Medicare Program Integrity Manual (Pub. 100-08), § 36
Overview of the CERT Process
36 - Overview of the CERT Process
(Rev. 726, Issued: 06-16-17, Effective: 10-01-17, Implementation: 01-02-18 - For VMS and
MCS for Business Requirements 11 through 22 and 22.1; 10-02-17 - For FISS)
The CERT process begins at the MAC processing site where claims that have entered the
standard claims processing system on a given day are extracted to create a Claims Universe File.
This file is transmitted each day to the CERT Operations Center, where it is routed through a
random sampling process. Claims that are selected as part of the sample are downloaded to the
Sampled Claims Database. This database holds all sampled claims from all MACs. Periodically,
sampled claim key data are extracted from the Sampled Claims Database to create a Sampled
Claims Transaction File. This file is transmitted back to the MAC and matched to the MAC’s
claims history and provider files. A Sampled Claims Resolution File, a Claims History Replica
File, and a Provider Address file are created automatically by the MAC and transmitted to the
CERT Operations Center. They are used to update the Sampled Claims database with claim
resolutions and provider addresses; the Claims History Replica records are added to a database
for future analysis.
Software applications at the CERT Operations Center are used to review, track, and report on the
sampled claims. Periodically, the CERT contractor requests the MAC to provide information
supporting decisions on denied/reduced claims or claim line items and claims that have been
subject to their medical review processes. The CERT contractor also sends reports identifying
incorrect claim payment to the appropriate MAC for follow-up. MACs then report on their
agreement and disagreement with CERT decisions, status of overpayment collections, and status
of claims that go through the appeals process.
Exhibit 36.1 - CERT Formats for A/B MAC (A) MACS and Shared Systems
(Rev. 10228; Issued: 07-27-20; Effective: 08-27-20; Implementation: 08-27-20)
Claims Universe File
Claims Universe Header Record (one record per file)
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
‘1’
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Universe Date
X(8)
9
16
Spaces
DATA ELEMENT DETAIL
Data Element: Contractor ID
Definition:
Contractor’s CMS assigned number
Validation:
Must be a valid CMS contractor ID
Remarks:
N/A
Requirement:
Required
NOTE:
For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single
processing environment, the Contractor ID will reflect the roll-up Contractor
ID specified by CMS
Data Element: Record Type
Definition:
Code indicating type of record
Validation:
N/A
Remarks:
1 = Header
record Requirement: Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Universe file
Validation:
Claim Universe files prior to 10/1/2007 did not contain this field.
Codes:
B = Record Format as of 10/1/2007
C = Record Format as of 10/1/2017
Remarks:
N/A
Requirement: Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor included in the file
Validation:
Must be ‘A’ or ‘R’
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should
be ‘R’.
All others will be contractor type ‘A’.
Remarks:
A = A/B MAC (A) only
R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)
Requirement: Required
Data Element: Universe Date
Definition:
Date the universe of claims entered the shared system
Validation:
Must be a valid date not equal to a universe date sent on any previous claims
universe file
Remarks:
Format is CCYYMMDD. May use shared system batch processing date;
however, the Universe Date must not equal the universe date on any previous
claims universe file.
Requirement: Required
Claims Universe File
Claims Universe Claim Record
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
“2”
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Internal Control Number
X(23)
9
31
Spaces
Beneficiary HICN
X(12)
32
43
Spaces
Billing Provider Number
X(9)
44
52
Spaces
Billing Provider NPI
X(10)
53
62
Spaces
Type of Bill
X(3)
63
65
Spaces
Claim From Date
X (8)
66
73
Spaces
Claim Through Date
X (8)
74
81
Spaces
Condition Code 1
X (2)
82
83
Spaces
Condition Code 2
X (2)
84
85
Spaces
Condition Code 3
X (2)
86
87
Spaces
Condition Code 4
X (2)
88
89
Spaces
Condition Code 5
X (2)
90
91
Spaces
Condition Code 6
X (2)
92
93
Spaces
Condition Code 7
X (2)
94
95
Spaces
Condition Code 8
X (2)
96
97
Spaces
Condition Code 9
X (2)
98
99
Spaces
Condition Code 10
X (2)
100
101
Spaces
Condition Code 11
X (2)
102
103
Spaces
Condition Code 12
X (2)
104
105
Spaces
Condition Code 13
X (2)
106
107
Spaces
Condition Code 14
X (2)
108
109
Spaces
Field Name
Picture
From
Thru
Initialization
Condition Code 15
X (2)
110
111
Spaces
Condition Code 16
X (2)
112
113
Spaces
Condition Code 17
X (2)
114
115
Spaces
Condition Code 18
X (2)
116
117
Spaces
Condition Code 19
X (2)
118
119
Spaces
Condition Code 20
X (2)
120
121
Spaces
Condition Code 21
X (2)
122
123
Spaces
Condition Code 22
X (2)
124
125
Spaces
Condition Code 23
X (2)
126
127
Spaces
Claim Demonstration Number
X(2)
128
129
Spaces
PPS Indicator Code
X(1)
130
130
Spaces
Claim State
X(2)
131
132
Spaces
Beneficiary State
X(2)
133
134
Spaces
Claim Total Charge Amount
9(8)V99
135
144
Zeroes
Beneficiary MBI
X(11)
145
155
Spaces
Hicn/MBI indicator
X(1)
156
156
Spaces
Filler
X(2)
157
158
Spaces
Revenue Code Count
9(3)
159
161
Zero
Claims Universe File
Claims Universe Revenue Code Group (Claim Line Items)
*The following group of fields occurs from 1 to 450 times (depending on Revenue Code
Count)
*From and Thru values relate to the 1st line item
DATA ELEMENT DETAIL
Claim (Header) Fields
Data Element: Contractor ID
Definition:
Contractor’s CMS assigned number
Validation:
Must be a valid CMS contractor ID
Remarks:
N/A
Requirement: Required
NOTE:
For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single
processing environment, the Contractor ID will reflect the roll-up Contractor
ID specified by CMS
Data Element: Record Type
Definition:
Code indicating type of record
Validation:
N/A
Remarks:
2 = claim
record Requirement:
Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Universe file
Validation:
Claim Universe files prior to 10/1/2007 did not contain this field.
Field Name
Picture
From
Thru
Initialization
Revenue Center Code
X(4)
162
165
Spaces
HCPCS
X(5)
166
170
Spaces
Revenue Center Total Charge
9(8)V99
171
180
Zeroes
Codes:
B = Record Format as of
10/1/2007 C = Record Format as
of 10/1/2017
Remarks:
N/A
Requirement: Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor included in the file
Validation:
Must be ‘A’ or ‘R’.
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should
be ‘R’.
All others will be contractor type ‘A’.
Data Element: Internal Control Number
Definition:
Number assigned by the shared system to uniquely identify the claim
Validation:
N/A
Remarks:
Do not include hyphens or spaces
Requirement: Required
Data Element: Beneficiary HICN
Definition:
Beneficiary’s Health Insurance Claim Number
Validation:
N/A
Remarks:
Do not include hyphens or spaces
Requirement:
Required
Data Element:
Billing Provider Number
Definition:
First nine characters of number assigned by Medicare to identify the
billing/pricing provider or supplier.
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element:
Billing Provider NPI
Definition:
NPI assigned to the Billing Provider.
Validation:
N/A
Remarks:
N/A.
Requirement: Required by May 23, 2007 for claims using HIPAA standard Transactions
Data Element: Type of Bill
Definition:
Three-digit alphanumeric code gives three specific pieces of information. The
first digit identifies the type of facility. The second classifies the type of care.
The third indicates the sequence of this bill in this particular episode of care.
It is referred to as “frequency” code.
Validation:
Must be a valid code as listed in Pub 100-4, Medicare Claims
Processing Manual, Chapter 25, Completing and Processing CMS-1450 Data
Set.
Remarks:
N/A
Requirement: Required
Data Element: Claim from Date
Definition:
The first day on the billing statement covering services rendered to the
beneficiary.
Validation:
Must be a valid date
Remarks:
Format is CCYYMMDD
Requirement:
Required
Data Element:
Claim through Date
Definition:
The last day on the billing statement covering services rendered to the
beneficiary.
Validation:
Must be a valid date
Remarks:
Format is CCYYMMDD
Requirement:
Required
Data Element: Condition Code 1
Condition Code 2
Condition Code 3
Condition Code 4
Condition Code 5
Condition Code 6
Condition Code 7
Condition Code 8
Condition Code 9
Condition Code 10
Condition Code 11
Condition Code 12
Condition Code 13
Condition Code 14
Condition Code 15
Condition Code 16
Condition Code 17
Condition Code 18
Condition Code 19
Condition Code 20
Condition Code 21
Condition Code 22
Condition Code 23
Definition:
The code that indicates a condition relating to an institutional
claim that may affect payer processing.
Validation:
Must be a valid code as defined in the Claims Processing Manual (Pub. 100-4)
chapter 25 (Completing and Processing CMS-1450 Data Set).
Remarks:
N/A
Requirement:
Required if claim has a condition code
Data Element: Claim Demonstration Identification Number
Definition:
The number assigned to identify a demonstration Project. This field is also
used to denote special processing (a.k.a. Special Processing Number, SPN).
Validation:
Must be a Valid Demo ID.
Remarks:
N/A
Requirement:
Required when available on claim
Data Element: PPS Indicator Code alias Claim PPS Indicator Code
Definition:
The code indicating whether (1) the claim is Prospective Payment System
(PPS), (2) Unknown or (0) not PPS.
Validation:
0 = Not PPS
1 = PPS
2 = Unknown
Remarks:
N/A
Requirement: Required
Data Element: Claim State
Definition:
2 character abbreviation identifying the state in which the service is furnished
Validation:
Must be a valid 2 digit state abbreviation as defined by the United States
Postal Service (USPS) or blank.
Remarks:
N/A
Requirement:
Required if on claim record
Data Element: Beneficiary State
Definition:
2 character abbreviation designating the state in which the beneficiary
resides.
Validation:
Must be a valid 2 digit state abbreviation as defined by the United States
Postal Service (USPS) or blank.
Remarks:
N/A
Requirement:
Required if on claim record
Data Element: Claim Total Charge Amount
Definition:
The total charges for all services included on the institutional claim.
Validation:
N/A
Remarks:
This field should contain the same amount as revenue center code 0001/total
charges.
Requirement:
Required
Data Element: Beneficiary MBI
Definition:
Beneficiary’s Medicare Beneficiary Identifier
Validation:
Comply with CMS Standards
• 11-character, fixed length alpha-numeric string
• Different, visibly distinguishable from HICN/RRB numbers
• Contain no more than 2 consecutive numbers
• Contain no more than 2 consecutive alphabetic characters
• Must limit the possibility of letters being interpreted as numbers (i.e.,
alphabetic characters [A…Z]; excluding S, L, O, I, B, Z)
• Must not contain lowercase letters
• Must not contain any special characters
Remarks:
Do not include hyphens or spaces
Requirement: Required, when available
Data Element: HICN/MBI Indicator
Definition:
Indicator that identifies if the provider submitted the claim with a HICN or MBI
Validation:
M = MBI submitted on the claim
H = HICN submitted on the claim
Remarks:
N/A
Requirement:
Required
Data Element: Revenue Code Count
Definition:
Number indicating number of revenue code lines on the claim. Include line 1
in the count.
Validation:
Must be a number 01 – 450
Remarks:
N/A
Requirement:
Required
Claim Line Item Fields
Data Element: Revenue Code
Definition:
Code assigned to each cost center for which a charge is billed.
Validation:
Must be a valid National Uniform Billing Committee (NUBC) approved code.
Remarks:
Include an entry for revenue code ‘0001’.
Requirement:
Required
Data Element: HCPCS Procedure Code or HIPPS Code
Definition:
The HCPCS/CPT-4 code that describes the service or Health Insurance PPS
(HIPPS) code.
Validation:
Must be a valid HCPCS/CPT-4 code.
Remarks:
Healthcare Common Procedure Coding System (HCPCS) is a collection of
codes that represent procedures, supplies, products and services which may
be provided to Medicare beneficiaries and to individuals enrolled in private
health insurance programs.
When revenue center code = '0022' (SNF PPS), '0023' (HH PPS), or '0024'
(IRF PPS); this field contains the Health Insurance PPS (HIPPS) code.
The HIPPS code for SNF PPS contains the rate code/assessment type that
identifies RUG-III group the beneficiary was classified into as of the RAI MDS
assessment reference date and (2) the type of assessment for payment
purposes.
The HIPPS code for Home Health PPS identifies (1) the three case-mix
dimensions of the HHRG system, clinical, functional and utilization, from
which a beneficiary is assigned to one of the 80 HHRG categories and (2) it
identifies whether or not the elements of the code were computed or derived.
The HHRGs, represented by the HIPPS coding, will be the basis of payment
for each episode.
The HIPPS code (CMG Code) for IRF PPS identifies the clinical characteristics
of the beneficiary. The HIPPS rate/CMG code (AXXYY - DXXYY) must contain
five digits. The first position of the code is an A, B, C, or 'D'. The HIPPS code
beginning with an 'A' in front of the CMG is defined as without co-morbidity.
The 'B' in front of the CMG is defined as with co-morbidity for Tier 1. The 'C' is
defined as co-morbidity for Tier 2 and 'D' is defined as co-morbidity for Tier 3.
The 'XX' in the HIPPS rate code is the Rehabilitation Impairment Code (RIC).
The 'YY' is the sequential number system within the RIC.
Requirement:
Required if present on bill
Data Element: Revenue Center Total Charge
Definition:
The total charges (covered and non-covered) for all accommodations and
services (related to the revenue code) for a billing period before reduction for
the deductible and coinsurance amounts and before an adjustment for the
cost of services provided
Validation:
N/A
Remarks:
N/A
Requirement:
Required
Claims Universe File
Claims Universe Trailer Record (one record per file)
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
‘3’
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Number of Claims
9(9)
9
17
Zeroes
DATA ELEMENT DETAIL
Data Element: Contractor ID
Definition:
Contractor’s CMS assigned number
Validation:
Must be a valid CMS contractor ID
Remarks:
N/A
Requirement:
Required
NOTE:
For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single
processing environment, the Contractor ID will reflect the roll-up Contractor
ID specified by CMS.
Data Element: Record Type
Definition:
Code indicating type of record
Validation:
N/A
Remarks:
3=Trailer Record
Requirement:
Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Universe file
Validation:
Claim Universe files prior to 10/1/2007 did not contain this field.
Codes:
B = Record Format as of 10/1/2007
C = Record Format as of 10/1/2017
Remarks:
N/A
Requirement:
Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor included in the file.
Validation:
Must be ‘A’ or ‘R’
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type
should be ‘R’.
All others will be contractor type ‘A’.
Remarks:
A = A/B MAC (A) only.
R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH).
Requirement:
Required
Data Element: Number of Claims
Definition:
Number of claim records on this file
Validation:
Must be equal to the number of claim records on the file.
Remarks:
Do not count header or trailer records
Requirement:
Required
Claims Transaction File
Claims Transaction Header Record (one record per file)
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
‘1’
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Transaction Date
X(8)
9
16
Spaces
DATA ELEMENT DETAIL
Data Element: Contractor ID
Definition:
Contractor’s CMS assigned number.
Validation:
Must be a valid CMS contractor ID.
Remarks:
N/A
Requirement:
Required
NOTE:
For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single
processing environment, the Contractor ID will reflect the roll-up Contractor ID
specified by CMS.
Data Element: Record Type
Definition:
Code indicating type of record
Validation:
N/A
Remarks:
1 = Header record
Requirement:
Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Transaction file.
Validation:
Claim Transaction files prior to 10/1/2007 did not contain this field.
Codes:
B = Record Format as of 10/1/2007
Remarks:
N/A
Requirement:
Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor included in the file
Validation:
Must be ‘A’ or ‘R’
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should
be ‘R’.
All others will be contractor type ‘A’.
Remarks:
A = A/B MAC (A) only
R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)
Requirement:
Required
Data Element: Transaction Date
Definition:
Date the Transaction file was created
Validation:
Must be a valid date not equal to a Transaction date sent on any previous
claims Transaction file.
Remarks:
Format is CCYYMMDD. May use shared system batch processing date.
Requirement:
Required
Sampled Claims Transaction File
Sampled Claims Transaction File Detail Record
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
‘2’
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Claim Control Number
X(23)
9
31
Spaces
Beneficiary HICN
X(12)
32
43
Spaces
DATA ELEMENT DETAIL
Data Element: Contractor ID
Definition:
Contractor’s CMS assigned number
Validation:
Must be a valid CMS contractor ID
Remarks:
N/A
Requirement:
Required
NOTE:
For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single
processing environment, the Contractor ID will reflect the roll-up Contractor
ID specified by CMS.
Data Element: Record Type
Definition:
Code indicating type of record
Validation:
N/A
Remarks:
2 = claim record
Requirement:
Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Universe file
Validation:
Claim Universe files prior to 10/1/2007 did not contain this field.
Codes:
B = Record Format as of 10/1/2007
Remarks:
N/A
Requirement: Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor included in the file
Validation:
Must be ‘A’ or ‘R’
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should
be ‘R’.
All others will be contractor type ‘A’.
Data Element: Claim Control Number
Definition:
Number assigned by the shared system to uniquely identify the claim
Validation:
N/A
Remarks:
Reflects the Claim Control Number selected from the Claim Universe file in the
sampling process.
Requirement: Required
Data Element: Beneficiary HICN
Definition:
Beneficiary’s Health Insurance Claim Number
Validation:
N/A
Remarks:
Reflects the Beneficiary HICN on the claim record selected from the Claim
Universe file in the sampling process.
Requirement:
Required
Claims Transaction File
Claims Transaction Trailer Record (one record per file)
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
‘3’
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Number of Claims
9(9)
9
17
Zeroes
DATA ELEMENT DETAIL
Data Element: Contractor ID
Definition:
Contractor’s CMS assigned number
Validation:
Must be a valid CMS contractor ID
Remarks:
N/A
Requirement:
Required
NOTE:
For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single
processing environment, the Contractor ID will reflect the roll-up Contractor
ID specified by CMS.
Data Element: Record Type
Definition:
Code indicating type of record
Validation:
N/A
Remarks:
1 = Header record
Requirement:
Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Universe file
Validation:
Claim Universe files prior to 10/1/2007 did not contain this field.
Codes:
B = Record Format as of 10/1/2007
Remarks:
N/A
Requirement:
Required
Data Element:
Contractor Type
Definition:
Type of Medicare Contractor included in the file
Validation:
Must be ‘A’ or ‘R’.
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should
be ‘R’.
All others will be contractor type ‘A’.
Remarks:
A = A/B MAC (A) only
R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)
Requirement:
Required
Data Element: Number of Claims
Definition:
Number of claim records on this file
Validation:
Must be equal to the number of claim records on the file
Remarks:
Do not count header or trailer records
Requirement:
Required
Claims Resolution File
Claims Resolution Header Record (one record per file)
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
‘1’
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Resolution Date
X(8)
9
16
Spaces
DATA ELEMENT DETAIL
Data Element: Contractor ID
Definition:
Contractor’s CMS assigned number
Validation:
Must be a valid CMS contractor ID
Remarks:
N/A
Requirement:
Required
NOTE:
For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single
processing environment, the Contractor ID will reflect the roll-up Contractor
ID specified by CMS
Data Element: Record Type
Definition:
Code indicating type of record
Validation:
N/A
Remarks:
1 = Header record
Requirement:
Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Resolution file
Validation:
Claim Resolution files prior to 10/1/2007 did not contain this field.
Codes:
B = Record Format as of 10/1/2007
C = Record Format as of 1/1/2010
D = Record Format as of 10/1/2012
E = Record Format as of 7/1/2016
F = Record Format as of 10/1/2017
Remarks:
N/A
Requirement:
Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor included in the file
Validation:
Must be ‘A’ or ‘R’
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should
be ‘R’.
All others will be contractor type ‘A’.
Remarks:
A = A/B MAC (A) only
R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)
Requirement: Required
Data Element: Resolution Date
Definition:
Date the Resolution Record was created.
Validation:
Must be a valid date not equal to a Resolution date sent on any previous
claims Resolution file
Remarks:
Format is CCYYMMDD. May use shared system batch processing date
Requirement:
Required
Sampled Claims Resolution File
Sampled Claims Resolution Claim Detailed Record
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
“2”
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Record Number
9(1)
9
9
Zero
Mode of Entry Indicator
X(1)
10
10
Space
Original Claim Control Number
X(23)
11
33
Spaces
Internal Control Number
X(23)
34
56
Spaces
Beneficiary HICN
X(12)
57
68
Spaces
Beneficiary Last Name
X(60)
69
128
Spaces
Beneficiary First Name
X(35)
129
163
Spaces
Beneficiary Middle Initial
X(1)
164
164
Spaces
Beneficiary Date of Birth
X(8)
165
172
Spaces
Beneficiary Gender
X(1)
173
173
Spaces
Billing Provider Number
X(9)
174
182
Spaces
Attending Physician UPIN
X(6)
183
188
Spaces
Claim Paid Amount
S9(8)V99 189
198
Zeroes
Claim ANSI Reason Code 1
X(8)
199
206
Spaces
Claim ANSI Reason Code 2
X(8)
207
214
Spaces
Claim ANSI Reason Code 3
X(8)
215
222
Spaces
Claim ANSI Reason Code 4
X(8)
223
230
Spaces
Claim ANSI Reason Code 5
X(8)
231
238
Spaces
Claim ANSI Reason Code 6
X(8)
239
246
Spaces
Claim ANSI Reason Code 7
X(8)
247
254
Spaces
Statement covers From Date
X(8)
255
262
Spaces
Statement covers Thru Date
X(8)
263
270
Spaces
Claim Entry Date
X(8)
271
278
Spaces
Claim Adjudicated Date
X(8)
279
286
Spaces
Condition Code 1
X(3)
287
289
Spaces
Condition Code 2
X(3)
290
292
Spaces
Condition Code 3
X(3)
293
295
Spaces
Condition Code 4
X(3)
296
298
Spaces
Condition Code 5
X(3)
299
301
Spaces
Condition Code 6
X(3)
302
304
Spaces
Condition Code 7
X(3)
305
307
Spaces
Condition Code 8
X(3)
308
310
Spaces
Condition Code 9
X(3)
311
313
Spaces
Condition Code 10
X(3)
314
316
Spaces
Condition Code 11
X(3)
317
319
Spaces
Condition Code 12
X(3)
320
322
Spaces
Condition Code 13
X(3)
323
325
Spaces
Field Name
Picture
From
Thru
Initialization
Condition Code 14
X(3)
326
328
Spaces
Condition Code 15
X(3)
329
331
Spaces
Condition Code 16
X(3)
332
334
Spaces
Condition Code 17
X(3)
335
337
Spaces
Condition Code 18
X(3)
338
340
Spaces
Condition Code 19
X(3)
341
343
Spaces
Condition Code 20
X(3)
344
346
Spaces
Condition Code 21
X(3)
347
349
Spaces
Condition Code 22
X(3)
350
352
Spaces
Condition Code 23
X(3)
353
355
Spaces
Condition Code 24
X(3)
356
358
Spaces
Condition Code 25
X(3)
359
361
Spaces
Condition Code 26
X(3)
362
364
Spaces
Condition Code 27
X(3)
365
367
Spaces
Condition Code 28
X(3)
368
370
Spaces
Condition Code 29
X(3)
371
373
Spaces
Condition Code 30
X(3)
374
376
Spaces
Type of Bill
X(3)
377
379
Spaces
Principal Diagnosis Code
X(7)
380
386
Spaces
Other Diagnosis Code 1
X(7)
387
393
Spaces
Other Diagnosis Code 2
X(7)
394
400
Spaces
Other Diagnosis Code 3
X(7)
401
407
Spaces
Other Diagnosis Code 4
X(7)
408
414
Spaces
Other Diagnosis Code 5
X(7)
415
421
Spaces
Other Diagnosis Code 6
X(7)
422
428
Spaces
Other Diagnosis Code 7
X(7)
429
435
Spaces
Other Diagnosis Code 8
X(7)
436
442
Spaces
Other Diagnosis Code 9
X(7)
443
449
Spaces
Other Diagnosis Code 10
X(7)
450
456
Spaces
Other Diagnosis Code 11
X(7)
457
463
Spaces
Other Diagnosis Code 12
X(7)
464
470
Spaces
Other Diagnosis Code 13
X(7)
471
477
Spaces
Other Diagnosis Code 14
X(7)
478
484
Spaces
Other Diagnosis Code 15
X(7)
485
491
Spaces
Other Diagnosis Code 16
X(7)
492
498
Spaces
Other Diagnosis Code 17
X(7)
499
505
Spaces
Other Diagnosis Code 18
X(7)
506
512
Spaces
Other Diagnosis Code 19
X(7)
513
519
Spaces
Other Diagnosis Code 20
X(7)
520
526
Spaces
Other Diagnosis Code 21
X(7)
527
533
Spaces
Other Diagnosis Code 22
X(7)
534
540
Spaces
Other Diagnosis Code 23
X(7)
541
547
Spaces
Other Diagnosis Code 24
X(7)
548
554
Spaces
Principal Diagnosis Code Version
Indicator Code
X(1)
555
555
Spaces
Other Diagnosis Code 1 Version
Indicator Code
X(1)
556
556
Spaces
Other Diagnosis Code 2 Version
Indicator Code
X(1)
557
557
Spaces
Field Name
Picture
From
Thru
Initialization
Other Diagnosis Code 3 Version
Indicator Code
X(1)
558
558
Spaces
Other Diagnosis Code 4 Version
Indicator Code
X(1)
559
559
Spaces
Other Diagnosis Code 5 Version
Indicator Code
X(1)
560
560
Spaces
Other Diagnosis Code 6 Version
Indicator Code
X(1)
561
561
Spaces
Other Diagnosis Code 7 Version
Indicator Code
X(1)
562
562
Spaces
Other Diagnosis Code 8 Version
Indicator Code
X(1)
563
563
Spaces
Other Diagnosis Code 9 Version
Indicator Code
X(1)
564
564
Spaces
Other Diagnosis Code 10 Version
Indicator Code
X(1)
565
565
Spaces
Other Diagnosis Code 11 Version
Indicator Code
X(1)
566
566
Spaces
Other Diagnosis Code 12 Version
Indicator Code
X(1)
567
567
Spaces
Other Diagnosis Code 13 Version
Indicator Code
X(1)
568
568
Spaces
Other Diagnosis Code 14 Version
Indicator Code
X(1)
569
569
Spaces
Other Diagnosis Code 15 Version
Indicator Code
X(1)
570
570
Spaces
Other Diagnosis Code 16 Version
Indicator Code
X(1)
571
571
Spaces
Other Diagnosis Code 17 Version
Indicator Code
X(1)
572
572
Spaces
Other Diagnosis Code 18 Version
Indicator Code
X(1)
573
573
Spaces
Other Diagnosis Code 19 Version
Indicator Code
X(1)
574
574
Spaces
Other Diagnosis Code 20 Version
Indicator Code
X(1)
575
575
Spaces
Other Diagnosis Code 21 Version
Indicator Code
X(1)
576
576
Spaces
Other Diagnosis Code 22 Version
Indicator Code
X(1)
577
577
Spaces
Other Diagnosis Code 23 Version
Indicator Code
X(1)
578
578
Spaces
Other Diagnosis Code 24 Version
Indicator Code
X(1)
579
579
Spaces
Principal Procedure
X(7)
580
586
Spaces
Principal Procedure Date
X(8)
587
594
Spaces
Other Procedure 1
X(7)
595
601
Spaces
Other Procedure 1 Date
X(8)
602
609
Spaces
Other Procedure 2
X(7)
610
616
Spaces
Other Procedure 2 Date
X(8)
617
624
Spaces
Other Procedure 3
X(7)
625
631
Spaces
Field Name
Picture
From
Thru
Initialization
Other Procedure 3 Date
X(8)
632
639
Spaces
Other Procedure 4
X(7)
640
646
Spaces
Other Procedure 4 Date
X(8)
647
654
Spaces
Other Procedure 5
X(7)
655
661
Spaces
Other Procedure 5 Date
X(8)
662
669
Spaces
Other Procedure 6
X(7)
670
676
Spaces
Other Procedure 6 Date
X(8)
677
684
Spaces
Other Procedure 7
X(7)
685
691
Spaces
Other Procedure 7 Date
X(8)
692
699
Spaces
Other Procedure 8
X(7)
700
706
Spaces
Other Procedure 8 Date
X(8)
707
714
Spaces
Other Procedure 9
X(7)
715
721
Spaces
Other Procedure 9 Date
X(8)
722
729
Spaces
Other Procedure 10
X(7)
730
736
Spaces
Other Procedure 10 Date
X(8)
737
744
Spaces
Other Procedure 11
X(7)
745
751
Spaces
Other Procedure 11 Date
X(8)
752
759
Spaces
Other Procedure 12
X(7)
760
766
Spaces
Other Procedure 12 Date
X(8)
767
774
Spaces
Other Procedure 13
X(7)
775
781
Spaces
Other Procedure 13 Date
X(8)
782
789
Spaces
Other Procedure 14
X(7)
790
796
Spaces
Other Procedure 14 Date
X(8)
797
804
Spaces
Other Procedure 15
X(7)
805
811
Spaces
Other Procedure 15 Date
X(8)
812
819
Spaces
Other Procedure 16
X(7)
820
826
Spaces
Other Procedure 16 Date
X(8)
827
834
Spaces
Other Procedure 17
X(7)
835
841
Spaces
Other Procedure 17 Date
X(8)
842
849
Spaces
Other Procedure 18
X(7)
850
856
Spaces
Other Procedure 18 Date
X(8)
857
864
Spaces
Other Procedure 19
X(7)
865
871
Spaces
Other Procedure 19 Date
X(8)
872
879
Spaces
Other Procedure 20
X(7)
880
886
Spaces
Other Procedure 20 Date
X(8)
887
894
Spaces
Other Procedure 21
X(7)
895
901
Spaces
Other Procedure 21 Date
X(8)
902
909
Spaces
Other Procedure 22
X(7)
910
916
Spaces
Other Procedure 22 Date
X(8)
917
924
Spaces
Other Procedure 23
X(7)
925
931
Spaces
Other Procedure 23 Date
X(8)
932
939
Spaces
Other Procedure 24
X(7)
940
946
Spaces
Other Procedure 24 Date
X(8)
947
954
Spaces
Principal Procedure Version
Indicator Code
X(1)
955
955
Spaces
Other Procedure 1 Version Indicator
Code
X(1)
956
956
Spaces
Other Procedure 2 Version Indicator
Code
X(1)
957
957
Spaces
Field Name
Picture
From
Thru
Initialization
Other Procedure 3 Version Indicator
Code
X(1)
958
958
Spaces
Other Procedure 4 Version Indicator
Code
X(1)
959
959
Spaces
Other Procedure 5 Version Indicator
Code
X(1)
960
960
Spaces
Other Procedure 6 Version Indicator
Code
X(1)
961
961
Spaces
Other Procedure 7 Version Indicator
Code
X(1)
962
962
Spaces
Other Procedure 8 Version Indicator
Code
X(1)
963
963
Spaces
Other Procedure 9 Version Indicator
Code
X(1)
964
964
Spaces
Other Procedure 10 Version
Indicator Code
X(1)
965
965
Spaces
Other Procedure 11 Version
Indicator Code
X(1)
966
966
Spaces
Other Procedure 12 Version
Indicator Code
X(1)
967
967
Spaces
Other Procedure 13 Version
Indicator Code
X(1)
968
968
Spaces
Other Procedure 14 Version
Indicator Code
X(1)
969
969
Spaces
Other Procedure 15 Version
Indicator Code
X(1)
970
970
Spaces
Other Procedure 16 Version
Indicator Code
X(1)
971
971
Spaces
Other Procedure 17 Version
Indicator Code
X(1)
972
972
Spaces
Other Procedure 18 Version
Indicator Code
X(1)
973
973
Spaces
Other Procedure 19 Version
Indicator Code
X(1)
974
974
Spaces
Other Procedure 20 Version
Indicator Code
X(1)
975
975
Spaces
Other Procedure 21 Version
Indicator Code
X(1)
976
976
Spaces
Other Procedure 22 Version
Indicator Code
X(1)
977
977
Spaces
Other Procedure 23 Version
Indicator Code
X(1)
978
978
Spaces
Other Procedure 24 Version
Indicator Code
X(1)
979
979
Spaces
Claim Demonstration Identification
Number
9(2)
980
981
Zeroes
PPS Indicator
X(1)
982
982
Spaces
Action Code
X(1)
983
983
Spaces
Patient Status
X(2)
984
985
Spaces
Billing Provider NPI
X(10)
986
995
Spaces
Field Name
Picture
From
Thru
Initialization
Claim Provider Taxonomy Code
X(25)
996
1020
Spaces
Medical Record Number
X(17)
1021
1037
Spaces
Patient Control Number
X(20)
1038
1057
Spaces
Attending Physician NPI
X(10)
1058
1067
Spaces
Attending Physician Last Name
X(16)
1068
1083
Spaces
Operating Physician NPI
X(10)
1084
1093
Spaces
Operating Physician Last Name
X(16)
1094
1109
Spaces
Claim Rendering Physician NPI
X(10)
1110
1119
Spaces
Claim Rendering Physician Last
Name
X(16)
1120
1135
Spaces
Date of Admission
X(8)
1136
1143
Spaces
Type of Admission
X(1)
1144
1144
Spaces
Source of Admission
X(1)
1145
1145
Spaces
DRG
X(3)
1146
1148
Spaces
Occurrence Code 1
X(2)
1149
1150
Spaces
Occurrence Code 1 Date
X(8)
1151
1158
Spaces
Occurrence Code 2
X(2)
1159
1160
Spaces
Occurrence Code 2 Date
X(8)
1161
1168
Spaces
Occurrence Code 3
X(2)
1169
1170
Spaces
Occurrence Code 3 Date
X(8)
1171
1178
Spaces
Occurrence Code 4
X(2)
1179
1180
Spaces
Occurrence Code 4 Date
X(8)
1181
1188
Spaces
Occurrence Code 5
X(2)
1189
1190
Spaces
Occurrence Code 5 Date
X(8)
1191
1198
Spaces
Occurrence Code 6
X(2)
1199
1200
Spaces
Occurrence Code 6 Date
X(8)
1201
1208
Spaces
Occurrence Code 7
X(2)
1209
1210
Spaces
Occurrence Code 7 Date
X(8)
1211
1218
Spaces
Occurrence Code 8
X(2)
1219
1220
Spaces
Occurrence Code 8 Date
X(8)
1221
1228
Spaces
Occurrence Code 9
X(2)
1231
1230
Spaces
Occurrence Code 9 Date
X(8)
1231
1238
Spaces
Occurrence Code 10
X(2)
1239
1240
Spaces
Occurrence Code 10 Date
X(8)
1241
1248
Spaces
Occurrence Code 11
X(2)
1249
1250
Spaces
Occurrence Code 11 Date
X(8)
1251
1258
Spaces
Occurrence Code 12
X(2)
1259
1260
Spaces
Occurrence Code 12 Date
X(8)
1261
1268
Spaces
Occurrence Code 13
X(2)
1269
1270
Spaces
Occurrence Code 13 Date
X(8)
1271
1278
Spaces
Occurrence Code 14
X(2)
1279
1280
Spaces
Occurrence Code 14 Date
X(8)
1281
1288
Spaces
Occurrence Code 15
X(2)
1289
1290
Spaces
Occurrence Code 15 Date
X(8)
1291
1298
Spaces
Occurrence Code 16
X(2)
1299
1300
Spaces
Occurrence Code 16 Date
X(8)
1301
1308
Spaces
Occurrence Code 17
X(2)
1309
1310
Spaces
Occurrence Code 17 Date
X(8)
1311
1318
Spaces
Occurrence Code 18
X(2)
1319
1320
Spaces
Field Name
Picture
From
Thru
Initialization
Occurrence Code 18 Date
X(8)
1321
1328
Spaces
Occurrence Code 19
X(2)
1329
1330
Spaces
Occurrence Code 19 Date
X(8)
1331
1338
Spaces
Occurrence Code 20
X(2)
1339
1340
Spaces
Occurrence Code 20 Date
X(8)
1341
1348
Spaces
Occurrence Code 21
X(2)
1349
1350
Spaces
Occurrence Code 21 Date
X(8)
1351
1358
Spaces
Occurrence Code 22
X(2)
1359
1360
Spaces
Occurrence Code 22 Date
X(8)
1361
1368
Spaces
Occurrence Code 23
X(2)
1369
1370
Spaces
Occurrence Code 23 Date
X(8)
1371
1378
Spaces
Occurrence Code 24
X(2)
1379
1380
Spaces
Occurrence Code 24 Date
X(8)
1381
1388
Spaces
Occurrence Code 25
X(2)
1389
1390
Spaces
Occurrence Code 25 Date
X(8)
1391
1398
Spaces
Occurrence Code 26
X(2)
1399
1400
Spaces
Occurrence Code 26 Date
X(8)
1401
1408
Spaces
Occurrence Code 27
X(2)
1409
1410
Spaces
Occurrence Code 27 Date
X(8)
1411
1418
Spaces
Occurrence Code 28
X(2)
1419
1420
Spaces
Occurrence Code 28 Date
X(8)
1421
1428
Spaces
Occurrence Code 29
X(2)
1429
1430
Spaces
Occurrence Code 29 Date
X(8)
1431
1438
Spaces
Occurrence Code 30
X(2)
1439
1440
Spaces
Occurrence Code 30 Date
X(8)
1441
1448
Spaces
Value Code 1
X(2)
1449
1450
Spaces
Value Amount 1
S9(8)V99 1451
1460
Zeroes
Value Code 2
X(2)
1461
1462
Spaces
Value Amount 2
S9(8)V99 1463
1472
Zeroes
Value Code 3
X(2)
1473
1474
Spaces
Value Amount 3
S9(8)V99 1475
1484
Zeroes
Value Code 4
X(2)
1485
1486
Spaces
Value Amount 4
S9(8)V99 1487
1496
Zeroes
Value Code 5
X(2)
1497
1498
Spaces
Value Amount 5
S9(8)V99 1499
1508
Zeroes
Value Code 6
X(2)
1509
1510
Spaces
Value Amount 6
S9(8)V99 1511
1520
Zeroes
Value Code 7
X(2)
1521
1522
Spaces
Value Amount 7
S9(8)V99 1523
1532
Zeroes
Value Code 8
X(2)
1533
1534
Spaces
Value Amount 8
S9(8)V99 1535
1544
Zeroes
Value Code 9
X(2)
1545
1546
Spaces
Value Amount 9
S9(8)V99 1547
1556
Zeroes
Value Code 10
X(2)
1557
1558
Spaces
Value Amount 10
S9(8)V99 1559
1568
Zeroes
Value Code 11
X(2)
1569
1570
Spaces
Value Amount 11
S9(8)V99 1571
1580
Zeroes
Value Code 12
X(2)
1581
1582
Spaces
Value Amount 12
S9(8)V99 1583
1592
Zeroes
Value Code 13
X(2)
1593
1594
Spaces
Field Name
Picture
From
Thru
Initialization
Value Amount 13
S9(8)V99 1595
1604
Zeroes
Value Code 14
X(2)
1605
1606
Spaces
Value Amount 14
S9(8)V99 1607
1616
Zeroes
Value Code 15
X(2)
1617
1618
Spaces
Value Amount 15
S9(8)V99 1619
1628
Zeroes
Value Code 16
X(2)
1629
1630
Spaces
Value Amount 16
S9(8)V99 1631
1640
Zeroes
Value Code 17
X(2)
1641
1642
Spaces
Value Amount 17
S9(8)V99 1643
1652
Zeroes
Value Code 18
X(2)
1653
1654
Spaces
Value Amount 18
S9(8)V99 1655
1664
Zeroes
Value Code 19
X(2)
1665
1666
Spaces
Value Amount 19
S9(8)V99 1667
1676
Zeroes
Value Code 20
X(2)
1677
1678
Spaces
Value Amount 20
S9(8)V99 1679
1688
Zeroes
Value Code 21
X(2)
1689
1690
Spaces
Value Amount 21
S9(8)V99 1691
1700
Zeroes
Value Code 22
X(2)
1701
1702
Spaces
Value Amount 22
S9(8)V99 1703
1712
Zeroes
Value Code 23
X(2)
1713
1714
Spaces
Value Amount 23
S9(8)V99 1715
1724
Zeroes
Value Code 24
X(2)
1725
1726
Spaces
Value Amount 24
S9(8)V99 1727
1736
Zeroes
Value Code 25
X(2)
1737
1738
Spaces
Value Amount 25
S9(8)V99 1739
1748
Zeroes
Value Code 26
X(2)
1749
1750
Spaces
Value Amount 26
S9(8)V99 1751
1760
Zeroes
Value Code 27
X(2)
1761
1762
Spaces
Value Amount 27
S9(8)V99 1763
1772
Zeroes
Value Code 28
X(2)
1773
1774
Spaces
Value Amount 28
S9(8)V99 1775
1784
Zeroes
Value Code 29
X(2)
1785
1786
Spaces
Value Amount 29
S9(8)V99 1787
1796
Zeroes
Value Code 30
X(2)
1797
1798
Spaces
Value Amount 30
S9(8)V99 1799
1808
Zeroes
Value Code 31
X(2)
1809
1810
Spaces
Value Amount 31
S9(8)V99 1811
1820
Zeroes
Value Code 32
X(2)
1821
1822
Spaces
Value Amount 32
S9(8)V99 1823
1832
Zeroes
Value Code 33
X(2)
1833
1834
Spaces
Value Amount 33
S9(8)V99 1835
1844
Zeroes
Value Code 34
X(2)
1845
1846
Spaces
Value Amount 34
S9(8)V99 1847
1856
Zeroes
Value Code 35
X(2)
1857
1858
Spaces
Value Amount 35
S9(8)V99 1859
1868
Zeroes
Claim Final Allowed Amount
S9(8)V99 1869
1878
Zeroes
Claim Deductible Amount
S9(8)V99 1879
1888
Zeroes
Claim State
X(2)
1889
1890
Spaces
Claim Zip Code
X(9)
1891
1899
Spaces
Field Name
Picture
From
Thru
Initialization
Beneficiary State
X(2)
1900
1901
Spaces
Beneficiary Zip Code
X(9)
1902
1910
Spaces
Claim PWK
X(60)
1911
1970
Spaces
Patient Reason for Visit 1
X(7)
1971
1977
Spaces
Patient Reason for Visit 2
X(7)
1978
1984
Spaces
Patient Reason for Visit 3
X(7)
1985
1991
Spaces
Patient Reason for Visit 1 Version
Indicator Code
X(1)
1992
1992
Spaces
Patient Reason for Visit 2 Version
Indicator Code
X(1)
1993
1993
Spaces
Patient Reason for Visit 3 Version
Indicator Code
X(1)
1994
1994
Spaces
Present on Admission/External
Cause of Injury Indicator
X(37)
1995
2031
Spaces
External Cause of Injury 1
X(7)
2032
2038
Spaces
External Cause of Injury 2
X(7)
2039
2045
Spaces
External Cause of Injury 3
X(7)
2046
2052
Spaces
External Cause of Injury 4
X(7)
2053
2059
Spaces
External Cause of Injury 5
X(7)
2060
2066
Spaces
External Cause of Injury 6
X(7)
2067
2073
Spaces
External Cause of Injury 7
X(7)
2074
2080
Spaces
External Cause of Injury 8
X(7)
2081
2087
Spaces
External Cause of Injury 9
X(7)
2088
2094
Spaces
External Cause of Injury 10
X(7)
2095
2101
Spaces
External Cause of Injury 11
X(7)
2102
2108
Spaces
External Cause of Injury 12
X(7)
2109
2115
Spaces
External Cause of Injury 1 Version
Indicator Code
X(1)
2116
2116
Spaces
External Cause of Injury 2 Version
Indicator Code
X(1)
2117
2117
Spaces
External Cause of Injury 3 Version
Indicator Code
X(1)
2118
2118
Spaces
External Cause of Injury 4 Version
Indicator Code
X(1)
2119
2119
Spaces
External Cause of Injury 5 Version
Indicator Code
X(1)
2120
2120
Spaces
External Cause of Injury 6 Version
Indicator Code
X(1)
2121
2121
Spaces
External Cause of Injury 7 Version
Indicator Code
X(1)
2122
2122
Spaces
External Cause of Injury 8 Version
Indicator Code
X(1)
2123
2123
Spaces
External Cause of Injury 9 Version
Indicator Code
X(1)
2124
2124
Spaces
External Cause of Injury 10 Version
Indicator Code
X(1)
2125
2125
Spaces
External Cause of Injury 11 Version
Indicator Code
X(1)
2126
2126
Spaces
External Cause of Injury 12 Version
Indicator Code
X(1)
2127
2127
Spaces
Field Name
Picture
From
Thru
Initialization
Service Facility Zip Code
X(9)
2128
2136
Spaces
RAC adjustment indicator
X(1)
2137
2137
Spaces
Split/Adjustment Indicator
9(2)
2138
2139
Spaces
Referring Physician NPI
X(10)
2140
2149
Spaces
Referring Physician Last Name
X(16)
2150
2165
Spaces
Referring Physician Specialty
X(2)
2166
2167
Spaces
Claim Rendering Physician
X(2)
2168
2169
Spaces
Overpay Indicator
X(1)
2170
2170
Spaces
Overpay Code
X(3)
2171
2173
Spaces
Claim Demonstration Identification
Number 2
X(2)
2174
2175
Spaces
Claim Demonstration Identification
Number 3
X(2)
2176
2177
Spaces
Claim Demonstration Identification
Number 4
X(2)
2178
2179
Spaces
Beneficiary MBI
X(11)
2180
2190
Spaces
MBI/HICN Indicator
X(1)
2191
2191
Spaces
Filler
X(10)
2192
2201
Spaces
Total Line Item Count
9(3)
2202
2204
Zeroes
Record Line Item Count
9(3)
2205
2207
Zeroes
Sampled Claims Resolution File
Sampled Claims Resolution Claim Line Item Group Record
*The following group of fields occurs from 1 to 450 times for the
claim (depending on Total Line Item Count) and 1 to 75 times
for the Record (depending on Record Line Item Count)
*From and Thru values relate to the 1st line item
Field Name
Picture
From
Thru
Initialization
Revenue center code
X(4)
2208
2211
Spaces
SNF-RUG-III code
X(3)
2212
2214
Spaces
APC adjustment code
X(5)
2215
2219
Spaces
HCPCS Procedure Code
X(5)
2220
2224
Spaces
HCPCS Modifier 1
X(2)
2225
2226
Spaces
HCPCS Modifier 2
X(2)
2227
2228
Spaces
HCPCS Modifier 3
X(2)
2229
2230
Spaces
HCPCS Modifier 4
X(2)
2231
2232
Spaces
HCPCS Modifier 5
X(2)
2233
2234
Spaces
Line Item Date
X(8)
2235
2242
Spaces
Line Submitted Charge
S9(8)V99
2243
2252
Zeroes
Line Medicare Initial Allowed
S9(8)V99
2253
2262
Zeroes
ANSI Reason Code 1
X(8)
2263
2270
Spaces
ANSI Reason Code 2
X(8)
2271
2278
Spaces
ANSI Reason Code 3
X(8)
2279
2286
Spaces
ANSI Reason Code 4
X(8)
2287
2294
Spaces
ANSI Reason Code 5
X(8)
2295
2302
Spaces
ANSI Reason Code 6
X(8)
2303
2310
Spaces
ANSI Reason Code 7
X(8)
2311
2318
Spaces
ANSI Reason Code 8
X(8)
2319
2326
Spaces
ANSI Reason Code 9
X(8)
2327
2334
Spaces
Field Name
Picture
From
Thru
Initialization
ANSI Reason Code 10
X(8)
2335
2342
Spaces
ANSI Reason Code 11
X(8)
2343
2350
Spaces
ANSI Reason Code 12
X(8)
2351
2358
Spaces
ANSI Reason Code 13
X(8)
2359
2366
Spaces
ANSI Reason Code 14
X(8)
2367
2374
Spaces
Manual Medical Review Indicator
X(1)
2375
2375
Spaces
Resolution Code
X(5)
2376
2380
Spaces
Field Name
Picture
From
Thru
Initialization
Line Final Allowed Charge
S9(8)V99
2381
2390
Zeroes
Line Cash Deductible
S9(8)V99
2391
2400
Zeroes
Special Action Code/Override Code X(1)
2401
2401
Zeroes
Units
S9(7)v999
2402
2411
Zeroes
Rendering Physician NPI
X(10)
2412
2421
Spaces
Rendering Physician Last Name
X(25)
2422
2446
Spaces
National Drug Code (NDC) field
X(11)
2447
2457
Spaces
National Drug Code (NDC)
S9(7)v999
2458
2467
Spaces
National Drug Code (NDC)
Quantity Qualifier
X(2)
2468
2469
Spaces
Line PWK
X(60)
2470
2529
Spaces
Line Rendering Physician specialty X(2)
2530
2531
Spaces
Prior Authorization Program
X(4)
2532
2535
Spaces
Unique Tracking Number (UTN)
X(14)
2536
2549
Spaces
Prior Authorization Affirmed
X(1)
2550
2550
Spaces
Filler
X(4)
2551
2554
Spaces
DATA ELEMENT DETAIL
Claim (Header) Fields
Data Element: Contractor ID
Definition:
Contractor’s CMS assigned number.
Validation:
Must be a valid CMS contractor ID.
Remarks:
N/A
Requirement:
Required
NOTE:
For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single
processing environment, the Contractor ID will reflect the roll-up Contractor
ID specified by CMS.
Data Element: Record Type
Definition:
Code indicating type of record
Validation:
N/A
Remarks:
2 = Claim record
Requirement:
Required
Data Element:
Record Version Code
Definition:
The code indicating the record version of the Claim Resolution file
Validation:
Claim Resolution files prior to 10/1/2007 did not contain this field.
Codes:
B = Record Format as of 10/1/2007
C = Record Format as of 1/1/2010
D = Record Format as of 10/1/2012
E = Record Format as of 7/1/2016
F = Record Format as of 10/1/2017
Remarks:
N/A
Requirement: Required
Data Element:
Contractor Type
Definition:
Type of Medicare Contractor included in the file
Validation:
Must be ‘A’ or ‘R’
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should
be ‘R’.
All others will be contractor type ‘A’.
Data Element: Record Number
Definition:
The sequence number of the record. A claim may have up to six records.
Validation:
Must be between 1 and 6
Remarks:
None Requirement: Required
Data Element: Mode of Entry Indicator
Definition:
Code that indicates if the claim is paper, EMC, or unknown
Validation:
Must be 'E’, 'P’, or 'U'
Remarks:
E = EMC
P = Paper
U= Unknown
Use the same criteria to determine EMC, paper, or unknown as that used for
workload reporting
Requirement:
Required
Data Element:
Original Claim Control Number
Definition:
The Claim Control Number the shared system assigned to the claim in the
Universe file. This number should be the same as the claim control number
for the claim in the Sample Claims Transactions file, and the claim control
number for the claim on the Universe file. If the shared system had to use a
crosswalk to pull the claim because the MAC or shared system changed the
claim control number during processing, enter the number the shared system
used to look up the number needed to pull all records associated with the
sample claim.
Validation:
For all records in the resolution file, the Original Claim Control must match the
Claim Control Number identified in the Sampled Claims Transaction File.
Remarks:
N/A
Requirement:
Required
Data Element: Internal Control Number
Definition:
Number currently assigned by the Shared System to uniquely identify the claim.
Validation:
N/A
Remarks:
Use the Original Claim Control Number if no adjustment has been made to the
claim. This number may be different from the Original Claim Control Number
if the shared system has assigned a new Claims Control Number to an
adjustment to the claim requested.
Requirement:
Required
Data Element: Beneficiary HICN
Definition:
Beneficiary’s Health Insurance Claim Number
Validation:
N/A
Remarks:
N/A
Requirement:
Required
Data Element: Beneficiary Last Name
Definition:
Last Name (Surname) of the beneficiary
Validation:
N/A
Remarks:
N/A
Requirement:
Required
Data Element: Beneficiary First Name
Definition:
First (Given) Name of the beneficiary
Validation:
N/A
Remarks:
N/A
Requirement:
Required
Data Element: Beneficiary Middle Initial
Definition:
First letter from Beneficiary Middle Name
Validation:
N/A
Remarks
:
N/A
Requirement:
Required
Data Element: Beneficiary Date of Birth
Definition:
Birth date of the beneficiary
Validation:
Must be a valid date
Remarks:
MMDDCCYY on which the beneficiary was born
Requirement:
Required
Data Element: Beneficiary Gender
Definition:
Gender of the beneficiary
Validation:
'M' = Male, 'F' = Female, or 'U' = Unknown
Remarks:
N/A
Requirement:
Required
Data Element: Billing Provider Number
Definition:
First nine characters of number used to identify the billing/pricing provider or
supplier.
Validation:
Must be present
If the same billing/pricing provider number does not apply to all lines on the
claim, enter the Billing provider number that applies to the first line of the claim.
Remarks:
N/A
Requirement: Required for all claims
Data Element: Attending Physician UPIN
Definition:
The UPIN submitted on the claim used to identify the physician that is
responsible for coordinating the care of the patient while in the facility.
Validation:
N/A
Remarks:
Left justify
Requirement:
Required when available on claim record.
Data Element: Claim Paid Amount
Definition:
Amount of payment made from the Medicare trust fund for the services
covered by the claim record. Generally, the amount is calculated by the A/B
MAC (A) or A/B MAC (B) and represents what CMS paid to the institutional
provider, physician, or supplier, i.e. The Claim Paid Amount is the net amount
paid after co-insurance and deductibles are applied.
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: Claim ANSI Reason Code 1-7
Definition:
Codes showing the reason for any adjustments to this claim, such as denials
or reductions of payment from the amount billed.
Validation:
Must be valid American National Standards Institute (ANSI) Ambulatory
Surgical Center (ASC) claim adjustment code and applicable group code.
Remarks:
Format is GGRRRRRR where: GG is the group code and RRRRRR is the
adjustment reason code.
Requirement:
Report all ANSI reason codes on the bill
Data Element: Statement Covers from Date
Definition:
The beginning date of the statement
Validation:
Must be a valid date
Remarks:
Format must be CCYYMMDD
Requirement:
Required
Data Element: Statement Covers thru Date
Definition:
The ending date of the statement
Validation:
Must be a valid date
Remarks:
Format must be CCYYMMDD
Requirement:
Required
Data Element: Claim Entry Date
Definition:
Date claim entered the shared claim processing system, the receipt date
Validation:
Must be a valid date
Remarks:
Format must be CCYYMMDD
Requirement:
Required
Data Element: Claim Adjudicated Date
Definition:
Date claim completed adjudication, i.e., process date
Validation:
Must be a valid date
Remarks:
Format must be CCYYMMDD Requirement: Required
Data Element: Condition Code 1 -30
Definition:
The code that indicates a condition relating to an institutional claim that may
affect payer processing
Validation:
Must be a valid code as listed in Pub 100-4, Medicare Claims Processing
Manual, Chapter 25, Completing and Processing CMS-1450 Data Set.
Remarks:
This field is left justified and blank filled.
Requirement:
Required if there is a condition code for the bill.
Data Element: Type of Bill
Definition:
A code indicating the specific type of bill (hospital, inpatient, SNF, outpatient,
adjustments, voids, etc.). This three-digit alphanumeric code gives three
specific pieces of information. The first digit identifies the type of facility. The
second classifies the type of care. The third indicates the sequence of this bill
in this particular episode of care. It is referred to as “frequency” code.
Validation:
Must be a valid code as listed in Pub 100-4, Medicare Claims Processing
Manual, Chapter 25, Completing and Processing CMS-1450 Data Set
Remarks:
N/A
Requirement: Required
Data Element: Principal Diagnosis
Definition:
The current version of ICD--CM diagnosis code identifying the diagnosis,
condition, problem or other reason for the admission/encounter/visit shown in
the medical record to be chiefly responsible for the services provided.
Validation:
Must be a valid ICD--CM diagnosis code
• CMS accepts only CMS approved ICD--CM diagnostic and
procedural codes. The CMS approves only changes issued by the Federal
ICD-- CM Coordination and Maintenance Committee.
• Diagnosis codes must be full ICD--CM diagnoses codes, including
the full number of digits (five for ICD-9-CM, seven for ICD-10-CM) where
applicable.
Remarks:
The principal diagnosis is the condition established after study to be chiefly
responsible for this admission. Even though another diagnosis may be more
severe than the principal diagnosis, the principal diagnosis, as defined above,
is entered.
Requirement:
Required
Data Element:
Principal Diagnosis Version Indicator Code
Definition:
The diagnosis version code identifying the version of ICD diagnosis code
submitted.
Validation:
• Version ICD9 use Version Code ‘9’
• Version ICD10 use Version Code ‘0’
Remarks:
With the exception of claims submitted by ambulance suppliers (specialty).
Requirement:
Principal Diagnosis Version Code 1 is required for ALL claims.
Data Element: Other Diagnosis Code 1-24
Definition:
The ICD-CM diagnosis code identifying the diagnosis, condition, problem or
other
reason for the admission/encounter/visit shown in the medical record to be
present during treatment.
Validation:
Must be a valid ICD--CM diagnosis code
• CMS accepts only CMS approved ICD-CM diagnostic and procedural codes.
The CMS approves only changes issued by the Federal ICD-CM Coordination
and Maintenance Committee.
• Diagnosis codes must be full ICD-CM diagnoses codes, including The full
number of digits (five for ICD-9-CM, seven for ICD-10-CM) where applicable.
Remarks:
Report the full ICD-CM codes for up to 24 additional conditions if they co-
existed at the time of admission or developed subsequently, and which had
an effect upon the treatment or the length of stay.
Requirement: Required if available on the claim record.
Data Element:
Other Diagnosis Version Indicator Code 1-24
Definition:
The ICD-CM diagnosis version code identifying the version of diagnosis code
submitted.
Validation:
•
Version ICD9 use Version Code ‘9’
•
Version ICD10 use Version Code ‘0
Remarks:
N/A
Requirement:
Principal Diagnosis Version Code 1 is required for ALL claims. Other
Diagnosis version codes 1-24 should be submitted to correspond to claim
level diagnosis codes 1-24.
Data Element: Principal Procedure and Date
Definition:
The ICD--CM code that indicates the principal procedure performed during the
period covered by the institutional claim. And the Date on which it was
performed.
Validation:
Must be a valid ICD--CM procedure code
• CMS accepts only CMS approved ICD--CM diagnostic and
procedural codes. The CMS approves only changes issued by the Federal
ICD--CM Coordination and Maintenance Committee.
• The procedure code shown must be the full ICD--CM, Volume 3,
procedure code, including the full number of digits (five for ICD-9-CM, seven
for ICD-10-CM).
Remarks:
The principal procedure is the procedure performed for definitive treatment
rather than for diagnostic or exploratory purposes, or which was necessary to
take care of a complication. It is also the procedure most closely related to
the principal diagnosis.
• The date applicable to the principal procedure is shown numerically as
CCYYMMDD in the “date” portion.
Requirement:
Required for inpatient claims.
Data Element:
Principal Procedure Version Indicator Code
Definition:
The version code identifying the version of ICD procedure code submitted.
Validation:
• Version ICD9 use Version Code ‘9’
• Version ICD10 use Version Code ‘0’
Remarks:
N/A
Requirement: Principal Procedure Code Version Code is required for ALL claims containing a
Principal Procedure.
Data Element: Other Procedure and Date 1-24
Definition:
The ICD-CM code identifying the procedure, other than the principal
procedure, performed during the billing period covered by this bill.
Validation:
Must be a valid ICD-CM procedure code
• CMS accepts only CMS approved ICD-CM diagnostic and
procedural codes. The CMS approves only changes issued by the Federal ICD-
CM Coordination and Maintenance Committee.
• The procedure code shown must be the full ICD-CM, Volume 3, procedure
code, including the full number of digits (five for ICD-9-CM, seven for ICD-10-
CM).
Remarks:
The date applicable to the procedure is shown numerically as CCYYMMDD in
the “date” portion.
Requirement:
Required if on claim record.
Data Element:
Other Procedure Code Version Indicator Code 1-24
Definition:
The ICD-CM diagnosis version code identifying the version of procedure code
submitted
Validation:
• Version ICD9 use Version Code ‘9’
• Version ICD10 use Version Code ‘0’
Remarks:
N/A
Requirement:
Principal Procedure Version Code is required for ALL claims. Other
Procedure version codes 1-24 should be submitted to correspond to other
procedure code 1-24.
Data Element: Claim Demonstration Identification Number
Definition:
The number assigned to identify a demonstration project.
Validation:
Must be numeric or zeroes
Remarks:
This field contains the value from the first populated
demonstration field.
Requirement:
Required for all claims involved in a
demonstration project
Data Element: PPS Indicator
Definition:
The code indicating whether (1) the claim is Prospective Payment System
(PPS) or not PPS.
Validation:
0 = Not PPS
1 = PPS
Remarks:
N/A
Requirement: Required
Data Element: Action Code
Definition:
Indicator identifying the type of action requested by the intermediary to be
taken on an institutional claim.
Validation:
Must be a valid action code.
1 = Original debit action (includes non-adjustment RTI correction items)
– it will always be a 1 in regular bills.
2 = Cancel by credit adjustment – used only in credit/debit pairs (under
HHPPS, updates the RAP).
3 = Secondary debit adjustment - used only in credit/debit pairs (under
HHPPS, would be the final claim or an adjustment on a LUPA).
4 = Cancel only adjustment (under HHPPS, RAP/final claim/LUPA).
5 = Force action code 3.
6 = Force action code 2.
8 = Benefits refused (for inpatient bills, an 'R' nonpayment code must also be
present.
9 = Payment requested (used on bills that replace previously-submitted
benefits- refused bills, action code 8. In such cases a debit/credit pair is
not required. For inpatient bills, a 'P' should be entered in the
nonpayment code.)
Remarks:
N/A
Requirement:
Required
Data Element: Patient Status
Definition:
This code indicates the patient’s status as of the “Through”
date of the billing period.
Validation:
Must be a valid code as listed in Pub 100-4, Medicare Claims
Processing
Manual, Chapter 25, Completing and Processing CMS-1450 Data
Set.
Remarks:
N/A
Requirement:
Required
Data Element: Billing Provider NPI
Definition:
NPI assigned to the Billing Provider.
Validation:
N/A
Remarks:
N/A.
Requirement:
Required for providers using HIPAA standard transactions
Data Element: Claim Provider Taxonomy Code
Definition:
The non-medical data code set used to classify health care providers
according to provider type or practitioner specialty in an electronic
environment, specifically within the American National Standards Institute
Accredited Standards Committee health care transaction.
Validation:
Must be present
•
If multiple taxonomy codes are associated with a provider
number, provide the first one in sequence.
Remarks:
N/A
Requirement:
Required when available.
Data Element:
Medical Record Number
Definition:
Number assigned to patient by hospital or other provider to assist in retrieval
of medical records.
Validation:
N/A
Remarks:
N/A
Requirement:
Required if available on claim record
Data Element: Patient Control Number
Definition:
The patient’s unique alpha-numeric control number assigned by the provider
to facilitate retrieval of individual financial records and posting payment.
Validation:
N/A
Remarks:
N/A
Requirement:
Required if available on claim record
Data Element: Attending Physician NPI
Definition:
NPI assigned to the Attending Physician.
Validation:
N/A
Remarks:
Left justify
Requirement:
Required when available on claim record.
Data Element: Attending Physician Last Name
Definition:
Last Name (Surname) of the attending physician.
Validation:
Must be present
Remarks:
N/A
Requirement: Required when available on claim record
Data Element: Operating Physician NPI
Definition:
NPI assigned to the Operating Physician.
Validation:
N/A
Remarks:
Left justify
Requirement:
Required when available on claim record.
Data Element: Operating Physician Last Name
Definition:
Last Name (Surname) of the operating physician.
Validation:
Must be present
Remarks:
N/A
Requirement:
Required when available on claim record
Data Element: Claim Rendering Physician NPI
Definition:
NPI assigned to the claim rendering physician (mapped from 2310D from the
837I version 5010A2).
Validation:
N/A
Remarks:
Left justify
Requirement:
Required when available on claim record.
Data Element: Claim Rendering Physician Last Name
Definition:
Last Name (Surname) of the claim rendering physician (mapped from 2310D
from the 837I version 5010A2).
Validation:
Must be present
Remarks:
N/A
Requirement:
Required when available on claim record
Data Element: Date of Admission
Definition:
The date the patient was admitted to the provider for inpatient care,
outpatient service, or start of care. For an admission notice for hospice care,
enter the effective date of election of hospice benefits.
Validation:
Must be a valid date
Remarks:
Format date as CCYYDDD
Requirement:
Required if on claim record.
Data Element: Type of Admission
Definition:
The code indicating the type and priority of an inpatient admission associated
with the service on an intermediary claim.
Validation:
Must be a valid code as listed in Pub 100-4, Medicare Claims
Processing Manual, Chapter 25, Completing and Processing
CMS-1450 Data Set Code Structure.
Remarks:
N/A
Requirement:
Required on inpatient claims only.
Data Element: Source of Admission
Definition:
The code indicating the means by which the beneficiary was admitted to the
inpatient health care facility or SNF if the type of admission is (1) emergency,
(2) urgent, or (3) elective.
Validation:
Must be a valid code as listed in Pub 100-4, Medicare Claims Processing
Manual, Chapter 25, Completing and Processing CMS-1450 Data Set Code
Structure (For Emergency, Elective, or Other Type of Admission)
Remarks:
N/A
Requirement:
Required when entered on the claim record.
Data Element:
DRG (Diagnosis Related Group)
Definition:
The code identifying the diagnostic related group to which a hospital claim
belongs for prospective payment purposes.
Validation:
Must be valid per the DRG DEFINITIONS MANUAL
Remarks:
N/A
Requirement:
Required if available on the claim record
Data Element: Occurrence Code and Date 1-30
Definition:
Code(s) and associated date(s) defining specific event(s) relating to this
billing period are shown.
Validation:
Must be a valid code as listed in Pub 100-4, Medicare Claims
Processing Manual, Chapter 25, Completing and Processing
CMS-1450 Data Set.
Remarks:
• Event codes are two alpha-numeric digits, and dates are shown as eight
numeric digits (MM-DD-CCYY)
• When occurrence codes 01-04 and 24 are entered, make sure the entry
includes the appropriate value codes, if there is another
payer
involved.
Requirement:
Required if available on claim record
Data Element: Value Codes and Amounts 1-35
Definition:
Code(s) and related dollar or unit amount(s) identify data of a monetary
nature that are necessary for the processing of this claim.
Validation:
Must be a valid code as listed in Pub 100-4, Medicare Claims Processing
Manual, Chapter 25, Completing and Processing CMS-1450 Data Set.
Remarks:
• The codes are two alpha-numeric digits, and each value allows
up to nine numeric digits (0000000.00).
• Negative amounts are not allowed except in the last entry.
• Whole numbers or non-dollar amounts are right justified to the left of the
dollars and cents delimiter.
•
Some values are reported as cents, so refer to specific codes for
instructions.
• If more than one value code is shown for a billing period, codes are shown in
ascending numeric sequence.
• Use the first line before the second, etc.
Requirement: Required if available on claim record
Data Element: Claim Final Allowed Amount
Definition:
Final Allowed Amount for this claim.
Validation:
N/A
Remarks:
The Gross Allowed charges on the claim. This represents the amount paid to
the provider plus any beneficiary responsibility (co-pay and deductible)
Requirement:
Required
Data Element: Claim Deductible Amount
Definition:
Amount of deductible applicable to the claim.
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: Claim State
Definition:
2 character indicator showing the state where the service is furnished.
Validation:
Must be a valid USPS state abbreviation
Remarks:
N/A
Requirement:
Required
Data Element:
Claim Zip Code
Definition:
Zip code of the physical location where the services were furnished.
Validation:
Must be a valid USPS zip code.
Remarks:
N/A
Requirement: Required
Data Element: Beneficiary State
Definition:
2 character indicator showing the state of beneficiary residence.
Validation:
Must be a valid USPS state abbreviation
Remarks:
N/A
Requirement: Required
Data Element: Beneficiary Zip Code
Definition:
Zip code associated with the beneficiary residence.
Validation:
Must be a valid USPS zip code.
Remarks:
N/A
Requirement: Required
Data Element: PWK Filler
Definition:
PWK space -- use to be determined
Validation:
N/A
Remarks:
N/A
Requirement:
Required when available on claim.
Data Element: Patient Reason for Visit 1-3
Definition:
An ICD--CM code on the institutional claim indicating the beneficiary's reason
for visit.
Validation:
Must be a valid ICD-CM diagnosis code.
• CMS accepts only CMS approved ICD-CM diagnostic and
procedural codes. The CMS approves only changes issued by the Federal
ICD-CM Coordination and Maintenance Committee.
• Diagnosis codes must be full ICD-CM diagnoses codes,
including the full number of digits (five for ICD-9-CM, seven
for ICD-10- CM) where applicable.
Remarks:
Report the full ICD-CM codes for up to 3 conditions responsible for the
patient’s visit.
Requirement: For OP claims, this field is populated for those claims that are required to
process
through OP PPS Pricer. The type of bills (TOB) required to process through
are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers,
hospitals located in American Samoa, Guam and Saipan and Critical Access
Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any
outpatient type of bill with a condition code '07' and certain HCPCS. These
claim types could have lines that are not required to price under OPPS rules
so those lines would not have data in this field. Additional exception: Virgin
Island hospitals and hospitals that furnish only inpatient Part B services.
Data Element:
Patient Reason for Visit Version Indicator Code 1-3
Definition:
The ICD-CM diagnosis version code identifying the version of diagnosis code
submitted.
Validation:
• Version ICD9 use Version Code ‘9’
• Version ICD10 use Version Code ‘0’
Remarks:
N/A
Requirement:
Patient Reason for Visit Version codes must be submitted to
correspond to patient reason for visit codes 1-3.
Data Element: Present on Admission/External Cause of Injury Indicator
Definition:
The code used to indicate a condition was present at the time the beneficiary
was admitted to a general acute care facility.
Validation:
Position 1 for Principle Diagnosis, positions 2-25 for the 24 Secondary
Diagnosis for the Present on Admission (POA) Indicator, Positions 26 – 37 for
the 12 External Cause of Injury.
Remarks:
N/A
Requirement: Required
Data Element: External Cause of Injury Diagnosis Codes 1-12
Definition:
The ICD-CM code used to identify the external cause of injury,
poisoning, or other adverse effect.
Validation:
Must be a valid ICD--CM diagnosis code.
• CMS accepts only CMS approved ICD-CM diagnostic and procedural codes.
The CMS approves only changes issued by the Federal ICD-CM Coordination
and Maintenance Committee.
• Diagnosis codes must be full ICD-CM diagnoses codes, including the full
number of digits (five for ICD-9-CM, seven for ICD-10- CM) where applicable.
Remarks:
Report the full ICD-CM codes for up to 12 conditions resulting from external
causes.
Requirement: Required if available on the claim record.
Data Element:
External Cause of Injury Version Indicator Code 1-12
Definition:
The ICD-CM diagnosis version code identifying the version of diagnosis code
identified as external cause of injury.
Validation:
• Version ICD9 use Version Code ‘9’
• Version ICD10 use Version Code ‘0
Remarks:
N/A
Requirement: External Cause of Injury version codes 1-12 should be submitted to
correspond to external cause of injury diagnosis codes 1-12.
Data Element:
Service Facility Zip Code
Definition:
Zip Code used to identify were the service was furnished.
Validation:
Must be a valid Zip Code
Remarks:
N/A
Requirement: Required, if available on claim record.
Data Element: RAC Adjustment Indicator
Definition:
Indicator used to identify RAC requested adjustments, which occur as a
result of post-payment review activities done by the Recovery Audit
Contractors (RAC).
Validation:
‘R’ identifies a RAC-requested adjustment
Remarks:
N/A
Requirement: Required when RAC adjustment indicator was furnished to CWF.
Data Element: Split/Adjustment Indicator
Definition:
Count of number of adjustments (with different DCNs) of the claim that are
included in the resolution file.
Validation:
‘0’ is used when only one DCN associated with the sampled claim is included
in the resolution file.
When the resolution file contains multiple adjustments associated with a
single claim, this field will provide a count of records.
• When the resolution file contains 2 DCNs related to a single
claim, one of the records would contain a split/adjustment
indicator of 1 and the second record would contain a
split/adjustment indicator of 2.
Remarks:
This indicator does not apply when multiple records are submitted for a single
claim record because of size restrictions.
CERT recognizes that Part A claims are not split. For Part A this field will
identify adjustments only.
Requirement:
Required when the resolution file contains multiple versions of a single
claim.
Data Element: Referring Physician NPI
Definition:
NPI assigned to the Referring Physician—the physician who requests an
item or service for the beneficiary for which payment may be made
under the Medicare program.
Validation:
N/A
Remarks:
Enter zeros if there is no referring physician
Requirement:
Required when available on the claim record
NOTES:
• Referring physician - is a physician who requests an item or service for the
beneficiary for which payment may be made under the Medicare program.
• Ordering physician - is a physician or, when appropriate, a non- physician
practitioner who orders non-physician services for the patient.
Data Element: Referring Physician Last Name
Definition:
Last name of the referring physician.
Validation:
N/A
Remarks:
Enter zeros if there is no referring/ordering provider
Requirement: Required when available on the claim record.
Data Element: Referring Physician Specialty
Definition:
Code indicating the primary specialty of the referring physician.
Validation:
N/A
Remarks:
Enter zeros if the referring physician specialty is not available
Requirement: Required when available on the claim record.
Data Element: Claim Rendering Physician Specialty
Definition:
Code indicating the primary specialty of the claim rendering physician.
Validation:
N/A
Remarks:
Enter zeros if the rendering physician specialty is not available
Requirement: Required when available on the claim record.
Data Element: Overpay Indicator
Definition:
Code indicating whether or not an overpayment exists on an OIG or UPIC
tracked adjustment claims.
Validation:
• Y indicates an overpayment exists on an OIG or UPIC claim
• N indicates an overpayment does not exist on an
OIG or UPIC claim.
• Default value is blank for claims that are not OIG or UPIC tracked claims.
Remarks:
This field is populated only when there is a value present in the FSSCIDRP-
OVERPAY-CODE field
Requirement:
Required when available on the claim record.
Data Element: Overpay Code
Definition:
Code that identifies an overpayment on an OIG or UPIC tracked adjustment
claim.
Validation:
Any of the user-defined values present in the online parm PRMOIGAA,
PRMOIG00 through PRMOIG20 records.
Remarks:
This field is populated only when the claim is an OIG or UPIC tracked
adjustment claim.
Requirement: Required when available on the claim record.
Data Element: Claim Demonstration Identification Number 2
Definition:
The number assigned to identify a demonstration project.
Validation:
Must be numeric or zeroes
Remarks:
This field contains the value from the second
populated demonstration field.
Requirement:
Required when available on the claim
Data Element: Claim Demonstration Identification Number 3
Definition:
The number assigned to identify a demonstration project.
Validation:
Must be numeric or zeroes
Remarks:
This field contains the value from the third populated demonstration field.
Requirement: Required when available on the claim
Data Element: Claim Demonstration Identification Number 4
Definition:
The number assigned to identify a demonstration project.
Validation:
Must be numeric or zeroes.
Remarks:
This field contains the value from the fourth populated demonstration field.
Requirement: Required when available on the claim.
Data Element:
Beneficiary MBI
Definition:
Beneficiary’s Medicare Beneficiary Identifier
Validation:
Comply with CMS Standards
•
11-character, fixed length alpha-numeric string
•
Different, visibly distinguishable from HICN/RRB numbers
•
Contain no more than 2 consecutive numbers
•
Contain no more than 2 consecutive alphabetic characters
•
Must limit the possibility of letters being interpreted as numbers (i.e.,
alphabetic characters [A…Z]; excluding S, L, O, I, B, Z)
•
Must not contain lowercase letters
•
Must not contain any special characters
Remarks:
Do not include hyphens or spaces
Requirement: Required
Data Element: HICN/MBI Indicator
Definition:
Indicator that identifies if the provider submitted the claim with a HICN or
MBI
Validation:
M = MBI submitted on the claim
H = HICN submitted on the claim
Remarks:
N/A
Requirement: Required
Data Element: Filler
Definition:
Additional space -- use to be determined
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element:
Total Line Item Count
Definition:
Number indicating number of service lines on the claim
Validation:
Must be a number 001 - 450
Remarks:
N/A
Requirement: Required
Data Element:
Record Line Item Count
Definition:
Number indicating number of service lines on this record
Validation:
Must be a number 001 - 100
Remarks:
N/A
Requirement: Required
Claim Line Item Fields
Data Element:
Revenue Center Code
Definition:
Code assigned to each cost center for which a charge is billed.
Validation:
Must be a valid NUBC-approved code.
Must be a valid code as listed in Pub 100-4, Medicare Claims Processing
Manual, Chapter 25, Completing and Processing CMS-1450 Data Set.
Remarks:
Include an entry for revenue code ‘0001’
Requirement: Required
Data Element: NF-RUG-III Code
Definition:
Skilled Nursing Facility Resource Utilization Group Version III (RUG-III)
descriptor. This is the rate code/assessment type that identifies (1) RUG-III
group the beneficiary was classified into as of the Minimum Data Set (MDS)
assessment reference date and (2) the type of assessment for payment
purposes.
Validation:
N/A
Remarks:
N/A
Requirement: Required for SNF inpatient bills
Data Element: APC Adjustment Code
Definition:
The Ambulatory Payment Classification (APC) Code or Home Health
Prospective Payment System (HIPPS) code. The APC codes are the basis for
the calculation of payment of services made for hospital outpatient services,
certain PTB services furnished to inpatients who have no Part A coverage,
CMHCs, and limited services provided by CORFs, Home Health Agencies or to
hospice patients for the treatment of a non-terminal illness.
This field may contain a HIPPS code. If a HHPPS HIPPS code is down coded,
the down coded HIPPS will be reported in this field.
The HIPPS code identifies (1) the three case-mix dimensions of the Home
Health Resource Group (HHRG) system, clinical, functional and utilization,
from which a beneficiary is assigned to one of the 80 HHRG categories and
(2) it identifies whether or not the elements of the code were computed or
derived. The HHRGs, represented by the HIPPS coding, is the basis of
payment for each episode.
Validation:
N/A
Remarks:
Left justify the APC Adjustment Code
Requirement:
Required if present on claim record
Data Element: HCPCS Procedure Code or HIPPS Code
Definition:
The HCPCS/CPT-4 code that describes the service or Health Insurance PPS
(HIPPS) code.
Validation:
Must be a valid HCPCS/CPT-4 or HIPPS code
Remarks:
Healthcare Common Procedure Coding System (HCPCS) is a collection of
codes that represent procedures, supplies, products and services which may
be provided to Medicare beneficiaries and to individuals enrolled in private
health insurance programs
When revenue center code = '0022' (SNF PPS), '0023' (HH PPS), or '0024'
(IRF
PPS); this field contains the Health Insurance PPS (HIPPS) code.
The HIPPS code for SNF PPS contains the rate code/assessment type that
identifies RUG-III group the beneficiary was classified into as of the RAI MDS
assessment reference date and (2) the type of assessment for payment
purposes.
The HIPPS code for Home Health PPS identifies (1) the three case-mix
dimensions of the HHRG system, clinical, functional and utilization, from
which a beneficiary is assigned to one of the 80 HHRG categories and (2) it
identifies whether or not the elements of the code were computed or derived.
The HHRGs, represented by the HIPPS coding, will be the basis of payment
for each episode.
The HIPPS code (CMG Code) for IRF PPS identifies the clinical characteristics
of the beneficiary. The HIPPS rate/CMG code (AXXYY - DXXYY) must contain
five digits. The first position of the code is an A, B, C, or 'D'. The HIPPS code
beginning with an 'A' in front of the CMG is defined as without co-morbidity.
The 'B' in front of the CMG is defined as with co-morbidity for Tier 1. The 'C' is
defined as co-morbidity for Tier 2 and 'D' is defined as co-morbidity for Tier 3.
The 'XX' in the HIPPS rate code is the Rehabilitation Impairment Code (RIC).
The 'YY' is the sequential number system within the RIC.
Requirement:
Required if present on claim record
Data Element:
HCPCS Modifier 1
HCPCS Modifier 2
HCPCS Modifier 3
HCPCS Modifier 4
HCPCS Modifier 5
Definition:
Codes identifying special circumstances related to the service
Validation:
N/A
Remarks:
N/A
Requirement: Required if available
Data Element:
Line Item Date
Definition:
The date the service was initiated
Validation:
Must be a valid date.
Remarks:
Format is CCYYMMDD
Requirement: Required if on bill and included in the shared system
Data Element: Line Submitted Charge
Definition:
Actual charge submitted by the provider or supplier for the service or
equipment
Validation:
N/A
Remarks:
This is a required field. CR3997 provided direction on how to populate this
field if data is not available in the claim record.
Requirement: Required
Data Element: Line Medicare Initial Allowed Charge
Definition:
Amount Medicare allowed for the service or equipment before any reduction or
denial.
Validation:
Must be a numeric value.
Remarks:
This is a required field. Use the value in FISS field FSSCPDCL-REV-COV-CHRG-
AMT to populate this field (per CMS Change Request 3912).
Requirement: Required
Data Element:
ANSI Reason Code 1-14
Definition:
Codes showing the reason for any adjustments to this line, such as denials or
reductions of payment from the amount billed.
Validation:
Must be valid ANSI ASC claim adjustment codes and applicable group codes.
Remarks:
Format is GGRRRRRR where: G is the group code and RRRRRR is the
adjustment reason code.
Requirement: Report all ANSI Reason Codes included on the bill.
Data Element: Manual Medical Review Indicator
Definition:
Code indicating whether or not the service received complex manual medical
review. Complex review goes beyond routine review. It includes the request
for, collection of, and evaluation of medical records or any other
documentation in addition to the documentation on the claim, attached to the
claim, or contained in the MAC’s history file. The review must require
professional medical expertise and must be for the purpose of preventing
payments of non-covered or incorrectly coded services. That includes reviews
for the purpose of determining if services were medically necessary.
Professionals must perform the review, i.e., at a minimum, a Licensed
Practical Nurse must perform the review. Review requiring use of the MAC's
history file does not make the review a complex review. A review is not
considered complex if a medical record is requested from a provider and not
received. If sufficient documentation accompanies a claim to allow complex
review to be done without requesting additional documentation, count the
review as complex. For instance if all relative pages from the patient's
medical record are submitted with the claim, complex MR could be conducted
without requesting additional documentation.
Validation:
Must be ‘Y’ or ’N’
Remarks:
Set to ‘Y’ if service was subjected to complex manual medical review, else ’N’.
Requirement: Required
Data Element: Resolution Code
Definition:
Code indicating how the MAC resolved the line.
Automated Review (AM): An automated review occurs when a claim/line item
passes through the MAC's claims processing system or any adjunct system
containing medical review edits.
Routine Manual Review (MR): Routine review uses human intervention, but
only to the extent that the claim reviewer reviews a claim or any attachment
submitted by the provider. It includes review that involves review of any of
the MAC's internal documentation, such as claims history file or policy
documentation. It does not include review that involves review of medical
records or other documentation requested from a provider. A review is
considered routine if a medical record is requested from a provider and not
received. Include prior authorization reviews in this category.
Complex Manual Review (MC): Complex review goes beyond routine review.
It includes the request for, collection of, and evaluation of medical records or
any other documentation in addition to the documentation on the claim,
attached to the claim, or contained in the MAC’s history file. The review must
require professional medical expertise and must be for the purpose of
preventing payments of non- covered or incorrectly coded services.
Professionals must perform the review, i.e., at a minimum; a Licensed
Practical Nurse must perform the review. Review requiring use of the MAC's
history file does not make the review a complex review. A review is not
considered complex if a medical record is requested from a provider and not
received. If sufficient documentation accompanies a claim to allow complex
review to be done without requesting additional documentation, the review is
complex. For instance if all relevant pages from the patient's medical record
are submitted with the claim, complex MR could be conducted without
requesting additional documentation.
Validation:
Must be ‘APP’, ‘APPMR’, ’APPMC’, ’DENMR’, ‘DENMC’, ’DEO’, ‘RTP’,
‘REDMR’, ‘REDMC’, ‘REO’, ‘DENAM’, ‘REDAM’,’INACT’.
Remarks:
Resolution Code
Description
APP
Approved as a valid submission without
manual medical review.
APPAM
Approved after automated medical review
APPMR
Approved after manual medical review routine
APPMC
Approved after manual medical review complex. If
this code is selected, set the Manual Medial
Review Indicator to 'Y.
DENAM
Denied after automated medical review
DENMR
Denied for medical review reasons or for
insufficient documentation of medical necessity,
manual medical review routine
DENMC
Denied for medical review reasons or for
insufficient documentation medical necessity,
manual medical review complex. If this codes
is selected, set the Manual Medial Review
Indicator to 'Y.'
DEO
Denied for non-medical reasons, other
than denied as unprocessable.
RTP
Denied as unprocessable (return/reject)
REDAM
Reduced after medical review
REDMR
Reduced for medical review reasons or for
insufficient
documentation of medical necessity, manual
medical review routine
REDMC
Reduced for medical review reasons or for
insufficient documentation of medical necessity,
manual medical review complex. If this code is
selected, set the Manual Medial
Review Indicator to 'Y.'
REO
Reduced for non-medical review reasons.
INACT
Claim is inactive as identified by “I” Status
Requirement: Required
Data Element: Final Allowed Charge
Definition:
Final amount paid to the provider for this service or equipment plus patient
responsibility.
Validation:
N/A
Remarks:
N/A
Requirement:
Required
Data Element:
Cash Deductible
Definition:
The amount of cash deductible the beneficiary paid for the line item service.
Validation:
N/A
Remarks:
N/A
Requirement:
Required
Data Element: Special Action/Override Code
Definition:
Code used to identify special actions taken in determining payment of this line
item.
Validation:
Must be valid
Remarks:
N/A
Requirement:
Required
Data Element: Units
Definition:
The total number of services or time periods provided for the line item.
Validation:
N/A
Remarks:
Zero filled to maintain the relative position of the decimal point. The last
three positions should contain the value to the right of the decimal in the
number of services. Put a zero in the last three positions for whole numbers.
For example if the number of units is 10, this field would be filled as
0000010000.
Requirement:
Required
Data Element:
Rendering Physician NPI
Definition:
NPI assigned to the Rendering Physician.
Validation:
N/A
Remarks:
Left justify
Requirement: Required when available on claim record.
Data Element: Rendering Physician Last Name
Definition:
Last Name (Surname) of the rendering physician.
Validation:
Must be present
Remarks:
N/A
Requirement: Required when available on claim record
Data Element: National Drug Code (NDC) field
Definition:
To be assigned at a later date.
Validation:
N/A
Remarks:
Left justify
Requirement: Required when available on claim record.
Data Element: National Drug Code (NDC) Quantity Qualifier
Definition:
To be assigned at a later date.
Validation:
Must be present.
Remarks:
N/A
Requirement: Required when available on claim record.
Data Element: National Drug Code (NDC) Quantity
Definition:
To be assigned at a later date.
Validation:
Must be present.
Remarks:
Zero filled to maintain the relative position of the decimal point.
For example, if the number of units is 10, this field would be filled as
0000010000.
Requirement: Required when available on claim record.
Data Element: PWK Filler
Definition:
PWK space -- use to be determined.
Validation:
N/A
Remarks:
N/A
Requirement: Required when available on claim
Data Element:
Rendering Physician Specialty
Definition:
Code indicating the primary specialty of the rendering physician.
Validation:
N/A
Remarks:
Enter zeros if the rendering physician specialty is not available
Requirement: Required when available on the claim record.
Data Element: Prior Authorization Program Indicator
Definition:
Prior Authorization Program Indicator issued by CMS to identify to which PA
program the service belongs
Validation:
Four character alphanumeric
• The first character identifies the line of business
• A for Part A,
• B for Part B,
• D for DME,
• H for Home Health and Hospice
• Followed by a three digit number.
Remarks:
N/A
Requirement:
Required for claims containing services subject to a prior authorization
program.
Data Element: Unique Tracking Number (UTN)
Definition:
Unique Tracking Number (UTN) assigned to the prior authorization request for
the service or item.
Validation:
UTN shall be 14 characters and use the following format:
• First two characters = MAC identifier (e.g., RR for Railroad, 0F for Jurisdiction
F, 05 for Jurisdiction 5, etc.).
• Third character = line of business (e.g., A for Part A, B for Part
B, D for DME, H for Home Health and Hospice).
• Remaining numerical characters = a unique sequence number assigned by
the Shared System.
Remarks:
N/A
Requirement:
Required for claims containing services covered by an affirmed prior
authorization.
Data Element:
Prior Auth Affirmed
Definition:
Code to identify if the prior authorization for the service(s) on this line was
affirmed.
Validation:
• Y indicates the prior authorization was affirmed.
N indicates the prior authorization was not affirmed.
Default value is blank for claims that are not part of prior authorization
demonstration.
Remarks:
N/A
Requirement: Required for claims containing services subject to prior authorization in the
state
where the service was furnished.
Data Element: Filler
Definition:
Additional space -- use to be determined
Validation:
N/A
Remarks:
N/A
Requirement: Required
Claims Resolution File
Claims Resolution Trailer Record (one record per file)
DATA ELEMENT DETAIL
Data Element:
Contractor ID
Definition:
Contractor’s CMS assigned number.
Validation:
Must be a valid CMS contractor ID.
Remarks:
N/A
Requirement:
Required
NOTE:
For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single
processing environment, the Contractor ID will reflect the roll-up Contractor
ID specified by CMS.
Data Element:
Record Type
Definition:
Code indicating type of record.
Validation:
N/A
Remarks:
3 = Trailer Record
Requirement: Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Resolution file.
Validation:
Claim Resolution files prior to 10/1/2007 did not contain this field.
Codes:
B = Record Format as of 10/1/2007
C = Record Format as of 1/1/2010
D = Record Format as of 10/1/2012
E = Record Format as of 7/1/2016
F = Record Format as of 10/1/2017
Remarks:
N/A
Requirement: Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor included in the file
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
‘3’
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Number of Claims
9(9)
9
17
Zeroes
Validation:
Must be ‘A’ or ‘R’.
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should
be ‘R’.
All others will be contractor type ‘A’.
Remarks:
A = A/B MAC (A) only
R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)
Requirement: Required
Data Element:
Number of Claims
Definition:
Number of claim records on this file
Validation:
Must be equal to the number of claim records on the file
Remarks:
Do not count header or trailer records
Requirement:
Required
Claims Provider Address File
Claims Provider Address Header Record (one record per file)
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
‘1’
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Provider Address Date
X(8)
9
16
Spaces
DATA ELEMENT DETAIL
Data Element: Contractor ID
Definition:
Contractor’s CMS assigned number
Validation:
Must be a valid CMS contractor ID
Remarks:
N/A
Requirement:
Required
NOTE:
For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single
processing environment, the Contractor ID will reflect the roll-up Contractor
ID specified by CMS
Data Element: Record Type
Definition:
Code indicating type of record
Validation:
N/A
Remarks:
1 = Header record
Requirement: Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Provider Address file
Validation:
Claim Provider Address files prior to 10/1/2007 did not contain this field.
Codes:
B = Record Format as of 10/1/2007
C = Record Format as of 1/1/2010
D = Record Format as of 10/1/2012
E = Record Format as of 7/1/2016
Remarks:
N/A
Requirement: Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor included in the file
Validation:
Must be ‘A’ or ‘R’
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should
be ‘R’.
All others will be contractor type ‘A’.
Remarks:
A = A/B MAC (A) only
R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)
Requirement: Required
Data Element:
Provider Address Date
Definition:
Date the Provider Address File was created.
Validation:
Must be a valid date not equal to a Provider Address date
sent on any previous claims Provider Address file
Remarks:
Format is CCYYMMDD. May use shared system batch processing date
Requirement: Required
Provider Address File
Provider Address Detail Record
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
Spaces
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Sequence Number
X(1)
9
9
Spaces
Provider Number
X(15)
10
24
Spaces
Provider Name
X(60)
25
84
Spaces
Provider Address 1
X(25)
85
109
Spaces
Provider Address 2
X(25)
110
134
Spaces
Provider City
X(15)
135
149
Spaces
Provider State Code
X(2)
150
151
Spaces
Provider Zip Code
X(9)
152
160
Spaces
Provider Phone Number
X(10)
161
170
Spaces
Provider Phone Number Extension
X(10)
171
180
Spaces
Provider FAX Number
X(10)
181
190
Spaces
Provider Type
X(1)
191
191
Spaces
Provider Address Type
9(3)
192
194
1
Provider E-mail Address
X(75)
195
269
Spaces
Provider Federal Tax number or EIN
9(10)
270
279
Zeroes
Filler
X(16)
280
295
Spaces
DATA ELEMENT DETAIL
Data Element: Contractor ID
Definition:
Contractor’s CMS assigned number
Validation:
Must be a valid CMS contractor ID
Remarks:
N/A
Requirement:
Required
NOTE:
For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single
processing environment, the Contractor ID will reflect the roll-up Contractor ID
specified by CMS
Data Element: Record Type
Definition:
Code indicating type of record
Validation:
N/A
Remarks:
2 = Detail record
Requirement: Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Provider Address file
Validation:
Claim Provider Address files prior to 10/1/2007 did not contain this field.
Codes:
B = Record Format as of 10/1/2007
C = Record Format as of 1/1/2010
D = Record Format as of 10/1/2012
E = Record Format as of 10/1/2017
Remarks:
N/A
Requirement: Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor included in the file
Validation:
Must be ‘A’ or ‘R’.
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should
be ‘R’.
All others will be contractor type ‘A’.
Data Element: Sequence Number
Definition:
Number occurrence number of addresses when there are multiple addresses
for a provider.
Validation:
Must be between 1 and 3
Remarks:
Enter 1 if there is only one address for a provider
Requirement: Required
Data Element: Provider Number
Definition:
Number assigned by Medicare to identify the provider
Validation:
N/A
Remarks:
Left justify
Requirement: Required
Data Element: Provider Name
Definition:
Provider's name
Validation:
N/A
Remarks:
This is the business name associated with the provider number. Must be
formatted into a name for mailing (e. g., Roger A Smith M.D. or Medical
Associates, Inc.)
Requirement: Required
Data Element: Provider Address 1
Definition:
First line of provider's address
Validation:
N/A
Remarks:
This is the first line of the address associated with the provider number
indicated in the record.
Requirement: Required for all Billing Provider Numbers. Furnish as available
for other types of provider numbers.
Data Element: Provider Address 2
Definition:
Second line of provider’s address
Validation:
N/A
Remarks:
This is the line of the address associated with the provider number indicated
in the record.
Requirement: Required for all Billing Provider Numbers. Furnish as available for other types
of provider numbers.
Data Element: Provider City
Definition:
Provider’s city name
Validation:
N/A
Remarks:
This is the city of the provider number
Requirement: Required for Billing Provider Numbers. Furnish as available for other types of
provider numbers.
Data Element: Provider State Code
Definition:
Provider's state code
Validation:
Must be a valid state code
Remarks:
This is the state associated with the address of the provider number.
Requirement: Required for Billing Provider Numbers. Furnish as available for other types of
provider numbers.
Data Element: Provider Zip Code
Definition:
Provider's zip code
Validation:
Must be a valid postal zip code
Remarks:
This is the zip code associated with the address furnished for the provider
number identified in this record.
Provide 9-digit zip code if available, otherwise provide 5-digit zip code.
Requirement: Required for Billing Provider Numbers. Furnish as available for other types of
provider numbers.
Data Element: Provider Phone Number
Definition:
Provider's phone number
Validation:
Must be a valid phone number
Remarks:
N/A
Requirement: Required if available
Data Element: Provider Phone Number Extension
Definition:
Provider's phone number extension
Validation:
Must be a valid phone number
Remarks:
N/A
Requirement: Required if available
Data Element: Provider Fax Number
Definition:
Provider’s fax number
Validation:
Must be a valid fax number
Remarks:
N/A
Requirement: Required if available
Data Element: Provider Type
Definition:
1=Billing Provider Number (OSCAR)
2=Attending Physician Number (UPIN)
3=Operating Physician Number (UPIN)
4=Other Physician Number (UPIN)
5=Billing Provider NPI
6=Attending Physician NPI
7=Operating Physician NPI
8=Rendering Physician NPI
Validation:
Must be 1-8.
Remarks:
This field identifies the type of provider number whose name, address, phone
number and identification information are included in the record.
Requirement: Required
Data Element: Provider Address Type
Definition:
The type of Provider Address furnished.
Validation:
1 = Master Address (FISS)
2 = Remittance Address (FISS)
3 = Check Address (FISS) (APASS)
4 = MSP Other Address (FISS)
5 = Medical Review Address (FISS) (APASS)
6 = Other Address (FISS) (APASS)
7 = Chain Address (APASS)
8 = Correspondence Address
9 = Medical Record Address
Remarks:
The first “address type” for each provider will always be a “1.”
Subsequent occurrences of addresses for the same provider will have the
“address type” to correspond to the address submitted. When your files
contain only one address for the provider, submit only one provider address
record. Submit additional address records for a single provider number only
when your files contain addresses that differ from the Master or Legal
address.
Correspondence Address—The Correspondence Address as indicated on the
855A. This is the address and telephone number where Medicare can directly
get in touch with the enrolling provider. This address cannot be that of the
billing agency, management service organization, or staffing company.
Medical Record Address—the Location of Patients’ Medical Records as
indicated on the 855A. This information is required if the Patients’ Medical
Records are stored at a location other than the Master Address (practice
location). Post Office Boxes and Drop Boxes are not acceptable as the
physical address where patient’s medical records are maintained.
Requirement:
Required Billing Provider Numbers. Furnish as available for
other types of provider numbers.
Data Element: Provider E-Mail Address
Definition:
Provider’s e-mail address.
Validation:
Must be a valid e-mail address.
Remarks:
N/A
Requirement: Required if available.
Data Element: Provider Federal Tax Number or EIN
Definition:
The number assigned to the billing provider by the Federal government for
tax report purposes. The Federal Tax Number is also known as a tax
identification number (TIN) or employer identification number (EIN).
Validation:
Must be present
Remarks:
N/A
Requirement: Required for all Billing Provider Numbers. For all other types of provider
numbers, the tax number is required when available
Data Element: Filler
Definition:
Additional space -- use to be determined
Validation:
N/A
Remarks:
N/A
Requirement: Required
Claims Provider Address File
Claims Provider Address Trailer Record (one record per file)
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
‘3’
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Number of Records
9(9)
9
17
Zeroes
DATA ELEMENT DETAIL
Data Element: Contractor ID
Definition:
Contractor’s CMS assigned number.
Validation:
Must be a valid CMS contractor ID.
Remarks:
N/A
Requirement:
Required
NOTE:
For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single
processing environment, the Contractor ID will reflect the roll-up Contractor
ID specified by CMS.
Data Element: Record Type
Definition:
Code indicating type of record
Validation:
N/A
Remarks:
3 = Trailer Record
Requirement: Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Universe file
Validation:
Claim Universe files prior to 10/1/2007 did not contain this field.
Codes:
B = Record Format as of 10/1/2007
C = Record Format as of 1/1/2010
D = Record Format as of 10/1/2012
E = Record Format as of 10/1/2017
Remarks:
N/A
Requirement: Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor included in the file
Validation:
Must be ‘A’ or ‘R’
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should
be ‘R’.
All others will be contractor type ‘A’.
Remarks:
A = A/B MAC (A) only
R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)
Requirement: Required
Data Element: Number of Records
Definition:
Number of provider address records on this file
Validation:
Must be equal to the number of provider address records on the file
Remarks:
Do not count header or trailer records
Requirement: Required
Exhibit 36.2
(Rev. 726, Issued: 06-16-17, Effective: 10-01-17, Implementation: 01-02-18 - For VMS and
MCS for Business Requirements 11 through 22 and 22.1; 10-02-17 - For FISS)
Claims Universe File
Claims Universe Header Record (one record per file)
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
‘1’
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Universe Date
X(8)
9
16
Spaces
DATA ELEMENT DETAIL
Data Element: Contractor ID
Definition: Contractor’s CMS assigned number.
Validation: Must be a valid CMS contractor ID.
Remarks:
N/A
Requirement: Required
NOTE:
For A/B MAC (B): when multiple workloads share a single
processing environment, the Contractor ID will reflect the contractor
ID of the primary workload.
Data Element: Record Type
Definition:
Code indicating type of record.
Validation:
N/A
Remarks:
1 = Header record
Requirement: Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Universe file.
Validation:
Claim Universe files prior to 7/1/2007 did not contain this field.
Codes:
B = Record Format as of 7/1/2007
C = Record Format as of 10/1/2017
Remarks:
N/A
Requirement: Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor
Validation:
Must be ‘B’ or ‘D’
Remarks:
B = A/B MAC (B)
D = DME MAC
Requirement: Required
Data Element: Universe Date
Definition:
Date the universe of claims entered the shared system.
Validation:
Must be a valid date not equal to a universe date sent on any previous
claims universe file.
Remarks:
Format is CCYYMMDD.
Shared System logic may use shared system batch processing date as long as
the date is not equal to the universe date sent on any previous claims universe
file.
Requirement: Required
Claims Universe File
Claims Universe Claim Detail Record
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
"2"
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Claim Control Number
X(15)
9
23
Spaces
Beneficiary HICN
X(12)
24
35
Spaces
Billing Provider NPI
X(10)
36
45
Spaces
Claim Submitted Charge Amount
S9(7)v99
46
54
Zeroes
Claim Demonstration Number
X(2)
55
56
Spaces
Claim State
X(2)
57
58
Spaces
Beneficiary State
X(2)
59
60
Spaces
Billing Provider Specialty
X(2)
61
62
Spaces
Beneficiary MBI
X(11)
63
73
Spaces
HICN/MBI Indicator
X(1)
74
74
Spaces
Filler
X(3)
75
77
Spaces
Line Item Count
9(2)
78
79
Zeroes
Claims Universe File
Claims Universe Claim Line Item Detail Record
*Line Item group: The following group of Fields occurs from 1 to 52 Times (depending on Line
Item Count).
*From and Thru values relate to the 1st line item
Field Name
Picture
From
Thru
Initialization
Performing Provider Number
X(15)
80
94
Spaces
Performing Provider Specialty
X(2)
95
96
Spaces
HCPCS Procedure Code
X(5)
97
101
Spaces
From Date of Service
X(8)
102
109
Spaces
To Date of Service
X(8)
110
117
Spaces
Line Submitted Charge
S9(7)v99
118
126
Zeroes
Performing Provider NPI
X(10)
127
136
Spaces
DATA ELEMENT DETAIL
Claim Header Fields
Data Element: Contractor ID
Definition: Contractor’s CMS assigned number
Validation: Must be a valid CMS contractor ID
Remarks:
N/A
Requirement: Required
NOTE:
For A/B MAC (B): when multiple workloads share a single
processing environment, the Contractor ID will reflect the contractor
ID of the primary workload.
Data Element: Record Type
Definition:
Code indicating type of record
Validation:
N/A
Remarks:
2 = claim record
Requirement: Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Universe file
Validation:
Claim Universe files prior to 7/1/2007 did not contain this field.
Codes:
B = Record Format as of 7/1/2007
C = Record Format as of 10/1/2017
Remarks:
N/A
Requirement: Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor
Validation:
Must be ‘B’ or ‘D’
Remarks:
B = A/B MAC (B)
D = DME MAC
Requirement: Required
Data Element: Claim Control Number
Definition:
Number assigned by the shared system to uniquely identify the claim.
Validation:
The required format for the Claim Control Number is different for each
claim type.
DME: must be 15 digits with a leading 1 as filler.
Part B: must be 15 digits, with two leading zeros as filler.
Remarks:
N/A
Requirement: Required
Data Element: Beneficiary HICN
Definition:
Beneficiary’s Health Insurance Claim Number.
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: Billing Provider NPI
Definition:
NPI assigned to the Billing Provider.
Validation:
N/A
Remarks:
N/A.
Requirement: Required.
Data Element: Claim Submitted Charge Amount
Definition:
The total submitted charges on the claim (the sum of line item
submitted charges).
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: Claim Demonstration Number
Definition:
Also known as Claim Demonstration Identification Number. The number
assigned to identify a demonstration Project. This field is also used to denote
special processing (a.k.a. Special Processing Number, SPN).
Validation:
Must be a Valid Demo ID.
Remarks:
N/A
Requirement: Required when available on claim.
Data Element: Claim State
Definition:
State abbreviation identifying the state in which the service is furnished.
Validation:
Must be a valid 2 digit state abbreviation as defined by the United States
Postal Service (USPS).
Remarks:
When services on a single claim are furnished in multiple states, enter the state
identifier for the first detail line.
Requirement: Required for all Part B Claims. For DME claims, required if available.
Data Element: Beneficiary State
Definition:
State abbreviation identifying the state in which the beneficiary resides.
Validation:
Must be a valid 2 digit state abbreviation as defined by the United States
Postal Service (USPS).
Remarks:
N/A
Requirement: Required, when available.
Data Element: Billing Provider Specialty
Definition:
Code indicating the primary specialty of the Billing provider or supplier.
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: Beneficiary MBI
Definition:
Beneficiary’s Medicare Beneficiary Identifier
Validation:
Comply with CMS Standards
11-character, fixed length alpha-numeric string.
Different, visibly distinguishable from HICN/RRB numbers.
Contain no more than 2 consecutive numbers.
Contain no more than 2 consecutive alphabetic characters.
Must limit the possibility of letters being interpreted as
numbers (i.e., alphabetic characters [A…Z]; excluding S, L, O, I, B, Z).
Must not contain lowercase letters.
Must not contain any special characters.
Remarks:
Do not include hyphens or spaces.
Requirement: Required
Data Element: HICN/MBI Indicator
Definition:
Indicator that identifies if the provider submitted the claim with a HICN or MBI.
Validation:
M = MBI submitted on the claim
H = HICN submitted on the claim
Remarks:
N/A
Requirement: Required
Data Element: Filler
Definition:
Additional space -- use to be determined
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: Line Item Count
Definition:
Number indicating number of service lines on the claim.
Validation:
Must be a number 01 – 52.
Remarks:
N/A
Requirement: Required
Claim Line Item Fields
Data Element: Performing Provider Number
Definition:
Number assigned by the NSC or MAC to identify the provider who performed the
service or the supplier who supplied the medical equipment.
Validation:
N/A
Remarks:
Enter the PIN of the performing provider. When several different
providers of service or suppliers are billing on the same claim, show the
individual PIN in the corresponding line item.
Requirement: Required
Data Element: Performing Provider Specialty
Definition:
Code indicating the primary specialty of the performing provider or
supplier.
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: HCPCS Procedure Code
Definition:
The HCPCS/CPT-4 code that describes the service.
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: From Date of Service
Definition:
The date the service was initiated.
Validation:
Must be a valid date less than or equal to To Date of Service.
Remarks:
Format is CCYYMMDD
Requirement: Required
Data Element: To Date of Service
Definition:
The date the service ended.
Validation:
Must be a valid date greater than or equal to From Date of Service.
Remarks:
Format is CCYYMMDD
Requirement: Required
Data Element: Line Submitted Charge
Definition:
Actual charge submitted by the provider or supplier for the service or
equipment.
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: Performing Provider NPI
Definition:
NPI assigned to the Performing Provider.
Validation:
N/A
Remarks:
N/A.
Requirement: Required
Claims Universe File
Claims Universe Trailer Record (one record per file)
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
‘3’
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Number of Claims
9(9)
9
17
Zeroes
DATA ELEMENT DETAIL
Data Element: Contractor ID
Definition: Contractor’s CMS assigned number.
Validation: Must be a valid CMS contractor ID.
Remarks:
N/A
Requirement: Required
NOTE:
For A/B MAC (B): when multiple workloads share a single processing
environment, the Contractor ID will reflect the contractor ID of the
primary workload.
Data Element: Record Type
Definition:
Code indicating type of record
Validation:
N/A
Remarks:
3 = Trailer Record
Requirement: Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Universe file
Validation:
Claim Universe files prior to 7/1/2007 did not contain this field.
Codes:
B = Record Format as of 7/1/2007
C = Record Format as of 10/1/2017
Remarks:
N/A
Requirement: Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor
Validation:
Must be ‘B’ or ‘D’
Remarks:
B = A/B MAC (B)
D = DME MAC
Requirement: Required
Data Element: Number of Claims
Definition:
Number of claim records on this file
Validation:
Must be equal to the number of claim records on the file
Remarks:
Do not count header or trailer records
Requirement: Required
Claims Transaction File
Claims Transaction Header Record (one record per file)
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
‘1’
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Transaction Date
X(8)
9
16
Spaces
DATA ELEMENT DETAIL
Data Element: Contractor ID
Definition: Contractor’s CMS assigned number
Validation: Must be a valid CMS contractor ID
Remarks:
N/A
Requirement: Required
NOTE:
For A/B MAC (B): when multiple workloads share a single processing
environment, the Contractor ID will reflect the contractor ID of the
primary workload.
Data Element: Record Type
Definition:
Code indicating type of record
Validation:
N/A
Remarks:
1 = Header record
Requirement: Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Transaction file
Validation:
Claim Transaction files prior to 7/1/2007 did not contain this field.
Codes:
B = Record Format as of 7/1/2007
Remarks:
N/A
Requirement: Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor
Validation:
Must be ‘B’ or ‘D’
Remarks:
B = A/B MAC (B)
D = DME MAC
Requirement: Required
Data Element: Transaction Date
Definition:
Date the Transaction File was created
Validation:
Must be a valid date not equal to a Transaction date sent on any previous claims
Transaction file.
Remarks:
Format is CCYYMMDD. May use shared system batch processing date.
Requirement: Required
Sampled Claims Transaction File
Sampled Claims Transaction File Detail Record
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
‘2’
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Claim Control Number
X(15)
9
23
Spaces
Beneficiary HICN
X(12)
24
35
Spaces
DATA ELEMENT DETAIL
Data Element: Contractor ID
Definition: Contractor’s CMS assigned number.
Validation: Must be a valid CMS contractor ID.
Remarks:
N/A
Requirement: Required
NOTE:
For A/B MAC (B): when multiple workloads share a single processing
environment, the Contractor ID will reflect the contractor ID of the
primary workload.
Data Element: Record Type
Definition:
Code indicating type of record
Validation:
N/A
Remarks:
2 = claim record
Requirement: Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Universe file.
Validation:
Claim Universe files prior to 7/1/2007 did not contain this field.
Codes:
B = Record Format as of 7/1/2007
Remarks:
N/A
Requirement: Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor.
Validation:
Must be ‘B’ or ‘D’
Remarks:
B = A/B MAC (B)
D = DME MAC
Requirement: Required
Data Element: Claim Control Number
Definition:
Number assigned by the shared system to uniquely identify the claim.
Validation:
N/A
Remarks:
Reflects the Claim Control Number selected from the Claim Universe file in
the sampling process.
Requirement: Required
Data Element: Beneficiary HICN
Definition:
Beneficiary’s Health Insurance Claim Number
Validation:
N/A
Remarks:
Reflects the Beneficiary HICN on the claim record selected from the
Claim Universe file in the sampling process
Requirement: Required
Claims Transaction File
Claims Transaction Trailer Record (one record per file)
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
‘3’
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Number of Claims
9(9)
9
17
Zeroes
DATA ELEMENT DETAIL
Data Element: Contractor ID
Definition: Contractor’s CMS assigned number
Validation: Must be a valid CMS contractor ID
Remarks:
N/A
Requirement: Required
NOTE:
For A/B MAC (B): when multiple workloads share a single processing
environment, the Contractor ID will reflect the contractor ID of the
primary workload.
Data Element: Record Type
Definition:
Code indicating type of record.
Validation:
N/A
Remarks:
3 = Trailer Record
Requirement: Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Universe file.
Validation:
Claim Universe files prior to 7/1/2007 did not contain this field.
Codes:
B = Record Format as of 7/1/2007
Remarks:
N/A
Requirement: Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor.
Validation:
Must be ‘B’ or ‘D’
Remarks:
B = A/B MAC (B)
D = DME MAC
Requirement: Required
Data Element: Number of Claims
Definition:
Number of claim records on this file.
Validation:
Must be equal to the number of claim records on the file.
Remarks:
Do not count header or trailer records.
Requirement: Required
Claims Resolution File
Claims Resolution Header Record (one record per file)
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
‘1’
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Resolution Date
X(8)
9
16
Spaces
DATA ELEMENT DETAIL
Data Element: Contractor ID
Definition: Contractor’s CMS assigned number.
Validation: Must be a valid CMS contractor ID.
Remarks:
N/A
Requirement: Required
NOTE:
For A/B MAC (B): when multiple workloads share a single processing
environment, the Contractor ID will reflect the contractor ID of the
primary workload.
Data Element: Record Type
Definition:
Code indicating type of record.
Validation:
N/A
Remarks:
1 = Header record
Requirement: Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Resolution file.
Validation:
Claim Resolution files prior to 7/1/2007 did not contain this field.
Codes:
B = Record Format as of 7/1/2007
C = Record Format as of 1/1/2010
D = Record Format as of 7/1/2016
E = Record Format as of 10/1/2017
Remarks:
N/A
Requirement: Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor
Validation:
Must be ‘B’ or ‘D’
Remarks:
B = A/B MAC (B)
D = DME MAC
Requirement: Required
Data Element: Resolution Date
Definition:
Date the Resolution Record was created.
Validation:
Must be a valid date not equal to a Resolution date sent on any previous
claims Resolution file.
Remarks:
Format is CCYYMMDD. May use shared system batch processing date.
Requirement: Required
Sampled Claims Resolution File
Sampled Claims Resolution Detail Record (one record per claim)
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
“2”
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Assignment Indicator
X(1)
9
9
Spaces
Mode of Entry Indicator
X(1)
10
10
Spaces
Original Claim Control Number
X(15)
11
25
Spaces
Claim Control Number
X(15)
26
40
Spaces
Beneficiary HICN
X(12)
41
52
Spaces
Beneficiary Last Name
X(60)
53
112
Spaces
Beneficiary First Name
X(35)
113
147
Spaces
Beneficiary Middle Initial
X(1)
148
148
Spaces
Beneficiary Date Of Birth
X(8)
149
156
Spaces
Billing Provider Number
X(15)
157
171
Spaces
Field Name
Picture
From
Thru
Initialization
Referring/Ordering UPIN
X(6)
172
177
Spaces
Claim Allowed Amount
S9(7)v99
178
186
Zeroes
Claim ANSI Reason Code 1
X(8)
187
194
Spaces
Claim ANSI Reason Code 2
X(8)
195
202
Spaces
Claim ANSI Reason Code 3
X(8)
203
210
Spaces
Claim Entry Date
X(8)
211
218
Spaces
Claim Adjudicated Date
X(8)
219
226
Spaces
Beneficiary Gender
X(1)
227
227
Spaces
Billing Provider NPI
X(10)
228
237
Spaces
Referring/Ordering Provider NPI
X(10)
238
247
Spaces
Claim Paid Amount
S9(7)v99
248
256
Zeroes
Beneficiary Paid Amount
S9(7)v99
257
265
Zeroes
Claim Diagnosis Code 1
X(7)
266
272
Spaces
Claim Diagnosis Code 1Version
Indicator Code
X(1)
273
273
Spaces
Claim Diagnosis Code 2
X(7)
274
280
Spaces
Claim Diagnosis Code 2Version
Indicator Code
X(1)
281
281
Spaces
Claim Diagnosis Code 3
X(7)
282
288
Spaces
Claim Diagnosis Code 3Version
Indicator Code
X(1)
289
289
Spaces
Claim Diagnosis Code 4
X(7)
290
296
Spaces
Claim Diagnosis Code 4Version
Indicator Code
X(1)
297
297
Spaces
Claim Diagnosis Code 5
X(7)
298
304
Spaces
Claim Diagnosis Code 5Version
Indicator Code
X(1)
305
305
Spaces
Claim Diagnosis Code 6
X(7)
306
312
Spaces
Claim Diagnosis Code 6Version
Indicator Code
X(1)
313
313
Spaces
Claim Diagnosis Code 7
X(7)
314
320
Spaces
Claim Diagnosis Code 7Version
Indicator Code
X(1)
321
321
Spaces
Claim Diagnosis Code 8
X(7)
322
328
Spaces
Claim Diagnosis Code 8Version
Indicator Code
X(1)
329
329
Spaces
Claim Diagnosis Code 9
X(7)
330
336
Spaces
Claim Diagnosis Code 9Version
Indicator Code
X(1)
337
337
Spaces
Claim Diagnosis Code 10
X(7)
338
344
Spaces
Claim Diagnosis Code 10Version
Indicator Code
X(1)
345
345
Spaces
Claim Diagnosis Code 11
X(7)
346
352
Spaces
Claim Diagnosis Code 11Version
Indicator Code
X(1)
353
353
Spaces
Claim Diagnosis Code 12
X(7)
354
360
Spaces
Claim Diagnosis Code 12Version
Indicator Code
X(1)
361
361
Spaces
Claim Zip Code
X(9)
362
370
Spaces
Claim Pricing State
X(2)
371
372
Spaces
Field Name
Picture
From
Thru
Initialization
Beneficiary Zip Code
X(9)
373
381
Spaces
Beneficiary State
X(2)
382
383
Spaces
Claim Demonstration Number
X(2)
384
385
Spaces
RAC Adjustment Indicator
X(1)
386
386
Spaces
Split/Adjustment Indicator
X(2)
387
388
Spaces
Facility NPI
X(10)
389
398
Spaces
Claim PWK
X(60)
399
458
Spaces
Claim Demonstration Identification
Number2
X(2)
459
460
Spaces
Claim Demonstration Identification
Number3
X(2)
461
462
Spaces
Claim Demonstration Identification
Number4
X(2)
463
464
Spaces
Beneficiary MBI
X(11)
465
475
Spaces
HICN/MBI indicator
X(1)
476
476
Spaces
Line Item Count
9(2)
477
478
Zeroes
Filler
X(32)
479
510
Spaces
Sampled Claims Resolution File
Sampled Claims Resolution Line Item Detail Group
*The following group of fields occurs from 1 to 13 times (Depending on Line Item Count).
*From and Thru values relate to the 1st line item
Field Name
Picture
From
Thru
Initialization
Performing Provider Number
X(15)
511
525
Spaces
Performing Provider Specialty
X(2)
526
527
Spaces
HCPCS Procedure Code
X(5)
528
532
Spaces
HCPCS Modifier 1
X(2)
533
534
Spaces
HCPCS Modifier 2
X(2)
535
536
Spaces
HCPCS Modifier 3
X(2)
537
538
Spaces
HCPCS Modifier 4
X(2)
539
540
Spaces
Number of Services
S9(7)v999 541
550
Zeroes
Service From Date
X(8)
551
558
Spaces
Service To Date
X(8)
559
566
Spaces
Place of Service
X(2)
567
568
Spaces
Type of Service
X(1)
569
569
Spaces
Diagnosis Code
X(7)
570
576
Spaces
Line Diagnosis Code Version
Indicator Code
X(1)
577
577
Spaces
CMN Control Number
X(15)
578
592
Spaces
Line Submitted Charge
S9(7)v99
593
601
Zeroes
Line Medicare Initial Allowed
S9(7)v99
602
610
Zeroes
ANSI Reason Code 1
X(8)
611
618
Spaces
ANSI Reason Code 2
X(8)
619
626
Spaces
ANSI Reason Code 3
X(8)
627
634
Spaces
ANSI Reason Code 4
X(8)
635
642
Spaces
ANSI Reason Code 5
X(8)
643
650
Spaces
ANSI Reason Code 6
X(8)
651
658
Spaces
ANSI Reason Code 7
X(8)
659
666
Spaces
Field Name
Picture
From
Thru
Initialization
Manual Medical Review Indicator
X(1)
667
667
Space
Resolution Code
X(5)
668
672
Spaces
Line Final Allowed Charge
S9(7)v99
673
681
Zeroes
Performing Provider NPI
X(10)
682
691
Spaces
Performing Provider UPIN
X(6)
692
697
Spaces
Miles/Time/Units/Services Indicator
Code
X(1)
698
698
Spaces
Line Deductible Applied
S9(7)v99
699
707
Zeroes
Line Co-Insurance
S9(7)V99
708
716
Zeroes
Line Paid Amount
S9(7)v99
717
725
Zeroes
Line MSP Code
X(1)
726
726
Spaces
Line MSP Paid Amount
S9(7)v99
727
735
Zeroes
Line Pricing Locality
X(2)
736
737
Spaces
Line Zip Code
X(9)
738
746
Spaces
Line Pricing State Code
X(2)
747
748
Spaces
Ambulance Point of Pick up Zip
X(9)
749
757
Spaces
Ambulance Point of Drop Off Zip
Code
X(9)
758
766
Spaces
Line PWK
X(60)
767
826
Spaces
Prior Authorization Program
X(4)
827
830
Spaces
Unique Tracking Number (UTN)
X(14)
831
844
Spaces
Prior Authorization Affirmed
Indicator
X(1)
845
845
Spaces
Filler
X(6)
846
851
Spaces
DATA ELEMENT DETAIL
Claim (Header) Fields
Data Element: Contractor ID
Definition: Contractor’s CMS assigned number
Validation: Must be a valid CMS contractor ID
Remarks:
N/A
Requirement: Required
NOTE:
For A/B MAC (B): when multiple workloads share a single processing
environment, the Contractor ID will reflect the contractor ID of the
primary workload.
Data Element: Record Type
Definition:
Code indicating type of record
Validation:
N/A
Remarks:
2 = Claim record
Requirement: Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Resolution file.
Validation:
Claim Resolution files prior to 7/1/2007 did not contain this field.
Codes:
B = Record Format as of 7/1/2007
C = Record Format as of 1/1/2010
D = Record Format as of 7/1/2016
E = Record Format as of 10/1/2017
Remarks:
N/A
Requirement: Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor.
Validation:
Must be ‘B’ or ‘D’
Remarks:
B = A/B MAC (B)
D = DME MAC
Requirement: Required
Data Element: Assignment Indicator
Definition:
Code indicating whether claim is assigned or non-assigned.
Validation:
Must be ’A’ or ’N’
Remarks:
A = Assigned
N = Non-assigned
Requirement: Required
Data Element: Mode of Entry Indicator
Definition:
Code that indicates if the claim is paper or EMC.
Validation:
Must be ’E’ or ‘P’
Remarks:
E = EMC P = Paper
Use the same criteria to determine EMC or paper as that used for
workload reporting.
Requirement: Required
Data Element: Original Claim Control Number
Definition:
The Claim Control Number the shared system assigned to the claim in
the Universe file. This number should be the same as the claim control
number for the claim in the Sample Claims Transactions file, and the
claim control
number for the claim on the Universe file. If the shared
system had to use a
crosswalk to pull the claim because the MAC or
shared system changed the claim
control number during processing,
enter the number the shared system used to look up the number needed
to pull all records associated with the sample claim.
Validation:
Must match the Claim Control Number identified in the Sampled
Claims Transaction File.
Remarks:
N/A
Requirement: Required
Data Element: Claim Control Number
Definition:
Number assigned by the shared system to uniquely identify the claim.
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: Beneficiary HICN
Definition:
Beneficiary’s Health Insurance Claim Number.
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: Beneficiary Last Name
Definition:
Last Name (Surname) of the beneficiary.
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: Beneficiary First Name
Definition:
First (Given) Name of the beneficiary.
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: Beneficiary Middle Initial
Definition:
First letter from Beneficiary Middle Name.
Validation:
N/A
Remarks:
N/A
Requirement: Required when available
Data Element: Beneficiary Date of Birth
Definition:
Date on which beneficiary was born.
Validation:
Must be a valid date
Remarks:
MMDDCCYY on which the beneficiary was born.
Requirement: Required
Data Element: Billing Provider Number
Definition:
Number assigned by the National Supplier Clearinghouse (NSC) or MAC
to identify the billing/pricing provider or supplier.
Validation:
Must be present. Use the same requirements as for Item 33 in HCFA
1500.
•
Enter the PIN, for the performing provider of service/supplier
who is not a member of a group practice.
•
Enter the group PIN, for the performing provider of
service/supplier who is a member of a group practice.
•
Suppliers billing the DME MAC will use the National Supplier
Clearinghouse (NSC) number in this item.
•
If the same billing/pricing provider number does not apply to all
lines on the claim, enter the Billing provider number that applies
to the performing provider on the first line of the claim.
Remarks:
N/A
Requirement: Required
Data Element: Referring/Ordering UPIN
Definition:
UPIN assigned to identify the referring/ordering provider.
Validation:
N/A
Remarks:
Enter zeros if there is no referring/ordering provider.
•
Referring physician - is a physician who requests an item or
service for the beneficiary for which payment may be made
under the Medicare program.
•
Ordering physician - is a physician or, when appropriate, a non-
physician practitioner who orders non-physician services for the
patient.
Requirement: Required when available on the claim record.
Data Element: Claim Allowed Amount
Definition:
Final Allowed Amount for this claim.
Validation:
N/A
Remarks:
The total allowed charges on the claim (the sum of line item allowed
charges)
Requirement: Required
Data Element: Claim ANSI Reason Code 1-3
Definition:
Codes showing the reason for any adjustments to this claim, such as
denials or reductions of payment from the amount billed.
Validation:
Must be valid ANSI ASC claim adjustment codes and applicable group
codes.
Remarks:
Format is GGRRRRRR where: GG is the group code and RRRRRR is
the adjustment reason code.
Requirement: ANSI Reason Code 1 must be present on all claims. Codes 2 and 3 should
be sent, if available.
Data Element: Claim Entry Date
Definition:
Date claim entered the shared claim processing system
Validation:
Must be a valid date
Remarks:
Format must be CCYYMMDD
Requirement: Required
Data Element: Claim Adjudicated Date
Definition:
Date claim completed adjudication.
Validation:
Must be a valid date. Format must be CCYYMMDD.
Remarks:
This must represent the processed date that may be prior to the pay date if the
claim is held on the payment floor after a payment decision has been made.
Requirement: Required
Data Element: Beneficiary Gender
Definition:
Gender of the Beneficiary.
Validation:
M=Male
F=Female
U=Unknown
Remarks:
N/A
Requirement: Required
Data Element: Billing Provider NPI
Definition:
NPI assigned to the Billing Provider.
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: Referring/Ordering Provider NPI
Definition:
NPI assigned to the Referring/Ordering Provider.
Validation:
N/A
Remarks:
Enter zeros if there is no referring/ordering provider.
•
Referring physician - is a physician who requests an item or
service
for the beneficiary for which payment may be made
under the Medicare program.
•
Ordering physician - is a physician or, when appropriate, a non-
physician practitioner who orders non-physician services for the
patient.
Requirement: Required when available on the claim record.
Data Element: Claim Paid Amount
Definition:
Net amount paid after co-insurance and deductible. Do not include
interest you paid in the amount reported.
Validation:
N/A
Remarks:
Amount of payment made from the Medicare trust fund for the services
covered by the claim record.
Requirement: Required
Data Element: Beneficiary Paid Amount
Definition:
Amount paid by Beneficiary to the provider.
Validation:
N/A
Remarks:
N/A
Requirement: Required if available.
Data Element: Claim Diagnosis Code 1-12
Definition:
The ICD-CM diagnosis code identifying the diagnosis, condition,
problem or other reason for the admission/encounter/visit shown in the medical
record to be chiefly responsible for the services provided.
Validation:
Must be a valid ICD-CM diagnosis code.
• CMS accepts only CMS approved ICD-CM diagnostic and procedural
codes. The CMS approves only changes issued by the Federal ICD-CM
Coordination and Maintenance Committee.
• Diagnosis codes must be full ICD-CM diagnoses codes, including the full
number of digits (five for ICD-9-CM, seven for ICD-10-CM) where
applicable.
Remarks:
• These fields should be left justified and space filled. For instance if the
primary diagnosis on the claim is five positions long, this field should contain
the diagnosis with 2 spaces at the end.
• With the exception of claims submitted by ambulance suppliers (specialty
type 59), all claims submitted on HCFA 1500 by physician and non-physician
specialties (i.e., PA, NP, CNS, CRNA) use an ICD-CM code number and code
to the highest level of specificity for the date of service. Independent
laboratories enter a diagnosis only for limited coverage procedures. Since this
is a required field, resolution records for claims billed by Ambulance suppliers
and independent clinical laboratories must include the following filler
information when the diagnosis is not otherwise available:
•
Ambulance supplier (specialty 59)—amb
•
Independent Clinical Lab (specialty 69)--lab
Requirement: Claim Diagnosis 1 is required for ALL claims.
Claim diagnosis codes 2-12 should be submitted if contained on the
claim record. Enter spaces for the diagnosis code fields that are not
populated on the claim record in the Shared Processing System.
Data Element: Claim Diagnosis Version Indicator Code 1-12
Definition:
The ICD--CM diagnosis version code identifying the version of
diagnosis code submitted.
Validation:
Version ICD9 use Version Code ‘9’
• Version ICD10 use Version Code ‘0’
• May be blank for claims billed by ambulance and independent
laboratory suppliers.
Remarks:
With the exception of claims submitted by ambulance suppliers (specialty type
59), all claims submitted on HCFA 1500 by physician and non-physician
specialties (i.e., PA, NP, CNS, CRNA) use an ICD-CM code number and code to
the highest level of specificity for the date of service. Independent laboratories
enter a diagnosis only for limited coverage procedures.
Requirement: Claim Diagnosis Version Code 1 is required for ALL claims, except
those billed by ambulance and independent laboratories. Claim
diagnosis version codes 2-12 should be submitted to correspond to claim
level diagnosis codes 2-12.
Data Element: Claim Zip Code
Definition:
Zip Code used to identify were the service was furnished.
Validation:
Must be a valid Zip Code
•
This field should be left justified and zero filled. When only a
five digit zip code is carried in the Shared Processing System, this field
will contain the five digit zip code followed by 4 zeros.
Remarks:
For DME MAC Claims use the zip code for beneficiary residence.
For Part B Claims, use the zip code identified in item 32 of the HCFA
1500, except in the listed situations.
• For ambulance services, identify the zip code where the patient was
picked up.
• If the service was furnished in the patient’s home, use the zip code from
the patient’s home address.
• For electronic claims, if multiple zip codes are identified enter the zip
code for the line with the highest allowed amount. (If this logic is too
cumbersome to implement, we can live with enter the zip code from the
first line).
Requirement: Required
Data Element: Claim Pricing State
Definition:
State where services were furnished.
Validation:
Must be a valid 2 digit state abbreviation as defined by the United States
Postal Service (USPS).
Remarks:
Furnish the state associated with the Claim Zip Code.
Requirement: Required
Data Element: Beneficiary Zip Code
Definition:
Zip Code associated with the beneficiary residence.
Validation:
Must be a valid Zip Code
•
This field should be left justified and zero filled. When only a
five digit zip code is carried in the Shared Processing System,
this field will contain the five digit zip code followed by 4 zeros.
Remarks:
Use the zip code for beneficiary residence.
Requirement: Required
Data Element: Beneficiary State
Definition:
State abbreviation identifying the state in which the beneficiary resides.
Validation:
Must be a valid 2 digit state abbreviation as defined by the United States Postal
Service (USPS).
Remarks:
N/A
Requirement: Required
Data Element: Claim Demonstration Number
Definition: This element is also known as the Claim Demonstration Identification
Number. It is the number assigned to identify a demonstration Project.
This
field is also used to denote special processing (a.k.a. Special
Processing
Number, SPN).
Validation:
Must be a Valid Demo ID.
Remarks:
Must be populated with the value from the first populated demonstration
number on the claim.
Requirement: Required on every claim processed under a CMS demonstration project.
Data Element: RAC Adjustment Indicator
Definition:
Indicator used to identify RAC requested adjustments, which occur as a
result of post-payment review activities done by the Recovery Audit
Contractors (RAC).
Validation:
‘R’ identifies a RAC-requested adjustment
Remarks:
N/A
Requirement: Required when RAC adjustment indicator was furnished to CWF
Data Element: Split/Adjustment Indicator
Definition:
Count of number of splits/replicates/adjustments (with different claim
control numbers (ICN/CCN)) of the sampled claim that are included in
the
resolution file.
Validation:
‘00’ is used when only one claim control number (ICN/CCN) associated
with the sampled claim is included in the resolution file.
When the resolution file contains multiple adjustments/splits/replicates
associated with a single claim, this field will provide a count of records.
• For example, if the file contains the original, replicate and
adjustment claims, one record would have an indicator of 01,
one record would have an indicator of 02, and the third record
would have an indicator of 03.
Remarks:
This indicator does not apply when multiple records are submitted for a
single claim record because of size restrictions.
This field is right justified and zero filled.
Requirement: Required when the resolution file contains multiple versions of a single claim.
Data Element: Facility NPI
Definition:
The NPI of the facility at which the service was performed.
Validation:
N/A
Remarks:
N/A
Requirement: Required when available on the claim record.
Data Element: PWK
Definition:
Space reserved for future use.
Validation:
N/A
Remarks:
N/A
Requirement: Required when available on the claim record.
Data Element: Claim Demonstration Number 2
Definition: This element is also known as the Claim Demonstration Identification
Number. It is the number assigned to identify a demonstration Project.
This field is
also used to denote special processing (a.k.a. Special
Processing Number,
SPN).
Validation:
Must be a Valid Demo ID.
Remarks:
Must be populated with the value from the second populated
demonstration number on the claim.
Requirement: Required when present on claim.
Data Element: Claim Demonstration Number 3
Definition: This element is also known as the Claim Demonstration Identification
Number. It is the number assigned to identify a demonstration Project.
This field is
also used to denote special processing (a.k.a. Special
Processing Number,
SPN).
Validation:
Must be a Valid Demo ID.
Remarks:
Must be populated with the value from the third populated demonstration
number on the claim.
Requirement: Required when present on claim
Data Element: Claim Demonstration Number 4
Definition: This element is also known as the Claim Demonstration Identification
Number. It is the number assigned to identify a demonstration Project.
This field is
also used to denote special processing (a.k.a. Special
Processing Number,
SPN).
Validation:
Must be a Valid Demo ID
Remarks:
Must be populated with the value from the fourth populated
demonstration number on the claim.
Requirement: Required when present on claim
Data Element: Beneficiary MBI
Definition:
Beneficiary’s Medicare Beneficiary Identifier
Validation:
Comply with CMS Standards
•
11-character, fixed length alpha-numeric string.
•
Different, visibly distinguishable from
HICN/RRB
numbers.
•
Contain no more than 2 consecutive numbers.
•
Contain no more than 2 consecutive alphabetic characters
•
Must limit the possibility of letters being
interpreted as
numbers (i.e., alphabetic characters [A…Z]; excluding S,
L, O, I, B, Z).
•
Must not contain lowercase letters.
•
Must not contain any special characters.
Remarks:
Do not include hyphens or spaces.
Requirement: Required
Data Element: HICN/MBI Indicator
Definition:
Indicator that identifies if the provider submitted the claim with a HICN
or MBI.
Validation:
M = MBI submitted on the claim
H = HICN submitted on the claim
Remarks:
N/A
Requirement: Required
Data Element: Line Item Count
Definition:
Number indicating number of service lines on the claim
Validation:
Must be a number 01 – 52
Remarks:
N/A
Requirement: Required
Data Element: Filler
Definition:
Additional space -- use to be determined
Validation:
N/A
Remarks:
N/A
Requirement: Required
Claim Line Item Fields
Data Element: Performing Provider Number
Definition:
Number assigned by the shared system to identify the provider who performed the
service or the supplier who supplied the medical equipment.
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: Performing Provider Specialty
Definition:
Code indicating the primary specialty of the performing provider or
supplier.
Validation:
Must be a valid Provider Specialty per IOM 10.4 ch26 10.8.
Remarks:
N/A
Requirement: Required
Data Element: HCPCS Procedure Code
Definition:
The HCPCS/CPT-4 code that describes the service.
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: HCPCS Modifier 1-4
Definition:
Codes identifying special circumstances related to the service.
Validation:
N/A
Remarks:
N/A
Requirement: Required if available
Data Element: Number of Services
Definition:
The number of service rendered in days or units.
Validation:
N/A
Remarks:
Zero filled to maintain the relative position of the decimal point.
The last three positions should contain the value to the right of the
decimal in the number of services. Put a zero in the last three positions
for
whole numbers. For example if the number of units is 10, this field
would be
filled as 0000010000.
Requirement: Required
Data Element: Service from Date
Definition:
The date the service was initiated.
Validation:
Must be a valid date less than or equal to Service to Date.
Remarks:
Format is CCYYMMDD
Requirement: Required
Data Element: Service to Date
Definition:
The date the service ended.
Validation:
Must be a valid date greater than or equal to Service from Date.
Remarks:
Format is CCYYMMDD.
Requirement: Required
Data Element: Place of Service
Definition:
Code that identifies where the service was performed.
Validation:
N/A
Remarks:
Must be a value in the range of 00-99.
Requirement: Required
Data Element: Type of Service
Definition:
Code that classifies the service.
Validation:
The code must match a valid CWF type of service code.
Remarks:
N/A
Requirement: Required
Data Element: Diagnosis Code
Definition:
Code identifying a diagnosed medical condition resulting in the line item service.
Validation:
Must be a valid ICD-CM diagnosis code.
• CMS accepts only CMS approved ICD-CM diagnostic and procedural
codes. The CMS approves only changes issued by the Federal ICD-CM
Coordination and Maintenance Committee.
• Diagnosis codes must be full ICD-CM diagnoses codes, including the full
number of digits (five for ICD-9-CM, seven for ICD-10-CM) where
applicable.
Remarks:
With the exception of claims submitted by ambulance suppliers (specialty type
59), all claims submitted on HCFA 1500 by physician and non-physician
specialties (i.e., PA, NP, CNS, CRNA) use an ICD-CM code number and code to
the highest level of specificity for the date of service. Independent laboratories
enter a diagnosis only for limited coverage procedures. Since this is a required
field, resolution records for claims billed by Ambulance suppliers and
independent clinical laboratories must include the following filler information
when the diagnosis is not otherwise available:
• Ambulance supplier (specialty 59)—amb
• Independent Clinical Lab (specialty 69)--lab
Requirement: Required
Data Element: Line Diagnosis Code Version Indicator Code
Definition:
The ICD--CM diagnosis version code identifying the version of diagnosis code
submitted.
Validation: • Version ICD9 use Version Code ‘9’
• Version ICD10 use Version Code ‘0
• May be blank for claims billed by ambulance and independent
laboratory suppliers.
Remarks:
With the exception of claims submitted by ambulance suppliers (specialty type
59), all claims submitted on HCFA 1500 by physician and non-physician
specialties (i.e., PA, NP, CNS, CRNA) use an ICD-CM code number and code to
the highest level of specificity for the date of service. Independent laboratories
enter a diagnosis only for limited coverage procedures.
Requirement: Diagnosis Version Code is required for ALL lines, except those billed by
ambulance and independent clinical laboratory suppliers.
Data Element: CMN Control Number
Definition:
Number assigned by the shared system to uniquely identify a Certificate
of Medical Necessity.
Validation:
N/A
Remarks:
Enter a zero if no number is assigned.
Requirement: Required on DME claims
Data Element: Line Submitted Charge
Definition:
Actual charge submitted by the provider or supplier for the service or
equipment.
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: Line Medicare Initial Allowed Charge
Definition:
Amount Medicare allowed for the service or equipment before any
reduction or denial.
Validation:
N/A
Remarks:
This charge is the lower of the fee schedule or billed amount (i.e., Submitted
Charge), except for those services (e.g., ASC) that are always paid at the fee
schedule amount even if it is higher than the Submitted Charge. If there is no fee
schedule amount, then insert the Submitted Charge.
• Use MPFDB, Clinical Lab FS, Ambulance FS, ASC FS, drug and
injectable FS, or DME fee schedule as appropriate.
Requirement: Required
Data Element: ANSI Reason Code 1-7
Definition:
Codes showing the reason for any adjustments to this line, such as denials or
reductions of payment from the amount billed.
Validation:
Must be valid ANSI ASC claim adjustment codes and applicable group
codes.
Remarks:
Format is GGRRRRRR where: GG is the group code and RRRRRR is
the adjustment reason code.
Requirement: ANSI Reason Code 1 must be present on all claims with resolutions of
'DENMR’, 'DENMC' ,'DEO’, 'RTP’, 'REDMR’, 'REDMC', or
'REO’,’APPAM’,’DENAM’,’REDAM’.
Data Element: Manual Medical Review Indicator
Definition:
Code indicating whether or not the service received complex manual medical
review. Complex review goes beyond routine review. It includes the request for,
collection of, and evaluation of medical records or any other documentation in
addition to the documentation on the claim, attached to the claim, or contained in
the MAC’s history file. The review must require professional medical expertise
and must be for the purpose of preventing payments of non-covered or incorrectly
coded services. That includes reviews for the purpose of determining if services
were medically necessary. Professionals must perform the review, i.e., at a
minimum, a Licensed Practical Nurse must perform the review. Review requiring
use of the MAC's history file does not make the review a complex review. A
review is not considered complex if a medical record is requested from a provider
and not received. If sufficient documentation accompanies a claim to allow
complex review to be done without requesting additional documentation, count
the review as complex.
Validation:
Must be 'Y’ or ’N’.
Remarks:
Set to 'Y’ if service was subjected to complex manual medical review,
else ’N’.
Requirement: Required
Data Element: Resolution Code
Definition:
Code indicating how the MAC resolved the line.
Automated Review (AM): An automated review occurs when a claim/line item
passes through the MAC's claims processing system or any adjunct system
containing medical review edits.
Routine Manual Review (MR): Routine review uses human intervention, but only
to the extent that the claim reviewer reviews a claim or any attachment submitted
by the provider. It includes review that involves review of any of the MAC's
internal documentation, such as claims history file or policy documentation. It
does not include review that involves review of medical records or other
documentation requested from a provider. A review is considered routine if a
medical record is requested from a provider and not received. Include prior
authorization reviews in this category.
Complex Manual Review (MC): Complex review goes beyond routine review. It
includes the request for, collection of, and evaluation of medical records or any
other documentation in addition to the documentation on the claim, attached to
the claim, or contained in the MAC’s history file. The review must require
professional medical expertise and must be for the purpose of preventing
payments of non-covered or incorrectly coded services. Professionals must
perform the review, i.e., at a minimum; a Licensed Practical Nurse must perform
the review. Review requiring use of the MAC's history file does not make the
review a complex review. A review is not considered complex if a medical record
is requested from a provider and not received. If sufficient documentation
accompanies a claim to allow complex review to be done without requesting
additional documentation, the review is complex. For instance if all relevant
pages from the patient's medical record are submitted with the claim, complex
MR could be conducted without requesting additional documentation.
Validation:
Must be ‘APP’, ‘APPMR’, ’APPMC’, ’DENMR’, ‘DENMC’, ’DEO’,
’RTP’, ‘REDMR’, ‘REDMC’, 'REO’, ’DENAM’, ’REDAM’, ‘DELET’,
or
‘TRANS’,
Remarks:
Resolutio
n Code
APP
Descriptio
APPA
M
APPM
DENA
M
DENM
R
Approved as a valid submission without manual
medical review.
Approved after automated medical review
Approved after manual medical review
routine
Approved after manual medical review complex. If
this code is selected, set the Manual Medial Review
Indicator to 'Y.
Denied after automated medical review
Denied for medical review reasons or for
insufficient documentation of medical necessity,
manual medical review routine
Denied for medical review reasons or for insufficient
Requirement: Required
Data Element: Line Final Allowed Charge
Definition:
Final Amount allowed for this service or equipment after any reduction or denial.
Validation:
N/A
Remarks:
This represents the MAC’s value of the service/item gross of co-pays and
deductibles.
Requirement: Required
Data Element: Performing Provider NPI
Definition:
NPI assigned to the Performing Provider.
Validation:
N/A
Remarks:
N/A.
Requirement: Required for providers that use HIPPA standard transactions.
Data Element: Performing Provider UPIN
Definition:
Unique Physician Identifier Number (UPIN) that identifies the physician supplier
actually performing/providing the service.
Validation:
N/A
Remarks:
N/A
Requirement: Required, when available
Data Element: Miles/Time/Units/Services Indicator
Definition:
Code indicating the units associated with services needing unit reporting on the
line item for the Part B claim.
Validation:
Must be a valid Indicator as identified in IOM 10.4 ch26 10.10.
0- No allowed services
1- Ambulance transportation miles
2- Anesthesia Time Units
3- Services
Resolutio
n Code
Descriptio
DEO
RTP
REDA
M
REDM
R
REDM
C
REO
Review Indicator to 'Y.'
Denied for non-medical reasons, other than
denied as unprocessable.
Denied as unprocessable
(return/reject) Reduced after
medical review
Reduced for medical review reasons or for
insufficient documentation of medical necessity,
manual medical review routine
Reduced for medical review reasons or for insufficient
documentation of medical necessity, manual medical
review complex. If this code is selected, set the
Manual Medial Review Indicator to 'Y.'
Reduced for non-medical review reasons.
Claim deleted from processing system—AC
maintains record of claim on system
4- Oxygen units
5- Units of Blood
Remarks:
N/A
Requirement: Required
Data Element: Line Deductible Applied
Definition:
Amount of deductible applied for this service or equipment.
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: Line Co-Insurance Amount
Definition:
Amount of co-insurance due for this service or equipment.
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: Line Paid Amount
Definition:
Amount of payment made from the trust funds (after deductible and
coinsurance amounts have been paid) for the line item service on the
non-institutional claim.
Validation:
N/A
Remarks:
This represents the MAC’s value of the claim after co-pays and
deductibles.
Requirement: Required
Data Element: Line MSP Code
Definition:
Code indicating primary payor for services on this line item.
Validation:
A-Working Aged
B-ESRD
D-No-Fault
E-Workers' Compensation
F-Federal (Public Health)
G-Disabled
H-Black Lung
I-Veterans
L-Liability
Remarks:
N/A
Requirement: Required, when contained on the claim record.
Data Element: Line MSP Paid Amount
Definition:
The amount paid by the primary payer when the payer is primary to
Medicare (Medicare is secondary or tertiary).
Validation:
N/A
Remarks:
Amount paid by Primary Payer
Requirement: Required, when contained on the claim record.
Data Element: Line Pricing Locality
Definition:
Code denoting the MAC-specific locality used for pricing this claim.
Validation:
Must be a valid pricing locality.
• Enter ‘00’ for claims priced at a statewide locality.
Requirement: Required
Data Element: Line Zip Code
Definition:
Zip Code used to determine claim pricing locality.
Validation:
Must be a valid Zip Code
This field should be left justified and zero filled. When only a five digit
zip code is carried in the Shared Processing System, this field will
contain the five digit zip code followed by 4 zeros.
Remarks:
For DME Claims use the zip code for beneficiary residence.
For Part B Claims, use the zip code identified in item 32 of the HCFA
1500, unless the service was furnished in the patient’s home. If the
service
was furnished in the patient’s home, use the zip code from the
patient’s home
address.
Requirement: Required
Data Element: Line Pricing State
Definition:
State where services were furnished.
Validation:
Must be a valid 2 digit state abbreviation as defined by the United States
Postal Service (USPS).
Remarks:
Furnish the state associated with the Line Zip Code.
Requirement: Required
Data Element: Ambulance Point of Pick-up Zip Code
Definition:
Zip Code identifying the ambulance point of pick up.
Validation:
Must be a valid Zip Code.
Remarks:
This field should be left justified and zero filled. When only a five digit
zip code is carried in the Shared Processing System, this field will
contain the five digit zip code followed by 4 zeros.
Requirement: Required for ambulance claims
Data Element: Ambulance Drop Off Zip Code
Definition:
Zip Code identifying the ambulance drop off point.
Validation:
Must be a valid Zip Code.
Remarks:
This field should be left justified and zero filled. When only a five digit
zip code is carried in the Shared Processing System, this field will
contain the five digit zip code followed by 4 zeros.
Requirement: Required for ambulance claims
Data Element: PWK
Definition:
Space reserved for future use.
Validation:
N/A
Remarks:
N/A
Requirement: Required when available on the claim record
Data Element: Prior Authorization Program Indicator
Definition:
Prior Authorization Program Indicator issued by CMS to identify to
which PA program the service belongs
Validation:
Four character alphanumeric
• The first character identifies the line of business
• A for Part A,
• B for Part B,
• D for DME,
• H for Home Health and Hospice
• Followed by a three digit number
Remarks:
N/A
Requirement: Required for claims containing services subject to a prior authorization
program.
Data Element: Unique Tracking Number (UTN)
Definition:
Unique Tracking Number (UTN) assigned to the prior authorization
request for the service or item.
Validation:
For Prior Authorization Claims/services the UTN shall be 14 characters
and use the following format:
• First two characters = MAC identifier (e.g. RR for Railroad, 0F for
Jurisdiction F, 05 for Jurisdiction 5, etc.).
• Third character = line of business (e.g. A for Part A, B for Part B, D for
DME, H for Home Health and Hospice).
• Remaining numerical characters = a unique sequence number assigned by
the Shared System.
For claims/services in the PMD Prior Authorization Project, the
UTN shall be 14 characters and use the following format:
• First character = DME MAC identifier (e.g. A for Jurisdiction A, B for
Jurisdiction B, etc.).
• Second and third characters = 00 (zero and zero).
• Remaining characters = a unique sequence number assigned by the Shared
System.
Remarks:
N/A
Requirement: Required for claims containing services covered by an affirmed prior
authorization.
Data Element: Prior Auth Affirmed
Definition:
Code to identify if the prior authorization for the service(s) on this line
was affirmed.
Validation: Y indicates the prior authorization was affirmed.
N indicates the prior authorization was not affirmed.
Default value is blank for services that are not part of prior
authorization demonstration.
Remarks:
N/A
Requirement: Required for claims containing services subject to prior authorization in
the state where the service was furnished.
Data Element: Filler
Definition:
Additional space TBD.
Validation:
N/A
Remarks:
N/A
Requirement: None
Claims Resolution File
Claims Resolution Trailer Record (one record per file)
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
‘3’
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Number of Claims
9(9)
9
1617
Zeroes
DATA ELEMENT DETAIL
Data Element: Contractor ID
Definition:
Contractor’s CMS assigned number.
Validation:
Must be a valid CMS contractor ID.
Remarks:
N/A
Requirement: Required
NOTE:
For A/B MAC (B): When multiple workloads share a single processing
environment, the Contractor ID will reflect the contractor ID of the
primary workload.
Data Element: Record Type
Definition:
Code indicating type of record.
Validation:
N/A
Remarks:
3 = Trailer Record
Requirement: Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Resolution file.
Validation:
Claim Resolution files prior to 7/1/2007 did not contain this field.
Codes:
B = Record Format as of 7/1/2007
C = Record Format as of 1/1/2010
D = Record Format as of 7/1/2016
E = Record Format as of 10/1/2017
Remarks:
N/A
Requirement: Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor.
Validation:
Must be ‘B’ or ‘D’
Remarks:
B = A/B MAC (B)
D = DME MAC
Requirement: Required
Data Element: Number of Claims
Definition:
Number of claim records on this file.
Validation:
Must be equal to the number of claim records on the file.
Remarks:
Do not count header or trailer records.
Requirement: Required
Claims Provider Address File
Claims Provider Address Header Record (one record per file)
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
‘1’
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Provider Address Date
X(8)
9
16
Spaces
DATA ELEMENT DETAIL
Data Element: Contractor ID
Definition: Contractor’s CMS assigned number.
Validation: Must be a valid CMS contractor ID.
Remarks:
N/A
Requirement: Required
NOTE:
For A/B MAC (B): when multiple workloads share a single processing
environment, the Contractor ID will reflect the contractor ID of the
primary workload.
Data Element: Record Type
Definition:
Code indicating type of record.
Validation:
N/A
Remarks:
1 = Header record
Requirement: Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Provider Address
file.
Validation:
Claim Provider Address files prior to 7/1/2007 did not contain this field.
Codes:
B = Record Format as of 7/1/2007
C = Record Format as of 1/1/2010
Remarks:
N/A
Requirement: Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor.
Validation:
Must be ‘B’ or ‘D’
Remarks:
B = A/B MAC (B)
D = DME MAC
Requirement: Required
Data Element: Provider Address Date
Definition:
Date the Provider Address File was created.
Validation:
Must be a valid date not equal to a Provider Address date sent on any
previous claims Provider Address file.
Remarks:
Format is CCYYMMDD. May use shared system batch processing date.
Requirement: Required
Provider Address File
Provider Address Detail Record
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
’2’
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Provider Number/NPI
X(15)
9
23
Spaces
Provider Name
X(60)
24
83
Spaces
Provider Address 1
X(25)
84
108
Spaces
Provider Address 2
X(25)
109
133
Spaces
Provider City
X(15)
134
148
Spaces
Provider State Code
X(2)
149
150
Spaces
Provider Zip Code
X(9)
151
159
Spaces
Provider Phone Number
X(10)
160
169
Spaces
Provider Phone Number Extension
X(10)
170
179
Spaces
Provider Fax Number
X(10)
180
189
Spaces
Provider Type
X(2)
190
191
Spaces
Provider Address Order
X(2)
192
193
Spaces
Provider Address Type
9(3)
194
196
Zero
Provider E-mail Address
X(75)
197
271
Spaces
Provider Federal Tax number or EIN 9(10)
272
281
Zeroes
Provider Taxonomy Code
9(10)
282
291
Zeroes
Provider License Number
X(16)
292
307
Spaces
Provider License State
X(2)
308
309
Spaces
Filler
X(25)
310
334
Spaces
DATA ELEMENT DETAIL
Data Element: Contractor ID
Definition: Contractor’s CMS assigned number.
Validation: Must be a valid CMS contractor ID.
Remarks:
N/A
Requirement: Required
NOTE:
For A/B MAC (B): when multiple workloads share a single processing
environment, the Contractor ID will reflect the contractor ID of the
primary workload.
Data Element: Record Type
Definition:
Code indicating type of record.
Validation:
N/A
Remarks:
2 = claim record
Requirement: Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Claim Universe file.
Validation:
Claim Universe files prior to 7/1/2007 did not contain this field.
Codes:
B = Record Format as of 7/1/2007
C = Record Format as of 1/1/2010
Remarks:
N/A
Requirement: Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor.
Validation:
Must be ‘B’ or ‘D’
Remarks:
B = A/B MAC (B)
D = DME MAC
Requirement: Required
Data Element: Provider Number/NPI
Definition:
Number assigned by the MAC/NSC or NPI agency to identify the provider.
Validation:
N/A
Remarks:
N/A
Requirement: Required
Data Element: Provider Name
Definition: Provider’s name.
Validation: N/A
Remarks:
This is the name of the provider.
The provider name must be formatted into a business name for mailing
(e.g. Roger A Smith M.D. or Medical Associates, Inc).
Where possible this should contain the Legal Business Name as carried
in the Shared Processing System.
Requirement: Required
Data Element: Provider Address 1
Definition:
1st line of provider’s address.
Validation:
N/A
Remarks:
This is the address1 of the provider.
Requirement: Required
Data Element: Provider Address 2
Definition:
2nd line of provider’s address.
Validation:
N/A
Remarks:
This is the address2 of the provider.
Requirement: Required if available
Data Element: Provider City
Definition:
Provider’s city name.
Validation:
N/A
Remarks:
This is the city of the provider’s address.
Requirement: Required
Data Element: Provider State Code
Definition:
Provider’s state code.
Validation:
Must be a valid state code.
Remarks:
This is the state of the provider’s address.
Requirement: Required
Data Element: Provider Zip Code
Definition:
Provider’s zip code.
Validation:
Must be a valid postal zip code.
Remarks:
This is the zip code of the provider’s address. Provide 9-digit zip code if
available, otherwise provide 5-digit zip code.
This field should be left justified and zero filled. When only a five digit
zip code is carried in the Shared Processing System, this field will
contain the five digit zip code followed by 4 zeros.
Requirement: Required
Data Element: Provider Phone Number
Definition:
Provider’s telephone number..
Validation:
Must be a valid telephone number.
Remarks:
This is the phone number.
Requirement: None
Data Element: Provider Phone Number Extension
Definition:
Provider’s telephone number Extension.
Validation:
Must be a valid telephone number.
Remarks:
This is the phone number.
Requirement: None
Data Element: Provider Fax Number
Definition:
Provider’s fax number
Validation:
Must be a valid fax number.
Remarks:
This is the fax number of the provider.
Requirement: None
Data Element: Provider Type
Definition:
1=Billing/pricing provider number (Assigned by MAC or NSC).
2=Referring/ordering provider (UPIN)
3=Performing/rendering provider (Assigned by MAC or NSC)
4=Entity is both billing/pricing and performing/rendering provider
5=Entity is both referring/ordering and performing/rendering provider
6=Entity is all (billing/pricing AND referring/ordering AND
performing/rendering provider)
7=Billing/pricing provider number (NPI)
8=Referring/ordering provider (NPI)
9=Performing/rendering provider (NPI)
10=Entity is both billing/pricing and performing/rendering provider
(NPI)
11=Entity is both referring/ordering and performing/rendering provider
(NPI)
12=Entity is all (billing/pricing AND referring/ordering AND
performing/rendering provider) (NPI)
Validation:
Must be a valid provider type.
Remarks:
This field indicates for which provider number associated with a
sampled claim the address information is furnished.
Requirement: Required
Data Element: Address Order
Definition: The order in which the records of provider addresses for the provider are
entered into the provider address file detailed record. This field in
combination with the Contractor ID, Provider number, and Provider.
Type
will make each record in the file unique.
Validation:
Must be a valid number between 01 and 99
Remarks:
This field indicated the order in which records containing the addresses
for a provider are entered into the detail file. For instance, if there are
three addresses for a provider, the record for the first address for that provider
with contain an ‘01’ in this field; and the record for the second address for that
provider will contain a ’02’ in this field.
Requirement: Required
Data Element: Provider Address Type
Definition:
The type of Provider Address furnished.
Validation:
1 = Practice Address (MCS)
Provider address (VMS)
2 = Pay To Address (MCS)
Payee Address (VMS)
3 = Billing Address (VMS)
4 = Correspondence Address
5 = Medical Record Address
Remarks:
The first “address type” for each provider will always be a “1.”
Subsequent occurrences of addresses for the same provider will have the
“address type” to correspond to the address submitted. When your files
contain
only one address for the provider, submit only one provider
address record.
Submit additional address records for a single provider
number only when your files
contain
addresses that differ from the
Master or Legal address.
• Correspondence Address—The Correspondence Address as indicated on the
855. This is the address and telephone number where
Medicare can directly get in touch with the enrolling provider. This
address cannot be that of the billing agency, management service
organization, or staffing company.
• Medical Record Address—the Location of Patients’ Medical Records as
indicated on the 855. This information is required if the Patients’ Medical
Records are stored at a location other than the Master
Address (practice location). Post Office Boxes and Drop Boxes are
not
acceptable as the physical address where patient’s medical
records are
maintained
Requirement: Required
Data Element: Provider E-Mail Address
Definition:
Provider’s e-mail address
Validation:
Must be a valid e-mail address
Remarks:
N/A
Requirement: Required if available
Data Element: Provider Federal Tax Number or EIN
Definition:
The number assigned to the provider by the Federal government for tax
report purposes. The Federal Tax Number is also known as a tax
identification number (TIN) or employer identification number (EIN).
Validation:
Must be present.
Remarks:
N/A
Requirement: Required for all provider numbers.
Data Element: Provider Taxonomy Code
Definition:
The non-medical data code set used to classify health care providers
according to provider type or practitioner specialty in an electronic
environment, specifically within the American National Standards
Institute Accredited Standards Committee health care transaction.
Validation:
Must be present
Remarks:
If multiple taxonomy codes are available, furnish the first one listed.
Requirement: Required if available
Data Element: Provider License Number
Definition:
The professional business license required to provide health care services.
Validation:
Must be present
Remarks:
N/A
Requirement: Required if available
Data Element: Provider License State
Definition:
Identify the state that issued the providers professional business license.
Validation:
Must be a valid 2 digit state abbreviation as defined by the United States
Postal Service (USPS).
Remarks:
N/A
Requirement: Required if available.
Data Element: Filler
Definition:
Additional space TBD.
Validation:
N/A
Remarks:
N/A
Requirement: N/A
Claims Provider Address File
Claims Provider Address Trailer Record (one record per file)
Field Name
Picture
From
Thru
Initialization
Contractor ID
X(5)
1
5
Spaces
Record Type
X(1)
6
6
‘3’
Record Version Code
X(1)
7
7
Spaces
Contractor Type
X(1)
8
8
Spaces
Number of Records
9(9)
9
17
Zeroes
DATA ELEMENT DETAIL
Data Element: Contractor ID
Definition: Contractor’s CMS assigned number.
Validation: Must be a valid CMS contractor ID.
Remarks:
N/A
Requirement: Required
NOTE:
For A/B MAC (B): When multiple workloads share a single processing
environment, the Contractor ID will reflect the contractor ID of the
primary workload.
Data Element: Record Type
Definition:
Code indicating type of record.
Validation:
N/A
Remarks:
3 = Trailer Record
Requirement: Required
Data Element: Record Version Code
Definition:
The code indicating the record version of the Provider Address file.
Validation:
Provider Address files prior to 7/1/2007 did not contain this field.
Codes:
B = Record Format as of 7/1/2007
C = Record Format as of 1/1/2010
Remarks:
N/A
Requirement: Required
Data Element: Contractor Type
Definition:
Type of Medicare Contractor.
Validation:
Must be ‘B’ or ‘D’
Remarks:
B = A/B MAC (B)
D = DME MAC
Requirement: Required
Data Element: Number of Records
Definition:
Number of provider records on this file.
Validation:
Must be equal to the number of provider records on the file.
Remarks:
Do not count header or trailer records.
Requirement: Required
Exhibit 37 - Office of Inspector General, Office of Investigations Data Use
Agreement
(Rev. 176, Issued: 11-24-06, Effective: 12-26-06, Implementation: 12-26-06)
DUA #:
(to be completed by CMS Staff)
OFFICE OF INSPECTOR GENERAL, OFFICE OF INVESTIGATIONS DATA USE
AGREEMENT
I,
, representing the Office of Inspector General (OIG), Office of
Investigations (OI), will observe the following in the use of the Centers for Medicare & Medicaid Services (CMS) files
released to me:
A. Purpose:
B. The following CMS data file(s) is/are covered under this Agreement.
Description of Data/File
Year(s)
System of Record
(to be completed by CMS Staff)
1.
The files will be used only for purposes authorized by the Inspector General Act of 1978 or other applicable law.
2.
No information in the files released to the OIG will be used or disclosed except in strict accordance with all applicable
confidentiality laws and regulations. Where practicable and consistent with OIG oversight responsibilities, the OIG will
notify CMS of files extracted or derived from these files are disclosed pursuant to Federal disclosure and
confidentiality laws.
3.
The information sought in this request is required to be produced to the Office of Investigations pursuant to the
Inspector General Act 1978, U.S.C. App. The information is also sought by the OIG in its capacity as a health
oversight agency, and this information is necessary to further health oversight activities. Disclosure is therefore
permitted under the Health Insurance Portability and Accountability Act (HIPAA) Standards for Privacy of
Individually Identifiable Health Information, 45 C.F.R. 164.501; 164.512(a); and 164.512(d).
4.
will be designated as custodian of these files and will be
responsible for establishment and maintenance of security arrangements to prevent unauthorized use. If the
custodianship is transferred within the organization, CMS will be notified.
5. No listings or information from individual records, with identifiers will be published or otherwise released outside of
those deemed appropriate by OIG to perform the legal scope of OIG duties and responsibilities.
6.
The OIG needs to retain these files for up to 10 years. CMS will contact the OIG representative at the end of 5 years to
confirm either that data will be destroyed or that OIG has a continuing need for the data. CMS will document its
tracking system to indicate OIG’s need for retention or destruction.
OIG Representative- Printed:
Phone Number:
Email Address:
Street Address:
City:
State:
Zip Code:
Signature:
Date:
Name of Custodian of Files, If Different:
Phone Number:
E-mail Address:
Street Address:
City:
State:
Zip Code:
CMS Representative- Printed:
Signature:
Date: