129 CMR 2.11
Health Care Claims Data Filing Format
(1) File Format. Eachdata file submission shall be an ASCII file, variable field length, and asterisk
delimited. When asterisks are used in any field values, they shall be enclosed in double quotes.
(2) Header and Trailer Records. Each member eligibility file and each medical claims file, and
pharmacy claims file that is submitted shallcontaina header record and a trailer record. The "Header
record" means the first record of each separate file that is submitted and the "Trailer record" means the
last record of each submitted file. The header and trailer record format shall conform to the record
specifications in 129 CMR 2.11(2)(a):
(a) Record Specifications. Carriers shall use the record specifications in 129 CMR 2.11(2)(a)
through (d) in submitting their claims records. The file headerrecordlayout shall be submitted using
the data elements in 129 CMR 2.11(2)(a)1. through 8.:
1. HD001. This element is named "record type". The data type of this element is text. Its
length is 2.
2. HD002. This element is named "payer". The data type of this element is text. Its length
is 6. Carriers shall code according to payer submitting payments, Council submitter code.
3. HD003. This element is named "National Plan ID". The data type of this element is text.
Its length is 30. Carriers shall code according to CMS National Plan ID.
4. HD004. This element is named "type of file". The data type of this element is text. Its
length is 2. Carriers shall code according to ME member eligibility, MC medical claims, PC
pharmacy claims.
5. HD005. This element is named "period beginning date". The data type of this element is
integer. Its length is 6. Carriers shall code according to CCYYMM, beginning of paid period
for claims, beginning of month covered for eligibility.
6. HD006. This element is named "period ending date". The data type of this element is
integer. Its length is 6. Carriers shall code according to CCYYMM, end of paid period for
claims, end of month covered for eligibility.
7. HD007. This element is named "record count". The data type of this element is integer.
Its lengthis 10. Carriers shall code according to total number ofrecords submitted inthis file,
with the header and trailer record excluded from the count.
8. HD008. This element is named "comments". The data type of this element is text. Its
length is 80. Carriers shall code according to their own option.
(b) The file header record layout shall conform to the following Table 1:
Table 1: File Header Record Layout
Data Element #
Element
Type
Maximum
Length
Description/Codes/Sources
HD001
Record Type
Text
HD
HD002
Payer
Text
Payer submitting payments
Council Submitter Code
HD003
National Plan ID
Text
CMS National Plan ID
HD004
Type of File
Text
MA Member Eligibility
MC Medical Claims
PC Pharmacy Claims
HD005
Period Beginning Date Integer
CCYYMM
Beginning of paid period for claims
Beginning of month covered for eligibility
HD006
Period Ending Date
Integer
CCYYMM
End of paid period for claims
End of month covered for eligibility
HD007
Record Count
Integer
Total number of records submitted in this file
HD008
Comments
Text
Submitter may use to document this
submission by assigning a filename, system
source, etc.
(c) The trailer header record layout shall be submitted using the data elements in 129 CMR
2.11(2)(a)3.a. through g.:
1. TR001. This element is named "record type". The data type of this element is text. Its
length is 2.
2. TR002. This element is named "payer". The data type of this element is text. Its length
is 6. Carriers shall code according to payer submitting payments, Council submitter code.
3. TR003. This element is named "National Plan ID". The data type of this element is text.
Its length is 30. Carriers shall code according to CMS National Plan ID.
4. TR004. This element is named "type of file". The data type of this element is text. Its
length is 2. Carriers shall code according to ME member eligibility, MC medical claims, PC
pharmacy claims.
5. TR005. This element is named "period beginning date". The data type of this element is
integer. Its length is 6. Carriers shall code according to CCYYMM, beginning of paid period
for claims, beginning of month covered for eligibility.
6. TR006. This element is named "period ending date". The data type of this element is
integer. Its length is 6. Carriers shall code according to CCYYMM, end of paid period for
claims, end of month covered for eligibility.
7. TR007. This element is named "date processed". The data type of this element is date.
Its lengthis 8. Carriers shall code according to CCYYMMDD, the date the file was created.
(d) The trailer record layout shall conform to the following Table 2:
Table 2: Trailer Record Layout
Data Element #
Element
Type
Maximum
Length
Description/Codes/Sources
TR001
Record Type
Text
TR
TR002
Payer
Text
Payer submitting payments
Council Submitter Code
TR003
National Plan ID
Text
CMS National Plan ID
TR004
Type of File
Text
MA Member Eligibility
MC Medical Claims
PC Pharmacy Claims
TR005
Period Beginning Date Integer
CCYYMM
Beginning of paid period for claims
Beginning of month covered for eligibility
TR006
Period Ending Date
Integer
CCYYMM
End of paid period for claims
End of month covered for eligibility
TR007
Date Processed
Date
CCYYMMDD
Date file was created
(3) Member Eligibility File.
(a) The specifications for the member eligibility file are listed in 129 CMR 2.11(3)(a)1. and 2.
1. ME001. This element is named "payer". The data type of this element is text. Its length
is 6. Carriers shall code according to payer submitting payments, Council submitter code.
2. ME002. This element is named "National Plan ID". The data type of this element is text.
Its length is 30. Carriers shall code according to CMS National Plan ID.
3. ME003. This element is named "insurance type code/product". The data type of this
element is text. Its length is 2. Carriers shall code according to the following Table 3:
Table 3: Insurance Type Code/Product
Code
Description
Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
Medicare Secondary End-Stage Renal Disease Beneficiary in the 12-month coordination
period with an Employer Group Health Plan
Medicare Secondary No-Fault Insurance including Insurance in which Auto is Primary
Medicare Secondary Workers' Compensation
Medicare Secondary Public Health Service or Other Federal Agency
Medicare Secondary Black Lung
Medicare Secondary Veterans' Administration
Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan
(LGHP)
Medicare Secondary Other Liability Insurance is Primary
AP
Auto Insurance Policy
CP
Medicare Conditionally Primary
D
Disability
DB
Disability Benefits
EP
Exclusive Provider Organization (for self-insured risks)
HM
Health Maintenance Organization (HMO)
HN
Health Maintenance Organization (HMO) Medicare Advantage
HS
Special Low Income Medicare Beneficiary
IN
Indemnity
LC
Long Term Care
LD
Long Term Policy
LI
Life Insurance
LT
Litigation
MA
Medicare Part A
MB
Medicare Part B
MC
Medicaid
MH
Medigap Part A
MI
Medigap Part B
MP
Medicare Primary
PR
Preferred Provider Organization (PPO)
PS
Point of Service (POS)
QM
Qualified Medicare Beneficiary
SP
Supplemental Policy
WC
Workers' Compensation
4. ME004. This element is named "year". The data type of this element is integer. Its length
is 4. Carriers shall code according to the year for which eligibility is reported in this
submission.
5. ME005. This element is named "month". The data type of this element is integer. Its
length is 2. Carriers shall code according to the month for which eligibility is reported in this
submission.
6. ME006. This element is named "insured group or policy number". The data type of this
element is text. Its length is 30. Carriers shall code according to the group or policy number
and not the number that uniquely identifies the subscriber.
7. ME007. This element is named "coverage level code". The data type of this element is
text. Its length is 3. Carriers shall code according to the benefit coverage level:
a. CHD Children Only;
b. DEP Dependents Only;
c. ECH Employee and Children;
d. EMP Employee Only;
e. ESP Employee and Spouse;
f. FAM Family;
g. IND Individual;
h. SPC Spouse and Children; and
i. SPO Spouse Only.
8. ME008. This element is named "encrypted subscriber unique identification number". The
data type of this element is text. Its length is 30. Carriers shall code according to the
encryption method developed by the Council or its designee. Carriers shall set as null if
unavailable.
9. ME009. This element is named "plan specific contract number". The data type of this
element is text. Its length is 30. Carriers shallcode accordingto the encrypted plan assigned
contract number. Carriers and health care claims processors shall set as nullifcontract number
is the same as the subscriber's social security number.
10. ME010. This element is named "member suffix or sequence number". The data type of
this element is integer. Its length is 2. Carriers shall code according to the unique number of
the member within the contract.
11. ME011. This element is named "member identification code". The data type of this
element is text. Its length is 30. Carriers shall code according to the encryption method
developed by the Council or its designee, and carriers shall set as null if unavailable.
12. ME012. This element is named "individual relationship code". The data type of this
element is integer. Its length is 2. Carriers shall code according to the member's relationship
to the subscriber as shown on the following Table 4:
Table 4: Individual Relationship Code
Code
Description
Spouse
Self/Employee
Child
Unknown
Other Adult
13. ME013. This element is named "member gender". The data type of this element is text.
Its length is1. Carriers shall code according to:
a. M = Male;
b. F = Female; and
c. U = Unknown.
14. ME014. This element is named "member date of birth". The data type of this element
is date. Its length is 8. Carriers shall code according to CCYYMMDD.
15. ME015. This element is named "member city name". The data type of this element is
text. Its length is 30. Carriers shall code according to the city location of the member’s
residence.
16. ME016. This element is named "member state or province". The data type of this
element is text. Its length is 2. Carriers shall code the state in which the member resides using
the standard abbreviations established by the U.S. Postal Service.
17. ME017. This element is named "member zip code". The data type of this element is text.
Its length is 11. Carriers shall code according to ZIP code of member’s residence, which may
include non-US codes. Carriers and health care claims processors shall not include the dash
in the coding.
18. ME018. This element is named "medical coverage". The data type of this element is text.
Its length is 1. Carriers shall code according to:
a. Y = Yes; and
b. N = No.
19. ME019. This element is named "prescription drug coverage". The data type of this
element is text. Its length is 1. Coverage for limited supplies only, such as diabetic test-strips,
syringes, and birth control, shall be coded as “No”. Carriers shall code according to:
a. Y = Yes; and
b. N = No.
20. ME020. This element is named “race 1”. The data type of this element is text. Its length
is 6. Carriers shall code according to the Race Code below.
21. ME021. This element is named “race 2”. The data type of this element is text. Its length
is 6. Carriers shall code according to the Race Code below. If none, set as null.
Table 5: Race Code
Code
Description
R1
American Indian/Alaska Native
R2
Asian
R3
Black/African American
R4
Native Hawaiian or other Pacific Islander
R5
White
R9
Other Race
UNKNOW
Unknown/not specified
22. ME022. This element is named “other race”. The data type of this element is text. Its
length is 15. Carriers shall enter patient race, if ME020 Race 1 or ME021 Race 2 is coded
as R9 Other Race.
23. ME023. This element is named “Hispanic indicator”. The data type of this element is
text. Its length is 1. Carriers shall code according to:
a. Y = Yes Patient is Hispanic/Latino/Spanish;
b. N = No Patient is not Hispanic/Latino/Spanish; and
c. U = Unknown.
24. ME024. This element is named “ethnicity 1”. The data type of this element is text. Its
length is 6. Carriers shall code according to the Ethnicity Code below.
24. ME025. This element is named “ethnicity 2”. The data type of this element is text. Its
length is 6. Carriers shall code according to the Ethnicity Code in Table 6.
Table 6: Ethnicity Code
Code
Description
2182-4
Cuban
2184-0
Dominican
2148-5
Mexican, Mexican American, Chicano
2180-8
Puerto Rican
2161-8
Salvadoran
2155-0
Central American (not otherwise specified)
2165-9
South American (not otherwise specified)
2060-2
African
2058-6
African American
AMERCN
American
2028-9
Asian
2029-7
Asian Indian
BRAZIL
Brazilian
2033-9
Cambodian
CVERDN
Cape Verdean
CARIBI
Caribbean Island
2034-7
Chinese
2169-1
Columbian
2108-9
European
2036-2
Filipino
2157-6
Guatemalan
2071-9
Haitian
2158-4
Honduran
2039-6
Japanese
2040-4
Korean
2041-2
Laotian
2118-8
Middle Eastern
PORTUG
Portuguese
RUSSIA
Russian
EASTEU
Eastern European
2047-9
Vietnamese
OTHER
Other Ethnicity
UNKNOW
Unknown/not specified
26. ME026. This element is named “other ethnicity”. The data type of this element is text.
Its length is 20. Carriers shall enter patient ethnicity, if ME024 Ethnicity 1 or ME025 Ethnicity
2 is coded as OTHER Other Ethnicity.
27. MEO27. This element is named "language." The data type of this element is text. Its
length is 20. Carriers shall code according to the language code as follows in Table 7.
Table 7: Language Code
Code
Description
African Languages (please specify)
Arabic
Chinese (please specify)
Cape Verdean Creole
English
French
German
Greek
Haitian Creole
Hebrew
Hindi
Italian
Japanese
Korean
Persian
Polish
Portuguese
Russian
Spanish
Tagalog
Urdu
Vietnamese
Other Language (please specify)
Declined
Unavailable
28. ME028. This element is named "record type". The data type of this element is text. Its
length is 2. Its value is literally "ME".
(b) The specifications for the member eligibility file shall be submitted using the following Table
8:
Table 8: Member Eligibility File Layout
Data
Element # Element
Type
Max.
Length Description/Codes/Sources
Payer
Text
Payer submitting payments
Council Submitter Code
National Plan ID
Text
CMS National Plan ID
Insurance Type
Code/Product
Text
12 Medicare Secondary Working Aged Beneficiary or Spouse
with Employer Group Health Plan
13 Medicare Secondary End-Stage Renal Disease Beneficiary
in the 12-month coordination period with an Employer Group
Health Plan
14 Medicare Secondary, No-fault insurance including insurance
in which auto is primary
15 Medicare Secondary Workers' Compensation
16 Medicare Secondary Public Health Service or Other Federal
Agency
41 Medicare Secondary Black Lung
42 Medicare Secondary Veterans Administration
43 Medicare Secondary Disabled Beneficiary Under Age 65
with Large Group Health Plan (LGHP)
47 Medicare Secondary, Other Liability Insurance is Primary
AP Auto Insurance Policy
CP Medicare Conditionally Primary
D Disability
DB Disability Benefits
EP Exclusive Provider Organization
HM Health Maintenance Organization (HMO)
HN Health Maintenance Organization (HMO) Medicare Risk
HS Special Low Income Medicare Beneficiary
IN Indemnity
LC Long Term Care
LD Long Term Policy
LI Life Insurance
LT Litigation
Table 8: Member Eligibility File Layout (continued)
Data
Element # Element
Type
Max.
Length Description/Codes/Sources
MA Medicare Part A
MB Medicare Part B
MC Medicaid
MH Medigap Part A
MI Medigap Part B
MP Medicare Primary
PR Preferred Provider Organization (PPO)
PS Point of Service (POS)
QM Qualified Medicare Beneficiary
SP Supplemental Policy
WC Workers' Compensation
Year
Integer
Year for which eligibility is reported in this submission
Month
Integer
Month for which eligibility is reported in this submission
Insured Group or
Policy Number
Text
Group or policy number (not the number that uniquely
identifies the subscriber)
Coverage Level Code
Text
Benefit Coverage Level
CHD Children Only
DEP Dependents Only
ECH Employee and Children
EMP Employee Only
ESP Employee and Spouse
FAM Family
IND Individual
SPC Spouse and Children
SPO Spouse Only
Encrypted Subscriber
Unique Identification
Number
Text
Encrypted subscriber's unique identification number (set as
null if unavailable)
Plan Specific Contract
Number
Text
Encrypted plan assigned contract number (set as null if
contract number = subscriber's social security number)
Member Suffice or
Sequence Number
Integer
Uniquely numbers the member within the contract
Member Identification
Code
Text
Encrypted member's unique identification number (set as null
if unavailable)
Individual Relationship
Code
Integer
Member's relationship to insured
01 Spouse
18 Self/Employee
Table 8: Member Eligibility File Layout (continued)
Data
Element # Element
Type
Max.
Length Description/Codes/Sources
19 Child
21 Unknown
34 Other Adult
Member Gender
Text
M Male
F Female
U Unknown
Member Date of Birth
Date
CCYYMMDD
Member City Name
Text
City name of member
Member State or
Province
Text
As defined by the US Postal Service
Member ZIP Code
Text
ZIP Code of member – may include non-US codes. (Do not
include dash)
Medical Coverage
Text
Y Yes
N No
Prescription Drug
Coverage
Text
Y Yes
N No
Race 1
Text
R1 American Indian/Alaska Native
R2 Asian
R3 Black/African American
R4 Native Hawaiian or other Pacific Islander
R5 White
R9 Other Race
UNKNOW Unknown/not specified
Race 2
Text
R1 American Indian/Alaska Native
R2 Asian
R3 Black/African American
R4 Native Hawaiian or other Pacific Islander
R5 White
R9 Other Race
UNKNOWN Unknown/not specified
Other Race
Text
Patient Race, if Race 1 or Race 2 is entered as R9 Other
Race (set as null if none)
Hispanic Indicator
Text
Y Patient is Hispanic/Latino/Spanish
N Patient is not Hispanic/Latino/ Spanish
U Unknown
Ethnicity 1
Text
2182-4 Cuban
2184-0 Dominican
Table 8: Member Eligibility File Layout (continued)
Data
Element # Element
Type
Max.
Length Description/Codes/Sources
2148-5 Mexican, Mexican American, Chicano
2180-8 Puerto Rican
2161-8 Salvadoran
2155-0 Central American (not otherwise specified)
2165-9 South American (not otherwise specified)
2060-2 African
2058-6 African American
AMERCN American
2028-9 Asian
2029-7 Asian Indian
BRAZIL Brazilian
2033-9 Cambodian
CVERDN Cape Verdean
CARIBI Caribbean Island
2034-7 Chinese
2169-1 Columbian
2108-9 European
2036-2 Filipino
2157-6 Guatemalan
2071-9 Haitian
2158-4 Honduran
2039-6 Japanese
2040-4 Korean
2041-2 Laotian
2118-8 Middle Eastern
PORTUG Portuguese
RUSSIA Russian
EASTEU Eastern European
2047-9 Vietnamese
OTHER Other Ethnicity
UNKNOW Unknown/not specified
Ethnicity 2
Text
2182-4 Cuban
2184-0 Dominican
2148-5 Mexican, Mexican American, Chicano
2180-8 Puerto Rican
2161-8 Salvadoran
2155-0 Central American (not otherwise specified)
2165-9 South American (not otherwise specified)
Table 8: Member Eligibility File Layout (continued)
Data
Element # Element
Type
Max.
Length Description/Codes/Sources
2060-2 African
2058-6 African American
AMERCN American
2028-9 Asian
2029-7 Asian Indian
BRAZIL Brazilian
2033-9 Cambodian
CVERDN Cape Verdean
CARIBI Caribbean Island
2034-7 Chinese
2169-1 Columbian
2108-9 European
2036-2 Filipino
2157-6 Guatemalan
2071-9 Haitian
2158-4 Honduran
2039-6 Japanese
2040-4 Korean
2041-2 Laotian
2118-8 Middle Eastern
PORTUG Portuguese
RUSSIA Russian
EASTEU Eastern European
2047-9 Vietnamese
OTHER Other Ethnicity
UNKNOW Unknown/not specified
Other Ethnicity
Text
Patient Ethnicity if Ethnicity 1 or Ethnicity 2 is entered as
OTHER Other Ethnicity. (set as null if none)
Language
Text
Africian Language (please specify)
Arabic
Chinese (please specify)
Cape Verdean Creole
English
French
German
Greek
Haitian Creole
Hebrew
Hindi
Italian
Japanese
Table 8: Member Eligibility File Layout (continued)
Data
Element # Element
Type
Max.
Length Description/Codes/Sources
Korean
Persian
Polish
Portuguese
Russian
Spanish
Tagalog
Urdu
Vietnamese
Other Language (please specify)
Declined
Unavailable
Record Type
Text
(c) The member eligibility file shall be mapped to a nationalstandard format that conforms to the
following Table 9:
Table 9: Member Eligibility File Mapping
Data
Element #
Element
HIPAA Reference Transaction
Set/Loop/Segment/Qualifier/Data Element
Payer
N/A
National Plan ID
271/2100A/NM1/XV/09
Insurance Type Code/Product
271/2110C/EB/ /04, 271/2110D/EB/ /04
Year
N/A
Month
N/A
Insured Group or Policy Number
271/2100C/REF/1L/02, 271/2100C/REF/IG/02,
271/2100C/REF/6P/02,
271/2100D/REF/1L/02,
271/2100D/REF/IG/02,
271/2100D/REF/6P/02
Coverage Level Code
271/2110C/EB/ /03, 271/2100D/EB/ /03
Encrypted Subscriber Unique
Identification Number
271/2100C/NM1/MI/09
Plan Specific Contract Number
271/2100C/NM1/MI/09
Member Suffix or Sequence Number
N/A
Member Identification Code
271/2100C/MN1/MI/09, 271/2100D/NM1/MI/09
Individual Relationship Code
271/2100C/INS/Y/02, 271/2100D/INS/N/02
Member Gender
271/2100C/DMG/ /03, 271/2100D/DMG/ /03
Member Date of Birth
271/2100C/DMG/D8/02,
271/2100D/DMG/D8/02
Member City Name
271/2100C/N4/ /01, 271/2100D/N4/ /01
Member State or Province
217/2100C/N4/ /02, 271/2100D/N4/ /02
Member ZIP Code
271/2100C/N4/ /03, 271/2100D/N4/ /03
Medical Coverage
N/A
Prescription Drug Coverage
N/A
Race 1
N/A
Race 2
N/A
Other Race
N/A
Hispanic Indicator
N/A
Ethnicity 1
N/A
Ethnicity 2
N/A
Other Ethnicity
N/A
Language
N/A
(4) Medical Claim File.
(a) Medical claim fileshallbe submitted using the data elements in 129 CMR 2.11(4)(a)1. through
69.:
1. MC001. This element is named "payer". The data type of this element is text. Its length
is 6. Carriers shall code according to the payer submitting payments, Council submitter code.
2. MC002. This element is named "national plan ID". The data type of this element is text.
Its length is 30. Carriers shall code according to the CMS national plan ID.
3. MC003. This element is named "insurance type/product code". The data type of this
element is text. Its length is 2. Carriers shall code according to the following Table 10:
Table 10: Insurance Type/Product Code
Code
Description
Preferred Provider Organization (PPO)
Point of Service (POS)
Exclusive Provider Organization (EPO)
Indemnity Insurance
Health Maintenance Organization (HMO) Medicare Risk
DS
Disability
HM
Health Maintenance Organization
MA
Medicare Part A
MB
Medicare Part B
MC
Medicaid
VA
Veterans Administration Plan
WC
Workers' Compensation
4. MC004. This element is named "payer claim control number". The data type of this
element is text. Its length is 35. Carriers shall code according to the entire claim and be unique
within the payer's system.
5. MC005. This element is named "line counter". The data type of this element is integer.
Its length is 4. Carriers shall code according to line number for this service. The line counter
shall begin with one and shall be incremented by one for each additional line of a claim.
6. MC005A. This element is named "version number". The data type of this element is
integer. Its length is 4. Carriers shall code according to version number of this claim service
line. The version number begins with zero, and is incremented by one for each subsequent
version of that service line.
7. MC006. This element is named "insured group or policy number". The data type ofthis
element is text. Its length is 30. Carriers shall code according to the group or policy number,
not the number that uniquely identifies the subscriber.
8. MC007. This element is named "encrypted subscriber unique identification number". The
data type of this element is text. Its length is 30. Carriers shall code according to the
encryption method developed by the Council or its designee. Carriers shall set as null if
unavailable.
9. MC008. This element is named "plan specific contract number". The data type of this
element is text. Its length is 30. Carriers shall code according to the encrypted planassigned
contract number. Carriers shall set as null if the contract number is the same as the subscriber's
social security number.
10. MC009. This element is named "member suffix or sequence number". The data type of
this element is integer. Its length is 2. Carriers shall code according to the unique number of
the member within the contract.
11. MC010. This element is named "member identification code". The data type of this
element is text. Its length is 30. Carriers shall code according to the encryption method
developed by the Council or its designee. Carriers shall set as null if unavailable.
12. MC011. This element is named "individual relationship code". The data type of this
element is integer. Its length is 2. Carriers shall code according to member's relationship to
subscriber shown as follows in Table 11:
Table 11: Individual Relationship Code
Code
Description
Spouse
Grandfather or Grandmother
Grandson or Granddaughter
Nephew or Niece
Foster Child
Ward
Stepson or Stepdaughter
Child
Employer
Unknown
Handicapped Dependent
Sponsored Dependent
Dependent of a Minor Dependent
Significant Other
Mother
Father
Emancipated Minor
Organ Donor
Cadaver Donor
Injured Plaintiff
Where Insured Has No Financial Responsibility
Life Partner
Dependent
13. MC012. This element is named "member gender". The data type of this element is text.
Its length is 1. Carriers shall code according to:
a. M Male;
b. F Female; and
c. U Unknown.
14. MC013. This element is named "member date of birth". The data type of this element
is date. Its length is 8. Carriers shall code according to CCYYMMDD.
15. MC014. This element is named "member city name". The data type of this element is
text. Its length is 30. Carriers shall code according to the city name of the member’s
residence.
16. MC015. This element is named "member state or province". The data type of this
element is text. Its length is 2. Carriers shall code the state in which the member resides using
the standard abbreviations established by the U.S. Postal Service.
17. MC016. This element is named "member ZIP code". The data type of this element is
text. Its length is 11. Carriers shall code according to ZIP Code of member’s residence. This
may include non-US codes. Carriers shall not use the dash in coding.
18.
MC017. This element is named "date service approved" (AP Date). This field is
designed to capture the paid date, also called the Accounts Payable date. The data type of
this element is date. Its length is 8. Carriers shall code this date in CCYYMMDD format.
19. MC018. This element is named "admission date". The data type ofthis element is date.
Its length is 12. Carriers shall code for all inpatient claims using CCYYMMDD.
20. MC019. This element is named "admission hour". The data type of this element is
integer. Its length is 4. Carriers shall code for all inpatient claims, and shall express time in
military time, and may report the hour as HH or as HHMM.
21. MC020. This element is named "admission type". The data type of this element is text.
Its length is 1. Carriers shall code using an integer shown as follows in Table 12:
Table 12: Admission Type
Code
Description
Emergency
Urgent
Elective
Newborn
Trauma Center
Information Not Available
22. MC021. This element is named "admission source". The data type of this element is text.
Its length is 1. Carriers shall code using text shown as follows in Table 13:
Table 13: Admission Source
Code
Description
Physician Referral
Clinic Referral
HMO Referral
Transfer from Hospital
Transfer from a Skilled Nursing Facility
Transfer from another Health Care Facility
Emergency Room
Court/Law Enforcement
Unknown
A
Transfer from a Rural Primary Care Hospital
23. MC022. This element is named "discharge hour". The data type of this element is
integer. Its length is 4. Carriers shall code using militarytime and mayreport the hour as HH
or as HHMM.
24. MC022A. This element is named "discharge date". The data type of this element is date.
Its length is 8. Carriers shall code for all inpatient claims using CCYYMMDD.
24. MC023. This element is named “discharge status". The data type of this element is
integer. Its length is 2. Carriers shall code shown as follows in Table 14:
Table 14: Discharge Status
Code
Description
Discharged to home or self care
Discharged/transferred to another short-term general hospital for inpatient care
Discharged/transferred to skilled nursing facility (SNF)
Discharged/transferred to nursing facility (NF)
Discharged/transferred to another type of institution for inpatient care or referred for outpatient
services to another institution
Discharged/transferred to home under care of organized home health service organization
Left against medical advice or discontinued care
Discharged/transferred to home under care of a Home IV provider
Admitted as an inpatient to this hospital
Expired
Still patient or expected to return for outpatient services
Expired at home
Expired in a medical facility
Expired, place unknown
Discharged/transferred to a Federal Hospital
Hospice – home
Hospice – medical facility
Discharged/transferred within this institution to a hospital-based Medicare-approved swing bed
Discharged/transferred to an inpatient rehabilitation facility including distinct parts of a hospital
Discharged/transferred to a long term care hospital
Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare
25. MC024. This element is named "service provider number". The data type of this element
is text. Its length is 30. Carriers shall code using the payer assigned provider number.
26. MC025. This element is named "service provider tax ID number". The data type ofthis
element is text. Its lengthis 10. Carriers shall code using the federal taxpayer's identification
number.
27. MC026. This element is named "national service provider ID". The data type of this
element is text. Its length is 20. Carriers shall code if national provider ID is mandated for use
under HIPAA.
28. MC027. This element is named "service provider entity type qualifier". The data type
of this element is text. Its length is 1. HIPAA provider taxonomy classifies provider groups
(clinicians who bill as a group practice or under a corporate name, even if that group is
composed of one provider) as a "person", and these shall be coded as a person. Carriers shall
code according to:
a. 1 = Person; and
b. 2 = Non-person entity
29. MC028. This element is named "service provider first name". The data type of this
element is text. Its length is 25. Carriers shall code according to the individual's first name, and
set to null if the provider is a facility or organization.
30. MC029. This element is named "service provider middle name". The data type of this
element is text. Its length is 25. Carriers shall code according to the entity's middle name or
initial, and shall set to null if provider is a facility or organization.
31. MC030. This element is named "service provider last name or organization name". The
data type of this element is text. Its length is 50. Carriers shall code using the full name of the
provider organization or last name of individual provider.
32. MC031. This element is named "service provider suffix". The data type of this element
is text. Its length is 10. Carriers shall code according to the suffixto the individualname, and
set to nullif the provider is a facility or organization. The service provider suffix shall be used
to capture the generation of individual clinician (e.g., Jr., Sr., III.), if applicable, rather than the
clinician's degree (e.g., MD, LICSW).
33. MC032. This element is named "service provider specialty". The data type of this
element is text. Its length is 10. Carriers shall code as defined by the payer dictionary for
specialty code value, which shall be supplied during testing.
34. MC033. This element is named "service provider city name". The data type of this
element is text. Its length is 30. Carriers shall code according to the city name of provider,
and preferably the practice location.
35. MC034. This element is named "service provider state". The data type of this element
is text. Its length is 2. Carriers shall code as defined by the US Postal Service.
36. MC035. This element is named "service provider ZIP Code". The data type of this
element is text. The length is 11. Carriers shall code according to ZIP code of provider, which
may include non-US codes. Carriers shall not use the dash in coding.
MC035A. This element is named "service provider country name". The data type of this
element is text. Its length is 30. Carriers shall code according to the country name of
provider, and preferably the practice location.
37. MC036. This element is named "type of bill on Facility Claims". The data type of this
element is integer. Its length is 2. Carriers shall use this coding on facility claims, including
those submitted using UB92 forms, shown as follows in Table 15:
Table 15: Type of Bill on Facility Claims
First Digit
Type of Facility
Hospital
Skilled Nursing
Home Health
Christian Science Hospital
Christian Science Extended Care
Intermediate Care
Clinic
Special Facility
Second Digit if First
Digit = 1 through 6
Bill Classification
Inpatient (including Medicare Part A)
Inpatient (including Medicare Part B Only)
Outpatient
Other (for hospital referenced diagnostic services
or home health not under a plan of treatment)
Nursing Facility Level I
Nursing Facility Level II
Intermediate Care – Level III Nursing Facility
Swing Beds
Second Digit if First
Digit = 7
Bill Classification
Rural Health
Hospital Based or Independent Renal
Dialysis Center
Free Standing
Outpatient Rehabilitation Facility (ORF)
Comprehensive Outpatient Rehabilitation
Facilities (CORFs)
Other
Second Digit if First
Digit = 8
Bill Classification
Hospice, Non-hospital based
Hospital, Hospital based
Ambulatory Surgery Center
Free Standing Birthing Center
Other
38. MC037. This element is named "site of service on NSF/CMS 1500 claims". The data
type of this element is text. Its length is 2. Carriers shall use this coding on professional claims,
including those submitted using NSF CMS 1500 forms, shown as follows in Table 16:
Table 16: Site of Service on NSF/CMS 1500 Claims
Code
Facility
Office
Home
Inpatient Hospital
Outpatient Hospital
Emergency Room – Hospital
Ambulatory Surgery Center
Birthing Center
Military Treatment Facility
Skilled Nursing Facility
Nursing Facility
Custodial Care Facility
Hospice
Ambulance – Land
Ambulance –Air or Water
Federally Qualified Center
Inpatient Psychiatric Facility
Psychiatric Facility Partial Hospitalization
Community Mental Health Center
Intermediate Care Facility/Mentally Retarded
Residential Substance Abuse Treatment Facility
Psychiatric Residential Treatment Center
Mass Immunization Center
Comprehensive Inpatient Rehabilitation Facility
Comprehensive Outpatient Rehabilitation Facility
End Stage Renal Disease Treatment Facility
State of Local Public Health Clinic
Rural Health Clinic
Independent Laboratory
Other Unlisted Facility
39. MC038. This element is named "claim status". The data type ofthis element is integer.
Its length is 2. This code describes the payment status of the specific service line record.
Carriers shall code according to 129 CMR 2.11(4)(a)39.a. through h.:
a. 01 Processed as primary;
b. 02 Processed as secondary;
c. 03 Processed as tertiary;
d. 04 Denied;
e. 19 Processed as primary, forwarded to additional payer(s);
f. 20 Processed as secondary, forwarded to additional payer(s);
g. 21 Processed as tertiary, forwarded to additional payer(s); and
h. 22 Reversal of previous payment.
40. MC039. This element is named "admitting diagnosis". The data type of this element is
text. Its length is 5. Carriers shall code according to all inpatient admission claims and
encounters using the ICD-9-CM without the decimal point.
41. MC040. This element is named "E-code". The data type of this element is text. Its
length is 5. Carriers shall use this code to describe an injury, poisoning or adverse effect, ICD
9-CM without coding decimal points.
42. MC041. This element is named "principal diagnosis". The data type of this element is
text. Its length is 5. Carriers shall code the principal diagnosis given on the claim header using
CD-9-CM without coding decimal points.
43. MC042. This element is named "other diagnosis – 1". The data type of this element is
text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points.
44. MC043. This element is named "other diagnosis – 2". The data type of this element is
text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points.
45. MC044. This element is named "other diagnosis – 3". The data type of this element is
text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points.
46. MC045. This element is named "other diagnosis – 4". The data type of this element is
text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points.
47. MC046. This element is named "other diagnosis – 5". The data type of this element is
text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points.
48. MC047. This element is named "other diagnosis – 6". The data type of this element is
text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points.
49. MC048. This element is named "other diagnosis – 7". The data type of this element is
text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points.
50. MC049. This element is named "other diagnosis – 8". The data type of this element is
text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points.
51. MC050. This element is named "other diagnosis – 9". The data type of this element is
text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points.
52. MC051. This element is named "other diagnosis – 10". The data type ofthis element is
text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points.
53. MC052. This element is named "other diagnosis – 11". The data type ofthis element is
text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points.
54. MC053. This element is named "other diagnosis – 12". The data type of this element is
text. Its length is 5. Carriers shall code using ICD-9-CM without coding decimal points.
55. MC054. This element is named "revenue code". The data type of this element is text.
Its length is 4. Carriers shall code using national uniform billing committee codes. Carriers
shall code using leading zeroes, left-justified, and four digits.
56. MC055. This element is named "procedure code". The data type of this element is text.
Its lengthis 5. Carriers shallcode according to the Health Care Common Procedural Coding
System (HCPCS). This includes the CPT codes of the American Medical Association.
57. MC056. This element is named "procedure modifier – 1". The data type of this element
is text. Its length is 2. Carriers shall code using a procedure modifier whena modifier clarifies
or improves the reporting accuracy of the associated procedure code.
58. MC057. This element is named "procedure modifier – 2". The data type of this element
is text. Its length is 2. Carriers shall code using a procedure modifier required when a modifier
clarifies or improves the reporting accuracy of the associated procedure code.
59. MC058. This element is named "ICD-9-CM procedure code". The data type of this
element is text. Its length is 4. Carriers shall code using the primary ICD-9-CM code given
on the claim header without coding decimal points.
60. MC059. This element is named "date of service – from". The data type of this element
is date. Its length is 8. Carriers shall code using the first date of service for this service line,
CCYYMMDD.
61. MC060. This element is named "date of service – through". The data type of this
element is date. Its length is 8. Carriers shall code using the last date of service for this service
line, CCYYMMDD.
62. MC061. This element is named "quantity". The data type of this element is integer. Its
length is 3. Carriers shall code according to the count of services performed, which shall be
set equal to one on all observation bed service lines and should be set equal to zero on all other
room and board service lines, regardless of the length of stay.
63. MC062. This element is named "charge amount". The data type of this element is
decimal. Its length is 10. Carriers shall code according to the charge without coding decimal
points.
64. MC063. This element is named "paid amount". The data type of this element is decimal.
Its length is 10. Carriers shall code including withhold amounts without coding decimal points.
65. MC064. This element is named "prepaid amount". The data type of this element is
decimal. Its length is 10. Carriers shall code using for capitated services, the fee for service
equivalent amount without coding decimal points.
66. MC065. This element is named "co-pay amount". The data type of this element is
decimal. Its length is 10. Carriers shall code using the preset, fixed dollar amount for which
the individual is responsible without coding decimal points.
67. MC066. This element is named "coinsurance amount". The data type of this element is
decimal. Its length is 10. Carriers shall code using the dollar amount of the coinsurance
without coding decimal points.
68. MC067. This element is named "deductible amount". The data type of this element is
decimal. Its length is 10. Carriers shall code using the dollar amount of the deductible without
coding decimal points.
69. MC068. This element is named "record type". The data type of this element is text. Its
length is 2.
(b) The file specification for the medical claim file shall conform to the following Table 17:
Table 17: Medical Claims File Layout
Data
Element
Data Element Name
Type
Max.
Length Description/Codes/Sources
Payer
Text
Payer submitting payments
Council Submitter Code
National Plan ID
Text
CMS National Plan ID
Insurance Type/
Product Code
Text
12 Preferred Provider Organization (PPO)
13 Point of Service (POS)
14 Exclusive Provider Organization (EPO)
15 Indemnity Insurance
16 Health Maintenance Organization (HMO) Medicare Risk
DS Disability
HM Health Maintenance Organization
MA Medicare Part A
MB Medicare Part B
MC Medicaid
VA Veteran Administration Plan
WC Worker's Compensation
Payer Claim Control
Number
Text
Must apply to the entire claim and be unique within the
payer's system
Line Counter
Integer
Line number for this service
The line counter begins with 1 and is incremented by 1 for
each additional service line of a claim
MC005A Version Number
Integer
Version number of this claim service line
The version number begins with 0 and is incremented by 1
for each subsequent version of that service line
Insured Group or
Policy Number
Text
Group or policy number (not the number that uniquely
identifies the subscriber)
Encrypted
Subscriber Unique
Identification
Number
Text
Encrypted subscriber’s Unique Identification number Set as
null if unavailable
Plan Specific
Contract Number
Text
Encrypted plan assigned Set as null if contract number =
subscriber’s social security number
Member Suffix or
Sequence Number
Integer
Uniquely numbers the member within the contract
Member
Identification Code
Text
Encrypted member’s Unique Identification number Set as
null if unavailable
Individual
Relationship Code
Integer
Member's relationship to subscriber
01 Spouse
04 Grandfather or Grandmother
05 Grandson or Granddaughter
07 Nephew or Niece
10 Foster Child
15 Ward
17 Stepson or Stepdaughter
19 Child
20 Employee
Table 17: Medical Claims File Layout (continued)
Data
Element
Data Element Name
Type
Max.
Length Description/Codes/Sources
21 Unknown
22 Handicapped Dependent
23 Sponsored Dependent
24 Dependent of a Minor Dependent
29 Significant Other
32 Mother
33 Father
36 Emancipated Minor
39 Organ Donor
40 Cadaver Donor
41 Injured Plaintiff
43 Where Insured Has No Financial Responsibility
53 Life Partner
76 Dependent
Member Gender
Text
M Male
F Female
U Unknown
Member Date of
Birth
Date
CCYYMMDD
Member City Name
Text
City name of member
Member State or
Province
Text
As defined by the US Postal Service
Member ZIP Code
Text
ZIP Code of member - may include non-US codes
Date Service
Approved (AP Date)
Date
CCYYMMDD
(Generally the same as the paid date)
Admission Date
Date
Required for all inpatient claims
CCYYMMDD
Admission Hour
Integer
Required for all inpatient claims
Time is expressed in military time – HH or HHMM
Admission Type
Integer
Admission Source
Text
Discharge Hour
Integer
Hour in military time – HH or HHMM
MC022A Discharge Date
Date
Required for all inpatient claims CCYYMMDD
Discharge Status
Integer
01 Discharged to home or self care
02 Discharged/transferred to another short-term general
hospital for inpatient care
03 Discharged/transferred to skilled nursing facility (SNF)
04 Discharged/transferred to nursing facility (NF)
05 Discharged/transferred to another type of institution for
inpatient care or referred for outpatient services to another
institution
06 Discharged/transferred to home under care of organized
home health service organization
07 Left against medical advice or discontinued care
08 Discharged/transferred to home under care of a Home
IV provider
Table 17: Medical Claims File Layout (continued)
Data
Element
Data Element Name
Type
Max.
Length Description/Codes/Sources
09 Admitted as an inpatient to this hospital
20 Expired
30 Still patient or expected to return for outpatient services
Service Provider
Number
Text
Payer assigned provider number
Service Provider Tax
ID Number
Text
Federal taxpayer's identification number
National Service
Provider ID
Text
Required if National Provider ID is mandated for use under
HIPAA
Service Provider
Entity Type Qualifier
Text
1 Person
2 Non-Person Entity
HIPAA provider taxonomy classifies provider groups
(clinicians who bill as a group practice or under a corporate
name, even if that group is composed of one provider) as
“Person”.
Service Provider
First Name
Text
Individual first name
Set to null if provider is a facility or organization
Service Provider
Middle Name
Text
Individual middle name or initial
Set to null if provider is a facility or organization
Service Provider
Last Name or
Organization Name
Text
Full name of provider organization or last name of individual
provider
Service Provider
Suffix
Text
Suffix to individual name
Set to null if provider is a facility or organization. Should be
used to capture the generation of the individual clinician (e.g.,
Jr. Sr., III), if applicable, rather than the clinician’s degree
(e.g., ‘MD’, ‘LICSW’).
Service Provider
Specialty
Text
As defined by payer
Dictionary for specialty code values must be supplied during
testing
Service Provider
City Name
Text
City name of provider - preferably practice location
Service Provider
State
Text
As defined by the US Postal Service
Service Provider ZIP
Code
Text
ZIP Code of provider - may include non-US codes Do not
include dash
MC035A Service Provider
Country Name
Text
Country name of provider - preferably practice location
Table 17: Medical Claims File Layout (continued)
Data
Element
Data Element Name
Type
Max.
Length Description/Codes/Sources
Type of Bill – on
Facility Claims
Integer
Type of Facility - First Digit
(Should be coded on
facility claims, such
as those submitted
using on UB92 forms)
1 Hospital
2 Skilled Nursing
3 Home Health
4 Christian Science Hospital
5 Christian Science Extended Care
6 Intermediate Care
7 Clinic
8 Special Facility
Bill Classification - Second Digit if First Digit = 1-6
1 Inpatient (Including Medicare Part A)
2 Inpatient (Medicare Part B Only)
3 Outpatient
4 Other (for hospital referenced diagnostic services or home
health not under a plan of treatment)
5 Nursing Facility Level I
6 Nursing Facility Level II
7 Intermediate Care - Level III Nursing Facility
8 Swing Beds
Bill Classification - Second Digit if First Digit = 7
1 Rural Health
2 Hospital Based or Independent Renal
3 Dialysis Center
4 Free Standing
5 Outpatient Rehabilitation Facility (ORF)
6 Comprehensive Outpatient Rehabilitation
7 Facilities (CORFs)
9 Other
Bill Classification – Second Digit if First Digit = 8
1 Hospice (Non Hospital Based)
2 Hospice (Hospital-Based)
3 Ambulatory Surgery Center
4 Free Standing Birthing Center
9 Other
Site of Service – on
NSF/CMS 1500
Claims
Text
11 Office
(Should be coded on
professional claims,
such as those
submitted using NSF
[CMS 1500 forms])
12 Home
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room – Hospital
Table 17: Medical Claims File Layout (continued)
Data
Element
Data Element Name
Type
Max.
Length Description/Codes/Sources
24 Ambulatory Surgery Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance – Land
42 Ambulance – Air or Water
51 Inpatient Psychiatric Facility
52 Psychiatric Facility Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
50 Federally Qualified Center
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End Stage Renal Disease Treatment Facility
71 State of Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Unlisted Facility
Claim Status
Integer
01 Processed as primary
(Actually describes
the payment status of
the specific service
line record)
02 Processed as secondary
03 Processed as tertiary
04 Denied
19 Processed as primary, forwarded to additional payer(s)
20 Processed as secondary, forwarded to additional payer(s)
21 Processed as tertiary, forwarded to additional payer(s)
22 Reversal of previous payment
Admitting Diagnosis
Text
Required on all inpatient admission claims and encounters
ICD-9-CM Do not code decimal point
E-Code
Text
Describes an injury, poisoning or adverse effect
ICD-9-CM Do not include decimal
Principal Diagnosis
Text
ICD-9-CM Do not code decimal point
This should be the
principal diagnosis
given on the claim
header.
Other Diagnosis – 1
Text
ICD-9-CM Do not code decimal point
Other Diagnosis – 2
Text
ICD-9-CM Do not code decimal point
Other Diagnosis – 3
Text
ICD-9-CM Do not code decimal point
Other Diagnosis – 4
Text
ICD-9-CM Do not code decimal point
Table 17: Medical Claims File Layout (continued)
Data
Element
Data Element Name
Type
Max.
Length Description/Codes/Sources
Other Diagnosis – 5
Text
ICD-9-CM Do not code decimal point
Other Diagnosis – 6
Text
ICD-9-CM Do not code decimal point
Other Diagnosis – 7
Text
ICD-9-CM Do not code decimal point
Other Diagnosis – 8
Text
ICD-9-CM Do not code decimal point
Other Diagnosis – 9
Text
ICD-9-CM Do not code decimal point
Other Diagnosis – 10
Text
ICD-9-CM Do not code decimal point
Other Diagnosis – 11
Text
ICD-9-CM Do not code decimal point
Other Diagnosis – 12
Text
ICD-9-CM Do not code decimal point
Revenue Code
Text
National Uniform Billing Committee Codes
Code using leading zeroes, left-justified, and four digits.
Procedure 1 Code
Text
Health Care Common Procedural Coding System (HCPCS)
This includes the CPT codes of the American Medical
Association
Procedure 1
Modifier – 1
Text
Procedure modifier required when a modifier clarifies/
improves the reporting accuracy of the associated procedure
code
Procedure 1
Modifier – 2
Text
Procedure modifier required when a modifier clarifies/
improves the reporting accuracy of the associated procedure
code
ICD-9-CM
Procedure 1 Code
Text
Primary ICD-9-CM code given on the claim header. Do not
code decimal point
Date of Service –
From
Date
First date of service for this service line
CCYYMMDD
Date of Service –
Through
Date
Last date of service for this service line
CCYYMMDD
Quantity
Integer
Count of services performed
Should be set equal to 1 on all Observation bed service lines,
for consistency.
Charge Amount
Decimal
Do not code decimal point
Paid Amount
Decimal
Includes any withhold amounts
Do not code decimal point
Prepaid Amount
Decimal
For capitated services, the fee for service equivalent amount
Do not code decimal point
Copay Amount
Decimal
The preset, fixed dollar amount for which the individual is
responsible Do not code decimal point
Coinsurance Amount
Decimal
Do not code decimal point
Deductible Amount
Decimal
Do not code decimal point
Record Type
Text
MC
(c) The mappingfor medical claims file shall conform to the following national standard in Table
18:
Table 18: Medical Claims File Mapping
UB-92
Form
UB-92
(Version
6.0) Record
Type/
HCFA
NSF (National
Standard Format)
HIPAA Reference
Transaction
Set/Loop/Segment/
Qualifier/
Data
Element #
Data Element Name
Locator
Field #
Locator
Data Element
Payer
N/A
N/A
N/A
N/A
N/A
National Plan ID
N/A
N/A
N/A
N/A
835/1000A/N1/XV/04
Product/Claim Filing
Indicator Code
N/A
30/4
N/A
N/A
835/2100/CLP/ /06
Payer Claim Control
Number
N/A
N/A
N/A
FA0-02.0, FB0-02.0,
FB1-02.0, GA0-02.0,
GC0-02.0, GX0-02.0,
GX2-02.0, HA0-02.0,
FB2-02.0, GU0-02.0
835/2100/CLP/ /07
Line Counter
N/A
N/A
N/A
N/A
837/2400/LX/ /01
Insured Group or Policy
Number
62 (A-C)
30/10
11C
DA0-10.0
837/2000B/SBR/ /03
Encrypted Subscriber
Unique Identification
Number
N/A
N/A
N/A
N/A
835/2100/NM1/34/08
Plan Specific Contract
Number
N/A
N/A
N/A
N/A
835/2100/NM1/HN/08
Member Suffix or
Sequence Number
N/A
N/A
N/A
N/A
N/A
Member Identification
Code
N/A
N/A
N/A
N/A
835/2100/NM1/34/08
Individual Relationship
Code
59 (A-C)
30/18
DA0-17.0
837/2000B/SBR/ /02,
837/2000C/PAT/ /01
Member Gender
20/7
CA0-09.0
837/2010CA/DMG/03
Member Date of Birth
20/8
CA0-08.0
837/2010CA/DMG/D8/02
Member City Name
20/14
CA0-13.0
837/2010CA/N4/ /01
Member State or Province
20/15
CA0-14.0
837/2010CA/N4/ /02
Member ZIP Code
20/16
CA0-15.0
837/2010CA/N4/ /03
Date Service Approved
N/A
N/A
N/A
N/A
N/A
Admission Date
20/17
N/A
N/A
837/2300/DTP/435/03
Admission Hour
20/18
N/A
N/A
837/2300/DTP/435/03
Admission Type
20/10
N/A
N/A
837/2300/CL1/ /01
Admission Source
20/11
N/A
837/2300/CL1/ /02
Discharge Hour
20/22
N/A
837/2300/DTP/096/03
Discharge Status
20/21
N/A
N/A
837/2300/CL1/ /03
Service Provider Number
N/A
N/A
N/A
N/A
N/A
MC025 Service Provider Tax ID
Number
10/4-5
BA0-09.0, CA0-28.0,
BA0-02.0, BA1-02.0,
YA0-02.0,BA0-06.0,
BA0-10.0, BA0-12.0,
BA0-13.0, BA0-14.0,
BA0-15.0, BA0-16.0,
BA0-17.0, BA0-24.0,
YA0-06.0
835/2100/NM1/FI/09
Table 18: Medical Claims File Mapping (continued)
UB-92
Form
UB-92
(Version
6.0) Record
Type/
HCFA
NSF (National
Standard Format)
HIPAA Reference
Transaction
Set/Loop/Segment/
Qualifier/
Data
Element #
Data Element Name
Locator
Field #
Locator
Data Element
National Service Provider
ID
N/A
10/6
N/A
N/A
835/2100/NM1/XX/09
Service Provider Entity
Type Qualifier
N/A
N/A
N/A
N/A
835/2100/NM1/82/02
Service Provider First
Name
10/12
BA0-20.0
835/2100/NM1/82/04
Service Provider Middle
Name
10/12
BA0-21.0
835/2100/NM1/82/05
Service Provider Last
Name or Organization
Name
10/12
BA0-18.0, BA0-19.0
835/2100/NM1/82/03
Service Provider Suffix
10/12
BA0-22.0
835/2100/NM1/82/07
Service Provider Specialty
N/A
N/A
N/A
N/A
837/2000A/PRV/ZZ/03
Service Provider City
Name
10/14
N/A
BA1-09.0, 15.0
837/2010A/N4/ /01
Service Provider State or
Province
10/15
N/A
BA1-10.0, 16.0
837/2010A/N4/ /02
Service Provider ZIP
Code
10/16
N/A
BA1-11.0, 17.0
837/2010A/N4/ /03
Type of Bill – on Facility
Claims
Positions
1-2: 40/4
N/A
N/A
837/2300/CLM/ /05-1
Site of Service – on
NSF/CMS 1500 Claims
N/A
N/A
N/A
FA0-07.0, GU0-0.50
835/2100/CLP/ /08
Claim Status
N/A
N/A
N/A
N/A
835/2100/CLP/ /02
Admitting Diagnosis
70/25
N/A
N/A
837/2300/HI/BJ/02-2
E-Code
70/26
N/A
N/A
837/2300/HI/BN/03-2
Principal Diagnosis
70/4
21.1
EA0-32.0, GX0-31.0,
GU0-12.0
837/2300/HI/BK/01-2
Other Diagnosis – 1
70/5
21.2
EA0-33.0, GX0-32.0,
GU0-13.0
837/2300/HI/BF/02-1
Other Diagnosis – 2
70/6
21.3
EA0-33.0, GX0-32.0,
GU0-13.0
837/2300/HI/BF/02-2
Other Diagnosis – 3
70/7
21.4
EA0-33.0, GX0-32.0,
GU0-13.0
837/2300/HI/BF/02-3
Other Diagnosis – 4
70/8
N/A
EA0-35.0, GX0-34.0,
GU0-15.0
837/2300/HI/BF/02-4
Other Diagnosis – 5
70/9
N/A
N/A
837/2300/HI/BF/02-5
Other Diagnosis – 6
70/10
N/A
N/A
837/2300/HI/BF/02-6
Other Diagnosis – 7
70/11
N/A
N/A
837/2300/HI/BF/02-7
Other Diagnosis – 8
70/12
N/A
N/A
837/2300/HI/BF/02-8
Other Diagnosis – 9
N/A
N/A
N/A
N/A
837/2300/HI/BF/02-9
Other Diagnosis –10
N/A
N/A
N/A
N/A
837/2300/HI/BF/02-10
Other Diagnosis –11
N/A
N/A
N/A
N/A
837/2300/HI/BF/02-11
Other Diagnosis –12
N/A
N/A
N/A
N/A
837/2300/HI/BF/02-12
Revenue Code
50/5,11-13,
60/5,15-16,
61/5,15-16
N/A
N/A
835/2110/SVC/RB/01-2,
835/2110/SVC/NU/01-2
Table 18: Medical Claims File Mapping (continued)
UB-92
Form
UB-92
(Version
6.0) Record
Type/
HCFA
NSF (National
Standard Format)
HIPAA Reference
Transaction
Set/Loop/Segment/
Qualifier/
Data
Element #
Data Element Name
Locator
Field #
Locator
Data Element
Procedure Code
60/6,15-16,
61/6,15-16
24.1-6
D
FA0-09.0, FB0-15.0,
GU0-07.0
835/2110/SVC/HC/01-2
Procedure Modifier – 1
60/7,15-16,
61/7, 15-16
24.1-6
D
FA0-10.0, GU0-08.0
835/2110/SVC/HC/01-3
Procedure Modifier – 2
60/8,15-16,
61/8,15-16
24.1-6
D
FA0-11.0
835/2110/SVC/HC/01-3
ICD-9-CM Procedure
Code
80,
81(A-E)
70/13, 15,
17, 19, 21,
N/A
N/A
835/2110/SVC/ID/01-2
Date of Service – From
61/13, 15
16, 61/13,
15-16
24.1-6
A
N/A
835/2110/DTM/150/02
Date of Service – Thru
N/A
N/A
24.1-6
A
FA0-05.0, FA0-06.0 835/2110/DTM/151/02
Quantity
50/7, 11-13,
60/9,15-16,
61/9,15-16
24.1-6
G
FA0-19.0, FB0-16.0 835/2110/SVC/ /05
Charge Amount
50/8, 11-13,
60/10, 16
16, 61/11,
15-16
24.1-6F FA0-13.0
835/2110/SVC/ /02
Paid Amount
N/A
N/A
N/A
835/2110/SVC/ /03
Prepaid Amount
N/A
N/A
N/A
N/A
N/A
Co-pay Amount
N/A
N/A
N/A
N/A
N/A
Coinsurance Amount
N/A
N/A
N/A
N/A
N/A
Deductible Amount
N/A
N/A
N/A
N/A
N/A
Record Type
N/A
N/A
N/A
N/A
N/A
(5) Pharmacy Claims File.
(a) The pharmacyclaimfile layout shall be submitted using the format in 129 CMR 2.11(5)(a)1.
through 44.:
1. PC001. This element is named "payer". The data type of this element is text. Its length
is 6. Carriers shall code using the payer submitting payments, Council submitter code.
2. PC002. This element is named "plan ID". The data type of this element is text. Its length
is 30. Carriers shall code using the CMS national plan ID.
3. PC003. This element is named "insurance type/product code". The data type of this
element is text. Its length is 2. Carriers shall code as follows in Table 19:
Table 19: Pharmacy Insurance Type/Product Code
Code Description
Preferred Provider Organization (PPO)
Point of Service (POS)
Exclusive Provider Organization (EPO)
Indemnity Insurance
Health Maintenance Organization (HMO) Medicare Risk
AM
Automobile Medical
DS
Disability
HM
Health Maintenance Organization
LI
Liability
LM
Liability Medical
MA
Medicare Part A
MB
Medicare Party B
MC
Medicaid
OF
Other Federal Program (e.g. Black Lung)
TV
Title V
VA
Veterans Administration Plan
WC
Workers' Compensation
4. PC004. This element is named "payer claim control number". The data type of this
element is text. Its length is 35. Carriers shall code using the entire claim, which shall be
unique within the payer's system.
5. PC005. This element is named "line counter". The data type of this element is integer. Its
length is 4. Carriers shall code according to line number for this service. The line counter shall
begin with one and be incrementally increased by one for eachadditionalservice line of a claim.
6. PC006. This element is named "insured group number". The data type of this element is
text. Its length is 30. Carriers shall code according to group or policy number and not the
number that uniquely identifies the subscriber.
7. PC007. This element is named "encrypted subscriber Unique Identification number". The
data type of this element is text. Its length is 30. Carriers shall code according to the
encryption method developed by the Council or its designee. Carriers shall set as null if
unavailable.
8. PC008. This element is named "plan specific contract number. The data type of this
element is text. Its length is 30. Carriers shallcode according to the encrypted plan assigned
contract number. Carriers shall set as null if contract number is the same as subscriber's social
security number.
9. PC009. This element is named "member suffix or sequence number". The data type of
this element is integer. Its length is 2. Carriers shall code according to the unique number that
identifies the member within the contract.
10. PC010. This element is named "member identification code". The data type of this
element is text. Its length is 30. Carriers shall code according to the encryption method
developed by the Council or its designee. Carriers shall set as null if unavailable.
11. PC011. This element is named "individual relationship code". The data type of this
element is integer. Its length is 2. Carriers shall code according to member's relationship to
subscriber as follows in Table 20:
Table 20: Individual Relationship Code
Code Description
Spouse
Grandfather or Grandmother
Grandson or Granddaughter
Nephew or Niece
Foster Child
Ward
Stepson or Stepdaughter
Child
Employee/Self
Unknown
Handicapped Dependent
Sponsored Dependent
Dependent of a Minor Dependent
Significant Other
Mother
Father
Emancipated Minor
Organ Donor
Cadaver Donor
Injured Plaintiff
Child Where Insured Has No Financial Responsibility
Life Partner
Dependent
12. PC012. This element is named "member gender". The data type of this element is
integer. Its length is 1. Carriers shall code as follows in Table 21:
Table 21: Member Gender
Code Description
Male
Female
Unknown
13. PC013. This element is named "member date of birth". The data type of this element is
date. Its length is 8. Carriers shall code according to CCYYMMDD.
14. PC014. This element is named "member city name of residence. The data type of this
element is text. Its length is 30. Carriers shall code according to the city name of member's
residence.
15. PC015. This element is named "member state". The data type ofthis element is text. Its
length is 2. Carriers shall code the state in which the member resides using the standard
abbreviations established by the US Postal Service.
16. PC016. This element is named "member ZIP code". The data type of this element is text.
Its length is 9. Carriers shall code according to the ZIP Code of member's residence, which
may include non-US codes. Carriers shall not include dash.
17. PC017. This element is named "date service approved" (AP Date). The data type of this
element is date. Its length is 8. Carriers shall code according to CCYYMMDD. This date
is generally the same as the paid date or the pharmacy benefits manager's billing date.
18. PC018. This element is named "pharmacy number". The data type of this element is text.
Its length is 30. Carriers shall code according to assigned pharmacy number (NCPDP or
NABP).
19. PC019. This element is named "pharmacy tax ID number". The data type of this element
is text. Its length is 10. Carriers shall code according to Federal taxpayer's identification
number. Carriers shall provide the pharmacy chain's federal tax identification number, if the
individual retail pharmacy's tax ID# is not available.
20. PC020. This element is named "pharmacy name". The data type ofthis element is text.
Its length is 30. Carriers shall code according to the name of pharmacy.
21. PC021. This element is named "national pharmacy ID number. The data type of this
element is text. Its length is 20. Carriers shall code according to the national provider ID, if
that is mandated for use under HIPAA.
22. PC022. This element is named "pharmacy location city". The data type of this element
is text. Its length is 30. Carriers shall code according to the city name of pharmacy.
23. PC023. This element is named "pharmacy location state". The data type ofthis element
is text. Its length is 2. Carriers shall code as defined by the US Postal Service.
24. PC024. This element is named "pharmacy ZIP code". The data type of this element is
text. Its length is 10. Carriers shall code according to ZIP code of pharmacy, which may
include non-US codes. Carriers shall not include the dash in their codes.
PC024A. This element is named "pharmacy country name". The data type of this element
is text. Its length is 30. Carriers shall code according to the country name of pharmacy.
25. PC025. This element is named "claim status". The data type of this element is integer.
Its length is 2. Carriers shall code according to:
a. 01 Processed as primary;
b. 02 Processed as secondary;
c. 03 Processed as tertiary;
d. 04 Denied;
e. 19 Processed as primary, forwarded to additional payer(s);
f. 20 Processed as secondary, forwarded to additional payer(s);
g. 21 Processed as tertiary, forwarded to additional payer(s); and
h. 22 Reversal of previous payment.
26. PC026. This element is named "drug code". The data type of this element is text. Its
length is 11. Carriers shall code according to NDC Code.
27. PC027. This element is named "drug name". The data type of this element is text. Its
length is 80. Carriers shall code according to text name of drug.
28. PC028. This element is named "new prescription". The data type of this element is text.
Its length is 1. Carriers shall code according to:
a. N = new prescription; and
b. R = refill prescription.
29. PCO28A. This element is named "refill number". The data type of this element is integer.
Its length is 2. Carriers shallcode according to 01-99 Number of refill. If the refill number is
unknown then code as 01.
30. PC029. This element is named "generic drug indicator". The data type of this element
is text. Its length is 1. Carriers shall code according to:
a. N = No, branded drug; and
b. Y = Yes, generic drug.
31. PC030. This element is named "dispense as written code". The data type of this element
is integer. Its length is 1. Carriers shall code according to:
a. 0 = Not dispensed as written;
b. 1 = Physician dispense as written;
c. 2 = Member dispense as written;
d. 3 = Pharmacy dispense as written;
e. 4 = No generic available;
f. 5 = Brand dispensed as generic;
g. 6 = Override;
h. 7 = Substitution not allowed, brand drug mandated by law;
i. 8 = Substitution allowed, generic drug not available in marketplace; and
j. 9 = Other.
32. PC031. This element is named "compound drug indicator". The data type of this element
is text. Its length is 1. Carriers shall code according to:
a. N = Non-compound drug;
b. Y = Compound drug; and
c. U = Non-specified drug compound.
33. PC032. This element is named "date prescription filled". The data type of this element
is date. Its length is 8. Carriers shall code according to CCYYMMDD.
34. PC033. This element is named "quantity dispensed". The data type of this element is
integer. Its length is 5. Carriers shall code according to the number of metric units of
medication dispensed.
35. PC034. This element is named "days supply". The data type of this element is integer.
Its length is 3. Carriers shall code according to estimated number of days the prescription will
last.
36. PC035. This element is named "charge amount". The data type of this element is
decimal. Its length is 10. Carriers shallcode accordingto the charge, without codingdecimal
points.
37. PC036. This element is named "paid amount". The data type of this element is decimal.
Its length is 10. Carriers shall code according to "includes all health plan payments and
excludes all member payments", without coding decimal points.
38. PC037. This element is named "ingredient cost/list price". The data type of this element
is decimal. Its length is 10. Carriers shall code according to Average Wholesale Price (AWP)
of the drug dispensed, without coding decimal points.
39. PC038. This element is named "postage amount claimed". The data type of this element
is decimal. Its length is 10. Carriers shall not code decimal points.
40. PC039. This element is named "dispensing fee". The data type of this element is decimal.
Its length is 10. Carriers shall code according to the fee, without coding decimal points.
41. PC040. This element is named "co-pay amount". The data type of this element is
decimal. Its length is 10. Carriers shall code accordingto the preset, fixed dollar amount for
which the individual is responsible, without coding decimal points.
42. PC041. This element is named "coinsurance amount". The data type of this element is
decimal. Its length is 10. Carriers shall code not code decimal points.
43. PC042. This element is named "deductible amount". The data type of this element is
decimal. Its length is 10. Carriers shall not code decimal points.
44. PC043. This element is named "record type". The data type of this element is text. Its
length is 2.
(b) The specifications for the pharmacy claims file layout shall conform to the following Table 22:
Table 22: Pharmacy Claims File Layout
Data
Element
Element
Type
Max.
Length
Description/Codes/Sources
Payer
Text
Payer submitting payments
Council Submitter Code
Plan ID
Text
CMS National Plan ID
Insurance Type/Product Code
Text
12 Preferred Provider Organization (PPO)
13 Point of Service (POS)
14 Exclusive Provider Organization (EPO)
15 Indemnity Insurance
16 Health Maintenance Organization (HMO)
Medicare Risk
AM Automobile Medical
DS Disability
HM Health Maintenance Organization
LI Liability
LM Liability Medical
MA Medicare Part A
MB Medicare Part B
MC Medicaid
OF Other Federal Program (e.g. Black Lung)
TV Title V
VA Veteran Administration Plan
WC Worker's Compensation
Payer Claim Control Number
Text
Must apply to the entire claim and be unique within
the payer's system
Line Counter
Integer
Line number for this service
The line counter begins with 1 and is incremented
by 1 for each additional service line of a claim
Insured Group Number
Text
Group or policy number - not the number that
uniquely identifies the subscriber
Encrypted Subscriber Unique
Identification Number
Text
Encrypted subscriber’s Unique Identification
number Set as null if unavailable
Plan Specific Contract Number
Text
Encrypted plan assigned contract number
Set as null if contract number = subscriber’s social
security number
Member Suffix or Sequence
Number
Integer
Uniquely numbers the member within the contract
Member Identification Code
Text
Encrypted member’s Unique Identification number
Set as null if unavailable
Individual Relationship Code
Integer
Member's relationship to subscriber
01 Spouse
04 Grandfather or Grandmother
05 Grandson or Granddaughter
07 Nephew or Niece
10 Foster Child
15 Ward
17 Stepson or Stepdaughter
19 Child
Table 22: Pharmacy Claims File Layout (continued)
Data
Element
Element
Type
Max.
Length
Description/Codes/Sources
20 Employee/Self
21 Unknown
22 Handicapped Dependent
23 Sponsored Dependent
24 Dependent of a Minor Dependent
29 Significant Other
32 Mother
33 Father
36 Emancipated Minor
39 Organ Donor
40 Cadaver Donor
41 Injured Plaintiff
43 Child Where Insured Has No Financial
Responsibility
53 Life Partner
76 Dependent
Member Gender
Integer
1 Male
2 Female
3 Unknown
Member Date of Birth
Date
CCYYMMDD
Member City Name of
Residence
Text
City name of member
Member State
Text
As defined by the US Postal Service
Member ZIP Code
Text
ZIP Code of member - may include non-US codes
Do not include dash
Date Service Approved (AP
Date)
Date
CCYYMMDD
(Generally the same as the paid date or the
Pharmacy Benefits Manager’s billing date)
Pharmacy Number
Text
pharmacy number (NCPDP or NABP)
Pharmacy Tax ID Number
Text
Federal taxpayer's identification number
(Please provide the pharmacy chain’s federal
tax
identification number, if the individual retail
pharmacy’s tax ID# is not available.)
Pharmacy Name
Text
Name of pharmacy
National Pharmacy ID Number
Text
Required if National Provider ID is mandated for
use under HIPAA
Pharmacy Location City
Text
City name of pharmacy - preferably pharmacy
location
Pharmacy Location State
Text
As defined by the US Postal Service
Pharmacy ZIP Code
Text
ZIP Code of pharmacy - may include non-US
codes Do not include dash
PC024A Pharmacy Country Name
Text
Country name of pharmacy
Claim Status
Integer
01 Processed as primary
02 Processed as secondary
03 Processed as tertiary
04 Denied
Table 22: Pharmacy Claims File Layout (continued)
Data
Element
Element
Type
Max.
Length
Description/Codes/Sources
19 Processed as primary, forwarded to additional
payer(s)
20 Processed as secondary, forwarded to
additional payer(s)
21 Processed as tertiary, forwarded to additional
payer(s)
22 Reversal of previous payment
Drug Code
Text
NDC Code
Drug Name
Text
Text name of drug
New Prescription
Integer
00 New prescription
PC028A Refill Number
Integer
01-99 Number of refill
(‘01’ should be used for all refills, if the
specific number of the prescription refill is not
available.)
Generic Drug Indicator
Text
N No, branded drug
Y Yes, generic drug
Dispense as Written Code
Integer
0 Not dispensed as written
1 Physician dispense as written
2 Member dispense as written
3 Pharmacy dispense as written
4 No generic available
5 Brand dispensed as generic
6 Override
7 Substitution not allowed - brand drug mandated
by law
8 Substitution allowed - generic drug not available
in marketplace
9 Other
Compound Drug Indicator
Text
N Non-compound drug
Y Compound drug
U Non-specified drug compound
Date Prescription Filled
Date
CCYYMMDD
Quantity Dispensed
Integer
Number of metric units of medication dispensed
Days Supply
Integer
Estimated number of days the prescription will last
Charge Amount
Decimal
Do not code decimal point
Paid Amount
Decimal
Includes all health plan payments and excludes
all member payments
Do not code decimal point
Average Wholesale Price
(AWP)
Decimal
Cost of the drug dispensed
Do not code decimal point
Postage Amount Claimed
Decimal
Do not code decimal point
Dispensing Fee
Decimal
Do not code decimal point
Copay Amount
Decimal
The preset, fixed dollar amount for which the
individual is responsible
Do not code decimal point
Table 22: Pharmacy Claims File Layout (continued)
Data
Element
Element
Type
Max.
Length
Description/Codes/Sources
Coinsurance Amount
Decimal
Do not code decimal point
Deductible Amount
Decimal
Do not code decimal point
Record Type
Text
PC
(c) The pharmacy claims file shall be mapped to a national standard as follows in Table 23:
Table 23: Pharmacy Claims File Mapping
Data
Element
Element
National Council for Prescription
Drug Programs
Field #
Payer
N/A
Plan ID
N/A
Insurance Type/Product Code
N/A
Payer Claim Control Number
N/A
Line Counter
N/A
Insured Group Number
301-C1
Encrypted Subscriber Unique Identification Number
302-C2
Plan Specific Contract Number
N/A
Member Suffix or Sequence Number
N/A
Member Identification Code
302-CY
Individual Relationship Code
306-C6
Member Gender
305-C5
Member Date of Birth
304-C4
Member City Name of Residence
323-CN
Member State or Province
324-CO
Member ZIP Code
325-CP
Date Service Approved (AP Date)
N/A
Pharmacy Number
202-B2
Pharmacy Tax ID Number
N/A
Pharmacy Name
833-5P
National Pharmacy ID Number
N/A
Pharmacy Location City
831-5N
Pharmacy Location State
832-6F
Pharmacy ZIP Code
835-5R
Claim Status
N/A
Drug Code
407-D7
Drug Name
516-FG
New Prescription
403-D3
Generic Drug Indicator
N/A
Table 23: Pharmacy Claims File Mapping (continued)
Data
Element
Element
National Council for Prescription
Drug Programs
Field #
Dispense as Written Code
408-D8
Compound Drug Indicator
406-D6
Date Prescription Filled
401-D1
Quantity Dispensed
442-E7
Days Supply
405-D5
Charge Amount
804-5B
Paid Amount
509-F9
Ingredient Cost/List Price
506-F6
Postage Amount Claimed
428-DS
Dispensing Fee
507-F7
Copay Amount
518-FI
Coinsurance Amount
518-FI
Deductible Amount
505-F5
Record Type
N/A