4 No family planning services provided 0 Unknown / Not Applicable / Not Avail Report the value that defines the Lookup Indicator - element. EXAMPLE: 1 = Yes, Claim MC Related 11/8/12 Table - int[1] All 100% A2 Accident Related Line was related to employment Indicator Integer accident. Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable Service related to Report the value that defines if Early Periodic service was related to EPSDT and Lookup EPSDT Screening, the type of EPSDT service, such as MC 11/8/12 Table - int[1] All 98% B Indicator Diagnosis and 'screening', 'treatment' or ‘referral’. Integer Treatment 0 = Unknown / Not EXAMPLE: (EPSDT) Applicable Value Description 1 EPSDT Screen 2 EPSDT Treatment 3 EPSDT Referral Unknown / Not Applicable / Not 0 Available Procedure Lookup Claim line Report the value that defines the type MC Code 11/8/12 Table - int[1] Procedure Code of Procedure Code expected in All 98% A1 Type Integer Type Identifier MC055. Description 1 CPT or Level 1 Code 2 HCPCS Level II Code HCPCS Level III Code (State 3 Medicare code).
4 No family planning services provided 0 Unknown / Not Applicable / Not Avail MC Related Indicator 11/8/12 Lookup Table - Integer int[1] Indicator - Accident Related Report the value that defines the element. EXAMPLE: 1 = Yes, Claim Line was related to employment accident. All 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable MC EPSDT Indicator 11/8/12 Lookup Table - Integer int[1] Service related to Early Periodic Screening, Diagnosis and Treatment (EPSDT) Report the value that defines if service was related to EPSDT and the type of EPSDT service, such as 'screening', 'treatment' or ‘referral’. EXAMPLE: 0 = Unknown / Not Applicable All 98% B Value Description 1 EPSDT Screen 2 EPSDT Treatment 3 EPSDT Referral 0 Unknown / Not Applicable / Not Available MC Procedure Code Type 11/8/12 Lookup Table - Integer int[1] Claim line Procedure Code Type Identifier Report the value that defines the type of Procedure Code expected in MC055. All 98% A1 Description 1 CPT or Level 1 Code 2 HCPCS Level II Code 3 HCPCS Level III Code (State Medicare code).
v3-1-apcd-medical-claim-file-submission-guide-2013-06.docx