Service Report the city name of provider - Address City City Name of the MC 34 Provider 6/24/10 Text preferably practice location. Do not All 98% B Provider Provider City Name report any value if not available. External Address State Report the state of the service Service Code External Code State of the providers as defined by the US MC 35 Provider 11/8/12 char[2] All 98% B Source 2 Source 2 - Service Provider Postal Service. Do not report any - Text States value if not available. External Address Zip Report the 5 or 9 digit Zip Code as Service Code External Code Zip Code of the defined by the United States Postal MC 36 Provider 11/8/12 varchar[9] All 98% B Source 2 Source 2 - Zip Service Provider Service. When submitting the 9-digit ZIP Code - Text Codes Zip Code do not include hyphen. External Type of Report the two-digit value that Code External Code Required Bill - on defines the Type of Bill on an MC 37 11/8/12 Source Source 14 - int[2] Type of Bill when 98% A0 Facility institutional claim. Do not report 14 - Type of Bill = 002 Claims leading zero Integer Site of External Service - Required Code External Code Report the two-digit value that on Place of Service when MC 38 11/8/12 Source Source 13 - char[2] defines the Place of Service on 100% A0 NSF/CMS Code MC094 = 13 - Place of Service professional claim 1500 001 Numeric Claims Lookup Claim Report the value that defines the MC 39 11/8/12 Table - tlkpClaimStatus varchar[2] Claim Line Status All 98% A0 Status payment status of this claim line Numeric Description 1 Processed as primary 2 Processed as secondary 3 Processed as tertiary 4 Denied Processed as primary, forwarded to 19 additional Processed as secondary, forwarded 20 to additional payer(s) Processed as tertiary, forwarded to 21 additional
MC 34 Service Provider City Name 6/24/10 Text Address City Provider City Name of the Provider Report the city name of provider - preferably practice location. Do not report any value if not available. All 98% B MC 35 Service Provider 11/8/12 External Code Source 2 - Text Address State External Code Source 2 - States char[2] State of the Service Provider Report the state of the service providers as defined by the US Postal Service. Do not report any value if not available. All 98% B MC 36 Service Provider ZIP Code 11/8/12 External Code Source 2 - Text Address Zip External Code Source 2 - Zip Codes varchar[9] Zip Code of the Service Provider Report the 5 or 9 digit Zip Code as defined by the United States Postal Service. When submitting the 9-digit Zip Code do not include hyphen. All 98% B MC 37 Type of Bill - on Facility Claims 11/8/12 External Code Source 14 - Integer External Code Source 14 - Type of Bill int[2] Type of Bill Report the two-digit value that defines the Type of Bill on an institutional claim. Do not report leading zero Required when = 002 98% A0 MC 38 Site of Service - on NSF/CMS 1500 Claims 11/8/12 External Code Source 13 - Numeric External Code Source 13 - Place of Service char[2] Place of Service Code Report the two-digit value that defines the Place of Service on professional claim Required when MC094 = 001 100% A0 MC 39 Claim Status 11/8/12 Lookup Table - Numeric tlkpClaimStatus varchar[2] Claim Line Status Report the value that defines the payment status of this claim line All 98% A0 Description 1 Processed as primary 2 Processed as secondary 3 Processed as tertiary 4 Denied 19 Processed as primary, forwarded to additional 20 Processed as secondary, forwarded to additional payer(s) 21 Processed as tertiary, forwarded to additional
apcd-medical-claim-file-submission-guide.docx