Required Report the number of partially when covered days the patient incurred Quantity Days Partially Covered MC094 = MC 92 11/8/12 during this admission. Report 0 if all 98% B Days - Integer Covered Coinsurance Days 002 and days were covered and/or MC039 is Noncovered days. populated Required Report the number of covered days when the patient incurred during this Covered Quantity Covered Inpatient MC094 = MC 93 11/8/12 Days Covered admission. Report 0 if days were 98% B Days - Integer Days 002 and Noncovered or partially covered MC039 is under Coinsurance Days. populated Required Report the number of Noncovered Non when Quantity Days Noncovered days the patient incurred during this MC 94 Covered 11/8/12 = 002 and 87% B - Integer Noncovered Inpatient Days admission. Report 0 if all days were Days MC039 is covered. populated Report the that defines the type Lookup Type of Type of Claim of claim submitted for payment. MC 95 11/8/12 - char[3] All 100% A0 Claim Indicator EXAMPLE: 001 = Professional Text Claim Line Value Description 001 Professional 002 Facility 003 Reimbursement Form Report the amount that another carrier / insurer is liable for after submitting payer has processed this Required of Amount due from claim line. Report 0 if there is no when a Secondary COB / TPL amount. Do not code MC 96 11/8/12 Integer Currency MC038 = 98% A2 Carrier when decimal or round up / down to whole 19, 20 or Liability known dollars, code zero cents (00) when 21 Amount applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070
MC 92 Days 11/8/12 Quantity - Integer Days Partially Covered Covered Coinsurance Days Report the number of partially covered days the patient incurred during this admission. Report 0 if all days were covered and/or Noncovered days. Required when MC094 = 002 and MC039 is populated 98% B MC 93 Covered Days 11/8/12 Quantity - Integer Days Covered Covered Inpatient Days Report the number of covered days the patient incurred during this admission. Report 0 if days were Noncovered or partially covered under Coinsurance Days. Required when MC094 = 002 and MC039 is populated 98% B MC 94 Non Covered Days 11/8/12 Quantity - Integer Days Noncovered Noncovered Inpatient Days Report the number of Noncovered days the patient incurred during this admission. Report 0 if all days were covered. Required when = 002 and MC039 is populated 87% B MC 95 Type of Claim 11/8/12 Lookup - Text char[3] Type of Claim Indicator Report the that defines the type of claim submitted for payment. EXAMPLE: 001 = Professional Claim Line All 100% A0 Value Description 001 Professional 002 Facility 003 Reimbursement Form MC 96 of Liability Amount 11/8/12 Integer Currency Amount due from a Secondary Carrier when known Report the amount that another carrier / insurer is liable for after submitting payer has processed this claim line. Report 0 if there is no COB / TPL amount. 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 Required when MC038 = 19, 20 or 21 98% A2
v3-1-apcd-medical-claim-file-submission-guide-2013-06.docx