1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable Carrier Defined External Code - Source 16 - Report the code that defines the reason for Required Denial OR - Reason Codes Denial Reason denial of the claim line. Carrier must submit DC 65 11/8/12 varchar[20] when 98% A2 Reason External OR Code denial reason codes in separate table to the – DC063 = 1 Code Carrier Defined APCD. Source Table - 16 Payment Lookup Payment Report the value that defines the contracted DC 66 11/8/12 Table - char[2] Arrangement payment methodology for this claim line. All 98% A0 Numeric Type Value 02 = Fee for Service EXAMPLE: Type 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 (Valid for Payment Amount Per Episode (PAPE) 09 MassHealth (MassHealth) ONLY) Report the GIC Member Identification Required GIC Member number as provided to GIC Plan Submitters. DC 67 GIC ID 11/8/12 Text ID GIC varchar[9] when 100% A0 ID If not applicable do not report any value DC067 = 3 here
1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable DC 65 Denial Reason 11/8/12 Carrier Defined - OR - External Code Source 16 External Code Source 16 - Reason Codes OR – Carrier Defined Table - varchar[20] Denial Reason Code Report the code that defines the reason for denial of the claim line. Carrier must submit denial reason codes in separate table to the APCD. Required when DC063 = 1 98% A2 DC 66 Payment Type 11/8/12 Lookup Table - Numeric char[2] Payment Arrangement Type Value Report the value 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) (Valid for MassHealth ONLY) DC 67 GIC ID 11/8/12 Text ID GIC varchar[9] GIC Member ID Report the GIC Member Identification number as provided to GIC Plan Submitters. If not applicable do not report any value here Required when DC067 = 3 100% A0
v3-1-apcd-dental-claim-file-submission-guide-2013-06.docx