N.H. Admin. Code § Ins 4010.04
Table 4010.05 (a) Provider File Header Record Layout | ||||
Data Element # | Element | Type | Length (decimal places) | Description/Codes/Sources |
HD001 | Record Type | Text | 2 | HD |
HD002 | Payer | Text | 8 | Payer submitting payments. NHID Submitter Code |
HD003 | National Plan ID | Text | 30 | CMS National Plan ID |
HD004 | Type of File | Text | 2 | DC Dental Claims |
HD005 | Period Beginning Date | Date | 8 | Beginning of paid period for claims or beginning of month covered for eligibility |
HD006 | Period Ending Date | Date | 8 | End of paid period for claims or end of month covered for eligibility |
HD008 | Comments | Text | 80 | Submitter may use to document this submission by assigning a filename, system source, etc. |
Table 4010.04 (c) Dental Claims Trailer File Record Layout | ||||
Data Element # | Element | Type | Length (decimal places) | Description/Codes/Sources |
TR001 | Record Type | Text | 2 | TR |
TR002 | Payer | Text | 8 | Payer submitting payments. NHID Submitter Code |
TR003 | National Plan ID | Text | 30 | CMS National Plan ID |
TR004 | Type of File | Text | 2 | DC Dental Claims |
TR005 | Period Beginning Date | Date | 8 | Beginning of paid period for claims or beginning of month covered for eligibility |
TR006 | Period Ending Date | Date | 8 | End of paid period for claims or beginning of month covered for eligibility |
TR007 | Extraction Date | Date | 8 | Date file was created |
TR008 | Record Count | Number | 10 (0) | Total number of records submitted in this file |
Table 4010.04 (d) Dental Claims Detailed File Specifications | ||||
Data Element # | Element | Type | Length (decimal places) | Description/Codes/Sources |
DC001 | Payer | Text | 8 | Payer submitting payments |
DC002 | National Plan ID | Text | 30 | CMS National Plan ID |
DC003 | Insurance Type/Product Code | Text | 2 | As established by X12 Accredited Standards Committee, available at https://ushik.ahrq.gov/ViewItemDetails?system=sdo&itemKey=133161000 |
DC004 | Payer Claim Control Number | Text | 35 | Must apply to entire claim and be unique within payer's system |
DC005 | Line Counter | Text | 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 | Text | 50 | Group or policy number (not the number that uniquely identifies the subscriber) |
DC007 | Subscriber Social Security Number | Text | 9 | Subscriber's social security number. Do not include dashes. Leave blank if not available. |
DC008 | Plan Specific Contract Number | Text | 50 | Plan assigned contract number. Leave blank if Plan Specific Contract Number is subscriber's social security number. If this is a Medicaid claim, provide Medicaid ID. |
DC009 | Member Suffix or Sequence Number | Text | 20 | Uniquely identifies the member within the contract |
DC010 | Member Social Security Number | Text | 9 | Member's social security number. Do not include dashes. Leave blank if not available. |
DC011 | Individual Relationship Code | Text | 2 | See Table 4010.6 (b) Relationship Codes |
DC012 | Member Gender | Text | 1 | M Male |
F Female | ||||
U Unknown | ||||
O Other | ||||
DC013 | Member Date of Birth | Date | 8 | |
DC014 | Member City Name | Text | 30 | City name of member |
DC015 | Member State or Province | Text | 2 | As defined by the U.S. Postal Service |
DC016 | Member ZIP Code | Text | 9 | ZIP Code of member - may include non- US codes. Do not include dash. |
DC017 | Paid Date/AP Date | Date | 8 | |
DC018 | Service Provider Number | Text | 30 | Payer assigned provider number |
DC019 | Service Provider Tax ID Number | Text | 10 | Federal taxpayer's identification number - if the tax id is a provider's social security number use 'SSN' and 'NA' if unavailable |
DC020 | National Service Provider ID | Text | 20 | Required if National Provider ID is mandated for use under HIPAA |
DC021 | Service Provider Entity Type Qualifier | Text | 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 "Person". |
1 Person | ||||
2 Non-Person Entity | ||||
DC022 | Service Provider First Name | Text | 35 | Individual first name. Leave blank if provider is a facility or organization |
DC023 | Service Provider Middle Name | Text | 25 | Individual middle name or initial. Leave blank if provider is a facility or organization |
DC024 | Servicing Provider Last Name or Organization Name | Text | 60 | Report the name of the organization or last name of the individual provider. DC021 determines if this is an Organization or Individual Name reported here. |
DC025 | Service Provider Suffix | Text | 10 | Suffix to individual name. Leave blank if provider is a facility or organization |
DC026 | Service Provider Specialty | Text | 10 | National Uniform Claims Committee (NUCC) standard code that defines this provider for this line of service. Dictionary for specialty code values must be supplied during testing. |
DC027 | Service Provider City Name | Text | 30 | City name of provider - practice location |
DC028 | Service Provider State or Province | Text | 2 | As defined by the U.S. Postal Service |
DC029 | Service Provider ZIP Code | Text | 9 | ZIP Code of provider - may include non-US codes. |
DC030 | Place of Service - Professional | Text | 2 | See Table 4010.6 (g) Place of Service -- Professional |
DC031 | Claim Status | Text | 2 | See Table 4010.6 (h) Claim Status |
DC032 | CDT Code | Text | 5 | Common Dental Terminology code |
DC033 | Procedure Modifier - 1 | Text | 2 | Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code |
DC034 | Procedure Modifier - 2 | Text | 2 | Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code |
DC035 | Date of Service - From | Date | 8 | First date of service for this service line. |
DC036 | Date of Service - Thru | Date | 8 | Last date of service for this service line. |
DC037 | Charge Amount | Number | 10 (2) | The full, undiscounted total and service-specific charges billed by the provider. |
DC038 | Paid Amount | Number | 10 (2) | Includes any withhold amounts. |
DC039 | Copay Amount | Number | 10 (2) | The present, fixed dollar amount for which the individual is responsible. |
DC040 | Coinsurance Amount | Number | 10 (2) | The dollar amount an individual is responsible for - not the percentage. |
DC041 | Deductible Amount | Number | 10 (2) | Deductible amount in dollars |
DC042 | Billing Provider Number | Text | 30 | Carriers, third-party administrators, and dental claims processors shall code using the payer assigned billing provider number. This number should be the identifier used by the payer for internal identification purposes, and does not routinely change |
DC043 | National Billing Provider Number ID | Text | 30 | This is the NPI for the billing provider |
DC044 | Billing Provider Last Name | Text | 60 | Full name of provider billing organization or last name of individual billing provider. |
DC101 | Subscriber Last Name | Text | 60 | |
DC102 | Subscriber First Name | Text | 35 | |
DC103 | Subscriber Middle Initial | Text | 1 | |
DC104 | Member Last Name | Text | 60 | |
DC105 | Member First Name | Text | 35 | |
DC106 | Member Middle Initial | Text | 1 | |
DC201 | Carrier Associated with Claim | Text | 8 | For each claim, the NAIC code of the carrier when a TPA processes claims on behalf of the carrier. Optional if all dental claims processed by a TPA under contract to a carrier for carved-out services are submitted by the carrier with unified member IDs in all files. |
DC202 | Carrier Plan Specific Contract Number or Subscriber/Member Social Security Number | Text | 128 | For each claim, the carrier specific contract number or subscriber/member social security number when a TPA processes claims on behalf of the carrier. Optional if all medical claims processed by a TPA under contract to a carrier for carved-out services are submitted by the carrier with unified member IDs in all files. |
DC203 | Practitioner Group Practice | Text | 60 | Name of group practice to which a practitioner is affiliated if different from DC044. |
DC204 | Tooth Number/Letter | Text | 2 | Report the tooth identifier(s) when DC032 is within the given range. Required when DC032 = D2000 thru D2999 |
DC205 | Dental Quadrant | Text | 2 | Standard quadrant identifier from the External Code Source referenced in Ins 4009.05. Provides further detail on procedure(s) |
DC206 | Tooth Surface | Text | 5 | Tooth surface(s) that this service relates to. Provides further detail on procedure |
DC207 | Claim Version | Text | 4 | Version number of this claim service line. The version number begins with 0 and is incremented by 1 for each subsequent version of that service line. No alpha or special characters. |
DC208 | Diagnosis Code | Text | 7 | ICD CM Diagnosis Code when applicable |
DC209 | ICD Indicator | Text | 1 | Report the value that defines whether the diagnoses on claim are ICD9 or ICD10. |
0 ICD-9 | ||||
1 ICD-10 | ||||
DC211 | Cross Reference Claims ID | Text | 35 | The original Payer Claim Control Number (DC004). Used when a new Payer Claim Control Number is assigned to an adjusted claim. |
DC212 | Allowed amount | Number | 10 (0) | Report the maximum amount contractually allowed and that a carrier will pay to a provider for a particular procedure or service. This will vary by provider contract and most often it is less than or equal to the fee charged by the provider. Shall be reported even when paid amount = 0 but member receives care. 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 |
DC213 | HIOS Plan ID | Text | 16 | The 16 character HIOS Plan ID (Standard component). Including a five digit issuer ID, two character state ID, three digit product number, four digit standard component number and two digit variant component ID. This field may not be available for all market segments; Leave blank where not available |
DC215 | Service Line Type | Text | 1 | Report the code that defines the claim line status in terms of adjudication |
O Original | ||||
V Void | ||||
R Replacement | ||||
B Back Out | ||||
A Amendment | ||||
DC218 | Claim Processing Level Indicator | Text | 1 | 1 Claim Level |
2 Service Line level | ||||
DC219 | Denied Claim Indicator | Text | 1 | 1 Fully Paid - the entire claim was paid at the allowed amount |
2 Partially denied - some of the claims lines were paid at the allowed amount | ||||
3 Encounter claim - this claim records a service provided that is paid under a non FFS payment arrangement such as capitation | ||||
4 No payment - no payment made for reasons other than non FFS payment arrangement | ||||
DC220 | Denial Reason | Text | 4 | Denial reason code. Required when denied claim indicator = 2 or 4 http://www.wpc-edi.com/reference/ |
DC899 | Record Type | Text | 2 | DC |
DC900 | In Network Indicator | Text | 1 | A yes/no indicator that specifies that the provider (not the benefit) is within the health plan network. Valid codes: Y=Yes, N=No |
DC901 | Quantity | Number | 12(0) | Count of services performed |
N.H. Admin. Code § Ins 4010.04