C.M.R. 90, 590, ch. 243, app 590-243-F-2
Data Element # | Data Element Name | ADA J400 Form Locator | HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/Segment ID/Code Value/Reference Designator |
DC001 | Submitter | N/A | N/A |
DC002 | Payor | N/A | N/A |
DC003 | Insurance Type/Product Code | N/A | 835/2100/CLP/06 |
DC004 | Payor Claim Control Number | N/A | 835/2100/CLP/07 |
DC005 | Line Counter | N/A | 837/2400/LX/01 |
DC006 | Insured Group or Policy Number | 16 | 837/2000B/SBR/03 |
DC007 | Subscriber Social Security Number | 15 | 837/2010BA/REF/SY/02 |
DC008 | Plan Specific Contract Number | N/A | 835/2100/NM1/MI/08 |
DC009 | Member Suffix or Sequence Number | N/A | N/A |
DC010 | Member Identification Code | N/A | 835/2100/NM1/34/09 |
DC011 | Individual Relationship Code | 18 | 837/2000B/SBR/02, 837/2000C/PAT/01 |
DC012 | Member Gender | 22 | 837/2010BA/DMG/03, 837/2010CA/DMG/03 |
DC013 | Member Date of Birth | 21 | 837/2010BA/DMG/D8/02, 837/2010CA/DMG/D8/02 |
DC014 | Member City Name | 20 | 837/2010BA/N4/01, 837/2010CA/N4/01 |
DC015 | Member State or Province | 20 | 837/2010BA/N4/02, 837/2010CA/N4/02 |
DC016 | Member ZIP Code of Residence | 20 | 837/2010BA/N4/03, 837/2010CA/N4/03 |
DC017 | Date Service Approved | N/A | 835/Header Financial Information/BPR/16 |
DC018 | Rendering Provider Number | 58 | 835/2100/REF/1A/02, 835/2100/REF/1B/02, 835/2100/REF/1C/02, 835/2100/REF/1D/02, 835/2100/REF/G2/02, 835/2100/NM1/BD/09, 835/2100/NM1/BS/09, 835/2100/NM1/MC/09, 835/2100/NM1/PC/09 |
DC019 | Rendering Provider Tax ID Number | 51 | 835/2100/NM1/FI/09 |
DC020 | National Provider ID - Rendering Provider | 54 | 837/2310B/NM1/XX/09 |
DC021 | Rendering Provider Entity Type Qualifier | N/A | 837/2310B/NM1/82/02 |
DC022 | Rendering Provider First Name | N/A | 837/2310B/NM1/82/04 |
DC023 | Rendering Provider Middle Name | N/A | 837/2310B/NM1/82/05 |
DC024 | Rendering Provider Last Name or Organization Name | N/A | 837/2310B/NM1/82/03 |
DC025 | Rendering Provider Suffix | N/A | 837/2310B/NM1/82/07 |
DC026 | Rendering Provider Specialty | 56A | 837/2310B/PRV/PXC/03 |
DC027 | Placeholder | N/A | N/A |
DC028 | Placeholder | N/A | N/A |
DC029 | Placeholder | N/A | N/A |
DC030 | Place of Service - Professional | 38 | 837/2300/CLM/05-1 |
DC031 | Claim Status | N/A | 835/2100/CLP/02 |
DC032 | CDT Code | 29 | 837/2400/SV3/AD/01-2 |
DC033 | Procedure Modifier - 1 | N/A | 837/2400/SV3/AD/01-3 |
DC034 | Procedure Modifier - 2 | N/A | 837/2400/SV3/AD/01-4 |
DC035 | Date of Service - From | 24 | 837/2400/DTP/472/D8/03, 837/2300/DTP/472/D8/03 |
DC036 | Date of Service - Thru | 24 | 837/2400/DTP/472/D8/03, 837/2300/DTP/472/D8/03 |
DC037 | Charge Amount | 31 | 837/2400/SV3/02 |
DC038 | Paid Amount | N/A | 835/2110/SVC/03 |
DC039 | Co-pay Amount | N/A | 835/2110/CAS/PR/3-03 |
DC040 | Coinsurance Amount | N/A | 835/2110/CAS/PR/2-03 |
DC041 | Deductible Amount | N/A | 835/2110/CAS/PR/1-03 |
DC042 | Billing Provider Number | 52A | 837/2010BB/REF/G2/02 |
DC043 | National Provider ID - Billing Provider | 49 | 837/2010AA/NM1/XX/09 |
DC044 | Billing Provider Last Name | 48 | 837/2010AA/NM1/ /03 |
DC045 | Billing Provider Tax ID | 51 | 837/2010AA/REF/EI/02 |
DC046 | Billing Provider Address Line 1 | 48 | 837/2010AA/N3/01 |
DC047 | Billing Provider Address Line 2 | 48 | 837/2010AA/N3/02 |
DC048 | Billing Provider City Name | 48 | 837/2010AA/N4/01 |
DC049 | Billing Provider State or Province | 48 | 837/2010AA/N4/02 |
DC050 | Billing Provider Zip Code | 48 | 837/2010AA/N4/03 |
DC051 | Service Facility Location Name | N/A | 837/2310C/NM1/77/2/03 |
DC052 | National Provider ID - Service Facility | N/A | 837/2310C/NM1/77/2/XX/09 |
DC053 | Service Facility Location Address Line 1 | 56 | 837/2310C/N3/01 |
DC054 | Service Facility Location Address Line 2 | 56 | 837/2310C/N3/02 |
DC055 | Service Facility Location City Name | 56 | 837/2310C/N4/01 |
DC056 | Service Facility Location State or Province | 56 | 837/2310C/N4/02 |
DC057 | Service Facility Location Zip Code | 56 | 837/2310C/N4/03 |
DC058 | Service Facility Number | N/A | 837/2310C/REF/G2/02 |
DC101 | Subscriber Last Name | 12 | 837/2010BA/NM1/ /03 |
DC102 | Subscriber First Name | 12 | 837/2010BA/NM1/ /04 |
DC103 | Subscriber Middle Name | 12 | 837/2010BA/NM1/ /05 |
DC104 | Member Last Name | 20 | 837/2010BA/NM1/ /03, 837/2010CA/NM1/ /03 |
DC105 | Member First Name | 20 | 837/2010BA/NM1/ /04, 837/2010CA/NM1/ /04 |
DC106 | Member Middle Name | 20 | 837/2010BA/NM1/ /05, 837/2010CA/NM1/ /05 |
DC107 | Member Address Line 1 | 20 | 837/2010BA/N3/01, 837/2010CA/N3/01 |
DC108 | Member Address Line 2 | 20 | 837/2010BA/N3/02, 837/2010CA/N3/02 |
DC109 | Member Country Code | 837/2010BA/N4/04, 837/2010CA/N4/04 | |
DC110 | In-Plan Network Indicator | N/A | N/A |
DC111 | Placeholder | N/A | N/A |
DC112 | Oral Cavity 1 | 25 | 837/2400/SV304-01 |
DC113 | Oral Cavity 2 | 25 | 837/2400/SV304-02 |
DC114 | Oral Cavity 3 | 25 | 837/2400/SV304-03 |
DC115 | Oral Cavity 4 | 25 | 837/2400/SV304-04 |
DC116 | Oral Cavity 5 | 25 | 837/2400/SV304-05 |
DC117 | Tooth Number or Letter (1) | 27 | 837/2400/TOO/JP/02 |
DC118 | Tooth - 1 Surface - 1 | 28 | 837/2400/TOO03-01 |
DC119 | Tooth - 1 Surface - 2 | 28 | 837/2400/TOO03-02 |
DC120 | Tooth - 1 Surface - 3 | 28 | 837/2400/TOO03-03 |
DC121 | Tooth - 1 Surface - 4 | 28 | 837/2400/TOO03-04 |
DC122 | Tooth - 1 Surface - 1 | 28 | 837/2400/TOO03-05 |
DC123 | Tooth Number or Letter (2) | 27 | 837/2400/TOO/JP/02 |
DC124 | Tooth - 2 Surface - 1 | 28 | 837/2400/TOO03-01 |
DC125 | Tooth - 2 Surface - 2 | 28 | 837/2400/TOO03-02 |
DC126 | Tooth - 2 Surface - 3 | 28 | 837/2400/TOO03-03 |
DC127 | Tooth - 2 Surface - 4 | 28 | 837/2400/TOO03-04 |
DC128 | Tooth - 2 Surface - 5 | 28 | 837/2400/TOO03-05 |
DC129 | Tooth Number or Letter (3) | 27 | 837/2400/TOO/JP/02 |
DC130 | Tooth - 3 Surface - 1 | 28 | 837/2400/TOO03-01 |
DC131 | Tooth - 3 Surface - 2 | 28 | 837/2400/TOO03-02 |
DC132 | Tooth - 3 Surface - 3 | 28 | 837/2400/TOO03-03 |
DC133 | Tooth - 3 Surface - 4 | 28 | 837/2400/TOO03-04 |
DC134 | Tooth - 3 Surface - 5 | 28 | 837/2400/TOO03-04 |
DC135 | Tooth Number or Letter (4) | 27 | 837/2400/TOO/JP/02 |
DC136 | Tooth - 4 Surface - 1 | 28 | 837/2400/TOO03-01 |
DC137 | Tooth - 4 Surface - 2 | 28 | 837/2400/TOO03-02 |
DC138 | Tooth - 4 Surface - 3 | 28 | 837/2400/TOO03-03 |
DC139 | Tooth - 4 Surface - 4 | 28 | 837/2400/TOO03-04 |
DC140 | Tooth - 4 Surface - 5 | 28 | 837/2400/TOO03-05 |
DC899 | Record Type | N/A | N/A |
C.M.R. 90, 590, ch. 243, app 590-243-F-2