Carrier External Code Defined Source 16 - Required Table - Report the value that describes how Claim when Payment OR - Payment Reason the claim line was paid, either using a MC 81 11/8/12 Adjustment MC038 = 100% A0 Reason External Code standard code set or a proprietary list Reasons- OR 1, 2, 3, 19, – Code pre-sent by submitter. Carrier Defined 20, or 21 Source Table 16 - Text Report the value that defines the Capitated Lookup Indicator - element. 1 = Yes EXAMPLE: MC 82 Encounter 11/8/12 Table - int[1] Capitation All 100% A0 payment for this service is covered Flag Integer Payment under a capitated arrangement. Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable Member Street address of Report the patient / member's Address 1 MC 83 Street 11/8/12 Text the address. Used to validate Unique All 90% B Member Address Member/Patient Member ID. Required External Code Report the subsequent ICD CM Other External when Source 8 - procedure code when applicable. ICD-CM ICD Secondary MC094 = MC 84 4/5/13 ICDCM varchar[7] Repeat this code on all lines of the 1% C Procedure Source 8 Procedure Code 002 and Procedure inpatient claim. Do not code decimal Code - 1 - Text MC039 is Codes point. populated Required Report the third ICD procedure code External External Code when when applicable. The Integer point is Codes Source 8 - ICD Other MC094 = MC 85 4/5/13 varchar[7] not coded. The ICD procedure must 1% C Procedure Source 8 Procedure Procedure Code 002 and be repeated for all lines of the claim if Code - 2 - Text Codes MC039 is necessary. populated
MC 81 Payment Reason 11/8/12 Carrier Defined Table - OR - External Code Source 16 - Text External Code Source 16 - Claim Adjustment Reasons- OR – Carrier Defined Table Payment Reason Code Report the value that describes how the claim line was paid, either using a standard code set or a proprietary list pre-sent by submitter. Required when MC038 = 1, 2, 3, 19, 20, or 21 100% A0 MC 82 Capitated Encounter Flag 11/8/12 Lookup Table - Integer int[1] Indicator - Capitation Payment Report the value that defines the element. EXAMPLE: 1 = Yes payment for this service is covered under a capitated arrangement. All 100% A0 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable MC 83 Member Street Address 11/8/12 Text Address 1 Member Street address of the Member/Patient Report the patient / member's address. Used to validate Unique Member ID. All 90% B MC 84 Other ICD-CM Procedure Code - 1 4/5/13 External Source 8 - Text External Code Source 8 - ICDCM Procedure Codes varchar[7] ICD Secondary Procedure Code Report the subsequent ICD CM procedure code when applicable. Repeat this code on all lines of the inpatient claim. Do not code decimal point. Required when MC094 = 002 and MC039 is populated 1% C MC 85 Procedure Code - 2 4/5/13 External Codes Source 8 - Text External Code Source 8 - Procedure Codes varchar[7] ICD Other Procedure Code Report the third ICD procedure code when applicable. The Integer point is not coded. The ICD procedure must be repeated for all lines of the claim if necessary. Required when MC094 = 002 and MC039 is populated 1% C
v3-1-apcd-medical-claim-file-submission-guide-2013-06.docx