Report the amount that defines a preset, Amount of 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 Street address Member Address 1 of the Report the patient / member's address. DC 44 Street 11/8/12 Text varchar[50] All 90% B Member Used to validate Unique Member ID. Address 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) Report the date that appears on the check and/or remit and/or explanation of benefits Full Century Year and corresponds to any and all types of Paid Paid date of DC 46 6/24/10 Date - Month Day - int[8] payment in CCYYMMDD Format. This can All 98% A0 Date the claim line Integer CCYYMMDD be the same date as Processed Date. Claims paid in full, partial or EXAMPLE: zero paid. Report the maximum amount contractually allowed, and that a carrier will pay to a provider for a particular procedure or service. This will vary by provider contract Required and most often it is less than or equal to the when Allowed Allowed DC 47 11/8/12 Integer Currency fee charged by the provider. Report 0 when DC031 99% A2 Amount Amount the claim line is denied. Do not code does not = decimal or round up / down to whole dollars, 4, 22, or 23 code zero cents (00) when applicable. 150.00 is reported as 15000; EXAMPLE: 150.70 is reported as 15070
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, 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 Member Street Address 11/8/12 Text Address 1 Member varchar[50] Street address of the Report the patient / member's address. Used to validate Unique Member ID. All 90% B 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 DC 46 Paid Date 6/24/10 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Paid date of the claim line Report the date that appears on the check and/or remit and/or explanation of benefits and corresponds to any and all types of payment in CCYYMMDD Format. This can be the same date as Processed Date. EXAMPLE: Claims paid in full, partial or zero paid. All 98% A0 DC 47 Allowed Amount 11/8/12 Integer Currency Allowed Amount Report the maximum amount contractually allowed, and that a carrier will pay to a provider for a particular procedure or service. This will vary by provider contract and most often it is less than or equal to the fee charged by the provider. Report 0 when the claim line is denied. 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 Required when DC031 does not = 4, 22, or 23 99% A2
v3-1-apcd-dental-claim-file-submission-guide-2013-06.docx