Report the submitter-assigned identifier as it appears in PR001 in Product ID ID Link to Product the Product File. This element is MC 80 11/8/12 Text All 100% A0 Number PR001 Identification used to understand Product and Eligibility attributes of the member / subscriber as applied to this record. Carrier External Code Defined Source 16 - Required - Report the value that describes how Claim when Payment Payment Reason the claim line was paid, either using a OR - MC 81 11/8/12 Adjustment = 1, 2, 3, 100% A0 Reason External Code standard code set or a proprietary list Reasons- OR 19, 20, or – Code pre-sent by submitter. Carrier Defined 21 Source Table 16 - Text Report the value that defines the Capitated Lookup Indicator - element. EXAMPLE: 1 = Yes 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. 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.
MC 80 Product ID Number 11/8/12 Text ID Link to PR001 Product Identification Report the submitter-assigned identifier as it appears in PR001 in the Product File. This element is used to understand Product and Eligibility attributes of the member / subscriber as applied to this record. All 100% A0 MC 81 Payment Reason 11/8/12 Carrier Defined - 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 = 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 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
apcd-medical-claim-file-submission-guide.docx