1 CPT or HCPCS Level 1 Code 2 HCPCS Level II Code HCPCS Level III Code (State 3 Medicare code). American Dental Association (ADA) 4 Procedure Code (Also referred to as CDT code.) 5 State defined Procedure Code 6 CPT Category II 7 CPTCategory III Code Lookup Indicator - Report the that defines the InNetwork MC 11/8/12 - int[1] Network Rate element. EXAMPLE: 1 = Yes claim All 100% A2 Indicator Integer Applied line was paid at an InNetwork rate. Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable Required when Report the code that defines the Carrier Submitter Carrier Defined service for Medicaid PCC Service Defined Service Class is identified MC 6/24/10 Table - MCO char[2] members receiving behavioral health 10% C Table - Code as a Service Class services (values based on Text MassHealth encounter table). / MCO Submitter External Report the valid frequency code of Required Bill External Code Code the claim to indicate version, when MC Frequency 11/8/12 Source 14 - char[1] Bill Frequency 100% A2 Source credit/debit activity and/or settling of = 001 or Code Type of Bill 14 - Text claim. 002
1 CPT or HCPCS Level 1 Code 2 HCPCS Level II Code 3 HCPCS Level III Code (State Medicare code). 4 American Dental Association (ADA) Procedure Code (Also referred to as CDT code.) 5 State defined Procedure Code 6 CPT Category II 7 CPTCategory III Code MC InNetwork Indicator 11/8/12 Lookup - Integer int[1] Indicator - Network Rate Applied Report the that defines the element. EXAMPLE: 1 = Yes claim line was paid at an InNetwork rate. All 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable MC Service 6/24/10 Carrier Defined Table - Text Carrier Defined Table - MCO Service Class char[2] Service Class Code Report the code that defines the service for Medicaid PCC members receiving behavioral health services (values based on MassHealth encounter table). Required when Submitter is identified as a / MCO Submitter 10% C MC Bill Frequency Code 11/8/12 External Code Source 14 - Text External Code Source 14 - Type of Bill char[1] Bill Frequency Report the valid frequency code of the claim to indicate version, credit/debit activity and/or settling of claim. Required when = 001 or 002 100% A2