RFP 2025HCA5 Attachment 9 - claim data.xlsx
XLSX spreadsheet 128 KB Posted
- Attached to
- Fully-Insured Medical Plans
- Solicitation number
- 2025HCA5
- Issued by
- Adams County, Asotin County, Benton County, Chelan County, Clallam County, Clark County, Columbia County, Cowlitz County, Douglas County, Ferry County, Franklin County, Garfield County, Grant County, Grays Harbor County, Island County, Jefferson County, King County, Kitsap County, Kittitas County, Klickitat County, Lewis County, Lincoln County, Mason County, Okanogan County, Pacific County, Pend Oreille County, Pierce County, San Juan County, Skagit County, Skamania County, Snohomish County, Spokane County, Stevens County, Thurston County, Wahkiakum County, Walla Walla County, Whatcom County, Whitman County, Yakima County, Asotin City, Clarkston City, Clarkston Heights-Vineland CDP, West Clarkston-Highland CDP, Benton City, Chelan City, Chelan Falls CDP, Clallam Bay CDP, Lewisville CDP, Rock Island City, Pacific Beach CDP, Whidbey Island Station CDP, Mercer Island City, Pacific City, Bainbridge Island City, Kingston CDP, Kitsap Lake CDP, Kittitas City, Klickitat CDP, Okanogan City, Anderson Island CDP, Fort Lewis CDP, Fox Island CDP, Herron Island CDP, Ketron Island CDP, North Fort Lewis CDP, Raft Island CDP, Stevenson City, Hat Island CDP, Lake Stevens City, Snohomish City, Spokane City, Spokane Valley City, Puget Island CDP, Garfield Town, Yakima City, Washington
About this file
This document is a technical specification file for medical claims data submission requirements issued by the Washington State Health Care Authority (HCA) in conjunction with a Request for Proposals (RFP) for fully-insured medical plans. The specification outlines standardized data formats and field requirements for three primary data submission categories: medical claims, pharmacy claims, and membership eligibility records. The medical claims section requires 150+ data fields including claim identifiers, member demographics, service dates, diagnosis and procedure codes (ICD-10), provider information, and financial details such as billed amounts, allowed amounts, patient cost-sharing, and coordination of benefits. Pharmacy claims require approximately 50 fields including NDC codes, ingredient costs, dispensing fees, and days supply information. Membership data requires approximately 60 fields capturing member demographics, eligibility status for various benefit types (medical, dental, pharmaceutical, vision), capitation amounts, premiums, risk scores, and Medicare/dual eligibility indicators. The specification document (version 09222026) provides detailed formatting requirements, including field length restrictions, data type specifications, and standard code sets such as CMS Place of Service codes, discharge status codes, and bill type classifications.
The specification mandates strict data formatting standards to ensure consistency across submissions, including leading zeros for numeric codes, specific date formats (mm/dd/yyyy), and specified decimal precision for financial data. The document references that some fields are conditionally required based on claim type (e.g., DRG fields differ between MS-DRG, APR-DRG, and TRICARE methodologies), and notes that membership data will overwrite certain claim-level data fields when available. The specification is designed to support Milliman's actuarial analysis and benchmarking processes for the fully-insured medical plan evaluation, and includes provisions for user-defined population variables and numeric fields to accommodate plan-specific data requirements or emerging technologies. No pricing, contract term, award timeline, or bidder meeting information is contained within this technical specifications attachment.
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Other files
| File | Type | Posted |
|---|---|---|
| RFP 2025HCA5 Exhibit I - Subc List.xlsx | XLSX spreadsheet | |
| RFP 2025HCA5 Exhibit C1.2 - Written P1.docx | DOCX document | |
| RFP 2025HCA5 Exhibit G - Plan Design Outline.xlsx | XLSX spreadsheet | |
| RFP 2025HCA5 Attachment 1_APM Framework_RFP.pdf | ||
| RFP 2025HCA5 Att 7 - Disaster Plan.docx | DOCX document | |
| RFP 2025HCA5 Exhibit H - Bree Collab.xlsx | XLSX spreadsheet | |
| RFP 2025HCA5 Final 10.12.26.pdf | ||
| RFP 2025HCA5 Exhibit C2 Written P2.docx | DOCX document | |
| RFP 2025HCA5 Exhibit A - Forms and Certs.docx | DOCX document | |
| RFP 2025HCA5 Exhibit E - Service Area.xlsx | XLSX spreadsheet | |
| RFP 2025HCA5 Att 4 - 834 Companion Guide.xlsx | XLSX spreadsheet | |
| RFP 2025HCA5 EXHIBIT C1.1 Attestations.docx | DOCX document | |
| RFP 2025HCA5 Attachment 3_MFT User Guide_RFP.pdf |
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Text version
Medical Claims
| v09222026 | |||||
| PEAA (RCW 41.05.028) Required medical claims data specifications | |||||
| Field Name | Data Type | Format | Description | Required | Comments |
| SequenceNumber | bigint | 8 bytes (+, -) | Sequence number in claims table | Yes | Primary key - must be unique |
| ClaimID | string | max(60) | Unique claim identifier | Yes | Required to associate services with claims |
| LineNum | string | max(3) | Sequence number within a claim | Yes | |
| ContractID | string | max(30) | Unique subscriber/contract identifier | Yes | |
| MemberID | string | max(40) | Unique member identifier | Yes | |
| DOB | date | (mm/dd/yyyy) | Member’s date of birth | Yes | |
| Gender | string | max(1) | Member’s gender | Yes | M (Male) or F (Female) |
| FromDate | date | (mm/dd/yyyy) | First date of service | Yes | |
| ToDate | date | (mm/dd/yyyy) | Last date of service | Yes | |
| AdmitDate | date | (mm/dd/yyyy) | Admission date | Yes | Both AdmitDate and DischDate must be populated for inpatient claims |
| DischDate | date | (mm/dd/yyyy) | Discharge date | Yes | Both AdmitDate and DischDate must be populated for inpatient claims |
| PaidDate | date | (mm/dd/yyyy) | Paid date | Yes | |
| DRG | string | max(3) | DRG Code + DRG Severity | No if MS-DRG, Yes if APR or TRICARE | Use leading zeros. Use blank if not available. Use 4 characters to append APR-DRG Severity to end if using APR DRGs. For example, APR DRGs would be written: 0013, indicating a DRG value of 001, and an APR DRG Severity value of 3. Only use 3 characters when populating for CMS or TRICARE DRGs. |
Some applications will use APR and TRICARE DRGs for RVU assignment, and some will assign MS-DRG across all claims. In the absence of a populated DRG, MS-DRG will be assigned.
| Severity | string | max(1) | DRG Severity | APR-DRG severity. Keep blank if not using APR-DRGs. | |
| DRGVersion | string | max(5) (previously this was 9) | DRG Version | No if MS-DRG, Yes if APR or TRICARE | TRI, MS, APR, OTHER. Use blank if not available. Optional version number suffix (e.g., MS34) |
For APR and TRICARE DRGs, both DRG and DRGVersion must be provided.
| Revcode | string | max(4) | Revenue code. | Yes | Use leading zeros |
| HCPCS | string | max(5) | CPT-4/HCPCS procedure code/Health Insurance Prospective Payment System (HIPPS) Rate Code | Yes | SNF claims have both HCPCS and HIPPS codes on them. Both are in the UB-04's HCPCS/HIPPS code field. |
| Modifier | string | max(2) | Modifier Code | Yes | |
| Modifier2 | string | max(2) | Second Modifier Code | Yes | |
| Modifier3 | string | max(2) | Third Modifier Code | ||
| Modifier4 | string | max(2) | Fourth Modifier Code | ||
| srcPOS | string | max(10) | Raw source place of service code | ||
| POS | string | max(2) | CMS standard place of service code | Yes | Map from srcPOS |
See the [CMS POS] tab for a list of valid values and how these values interact with member and provider location fields
| Provider taxonomy | string | max(30) | Raw source specialty code | Yes | Populate with provider taxonomy |
| Specialty | string | max(2) | Milliman standard specialty code | Map from srcSpecialty | |
| EncounterFlag | string | max(1) | Encounter flag | Yes | "Y" if service is capitated. "N" otherwise. |
| ProviderNPI | string | max(40) | Provider identifier | Yes | |
| ProviderTIN | string | max(40) | Provider identifier | Yes | |
| ProviderZip | string | max(5) | Provider’s Zip code | Yes | 5 digits, prepend leading 0s if needed |
| ProviderCounty | string | max(5) | Provider's FIPS county code | FIPS code |
5 digits, prepend leading 0s if needed
| RenderingProviderNPI | string | max(40) | Rendering Provider identifier, used for Professional claims. Rendering and billing provider will be the same for IP | Yes | |
| RenderingProviderTIN | string | max(40) | Rendering Provider identifier, used for Professional claims. Rendering and billing provider will be the same for IP | Yes | |
| RenderingProviderZip | string | max(5) | Rendering Provider Zip | Yes | 5 digits, prepend leading 0s if needed |
| RenderingProviderCounty | string | max(5) | Rendering Provider FIPS county code | FIPS code |
5 digits, prepend leading 0s if needed
| MedicareID | string | max(40) | Medicare ID of the provider. | Yes | 6 character Medicare CCN for hospitals. | |
| BillType | string | max(3) | CMS standard bill type | Yes | Also known as Type of Bill | |
| AdmitSource | string | max(3) | The site and licensure where the patient originated, and route by which the patient was admitted. | |||
| AdmitType | string | max(1) | How patient's admission was arranged | |||
| Billed | decimal | (18,4) | Billed amount. | Yes | Can affect sign of RVU assignment. Validation of financial charges can affect which claims appear in reports. Can be used for imputation. | |
| Allowed | decimal | (18,4) | Allowed amount | Yes | See above | |
| Paid | decimal | (18,4) | Paid amount | Yes | See above | |
| COB | decimal | (18,4) | Coordination of benefits amount | Yes | See above | |
| Copay | decimal | (18,4) | Copay amount | |||
| Coinsurance | decimal | (18,4) | Coinsurance amount | |||
| Deductible | decimal | (18,4) | Deductible amount | |||
| PatientPay | decimal | (18,4) | Cost sharing amount | Yes | Sum of Copay, Coinsurance and Deductible. Can affect adjudication. | |
| Days | int | 4 bytes (+, -) | IP hospital days for the claim line | Yes | ||
| Units | decimal | (19,6) | Units of Service | Yes | Required | |
| DischargeStatus | string | max(2) | CMS standard discharge status | Yes | Required for DRG assignment and for Medicare Allowed assignment. | |
| ICDVersion | string | max(2) | ICD code version | Yes | ICD code version "0" or "10" for ICD-10. ICD-9 no longer supported. | |
| AdmitDiag | string | max(7) | Admission Diagnosis | Retain any leading zeros, no decimal | ||
| ICDDiag1 | string | max(7) | Primary ICD diagnosis code | Yes | Retain any leading zeros, no decimal | |
| ICDDiag2 | string | max(7) | ICD diagnosis code 2 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag3 | string | max(7) | ICD diagnosis code 3 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag4 | string | max(7) | ICD diagnosis code 4 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag5 | string | max(7) | ICD diagnosis code 5 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag6 | string | max(7) | ICD diagnosis code 6 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag7 | string | max(7) | ICD diagnosis code 7 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag8 | string | max(7) | ICD diagnosis code 8 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag9 | string | max(7) | ICD diagnosis code 9 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag10 | string | max(7) | ICD diagnosis code 10 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag11 | string | max(7) | ICD diagnosis code 11 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag12 | string | max(7) | ICD diagnosis code 12 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag13 | string | max(7) | ICD diagnosis code 13 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag14 | string | max(7) | ICD diagnosis code 14 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag15 | string | max(7) | ICD diagnosis code 15 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag16 | string | max(7) | ICD diagnosis code 16 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag17 | string | max(7) | ICD diagnosis code 17 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag18 | string | max(7) | ICD diagnosis code 18 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag19 | string | max(7) | ICD diagnosis code 19 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag20 | string | max(7) | ICD diagnosis code 20 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag21 | string | max(7) | ICD diagnosis code 21 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag22 | string | max(7) | ICD diagnosis code 22 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag23 | string | max(7) | ICD diagnosis code 23 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag24 | string | max(7) | ICD diagnosis code 24 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag25 | string | max(7) | ICD diagnosis code 25 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag26 | string | max(7) | ICD diagnosis code 26 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag27 | string | max(7) | ICD diagnosis code 27 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag28 | string | max(7) | ICD diagnosis code 28 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag29 | string | max(7) | ICD diagnosis code 29 | Yes | Retain any leading zeros, no decimal | |
| ICDDiag30 | string | max(7) | ICD diagnosis code 30 | Yes | Retain any leading zeros, no decimal | |
| POA1 | string | max(1) | Primary present on admission code | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA2 | string | max(1) | Present on admission code 2 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA3 | string | max(1) | Present on admission code 3 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA4 | string | max(1) | Present on admission code 4 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA5 | string | max(1) | Present on admission code 5 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA6 | string | max(1) | Present on admission code 6 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA7 | string | max(1) | Present on admission code 7 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA8 | string | max(1) | Present on admission code 8 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA9 | string | max(1) | Present on admission code 9 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA10 | string | max(1) | Present on admission code 10 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA11 | string | max(1) | Present on admission code 11 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA12 | string | max(1) | Present on admission code 12 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA13 | string | max(1) | Present on admission code 13 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA14 | string | max(1) | Present on admission code 14 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA15 | string | max(1) | Present on admission code 15 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA16 | string | max(1) | Present on admission code 16 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA17 | string | max(1) | Present on admission code 17 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA18 | string | max(1) | Present on admission code 18 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA19 | string | max(1) | Present on admission code 19 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA20 | string | max(1) | Present on admission code 20 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA21 | string | max(1) | Present on admission code 21 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA22 | string | max(1) | Present on admission code 22 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA23 | string | max(1) | Present on admission code 23 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA24 | string | max(1) | Present on admission code 24 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA25 | string | max(1) | Present on admission code 25 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA26 | string | max(1) | Present on admission code 26 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA27 | string | max(1) | Present on admission code 27 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA28 | string | max(1) | Present on admission code 28 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA29 | string | max(1) | Present on admission code 29 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| POA30 | string | max(1) | Present on admission code 30 | Yes | "Y"=Yes, "N"=No, "U"=Unknown, "W"=Undetermined, "1"=Unreported/Not Used | |
| ICDProc1 | string | max(7) | Primary ICD procedure code | Yes | Retain any leading zeros, no decimal | |
| ICDProc2 | string | max(7) | ICD procedure code 2 | Yes | Retain any leading zeros, no decimal | |
| ICDProc3 | string | max(7) | ICD procedure code 3 | Yes | Retain any leading zeros, no decimal | |
| ICDProc4 | string | max(7) | ICD procedure code 4 | Yes | Retain any leading zeros, no decimal | |
| ICDProc5 | string | max(7) | ICD procedure code 5 | Yes | Retain any leading zeros, no decimal | |
| ICDProc6 | string | max(7) | ICD procedure code 6 | Yes | Retain any leading zeros, no decimal | |
| ICDProc7 | string | max(7) | ICD procedure code 7 | Yes | Retain any leading zeros, no decimal | |
| ICDProc8 | string | max(7) | ICD procedure code 8 | Yes | Retain any leading zeros, no decimal | |
| ICDProc9 | string | max(7) | ICD procedure code 9 | Yes | Retain any leading zeros, no decimal | |
| ICDProc10 | string | max(7) | ICD procedure code 10 | Yes | Retain any leading zeros, no decimal | |
| ICDProc11 | string | max(7) | ICD procedure code 11 | Yes | Retain any leading zeros, no decimal | |
| ICDProc12 | string | max(7) | ICD procedure code 12 | Yes | Retain any leading zeros, no decimal | |
| ICDProc13 | string | max(7) | ICD procedure code 13 | Yes | Retain any leading zeros, no decimal | |
| ICDProc14 | string | max(7) | ICD procedure code 14 | Yes | Retain any leading zeros, no decimal | |
| ICDProc15 | string | max(7) | ICD procedure code 15 | Yes | Retain any leading zeros, no decimal | |
| ICDProc16 | string | max(7) | ICD procedure code 16 | Yes | Retain any leading zeros, no decimal | |
| ICDProc17 | string | max(7) | ICD procedure code 17 | Yes | Retain any leading zeros, no decimal | |
| ICDProc18 | string | max(7) | ICD procedure code 18 | Yes | Retain any leading zeros, no decimal | |
| ICDProc19 | string | max(7) | ICD procedure code 19 | Yes | Retain any leading zeros, no decimal | |
| ICDProc20 | string | max(7) | ICD procedure code 20 | Yes | Retain any leading zeros, no decimal | |
| ICDProc21 | string | max(7) | ICD procedure code 21 | Yes | Retain any leading zeros, no decimal | |
| ICDProc22 | string | max(7) | ICD procedure code 22 | Yes | Retain any leading zeros, no decimal | |
| ICDProc23 | string | max(7) | ICD procedure code 23 | Yes | Retain any leading zeros, no decimal | |
| ICDProc24 | string | max(7) | ICD procedure code 24 | Yes | Retain any leading zeros, no decimal | |
| ICDProc25 | string | max(7) | ICD procedure code 25 | Yes | Retain any leading zeros, no decimal | |
| ICDProc26 | string | max(7) | ICD procedure code 26 | Yes | Retain any leading zeros, no decimal | |
| ICDProc27 | string | max(7) | ICD procedure code 27 | Yes | Retain any leading zeros, no decimal | |
| ICDProc28 | string | max(7) | ICD procedure code 28 | Yes | Retain any leading zeros, no decimal | |
| ICDProc29 | string | max(7) | ICD procedure code 29 | Yes | Retain any leading zeros, no decimal | |
| ICDProc30 | string | max(7) | ICD procedure code 30 | Yes | Retain any leading zeros, no decimal | |
| RiskPool | string | max(40) | RiskPool | e.g., Hospital, Physician or other risk pool, if applicable | ||
| OON | string | max(1) | Out of network indicator | Yes | "Y" if OON claim. "N" otherwise. | |
| ClaimLineStatus | string | max(1) | Claim line status code | Yes | "P"=Paid, "D"=Denied, "R"=Reversed, "E"=Encounter. Null entries are assumed Paid. | |
| CurrentAllowed | decimal | (18,4) | Allowed amount repriced using | |||
| current contracts | Should have same sign (-1, 0, 1) as allowed. | |||||
| LOINC | string | max(10) | Logical Observation Identifiers Names and Codes | |||
| srcLOB | string | max(10) | Source line of business | Used to assign summarized LOB | ||
| LOB | string | max(3) | Line of business | Recommended for benchmarks/reports. See "Milliman Elig" tab for Milliman standard, no limits on customization. | ||
| srcProduct | string | max(40) | Source product | Used to assign summarized Product | ||
| Product | string | max(3) | Name of the product | See "Milliman Elig" tab for Milliman standard, no limits on customization | ||
| GroupID | string | max(40) | Unique group identifier | |||
| Zip | string | max(5) | Member Zip Code | Yes | 5-digit Zip Code. Either Zip or County is required to assign MSA. |
Prepend with leading 0s if needed.
County string max(5) Member FIPS County Code 5-digit FIPS County Code. Either Zip or County is required to assign MSA.
Prepend with leading 0s if needed.
| MemberStatus | string | max(40) | Member status | Dual, ESRD, Hospice, etc. |
| UserDefPop1 | string | max(40) | User-Defined Population Variable 1, when New Tech enabled and NDC Stored in Field set to “UserDefPop1” then NDCs will be passed thru in UDF1 | User-Defined Population Variable 1, when New Tech enabled and NDC Stored in Field set to “UserDefPop1” then NDCs will be used for inpatient Medicare repricing. |
| UserDefPop2 | string | max(40) | User-Defined Population Variable 2, when New Tech enabled and NDC Stored in Field set to “UserDefPop2” then NDCs will be passed thru in UDF2 | User-Defined Population Variable 2, when New Tech enabled and NDC Stored in Field set to “UserDefPop2” then NDCs will be used for inpatient Medicare repricing. |
| UserDefPop3 | string | max(40) | User-Defined Population Variable 3, when New Tech enabled and NDC Stored in Field set to “UserDefPop3” then NDCs will be passed thru in UDF3 | User-Defined Population Variable 3, when New Tech enabled and NDC Stored in Field set to “UserDefPop3” then NDCs will be used for inpatient Medicare repricing. |
| UserDefNum1 | decimal | (19,6) | User-Defined Numeric Variable 1 | User-Defined Numeric Variable 1. Populate with CurrentAllowed if available. |
| UserDefNum2 | decimal | (19,6) | User-Defined Numeric Variable 2 | User-Defined Numeric Variable 2 |
| UserDefNum3 | decimal | (19,6) | User-Defined Numeric Variable 3 | User-Defined Numeric Variable 3 |
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Pharmacy Claims
| v09222026 | |||||
| Pharmacy claims data - Required fields and specifications | |||||
| Field Name | Data Type | Format | Required Field? | Description | Comments |
| SequenceNumber | bigint | 8 bytes (+, -) | Yes | Sequence number in pharmacy table | Primary key – must be unique |
| ClaimID | string | max(60) | Yes | Unique claim identifier | |
| ContractID | string | max(30) | Yes | Unique subscriber/contract identifier | |
| MemberID | string | max(40) | Yes | Unique member identifier | |
| DOB | date | (mm/dd/yyyy) | No | Member’s date of birth | If a membership table is available for processing, this field will be overwritten using the values from the inpMemberMonths.txt file. |
| Gender | string | max(1) | No | Member’s gender | M (Male) or F (Female) |
If a membership table is available for processing, this field will be overwritten using the values from the inpMemberMonths.txt file.
| FromDate | date | (mm/dd/yyyy) | Yes | First date of service | ||
| PaidDate | date | (mm/dd/yyyy) | No | Paid date | ||
| NDC | string | max(11) | Yes | NDC code | ||
| EncounterFlag | string | max(1) | No | Encounter flag | "Y" if service is capitated. "N" otherwise. | |
| MedicalCovered | string | max(1) | Yes | Covered under Medical Plan indicator | "Y" if drug covered under the Medical plan (e.g. Part B drugs). "N" otherwise. | |
| ProviderID | string | max(40) | No | Provider identifier | Dispensing provider, not prescribing provider. | |
| ProviderZIP | string | max(5) | No | Provider’s5 digit Zip code | ||
| ProviderCounty | string | max(5) | No | Provider's county code | Dispensing provider FIPS county code | |
| MailOrder | string | max(1) | No | Mail order indicator | "M" for mail order, "R" for retail | |
| IngredientCost | decimal | (18,4) | No | Ingredient cost | ||
| DispensingFee | decimal | (18,4) | No | Dispensing fee | ||
| Billed | decimal | (18,4) | Yes | Billed amount | ||
| Allowed | decimal | (18,4) | Yes | Allowed amount | ||
| Paid | decimal | (18,4) | No | Paid amount | ||
| COB | decimal | (18,4) | No | Coordination of benefits amount | ||
| Copay | decimal | (18,4) | No | Copay amount | ||
| Coinsurance | decimal | (18,4) | No | Coinsurance amount | ||
| Deductible | decimal | (18,4) | No | Deductible amount | ||
| PatientPay | decimal | (18,4) | Yes | Cost sharing amount | Sum of Copay, Coinsurance and Deductible | |
| Units | decimal | (19,6) | Yes | Units of Service | Populate with Days Supply or Quantity Dispensed | |
| DaysSupply | int | 4 bytes (+, -) | No | Days' Supply | Values 0-999, Please Supply DaysSupply or QuantityDispensed or both. | |
| QuantityDispensed | decimal | (19,6) | No | Quantity Dispensed | Number of Units, Grams, Milliliters, other. If compounded item, total of all ingredients. Please Supply DaysSupply or QuantityDispensed or both. | |
| RiskPool | string | max(40) | No | RiskPool | e.g. Hospital, Physician or other risk pool, if applicable | |
| OON | string | max(1) | No | Out of network indicator | "Y" if OON claim. "N" otherwise. | |
| ClaimLineStatus | string | max(1) | No | Claim line status code | "P"=Paid, "D"=Denied, "R"=Reversed, "E"=Encounter. Null entries are assumed Paid. | |
| CurrentAllowed | decimal | (18,4) | No | Allowed amount repriced using | ||
| current contracts | Should have same sign (-1, 0, 1) as allowed | |||||
| srcLOB | string | max(10) | No | Source line of business | Used to assign summarized LOB |
If a membership table is available for processing, this field will be overwritten using the values from the inpMemberMonths.txt file.
LOB string max(3) Yes Line of business See "Milliman Elig" tab for Milliman standard, no limits on customization
If a membership table is available for processing, this field will be overwritten using the values from the inpMemberMonths.txt file.
srcProduct string max(40) No Source product Used to assign summarized Product
If a membership table is available for processing, this field will be overwritten using the values from the inpMemberMonths.txt file.
Product string max(3) No Name of the product See "Milliman Elig" tab for Milliman standard, no limits on customization
If a membership table is available for processing, this field will be overwritten using the values from the inpMemberMonths.txt file.
| GroupID | string | max(40) | No | Unique group identifier | If a membership table is available for processing, this field will be overwritten using the values from the inpMemberMonths.txt file. |
| Zip | string | max(5) | No | Member Zip Code | 5 digit Zip Code. Either Zip or County is required to assign MSA. |
If a membership table is available for processing, this field will be overwritten using the values from the inpMemberMonths.txt file.
County string max(5) No Member FIPS County Code 5 digit FIPS County Code. Either Zip or County is required to assign MSA.
If a membership table is available for processing, this field will be overwritten using the values from the inpMemberMonths.txt file.
MemberStatus string max(40) No Member status Active, Retiree, and Cobra
If a membership table is available for processing, this field will be overwritten using the values from the inpMemberMonths.txt file.
| UserDefPop1 | string | max(40) | No | User-Defined Population Variable 1 | If a membership table is available for processing, this field will be overwritten using the values from the inpMemberMonths.txt file. |
| UserDefPop2 | string | max(40) | No | User-Defined Population Variable 2 | If a membership table is available for processing, this field will be overwritten using the values from the inpMemberMonths.txt file. |
| UserDefPop3 | string | max(40) | No | User-Defined Population Variable 3 | If a membership table is available for processing, this field will be overwritten using the values from the inpMemberMonths.txt file. |
| UserDefNum1 | decimal | (19,6) | No | User-Defined Numeric Variable 1 | |
| UserDefNum2 | decimal | (19,6) | No | User-Defined Numeric Variable 2 | |
| UserDefNum3 | decimal | (19,6) | No | User-Defined Numeric Variable 3 |
v09222026
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Membership
| v09222026 | |||||
| Eligibility data - member months | |||||
| Field Name | Data Type | Format | Required Field? | Description | Comments |
| MemberID | string | max(40) | Yes | Unique member identifier | |
| MedicareHIC | string | max(40) | No | Unique MA member identifier | HIC Number for Medicare enrollees |
| ContractID | string | max(30) | Yes | Unique subscriber/contract identifier | If only MemberID is available, then set ContractID equal to MemberID |
| YearMo | string | max(6) | Yes | Year and month of eligibility (e.g., YearMo = 202001 for January 2020). | If a member is eligible for at least one day in a month, then a member month record should be created. |
| DepCode | int | 4 bytes (+, -) | Yes | Type of member | Milliman standards are: 0 (Subscriber), 1 (Spouse), 2 (Dependent Child), however additional custom codes are allowed. |
| DOB | date | (mm/dd/yyyy) | Yes | Member’s date of birth | |
| Gender | string | max(1) | Yes | Member’s gender | M (Male) or F (Female) |
| srcLOB | string | max(10) | No | Source line of business | Used to assign summarized LOB |
| LOB | string | max(3) | Yes | Line of business | See "Milliman Elig" tab for Milliman standard, no limits on customization |
| srcProduct | string | max(40) | No | Source product | Used to assign summarized Product |
| Product | string | max(3) | No | Name of the product | See "Milliman Elig" tab for Milliman standard, no limits on customization |
| GroupID | string | max(40) | No | Unique group identifier | Used in Partial Year Group logic |
| Zip | string | max(5) | No | Member Zip Code | 5 digit Zip Code. Either Zip or County is required to assign MSA. |
| County | string | max(5) | No | Member FIPS County Code | 5 digit FIPS County Code. Either Zip or County is required to assign MSA. |
| Industry | string | max(6) | No | Industrial classification | SIC or NAICS |
| Medical | int | 4 bytes (+, -) | Yes | Medical eligibility | 1 if eligible, 0 otherwise |
| Dental | int | 4 bytes (+, -) | Yes | Dental eligibility | 1 if eligible, 0 otherwise |
| Rx | int | 4 bytes (+, -) | Yes | Prescription drug eligibility | 1 if eligible, 0 otherwise |
| Vision | int | 4 bytes (+, -) | Yes | Vision eligibility | 1 if eligible, 0 otherwise |
| Capitation | decimal | (18,4) | No | Total member capitation amount | |
| Capitation1 | decimal | (18,4) | No | Member capitation amount 1 | |
| Capitation2 | decimal | (18,4) | No | Member capitation amount 2 | |
| Capitation3 | decimal | (18,4) | No | Member capitation amount 3 | |
| Capitation4 | decimal | (18,4) | No | Member capitation amount 4 | |
| Capitation5 | decimal | (18,4) | No | Member capitation amount 5 | |
| Premium | decimal | (18,4) | No | Total premium for the member | |
| PremiumMedical | decimal | (18,4) | No | Medical premium for the member | |
| PremiumDrug | decimal | (18,4) | No | Prescription drug premium for the member | |
| PremiumVision | decimal | (18,4) | No | Vision premium for the member | |
| PremiumDental | decimal | (18,4) | No | Dental premium for the member | |
| Expense | decimal | (18,4) | No | Total member expense amount | |
| Expense1 | decimal | (18,4) | No | Member expense amount 1 | |
| Expense2 | decimal | (18,4) | No | Member expense amount 2 | |
| Expense3 | decimal | (18,4) | No | Member expense amount 3 | |
| Expense4 | decimal | (18,4) | No | Member expense amount 4 | |
| Expense5 | decimal | (18,4) | No | Member expense amount 5 | |
| AgeSex | decimal | (19,6) | No | Member age/sex factor | |
| PCP | string | max(40) | No | Primary care identification | |
| ManagedPopulation | string | max(40) | No | Capitated entity identification | IPA or Medical Group |
| RiskScore | decimal | (19,6) | No | Member risk score | |
| MemberStatus | string | max(40) | No | Member status | Active, Retiree, and Cobra |
| MedicareStatusCode | string | max(2) | No | Medicare Enrollment Status Indicator | Dual, ESRD, Hospice, etc. Custom values OK. |
| DualStatusCode | string | max(2) | No | Dual Status Indicator | Per CMS: 1, 3, 5 or 6 = Partial Dual. 2, 4 or 8 = Full Dual. Blank = Non-Dual. |
| OREC | string | max(1) | No | Original Reason for Entitlement Code | "0" = Old Age |
"1" = Disability
"2" = ESRD
"3" = Both Disability and ESRD
| UserDefPop1 | string | max(40) | No | User Defined Population Variable 1 |
| UserDefPop2 | string | max(40) | No | User Defined Population Variable 2 |
| UserDefPop3 | string | max(40) | No | User Defined Population Variable 3 |
v09222026
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CMS POS
| Medicare Standard Place of Service (POS) | |
| POS | Description |
| 01 | Pharmacy |
| 02 | Telehealth Provided Other than in Patient's Home |
| 03 | School |
| 04 | Homeless Shelter |
| 05 | Indian Health Service - Free Standing Facility |
| 06 | Indian Health Service - Provider-Based Facility |
| 07 | Tribal 638 - Free Standing Facility |
| 08 | Tribal 638 - Provider-Based Facility |
| 09 | Prison - Correctional Facility |
| 10 | Telehealth Provided in Patient's Home |
| 11 | Office |
| 12 | Home |
| 13 | Assisted Living Facility |
| 14 | Group Home |
| 15 | Mobile Unit |
| 16 | Temporary Lodging |
| 17 | Walk-in Retail Health Clinic |
| 18 | Place of Employment/Worksite |
| 19 | Off Campus-Outpatient hospital |
| 20 | Urgent Care Facility |
| 21 | Inpatient hospital |
| 22 | On Campus-Outpatient hospital |
| 23 | Emergency room - hospital |
| 24 | Ambulatory surgical center |
| 25 | Birthing center |
| 26 | Military treatment facility |
| 27 | Outreach Site/ Street |
| 31 | Skilled nursing facility |
| 32 | Nursing facility |
| 33 | Custodial care facility |
| 34 | Hospice |
| 35 | Unassigned |
| 41 | Ambulance - land |
| 42 | Ambulance - air or water |
| 49 | Independent Clinic |
| 50 | Federally qualified health centers |
| 51 | Inpatient psychiatric facility |
| 52 | Psychiatric facility partial hospitalization |
| 53 | Community mental health center |
| 54 | Intermediate care facility/mentally retarded |
| 55 | Residential substance abuse treatment facility |
| 56 | Psychiatric residential treatment center |
| 57 | Non-residential Substance Abuse Treatment Facility |
| 58 | Non-residential Opioid Treatment Facility |
| 60 | Mass immunizations center (eff. 9/1/97) |
| 61 | Comprehensive inpatient rehabilitation facility |
| 62 | Comprehensive outpatient rehabilitation facility |
| 65 | End stage renal disease treatment facility |
| 66 | Programs of All-Inclusive Care for the Elderly (PACE) Center |
| 71 | State or local public health clinic |
| 72 | Rural health clinic |
| 81 | Independent laboratory |
| 99 | Other unlisted facility |
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CMS Discharge Status
| Medicare Standard Patient Discharge Status Codes | |
| Patient Status Codes | Description |
| 01 | Home, self-care status |
| 02 | Short term hospital |
| 03 | SNF |
| 04 | Custodial/Supportive Care |
| 05 | Cancer/Children's Hospital |
| 06 | Home health Service |
| 07 | Against medical advice |
| 09 | Admitted as an Inpatient to this Hospital |
| 20 | Expired |
| 21 | Court/Law enforcement |
| 30 | Still a patient |
| 40 | Hospice - Expired at Home |
| 41 | Hospice - Expired in a Medical Facility |
| 42 | Hospice - Expired - Place Unknown |
| 43 | Federal Health Care Facility |
| 50 | Hospice-home |
| 51 | Hospice-medical facility |
| 61 | Swing bed |
| 62 | Rehab facility/unit |
| 63 | LTC hospital |
| 64 | Nursing facility |
| 65 | Psych hosp/unit |
| 66 | Critical Access Hospital |
| 69 | Designated Disaster Alternative Care Site |
| 70 | Other institution |
| 81 | Home-Self care w Planned Readmission |
| 82 | Short Term Hospital w Planned Readmission |
| 83 | SNF w Planned Readmission |
| 84 | Cust/supp care w Planned Readmission |
| 85 | Canc/child hosp w Planned Readmission |
| 86 | Home health Service w Planned Readmission |
| 87 | Court/Law enforcement w Planned Readmission |
| 88 | Federal health care facility w Planned Readmission |
| 89 | Swing bed w Planned Readmission |
| 90 | Rehab facility/unit w Planned Readmission |
| 91 | LTC hospital w Planned Readmission |
| 92 | Nursg Fac-Medicaid Cert w Planned Readmission |
| 93 | Psych hosp/unit w Planned Readmission |
| 94 | Critical Access Hospital w Planned Readmission |
| 95 | Other institution w Planned Readmission |
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Bill Type
| Bill Type | |||
| Billtype | Factype Desc | Billclass Des | Freq Desc |
| 110 | Hospital | Inpatient (Including Medicare Part A) | Non-Payment / Zero Claims |
| 111 | Hospital | Inpatient (Including Medicare Part A) | Admit through Discharge Claim |
| 112 | Hospital | Inpatient (Including Medicare Part A) | Interim - First Claim |
| 113 | Hospital | Inpatient (Including Medicare Part A) | Interim - Continuing Claim |
| 114 | Hospital | Inpatient (Including Medicare Part A) | Interim - Last Claim |
| 115 | Hospital | Inpatient (Including Medicare Part A) | Late Charge(s) Only Claim |
| 116 | Hospital | Inpatient (Including Medicare Part A) | Reserved for National Assignment |
| 117 | Hospital | Inpatient (Including Medicare Part A) | Replacement of Prior Claim |
| 118 | Hospital | Inpatient (Including Medicare Part A) | Void/Cancel of Prior Claim |
| 119 | Hospital | Inpatient (Including Medicare Part A) | Final Claim for a Home Health PPS Episode |
| 11A | Hospital | Inpatient (Including Medicare Part A) | Admission/Election Notice |
| 11B | Hospital | Inpatient (Including Medicare Part A) | Termination/Revocation Notice; eff 1/2019 |
| 11C | Hospital | Inpatient (Including Medicare Part A) | Hospice Change of Provider Notice |
| 11D | Hospital | Inpatient (Including Medicare Part A) | Cancellation Of Election Notice; eff 1/2019 |
| 11E | Hospital | Inpatient (Including Medicare Part A) | Hospice Change of Ownership |
| 11F | Hospital | Inpatient (Including Medicare Part A) | Beneficiary Initiated Adjustment Claim |
| 11G | Hospital | Inpatient (Including Medicare Part A) | CWF Initiated Adjustment Claim |
| 11H | Hospital | Inpatient (Including Medicare Part A) | CMS Initiated Adjustment Claim |
| 11I | Hospital | Inpatient (Including Medicare Part A) | Intermediary Adjustment Claim (Other than QIO or Provider) |
| 11J | Hospital | Inpatient (Including Medicare Part A) | Initiated Adjustment Claim - Other |
| 11K | Hospital | Inpatient (Including Medicare Part A) | OIG Initiated Adjustment Claim |
| 11L | Hospital | Inpatient (Including Medicare Part A) | Reserved for National Assignment |
| 11M | Hospital | Inpatient (Including Medicare Part A) | MSP Initiated Adjustment Claim |
| 11N | Hospital | Inpatient (Including Medicare Part A) | Reserved for National Assignment |
| 11O | Hospital | Inpatient (Including Medicare Part A) | Nonpayment / Zero Claims |
| 11P | Hospital | Inpatient (Including Medicare Part A) | QIO Adjustment Claims |
| 11Q | Hospital | Inpatient (Including Medicare Part A) | Claim Submitted For Reconsideration/Reopening Outside Of Timely Limits |
| 11R | Hospital | Inpatient (Including Medicare Part A) | Reserved for National Assignment |
| 11S | Hospital | Inpatient (Including Medicare Part A) | Reserved for National Assignment |
| 11T | Hospital | Inpatient (Including Medicare Part A) | Reserved for National Assignment |
| 11U | Hospital | Inpatient (Including Medicare Part A) | Reserved for National Assignment |
| 11V | Hospital | Inpatient (Including Medicare Part A) | Reserved for National Assignment |
| 11W | Hospital | Inpatient (Including Medicare Part A) | Reserved for National Assignment |
| 11X | Hospital | Inpatient (Including Medicare Part A) | Void/Cancel a Prior Abbreviated Encounter Submission |
| 11Y | Hospital | Inpatient (Including Medicare Part A) | Replacement of Prior Abbreviated Encounter Submission |
| 11Z | Hospital | Inpatient (Including Medicare Part A) | New Abbreviated Encounter Submission |
| 120 | Hospital | Inpatient (Medicare Part B only) | Non-Payment / Zero Claims |
| 121 | Hospital | Inpatient (Medicare Part B only) | Admit through Discharge Claim |
| 122 | Hospital | Inpatient (Medicare Part B only) | Interim - First Claim |
| 123 | Hospital | Inpatient (Medicare Part B only) | Interim - Continuing Claim |
| 124 | Hospital | Inpatient (Medicare Part B only) | Interim - Last Claim |
| 125 | Hospital | Inpatient (Medicare Part B only) | Late Charge(s) Only Claim |
| 126 | Hospital | Inpatient (Medicare Part B only) | Reserved for National Assignment |
| 127 | Hospital | Inpatient (Medicare Part B only) | Replacement of Prior Claim |
| 128 | Hospital | Inpatient (Medicare Part B only) | Void/Cancel of Prior Claim |
| 129 | Hospital | Inpatient (Medicare Part B only) | Final Claim for a Home Health PPS Episode |
| 12A | Hospital | Inpatient (Medicare Part B only) | Admission/Election Notice |
| 12B | Hospital | Inpatient (Medicare Part B only) | Termination/Revocation Notice; eff 1/2019 |
| 12C | Hospital | Inpatient (Medicare Part B only) | Hospice Change of Provider Notice |
| 12D | Hospital | Inpatient (Medicare Part B only) | Cancellation Of Election Notice; eff 1/2019 |
| 12E | Hospital | Inpatient (Medicare Part B only) | Hospice Change of Ownership |
| 12F | Hospital | Inpatient (Medicare Part B only) | Beneficiary Initiated Adjustment Claim |
| 12G | Hospital | Inpatient (Medicare Part B only) | CWF Initiated Adjustment Claim |
| 12H | Hospital | Inpatient (Medicare Part B only) | CMS Initiated Adjustment Claim |
| 12I | Hospital | Inpatient (Medicare Part B only) | Intermediary Adjustment Claim (Other than QIO or Provider) |
| 12J | Hospital | Inpatient (Medicare Part B only) | Initiated Adjustment Claim - Other |
| 12K | Hospital | Inpatient (Medicare Part B only) | OIG Initiated Adjustment Claim |
| 12L | Hospital | Inpatient (Medicare Part B only) | Reserved for National Assignment |
| 12M | Hospital | Inpatient (Medicare Part B only) | MSP Initiated Adjustment Claim |
| 12N | Hospital | Inpatient (Medicare Part B only) | Reserved for National Assignment |
| 12O | Hospital | Inpatient (Medicare Part B only) | Nonpayment / Zero Claims |
| 12P | Hospital | Inpatient (Medicare Part B only) | QIO Adjustment Claims |
| 12Q | Hospital | Inpatient (Medicare Part B only) | Claim Submitted For Reconsideration/Reopening Outside Of Timely Limits |
| 12R | Hospital | Inpatient (Medicare Part B only) | Reserved for National Assignment |
| 12S | Hospital | Inpatient (Medicare Part B only) | Reserved for National Assignment |
| 12T | Hospital | Inpatient (Medicare Part B only) | Reserved for National Assignment |
| 12U | Hospital | Inpatient (Medicare Part B only) | Reserved for National Assignment |
| 12V | Hospital | Inpatient (Medicare Part B only) | Reserved for National Assignment |
| 12W | Hospital | Inpatient (Medicare Part B only) | Reserved for National Assignment |
| 12X | Hospital | Inpatient (Medicare Part B only) | Void/Cancel a Prior Abbreviated Encounter Submission |
| 12Y | Hospital | Inpatient (Medicare Part B only) | Replacement of Prior Abbreviated Encounter Submission |
| 12Z | Hospital | Inpatient (Medicare Part B only) | New Abbreviated Encounter Submission |
| 130 | Hospital | Outpatient | Non-Payment / Zero Claims |
| 131 | Hospital | Outpatient | Admit through Discharge Claim |
| 132 | Hospital | Outpatient | Interim - First Claim |
| 133 | Hospital | Outpatient | Interim - Continuing Claim |
| 134 | Hospital | Outpatient | Interim - Last Claim |
| 135 | Hospital | Outpatient | Late Charge(s) Only Claim |
| 136 | Hospital | Outpatient | Reserved for National Assignment |
| 137 | Hospital | Outpatient | Replacement of Prior Claim |
| 138 | Hospital | Outpatient | Void/Cancel of Prior Claim |
| 139 | Hospital | Outpatient | Final Claim for a Home Health PPS Episode |
| 13A | Hospital | Outpatient | Admission/Election Notice |
| 13B | Hospital | Outpatient | Termination/Revocation Notice; eff 1/2019 |
| 13C | Hospital | Outpatient | Hospice Change of Provider Notice |
| 13D | Hospital | Outpatient | Cancellation Of Election Notice; eff 1/2019 |
| 13E | Hospital | Outpatient | Hospice Change of Ownership |
| 13F | Hospital | Outpatient | Beneficiary Initiated Adjustment Claim |
| 13G | Hospital | Outpatient | CWF Initiated Adjustment Claim |
| 13H | Hospital | Outpatient | CMS Initiated Adjustment Claim |
| 13I | Hospital | Outpatient | Intermediary Adjustment Claim (Other than QIO or Provider) |
| 13J | Hospital | Outpatient | Initiated Adjustment Claim - Other |
| 13K | Hospital | Outpatient | OIG Initiated Adjustment Claim |
| 13L | Hospital | Outpatient | Reserved for National Assignment |
| 13M | Hospital | Outpatient | MSP Initiated Adjustment Claim |
| 13N | Hospital | Outpatient | Reserved for National Assignment |
| 13O | Hospital | Outpatient | Nonpayment / Zero Claims |
| 13P | Hospital | Outpatient | QIO Adjustment Claims |
| 13Q | Hospital | Outpatient | Claim Submitted For Reconsideration/Reopening Outside Of Timely Limits |
| 13R | Hospital | Outpatient | Reserved for National Assignment |
| 13S | Hospital | Outpatient | Reserved for National Assignment |
| 13T | Hospital | Outpatient | Reserved for National Assignment |
| 13U | Hospital | Outpatient | Reserved for National Assignment |
| 13V | Hospital | Outpatient | Reserved for National Assignment |
| 13W | Hospital | Outpatient | Reserved for National Assignment |
| 13X | Hospital | Outpatient | Void/Cancel a Prior Abbreviated Encounter Submission |
| 13Y | Hospital | Outpatient | Replacement of Prior Abbreviated Encounter Submission |
| 13Z | Hospital | Outpatient | New Abbreviated Encounter Submission |
| 140 | Hospital | Laboratory Services Provided to Non-patients | Non-Payment / Zero Claims |
| 141 | Hospital | Laboratory Services Provided to Non-patients | Admit through Discharge Claim |
| 142 | Hospital | Laboratory Services Provided to Non-patients | Interim - First Claim |
| 143 | Hospital | Laboratory Services Provided to Non-patients | Interim - Continuing Claim |
| 144 | Hospital | Laboratory Services Provided to Non-patients | Interim - Last Claim |
| 145 | Hospital | Laboratory Services Provided to Non-patients | Late Charge(s) Only Claim |
| 146 | Hospital | Laboratory Services Provided to Non-patients | Reserved for National Assignment |
| 147 | Hospital | Laboratory Services Provided to Non-patients | Replacement of Prior Claim |
| 148 | Hospital | Laboratory Services Provided to Non-patients | Void/Cancel of Prior Claim |
| 149 | Hospital | Laboratory Services Provided to Non-patients | Final Claim for a Home Health PPS Episode |
| 14A | Hospital | Laboratory Services Provided to Non-patients | Admission/Election Notice |
| 14B | Hospital | Laboratory Services Provided to Non-patients | Termination/Revocation Notice; eff 1/2019 |
| 14C | Hospital | Laboratory Services Provided to Non-patients | Hospice Change of Provider Notice |
| 14D | Hospital | Laboratory Services Provided to Non-patients | Cancellation Of Election Notice; eff 1/2019 |
| 14E | Hospital | Laboratory Services Provided to Non-patients | Hospice Change of Ownership |
| 14F | Hospital | Laboratory Services Provided to Non-patients | Beneficiary Initiated Adjustment Claim |
| 14G | Hospital | Laboratory Services Provided to Non-patients | CWF Initiated Adjustment Claim |
| 14H | Hospital | Laboratory Services Provided to Non-patients | CMS Initiated Adjustment Claim |
| 14I | Hospital | Laboratory Services Provided to Non-patients | Intermediary Adjustment Claim (Other than QIO or Provider) |
| 14J | Hospital | Laboratory Services Provided to Non-patients | Initiated Adjustment Claim - Other |
| 14K | Hospital | Laboratory Services Provided to Non-patients | OIG Initiated Adjustment Claim |
| 14L | Hospital | Laboratory Services Provided to Non-patients | Reserved for National Assignment |
| 14M | Hospital | Laboratory Services Provided to Non-patients | MSP Initiated Adjustment Claim |
| 14N | Hospital | Laboratory Services Provided to Non-patients | Reserved for National Assignment |
| 14O | Hospital | Laboratory Services Provided to Non-patients | Nonpayment / Zero Claims |
| 14P | Hospital | Laboratory Services Provided to Non-patients | QIO Adjustment Claims |
| 14Q | Hospital | Laboratory Services Provided to Non-patients | Claim Submitted For Reconsideration/Reopening Outside Of Timely Limits |
| 14R | Hospital | Laboratory Services Provided to Non-patients | Reserved for National Assignment |
| 14S | Hospital | Laboratory Services Provided to Non-patients | Reserved for National Assignment |
| 14T | Hospital | Laboratory Services Provided to Non-patients | Reserved for National Assignment |
| 14U | Hospital | Laboratory Services Provided to Non-patients | Reserved for National Assignment |
| 14V | Hospital | Laboratory Services Provided to Non-patients | Reserved for National Assignment |
| 14W | Hospital | Laboratory Services Provided to Non-patients | Reserved for National Assignment |
| 14X | Hospital | Laboratory Services Provided to Non-patients | Void/Cancel a Prior Abbreviated Encounter Submission |
| 14Y | Hospital | Laboratory Services Provided to Non-patients | Replacement of Prior Abbreviated Encounter Submission |
| 14Z | Hospital | Laboratory Services Provided to Non-patients | New Abbreviated Encounter Submission |
| 180 | Hospital | Swing Beds | Non-Payment / Zero Claims |
| 181 | Hospital | Swing Beds | Admit through Discharge Claim |
| 182 | Hospital | Swing Beds | Interim - First Claim |
| 183 | Hospital | Swing Beds | Interim - Continuing Claim |
| 184 | Hospital | Swing Beds | Interim - Last Claim |
| 185 | Hospital | Swing Beds | Late Charge(s) Only Claim |
| 186 | Hospital | Swing Beds | Reserved for National Assignment |
| 187 | Hospital | Swing Beds | Replacement of Prior Claim |
| 188 | Hospital | Swing Beds | Void/Cancel of Prior Claim |
| 189 | Hospital | Swing Beds | Final Claim for a Home Health PPS Episode |
| 18A | Hospital | Swing Beds | Admission/Election Notice |
| 18B | Hospital | Swing Beds | Termination/Revocation Notice; eff 1/2019 |
| 18C | Hospital | Swing Beds | Hospice Change of Provider Notice |
| 18D | Hospital | Swing Beds | Cancellation Of Election Notice; eff 1/2019 |
| 18E | Hospital | Swing Beds | Hospice Change of Ownership |
| 18F | Hospital | Swing Beds | Beneficiary Initiated Adjustment Claim |
| 18G | Hospital | Swing Beds | CWF Initiated Adjustment Claim |
| 18H | Hospital | Swing Beds | CMS Initiated Adjustment Claim |
| 18I | Hospital | Swing Beds | Intermediary Adjustment Claim (Other than QIO or Provider) |
| 18J | Hospital | Swing Beds | Initiated Adjustment Claim - Other |
| 18K | Hospital | Swing Beds | OIG Initiated Adjustment Claim |
| 18L | Hospital | Swing Beds | Reserved for National Assignment |
| 18M | Hospital | Swing Beds | MSP Initiated Adjustment Claim |
| 18N | Hospital | Swing Beds | Reserved for National Assignment |
| 18O | Hospital | Swing Beds | Nonpayment / Zero Claims |
| 18P | Hospital | Swing Beds | QIO Adjustment Claims |
| 18Q | Hospital | Swing Beds | Claim Submitted For Reconsideration/Reopening Outside Of Timely Limits |
| 18R | Hospital | Swing Beds | Reserved for National Assignment |
| 18S | Hospital | Swing Beds | Reserved for National Assignment |
| 18T | Hospital | Swing Beds | Reserved for National Assignment |
| 18U | Hospital | Swing Beds | Reserved for National Assignment |
| 18V | Hospital | Swing Beds | Reserved for National Assignment |
| 18W | Hospital | Swing Beds | Reserved for National Assignment |
| 18X | Hospital | Swing Beds | Void/Cancel a Prior Abbreviated Encounter Submission |
| 18Y | Hospital | Swing Beds | Replacement of Prior Abbreviated Encounter Submission |
| 18Z | Hospital | Swing Beds | New Abbreviated Encounter Submission |
| 210 | Skilled Nursing | Inpatient (Including Medicare Part A) | Non-Payment / Zero Claims |
| 211 | Skilled Nursing | Inpatient (Including Medicare Part A) | Admit through Discharge Claim |
| 212 | Skilled Nursing | Inpatient (Including Medicare Part A) | Interim - First Claim |
| 213 | Skilled Nursing | Inpatient (Including Medicare Part A) | Interim - Continuing Claim |
| 214 | Skilled Nursing | Inpatient (Including Medicare Part A) | Interim - Last Claim |
| 215 | Skilled Nursing | Inpatient (Including Medicare Part A) | Late Charge(s) Only Claim |
| 216 | Skilled Nursing | Inpatient (Including Medicare Part A) | Reserved for National Assignment |
| 217 | Skilled Nursing | Inpatient (Including Medicare Part A) | Replacement of Prior Claim |
| 218 | Skilled Nursing | Inpatient (Including Medicare Part A) | Void/Cancel of Prior Claim |
| 219 | Skilled Nursing | Inpatient (Including Medicare Part A) | Final Claim for a Home Health PPS Episode |
| 21A | Skilled Nursing | Inpatient (Including Medicare Part A) | Admission/Election Notice |
| 21B | Skilled Nursing | Inpatient (Including Medicare Part A) | Termination/Revocation Notice; eff 1/2019 |
| 21C | Skilled Nursing | Inpatient (Including Medicare Part A) | Hospice Change of Provider Notice |
| 21D | Skilled Nursing | Inpatient (Including Medicare Part A) | Cancellation Of Election Notice; eff 1/2019 |
| 21E | Skilled Nursing | Inpatient (Including Medicare Part A) | Hospice Change of Ownership |
| 21F | Skilled Nursing | Inpatient (Including Medicare Part A) | Beneficiary Initiated Adjustment Claim |
| 21G | Skilled Nursing | Inpatient (Including Medicare Part A) | CWF Initiated Adjustment Claim |
| 21H | Skilled Nursing | Inpatient (Including Medicare Part A) | CMS Initiated Adjustment Claim |
| 21I | Skilled Nursing | Inpatient (Including Medicare Part A) | Intermediary Adjustment Claim (Other than QIO or Provider) |
| 21J | Skilled Nursing | Inpatient (Including Medicare Part A) | Initiated Adjustment Claim - Other |
| 21K | Skilled Nursing | Inpatient (Including Medicare Part A) | OIG Initiated Adjustment Claim |
| 21L | Skilled Nursing | Inpatient (Including Medicare Part A) | Reserved for National Assignment |
| 21M | Skilled Nursing | Inpatient (Including Medicare Part A) | MSP Initiated Adjustment Claim |
| 21N | Skilled Nursing | Inpatient (Including Medicare Part A) | Reserved for National Assignment |
| 21O | Skilled Nursing | Inpatient (Including Medicare Part A) | Nonpayment / Zero Claims |
| 21P | Skilled Nursing | Inpatient (Including Medicare Part A) | QIO Adjustment Claims |
| 21Q | Skilled Nursing | Inpatient (Including Medicare Part A) | Claim Submitted For Reconsideration/Reopening Outside Of Timely Limits |
| 21R | Skilled Nursing | Inpatient (Including Medicare Part A) | Reserved for National Assignment |
| 21S | Skilled Nursing | Inpatient (Including Medicare Part A) | Reserved for National Assignment |
| 21T | Skilled Nursing | Inpatient (Including Medicare Part A) | Reserved for National Assignment |
| 21U | Skilled Nursing | Inpatient (Including Medicare Part A) | Reserved for National Assignment |
| 21V | Skilled Nursing | Inpatient (Including Medicare Part A) | Reserved for National Assignment |
| 21W | Skilled Nursing | Inpatient (Including Medicare Part A) | Reserved for National Assignment |
| 21X | Skilled Nursing | Inpatient (Including Medicare Part A) | Void/Cancel a Prior Abbreviated Encounter Submission |
| 21Y | Skilled Nursing | Inpatient (Including Medicare Part A) | Replacement of Prior Abbreviated Encounter Submission |
| 21Z | Skilled Nursing | Inpatient (Including Medicare Part A) | New Abbreviated Encounter Submission |
| 220 | Skilled Nursing | Inpatient (Medicare Part B only) | Non-Payment / Zero Claims |
| 221 | Skilled Nursing | Inpatient (Medicare Part B only) | Admit through Discharge Claim |
| 222 | Skilled Nursing | Inpatient (Medicare Part B only) | Interim - First Claim |
| 223 | Skilled Nursing | Inpatient (Medicare Part B only) | Interim - Continuing Claim |
| 224 | Skilled Nursing | Inpatient (Medicare Part B only) | Interim - Last Claim |
| 225 | Skilled Nursing | Inpatient (Medicare Part B only) | Late Charge(s) Only Claim |
| 226 | Skilled Nursing | Inpatient (Medicare Part B only) | Reserved for National Assignment |
| 227 | Skilled Nursing | Inpatient (Medicare Part B only) | Replacement of Prior Claim |
| 228 | Skilled Nursing | Inpatient (Medicare Part B only) | Void/Cancel of Prior Claim |
| 229 | Skilled Nursing | Inpatient (Medicare Part B only) | Final Claim for a Home Health PPS Episode |
| 22A | Skilled Nursing | Inpatient (Medicare Part B only) | Admission/Election Notice |
| 22B | Skilled Nursing | Inpatient (Medicare Part B only) | Termination/Revocation Notice; eff 1/2019 |
| 22C | Skilled Nursing | Inpatient (Medicare Part B only) | Hospice Change of Provider Notice |
| 22D | Skilled Nursing | Inpatient (Medicare Part B only) | Cancellation Of Election Notice; eff 1/2019 |
| 22E | Skilled Nursing | Inpatient (Medicare Part B only) | Hospice Change of Ownership |
| 22F | Skilled Nursing | Inpatient (Medicare Part B only) | Beneficiary Initiated Adjustment Claim |
| 22G | Skilled Nursing | Inpatient (Medicare Part B only) | CWF Initiated Adjustment Claim |
| 22H | Skilled Nursing | Inpatient (Medicare Part B only) | CMS Initiated Adjustment Claim |
| 22I | Skilled Nursing | Inpatient (Medicare Part B only) | Intermediary Adjustment Claim (Other than QIO or Provider) |
| 22J | Skilled Nursing | Inpatient (Medicare Part B only) | Initiated Adjustment Claim - Other |
| 22K | Skilled Nursing | Inpatient (Medicare Part B only) | OIG Initiated Adjustment Claim |
| 22L | Skilled Nursing | Inpatient (Medicare Part B only) | Reserved for National Assignment |
| 22M | Skilled Nursing | Inpatient (Medicare Part B only) | MSP Initiated Adjustment Claim |
| 22N | Skilled Nursing | Inpatient (Medicare Part B only) | Reserved for National Assignment |
| 22O | Skilled Nursing | Inpatient (Medicare Part B only) | Nonpayment / Zero Claims |
| 22P | Skilled Nursing | Inpatient (Medicare Part B only) | QIO Adjustment Claims |
| 22Q | Skilled Nursing | Inpatient (Medicare Part B only) | Claim Submitted For Reconsideration/Reopening Outside Of Timely Limits |
| 22R | Skilled Nursing | Inpatient (Medicare Part B only) | Reserved for National Assignment |
| 22S | Skilled Nursing | Inpatient (Medicare Part B only) | Reserved for National Assignment |
| 22T | Skilled Nursing | Inpatient (Medicare Part B only) | Reserved for National Assignment |
| 22U | Skilled Nursing | Inpatient (Medicare Part B only) | Reserved for National Assignment |
| 22V | Skilled Nursing | Inpatient (Medicare Part B only) | Reserved for National Assignment |
| 22W | Skilled Nursing | Inpatient (Medicare Part B only) | Reserved for National Assignment |
| 22X | Skilled Nursing | Inpatient (Medicare Part B only) | Void/Cancel a Prior Abbreviated Encounter Submission |
| 22Y | Skilled Nursing | Inpatient (Medicare Part B only) | Replacement of Prior Abbreviated Encounter Submission |
| 22Z | Skilled Nursing | Inpatient (Medicare Part B only) | New Abbreviated Encounter Submission |
| 230 | Skilled Nursing | Outpatient | Non-Payment / Zero Claims |
| 231 | Skilled Nursing | Outpatient | Admit through Discharge Claim |
| 232 | Skilled Nursing | Outpatient | Interim - First Claim |
| 233 | Skilled Nursing | Outpatient | Interim - Continuing Claim |
| 234 | Skilled Nursing | Outpatient | Interim - Last Claim |
| 235 | Skilled Nursing | Outpatient | Late Charge(s) Only Claim |
| 236 | Skilled Nursing | Outpatient | Reserved for National Assignment |
| 237 | Skilled Nursing | Outpatient | Replacement of Prior Claim |
| 238 | Skilled Nursing | Outpatient | Void/Cancel of Prior Claim |
| 239 | Skilled Nursing | Outpatient | Final Claim for a Home Health PPS Episode |
| 23A | Skilled Nursing | Outpatient | Admission/Election Notice |
| 23B | Skilled Nursing | Outpatient | Termination/Revocation Notice; eff 1/2019 |
| 23C | Skilled Nursing | Outpatient | Hospice Change of Provider Notice |
This is the start of the file's text. The full file is on GovTribe.
File details come from the government source that posted it. Updated .