Dental Maintenance Organization 17 (DMO) AM Automobile Medical BL Blue Cross / Blue Shield CC Commonwealth Care CE Commonwealth Choice CH Champus CI Commercial Insurance Co. DS Disability HM Health Maintenance Organization LI Liability LM Liability Medical MA Medicare Part A MB Medicare Part B Medicaid OF Other Federal Program TF HSN Trust Fund TV V VA Veterans Administration Plan WC Workers' Compensation ZZ Other Payer Payer Claim Report the Unique identifier within Claim ID Claim 4 6/24/10 Text Control the payer's system that applies to the All 100% A0 04 Control Number Identification entire claim. Number Report the line number for this service within the claim. Start with 1 Line Incremental Line MC 5 11/8/12 Integer ID Count varchar[4] and increment by 1 for each All 100% A0 05 Counter Counter additional line. Do not start with 0, include alphas or special characters.
17 Dental Maintenance Organization (DMO) AM Automobile Medical BL Blue Cross / Blue Shield CC Commonwealth Care CE Commonwealth Choice CH Champus CI Commercial Insurance Co. DS Disability HM Health Maintenance Organization LI Liability LM Liability Medical MA Medicare Part A MB Medicare Part B Medicaid OF Other Federal Program TF HSN Trust Fund TV V VA Veterans Administration Plan WC Workers' Compensation ZZ Other 4 Payer Claim Control Number 6/24/10 Text ID Claim Number Payer Claim Control Identification Report the Unique identifier within the payer's system that applies to the entire claim. All 100% A0 MC 5 Line Counter 11/8/12 Integer ID Count varchar[4] Incremental Line Counter Report the line number for this service within the claim. Start with 1 and increment by 1 for each additional line. Do not start with 0, include alphas or special characters. All 100% A0 04 05
v6-apcd-medical-claim-file-submission-guide-FINAL.docx