Schedule I - Medical Claim Layout.xlsx

21 KB Posted

Attached to
HMO Services for MPSERS
Solicitation number
RFP 171 190000002803 2
Issued by
Michigan

About this file

Written by GovTribe AI ·

This is a technical data layout specification document for medical claim submissions to a state or local health plan. The document defines the fixed-record format structure for electronic submission of medical claims data, including both detail-level claim records and trailer records containing summary information. The layout accommodates facility claims, professional claims, and dental claims through client-specific coding fields, with support for comprehensive clinical data including up to 25 diagnosis codes, 25 Present on Admission indicators, and up to 25 surgical procedure codes. The specification utilizes industry-standard code sets including UB-04 codes for facility claims, CPT/HCPCS codes for professional services, and ICD-9 or ICD-10 codes for diagnoses and procedures, with flexibility to accommodate both coding standards through an ICD Version qualifier field.

The data layout requires submission of detailed claim payment information at the service or detail level, including allowed amounts, submitted charges, net payments, patient cost-sharing amounts (deductibles, copayments, and coinsurance), and third-party coordination of benefits adjustments. Records must include member identification, provider information (including NPI numbers and taxonomy codes), dates of service, and place of service indicators. The specification establishes a fixed-record format with the detail record extending to position 1000 and includes a trailer record that summarizes the submission period (monthly data with specified start and end dates), total record count, and total net payments. Additional fields are designated for client-specific customization, and the specification notes that certain field values require identification in accompanying data dictionaries to be provided by the data supplier.

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Detail Layout

Field NumberField NameStartEndLengthTypeData Element DescriptionData Dictionary NeededData Supplier Instructions/Notes
Fixed-Record Length
1Adjustment Type Code111CharacterClient-specific code for the claim adjustment typeYesAdjustment Type values will be identified in the Data Dictionary.
2Admit Source Code UB221NumericThe UB standard code for the admission source.
3Admit Type Code UB331CharacterThe UB standard code for the type of admission, indicating the priority of the admission or visit.
4Allowed Amount41310NumericThe maximum amount allowed by the plan for payment.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.

5Bill Type Code UB14174CharacterThe UB-04 standard code for the billing type, indicating type of facility, bill classification, and frequency of bill. Length expanded from 3 to 4 for future use.YesBill Type values will be identified in the Data Dictionary.
6Capitated Service Indicator18181CharacterAn indicator that this service (encounter record) was capitatedApplicable field values are "Y" for Capitated services and "N" for non-cap services.
7Charge Submitted192810NumericThe submitted or billed charge amountFormat 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.

8Claim ID294315CharacterThe client-specific identifier of the claim.
9Claim Type Code44452CharacterClient-specific code for the type of claim to differentiate facility, professional and dental for example.YesClaim Type Codes will be identified in the Data Dictionary.
10Co-Insurance465510NumericThe coinsurance paid by the subscriber as specified in the plan provision.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.

11 Copayment 56 65 10 Numeric The copayment paid by the subscriber as specified in the plan provision. 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.

12 Date of Birth 66 75 10 Date The birth date of the person. MM/DD/CCYY format The four-digit year is required for date of birth. The century cannot be accurately assigned based on a two-digit year.

13Date of First Service768510DateThe date of the first service reported on the claim or authorization record.MM/DD/CCYY format
14Date of Last Service869510DateThe date of the last service reported on the claim or authorization record.MM/DD/CCYY format
15Date of Service Facility Detail9610510DateThe date of service for the facility detail record.MM/DD/CCYY format
16Date Paid10611510DateThe date the claim or data record was paid.MM/DD/CCYY format

This is the check date.

17Days1161216NumericThe number of inpatient days for the facility claim.
18Deductible12213110NumericThe amount paid by the subscriber through the deductible arrangement of the plan.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.

19Diagnosis Code Principal1321398CharacterThe first or principal diagnosis code for a service, claim or lab result. Length expanded from 5 to 8 for future use.No decimal point.
20Diagnosis Code 21401478CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
21Diagnosis Code 31481558CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
22Diagnosis Code 41561638CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
23Diagnosis Code 51641718CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
24Diagnosis Code 61721798CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
25Diagnosis Code 71801878CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
26Diagnosis Code 81881958CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
27Diagnosis Code 91962038CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
28Diagnosis Code 102042118CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
29Diagnosis Code 112122198CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
30Diagnosis Code 122202278CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
31Diagnosis Code 132282358CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
32Diagnosis Code 142362438CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
33Diagnosis Code 152442518CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
34Diagnosis Code 162522598CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
35Diagnosis Code 172602678CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
36Diagnosis Code 182682758CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
37Diagnosis Code 192762838CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
38Diagnosis Code 202842918CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
39Diagnosis Code 212922998CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
40Diagnosis Code 223003078CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
41Diagnosis Code 233083158CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
42Diagnosis Code 243163238CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
43Diagnosis Code 253243318CharacterA secondary diagnosis code for the claim. Length expanded from 5 to 8 for future use.No decimal point.
44Discharge Status Code UB3323332CharacterThe UB-04 standard patient status code, indicating disposition at the time of billing.
45Family ID3343429CharacterThe unique identifier for the Subscriber (contract holder) and their associated dependents.If Member ID includes a suffix differentiating family members (see Member ID field), it may not be necessary to also provide Family ID.
46Member ID34335715CharacterUnique member identifier.Often this identifier contains a suffix differentiating family members and the beginning is identical across families. If this is a unique number without a common portion for a family, family identifier should be included in addition to Member ID.
47Gender Code3583581CharacterThe member's gender code.M or "F"
48Line Number3593602NumericThe detail line number for the service on the claim
49Net Payment36137010NumericThe actual check amount for the recordFormat 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.

50Network Paid Indicator3713711CharacterAn indicator of whether the claim was paid at in-network or out-of-network levelY or "N"
51Network Provider Indicator3723721CharacterIndicates if the servicing provider participates in the network to which the patient belongsY or "N"
52Ordering Provider ID37338513CharacterThe ID number of the provider who referred the patient or ordered the test or procedure.The ID should be the plan specific identifier.
53Ordering Provider Name38641530CharacterThe Name of the provider who referred the patient or ordered the test or procedure.
54Ordering Provider Zip Code4164205CharacterThe zip code of the provider who referred the patient or ordered the test or procedure.
55PCP Responsibility Indicator4214211CharacterAn indicator signifying that the PCP is the physician considered responsible or accountable for this claim.
56Place of Service Code4224232CharacterClient-specific code for the place of service.YesPlace of Service values will be identified in the Data Dictionary.
57Procedure Code4244307CharacterThe procedure code for the service record. Length expanded from 5 to 7 for future use.CPT/HCPCS codes.
58Procedure Code UB Surg 14314377CharacterThe primary surgical procedure code (1) on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
59Procedure Code UB Surg 24384447CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
60Procedure Code UB Surg 34454517CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
61Procedure Code UB Surg 44524587CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
62Procedure Code UB Surg 54594657CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
63Procedure Code UB Surg 64664727CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
64Procedure Code UB Surg 74734797CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
65Procedure Code UB Surg 84804867CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
66Procedure Code UB Surg 94874937CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
67Procedure Code UB Surg 104945007CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
68Procedure Code UB Surg 115015077CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
69Procedure Code UB Surg 125085147CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
70Procedure Code UB Surg 135155217CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
71Procedure Code UB Surg 145225287CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
72Procedure Code UB Surg 155295357CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
73Procedure Code UB Surg 165365427CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
74Procedure Code UB Surg 175435497CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
75Procedure Code UB Surg 185505567CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
76Procedure Code UB Surg 195575637CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
77Procedure Code UB Surg 205645707CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
78Procedure Code UB Surg 215715777CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
79Procedure Code UB Surg 225785847CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
80Procedure Code UB Surg 235855917CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
81Procedure Code UB Surg 245925987CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
82Procedure Code UB Surg 255996057CharacterThe secondary surgical procedure code on the facility claim. Length expanded from 5 to 7 for future use.ICD-9 or 10 Surgical procedure codes.
83Procedure Modifier Code 16066072CharacterThe 2-character code of the first procedure code modifier on the professional claim
84Procedure Modifier Code 26086092CharacterThe 2-character code of an additional procedure code modifier on the professional claim
85Procedure Modifier Code 36106112CharacterThe 2-character code of an additional procedure code modifier on the professional claim
86Procedure Modifier Code 46126132CharacterThe 2-character code of an additional procedure code modifier on the professional claim
87Provider ID61462613CharacterThe unique identifier for the provider of service.The Provider ID should be specific to the individual provider and not a group.
88Provider Name62765630CharacterThe description or name corresponding to the Provider ID.The Provider Name should be specific to the provider and not a group name.
89TIN6576659CharacterThe federal tax ID of the provider.Federal Tax ID is required to assign the standard hospital identifier (UNIHOSP).
90Provider Type Code Claim6666683CharacterClient-specific code for the provider type on the claim recordYesProvider Type codes are further defined in the Data Dictionary
91Provider Taxonomy Code66967810CharacterThe Healthcare Provider Taxonomy code specific to the professional servicing provider associated with the claim. (Note: This is not a standard field in the database, but is used in the mapping of Provider Type Code Claim to standardized values.)The National Uniform Claim Committee standard taxonomy code for the provider.
92Provider Zip Code6796835CharacterThe 5-digit zip code corresponding to the Provider IDProvider Location zip code
93Referral Indicator6846841CharacterIndicates if the service resulted from a referral.Applicable field values are "Y" for referred services and "N" for non-referred services.
94Referral Type Code6856851CharacterClient-specific code of the type of referral.YesReferral Type values will be identified in the Data Dictionary.
95Revenue Code UB6866894CharacterThe CMS standard revenue code from the facility claimThis field must be at the service/detail level.
96Risk Withhold Amount69069910NumericThe amount of the net payment retained or withheld from the servicing provider and placed in a risk-sharing pool for future distribution.Format 9(8)v99 (2 - digit, implied decimal)
97Third Party Amount70070910NumericThe amount saved due to integration of third party liability (Coordination of Benefits) by all third party payers (including Medicare).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.

98Units of Service7107134NumericClient-specific quantity of services or units
99Group ID7147218CharacterClient-specific code for the group number.YesGroup ID values will be identified in the Data Dictionary.

Additional fields may be added to the layout if there is more than one component of the account structure.

100Provider NPI Number72273110CharacterThe National Provider ID number for the provider.
101DRG MS Payment Code7327343NumericThe Diagnosis Related Group (MS-DRG) code under which the claim was paid.
102Present on Admission Principal7357351CharacterThe 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 admissionSee NotesIf standard values are not used, define in the Data Dictionary.
103Present on Admission 027367361CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
104Present on Admission 037377371CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
105Present on Admission 047387381CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
106Present on Admission 057397391CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
107Present on Admission 067407401CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
108Present on Admission 077417411CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
109Present on Admission 087427421CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
110Present on Admission 097437431CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
111Present on Admission 107447441CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
112Present on Admission 117457451CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
113Present on Admission 127467461CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
114Present on Admission 137477471CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
115Present on Admission 147487481CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
116Present on Admission 157497491CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
117Present on Admission 167507501CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
118Present on Admission 177517511CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
119Present on Admission 187527521CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
120Present on Admission 197537531CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
121Present on Admission 207547541CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
122Present on Admission 217557551CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
123Present on Admission 227567561CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
124Present on Admission 237577571CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
125Present on Admission 247587581CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
126Present on Admission 257597591CharacterA secondary POA code for the facility claim. Indicates whether the secondary diagnosis was present on admission. Standard Values listed in principal field.See NotesIf standard values are not used, define in the Data Dictionary.
127ICD Version7607601CharacterThe ICD version or qualifier code that identifies either ICD-9 (9) or ICD-10 (0) diagnosis and procedure codes on the facility claim.See NotesIf 0 and 9 not used, values defined in the Data Dictionary.
128Tax Amount76177010NumericThe amount charged by some states per drug claim.Format 9(8)v99 (2 – digit, implied decimal)
129Tax Type Code7717711CharacterHealth Plan specific code identifying the state or type of tax.YesTax Type Code values will be identified in the Data Dictionary.
130NDC Number Code77278211CharacterThe FDA (Food and Drug Administration) registered number for the drug, as reported on the prescription drug claims. Please include for any drugs dispensed in the medical setting.Please leave out the dashes.
131CUSTOM FIELD # (if applicable)7837831TBDAdditional Rows/Fields to be added as Custom FieldsTBDTBD
132Filler784999216CharacterReserved for future useFill with blanks
133Record Type100010001CharacterRecord type identifierHard Code to "D"
End of Layout - Do not remove this row - All field additions to be inserted above the Filler row

Trailer Layout

Field NumberField NameStartEndLengthTypeData Element DescriptionData Supplier Instructions/Notes
Fixed-Record Length
1Data Start Date11010DateData Start DateMM/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.

3Record Count213010NumericNumber of Records on FileThe count of records provided in the data including the Trailer Record.
4Total Net Payments314414NumericTotal net payments on the fileThe sum of net payments provided in the file
5Filler45999955CharacterReserved for future useFill with Blanks
6Record Type100010001CharacterRecord Type IdentifierHard Code ‘T’
End of Layout - Do not remove this row - All field additions to be inserted above the Filler row

File details come from the government source that posted it. Updated .