Appendix%207.10%20Decision%20Support%20System%20File%20Format.xlsx

XLSX spreadsheet 184 KB Posted Sep 15, 2026

Attached to: Third Party Administrator Services for the State's Public Sector Health Plans
Solicitation number: RFP 31786-00190
Issued by: Davidson County, Tennessee

About this file

Written by GovTribe AI · Sep 16, 2026

This is a Medical Claims Functional Specification document for the State of Tennessee, prepared by Merative (formerly Truven Health Analytics), outlining the technical requirements and file format standards for medical claims data submission to support the state's public sector health plans administered through a Third Party Administrator. The specification establishes fixed-record length ASCII file formatting requirements for both facility and professional claims data, with detailed field definitions for claim-level and service-level information. Data submissions are required monthly, with files due on or before the 15th of the month following the close of each month. The document does not specify an explicit contract award date or term but indicates this is an ongoing operational requirement for the state's health plan administration, with the specification having undergone annual reviews and updates through July 28, 2025.

The specification requires data suppliers to submit claims in a standardized format with 130 detail layout fields and trailer record fields containing record counts and total net payments. Key data elements include claim identifiers, provider information (requiring unique identifiers such as TAXID, NPI, and provider qualifiers for group practices), service dates, diagnosis codes (supporting up to 25 secondary diagnoses), procedure codes, financial fields (formatted with implied decimal points and right-justified numeric values), and member demographic information. The document establishes specific rules for handling denied claims, capitated versus fee-for-service arrangements, risk-sharing withholds, and corrections through void/replacement or adjustment methodologies. Financial fields must be populated at the service line level rather than claim level, with particular attention to spreading amounts across multiple lines when claims are paid under alternative arrangements such as DRG or per diem methods. The specification emphasizes strict adherence to formatting standards, including character restrictions (prohibiting asterisks, exclamation points, question marks, percentages, underscores, and commas) and the use of MM/DD/CCYY date format throughout all submissions.

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State of Tennessee Medical Claims Functional Specification

Revision History

REVISION HISTORY
DATE	AUTHOR	DESCRIPTION OF ACTIVITY
5/24/21	Cherie Hicks	Annual review, reviewed for accuracy. No changes.
3/29/23	Niall McCullough	Rebranded footers, shortcut menu, and pop-ups.
9/20/23	Cherie Hicks	Annual review, reviewed for accuracy. No changes.
7/19/24	Cherie Hicks	Annual review, reviewed for accuracy. No changes.
7/22/24	Niall McCullough	Rebranded with Truven logo.
7/28/25	Cherie Hicks	Annual review: reviewed for accuracy. No changes.

&"Calibri,Bold"&9 Med Claims Functional Specifications for File Layout

&9&K000000© Copyright Merative 2023 &9&K000000Merative Confidential &9&K000000&P

General Information

DESCRIPTION/GENERAL INFORMATION

This interface is designed to produce a medical claims file for plan participants administered through <Data Supplier>.

FILE/DATA FORMATTING AND SUBMISSION
DATA SUBMISSION	[To be determined] Merative supports a number of file submission options including FTP and Web Submission.

The data will be submitted to Merative on a <monthly/quarterly> basis. <Monthly/Quarterly> files should be submitted on or before the 15th of the month following the close of each <month/quarter>.

FILE FORMAT	• Fixed-Record Length, ASCII File
	• Contains Detail (Data) Layout and Trailer Layout for each layout group
CHARACTER FIELDS	• Includes A - Z (lower or upper case), 0 - 9, and spaces

• Left justified, right blank/space filled

• Unrecorded or missing values in character fields are blank/spaces

DATE FIELDS	• Format of all dates should be MM/DD/CCYY
NUMERIC FIELDS	• All numeric fields should be right-justified and left zero-filled

• Unrecorded or missing values in numeric fields should be set to zero

FINANCIAL FIELDS • All financial fields should be right-justified and left zero-filled

• Merative prefers to receive both dollars and cents, with an implied decimal point before the last two digits in the data. For example: "1234567" would represent $12,345.67 Please do not include an actual decimal point in the data.

• Negative signs should be the leading value in the first position. For example: "-1234567" would represent -$12,345.67

• Unrecorded or missing values in numeric fields should be zero (000 to accommodate the 2-digit implied decimal)

INVALID CHARACTERS Please note that the following characters should not be included in the data or the descriptions in the data dictionary.

* ! ? % _ (under score) , (comma)

&"Calibri,Bold" Eligibility Functional Specifications for File Layout

&"Calibri,Bold"&9 Med Claims Functional Specifications for File Layout

&9&K000000© Copyright Merative 2023 &9&K000000Merative Confidential &9&K000000&P

Discussion Topics

DEFINITIONS
�	Fully denied claims should be removed from the extract of claims prior to submission, while partially denied claims should be included. Merative defines denied claims as follows:
	Fully denied claim: The entire claim has been denied (typical reasons include an ineligible member, an ineligible provider, or a duplicate claims).
	Partially denied claim: The claim contains one or more service lines that are denied, but some that are paid. All service lines should be included on the file.
�	Fee-for-service claims: Claims records for services that result in direct payment to providers on a service-specific basis.
�	Encounter records: Utilization records for services provided under capitation arrangements (i.e., plans in which a provider is paid based on the number of enrollees rather than the services rendered.) These records enable documentation of all services provided regardless of whether or not direct payment was made to the provider.

� Facility Data: Facility data includes all services rendered by an inpatient or outpatient facility. The basis for the requirements of facility data is the information found on the standard UB-04 claim form.

� Professional Data: Professional data includes all services rendered by a physician or other professional provider, including dental, vision and hearing. The basis for the requirements of professional data is the information found on the standard CMS-1500 claim form.

�	Fee-for-Service Equivalents: Financial amounts for services rendered under a capitated arrangement found within encounter records.
DISCUSSION ITEMS
�	If both fee-for-service claims and encounter records are included on the data file, Merative will rely on the data supplier to explain how to differentiate them, preferably using the field Capitated Service Indicator.

�	If encounter records contain fee-for-service equivalents, it is essential for Merative to understand which fields contain these amounts.
�	Financial fields should be populated at the service line level, not at the claim level.
�	Merative will need to understand the circumstances under which claims are not paid on a line item basis. For example, situations where claims are paid on a per diem basis or paid based on a DRG. It is our preference if the supplier can apply a factor so that the financials are spread across the lines based on the service rendered.

Claim is paid based on the DRG and Net Payment for the entire claim is $3,632.00;

financials are applied across lines

CLAIM LEVEL INFORMATION				SERVICE LEVEL DETAIL
Claim Id	Provider Id	DRG	Provider Type	Line Number	Revenue Code	Service Count	Allowed Amount	Net Payment
11111	121212121	177	25	1	120	2	$ 2,500.00	$ 2,000.00
11111	121212121	177	25	2	250	1	$ 115.00	$ 100.00
11111	121212121	177	25	3	720	10	$ 1,800.00	$ 1,532.00

� If the managed care program includes a risk-sharing arrangement with providers such that a portion of the approved payment amount is withheld from the provider payment and placed in a risk-sharing pool for later distribution, then the withhold amount should be recorded as a separate field and also included in the Charge Submitted, Allowed Amount and Net Payment fields.

Med Claims Functional Specifications for File Layout

&9&K000000© Copyright Merative 2023 &9&K000000Merative Confidential &9&K000000&P

Provider Data

DISCUSSION ITEMS - PROVIDER
�	Merative requires unique provider identifiers and associated names. Merative would like both the identifier and the name to be specific to each provider, rather than group level information. TAXID is preferred for the identifier.

�	If providers within group practices use a single TAXID, Watson Health would prefer an additional qualifier that would make each identifier and name unique.
�	If only the group name is available with the associated TIN, and a qualifier is not available, Merative prefers another identifier for professional claims and the TAXID for the facility claims. NPI is preferred for the alternate identifier. In this case, the TAXID is still requested in addition to the NPI or alternate identifier.

Provider Example 1 When providers in group practices use the same TAXID, a qualifier is needed to insure unique provider names.

Claim ID	TAXID	Qualifier	Provider Name	Prov Type	Service Count	Net Payment
11111	121212121	2222	Dr. Brown	25	2	$ 2,000.00
22222	121212121	3333	Dr. Smith	35	1	$ 100.00

Provider Example 2 The following is an example of what is not desired.

Claim ID	TAXID	Provider Name	Prov Type	Svc Count	Net Payment
11111	121212121	Dr. Brown	25	2	$ 2,000.00
22222	121212121	Dr. Smith	35	1	$ 100.00
33333	232323232	XYZ	25	1	$ 125.00
22222	232323232	XYZ	35	1	$ 110.00

Provider Example 3 When only the groups name is available with TAXID, NPI is requested in addition to TAXID.

Professional
	Claim ID	TAXID	Group Name	NPI	Prov Name	Prov Type	Svc Count	Net Payment
	11111	121212121	XYZ Pediatrics	2222222222	Dr Brown	25	2	$ 2,000.00
	22222	121212121	XYZ Pediatrics	3333333333	Dr Smith	35	1	$ 100.00
Facility
	Claim ID	TAXID	NPI	Provider Name	Prov Type	Rev Code	Net Payment
	11111	343434343	22222222222	University Hospital	1	110	$ 2,000.00
	22222	454545454	33333333333	University Children's Hospital	1	120	$ 100.00

Med Claims Functional Specifications for File Layout

&9&K000000© Copyright Merative 2023 &9&K000000Merative Confidential &9&K000000&P

Financials and Corrections

FINANCIAL RELATIONSHIP
Merative defines the relationship among financial fields as follows. Those marked with an asterisk are desirable, but not required for the data extract.
	Charge Submitted
	Not Covered Amount *		Charge Covered *
			Discount Amount	Allowed Amount
				Coinsurance
				Copayment	Net Payment
				Deductible
				Penalty/Sanction Amount *
				Third Party Amount
CORRECTIONS TO PAID CLAIMS
Data suppliers generally use either Void/Replacement or Adjustment records to make corrections to paid claims. Merative defines these as follows:
		VOID/REPLACEMENT

A void is a claim that reverses or backs out a previously paid one. All financials and quantities are negated on the void record. A replacement record that contains the corrected information generally follows it. The original, void and replacement need not appear in the same file. After adjudication, a paid claim with a $25 Copay and $50 Net Pay, a correction was necessary. The correction contains a $10 Copay and $65 Net Pay.

	Record Type	Svc Count	Charge Submitted	Copay	Deductible	Net Payment
	Original	1	$ 75.00	$ 25.00	$ - 0	$ 50.00
	Void	-1	$ (75.00)	$ (25.00)	$ - 0	$ (50.00)
	Replacement	1	$ 75.00	$ 10.00	$ - 0	$ 65.00
ADJUSTMENT

A financial adjustment is a claim line where one or more of the financial fields display the difference between the original amount and the final amount. Any financial not being adjusted should be zero. All quantities should be zero on the adjustment as well. The original and adjustment need not appear in the same file. After a claim was adjudicated with a $25 Copay and $50 Net Pay, it was discovered that there should have been a $10 Copay and $65 Net Pay.

Record Type	Svc Count	Charge Submitted	Copay	Deductible	Net Payment
Original	1	$ 75.00	$ 25.00	$ - 0	$ 50.00
Adjustment	0	$ - 0	$ (15.00)	$ - 0	$ 15.00

Med Claims Functional Specifications for File Layout

&9&K000000© Copyright Merative 2023 &9&K000000Merative Confidential &9&K000000&P

Fac and Prof Content

FACILITY RECORD CONTENT

�	The standard UB-04 claim form contains both information that pertains to the entire claim and single service/procedure within the claim.
�	Each record in the data file should represent one service (detail) line.
�	All financials and quantities on each record should pertain to that service only (as opposed to the entire claim).
�	The repeating of non-quantitative claim-level information (e.g., Claim ID, Provider ID, Provider Type, etc.) on each record is necessary.

One facility claim with three service lines

CLAIM LEVEL INFORMATION			SERVICE LEVEL DETAIL
Claim Id	Provider Id	Provider Type	Line Number	Revenue Code	Service Count	Net Payment
11111	121212121	25	1	120	2	$ 2,000.00
11111	121212121	25	2	250	1	$ 100.00
11111	121212121	25	3	720	10	$ 1,532.00

PROFESSIONAL RECORD CONTENT

Merative does not store separate header/claim-level and detail/service-level information for professional claims. Merative requires the following:

�	Each record in the data file should represent one service (detail) line.
�	All financials and quantities on each record should pertain to that service only (as opposed to the entire claim).
�	The repeating of non-quantitative claim-level information (e.g., Claim ID, Provider ID, Provider Type, etc.) on each record is necessary.

One professional claim with two service lines

CLAIM LEVEL INFORMATION			SERVICE LEVEL DETAIL
Claim Id	Provider Id	Provider Type	Line Number	Procedure Code	Service Count	Net Payment
13331	621262121	51	1	99201	1	$ 100.00
13331	621262121	51	2	99175	1	$ 150.00

Med Claims Functional Specifications for File Layout

&9&K000000© Copyright Merative 2023 &9&K000000Merative Confidential &9&K000000&P

Detail Layout

Field Number	Field Name	Start	End	Length	Type	Data Element Description	Standard Field	Data Dictionary Needed	Data Supplier Instructions/Notes
Fixed-Record Length
0	ROW FOR CALCULATIONS ONLY	1	0	0
1	Adjustment Type Code	1	1	1	Character	Client-specific code for the claim adjustment type	Yes	Yes	Adjustment Type values will be identified in the Data Dictionary.
2	Allowed Amount	2	11	10	Numeric	The maximum amount allowed by the plan for payment.	Yes		Format 9(8)v99 (2 – digit, implied decimal)

On facility records, this field must be at the service/detail level as opposed to the header/claim level.

3	Bill Type Code UB	12	15	4	Character	The UB-04 standard code for the billing type, indicating type of facility, bill classification, and frequency of bill.	Yes	See Notes	Bill Type values will be identified in the Data Dictionary only if standard codes are not used.
4	Capitated Service Indicator	16	16	1	Character	An indicator that this service (encounter record) was capitated	Yes		Applicable field values are “Y” for Capitated services and “N” for non-cap services.
5	Charge Submitted	17	26	10	Numeric	The submitted or billed charge amount	Yes		Format 9(8)v99 (2 – digit, implied decimal)

On facility records, this field must be at the service/detail level as opposed to the header/claim level.

6	Claim ID	27	41	15	Character	The client-specific identifier of the claim.	Yes
7	Claim Type Code	42	43	2	Character	Client-specific code for the type of claim	Yes	Yes	Claim Type Codes will be identified in the Data Dictionary.
8	Coinsurance	44	53	10	Numeric	The coinsurance paid by the subscriber as specified in the plan provision.	Yes		Format 9(8)v99 (2 – digit, implied decimal)

On facility records, this field must be at the service/detail level as opposed to the header/claim level.

9	Copayment	54	63	10	Numeric	The copayment paid by the subscriber as specified by the plan provision.	Yes
10	Date of Birth	64	73	10	Date	Birth date of the person		MM/DD/CCYY format

The member’s birth date is part of the Person ID key and is, therefore, critical to tagging claims to eligibility.

The four-digit year is required for date of birth. The century cannot be accurately assigned based on a two-digit year.

11	Date of First Service	74	83	10	Date	The date of the first service reported on the claim or authorization record.	Yes	MM/DD/CCYY Format
12	Date of Last Service	84	93	10	Date	The date of the last service reported on the claim or authorization record.	Yes	MM/DD/CCYY Format
13	Date of Service Facility Detail	94	103	10	Date	The date of service for the facility detail record.	Yes	MM/DD/CCYY Format
14	Date Paid	104	113	10	Date	The date the claim or data record was paid.	Yes	MM/DD/CCYY format

This is the check date.

15	Days	114	119	6	Numeric	The number of inpatient days for the facility claim.	Yes
16	Deductible	120	129	10	Numeric	The amount paid by the subscriber through the deductible arrangement of the plan.	Yes	Format 9(8)v99 (2 – digit, implied decimal)

On facility records, this field must be at the service/detail level as opposed to the header/claim level.

17	Diagnosis Code Principal	130	137	8	Character	The first or principal diagnosis code for a service, claim or lab result. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
18	Diagnosis Code 2	138	145	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
19	Diagnosis Code 3	146	153	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
20	Diagnosis Code 4	154	161	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
21	Diagnosis Code 5	162	169	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
22	Diagnosis Code 6	170	177	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
23	Diagnosis Code 7	178	185	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
24	Diagnosis Code 8	186	193	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
25	Diagnosis Code 9	194	201	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
26	Diagnosis Code 10	202	209	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
27	Diagnosis Code 11	210	217	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
28	Diagnosis Code 12	218	225	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
29	Diagnosis Code 13	226	233	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
30	Diagnosis Code 14	234	241	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
31	Diagnosis Code 15	242	249	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
32	Diagnosis Code 16	250	257	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
33	Diagnosis Code 17	258	265	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
34	Diagnosis Code 18	266	273	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
35	Diagnosis Code 19	274	281	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
36	Diagnosis Code 20	282	289	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
37	Diagnosis Code 21	290	297	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
38	Diagnosis Code 22	298	305	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
39	Diagnosis Code 23	306	313	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
40	Diagnosis Code 24	314	321	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
41	Diagnosis Code 25	322	329	8	Character	A secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.	Yes	No decimal point.
42	Discharge Status Code UB	330	331	2	Numeric	The UB-04 standard patient status code, indicating disposition at the time of billing.	Yes
43	Discount	332	341	10	Numeric	The discount amount of the claim, applied to charges for any plan pricing reductions.	Yes	Format 9(8)v99 (2 – digit, implied decimal)

On facility records, this field must be at the service/detail level as opposed to the header/claim level.

44	Family ID/Employee SSN	342	350	9	Character	The unique identifier (Social Security Number) for the subscriber (contract holder, employee) and their associated dependents.	Yes	The subscriber’s social security number is part of the Person ID key and is, therefore, critical to tagging claims to eligibility.
45	Gender	351	351	1	Character	Gender of the person.	Yes	M or F

The member’s gender is part of the Person ID key and is, therefore, critical to tagging claims to eligibility

46	Line Number	352	353	2	Numeric	The detail line number for the service on the claim	Yes
47	Net Payment	354	363	10	Numeric	The actual check amount for the record	Yes		Format 9(8)v99 (2 - digit, implied decimal)
48	Network Paid Indicator	364	364	1	Character	An indicator of whether the claim was paid at in-network or out-of-network level	Yes		On facility records, this field must be at the service/detail level as opposed to the header/claim level.
49	Network Provider Indicator	365	365	1	Character	Indicates if the servicing provider participates in the network to which the patient belongs	Yes		Y or "N"
50	Ordering Provider ID	366	378	13	Character	The ID number of the provider who referred the patient or ordered the test or procedure.	Yes
51	Ordering Provider Name	379	408	30	Character	The Name of the provider who referred the patient or ordered the test or procedure.	Yes
52	Ordering Provider Zip Code	409	413	5	Character	The zip code of the provider who referred the patient or ordered the test or procedure.	Yes
53	PCP Responsibility Indicator	414	414	1	Character	An indicator signifying that the PCP is the physician considered responsible or accountable for this claim.	Yes
54	Place of Service Code	415	416	2	Character	Client-specific code for the place of service.	Yes	See Notes	Merative prefers the CMS place of service values. Place of Service values will be identified in the Data Dictionary only if non-standard values are used.
55	Procedure Code	417	423	7	Character	The procedure code for the service record. Length expanded from 5 to 7 for future use.	Yes		CPT/HCPCS codes.
56	Procedure Code UB Surg 1	424	430	7	Character	The primary surgical procedure code (1) on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
57	Procedure Code UB Surg 2	431	437	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
58	Procedure Code UB Surg 3	438	444	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
59	Procedure Code UB Surg 4	445	451	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
60	Procedure Code UB Surg 5	452	458	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
61	Procedure Code UB Surg 6	459	465	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
62	Procedure Code UB Surg 7	466	472	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
63	Procedure Code UB Surg 8	473	479	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
64	Procedure Code UB Surg 9	480	486	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
65	Procedure Code UB Surg 10	487	493	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
66	Procedure Code UB Surg 11	494	500	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
67	Procedure Code UB Surg 12	501	507	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
68	Procedure Code UB Surg 13	508	514	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
69	Procedure Code UB Surg 14	515	521	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
70	Procedure Code UB Surg 15	522	528	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
71	Procedure Code UB Surg 16	529	535	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
72	Procedure Code UB Surg 17	536	542	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
73	Procedure Code UB Surg 18	543	549	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
74	Procedure Code UB Surg 19	550	556	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
75	Procedure Code UB Surg 20	557	563	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
76	Procedure Code UB Surg 21	564	570	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
77	Procedure Code UB Surg 22	571	577	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
78	Procedure Code UB Surg 23	578	584	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
79	Procedure Code UB Surg 24	585	591	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
80	Procedure Code UB Surg 25	592	598	7	Character	The secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.	Yes		ICD-9 or 10 Surgical procedure codes.
81	Procedure Modifier Code 1	599	600	2	Character	The 2-character code of the first procedure code modifier on the professional claim	Yes
82	Provider ID	601	613	13	Character	The unique identifier for the provider of service.	Yes		This must be the federal tax ID in order to use the standard hospital identifier lookup (Standard Facility).
83	TIN	614	622	9	Character	The federal tax ID of the provider.			Only needed if Provider ID is not the federal tax ID.
84	Provider Qualifier	623	632	10	Character	A qualifier to make Provider ID unique.			Only required if Provider ID is not unique.
85	Provider Type Code Claim	633	635	3	Character	Client-specific code for the provider type on the claim record	Yes	Yes	Provider Type codes are further defined in the Data Dictionary
86	Provider Taxonomy Code	636	645	10	Character	The Healthcare Provider Taxonomy code specific to the professional servicing provider associated with the claim. (Note: This is not a standard field in Health Insights. Merative asks for this field to aid in the mapping of Provider Type Code Code Claim to Merative's standard values.)			The National Uniform Claim Committee standard taxonomy code for the provider.
87	Provider Zip Code	646	650	5	Character	The 5-digit zip code corresponding to the Provider ID	Yes		Provider Location zip code
88	Revenue Code UB	651	654	4	Character	The CMS standard revenue code from the facility claim	Yes		This field must be at the service/detail level.
89	Third Party Amount	655	664	10	Numeric	The amount saved due to integration of third party liability (Coordination of Benefits) by all third party payers (including Medicare).	Yes		Format 9(8)v99 (2 - digit, implied decimal)

On facility records, this field must be at the service/detail level as opposed to the header/claim level.

90	Units of Service	665	668	4	Numeric	Client-specific quantity of services or units	Yes
91	Provider Name	669	698	30	Character	The description or name corresponding to the Provider ID.	Yes	The Provider Name should be specific to the provider and not a group name.
92	Funding Type Code	699	699	1	Character	Specifies whether the claim was paid under a fully or self-funded arrangement	Yes	“S” = Self-funded

“F” = Fully-funded

93	Account Structure	700	707	8	Character	Client-specific code for the account structure of the plan that the member is enrolled in. This is usually a group number.	TBD	Yes	Additional fields may be added to the layout if there is more than one component of the account structure.
94	Provider NPI Number	708	717	10	Character	The National Provider ID number for the provider.	Yes
95	Provider Address 1	718	767	50	Character	The current street address1 of the provider of service.	Yes		If the provider has multiple addresses, the primary address is preferred.
96	Provider Address 2	768	817	50	Character	The current street address2 of the provider of service.	Yes		If the provider has multiple addresses, the primary address is preferred.
97	HRA Amount	818	827	10	Numeric	The amount paid from the HRA as a result of this claim.	Yes		Format 9(8)v99 (2 - digit, implied decimal)

On facility records, this field must be at the service/detail level as opposed to the header/claim level.

98 HSA Amount 828 837 10 Numeric The amount paid from the HSA as a result of this claim. Yes Format 9(8)v99 (2 - digit, implied decimal) On facility records, this field must be at the service/detail level as opposed to the header/claim level.

99 Present on Admission Principal 838 838 1 Character The principal POA code for the facility claim. Indicates whether the principal diagnosis was present on admission. Standard Values:

1 – Unreported/Not Used N – No, not present at admission U – Unknown W – Clinically Undetermined Y – Yes, present at admission

Yes	See Notes	If standard values are not used, define in the Data Dictionary.
100	Present on Admission 02	839	839	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
101	Present on Admission 03	840	840	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
102	Present on Admission 04	841	841	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
103	Present on Admission 05	842	842	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
104	Present on Admission 06	843	843	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
105	Present on Admission 07	844	844	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
106	Present on Admission 08	845	845	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
107	Present on Admission 09	846	846	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
108	Present on Admission 10	847	847	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
109	Present on Admission 11	848	848	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
110	Present on Admission 12	849	849	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
111	Present on Admission 13	850	850	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
112	Present on Admission 14	851	851	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
113	Present on Admission 15	852	852	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
114	Present on Admission 16	853	853	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
115	Present on Admission 17	854	854	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
116	Present on Admission 18	855	855	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
117	Present on Admission 19	856	856	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
118	Present on Admission 20	857	857	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
119	Present on Admission 21	858	858	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
120	Present on Admission 22	859	859	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
121	Present on Admission 23	860	860	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
122	Present on Admission 24	861	861	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
123	Present on Admission 25	862	862	1	Character	A secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.	Yes	See Notes	If standard values are not used, define in the Data Dictionary.
124	DRG MS Payment Code	863	865	3	Numeric	The Diagnosis Related Group (MS-DRG) code under which the claim was paid.	Yes
125	ICD Version	866	866	1	Character	The ICD version or qualifier code that identifies either ICD-9 (9) or ICD-10 (0) diagnosis and procedure codes on the facility claim.	Yes	See Notes	If 0 and 9 not used, values defined in the Data Dictionary.
126	Tax Amount	867	876	10	Numeric	The amount charged by some states per medical claim.	Yes		Format 9(8)v99 (2 – digit, implied decimal)

127	Tax Type Code	877	877	1	Character	Data Supplier specific code identifying the state and/or type of tax.		Yes	Tax Type Codes will be identified in the Data Dictionary.
128	NDC Number Code	878	888	11	Character	The FDA (Food and Drug Administration) registered number for the drug. Please include for any drugs dispensed in the medical setting if available.	Yes		Please leave out the dashes.
129	Filler	889	999	111	Character	Reserved for future use			Fill with blanks
130	Record Type	1000	1000	1	Character	Record type identifier			Hard Code to "D"
End of Layout - Do not remove this row - All field additions to be inserted above the Filler row

&"Calibri,Bold"&9 Med Claims Functional Specifications for File Layout

Trailer Layout

Field Number	Field Name	Start	End	Length	Type	Data Element Description	Data Supplier Instructions/Notes
Fixed-Record Length
0	ROW USED FOR CALCULATIONS	1	0	0
1	Data Start Date	1	10	10	Date	Data Start Date	MM/DD/CCYY format – i.e. 09/01/2014

This will represent the 1st day of the month for which data is provided.

2 Data End Date 11 20 10 Date Data End Date MM/DD/CCYY format – i.e. 09/30/2014

This will represent the last day of the month for which data is provided.

3	Record Count	21	30	10	Numeric	Number of Records on File	The count of records provided in the data including the Trailer Record.
4	Total Net Payments	31	44	14	Numeric	Total net payments on the file	The sum of net payments provided in the file
5	Filler	45	999	955	Character	Reserved for future use	Fill with Blanks
6	Record Type	1000	1000	1	Character	Record Type Identifier	Hard Code ‘T’
End of Layout - Do not remove this row - All field additions to be inserted above the Filler row

&"Calibri,Bold"&9 Med Claims Functional Specifications for File Layout

Detail Layout (2)

	Field Number	Field Name	Start	End	Length	Type	Data Element Description	Data Supplier Instructions/Notes	Standard
Advantage Field	Data Dictionary Needed	Population of Employee / Dependent Records
	Fixed-Record Length
	0	ROW FOR CALCULATIONS ONLY	1	0	0
	1	Field 1	1	4	4
	2	CUSTOM FIELD # (if applicable)	5	5	1
	3	Filler	6	499	494	Character	Reserved for future use	Fill with blanks		Member-Specific
	4	Record Type	500	500	1	Character	Record type identifier	Hard Code to "D"		Member-Specific
	End of Layout - Do not remove this row - All field additions to be inserted above the Filler row

&"Calibri,Bold"&9Eligibility Functional Specifications for File Layout --- &A ---

&G &9&P &9&A &F

Trailer Layout (2)

Field Number	Field Name	Start	End	Length	Type	Data Element Description	Data Supplier Instructions/Notes	Advantage Field	Population of Employee / Dependent Records
Fixed-Record Length
0	ROW USED FOR CALCULATIONS	1	0	0
1	Start Date	1	10	10	Date	Start Date of the data within the file	MM/DD/CCYY format – i.e. 09/01/2015

This will represent the 1st day of the month for which data is provided.	N/A	N/A
	2	End Date	11	20	10	Date	End Date of the data within the file	MM/DD/CCYY format – i.e. 09/01/2015

This will represent the 1st day of the month for which data is provided.	N/A	N/A
	3	Record Count	21	30	10	Numeric	Number of Records on File	The count of records provided in the data including the Trailer Record.	N/A	N/A
	4	Total Dollars	31	40	10	Numeric	Total dollars on the file
	5	Filler	41	499	459	Character	Reserved for future use	Fill with Blanks	N/A	N/A
	6	Record Type	500	500	1	Character	Record Type Identifier	Hard Code ‘T’	N/A	N/A
	End of Layout - Do not remove this row - All field additions to be inserted above the Filler row

&"Calibri,Bold"&9Eligibility Functional Specifications for File Layout --- &A ---

&G &9&P &9&A

Detail Layout (3)

	Field Number	Field Name	Start	End	Length	Type	Data Element Description	Data Supplier Instructions/Notes	Standard
Advantage Field	Data Dictionary Needed	Population of Employee / Dependent Records
	Fixed-Record Length
	0	ROW FOR CALCULATIONS ONLY	1	0	0
	1	Field 1	1	4	4	Character
	2	CUSTOM FIELD # (if applicable)	5	5	1	TBD	Additional Rows/Fields to be added as Custom Fields are identified.

Common custom fields include:

Employee Status Relationship Department

Accrual Rate(s)	TBD	N/A	TBD	TBD
	3	Filler	6	399	394	Character	Reserved for future use	Fill with blanks	Member-Specific
	4	Record Type	400	400	1	Character	Record type identifier	Hard Code to "D"	Member-Specific
	End of Layout - Do not remove this row - All field additions to be inserted above the Filler row

&"Calibri,Bold"&9Eligibility Functional Specifications for File Layout --- &A ---

&G &9&P &9&A

Trailer Layout (3)

Field Number	Field Name	Start	End	Length	Type	Data Element Description	Data Supplier Instructions/Notes	Advantage Field	Population of Employee / Dependent Records
Fixed-Record Length
0	ROW USED FOR CALCULATIONS	1	0	0
1	Start Date	1	10	10	Date	Start Date of the data within the file	MM/DD/CCYY format – i.e. 09/01/2015

This will represent the 1st day of the month for which data is provided.	N/A	N/A
	2	End Date	11	20	10	Date	End Date of the data within the file	MM/DD/CCYY format – i.e. 09/01/2015

This will represent the 1st day of the month for which data is provided.	N/A	N/A
	3	Record Count	21	30	10	Numeric	Number of Records on File	The count of records provided in the data including the Trailer Record.	N/A	N/A
	4	Total Dollars	31	40	10	Numeric	Total dollars on the file
	5	Filler	41	399	359	Character	Reserved for future use	Fill with Blanks	N/A	N/A
	6	Record Type	400	400	1	Character	Record Type Identifier	Hard Code ‘T’	N/A	N/A
	End of Layout - Do not remove this row - All field additions to be inserted above the Filler row

&"Calibri,Bold"&9Eligibility Functional Specifications for File Layout --- &A ---

&G &9&P &9&A

Detail Layout (4)

	Field Number	Field Name	Start	End	Length	Type	Data Element Description	Data Supplier Instructions/Notes	Standard
Advantage Field	Data Dictionary Needed	Population of Employee / Dependent Records
	Fixed-Record Length
	0	ROW FOR CALCULATIONS ONLY	1	0	0
	1	Field 1	1	4	4	Character
	2	CUSTOM FIELD # (if applicable)	5	5	1	TBD	Additional Rows/Fields to be added as Custom Fields are identified.

Common custom fields include:

Employee Status Relationship Department

Accrual Rate(s)	TBD	N/A	TBD	TBD
	3	Filler	6	399	394	Character	Reserved for future use	Fill with blanks	Member-Specific
	4	Record Type	400	400	1	Character	Record type identifier	Hard Code to "D"	Member-Specific
	End of Layout - Do not remove this row - All field additions to be inserted above the Filler row

&"Calibri,Bold"&9Eligibility Functional Specifications for File Layout --- &A ---

&G &9&P &9&A

Trailer Layout (4)

Field Number	Field Name	Start	End	Length	Type	Data Element Description	Data Supplier Instructions/Notes	Advantage Field	Population of Employee / Dependent Records
Fixed-Record Length
0	ROW USED FOR CALCULATIONS	1	0	0
1	Start Date	1	10	10	Date	Start Date of the data within the file	MM/DD/CCYY format – i.e. 09/01/2015

This will represent the 1st day of the month for which data is provided.	N/A	N/A
	2	End Date	11	20	10	Date	End Date of the data within the file	MM/DD/CCYY format – i.e. 09/01/2015

This will represent the 1st day of the month for which data is provided.	N/A	N/A
	3	Record Count	21	30	10	Numeric	Number of Records on File	The count of records provided in the data including the Trailer Record.	N/A	N/A
	4	Total Dollars	31	40	10	Numeric	Total dollars on the file
	5	Filler	41	399	359	Character	Reserved for future use	Fill with Blanks	N/A	N/A
	6	Record Type	400	400	1	Character	Record Type Identifier	Hard Code ‘T’	N/A	N/A
	End of Layout - Do not remove this row - All field additions to be inserted above the Filler row

&"Calibri,Bold"&9Eligibility Functional Specifications for File Layout --- &A ---

&G &9&P &9&A

Data

Style	Fixed
IntroSplash	NoShow

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File details come from the government source that posted it. Updated Sep 16, 2026.