Statutes, codes, and regulations
Maine Administrative Code
Department 90 - INDEPENDENT AGENCIESDivision 590 - MAINE HEALTH DATA ORGANIZATION
Chapter 243 - UNIFORM REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS
Appendix 590-243-F-1 - Maine Health Data Organization Dental Claims File Specifications

C.M.R. 90, 590, ch. 243, app 590-243-F-1

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Current through 2024-51, December 18, 2024
Appendix 590-243-F-1 - Maine Health Data Organization Dental Claims File Specifications

Data Element #

Data Element Name

Date Effective

Type

Maximum Length

Description/Codes/Sources

DC001

Submitter

1/1/2003

Text

8

MHDO-assigned identifier of payor submitting claims data. Do not leave blank.

DC002

Payor

7/1/2012

Text

8

MHDO-assigned code of the insurer/ underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage.

Do not leave blank.

DC003

Insurance Type/Product Code

1/1/2003

Text

2

Code identifying the type of insurance policy within a specific insurance program. Refer to Appendix A

DC004

Payor Claim Control Number

1/1/2003

Text

35

Must apply to entire claim and be unique within the payor's system

DC005

Line Counter

4/1/2004

Number

4

Line number for this service The line counter begins with 1 and is incremented by 1 for each additional service line of a claim.

DC006

Insured Group or Policy Number

1/1/2003

Text

30

Group or policy number - not the number that uniquely identifies the subscriber

DC007

Subscriber Social Security Number

1/1/2003

Text

9

Subscriber's social security number Leave blank if unavailable.

DC008

Plan Specific Contract Number

1/1/2003

Text

80

Plan-assigned contract number Leave blank if contract number = subscriber's social security number.

DC009

Member Suffix or Sequence Number

1/1/2003

Text

20

Uniquely numbers the member within the contract

DC010

Member Identification Code

1/1/2003

Text

50

Member's social security number Leave blank if unavailable.

DC011

Individual Relationship Code

1/1/2003

Text

2

Member's relationship to insured Refer to Appendix A

DC012

Member Gender

1/1/2003

Text

1

Refer to Appendix A

DC013

Member Date of Birth

1/1/2003

Text

8

CCYYMMDD

DC014

Member City Name

4/1/2004

Text

30

City name of member Refer to Appendix A

DC015

Member State or Province

4/1/2004

Text

2

As defined by the US Postal Service and Canada Post Refer to Appendix A

DC016

Member ZIP Code

1/1/2003

Text

11

ZIP Code of member - may include non-US codes Do not include dash.

Refer to Appendix A

DC017

Date Service Approved (AP Date)

1/1/2003

Text

8

CCYYMMDD

DC018

Rendering Provider Number

1/1/2003

Text

30

Payor-assigned provider number

DC019

Rendering Provider Tax ID Number

1/1/2003

Text

10

Federal taxpayer's identification number

DC020

National Provider ID - Rendering Provider

4/1/2004

Text

20

National Provider ID This data element pertains to the entity or individual directly providing the service.

Refer to Appendix A

DC021

Rendering Provider Entity Type Qualifier

4/1/2004

Number

1

HIPAA provider taxonomy classifies provider groups (clinicians who bill as a group practice or under a corporate name, even if that group is composed of one provider) as a "person", and these shall be coded as a person.

Refer to Appendix A

DC022

Rendering Provider First Name

1/1/2003

Text

40

Individual first name Leave blank if provider is a facility or organization.

DC023

Rendering Provider Middle Name

1/1/2003

Text

25

Individual middle name or initial Leave blank if provider is a facility or organization.

DC024

Rendering Provider Last Name or Organization Name

1/1/2003

Text

60

Full name of provider organization or last name of individual provider

DC025

Rendering Provider Suffix

1/1/2003

Text

10

Suffix to individual name Leave blank if provider is a facility or organization.

The service provider suffix shall be used to capture the generation of the individual clinician (e.g., Jr., Sr., III), if applicable, rather than the clinician's degree (e.g., MD, LCSW).

DC026

Rendering Provider Specialty

1/1/2003

Text

10

Refer to Appendix A

If defined by payor, then dictionary for specialty code values must be supplied during testing.

DC027

Placeholder

2/1/2016

N/A

0

Leave blank Service Provider City Name retired; refer to DC055 - Service Facility Location City Name

DC028

Placeholder

2/1/2016

N/A

0

Leave blank Service Provider State or Province retired; refer to DC056 - Service Facility Location Address State or Province

DC029

Placeholder

2/1/2016

N/A

0

Leave blank Service Provider ZIP Code retired; refer to DC057 - Service Facility Location Address State or Province

DC030

Place of Service - Professional

4/1/2004

Text

2

Refer to Appendix A

DC031

Claim Status

1/1/2003

Text

2

Refer to Appendix A

DC032

CDT Code

1/1/2003

Text

5

Common Dental Terminology code Refer to Appendix A

DC033

Procedure Modifier - 1

1/1/2003

Text

2

Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code

DC034

Procedure Modifier - 2

1/1/2003

Text

2

Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code

DC035

Date of Service - From

1/1/2003

Text

8

First date of service for this service line CCYYMMDD

DC036

Date of Service - Thru

1/1/2003

Text

8

Last date of service for this service line CCYYMMDD

DC037

Charge Amount

1/1/2003

Number

10

Do not code decimal point. Two decimal places implied.

DC038

Paid Amount

1/1/2003

Number

10

Do not code decimal point. Two decimal places implied.

DC039

Co-pay Amount

1/1/2003

Number

10

The preset, fixed dollar amount for which the individual is responsible Do not code decimal point. Two decimal places implied.

DC040

Coinsurance Amount

1/1/2003

Number

10

The dollar amount an individual is responsible for - not the percentage Do not code decimal point. Two decimal places implied.

DC041

Deductible Amount

1/1/2003

Number

10

Do not code decimal point. Two decimal places implied.

DC042

Billing Provider Number

1/1/2010

Text

30

Payor-assigned billing provider number. This number should be the identifier used by the payor for internal identification purposes, and does not routinely change.

DC043

National Provider ID - Billing Provider

1/1/2010

Text

20

National Provider ID for billing provider Refer to Appendix A

DC044

Billing Provider Last Name or Organization Name

1/1/2010

Text

60

Full name of provider billing organization or last name of individual billing provider.

DC045

Billing Provider Tax ID

2/1/2016

Text

10

Federal taxpayer's identification number

DC046

Billing Provider Address Line 1

2/1/2016

Text

55

Address information for billing provider

DC047

Billing Provider Address Line 2

2/1/2016

Text

55

Address information for billing provider

DC048

Billing Provider City Name

2/1/2016

Text

30

City name of billing provider Refer to Appendix A

DC049

Billing Provider State or Province

2/1/2016

Text

2

As defined by the US Postal Service and Canada Post Refer to Appendix A

DC050

Billing Provider Zip Code

2/1/2016

Text

11

Zip Code of billing provider - may include non-US codes Do not include dash Refer to Appendix A

DC051

Service Facility Location Name

2/1/2016

Text

60

Laboratory or service facility name If not available or not specified, do not populate.

DC052

National Provider ID - Service Facility

2/1/2016

Text

20

National Provider ID for laboratory or service facility If not available or not specified, do not populate.

Refer to Appendix A

DC053

Service Facility Location Address Line 1

2/1/2016

Text

55

Address information for laboratory or service facility If not available or not specified, do not populate.

DC054

Service Facility Location Address Line 2

2/1/2016

Text

55

Address information for laboratory or service facility If not available or not specified, do not populate.

DC055

Service Facility Location City Name

2/1/2016

Text

30

City name of laboratory or service facility If not available or not specified, do not populate. Refer to Appendix A

DC056

Service Facility Location State or Province

2/1/2016

Text

2

As defined by the US Postal Service and Canada Post If not available or not specified, do not populate.

Refer to Appendix A

DC057

Service Facility Location Zip Code

2/1/2016

Text

11

Zip Code of service facility - may include non-US codes Do not include dash If not available or not specified, do not populate.

Refer to Appendix A

DC058

Service Facility Number

2/1/2016

Text

30

Payor-assigned service facility number. This number

should be the identifier used by the payor for internal identification purposes and does not routinely change. If not available or not specified, do not populate.

DC101

Subscriber Last Name

1/1/2010

Text

60

The subscriber last name

DC102

Subscriber First Name

1/1/2010

Text

35

The subscriber first name

DC103

Subscriber Middle Name

1/1/2010

Text

25

The subscriber middle name or initial

DC104

Member Last Name

1/1/2010

Text

60

The member last name

DC105

Member First Name

1/1/2010

Text

35

The member first name

DC106

Member Middle Name

1/1/2010

Text

25

The member middle name or initial

DC107

Member Address Line 1

2/1/2019

Text

55

DC108

Member Address Line 2

2/1/2019

Text

55

DC109

Member Country Code

2/1/2019

Text

2

Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A.

DC110

In-Plan Network Indicator

2/1/2021

Text

1

A yes/no indicator that specifies if the Billing Provider (not the benefit) is within the health plan network. Valid codes are: N=No; Y=Yes.

DC111

Placeholder

2/1/2025

N/A

0

Leave blank. Payment Arrangement Type Indicator retired

DC112

Oral Cavity 1

2/1/2025

Text

2

Always report the area of the oral cavity when the procedure reported in field DC032 (CDT Code) refers to a quadrant or arch and the area of the oral cavity is not uniquely defined by the procedure's nomenclature.

Area of the oral cavity is designated by a two-digit code, selected from the following code list:

00=entire oral cavity;

01=maxillary arch;

02=mandibular arch;

10=upper right quadrant;

20=upper left quadrant;

30=lower left quadrant;

40=lower right quadrant.

DC113

Oral Cavity 2

2/1/2025

Text

2

Always report the area of the oral cavity when the procedure reported in field DC032 (CDT Code) refers to a quadrant or arch and the area of the oral cavity is not uniquely defined by the procedure's nomenclature.

Area of the oral cavity is designated by a two-digit code, selected from the following code list:

00=entire oral cavity;

01=maxillary arch;

02=mandibular arch;

10=upper right quadrant;

20=upper left quadrant;

30=lower left quadrant;

40=lower right quadrant.

DC114

Oral Cavity 3

2/1/2025

Text

2

Always report the area of the oral cavity when the procedure reported in field DC032 (CDT Code) refers to a quadrant or arch and the area of the oral cavity is not uniquely defined by the procedure's nomenclature.

Area of the oral cavity is designated by a two-digit code, selected from the following code list:

00=entire oral cavity;

01=maxillary arch;

02=mandibular arch;

10=upper right quadrant;

20=upper left quadrant;

30=lower left quadrant;

40=lower right quadrant.

DC115

Oral Cavity 4

2/1/2025

Text

2

Always report the area of the oral cavity when the procedure reported in field DC032 (CDT Code) refers to a quadrant or arch and the area of the oral cavity is not uniquely defined by the procedure's nomenclature.

Area of the oral cavity is designated by a two-digit code, selected from the following code list:

00=entire oral cavity;

01=maxillary arch;

02=mandibular arch;

10=upper right quadrant;

20=upper left quadrant;

30=lower left quadrant;

40=lower right quadrant.

DC116

Oral Cavity 5

2/1/2025

Text

2

Always report the area of the oral cavity when the procedure reported in field DC032 (CDT Code) refers to a quadrant or arch and the area of the oral cavity is not uniquely defined by the procedure's nomenclature.

Area of the oral cavity is designated by a two-digit code, selected from the following code list:

00=entire oral cavity;

01=maxillary arch;

02=mandibular arch;

10=upper right quadrant;

20=upper left quadrant;

30=lower left quadrant;

E40=lower right quadrant.

DC117

Tooth Number or Letter (1)

2/1/2025

Text

2

Required when DC032 = D2000 thru D2999. Enter the appropriate tooth number or letter when the procedure directly involves a tooth or range of teeth. If not available, leave blank. Tooth Number codes are maintained by the American Dental Association. See Appendix A.

DC118

Tooth - 1 Surface - 1

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). Required when Tooth Number/ Letter DC117 is populated.

DC119

Tooth - 1 Surface - 2

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC120

Tooth - 1 Surface - 3

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC121

Tooth - 1 Surface - 4

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC122

Tooth - 1 Surface - 5

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC123

Tooth Number or Letter (2)

2/1/2025

Text

2

Report the tooth identifier(s) when DC032 is within the given range if a second tooth is involved in the procedure. Required when DC032 = D2000 thru D2999.

See Appendix A.

DC124

Tooth - 2 Surface - 1

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). Required when Tooth Number/ Letter DC123 is populated.

DC125

Tooth - 2 Surface - 2

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC126

Tooth - 2 Surface - 3

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC127

Tooth - 2 Surface - 4

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC128

Tooth - 2 Surface - 5

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC129

Tooth Number or Letter (3)

2/1/2025

Text

2

Report the tooth identifier(s) when DC032 is within the given range if a third tooth is involved in the procedure. Required when DC032 = D2000 thru D2999.

See Appendix A.

DC130

Tooth - 3 Surface - 1

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). Required when Tooth Number/ Letter DC129 is populated.

DC131

Tooth - 3 Surface - 2

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC132

Tooth - 3 Surface - 3

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC133

Tooth - 3 Surface - 4

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC134

Tooth - 3 Surface - 5

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC135

Tooth Number or Letter (4)

2/1/2025

Text

2

Report the tooth identifier(s) when DC032 is within the given range if a fourth tooth is involved in the procedure. Required when DC032 = D2000 thru D2999.

See Appendix A.

DC136

Tooth - 4 Surface - 1

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). Required when Tooth Number/ Letter DC135 is populated.

DC137

Tooth - 4 Surface - 2

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC138

Tooth - 4 Surface - 3

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC139

Tooth - 4 Surface - 4

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC140

Tooth - 4 Surface - 5

2/1/2025

Text

1

Report the tooth surface(s) on which this service was performed. Provides further detail on procedure(s). If not required to report an additional tooth surface, leave blank.

DC899

Record Type

1/1/2003

Text

2

DC

C.M.R. 90, 590, ch. 243, app 590-243-F-1