5 Not Applicable Carrier Defined External Code - Source 16 - Report the code that defines the reason Required Denial OR - Reason Codes Denial Reason for denial of the claim 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 16 Report the value that defines the Payment Lookup Payment contracted payment methodology for this PC 95 11/8/12 Table - char[2] Arrangement All 98% A0 claim line. EXAMPLE: 02 = Fee for Type Numeric Type Value 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 ) Do not populate with any data. Required PC 96 Filler 2/2017 text Filler char[0] Filler All 100% A0 to be NULL. 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 - Fully-Insured Commercial Group 1 Enrollee 2 SIG - Self-Insured Group Enrollee
5 Not Applicable PC 94 Denial Reason 11/8/12 Carrier Defined - OR - External Code Source 16 External Code Source 16 - Reason Codes -OR – Carrier Defined 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 PC116 = 1 98% A2 PC 95 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). (09 Valid for HD002 = MassHealth orgid ONLY ) PC 96 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 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 - Fully-Insured Commercial Group Enrollee 2 SIG - Self-Insured Group Enrollee
v6-apcd-pharmacy-claim-file-submission-guide-FINAL.docx