Carrier Defined External Code Table - Source 16 - Report the code that defines the reason Required Denial OR - Reason Codes Denial Reason for denial of the line. Carrier must PC 94 11/8/12 when 98% A2 Reason External -OR Code submit denial reason codes in separate – PC116 = 1 Code Carrier Defined table to the APCD. Source Table 16 Payment Lookup Payment Report the that defines the contracted PC 95 11/8/12 Table - char[2] Arrangement payment methodology for this claim line. All 98% A0 Type Numeric Type Value EXAMPLE: 02 = Fee for Service Value Description 01 Capitation 02 Fee for Service 03 Percent of Charges 04 DRG 05 Pay for Performance 06 Global Payment 07 Other 08 Bundled Payment (09 Valid for HD002 = Payment Amount Per Episode (PAPE) 09 MassHealth (MassHealth) orgid ONLY ) PC 96 Report the value that describes the member's / subscriber's enrollment into Lookup APCD ID Member one of the predefined categories; aligns PC 97 Table - tlkpADCDIdentifier int[1] All 100% A2 Code Enrollment Type enrollment to appropriate editing and Integer thresholds. EXAMPLE: 1 = FIG - Fully Insured Commercial Group Enrollee. Value Description FIG - Commercial Group 1 Enrollee 2 SIG - Self-Insured Group Enrollee GIC - Group Insurance Commission 3 Enrollee
PC 94 Denial Reason 11/8/12 Carrier Defined Table - OR - External Code Source 16 External Code Source 16 - Reason Codes -OR – Carrier Defined Table Denial Reason Code Report the code that defines the reason for denial of the line. Carrier must submit denial reason codes in separate table to the APCD. Required when PC116 = 1 98% A2 PC 95 Payment Type 11/8/12 Lookup Table - Numeric char[2] Payment Arrangement Type Value Report the that defines the contracted payment methodology for this claim line. EXAMPLE: 02 = Fee for Service All 98% A0 Value Description 01 Capitation 02 Fee for Service 03 Percent of Charges 04 DRG 05 Pay for Performance 06 Global Payment 07 Other 08 Bundled Payment 09 Payment Amount Per Episode (PAPE) (MassHealth) (09 Valid for HD002 = MassHealth orgid ONLY ) PC 96 PC 97 APCD ID Code Lookup Table - Integer tlkpADCDIdentifier int[1] Member Enrollment Type Report the value that describes the member's / subscriber's enrollment into one of the predefined categories; aligns enrollment to appropriate editing and thresholds. EXAMPLE: 1 = FIG - Fully Insured Commercial Group Enrollee. All 100% A2 Value Description 1 FIG - Commercial Group Enrollee 2 SIG - Self-Insured Group Enrollee 3 GIC - Group Insurance Commission Enrollee
v6-apcd-pharmacy-claim-file-submission-guide-Redline-.docx