Required when MC094 = 002 and MC036 = Report the number of Noncovered 11, 18, 21, Non Quantity Days Noncovered days the patient incurred during this 28, 41, 65, MC 94 Covered 10/30/14 87% B - Integer Noncovered Inpatient Days admission. Report 0 if all days were 66, 84, 86 Days covered. or 89 (type of bill indicates an inpatient visit) Report the value that defines the type Lookup Type of Type of of claim submitted for payment. MC 95 11/8/12 Table - char[3] All 100% A0 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 94 Non Covered Days 10/30/14 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 MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86 or 89 (type of bill indicates an inpatient visit) 87% B MC 95 Type of 11/8/12 Lookup Table - Text char[3] Type of Indicator Report the value 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
apcd-medical-claim-file-submission-guide.docx