Report the amount that defines a preset, fixed amount for this claim line service that Amount of the patient is responsible to pay. Report 0 if Copay Copay no Copay applies. Do not code decimal or DC 40 6/24/10 Integer Currency All 99% A1 Amount round up / down to whole dollars code zero is responsible cents (00) when applicable. EXAMPLE: to pay 150.00 is reported as 15000; 150.70 is reported as 15070 Report the amount that defines a calculated percentage amount for this claim line Amount of service that the patient is responsible to coinsurance pay. Report 0 if no Coinsurance applies. Do DC 41 6/24/10 Integer Currency All 99% A1 not code decimal or round up / down to Amount is responsible whole dollars code zero cents (00) when to pay applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Report the amount that defines a preset, Amount of fixed amount for this claim line service that deductible the patient is responsible to pay. Report 0 if no Deductible applies to service. Do not DC 42 6/24/10 Integer Currency All 99% A1 Amount is responsible code decimal or round up / down to whole to pay on the dollars, code zero cents (00) when claim line applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Report the submitter-assigned identifier as it Product appears in PR001 in the Product File. This ID Link to Product DC 43 ID 11/8/12 Text varchar[30] element is used to understand Product and All 100% A0 PR001 Identification Number Eligibility attributes of the member / subscriber as applied to this record DC 44 The Billing Billing Provider's Report the Federal Tax ID of the Billing Provider DC 45 11/8/12 Numeric ID Tax char[9] Federal Tax Provider here. Do not use hyphen or alpha All 90% C Tax ID Identification prefix. Number Number (FTIN)
DC 40 Copay Amount 6/24/10 Integer Currency Amount of Copay is responsible to pay Report the amount that defines a preset, fixed amount for this claim line service that the patient is responsible to pay. Report 0 if no Copay applies. 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 99% A1 DC 41 Amount 6/24/10 Integer Currency Amount of coinsurance is responsible to pay Report the amount that defines a calculated percentage amount for this claim line service that the patient is responsible to pay. Report 0 if no Coinsurance applies. 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 99% A1 DC 42 Amount 6/24/10 Integer Currency Amount of deductible is responsible to pay on the claim line Report the amount that defines a preset, fixed amount for this claim line service that the patient is responsible to pay. Report 0 if no Deductible applies to service. 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 99% A1 DC 43 Product ID Number 11/8/12 Text ID Link to PR001 varchar[30] Product Identification Report the submitter-assigned identifier as it appears in PR001 in the Product File. This element is used to understand Product and Eligibility attributes of the member / subscriber as applied to this record All 100% A0 DC 44 DC 45 Billing Provider Tax ID Number 11/8/12 Numeric ID Tax char[9] The Billing Provider's Federal Tax Identification Number (FTIN) Report the Federal Tax ID of the Billing Provider here. Do not use hyphen or alpha prefix. All 90% C
v6-apcd-dental-claim-file-submission-guide-Redline-.docx