Report the code that defines the Lookup Line Claim Line Activity claim line status in terms of MC 11/8/12 Table - char[1] All 98% A2 Type Type Code adjudication. EXAMPLE: O = Text Original Code Description O Original V Void R Replacement B Back Out A Amendment Report the Claim Control Number (MC004) that was originally sent in a prior filing that this line corresponds Former to. When reported, this data cannot ID Claim Previous MC Claim 12/1/10 Text equal its own MC004. Use of All 0% B Number Number Number Claim Number” to version “Former claims can only be used if approved by the MA APCD. Contact the MA APCD for conditions of use. Report the address of member which Member Secondary Street may include apartment number or Address 2 MC Street 11/8/12 Text Address of the suite, or other secondary information All 1% B Member Address 2 Member/Patient besides the street. Used to validate Unique Member ID. Carrier Report the identifier the carrier / Specific submitter uses internally to uniquely ID Link to Subscriber's MC Unique 11/8/12 Text identify the subscriber. Used to All 100% A0 ME117 Unique ID Subscriber validate Unique Member ID and link ID back to Member Eligibility (ME117). External Codes External Other ICD Diagnosis Code - 13. If Other Source 8 - Code ICD Other not applicable do not report any MC Diagnosis 2/2016 International varchar[7] All 1% C Source 8 Diagnosis Code value here. - 13 Classification of - Text Do not code decimal point. Diseases
MC Line Type 11/8/12 Lookup Table - Text char[1] Claim Line Activity Type Code Report the code that defines the claim line status in terms of adjudication. EXAMPLE: O = Original All 98% A2 Code Description O Original V Void R Replacement B Back Out A Amendment MC Former Claim Number 12/1/10 Text ID Claim Number Previous Number Report the Claim Control Number (MC004) that was originally sent in a prior filing that this line corresponds to. When reported, this data cannot equal its own MC004. Use of “Former Claim Number” to version claims can only be used if approved by the MA APCD. Contact the MA APCD for conditions of use. All 0% B MC Member Street Address 2 11/8/12 Text Address 2 Member Secondary Street Address of the Member/Patient Report the address of member which may include apartment number or suite, or other secondary information besides the street. Used to validate Unique Member ID. All 1% B MC Carrier Specific Unique Subscriber ID 11/8/12 Text ID Link to ME117 Subscriber's Unique ID Report the identifier the carrier / submitter uses internally to uniquely identify the subscriber. Used to validate Unique Member ID and link back to Member Eligibility (ME117). All 100% A0 MC Other Diagnosis - 13 2/2016 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 13. If not applicable do not report any value here. Do not code decimal point. All 1% C