 17 Character 1 Present on admission indicator. 18 Character 7 Code describing the eighteenth diagnosis condition that affects the recipient. Type 18 cde_diag_seq = 17) cde_diag_seq = 18) cde_diag_seq = 18) POA Indicator 18 Character 1 Present on admission indicator. 19 Character 7 Code describing the nineteenth diagnosis condition that affects the recipient. Type 19 cde_diag_seq = 18) cde_diag_seq = 19) cde_diag_seq = 19) POA Indicator 19 Character 1 Present on admission indicator. 20 Character 7 Code describing the twentieth diagnosis condition that affects the recipient. Type 20 cde_diag_seq = 19) cde_diag_seq = 20) cde_diag_seq = 20) POA Indicator 20 Character 1 Present on admission indicator. cde_diag_seq = 20)

35 21 Character 7 Code describing the twenty first diagnosis condition that affects the recipient. Type 21 cde_diag_seq = 21) cde_diag_seq = 21) POA Indicator 21 Character 1 Present on admission indicator. 22 Character 7 Code describing the twenty second diagnosis condition that affects the recipient. Type 22 cde_diag_seq = 21) cde_diag_seq = 22) cde_diag_seq = 22) POA Indicator 22 Character 1 Present on admission indicator. 23 Character 7 Code describing the twenty third diagnosis condition that affects the recipient. Type 23 cde_diag_seq = 22) cde_diag_seq = 23) cde_diag_seq = 23) POA Indicator 23 Character 1 Present on admission indicator. 24 Character 7 Code describing the twenty fourth diagnosis condition that affects the recipient. cde_diag_seq = 23) cde_diag_seq = 24)

36 Type 24 cde_diag_seq = 24) POA Indicator 24 Character 1 Present on admission indicator. 25 Character 7 Code describing the twenty fifth diagnosis condition that affects the recipient. Type 25 cde_diag_seq = 24) cde_diag_seq = 25) cde_diag_seq = 25) POA Indicator 25 Character 1 Present on admission indicator. Admission Source Character 1 The source of admission code for inpatient and LTC claims. Procedure Code 4 Character 7 Code to indicate when applicable the fourth medical, surgical, or obstetrical procedure performed. Procedure Date 4 Character 8 Date the fourth procedure was performed. Format: CCYYMMDD Procedure Code 5 Character 7 Code to indicate when applicable the fifth medical, surgical, or obstetrical procedure performed. Procedure Date 5 Character 8 Date the fifth procedure was performed. Format: CCYYMMDD Procedure Code 6 Character 7 Code to indicate when applicable the sixth medical, surgical, or obstetrical procedure performed. Procedure Date 6 Character 8 Date the sixth procedure was performed. Format: CCYYMMDD t_ub92_hdr_icd9cm t_ub92_hdr_icd9cm t_ub92_hdr_icd9cm t_ub92_hdr_icd9cm t_ub92_hdr_icd9cm t_ub92_hdr_icd9cm cde_diag_seq = 25) cde_admit_source cde_proc_icd9 where num_seq=4 dte_icd_9_cm_proc where num_seq=4 cde_proc_icd9 where num_seq=5 dte_icd_9_cm_proc where num_seq=5 cde_proc_icd9 where num_seq=6 dte_icd_9_cm_proc where num_seq=6

37 PROMISe Allowed Amount PROMISe DRG Type PROMISe Severity Level Character 9 Allowed amount calculated for services rendered. Character 1 This column will be used to determine which DRG version is being used for pricing. ' ' -- for current DRG version 'A' -- for the new APR DRG version. Character 1 Determines the severity level that each DRG will be associated with. For APR DRG it is from 1 to 4. t_ub92_hdr_inp t_ub92_hdr_inp amt_reimbursement cde_drg_type sev_level Birth Weight Character 7 Newborn birth weight in grams. t_ub92_hdr_value amt_value where cde_value = '54' Severity Level Submitted Character 1 Submitted severity level code from encounter claims. t_ub92_hdr_inp sev_level_submitted Total 528 EOR not included. EOR Character 2 Carriage Return/Line Feed Hexadecimal 0d/0a) N/A N/A

38 Institutional Claim Detail Record Field Name Data Type Length Description Table Name Column Name MCO Code Character 2 Code assigned by DHS to the MCO to identify the MCO ICN Character 13 Claim s internal control number (ICN). t_pmp_svc_loc Record Type Character 1 F N/A N/A Detail Number Character 4 Number of the detail on the claim. t_pd_ub92_dtl t_deny_ub92_dtl Begin Date of Service End Date of Service Character 8 Date on which services were first performed for a recipient. Format: CCYYMMDD Character 8 Date on which services were last performed for a recipient. Format: CCYYMMDD Quantity Character 9 Number of units of service that were billed. Revenue Code Character 4 Codes to indicate the services provided during the service period Procedure Code Character 6 Code which indicates the service that was performed. Billed Amount Character 11 Amount of money requested by a provider for payment on an institutional claim. Medicare Approved Amount Medicare Paid Amount Approved/Rejecte d Indicator Character 9 Amount approved by Medicare for the service. Character 9 Amount paid by Medicare for the service. Character 1 The codes are derived from the accompanying Claim Adjustment Segment (CAS). t_pd_ub92_dtl t_deny_ub92_dtl t_pd_ub92_dtl t_deny_ub92_dtl t_pd_ub92_dtl t_deny_ub92_dtl t_pd_ub92_dtl t_deny_ub92_dtl t_ub92_dtl_ext_key t_pd_ub92_dtl t_deny_ub92_dtl t_final_ub92_xover t_final_ub92_xover t_pd_ub92_dtl t_deny_ub92_dtl plan_cde num_icn num_dtl dte_first_svc dte_last_svc qty_units_billed cde_revenue cde_proc amt_billed_ub92 amt_apprvd_mcare amt_paid_mcare ind_carrier_denied

39 Provider Specialty Code Character 3 Provider Specialty Code Claim Note Character 3 Code identifying the functional area or purpose for which the note applies. Claim Note Description Character 80 Free-form description to clarify the related data elements and their content. Units Paid Character 9 Quantity allowed for payment for services rendered to a recipient. Quantity Qualifier Character 2 Quantity Qualifier. Code specifying the type of quantity. MCO Copay Amount Procedure Code Modifier 1 Procedure Code Modifier 2 Procedure Code Modifier 3 Procedure Code Modifier 4 Character 9 This is the service line level copay amount reported by MCOs for encounter data. Character 2 Service Procedure Code Modifier 1. Code used to further define a procedure provided. Character 2 Service Procedure Code Modifier 2. Code used to further define a procedure provided. Character 2 Service Procedure Code Modifier 3. Code used to further define a procedure provided. Character 2 Service Procedure Code Modifier 4. Code used to further define a procedure provided. MCO Paid Amount Character 10 The amount the MCO paid for the claim detail. PROMISe Allowed Quantity/Units Character 9 Quantity allowed for payment for services rendered to a recipient. t_clm_nte t_clm_nte t_pd_ub92_dtl t_deny_ub92_dtl t_clm_qty t_pd_ub92_dtl t_deny_ub92_dtl t_clm_modifier t_clm_modifier t_clm_modifier t_clm_modifier t_pd_ub92_dtl t_deny_ub92_dtl t_pd_ub92_dtl t_deny_ub92_dtl cde_prov_spec cde_note dsc_note qty_units_alwd qlf_quantity mco_copay_amt_dtl cde_modifier where seq = 1 cde_modifier where seq = 2 cde_modifier where seq = 3 cde_modifier where seq = 4 mco_pd_amt_dtl qty_units_alwd

40 Disposition Code (detail) PROMISe Allowed Amount Character 1 Indicates the status of a claim. The complete list of valid values is "P"- Paid, "S"-Suspended, "D"-Denied, "X"-Super-Suspend, "R"-Resubmit, "L"-Pay and List, "I"-Inactive, and "B"-Batch Error. Character 9 Amount allowed by the specific program (Medicaid, 590, etc.) for the procedure. t_pd_ub92_dtl t_deny_ub92_dtl t_pd_ub92_dtl t_deny_ub92_dtl Filler Character 183 Blanks N/A N/A Total 411 EOR not included. EOR Character 2 Carriage Return/Line Feed (Hexadecimal 0d/0a) N/A cde_clm_status amt_alwd N/A

41 Dental Claim Detail Record Field Name Data Type Length Description Table Name Column Name MCO Code Character 2 Code assigned by DHS to the MCO to identify the MCO ICN Character 13 Claim s internal control number (ICN). t_pmp_svc_loc t_pd_dntl_hdr t_deny_dntl_hdr Record Type Character 1 G N/A N/A Detail Number Character 4 Number of the detail on the claim. t_pd_dntl_dtl t_deny_dntl_dtl Begin Date of Service Character 8 Date on which services were first performed for a recipient. Format: CCYYMMDD Tooth Number Character 2 Indicates the tooth on which a particular service was performed. Capitation FFS Indicator Character 2 Code to indicate the type of payment arrangement applicable to the encounter. Valid values are: 05-Capitated 06-Percent Contract Amount Character 9 Subcapitation contract amount (Behavioral Health only) Contract Percent Character 9 Contract percentage, expressed as a percent. Also known as allowance or charge percent. (Behavioral Health only) Contract ID Character 50 Contract reference ID. Required if the provider is required by contract to supply this information on the claim(behavioral Health only) t_pd_dntl_dtl t_deny_dntl_dtl t_pd_dntl_dtl t_deny_dntl_dtl t_clm_cn1 t_clm_cn1 t_clm_cn1 t_clm_cn1 plan_cde num_icn num_dtl dte_first_svc cde_tooth_nbr cde_contract_type amt_contract num_contract_percent cde_contract_id

42 Terms Discount Percentage Character 9 Terms Discount Percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount due Date(Behavioral Health only) Contract version Character 30 Contract Version Identifier(Behavioral Health only) Approved/Rejecte d Indicator Provider Specialty Code Character 1 The codes are derived from the accompanying Claim Adjustment Segment (CAS). t_clm_cn1 t_clm_cn1 t_pd_dntl_dtl t_deny_dntl_dtl Character 3 Provider Specialty Code t_pd_dntl_dtl t_deny_dntl_dtl Quantity Qualifier Character 2 Quantity Qualifier. Code specifying the type of quantity. Procedure Code Character 6 Service Procedure Code. Code that identifies the service performed for a recipient. Procedure Code Modifier 1 Procedure Code Modifier 2 Procedure Code Modifier 3 Procedure Code Modifier 4 MCP Copay Amount Character 2 Service Procedure Code Modifier 1. Code used to further define a procedure provided. Character 2 Service Procedure Code Modifier 2. Code used to further define a procedure provided. Character 2 Service Procedure Code Modifier 3. Code used to further define a procedure provided. Character 2 Service Procedure Code Modifier 4. Code used to further define a procedure provided. Character 9 This is the service line level copay amount reported by MCOs for encounter data. t_clm_qty t_dental_dtl_keys t_clm_modifier t_clm_modifier t_clm_modifier t_clm_modifier t_pd_dntl_dtl t_deny_dntl_dtl num_terms_disc_pcnt cde_contract_version ind_carrier_denied cde_prov_spec qlf_quantity cde_proc cde_modifier where seq = 1 cde_modifier where seq = 2 cde_modifier where seq = 3 cde_modifier where seq = 4 mco_copay_amt_dtl

43 MCO Paid Amount Character 10 The amount the MCO paid for the claim detail. Quantity (Units of Service) PROMISe Allowed Amount Character 6 The number of units allowed for the service. Character 9 Amount approved to pay for services provided to a recipient. t_pd_dntl_dtl t_deny_dntl_dtl t_pd_dntl_dtl t_deny_dntl_dtl t_pd_dntl_dtl t_deny_dntl_dtl mco_pd_amt_dtl qty_allowed amt_alwd Filler Character 218 Blanks N/A N/A Total 411 EOR not included. EOR (End of Record) Character 2 Carriage Return/Line Feed (Hexadecimal 0d/0a) N/A N/A

44 Pharmacy Claim Detail Record Field Name Data Type Length Description Table Name Column Name MCO Code Character 2 Code assigned by DHS to the MCO to identify the MCO ICN Character 13 Claim s internal control number (ICN). t_pmp_svc_loc Record Type Character 1 H N/A N/A Detail Number Character 4 Number of the detail on the claim. t_pd_pharm_dtl t_deny_phrm_dtl NDC Character 11 National Drug Code prescribed/dispensed to a recipient Days Supply Character 9 Number of days a prescribed drug should last a recipient. Refill Number Character 2 The refill number of the drug that was dispensed on the claim. t_phrm_dtl_keys plan_cde num_icn num_dtl cde_ndc num_day_supply qty_refill Therapy Class Character 3 The therapeutic class t_phrm_dtl_keys cde_thera_cls_spec Quantity Dispensed Character 10 Number of units of a drug dispensed to a recipient. The type of unit is expressed in CDE DRUG FORM. Drug Form Code Character 2 The basic drug measurement unit (each, milliliter, or grams) for performing price calculations. Approved/Rejecte d Indicator Character 1 The codes are derived from the accompanying Claim Adjustment Segment (CAS). t_pd_pharm_dtl t_deny_phrm_dtl t_pd_pharm_dtl t_deny_phrm_dtl t_pd_pharm_dtl t_deny_phrm_dtl qty_dispense cde_drug_form ind_carrier_denied

45 Provider Specialty Code Character 3 Provider Specialty Code Quantity Qualifier Character 2 Quantity Qualifier. Code specifying the type of quantity. MCO Copay Amount PROMISe Allowed Amount Dispense as Written Code Character 9 This is the service line level copay amount reported by MCOs for encounter data. Character 9 Amount requested by provider for payment for services rendered to a recipient. Character 1 Field indicates the reason, if any, that a brand name drug was dispensed. Spaces t_pd_pharm_dtl t_deny_phrm_dtl t_pd_pharm_dtl t_deny_phrm_dtl cde_prov_spec Spaces mco_copay_amt_dtl amt_alwd ind_brand_med_nec PA Type Code Character 2 Code clarifying the Prior Authorization Number. Procedure Code Character 6 The procedure code for the service performed for the recipient Procedure Code Quantity Character 6 Number of units of service that were provided. t_phrm_hdr_keys t_phrm_proc t_phrm_proc Filler Character 314 Blanks N/A N/A Total 410 EOR not included. EOR Character 2 Carriage Return/Line Feed (Hexadecimal 0d/0a) N/A pa_type cde_proc qty_billed N/A

46 Claim Error Detail Record Field Name Data Type Length Description Table Name Column Name MCO Code Character 2 Code assigned by DHS to the MCO to identify the MCO ICN Character 13 Claim s internal control number (ICN). t_pmp_svc_loc t_pd_phys_hdr t_pd_dntl_hdr t_deny_dntl_hdr Record Type Character 1 I N/A N/A Detail Number Character 4 Number of the detail on the claim. t_pd_phys_dtl t_deny_phys_dtl t_pd_dntl_dtl t_deny_dntl_dtl t_pd_ub92_dtl t_deny_dntl_dtl t_pd_pharm_dtl t_deny_phrm_dtl plan_cde num_icn num_dtl ESC Character 4 Error Status Code. t_error_disp cde_esc from t_claim_error.sak_esc Filler Character 347 Blanks N/A N/A Total 371 EOR not included. EOR Character 2 Carriage Return/Line Feed (Hexadecimal 0d/0a) N/A N/A

47 File Trailer Record Field Name Data Length Description Type Record Type Character 1 ~ ; sorts very high in the ASCII sequence. Professional Encounter Record Count Institutional Encounter Record Count Dental Encounter Record Count Pharmacy Encounter Record Count Total Encounter Record Count Character 9 Total accepted, denied or suspended BH, PH, or CCR Professional services encounter record count. Character 9 Total accepted, denied or suspended BH, PH, or CCR Institutional encounter record count. Character 9 Total accepted, denied or suspended PH Dental services encounter record count. Character 9 Total accepted, denied or suspended PH Pharmacy encounter record count. Character 9 Total accepted, denied or suspended BH, PH, or CCR encounter record count. Filler Character 325 Blanks Total 371 EOR not included. EOR (End of Record) Character 2 Carriage Return/Line Feed (Hexadecimal 0d/0a)