Report the amount that was charged on a claim that is not reimbursable due to eligibility limitations or provider requirements. Report 0 if all charges Amount of claim are covered or fall into other MC 11/8/12 Integer Currency line charge not categories. Do not code decimal or All 98% A2 Amount covered round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Risk holders report the OrgID of the DBA here. DBAs report the OrgID of Delegated the insurance carrier here. This Benefit CHIA defined and element contains the CHIA assigned maintained Org ID MC 11/8/12 Integer ID Link to OrgID varchar[6] organization ID for the DBA. Contact All 98% A2 for linking across the APCD for the appropriate value. submitters If no DBA is affiliated with this claim ID line do not report any value here: i.e., do not repeat the OrgID from MC001 Report the last name of the subscriber. Used to validate Unique Member ID. Last name should exclude all punctuation, including Subscriber hyphens and apostrophes, and be Name Last Last name of MC Last 10/15/10 Text reported in case. Name should All 98% B Subscriber Subscriber Name be contracted where punctuation is removed, do not report spaces. EXAMPLE: O'Brien becomes OBRIEN; Carlton-Smythe becomes CARLTONSMYTHE Report the first name of the subscriber here. Used to validate Unique Member ID. Exclude all Subscriber punctuation, including hyphens and Name First First name of MC First 10/15/10 Text apostrophes. Name should be All 98% B Subscriber Subscriber Name contracted where punctuation is removed, do not report spaces. EXAMPLE: Anne-Marie becomes ANNEMARIE
MC Amount 11/8/12 Integer Currency Amount of claim line charge not covered Report the amount that was charged on a claim that is not reimbursable due to eligibility limitations or provider requirements. Report 0 if all charges are covered or fall into other categories. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 All 98% A2 MC Delegated Benefit ID 11/8/12 Integer ID Link to OrgID varchar[6] CHIA defined and maintained Org ID for linking across submitters Risk holders report the OrgID of the DBA here. DBAs report the OrgID of the insurance carrier here. This element contains the CHIA assigned organization ID for the DBA. Contact the APCD for the appropriate value. If no DBA is affiliated with this claim line do not report any value here: i.e., do not repeat the OrgID from MC001 All 98% A2 MC Subscriber Last Name 10/15/10 Text Name Last Subscriber Last name of Subscriber Report the last name of the subscriber. Used to validate Unique Member ID. Last name should exclude all punctuation, including hyphens and apostrophes, and be reported in case. Name should be contracted where punctuation is removed, do not report spaces. EXAMPLE: O'Brien becomes OBRIEN; Carlton-Smythe becomes CARLTONSMYTHE All 98% B MC Subscriber First Name 10/15/10 Text Name First Subscriber First name of Subscriber Report the first name of the subscriber here. Used to validate Unique Member ID. Exclude all punctuation, including hyphens and apostrophes. Name should be contracted where punctuation is removed, do not report spaces. EXAMPLE: Anne-Marie becomes ANNEMARIE All 98% B
v3-1-apcd-medical-claim-file-submission-guide-2013-06.docx