Report the amount that defines a preset, amount for this claim line service that the patient is responsible Amount of Copay to pay. Report 0 if no Copay applies. Copay MC 66 6/24/10 Integer Currency member/patient is Do not code decimal or round up / All 99% A1 Amount responsible to pay down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 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 service that the patient Amount of is responsible to pay. Report 0 if no coinsurance Coinsurance applies. Do not code MC 67 6/24/10 Integer Currency All 99% A1 Amount member/patient is decimal or round up / down to whole responsible to pay dollars, code zero cents (00) when applicable. 150.00 is EXAMPLE: reported as 15000; 150.70 is reported as 15070 Report the amount that defines a preset, fixed amount for this claim line service that the patient is Amount of responsible to pay. Report 0 if no deductible Deductible Deductible applies to service. Do not MC 68 6/24/10 Integer Currency member/patient is All 99% A1 Amount code decimal or round up / down to responsible to pay whole dollars, code zero cents (00) on the claim line when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Report the provider assigned Required Patient ID Claim Patient Control Encounter / Visit number to identify when MC 69 Control 11/8/12 Text 98% A2 Number Number patient treatment. Also known as the MC094 = Number Patient Account Number. 002 Report the date the member was Required discharged from the facility in when Century Year Discharge Full Date CCYYMMDD Format. If patient is MC094 = MC 70 11/8/12 Month Day - int[8] Discharge Date 98% A2 Date - Integer still in-house and claim represents 002 and CCYYMMDD interim billing for interim payment, MC039 is report the interim through date. populated
MC 66 Copay Amount 6/24/10 Integer Currency Amount of Copay member/patient is responsible to pay Report the amount that defines a preset, 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 MC 67 Amount 6/24/10 Integer Currency Amount of coinsurance member/patient 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 MC 68 Deductible Amount 6/24/10 Integer Currency Amount of deductible member/patient 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 MC 69 Patient Control Number 11/8/12 Text ID Claim Number Patient Control Number Report the provider assigned Encounter / Visit number to identify patient treatment. Also known as the Patient Account Number. Required when MC094 = 002 98% A2 MC 70 Discharge Date 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Discharge Date Report the date the member was discharged from the facility in CCYYMMDD Format. If patient is still in-house and claim represents interim billing for interim payment, report the interim through date. Required when MC094 = 002 and MC039 is populated 98% A2
v3-1-apcd-medical-claim-file-submission-guide-2013-06.docx