American Dental Association (ADA) 4 Procedure Code (Also referred to as CDT code.) 5 State defined Procedure Code 6 CPT Category II Lookup Indicator - Report the value that defines the InNetwork MC 11/8/12 Table - int[1] Network Rate element. EXAMPLE: 1 = Yes claim All 100% A2 Indicator Integer Applied line was paid at an InNetwork rate. Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable Required when Report the code that defines the Carrier Submitter Carrier Defined service class for Medicaid PCC Service Defined Service Class is identified MC 6/24/10 Table - MCO char[2] members receiving behavioral health 10% C Class Table - Code as a Service Class services (values based on Text MassHealth encounter table). / MCO Submitter External Report the valid frequency code of Required Bill External Code Code the claim to indicate version, when MC Frequency 11/8/12 Source 14 - char[1] Bill Frequency 100% A2 Source credit/debit activity and/or settling of = 001 or Code Type of Bill 14 - Text claim. 002 Report the unique code which identifies for the carrier / submitter who or which individual provider Plan cared for the patient for the claim line Rendering ID Link to Plan Rendering MC 11/8/12 Text in question. This code must be able All 100% A0 Provider PV002 Number to link to the Provider File. Any value Identifier in this field must also show up as a value in field PV002 (Provider ID) on the Provider File.
4 American Dental Association (ADA) Procedure Code (Also referred to as CDT code.) 5 State defined Procedure Code 6 CPT Category II MC InNetwork Indicator 11/8/12 Lookup Table - Integer int[1] Indicator - Network Rate Applied Report the value that defines the element. EXAMPLE: 1 = Yes claim line was paid at an InNetwork rate. All 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable MC Service Class 6/24/10 Carrier Defined Table - Text Carrier Defined Table - MCO Service Class char[2] Service Class Code Report the code that defines the service class for Medicaid PCC members receiving behavioral health services (values based on MassHealth encounter table). Required when Submitter is identified as a / MCO Submitter 10% C MC Bill Frequency Code 11/8/12 External Code Source 14 - Text External Code Source 14 - Type of Bill char[1] Bill Frequency Report the valid frequency code of the claim to indicate version, credit/debit activity and/or settling of claim. Required when = 001 or 002 100% A2 MC Plan Rendering Provider Identifier 11/8/12 Text ID Link to PV002 Plan Rendering Number Report the unique code which identifies for the carrier / submitter who or which individual provider cared for the patient for the claim line in question. This code must be able to link to the Provider File. Any value in this field must also show up as a value in field PV002 (Provider ID) on the Provider File. All 100% A0
v3-1-apcd-medical-claim-file-submission-guide-2013-06.docx