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Attachment J-12 Military Health System (MHS) Data Repository (MDR) Data Elements Layout
1.0. DATA FILE REQUIREMENTS. Some data file elements will be revised, added or deleted as necessary after award to reflect the contractor’s data systems and/or the needs of the DHA.
1.1. File Content. Bi-monthly data feeds, reflecting previous claim activity and provider data feeds.
1.2. Format. Fixed length and in order listed below for claims and providers.
1.3. Submission. The Contractor shall submit the data on the 1st and 15th of each month. In addition to the data stated below the contractor shall submit a separate control document for a data quality control review. The control document will state the year, month, total dollars paid, and total records by month. This data will be cumulative to the contract.
1.4. Method of Delivery to Government. ADDP files shall be sent to the Military Health System Data Repository (MDR) via Secure File Transfer Protocol (SFTP), to a fixed IP address provided by the Government, in accordance with the Interface Control Document (ICD). See Section C.5.8.
1.5. Description of TDRAW Claims Data File Elements:
| Field # |
| Field Name |
| Field Length |
| Position |
| Data Type |
| Value Range |
| Functional Description |
| 1 |
| Patient’s Last Name |
| 35 |
| 1-35 |
| Alpha |
| None |
| Last name of patient |
| 2 |
| Patient’s First Name |
| 25 |
| 36-60 |
| Alpha |
| None |
| First name of patient |
| 3 |
| Patient’s Middle Name |
| 25 |
| 61-85 |
| Alpha |
| None |
| Middle name of patient |
| 4 |
| Gender |
| 1 |
| 86 |
| Alpha |
| F, M, X |
| Patient’s sex code. Coded as follows: |
| F | Female |
| M | Male |
| X | Unknown |
| 5 |
| Patient’s SSN |
| 9 |
| 87-95 |
| Alpha-numeric |
| None |
| Social Security Number (SSN) of the Sponsor. |
| 6 |
| DEERS ID Number |
| 10 |
| 96-105 |
| Alpha-numeric |
| None |
| The identifier assigned by Defense Enrollment Eligibility Reporting System (DEERS) that is used to represent a patient within a Department of Defense Electronic Data Interchange (DoD EDI_PN) |
| 7 |
| Patient Birth Date |
| 8 |
| 106-113 |
| Date |
| None |
| The patient's date of birth. |
Format YYYYMMDD
| 8 |
| Sponsor’s Branch of Service |
| 1 |
| 114 |
| Alpha -numeric |
| A, C, F, H. M, N, O, X, Z |
| Code representing the sponsor’s branch of service. |
A = Army C = Coast Guard F = Air Force H = Commissioned Corps of the Public Health Service M = Marine Corps N = Navy O = Commissioned Corps of the National Oceanographic and Atmospheric Administration (NOAA) X = Not Applicable Z = Unknown
| 9 |
| Components |
| 1 |
| 115 |
| Alpha -numeric |
| A, N, D, R |
| Code representing the sponsor’s service component as of the time of the claim. |
A = Active Duty (including Active Guard and Reserve) D = ADSM within reach of a DTF R = ADSM is remote and not within reach of a DTF
| 10 |
| Sponsor’s Home Phone Number |
| 23 |
| 116-138 |
| Alpha -numeric |
| None |
| The home telephone number of the sponsor - for U.S. and Foreign phone numbers. |
Format: Area code, exchange, and number (10 digits) plus four positions for extension.
| 11 |
| Performing Provider Number |
| 9 |
| 139-147 |
| Alpha -numeric |
| None |
| A unique number assigned by the Contractor to the individual who performs dental services. |
| 12 |
| Provider Tax ID |
| 9 |
| 148-156 |
| Alpha -numeric |
| None |
| The Internal Revenue Service assigned Taxpayer Identification Number (TIN) of the provider |
| 13 |
| National Provider ID (NPI) – Performing Provider |
| 10 |
| 157-166 |
| Alpha -numeric |
| None |
| National Provider Identification (NPI) number of the provider rendering the dental services. |
| 14 |
| National Provider ID (NPI) - Group |
| 10 |
| 167-176 |
| Alpha -numeric |
| None |
| National Provider ID (NPI) number of the provider rendering the dental services. |
| 15 |
| Performing Provider Zip Code |
| 5 |
| 177-181 |
| Alpha -numeric |
| None |
| The business address ZIP code of the provider. |
| 16 |
| Performing Provider Specialty |
| 3 |
| 182-184 |
| Alpha -numeric |
| See Appendix 1 |
A numeric coded value that identifies the primary specialty of the provider.
| 17 |
| Performing Provider Specialty – HIPAA Taxonomy |
| 10 |
| 185-194 |
| Alpha -numeric |
| None |
| A unique alphanumeric code structured into three distinct levels including provider type, classification, and area of specialization |
| 18 |
| Provider Network Status |
| 1 |
| 195 |
| Alpha -numeric |
| 1, 2 |
| Indicates if the provider was an in network provider at the time of the Claim. |
1 = Network provider 2 = Non-network provider
| 19 |
| Provider Degree |
| 4 |
| 196-199 |
| Alpha -numeric |
| CRNA, DDS, DMD, MD, RDH |
| The professional degree which a provider receives upon graduation from a college or university |
| 20 |
| Billing Provider Zip Code |
| 5 |
| 200-204 |
| Alpha -numeric |
| None |
| ZIP code of the billing provider. |
| 21 |
| Claim Number |
| 13 |
| 205-217 |
| Alpha -numeric |
| None |
| A unique number assigned by the Contractor. |
Format: yyjjjbbbbss where yy = last two digits of year jjj = julian day bbbb = batch number ss = sequence number of item within the batch
Last two positions are reserved for future use.
| 22 |
| Claim Line-Item Number |
| 4 |
| 218-221 |
| Alpha -numeric |
| None |
| A sequentially assigned identifier that identifies the line item in the claim. |
| 23 |
| Claim Status Indicator |
| 1 |
| 222 |
| Alpha -numeric |
| A, R, B |
| The final life cycle status resolution of the claim. |
A = Approved R = Rejected B = Both
| 24 |
| Claim Rejection Reason |
| 5 |
| 223-227 |
| Alpha-numeric |
| None |
| The reason for the rejection of the claim. |
| 25 |
| Claim Line Rejection Reason Code |
| 1 |
| 228 |
| Alpha -numeric |
| See Appendix 2. |
| Rejection codes at procedure level |
| 26 |
| Special Processing Code |
| 2 |
| 229-230 |
| Alpha -numeric |
| CT, OT |
| The structure by which the claim is paid will be translated into a code to indicate if it was processed as CONUS or OCONUS |
CT = CONUS
OT = OCONUS
| 27 |
| Alternate Treatment Code |
| 2 |
| 231-232 |
| Alpha -numeric |
| See Appendix 3. |
| SP = Service Package - when several procedures are performed on the same date of service in the same location in the mouth, the system will identify only one complex primary procedure for reimbursement |
RD = Rebundling - the use of two or more procedure codes to describe a procedure performed in a single instance when a single code comprehensively describes the procedure performed NC = Submitted procedure has been down coded to an alternate procedure
| 28 |
| Benefit Category |
| 35 |
| 233-267 |
| Alpha -numeric |
| See Appendix 4 |
| The ADA procedure category (which is textual) is a rollup of the detailed ADA procedure into a broad categorization of the procedure / benefit. |
| 29 |
| Date of Service |
| 8 |
| 268-275 |
| Date |
| None |
| The date the service was performed. |
Format: YYYYMMDD.
| 30 |
| Claim Receipt Date |
| 8 |
| 276-283 |
| Date |
| None |
| The date that the claim was originally received for processing. |
Format: YYYYMMDD.
| 31 |
| Claim Paid Date |
| 8 |
| 284-291 |
| Date |
| None |
| The date the payment determination was made for this claim line. |
Format: YYYYMMDD
| 32 |
| Claim Finalized Date |
| 8 |
| 292-299 |
| Date |
| None |
| The date that the claim was processed in the contractor’s claims processing system and something on the claim has changed. |
Format: YYYYMMDD
| 33 |
| Date of Last Exam |
| 8 |
| 300-307 |
| Date |
| None |
| The latest date that the patient had a dental examination. Format: YYYYMMDD |
| 34 |
| Accident Indicator |
| 1 |
| 308 |
| Alpha-numeric |
| N, Y |
| An indicator that identifies whether or not the procedures were performed as the result of an accident. |
N = No Y = Yes
| 35 |
| CDT Procedure Code |
| 5 |
| 309-313 |
| Alpha -numeric |
| None |
| The ADA procedure code that describes the service for which the claim line item is being paid or denied. |
| 36 |
| CDT Version |
| 2 |
| 314-315 |
| Alpha -numeric |
| None |
| The CDT version that was used to determine the procedure code. |
Coded as follows: Last two digits of four-digit calendar year (e.g.,17 = 2017)
| 37 |
| Adjustment Reason Code |
| 2 |
| 316-317 |
| Alpha -numeric |
| See Appendix 5 |
| Code that identifies the reason for adjustment of the dental line item. |
| 38 |
| Adjustment Code |
| 1 |
| 318 |
| Alpha -numeric |
| See Appendix 6 |
| Code indicating the type of adjustment made to the claim. |
| 39 |
| Original Line Item Number |
| 4 |
| 319-322 |
| Alpha -numeric |
| None |
| The line number of the original service line that the adjustment line replaced. |
| 40 |
| First Treated Tooth - Number |
| 2 |
| 323-324 |
| Alpha -numeric |
| 01-32 |
A0-T0 The Universal Tooth Numbering Identification of the tooth associated with the procedure. For primary/deciduous teeth, the two-digit a ‘zero’ will follow the alpha value.
| 41 |
| Second Treated Tooth - Number |
| 2 |
| 325-326 |
| Alpha -numeric |
| 01-32 |
A0-T0 The Universal Tooth Numbering Identification of the tooth associated with the procedure. For primary/deciduous teeth, the two-digit a ‘zero’ will follow the alpha value.
| 42 |
| Third Treated Tooth - Number |
| 2 |
| 327-328 |
| Alpha -numeric |
| 01-32 |
A0-T0 The Universal Tooth Numbering Identification of the tooth associated with the procedure. For primary/deciduous teeth, the two-digit a ‘zero’ will follow the alpha value.
| 43 |
| Fourth Treated Tooth - Number |
| 2 |
| 329-330 |
| Alpha -numeric |
| 01-32 |
A0-T0 The Universal Tooth Numbering Identification of the tooth associated with the procedure. For primary/deciduous teeth, the two-digit a ‘zero’ will follow the alpha value.
| 44 |
| First Treated Tooth - Anterior/Posterior Indicator |
| 1 |
| 331 |
| Alpha -numeric |
| A, P |
| The tooth type code identifies if the location of the treatment is Anterior, Posterior or undetermined (when for general checkup). |
A = Anterior P = Posterior
| 45 |
| Second Treated Tooth - Anterior/Posterior Indicator |
| 1 |
| 332 |
| Alpha -numeric |
| A, P |
| The tooth type code identifies if the location of the treatment is Anterior, Posterior or undetermined (when for general checkup). |
A = Anterior P = Posterior
| 46 |
| Third Treated Tooth - Anterior/Posterior Indicator |
| 1 |
| 333 |
| Alpha -numeric |
| A, P |
| The tooth type code identifies if the location of the treatment is Anterior, Posterior or undetermined (when for general checkup). |
A = Anterior P = Posterior
| 47 |
| Fourth Treated Tooth - Anterior/Posterior Indicator |
| 1 |
| 334 |
| Alpha -numeric |
| A, P |
| The tooth type code identifies if the location of the treatment is Anterior, Posterior or undetermined (when for general checkup). |
A = Anterior P = Posterior
| 48 |
| First Treated Tooth - Surface |
| 5 |
| 335-339 |
| Alpha -numeric |
| M, O, D, F, L, I |
| The tooth surface associated with the procedure. |
M = Mesial O = Occlusal D = Distal F = Facial L = Lingual I = Incisal
| 49 |
| Second Treated Tooth - Surface |
| 5 |
| 340-344 |
| Alpha -numeric |
| M, O, D, F, L, I |
| The tooth surface associated with the procedure. |
M = Mesial O = Occlusal D = Distal F = Facial L = Lingual I = Incisal
| 50 |
| Third Treated Tooth - Surface |
| 5 |
| 345-349 |
| Alpha -numeric |
| M, O, D, F, L, I |
| The tooth surface associated with the procedure. |
M = Mesial O = Occlusal D = Distal F = Facial L = Lingual I = Incisal
| 51 |
| Fourth Treated Tooth - Surface |
| 5 |
| 350-354 |
| Alpha -numeric |
| M, O, D, F, L, I |
| The tooth surface associated with the procedure. |
M = Mesial O = Occlusal D = Distal F = Facial L = Lingual I = Incisal
| 52 |
| Mouth Area Code |
| 2 |
| 355-356 |
| Alpha -numeric |
| LL, LR, UL, UR |
The quadrant of the tooth that the procedure was performed against LL = Lower Left Quadrant LR = Lower Right Quadrant UL = Upper Left Quadrant UR = Upper Right Quadrant
| 53 |
| Provider Charge |
| 9 |
| 357-365 |
| Numeric |
| None |
| The amount of charges submitted by the provider for the procedure. |
Format: “dddddd.cc”
| 54 |
| Allowed Amount |
| 9 |
| 366-374 |
| Numeric |
| None |
| The amount, in dollars, allowed under the plan for the specified procedure. |
Format: “dddddd.cc”
| 55 |
| Approved Amount |
| 9 |
| 375-383 |
| Numeric |
| None |
| Benefit amount for the procedure (after the application of co-insurance and deductible) |
Format: “dddddd.cc”
| 56 |
| Other Carrier Payment |
| 9 |
| 384-392 |
| Numeric |
| None |
| Amount Paid by Other Insurance Carrier for this procedure (claim level, allocated to the procedure level) |
Format: “dddddd.cc”
| 57 |
| Third Party Liability (TPL) |
| 9 (6,2) |
| 393-401 |
| Numeric |
| None |
| The amount paid by Third Party Liability (TPL) plan carriers towards the Provider Charges, by line item. Format: “dddddd.cc” |
| 58 |
| Prior Placement Date |
| 8 |
| 402-409 |
| Date |
| None |
| The date of initial placement of a prosthesis (captured at the procedure level). |
Format: YYYYMMDD.
| 59 |
| Replacement Reason |
| 1 |
| 410 |
| Alpha-numeric |
| 1, 2, 3, 4 |
| The replacement code representing the reason a specific crown, prosthesis, inlay or onlay is to be replaced. |
| 1 | Lost |
| 2 | Broken |
| 3 | Accident |
| 4 | No longer serviceable |
| 60 |
| Ortho Indicator |
| 1 |
| 411 |
| Alpha -numeric |
| N, Y |
| Indicates that the procedure is related to ortho. |
Coded as follows:
Y = Yes, the service line items associated with the claim are related to the orthodontic care of the patient.
N = No, service line items are not related to orthodontic care.
| 61 |
| Treatment Type |
| 1 |
| 412 |
| Alpha -numeric |
| I, P |
| Code indicating the status of a restorative prosthetic treatment. |
Coded as follows:
I = Initial placement P = Prior placement
| 62 |
| Pay Grade |
| 3 |
| 413-415 |
| Alpha-numeric |
| E1-E9 |
W1-W5 O1-O10 Indicates the pay grade of the patient.
| 63 |
| Oral Health Initiative Indicator |
| 1 |
| 416 |
| Alpha-numeric |
| N, Y |
| A code indicating if this service is part of an Oral Health Initiative. |
| N | No |
| Y | Yes |
| 64 |
| Dental Readiness Classification |
| 1 |
| 417 |
| Alpha-numeric |
| 1, 2, 3 |
| A DoD code representing the ADSM’s or Reservist’s dental readiness by claim. |
| 1 | No dental treatment needed |
| 2 | Minor dental treatment needed |
| 3 | Urgent or emergent dental care required |
| 65 |
| Referral Number |
| 16 |
| 418-433 |
| Alpha-numeric |
A unique referral number associated with the claim.
| 66 |
| Authorization Number |
| 16 |
| 434-449 |
| Alpha-numeric |
A unique authorization number associated with the claim.
| 67 |
| DMIS Code |
| 4 |
| 450-453 |
| Numeric |
A code representing a particular Dental Treatment Facility (DTF).
| 68 |
| Special Processing Arrangement (SPA) Code |
| 2 |
| 454-455 |
| Alpha |
| AT, RT |
| A code that represents if the claim was processed as a DTF Referred or Remote ADSM, |
| AT | DTF Referred |
| RT | Remote ADSM |
| 69 |
| Government Charged Amount |
| 9 (6,2) |
| 456-464 |
| Numeric |
| None |
| The allowed amount paid by the Government to the Contractor for the specified services, by line item. Format: “dddddd.cc”. |
| 70 |
| Diabetic Indicator |
| 3 |
| 465-467 |
| Numeric |
| 250 |
| The claim form will report if the beneficiary is diabetic. |
| 71 |
| Pregnancy Indicator |
| 3 |
| 468-470 |
| Alpha-numeric |
| V22 |
| The claim form will report if the beneficiary is pregnant. |
| 72 |
| Health Care Delivery Program (HCDP) Plan Coverage Code |
| 3 |
| 471-473 |
| Numeric |
| 025 |
The code that represents the plan coverage a patient has within a HCDP type.
025 – Direct Care Dental for Active Duty Sponsors 026 – Direct Care Dental for Active Duty Foreign Military 232 – Remote Dental – ADSMs enrolled in TRICARE Prime Remote 233 – Remote Dental – ADSMs not enrolled in TRICARE Prime Remote 234 – Remote Dental – ADSMs auto enrollment as deemed by DHA Dental Program Section
| 73 |
| Health Care Coverage (HCC) Member Category Code |
| 1 |
| 474 |
| Alpha |
| A, G, J, P, S, T |
| The member category code during the HCC period. |
A – Active Duty G – National Guard member (mobilized or on active duty for 31 days or more) Early ID Alert Status.
J – Academy student (does not include Officer Candidate School or Merchant Marine Academy) P – Transitional Assistance Management Program member S – Reserve member (mobilized or on active duty for 31 days or more) Early ID Alert Status T – Foreign military member
| 74 |
| Remote Authorization |
| 1 |
| 475 |
| Alpha-numeric |
| 1, 2, 3 |
| A code representing remote authorizations by line item: |
| 1 | Approved |
| 2 | Disapproved |
| 3 | Authorized care not completed |
Description of ADDP Provider Data File Elements:
| Field # |
| Field Name |
| Field Length |
| Position |
| Data Type |
| Value Range |
| Functional Description |
| 1 |
| Provider Tax Identifier |
| 9 |
| 1 - 9 |
| Alpha -Numeric |
| None |
| The Internal Revenue Service assigned Taxpayer Identification Number (TIN) of the provider |
| 2 |
| Performing Provider Identifier |
| 18 |
| 10 - 27 |
| Alpha -Numeric |
| None |
| A unique number assigned by the Contractor to the individual who performs dental services. |
| 3 |
| Provider / Group Name |
| 53 |
| 28 - 80 |
| Alpha -Numeric |
| None |
| The first and last name of the provider (dentist) concatenated in one field. A comma will separate the first from the last name on the extract. |
| 4 |
| Performing Provider Specialty |
| 3 |
| 81 -83 |
| Alpha -Numeric |
| See Appendix 1 |
| A numeric coded value that identifies the primary specialty of the provider. |
| 5 |
| Performing Provider HIPAA Taxonomy |
| 10 |
| 84-93 |
| Alpha-Numeric |
| None |
| A unique alphanumeric code structured into three distinct levels including provider type, classification, and area of specialization |
| 6 |
| Performing Provider Network Status |
| 1 |
| 94 |
| Alpha -Numeric |
| 1, 2 |
| Indicates if the provider is currently an in network provider. |
1 = Network provider 2 = Non-network provider
| 7 |
| Provider Telephone Number |
| 23 |
| 95 - 117 |
| Alpha -Numeric |
| None |
| For U.S. providers, the full 10 digit US area code and number of the provider. This will be right justified with leading spaces. |
For Foreign providers, the full 23 digit (telephone and extension numbers) number of the provider.
| 8 |
| Provider Street Address Line 1 |
| 50 |
| 118 - 167 |
| Alpha -Numeric |
| None |
| Provider’s business street address line 1 |
| 9 |
| Provider Street Address Line 2 |
| 50 |
| 168 - 217 |
| Alpha -Numeric |
| None |
| Provider’s business street address line 2. |
| 10 |
| State |
| 2 |
| 218 - 219 |
| Alpha -Numeric |
| ISO State Codes found at https://nsgreg.nga.mil/genc/discovery |
| The abbreviation of the state/province of provider. |
If the state is unknown, then the code ZZ will be added to the extract.
The following U.S. Territories are considered as CONUS:
American Samoa Northern Mariana Islands Guam Puerto Rico U.S. Virgin Islands
| 11 |
| Performing Provider Zip Code |
| 9 |
| 220 - 228 |
| Alpha -Numeric |
| None |
| The full 9 digit zip code of the provider. This can be the actual zip location where services are rendered. If the plus 4 digits are not available, only the first 5 will be populated with trailing spaces. If unknown, will be populated with 0's |
| 12 |
| Country Code |
| 2 |
| 229 - 230 |
| Alpha -Numeric |
| ISO Country Codes found at https://nsgreg.nga.mil/genc/discovery |
| The 2 digit country code of the provider (i.e., ISO3166) |
| 13 |
| Individual National Provider Identifier |
| 10 |
| 231 - 240 |
| Alpha -Numeric |
| None |
| Individual National Provider Identification (NPI) number of the provider rendering the dental services. |
| 14 |
| Group National Provider Identifier |
| 10 |
| 241 - 250 |
| Alpha -Numeric |
| None |
| Group National Provider Identification (NPI) number of the provider rendering the dental services. |
APPENDIX 1: PERFORMING PROVIDER SPECIALTY CODES
| 079 |
| Certified Registered Nurse Anesthetist |
APPENDIX 2: CLAIM LINE REJECTION REASON CODES
To be provided by the contractor after award
APPENDIX 3: ALTERNATE TREATMENT CODES
To be provided by the contractor after award
APPENDIX 4: BENEFIT CATEGORY CODES
| CIO |
| Crowns, Inlays, and Onlays |
| D GENL |
| Dental General Services |
| D ORAL |
| Dental Oral Surgery |
| M ORAL |
| Medical/Surgical Oral Surgery |
APPENDIX 5: ADJUSTMENT REASON CODES
To be provided by the contractor after award
APPENDIX 6: ADJUSTMENT CODES
To be provided by the contractor after award
| ADDP3 | Attachment J-12 |
| HT94002-20-R-0001 | Page 1 of 9 |