Version 4.0; required for reporting 4.0 periods October 2013 onward as of May 2015 Report the Unique Submitter ID as CHIA defined and defined by CHIA here. This must 1 Submitter 11/8/12 Integer ID Submitter varchar[6] maintained unique All 100% A0 match the Submitter ID reported in identifier HD002. Do not report any value here until National PlanID is fully implemented. CMS National National This is a unique identifier as outlined 2 11/8/12 Integer ID Nat'l PlanID int[10] Plan Identification All 0% Z Plan ID by Centers for Medicare and Number (PlanID) Medicaid Services (CMS) for Plans or Sub plans. Insurance Report the code that defines the type Lookup Type Type / Product of insurance under which this 3 10/30/14 Table char[2] All 98% A2 03 Identification Code patient's claim line was processed. Text HM = HMO EXAMPLE: Code Description 09 Self-pay 10 Central Certification 11 Non-Federal Programs Preferred Provider Organization 12 (PPO) 13 Point of Service (POS) Exclusive Provider Organization 14 (EPO) 15 Indemnity Insurance Health Maintenance Organization 16 (HMO) Medicare Risk Dental Maintenance Organization 17 (DMO) AM Automobile Medical BL Blue Cross / Blue Shield CC Commonwealth Care
4.0 Version 4.0; required for reporting periods October 2013 onward as of May 2015 1 Submitter 11/8/12 Integer ID Submitter varchar[6] CHIA defined and maintained unique identifier Report the Unique Submitter ID as defined by CHIA here. This must match the Submitter ID reported in HD002. All 100% A0 2 National Plan ID 11/8/12 Integer ID Nat'l PlanID int[10] CMS National Plan Identification Number (PlanID) Do not report any value here until National PlanID is fully implemented. This is a unique identifier as outlined by Centers for Medicare and Medicaid Services (CMS) for Plans or Sub plans. All 0% Z 3 Insurance Type 10/30/14 Lookup Table Text char[2] Type / Product Identification Code Report the code that defines the type of insurance under which this patient's claim line was processed. EXAMPLE: HM = HMO All 98% A2 Code Description 09 Self-pay 10 Central Certification 11 Non-Federal Programs 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 17 Dental Maintenance Organization (DMO) AM Automobile Medical BL Blue Cross / Blue Shield CC Commonwealth Care 03