1 Person 2 Non-person entity Service First name of Report the individual's first name here. If Provider Name DC 23 11/8/12 Text varchar[25] Service provider is a facility or organization , do not All 98% C First Provider Provider report any value here Name Service Middle initial of Report the individual's middle name here. If Provider Name Middle DC 24 11/8/12 Text varchar[25] Service provider is a facility or organization , do not All 2% C Middle Provider Provider report any value here Name Service Provider Last name or Report the name of the organization or last Last Organization Name Last / name of the individual provider. DC 25 Name or 6/24/10 Text varchar[60] Name of All 98% B Org Provider determines if this is an Organization or Service Individual Name reported here. Provider Name Riskholders report the OrgID of the DBA here. DBAs report the OrgID of the CHIA defined insurance carrier here. This element Benefit and contains the CHIA assigned organization ID maintained DC 26 11/8/12 Integer ID Link to varchar[6] for the DBA or carrier. Contact the MA All 98% A2 Org ID for APCD for the appropriate value. If no DBA linking across is affiliated with this claim line do not report ID submitters any value here: i.e., do not repeat the OrgID from DC001 Report the standard code that defines this Service External provider for this line of service. Taxonomy External Code Provider Code Taxonomy values for the reporting of hygienists, DC 27 11/8/12 Source 5 varchar[10] All 98% A2 – Source Code assistants and laboratory technicians, Taxonomy 5 - Text where applicable, as well as Dentists, Orthodontists, etc. Service Provider Address City City name of DC 28 6/24/10 Text varchar[30] Report the Providers practice city location All 98% B City Provider the Provider Name
1 Person 2 Non-person entity DC 23 Service Provider First Name 11/8/12 Text Name Provider varchar[25] First name of Service Provider Report the individual's first name here. If provider is a facility or organization , do not report any value here All 98% C DC 24 Service Provider Middle Name 11/8/12 Text Name Middle Provider varchar[25] Middle initial of Service Provider Report the individual's middle name here. If provider is a facility or organization , do not report any value here All 2% C DC 25 Service Provider Last Name or Name 6/24/10 Text Name Last / Org Provider varchar[60] Last name or Organization Name of Service Provider Report the name of the organization or last name of the individual provider. determines if this is an Organization or Individual Name reported here. All 98% B DC 26 Benefit ID 11/8/12 Integer ID Link to varchar[6] CHIA defined and maintained Org ID for linking across submitters Riskholders 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 or carrier. Contact the MA 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 DC001 All 98% A2 DC 27 Service Provider 11/8/12 External Code Source 5 - Text External Code Source 5 – Taxonomy varchar[10] Taxonomy Code Report the standard code that defines this provider for this line of service. Taxonomy values for the reporting of hygienists, assistants and laboratory technicians, where applicable, as well as Dentists, Orthodontists, etc. All 98% A2 DC 28 Service Provider City Name 6/24/10 Text Address City Provider varchar[30] City name of the Provider Report the Providers practice city location All 98% B
v6-apcd-dental-claim-file-submission-guide-Redline-.docx