Quantity Claim line units of Report the count of services / units MC 62 Quantity 11/8/12 Counter All 98% A1 - Integer service performed. Report the charge amount for this claim line. 0 dollar charges allowed only when the procedure code indicates a Category II procedure All code vs. a service code. When reporting Total Charges for facilities MC062 Amount of for the entire claim use 001 (the must be Charge MC 63 11/8/12 Integer Currency provider charges generally accepted Total Charge greater 99% A0 Amount for the claim line Revenue Code) in MC054 (Revenue than zero Code). Do not code decimal or when round up / down to whole dollars, MC0130 is code zero cents (00) when not 6. applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Report the amount paid for the claim line. Report 0 if line is paid as part of another procedure / claim line. Do Required not report any value if the line is Amount paid by when Paid denied. Do not code decimal or MC 64 10/30/14 Integer Currency the carrier for the MC038 = 99% A0 Amount round up / down to whole dollars, claim line 1, 2, 3, 19, code zero cents (00) when 20 or 21 applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Report the prepaid amount for this claim line. Report the Fee for Service equivalent amount for Amount carrier Capitated services. Report 0 when Prepaid has prepaid there is no Prepaid amount. Do not MC 65 11/8/12 Integer Currency All 100% A2 Amount towards the claim code decimal or round up / down to line whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070
MC 62 Quantity 11/8/12 Quantity - Integer Counter Claim line units of service Report the count of services / units performed. All 98% A1 MC 63 Charge Amount 11/8/12 Integer Currency Amount of provider charges for the claim line Report the charge amount for this claim line. 0 dollar charges allowed only when the procedure code indicates a Category II procedure code vs. a service code. When reporting Total Charges for facilities for the entire claim use 001 (the generally accepted Total Charge Revenue Code) in MC054 (Revenue Code). 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 MC062 must be greater than zero when MC0130 is not 6. 99% A0 MC 64 Paid Amount 10/30/14 Integer Currency Amount paid by the carrier for the claim line Report the amount paid for the claim line. Report 0 if line is paid as part of another procedure / claim line. Do not report any value if the line is denied. 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 = 1, 2, 3, 19, 20 or 21 99% A0 MC 65 Prepaid Amount 11/8/12 Integer Currency Amount carrier has prepaid towards the claim line Report the prepaid amount for this claim line. Report the Fee for Service equivalent amount for Capitated services. Report 0 when there is no Prepaid 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 All 100% A2
v6-apcd-medical-claim-file-submission-guide-FINAL.docx