Carrier Report the identifier the carrier / Specific submitteruses internally to uniquely identify Subscriber's DC 58 Unique 11/8/12 Text ID Link to varchar[50] the subscriber. Used to validate Unique All 100% A0 Unique ID Member ID and link back to Member ID Eligibility (ME117) DC 59 Claim Lookup Line Report the code that defines the claim line DC 60 Line 11/8/12 Table - char[1] Activity Type status in terms of adjudication. EXAMPLE: All 98% A2 Type Text Code O = Original Code Description O Original V Void R Replacement B Back Out A Amendment Report the Claim Control Number (DC004) that was originally sent in a prior filing that this line corresponds to. When reported, Former ID Claim Previous this data cannot equal its own DC004. Use DC 61 Claim 12/1/10 Text varchar[35] All 0% B Number Number of Claim Number” to version claims “Former Number can only be used if approved by the MA APCD. Contact the MA APCD for conditions of use. Required when External External is within Source 8 - Code ICD Diagnosis Report the ICD Diagnosis Code when the ranges DC 62 11/8/12 International varchar[7] 1% B Code Source Code applicable of Classification of 8 - Text or Diseases D9220 or D9221
DC 58 Carrier Specific Unique ID 11/8/12 Text ID Link to varchar[50] Subscriber's Unique ID Report the identifier the carrier / submitteruses internally to uniquely identify the subscriber. Used to validate Unique Member ID and link back to Member Eligibility (ME117) All 100% A0 DC 59 DC 60 Claim Line Type 11/8/12 Lookup Table - Text char[1] Line Activity Type Code Report the code that defines the claim line status in terms of adjudication. EXAMPLE: O = Original All 98% A2 Code Description O Original V Void R Replacement B Back Out A Amendment DC 61 Former Claim Number 12/1/10 Text ID Claim Number varchar[35] Previous Number Report the Claim Control Number (DC004) that was originally sent in a prior filing that this line corresponds to. When reported, this data cannot equal its own DC004. Use of “Former Claim Number” to version claims can only be used if approved by the MA APCD. Contact the MA APCD for conditions of use. All 0% B DC 62 Code 11/8/12 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] ICD Diagnosis Code Report the ICD Diagnosis Code when applicable Required when is within the ranges of or D9220 or D9221 1% B
v6-apcd-dental-claim-file-submission-guide-Redline-.docx