US · guidance

CMS Pub. 100-08, ch. pim83exhibits, § 36

Overview of the CERT Process

activein force · 2026-08-25 – presentas-observed

The CERT process begins at the MAC processing site where claims that have entered the

standard claims processing system on a given day are extracted to create a Claims Universe File.

This file is transmitted each day to the CERT Operations Center, where it is routed through a

random sampling process. Claims that are selected as part of the sample are downloaded to the

Sampled Claims Database. This database holds all sampled claims from all MACs. Periodically,

sampled claim key data are extracted from the Sampled Claims Database to create a Sampled

Claims Transaction File. This file is transmitted back to the MAC and matched to the MAC’s

claims history and provider files. A Sampled Claims Resolution File, a Claims History Replica

File, and a Provider Address file are created automatically by the MAC and transmitted to the

CERT Operations Center. They are used to update the Sampled Claims database with claim

resolutions and provider addresses; the Claims History Replica records are added to a database

for future analysis.

Software applications at the CERT Operations Center are used to review, track, and report on the

sampled claims. Periodically, the CERT contractor requests the MAC to provide information

supporting decisions on denied/reduced claims or claim line items and claims that have been

subject to their medical review processes. The CERT contractor also sends reports identifying

incorrect claim payment to the appropriate MAC for follow-up. MACs then report on their

agreement and disagreement with CERT decisions, status of overpayment collections, and status

of claims that go through the appeals process.

Exhibit 36.1 - CERT Formats for A/B MAC (A) MACS and Shared Systems

(Rev. 10228; Issued: 07-27-20; Effective: 08-27-20; Implementation: 08-27-20)

Claims Universe File

Claims Universe Header Record (one record per file)

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 ‘1’

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Universe Date X(8) 9 16 Spaces

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number

Validation: Must be a valid CMS contractor ID

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single

processing environment, the Contractor ID will reflect the roll-up Contractor

ID specified by CMS

Data Element: Record Type

Definition: Code indicating type of record

Validation: N/A

Remarks: 1 = Header

record Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Universe file

Validation: Claim Universe files prior to 10/1/2007 did not contain this field.

Codes:

B = Record Format as of 10/1/2007

C = Record Format as of 10/1/2017

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor included in the file

Validation: Must be ‘A’ or ‘R’

Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.

Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should

be ‘R’.

All others will be contractor type ‘A’.

Remarks: A = A/B MAC (A) only

R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)

Requirement: Required

Data Element: Universe Date

Definition: Date the universe of claims entered the shared system

Validation: Must be a valid date not equal to a universe date sent on any previous claims

universe file

Remarks: Format is CCYYMMDD. May use shared system batch processing date;

however, the Universe Date must not equal the universe date on any previous

claims universe file.

Requirement: Required

Claims Universe File

Claims Universe Claim Record

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 “2”

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Internal Control Number X(23) 9 31 Spaces

Beneficiary HICN X(12) 32 43 Spaces

Billing Provider Number X(9) 44 52 Spaces

Billing Provider NPI X(10) 53 62 Spaces

Type of Bill X(3) 63 65 Spaces

Claim From Date X (8) 66 73 Spaces

Claim Through Date X (8) 74 81 Spaces

Condition Code 1 X (2) 82 83 Spaces

Condition Code 2 X (2) 84 85 Spaces

Condition Code 3 X (2) 86 87 Spaces

Condition Code 4 X (2) 88 89 Spaces

Condition Code 5 X (2) 90 91 Spaces

Condition Code 6 X (2) 92 93 Spaces

Condition Code 7 X (2) 94 95 Spaces

Condition Code 8 X (2) 96 97 Spaces

Condition Code 9 X (2) 98 99 Spaces

Condition Code 10 X (2) 100 101 Spaces

Condition Code 11 X (2) 102 103 Spaces

Condition Code 12 X (2) 104 105 Spaces

Condition Code 13 X (2) 106 107 Spaces

Condition Code 14 X (2) 108 109 Spaces

Field Name Picture From Thru Initialization

Condition Code 15 X (2) 110 111 Spaces

Condition Code 16 X (2) 112 113 Spaces

Condition Code 17 X (2) 114 115 Spaces

Condition Code 18 X (2) 116 117 Spaces

Condition Code 19 X (2) 118 119 Spaces

Condition Code 20 X (2) 120 121 Spaces

Condition Code 21 X (2) 122 123 Spaces

Condition Code 22 X (2) 124 125 Spaces

Condition Code 23 X (2) 126 127 Spaces

Claim Demonstration Number X(2) 128 129 Spaces

PPS Indicator Code X(1) 130 130 Spaces

Claim State X(2) 131 132 Spaces

Beneficiary State X(2) 133 134 Spaces

Claim Total Charge Amount 9(8)V99 135 144 Zeroes

Beneficiary MBI X(11) 145 155 Spaces

Hicn/MBI indicator X(1) 156 156 Spaces

Filler X(2) 157 158 Spaces

Revenue Code Count 9(3) 159 161 Zero

Claims Universe File

Claims Universe Revenue Code Group (Claim Line Items)

*The following group of fields occurs from 1 to 450 times (depending on Revenue Code

Count)

*From and Thru values relate to the 1st line item

DATA ELEMENT DETAIL

Claim (Header) Fields

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number

Validation: Must be a valid CMS contractor ID

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single

processing environment, the Contractor ID will reflect the roll-up Contractor

ID specified by CMS

Data Element: Record Type

Definition: Code indicating type of record

Validation: N/A

Remarks: 2 = claim

record Requirement:

Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Universe file

Validation: Claim Universe files prior to 10/1/2007 did not contain this field.

Field Name Picture From Thru Initialization

Revenue Center Code X(4) 162 165 Spaces

HCPCS X(5) 166 170 Spaces

Revenue Center Total Charge 9(8)V99 171 180 Zeroes

Codes:

B = Record Format as of

10/1/2007 C = Record Format as

of 10/1/2017

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor included in the file

Validation: Must be ‘A’ or ‘R’.

Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.

Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should

be ‘R’.

All others will be contractor type ‘A’.

Data Element: Internal Control Number

Definition: Number assigned by the shared system to uniquely identify the claim

Validation: N/A

Remarks: Do not include hyphens or spaces

Requirement: Required

Data Element: Beneficiary HICN

Definition: Beneficiary’s Health Insurance Claim Number

Validation: N/A

Remarks: Do not include hyphens or spaces

Requirement: Required

Data Element: Billing Provider Number

Definition: First nine characters of number assigned by Medicare to identify the

billing/pricing provider or supplier.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Billing Provider NPI

Definition: NPI assigned to the Billing Provider.

Validation: N/A

Remarks: N/A.

Requirement: Required by May 23, 2007 for claims using HIPAA standard Transactions

Data Element: Type of Bill

Definition: Three-digit alphanumeric code gives three specific pieces of information. The

first digit identifies the type of facility. The second classifies the type of care.

The third indicates the sequence of this bill in this particular episode of care.

It is referred to as “frequency” code.

Validation: Must be a valid code as listed in Pub 100-4, Medicare Claims

Processing Manual, Chapter 25, Completing and Processing CMS-1450 Data

Set.

Remarks: N/A

Requirement: Required

Data Element: Claim from Date

Definition: The first day on the billing statement covering services rendered to the

beneficiary.

Validation: Must be a valid date

Remarks: Format is CCYYMMDD

Requirement: Required

Data Element: Claim through Date

Definition: The last day on the billing statement covering services rendered to the

beneficiary.

Validation: Must be a valid date

Remarks: Format is CCYYMMDD

Requirement: Required

Data Element: Condition Code 1

Condition Code 2

Condition Code 3

Condition Code 4

Condition Code 5

Condition Code 6

Condition Code 7

Condition Code 8

Condition Code 9

Condition Code 10

Condition Code 11

Condition Code 12

Condition Code 13

Condition Code 14

Condition Code 15

Condition Code 16

Condition Code 17

Condition Code 18

Condition Code 19

Condition Code 20

Condition Code 21

Condition Code 22

Condition Code 23

Definition: The code that indicates a condition relating to an institutional

claim that may affect payer processing.

Validation: Must be a valid code as defined in the Claims Processing Manual (Pub. 100-4)

chapter 25 (Completing and Processing CMS-1450 Data Set).

Remarks: N/A

Requirement: Required if claim has a condition code

Data Element: Claim Demonstration Identification Number

Definition: The number assigned to identify a demonstration Project. This field is also

used to denote special processing (a.k.a. Special Processing Number, SPN).

Validation: Must be a Valid Demo ID.

Remarks: N/A

Requirement: Required when available on claim

Data Element: PPS Indicator Code alias Claim PPS Indicator Code

Definition: The code indicating whether (1) the claim is Prospective Payment System

(PPS), (2) Unknown or (0) not PPS.

Validation: 0 = Not PPS

1 = PPS

2 = Unknown

Remarks: N/A

Requirement: Required

Data Element: Claim State

Definition: 2 character abbreviation identifying the state in which the service is furnished

Validation: Must be a valid 2 digit state abbreviation as defined by the United States

Postal Service (USPS) or blank.

Remarks: N/A

Requirement: Required if on claim record

Data Element: Beneficiary State

Definition: 2 character abbreviation designating the state in which the beneficiary

resides.

Validation: Must be a valid 2 digit state abbreviation as defined by the United States

Postal Service (USPS) or blank.

Remarks: N/A

Requirement: Required if on claim record

Data Element: Claim Total Charge Amount

Definition: The total charges for all services included on the institutional claim.

Validation: N/A

Remarks: This field should contain the same amount as revenue center code 0001/total

charges.

Requirement: Required

Data Element: Beneficiary MBI

Definition: Beneficiary’s Medicare Beneficiary Identifier

Validation: Comply with CMS Standards

• 11-character, fixed length alpha-numeric string

• Different, visibly distinguishable from HICN/RRB numbers

• Contain no more than 2 consecutive numbers

• Contain no more than 2 consecutive alphabetic characters

• Must limit the possibility of letters being interpreted as numbers (i.e.,

alphabetic characters [A…Z]; excluding S, L, O, I, B, Z)

• Must not contain lowercase letters

• Must not contain any special characters

Remarks: Do not include hyphens or spaces

Requirement: Required, when available

Data Element: HICN/MBI Indicator

Definition: Indicator that identifies if the provider submitted the claim with a HICN or MBI

Validation: M = MBI submitted on the claim

H = HICN submitted on the claim

Remarks: N/A

Requirement:

Required

Data Element: Revenue Code Count

Definition: Number indicating number of revenue code lines on the claim. Include line 1

in the count.

Validation: Must be a number 01 – 450

Remarks: N/A

Requirement:

Required

Claim Line Item Fields

Data Element: Revenue Code

Definition: Code assigned to each cost center for which a charge is billed.

Validation: Must be a valid National Uniform Billing Committee (NUBC) approved code.

Remarks: Include an entry for revenue code ‘0001’.

Requirement: Required

Data Element: HCPCS Procedure Code or HIPPS Code

Definition: The HCPCS/CPT-4 code that describes the service or Health Insurance PPS

(HIPPS) code.

Validation: Must be a valid HCPCS/CPT-4 code.

Remarks: Healthcare Common Procedure Coding System (HCPCS) is a collection of

codes that represent procedures, supplies, products and services which may

be provided to Medicare beneficiaries and to individuals enrolled in private

health insurance programs.

When revenue center code = '0022' (SNF PPS), '0023' (HH PPS), or '0024'

(IRF PPS); this field contains the Health Insurance PPS (HIPPS) code.

The HIPPS code for SNF PPS contains the rate code/assessment type that

identifies RUG-III group the beneficiary was classified into as of the RAI MDS

assessment reference date and (2) the type of assessment for payment

purposes.

The HIPPS code for Home Health PPS identifies (1) the three case-mix

dimensions of the HHRG system, clinical, functional and utilization, from

which a beneficiary is assigned to one of the 80 HHRG categories and (2) it

identifies whether or not the elements of the code were computed or derived.

The HHRGs, represented by the HIPPS coding, will be the basis of payment

for each episode.

The HIPPS code (CMG Code) for IRF PPS identifies the clinical characteristics

of the beneficiary. The HIPPS rate/CMG code (AXXYY - DXXYY) must contain

five digits. The first position of the code is an A, B, C, or 'D'. The HIPPS code

beginning with an 'A' in front of the CMG is defined as without co-morbidity.

The 'B' in front of the CMG is defined as with co-morbidity for Tier 1. The 'C' is

defined as co-morbidity for Tier 2 and 'D' is defined as co-morbidity for Tier 3.

The 'XX' in the HIPPS rate code is the Rehabilitation Impairment Code (RIC).

The 'YY' is the sequential number system within the RIC.

Requirement: Required if present on bill

Data Element: Revenue Center Total Charge

Definition: The total charges (covered and non-covered) for all accommodations and

services (related to the revenue code) for a billing period before reduction for

the deductible and coinsurance amounts and before an adjustment for the

cost of services provided

Validation: N/A

Remarks: N/A

Requirement:

Required

Claims Universe File

Claims Universe Trailer Record (one record per file)

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 ‘3’

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Number of Claims 9(9) 9 17 Zeroes

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number

Validation: Must be a valid CMS contractor ID

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single

processing environment, the Contractor ID will reflect the roll-up Contractor

ID specified by CMS.

Data Element: Record Type

Definition: Code indicating type of record

Validation: N/A

Remarks: 3=Trailer Record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Universe file

Validation: Claim Universe files prior to 10/1/2007 did not contain this field.

Codes: B = Record Format as of 10/1/2007

C = Record Format as of 10/1/2017

Remarks: N/A

Requirement:

Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor included in the file.

Validation: Must be ‘A’ or ‘R’

Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.

Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type

should be ‘R’.

All others will be contractor type ‘A’.

Remarks: A = A/B MAC (A) only.

R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH).

Requirement: Required

Data Element: Number of Claims

Definition: Number of claim records on this file

Validation: Must be equal to the number of claim records on the file.

Remarks: Do not count header or trailer records

Requirement: Required

Claims Transaction File

Claims Transaction Header Record (one record per file)

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 ‘1’

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Transaction Date X(8) 9 16 Spaces

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number.

Validation: Must be a valid CMS contractor ID.

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single

processing environment, the Contractor ID will reflect the roll-up Contractor ID

specified by CMS.

Data Element: Record Type

Definition: Code indicating type of record

Validation: N/A

Remarks: 1 = Header record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Transaction file.

Validation: Claim Transaction files prior to 10/1/2007 did not contain this field.

Codes:

B = Record Format as of 10/1/2007

Remarks: N/A

Requirement:

Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor included in the file

Validation: Must be ‘A’ or ‘R’

Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.

Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should

be ‘R’.

All others will be contractor type ‘A’.

Remarks: A = A/B MAC (A) only

R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)

Requirement: Required

Data Element: Transaction Date

Definition: Date the Transaction file was created

Validation: Must be a valid date not equal to a Transaction date sent on any previous

claims Transaction file.

Remarks: Format is CCYYMMDD. May use shared system batch processing date.

Requirement: Required

Sampled Claims Transaction File

Sampled Claims Transaction File Detail Record

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 ‘2’

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Claim Control Number X(23) 9 31 Spaces

Beneficiary HICN X(12) 32 43 Spaces

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number

Validation: Must be a valid CMS contractor ID

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single

processing environment, the Contractor ID will reflect the roll-up Contractor

ID specified by CMS.

Data Element: Record Type

Definition: Code indicating type of record

Validation: N/A

Remarks: 2 = claim record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Universe file

Validation: Claim Universe files prior to 10/1/2007 did not contain this field.

Codes:

B = Record Format as of 10/1/2007

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor included in the file

Validation: Must be ‘A’ or ‘R’

Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.

Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should

be ‘R’.

All others will be contractor type ‘A’.

Data Element: Claim Control Number

Definition: Number assigned by the shared system to uniquely identify the claim

Validation: N/A

Remarks: Reflects the Claim Control Number selected from the Claim Universe file in the

sampling process.

Requirement: Required

Data Element: Beneficiary HICN

Definition: Beneficiary’s Health Insurance Claim Number

Validation: N/A

Remarks: Reflects the Beneficiary HICN on the claim record selected from the Claim

Universe file in the sampling process.

Requirement: Required

Claims Transaction File

Claims Transaction Trailer Record (one record per file)

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 ‘3’

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Number of Claims 9(9) 9 17 Zeroes

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number

Validation: Must be a valid CMS contractor ID

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single

processing environment, the Contractor ID will reflect the roll-up Contractor

ID specified by CMS.

Data Element: Record Type

Definition: Code indicating type of record

Validation: N/A

Remarks: 1 = Header record

Requirement:

Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Universe file

Validation: Claim Universe files prior to 10/1/2007 did not contain this field.

Codes:

B = Record Format as of 10/1/2007

Remarks: N/A

Requirement:

Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor included in the file

Validation: Must be ‘A’ or ‘R’.

Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.

Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should

be ‘R’.

All others will be contractor type ‘A’.

Remarks: A = A/B MAC (A) only

R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)

Requirement: Required

Data Element: Number of Claims

Definition: Number of claim records on this file

Validation: Must be equal to the number of claim records on the file

Remarks: Do not count header or trailer records

Requirement: Required

Claims Resolution File

Claims Resolution Header Record (one record per file)

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 ‘1’

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Resolution Date X(8) 9 16 Spaces

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number

Validation: Must be a valid CMS contractor ID

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single

processing environment, the Contractor ID will reflect the roll-up Contractor

ID specified by CMS

Data Element: Record Type

Definition: Code indicating type of record

Validation: N/A

Remarks: 1 = Header record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Resolution file

Validation: Claim Resolution files prior to 10/1/2007 did not contain this field.

Codes:

B = Record Format as of 10/1/2007

C = Record Format as of 1/1/2010

D = Record Format as of 10/1/2012

E = Record Format as of 7/1/2016

F = Record Format as of 10/1/2017

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor included in the file

Validation: Must be ‘A’ or ‘R’

Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.

Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should

be ‘R’.

All others will be contractor type ‘A’.

Remarks: A = A/B MAC (A) only

R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)

Requirement: Required

Data Element: Resolution Date

Definition: Date the Resolution Record was created.

Validation: Must be a valid date not equal to a Resolution date sent on any previous

claims Resolution file

Remarks: Format is CCYYMMDD. May use shared system batch processing date

Requirement: Required

Sampled Claims Resolution File

Sampled Claims Resolution Claim Detailed Record

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 “2”

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Record Number 9(1) 9 9 Zero

Mode of Entry Indicator X(1) 10 10 Space

Original Claim Control Number X(23) 11 33 Spaces

Internal Control Number X(23) 34 56 Spaces

Beneficiary HICN X(12) 57 68 Spaces

Beneficiary Last Name X(60) 69 128 Spaces

Beneficiary First Name X(35) 129 163 Spaces

Beneficiary Middle Initial X(1) 164 164 Spaces

Beneficiary Date of Birth X(8) 165 172 Spaces

Beneficiary Gender X(1) 173 173 Spaces

Billing Provider Number X(9) 174 182 Spaces

Attending Physician UPIN X(6) 183 188 Spaces

Claim Paid Amount S9(8)V99 189 198 Zeroes

Claim ANSI Reason Code 1 X(8) 199 206 Spaces

Claim ANSI Reason Code 2 X(8) 207 214 Spaces

Claim ANSI Reason Code 3 X(8) 215 222 Spaces

Claim ANSI Reason Code 4 X(8) 223 230 Spaces

Claim ANSI Reason Code 5 X(8) 231 238 Spaces

Claim ANSI Reason Code 6 X(8) 239 246 Spaces

Claim ANSI Reason Code 7 X(8) 247 254 Spaces

Statement covers From Date X(8) 255 262 Spaces

Statement covers Thru Date X(8) 263 270 Spaces

Claim Entry Date X(8) 271 278 Spaces

Claim Adjudicated Date X(8) 279 286 Spaces

Condition Code 1 X(3) 287 289 Spaces

Condition Code 2 X(3) 290 292 Spaces

Condition Code 3 X(3) 293 295 Spaces

Condition Code 4 X(3) 296 298 Spaces

Condition Code 5 X(3) 299 301 Spaces

Condition Code 6 X(3) 302 304 Spaces

Condition Code 7 X(3) 305 307 Spaces

Condition Code 8 X(3) 308 310 Spaces

Condition Code 9 X(3) 311 313 Spaces

Condition Code 10 X(3) 314 316 Spaces

Condition Code 11 X(3) 317 319 Spaces

Condition Code 12 X(3) 320 322 Spaces

Condition Code 13 X(3) 323 325 Spaces

Field Name Picture From Thru Initialization

Condition Code 14 X(3) 326 328 Spaces

Condition Code 15 X(3) 329 331 Spaces

Condition Code 16 X(3) 332 334 Spaces

Condition Code 17 X(3) 335 337 Spaces

Condition Code 18 X(3) 338 340 Spaces

Condition Code 19 X(3) 341 343 Spaces

Condition Code 20 X(3) 344 346 Spaces

Condition Code 21 X(3) 347 349 Spaces

Condition Code 22 X(3) 350 352 Spaces

Condition Code 23 X(3) 353 355 Spaces

Condition Code 24 X(3) 356 358 Spaces

Condition Code 25 X(3) 359 361 Spaces

Condition Code 26 X(3) 362 364 Spaces

Condition Code 27 X(3) 365 367 Spaces

Condition Code 28 X(3) 368 370 Spaces

Condition Code 29 X(3) 371 373 Spaces

Condition Code 30 X(3) 374 376 Spaces

Type of Bill X(3) 377 379 Spaces

Principal Diagnosis Code X(7) 380 386 Spaces

Other Diagnosis Code 1 X(7) 387 393 Spaces

Other Diagnosis Code 2 X(7) 394 400 Spaces

Other Diagnosis Code 3 X(7) 401 407 Spaces

Other Diagnosis Code 4 X(7) 408 414 Spaces

Other Diagnosis Code 5 X(7) 415 421 Spaces

Other Diagnosis Code 6 X(7) 422 428 Spaces

Other Diagnosis Code 7 X(7) 429 435 Spaces

Other Diagnosis Code 8 X(7) 436 442 Spaces

Other Diagnosis Code 9 X(7) 443 449 Spaces

Other Diagnosis Code 10 X(7) 450 456 Spaces

Other Diagnosis Code 11 X(7) 457 463 Spaces

Other Diagnosis Code 12 X(7) 464 470 Spaces

Other Diagnosis Code 13 X(7) 471 477 Spaces

Other Diagnosis Code 14 X(7) 478 484 Spaces

Other Diagnosis Code 15 X(7) 485 491 Spaces

Other Diagnosis Code 16 X(7) 492 498 Spaces

Other Diagnosis Code 17 X(7) 499 505 Spaces

Other Diagnosis Code 18 X(7) 506 512 Spaces

Other Diagnosis Code 19 X(7) 513 519 Spaces

Other Diagnosis Code 20 X(7) 520 526 Spaces

Other Diagnosis Code 21 X(7) 527 533 Spaces

Other Diagnosis Code 22 X(7) 534 540 Spaces

Other Diagnosis Code 23 X(7) 541 547 Spaces

Other Diagnosis Code 24 X(7) 548 554 Spaces

Principal Diagnosis Code Version

Indicator Code

X(1)

555

Spaces

Other Diagnosis Code 1 Version

Indicator Code

X(1)

556

Spaces

Other Diagnosis Code 2 Version

Indicator Code

X(1)

557

Spaces

Field Name Picture From Thru Initialization

Other Diagnosis Code 3 Version

Indicator Code

X(1)

558

Spaces

Other Diagnosis Code 4 Version

Indicator Code

X(1)

559

Spaces

Other Diagnosis Code 5 Version

Indicator Code

X(1)

560

Spaces

Other Diagnosis Code 6 Version

Indicator Code

X(1)

561

Spaces

Other Diagnosis Code 7 Version

Indicator Code

X(1)

562

Spaces

Other Diagnosis Code 8 Version

Indicator Code

X(1)

563

Spaces

Other Diagnosis Code 9 Version

Indicator Code

X(1)

564

Spaces

Other Diagnosis Code 10 Version

Indicator Code

X(1)

565

Spaces

Other Diagnosis Code 11 Version

Indicator Code

X(1)

566

Spaces

Other Diagnosis Code 12 Version

Indicator Code

X(1)

567

Spaces

Other Diagnosis Code 13 Version

Indicator Code

X(1)

568

Spaces

Other Diagnosis Code 14 Version

Indicator Code

X(1)

569

Spaces

Other Diagnosis Code 15 Version

Indicator Code

X(1)

570

Spaces

Other Diagnosis Code 16 Version

Indicator Code

X(1)

571

Spaces

Other Diagnosis Code 17 Version

Indicator Code

X(1)

572

Spaces

Other Diagnosis Code 18 Version

Indicator Code

X(1)

573

Spaces

Other Diagnosis Code 19 Version

Indicator Code

X(1)

574

Spaces

Other Diagnosis Code 20 Version

Indicator Code

X(1)

575

Spaces

Other Diagnosis Code 21 Version

Indicator Code

X(1)

576

Spaces

Other Diagnosis Code 22 Version

Indicator Code

X(1)

577

Spaces

Other Diagnosis Code 23 Version

Indicator Code

X(1)

578

Spaces

Other Diagnosis Code 24 Version

Indicator Code

X(1)

579

Spaces

Principal Procedure X(7) 580 586 Spaces

Principal Procedure Date X(8) 587 594 Spaces

Other Procedure 1 X(7) 595 601 Spaces

Other Procedure 1 Date X(8) 602 609 Spaces

Other Procedure 2 X(7) 610 616 Spaces

Other Procedure 2 Date X(8) 617 624 Spaces

Other Procedure 3 X(7) 625 631 Spaces

Field Name Picture From Thru Initialization

Other Procedure 3 Date X(8) 632 639 Spaces

Other Procedure 4 X(7) 640 646 Spaces

Other Procedure 4 Date X(8) 647 654 Spaces

Other Procedure 5 X(7) 655 661 Spaces

Other Procedure 5 Date X(8) 662 669 Spaces

Other Procedure 6 X(7) 670 676 Spaces

Other Procedure 6 Date X(8) 677 684 Spaces

Other Procedure 7 X(7) 685 691 Spaces

Other Procedure 7 Date X(8) 692 699 Spaces

Other Procedure 8 X(7) 700 706 Spaces

Other Procedure 8 Date X(8) 707 714 Spaces

Other Procedure 9 X(7) 715 721 Spaces

Other Procedure 9 Date X(8) 722 729 Spaces

Other Procedure 10 X(7) 730 736 Spaces

Other Procedure 10 Date X(8) 737 744 Spaces

Other Procedure 11 X(7) 745 751 Spaces

Other Procedure 11 Date X(8) 752 759 Spaces

Other Procedure 12 X(7) 760 766 Spaces

Other Procedure 12 Date X(8) 767 774 Spaces

Other Procedure 13 X(7) 775 781 Spaces

Other Procedure 13 Date X(8) 782 789 Spaces

Other Procedure 14 X(7) 790 796 Spaces

Other Procedure 14 Date X(8) 797 804 Spaces

Other Procedure 15 X(7) 805 811 Spaces

Other Procedure 15 Date X(8) 812 819 Spaces

Other Procedure 16 X(7) 820 826 Spaces

Other Procedure 16 Date X(8) 827 834 Spaces

Other Procedure 17 X(7) 835 841 Spaces

Other Procedure 17 Date X(8) 842 849 Spaces

Other Procedure 18 X(7) 850 856 Spaces

Other Procedure 18 Date X(8) 857 864 Spaces

Other Procedure 19 X(7) 865 871 Spaces

Other Procedure 19 Date X(8) 872 879 Spaces

Other Procedure 20 X(7) 880 886 Spaces

Other Procedure 20 Date X(8) 887 894 Spaces

Other Procedure 21 X(7) 895 901 Spaces

Other Procedure 21 Date X(8) 902 909 Spaces

Other Procedure 22 X(7) 910 916 Spaces

Other Procedure 22 Date X(8) 917 924 Spaces

Other Procedure 23 X(7) 925 931 Spaces

Other Procedure 23 Date X(8) 932 939 Spaces

Other Procedure 24 X(7) 940 946 Spaces

Other Procedure 24 Date X(8) 947 954 Spaces

Principal Procedure Version

Indicator Code

X(1)

955

Spaces

Other Procedure 1 Version Indicator

Code

X(1)

956

Spaces

Other Procedure 2 Version Indicator

Code

X(1)

957

Spaces

Field Name Picture From Thru Initialization

Other Procedure 3 Version Indicator

Code

X(1)

958

Spaces

Other Procedure 4 Version Indicator

Code

X(1)

959

Spaces

Other Procedure 5 Version Indicator

Code

X(1)

960

Spaces

Other Procedure 6 Version Indicator

Code

X(1)

961

Spaces

Other Procedure 7 Version Indicator

Code

X(1)

962

Spaces

Other Procedure 8 Version Indicator

Code

X(1)

963

Spaces

Other Procedure 9 Version Indicator

Code

X(1)

964

Spaces

Other Procedure 10 Version

Indicator Code

X(1)

965

Spaces

Other Procedure 11 Version

Indicator Code

X(1)

966

Spaces

Other Procedure 12 Version

Indicator Code

X(1)

967

Spaces

Other Procedure 13 Version

Indicator Code

X(1)

968

Spaces

Other Procedure 14 Version

Indicator Code

X(1)

969

Spaces

Other Procedure 15 Version

Indicator Code

X(1)

970

Spaces

Other Procedure 16 Version

Indicator Code

X(1)

971

Spaces

Other Procedure 17 Version

Indicator Code

X(1)

972

Spaces

Other Procedure 18 Version

Indicator Code

X(1)

973

Spaces

Other Procedure 19 Version

Indicator Code

X(1)

974

Spaces

Other Procedure 20 Version

Indicator Code

X(1)

975

Spaces

Other Procedure 21 Version

Indicator Code

X(1)

976

Spaces

Other Procedure 22 Version

Indicator Code

X(1)

977

Spaces

Other Procedure 23 Version

Indicator Code

X(1)

978

Spaces

Other Procedure 24 Version

Indicator Code

X(1)

979

Spaces

Claim Demonstration Identification

Number

9(2)

980

981

Zeroes

PPS Indicator X(1) 982 982 Spaces

Action Code X(1) 983 983 Spaces

Patient Status X(2) 984 985 Spaces

Billing Provider NPI X(10) 986 995 Spaces

Field Name Picture From Thru Initialization

Claim Provider Taxonomy Code X(25) 996 1020 Spaces

Medical Record Number X(17) 1021 1037 Spaces

Patient Control Number X(20) 1038 1057 Spaces

Attending Physician NPI X(10) 1058 1067 Spaces

Attending Physician Last Name X(16) 1068 1083 Spaces

Operating Physician NPI X(10) 1084 1093 Spaces

Operating Physician Last Name X(16) 1094 1109 Spaces

Claim Rendering Physician NPI X(10) 1110 1119 Spaces

Claim Rendering Physician Last

Name

X(16)

1120

1135

Spaces

Date of Admission X(8) 1136 1143 Spaces

Type of Admission X(1) 1144 1144 Spaces

Source of Admission X(1) 1145 1145 Spaces

DRG X(3) 1146 1148 Spaces

Occurrence Code 1 X(2) 1149 1150 Spaces

Occurrence Code 1 Date X(8) 1151 1158 Spaces

Occurrence Code 2 X(2) 1159 1160 Spaces

Occurrence Code 2 Date X(8) 1161 1168 Spaces

Occurrence Code 3 X(2) 1169 1170 Spaces

Occurrence Code 3 Date X(8) 1171 1178 Spaces

Occurrence Code 4 X(2) 1179 1180 Spaces

Occurrence Code 4 Date X(8) 1181 1188 Spaces

Occurrence Code 5 X(2) 1189 1190 Spaces

Occurrence Code 5 Date X(8) 1191 1198 Spaces

Occurrence Code 6 X(2) 1199 1200 Spaces

Occurrence Code 6 Date X(8) 1201 1208 Spaces

Occurrence Code 7 X(2) 1209 1210 Spaces

Occurrence Code 7 Date X(8) 1211 1218 Spaces

Occurrence Code 8 X(2) 1219 1220 Spaces

Occurrence Code 8 Date X(8) 1221 1228 Spaces

Occurrence Code 9 X(2) 1231 1230 Spaces

Occurrence Code 9 Date X(8) 1231 1238 Spaces

Occurrence Code 10 X(2) 1239 1240 Spaces

Occurrence Code 10 Date X(8) 1241 1248 Spaces

Occurrence Code 11 X(2) 1249 1250 Spaces

Occurrence Code 11 Date X(8) 1251 1258 Spaces

Occurrence Code 12 X(2) 1259 1260 Spaces

Occurrence Code 12 Date X(8) 1261 1268 Spaces

Occurrence Code 13 X(2) 1269 1270 Spaces

Occurrence Code 13 Date X(8) 1271 1278 Spaces

Occurrence Code 14 X(2) 1279 1280 Spaces

Occurrence Code 14 Date X(8) 1281 1288 Spaces

Occurrence Code 15 X(2) 1289 1290 Spaces

Occurrence Code 15 Date X(8) 1291 1298 Spaces

Occurrence Code 16 X(2) 1299 1300 Spaces

Occurrence Code 16 Date X(8) 1301 1308 Spaces

Occurrence Code 17 X(2) 1309 1310 Spaces

Occurrence Code 17 Date X(8) 1311 1318 Spaces

Occurrence Code 18 X(2) 1319 1320 Spaces

Field Name Picture From Thru Initialization

Occurrence Code 18 Date X(8) 1321 1328 Spaces

Occurrence Code 19 X(2) 1329 1330 Spaces

Occurrence Code 19 Date X(8) 1331 1338 Spaces

Occurrence Code 20 X(2) 1339 1340 Spaces

Occurrence Code 20 Date X(8) 1341 1348 Spaces

Occurrence Code 21 X(2) 1349 1350 Spaces

Occurrence Code 21 Date X(8) 1351 1358 Spaces

Occurrence Code 22 X(2) 1359 1360 Spaces

Occurrence Code 22 Date X(8) 1361 1368 Spaces

Occurrence Code 23 X(2) 1369 1370 Spaces

Occurrence Code 23 Date X(8) 1371 1378 Spaces

Occurrence Code 24 X(2) 1379 1380 Spaces

Occurrence Code 24 Date X(8) 1381 1388 Spaces

Occurrence Code 25 X(2) 1389 1390 Spaces

Occurrence Code 25 Date X(8) 1391 1398 Spaces

Occurrence Code 26 X(2) 1399 1400 Spaces

Occurrence Code 26 Date X(8) 1401 1408 Spaces

Occurrence Code 27 X(2) 1409 1410 Spaces

Occurrence Code 27 Date X(8) 1411 1418 Spaces

Occurrence Code 28 X(2) 1419 1420 Spaces

Occurrence Code 28 Date X(8) 1421 1428 Spaces

Occurrence Code 29 X(2) 1429 1430 Spaces

Occurrence Code 29 Date X(8) 1431 1438 Spaces

Occurrence Code 30 X(2) 1439 1440 Spaces

Occurrence Code 30 Date X(8) 1441 1448 Spaces

Value Code 1 X(2) 1449 1450 Spaces

Value Amount 1 S9(8)V99 1451 1460 Zeroes

Value Code 2 X(2) 1461 1462 Spaces

Value Amount 2 S9(8)V99 1463 1472 Zeroes

Value Code 3 X(2) 1473 1474 Spaces

Value Amount 3 S9(8)V99 1475 1484 Zeroes

Value Code 4 X(2) 1485 1486 Spaces

Value Amount 4 S9(8)V99 1487 1496 Zeroes

Value Code 5 X(2) 1497 1498 Spaces

Value Amount 5 S9(8)V99 1499 1508 Zeroes

Value Code 6 X(2) 1509 1510 Spaces

Value Amount 6 S9(8)V99 1511 1520 Zeroes

Value Code 7 X(2) 1521 1522 Spaces

Value Amount 7 S9(8)V99 1523 1532 Zeroes

Value Code 8 X(2) 1533 1534 Spaces

Value Amount 8 S9(8)V99 1535 1544 Zeroes

Value Code 9 X(2) 1545 1546 Spaces

Value Amount 9 S9(8)V99 1547 1556 Zeroes

Value Code 10 X(2) 1557 1558 Spaces

Value Amount 10 S9(8)V99 1559 1568 Zeroes

Value Code 11 X(2) 1569 1570 Spaces

Value Amount 11 S9(8)V99 1571 1580 Zeroes

Value Code 12 X(2) 1581 1582 Spaces

Value Amount 12 S9(8)V99 1583 1592 Zeroes

Value Code 13 X(2) 1593 1594 Spaces

Field Name Picture From Thru Initialization

Value Amount 13 S9(8)V99 1595 1604 Zeroes

Value Code 14 X(2) 1605 1606 Spaces

Value Amount 14 S9(8)V99 1607 1616 Zeroes

Value Code 15 X(2) 1617 1618 Spaces

Value Amount 15 S9(8)V99 1619 1628 Zeroes

Value Code 16 X(2) 1629 1630 Spaces

Value Amount 16 S9(8)V99 1631 1640 Zeroes

Value Code 17 X(2) 1641 1642 Spaces

Value Amount 17 S9(8)V99 1643 1652 Zeroes

Value Code 18 X(2) 1653 1654 Spaces

Value Amount 18 S9(8)V99 1655 1664 Zeroes

Value Code 19 X(2) 1665 1666 Spaces

Value Amount 19 S9(8)V99 1667 1676 Zeroes

Value Code 20 X(2) 1677 1678 Spaces

Value Amount 20 S9(8)V99 1679 1688 Zeroes

Value Code 21 X(2) 1689 1690 Spaces

Value Amount 21 S9(8)V99 1691 1700 Zeroes

Value Code 22 X(2) 1701 1702 Spaces

Value Amount 22 S9(8)V99 1703 1712 Zeroes

Value Code 23 X(2) 1713 1714 Spaces

Value Amount 23 S9(8)V99 1715 1724 Zeroes

Value Code 24 X(2) 1725 1726 Spaces

Value Amount 24 S9(8)V99 1727 1736 Zeroes

Value Code 25 X(2) 1737 1738 Spaces

Value Amount 25 S9(8)V99 1739 1748 Zeroes

Value Code 26 X(2) 1749 1750 Spaces

Value Amount 26 S9(8)V99 1751 1760 Zeroes

Value Code 27 X(2) 1761 1762 Spaces

Value Amount 27 S9(8)V99 1763 1772 Zeroes

Value Code 28 X(2) 1773 1774 Spaces

Value Amount 28 S9(8)V99 1775 1784 Zeroes

Value Code 29 X(2) 1785 1786 Spaces

Value Amount 29 S9(8)V99 1787 1796 Zeroes

Value Code 30 X(2) 1797 1798 Spaces

Value Amount 30 S9(8)V99 1799 1808 Zeroes

Value Code 31 X(2) 1809 1810 Spaces

Value Amount 31 S9(8)V99 1811 1820 Zeroes

Value Code 32 X(2) 1821 1822 Spaces

Value Amount 32 S9(8)V99 1823 1832 Zeroes

Value Code 33 X(2) 1833 1834 Spaces

Value Amount 33 S9(8)V99 1835 1844 Zeroes

Value Code 34 X(2) 1845 1846 Spaces

Value Amount 34 S9(8)V99 1847 1856 Zeroes

Value Code 35 X(2) 1857 1858 Spaces

Value Amount 35 S9(8)V99 1859 1868 Zeroes

Claim Final Allowed Amount S9(8)V99 1869 1878 Zeroes

Claim Deductible Amount S9(8)V99 1879 1888 Zeroes

Claim State X(2) 1889 1890 Spaces

Claim Zip Code X(9) 1891 1899 Spaces

Field Name Picture From Thru Initialization

Beneficiary State X(2) 1900 1901 Spaces

Beneficiary Zip Code X(9) 1902 1910 Spaces

Claim PWK X(60) 1911 1970 Spaces

Patient Reason for Visit 1 X(7) 1971 1977 Spaces

Patient Reason for Visit 2 X(7) 1978 1984 Spaces

Patient Reason for Visit 3 X(7) 1985 1991 Spaces

Patient Reason for Visit 1 Version

Indicator Code

X(1)

1992 1992

Spaces

Patient Reason for Visit 2 Version

Indicator Code

X(1)

1993 1993

Spaces

Patient Reason for Visit 3 Version

Indicator Code

X(1)

1994 1994

Spaces

Present on Admission/External

Cause of Injury Indicator

X(37)

1995 2031

Spaces

External Cause of Injury 1 X(7) 2032 2038 Spaces

External Cause of Injury 2 X(7) 2039 2045 Spaces

External Cause of Injury 3 X(7) 2046 2052 Spaces

External Cause of Injury 4 X(7) 2053 2059 Spaces

External Cause of Injury 5 X(7) 2060 2066 Spaces

External Cause of Injury 6 X(7) 2067 2073 Spaces

External Cause of Injury 7 X(7) 2074 2080 Spaces

External Cause of Injury 8 X(7) 2081 2087 Spaces

External Cause of Injury 9 X(7) 2088 2094 Spaces

External Cause of Injury 10 X(7) 2095 2101 Spaces

External Cause of Injury 11 X(7) 2102 2108 Spaces

External Cause of Injury 12 X(7) 2109 2115 Spaces

External Cause of Injury 1 Version

Indicator Code

X(1)

2116 2116

Spaces

External Cause of Injury 2 Version

Indicator Code

X(1)

2117 2117

Spaces

External Cause of Injury 3 Version

Indicator Code

X(1)

2118 2118

Spaces

External Cause of Injury 4 Version

Indicator Code

X(1)

2119 2119

Spaces

External Cause of Injury 5 Version

Indicator Code

X(1)

2120 2120

Spaces

External Cause of Injury 6 Version

Indicator Code

X(1)

2121 2121

Spaces

External Cause of Injury 7 Version

Indicator Code

X(1)

2122 2122

Spaces

External Cause of Injury 8 Version

Indicator Code

X(1)

2123 2123

Spaces

External Cause of Injury 9 Version

Indicator Code

X(1)

2124 2124

Spaces

External Cause of Injury 10 Version

Indicator Code

X(1)

2125 2125

Spaces

External Cause of Injury 11 Version

Indicator Code

X(1)

2126 2126

Spaces

External Cause of Injury 12 Version

Indicator Code

X(1)

2127 2127

Spaces

Field Name Picture From Thru Initialization

Service Facility Zip Code X(9) 2128 2136 Spaces

RAC adjustment indicator X(1) 2137 2137 Spaces

Split/Adjustment Indicator 9(2) 2138 2139 Spaces

Referring Physician NPI X(10) 2140 2149 Spaces

Referring Physician Last Name X(16) 2150 2165 Spaces

Referring Physician Specialty X(2) 2166 2167 Spaces

Claim Rendering Physician X(2) 2168 2169 Spaces

Overpay Indicator X(1) 2170 2170 Spaces

Overpay Code X(3) 2171 2173 Spaces

Claim Demonstration Identification

Number 2

X(2) 2174 2175 Spaces

Claim Demonstration Identification

Number 3

X(2) 2176 2177 Spaces

Claim Demonstration Identification

Number 4

X(2) 2178 2179 Spaces

Beneficiary MBI X(11) 2180 2190 Spaces

MBI/HICN Indicator X(1) 2191 2191 Spaces

Filler X(10) 2192 2201 Spaces

Total Line Item Count 9(3) 2202 2204 Zeroes

Record Line Item Count 9(3) 2205 2207 Zeroes

Sampled Claims Resolution File

Sampled Claims Resolution Claim Line Item Group Record

*The following group of fields occurs from 1 to 450 times for the

claim (depending on Total Line Item Count) and 1 to 75 times

for the Record (depending on Record Line Item Count)

*From and Thru values relate to the 1st line item

Field Name Picture From Thru Initialization

Revenue center code X(4) 2208 2211 Spaces

SNF-RUG-III code X(3) 2212 2214 Spaces

APC adjustment code X(5) 2215 2219 Spaces

HCPCS Procedure Code X(5) 2220 2224 Spaces

HCPCS Modifier 1 X(2) 2225 2226 Spaces

HCPCS Modifier 2 X(2) 2227 2228 Spaces

HCPCS Modifier 3 X(2) 2229 2230 Spaces

HCPCS Modifier 4 X(2) 2231 2232 Spaces

HCPCS Modifier 5 X(2) 2233 2234 Spaces

Line Item Date X(8) 2235 2242 Spaces

Line Submitted Charge S9(8)V99 2243 2252 Zeroes

Line Medicare Initial Allowed S9(8)V99 2253 2262 Zeroes

ANSI Reason Code 1 X(8) 2263 2270 Spaces

ANSI Reason Code 2 X(8) 2271 2278 Spaces

ANSI Reason Code 3 X(8) 2279 2286 Spaces

ANSI Reason Code 4 X(8) 2287 2294 Spaces

ANSI Reason Code 5 X(8) 2295 2302 Spaces

ANSI Reason Code 6 X(8) 2303 2310 Spaces

ANSI Reason Code 7 X(8) 2311 2318 Spaces

ANSI Reason Code 8 X(8) 2319 2326 Spaces

ANSI Reason Code 9 X(8) 2327 2334 Spaces

Field Name Picture From Thru Initialization

ANSI Reason Code 10 X(8) 2335 2342 Spaces

ANSI Reason Code 11 X(8) 2343 2350 Spaces

ANSI Reason Code 12 X(8) 2351 2358 Spaces

ANSI Reason Code 13 X(8) 2359 2366 Spaces

ANSI Reason Code 14 X(8) 2367 2374 Spaces

Manual Medical Review Indicator X(1) 2375 2375 Spaces

Resolution Code X(5) 2376 2380 Spaces

Field Name Picture From Thru Initialization

Line Final Allowed Charge S9(8)V99 2381 2390 Zeroes

Line Cash Deductible S9(8)V99 2391 2400 Zeroes

Special Action Code/Override Code X(1) 2401 2401 Zeroes

Units S9(7)v999 2402 2411 Zeroes

Rendering Physician NPI X(10) 2412 2421 Spaces

Rendering Physician Last Name X(25) 2422 2446 Spaces

National Drug Code (NDC) field X(11) 2447 2457 Spaces

National Drug Code (NDC) S9(7)v999 2458 2467 Spaces

National Drug Code (NDC)

Quantity Qualifier

X(2)

2468

2469

Spaces

Line PWK X(60) 2470 2529 Spaces

Line Rendering Physician specialty X(2) 2530 2531 Spaces

Prior Authorization Program X(4) 2532 2535 Spaces

Unique Tracking Number (UTN) X(14) 2536 2549 Spaces

Prior Authorization Affirmed X(1) 2550 2550 Spaces

Filler X(4) 2551 2554 Spaces

DATA ELEMENT DETAIL

Claim (Header) Fields

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number.

Validation: Must be a valid CMS contractor ID.

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single

processing environment, the Contractor ID will reflect the roll-up Contractor

ID specified by CMS.

Data Element: Record Type

Definition: Code indicating type of record

Validation: N/A

Remarks: 2 = Claim record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Resolution file

Validation: Claim Resolution files prior to 10/1/2007 did not contain this field.

Codes:

B = Record Format as of 10/1/2007

C = Record Format as of 1/1/2010

D = Record Format as of 10/1/2012

E = Record Format as of 7/1/2016

F = Record Format as of 10/1/2017

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor included in the file

Validation: Must be ‘A’ or ‘R’

Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.

Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should

be ‘R’.

All others will be contractor type ‘A’.

Data Element: Record Number

Definition: The sequence number of the record. A claim may have up to six records.

Validation: Must be between 1 and 6

Remarks: None Requirement: Required

Data Element: Mode of Entry Indicator

Definition: Code that indicates if the claim is paper, EMC, or unknown

Validation: Must be 'E’, 'P’, or 'U'

Remarks: E = EMC

P = Paper

U= Unknown

Use the same criteria to determine EMC, paper, or unknown as that used for

workload reporting

Requirement: Required

Data Element: Original Claim Control Number

Definition: The Claim Control Number the shared system assigned to the claim in the

Universe file. This number should be the same as the claim control number

for the claim in the Sample Claims Transactions file, and the claim control

number for the claim on the Universe file. If the shared system had to use a

crosswalk to pull the claim because the MAC or shared system changed the

claim control number during processing, enter the number the shared system

used to look up the number needed to pull all records associated with the

sample claim.

Validation: For all records in the resolution file, the Original Claim Control must match the

Claim Control Number identified in the Sampled Claims Transaction File.

Remarks: N/A

Requirement: Required

Data Element: Internal Control Number

Definition: Number currently assigned by the Shared System to uniquely identify the claim.

Validation: N/A

Remarks: Use the Original Claim Control Number if no adjustment has been made to the

claim. This number may be different from the Original Claim Control Number

if the shared system has assigned a new Claims Control Number to an

adjustment to the claim requested.

Requirement: Required

Data Element: Beneficiary HICN

Definition: Beneficiary’s Health Insurance Claim Number

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Beneficiary Last Name

Definition: Last Name (Surname) of the beneficiary

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Beneficiary First Name

Definition: First (Given) Name of the beneficiary

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Beneficiary Middle Initial

Definition: First letter from Beneficiary Middle Name

Validation: N/A

Remarks

: N/A

Requirement: Required

Data Element: Beneficiary Date of Birth

Definition: Birth date of the beneficiary

Validation: Must be a valid date

Remarks: MMDDCCYY on which the beneficiary was born

Requirement: Required

Data Element: Beneficiary Gender

Definition: Gender of the beneficiary

Validation: 'M' = Male, 'F' = Female, or 'U' = Unknown

Remarks: N/A

Requirement: Required

Data Element: Billing Provider Number

Definition: First nine characters of number used to identify the billing/pricing provider or

supplier.

Validation: Must be present

If the same billing/pricing provider number does not apply to all lines on the

claim, enter the Billing provider number that applies to the first line of the claim.

Remarks: N/A

Requirement: Required for all claims

Data Element: Attending Physician UPIN

Definition: The UPIN submitted on the claim used to identify the physician that is

responsible for coordinating the care of the patient while in the facility.

Validation: N/A

Remarks: Left justify

Requirement: Required when available on claim record.

Data Element: Claim Paid Amount

Definition: Amount of payment made from the Medicare trust fund for the services

covered by the claim record. Generally, the amount is calculated by the A/B

MAC (A) or A/B MAC (B) and represents what CMS paid to the institutional

provider, physician, or supplier, i.e. The Claim Paid Amount is the net amount

paid after co-insurance and deductibles are applied.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Claim ANSI Reason Code 1-7

Definition: Codes showing the reason for any adjustments to this claim, such as denials

or reductions of payment from the amount billed.

Validation: Must be valid American National Standards Institute (ANSI) Ambulatory

Surgical Center (ASC) claim adjustment code and applicable group code.

Remarks: Format is GGRRRRRR where: GG is the group code and RRRRRR is the

adjustment reason code.

Requirement: Report all ANSI reason codes on the bill

Data Element: Statement Covers from Date

Definition: The beginning date of the statement

Validation: Must be a valid date

Remarks: Format must be CCYYMMDD

Requirement: Required

Data Element: Statement Covers thru Date

Definition: The ending date of the statement

Validation: Must be a valid date

Remarks: Format must be CCYYMMDD

Requirement: Required

Data Element: Claim Entry Date

Definition: Date claim entered the shared claim processing system, the receipt date

Validation: Must be a valid date

Remarks: Format must be CCYYMMDD

Requirement: Required

Data Element: Claim Adjudicated Date

Definition: Date claim completed adjudication, i.e., process date

Validation: Must be a valid date

Remarks: Format must be CCYYMMDD Requirement: Required

Data Element: Condition Code 1 -30

Definition: The code that indicates a condition relating to an institutional claim that may

affect payer processing

Validation: Must be a valid code as listed in Pub 100-4, Medicare Claims Processing

Manual, Chapter 25, Completing and Processing CMS-1450 Data Set.

Remarks: This field is left justified and blank filled.

Requirement: Required if there is a condition code for the bill.

Data Element: Type of Bill

Definition: A code indicating the specific type of bill (hospital, inpatient, SNF, outpatient,

adjustments, voids, etc.). This three-digit alphanumeric code gives three

specific pieces of information. The first digit identifies the type of facility. The

second classifies the type of care. The third indicates the sequence of this bill

in this particular episode of care. It is referred to as “frequency” code.

Validation: Must be a valid code as listed in Pub 100-4, Medicare Claims Processing

Manual, Chapter 25, Completing and Processing CMS-1450 Data Set

Remarks: N/A

Requirement: Required

Data Element: Principal Diagnosis

Definition: The current version of ICD--CM diagnosis code identifying the diagnosis,

condition, problem or other reason for the admission/encounter/visit shown in

the medical record to be chiefly responsible for the services provided.

Validation: Must be a valid ICD--CM diagnosis code

• CMS accepts only CMS approved ICD--CM diagnostic and

procedural codes. The CMS approves only changes issued by the Federal

ICD-- CM Coordination and Maintenance Committee.

• Diagnosis codes must be full ICD--CM diagnoses codes, including

the full number of digits (five for ICD-9-CM, seven for ICD-10-CM) where

applicable.

Remarks: The principal diagnosis is the condition established after study to be chiefly

responsible for this admission. Even though another diagnosis may be more

severe than the principal diagnosis, the principal diagnosis, as defined above,

is entered.

Requirement: Required

Data Element: Principal Diagnosis Version Indicator Code

Definition: The diagnosis version code identifying the version of ICD diagnosis code

submitted.

Validation:

• Version ICD9 use Version Code ‘9’

• Version ICD10 use Version Code ‘0’

Remarks: With the exception of claims submitted by ambulance suppliers (specialty).

Requirement: Principal Diagnosis Version Code 1 is required for ALL claims.

Data Element: Other Diagnosis Code 1-24

Definition: The ICD-CM diagnosis code identifying the diagnosis, condition, problem or

other

reason for the admission/encounter/visit shown in the medical record to be

present during treatment.

Validation: Must be a valid ICD--CM diagnosis code

• CMS accepts only CMS approved ICD-CM diagnostic and procedural codes.

The CMS approves only changes issued by the Federal ICD-CM Coordination

and Maintenance Committee.

• Diagnosis codes must be full ICD-CM diagnoses codes, including The full

number of digits (five for ICD-9-CM, seven for ICD-10-CM) where applicable.

Remarks: Report the full ICD-CM codes for up to 24 additional conditions if they co-existed at the time of admission or developed subsequently, and which had

an effect upon the treatment or the length of stay.

Requirement: Required if available on the claim record.

Data Element: Other Diagnosis Version Indicator Code 1-24

Definition: The ICD-CM diagnosis version code identifying the version of diagnosis code

submitted.

Validation:

• Version ICD9 use Version Code ‘9’

• Version ICD10 use Version Code ‘0

Remarks: N/A

Requirement: Principal Diagnosis Version Code 1 is required for ALL claims. Other

Diagnosis version codes 1-24 should be submitted to correspond to claim

level diagnosis codes 1-24.

Data Element: Principal Procedure and Date

Definition: The ICD--CM code that indicates the principal procedure performed during the

period covered by the institutional claim. And the Date on which it was

performed.

Validation: Must be a valid ICD--CM procedure code

• CMS accepts only CMS approved ICD--CM diagnostic and

procedural codes. The CMS approves only changes issued by the Federal

ICD--CM Coordination and Maintenance Committee.

• The procedure code shown must be the full ICD--CM, Volume 3,

procedure code, including the full number of digits (five for ICD-9-CM, seven

for ICD-10-CM).

Remarks: The principal procedure is the procedure performed for definitive treatment

rather than for diagnostic or exploratory purposes, or which was necessary to

take care of a complication. It is also the procedure most closely related to

the principal diagnosis.

• The date applicable to the principal procedure is shown numerically as

CCYYMMDD in the “date” portion.

Requirement: Required for inpatient claims.

Data Element: Principal Procedure Version Indicator Code

Definition: The version code identifying the version of ICD procedure code submitted.

Validation:

• Version ICD9 use Version Code ‘9’

• Version ICD10 use Version Code ‘0’

Remarks: N/A

Requirement: Principal Procedure Code Version Code is required for ALL claims containing a

Principal Procedure.

Data Element: Other Procedure and Date 1-24

Definition: The ICD-CM code identifying the procedure, other than the principal

procedure, performed during the billing period covered by this bill.

Validation: Must be a valid ICD-CM procedure code

• CMS accepts only CMS approved ICD-CM diagnostic and

procedural codes. The CMS approves only changes issued by the Federal ICD-CM Coordination and Maintenance Committee.

• The procedure code shown must be the full ICD-CM, Volume 3, procedure

code, including the full number of digits (five for ICD-9-CM, seven for ICD-10-

CM).

Remarks: The date applicable to the procedure is shown numerically as CCYYMMDD in

the “date” portion.

Requirement: Required if on claim record.

Data Element: Other Procedure Code Version Indicator Code 1-24

Definition: The ICD-CM diagnosis version code identifying the version of procedure code

submitted

Validation:

• Version ICD9 use Version Code ‘9’

• Version ICD10 use Version Code ‘0’

Remarks: N/A

Requirement: Principal Procedure Version Code is required for ALL claims. Other

Procedure version codes 1-24 should be submitted to correspond to other

procedure code 1-24.

Data Element: Claim Demonstration Identification Number

Definition: The number assigned to identify a demonstration project.

Validation: Must be numeric or zeroes

Remarks: This field contains the value from the first populated

demonstration field.

Requirement: Required for all claims involved in a

demonstration project

Data Element: PPS Indicator

Definition: The code indicating whether (1) the claim is Prospective Payment System

(PPS) or not PPS.

Validation: 0 = Not PPS

1 = PPS

Remarks: N/A

Requirement: Required

Data Element: Action Code

Definition: Indicator identifying the type of action requested by the intermediary to be

taken on an institutional claim.

Validation: Must be a valid action code.

1 = Original debit action (includes non-adjustment RTI correction items)

– it will always be a 1 in regular bills.

2 = Cancel by credit adjustment – used only in credit/debit pairs (under

HHPPS, updates the RAP).

3 = Secondary debit adjustment - used only in credit/debit pairs (under

HHPPS, would be the final claim or an adjustment on a LUPA).

4 = Cancel only adjustment (under HHPPS, RAP/final claim/LUPA).

5 = Force action code 3.

6 = Force action code 2.

8 = Benefits refused (for inpatient bills, an 'R' nonpayment code must also be

present.

9 = Payment requested (used on bills that replace previously-submitted

benefits- refused bills, action code 8. In such cases a debit/credit pair is

not required. For inpatient bills, a 'P' should be entered in the

nonpayment code.)

Remarks: N/A

Requirement: Required

Data Element: Patient Status

Definition: This code indicates the patient’s status as of the “Through”

date of the billing period.

Validation: Must be a valid code as listed in Pub 100-4, Medicare Claims

Processing Manual, Chapter 25, Completing and Processing CMS-1450 Data

Set.

Remarks: N/A

Requirement: Required

Data Element: Billing Provider NPI

Definition: NPI assigned to the Billing Provider.

Validation: N/A

Remarks: N/A.

Requirement: Required for providers using HIPAA standard transactions

Data Element: Claim Provider Taxonomy Code

Definition: The non-medical data code set used to classify health care providers

according to provider type or practitioner specialty in an electronic

environment, specifically within the American National Standards Institute

Accredited Standards Committee health care transaction.

Validation: Must be present

• If multiple taxonomy codes are associated with a provider

number, provide the first one in sequence.

Remarks: N/A

Requirement: Required when available.

Data Element: Medical Record Number

Definition: Number assigned to patient by hospital or other provider to assist in retrieval

of medical records.

Validation: N/A

Remarks: N/A

Requirement: Required if available on claim record

Data Element: Patient Control Number

Definition: The patient’s unique alpha-numeric control number assigned by the provider

to facilitate retrieval of individual financial records and posting payment.

Validation: N/A

Remarks: N/A

Requirement: Required if available on claim record

Data Element: Attending Physician NPI

Definition: NPI assigned to the Attending Physician.

Validation: N/A

Remarks: Left justify

Requirement: Required when available on claim record.

Data Element: Attending Physician Last Name

Definition: Last Name (Surname) of the attending physician.

Validation: Must be present

Remarks: N/A

Requirement: Required when available on claim record

Data Element: Operating Physician NPI

Definition: NPI assigned to the Operating Physician.

Validation: N/A

Remarks: Left justify

Requirement: Required when available on claim record.

Data Element: Operating Physician Last Name

Definition: Last Name (Surname) of the operating physician.

Validation: Must be present

Remarks: N/A

Requirement: Required when available on claim record

Data Element: Claim Rendering Physician NPI

Definition: NPI assigned to the claim rendering physician (mapped from 2310D from the

837I version 5010A2).

Validation: N/A

Remarks: Left justify

Requirement: Required when available on claim record.

Data Element: Claim Rendering Physician Last Name

Definition: Last Name (Surname) of the claim rendering physician (mapped from 2310D

from the 837I version 5010A2).

Validation: Must be present

Remarks: N/A

Requirement: Required when available on claim record

Data Element: Date of Admission

Definition: The date the patient was admitted to the provider for inpatient care,

outpatient service, or start of care. For an admission notice for hospice care,

enter the effective date of election of hospice benefits.

Validation: Must be a valid date

Remarks: Format date as CCYYDDD

Requirement: Required if on claim record.

Data Element: Type of Admission

Definition: The code indicating the type and priority of an inpatient admission associated

with the service on an intermediary claim.

Validation: Must be a valid code as listed in Pub 100-4, Medicare Claims

Processing Manual, Chapter 25, Completing and Processing

CMS-1450 Data Set Code Structure.

Remarks: N/A

Requirement: Required on inpatient claims only.

Data Element: Source of Admission

Definition: The code indicating the means by which the beneficiary was admitted to the

inpatient health care facility or SNF if the type of admission is (1) emergency,

(2) urgent, or (3) elective.

Validation: Must be a valid code as listed in Pub 100-4, Medicare Claims Processing

Manual, Chapter 25, Completing and Processing CMS-1450 Data Set Code

Structure (For Emergency, Elective, or Other Type of Admission)

Remarks: N/A

Requirement: Required when entered on the claim record.

Data Element: DRG (Diagnosis Related Group)

Definition: The code identifying the diagnostic related group to which a hospital claim

belongs for prospective payment purposes.

Validation: Must be valid per the DRG DEFINITIONS MANUAL

Remarks: N/A

Requirement: Required if available on the claim record

Data Element: Occurrence Code and Date 1-30

Definition: Code(s) and associated date(s) defining specific event(s) relating to this

billing period are shown.

Validation: Must be a valid code as listed in Pub 100-4, Medicare Claims

Processing Manual, Chapter 25, Completing and Processing

CMS-1450 Data Set.

Remarks:

• Event codes are two alpha-numeric digits, and dates are shown as eight

numeric digits (MM-DD-CCYY)

• When occurrence codes 01-04 and 24 are entered, make sure the entry

includes the appropriate value codes, if there is another payer

involved.

Requirement: Required if available on claim record

Data Element: Value Codes and Amounts 1-35

Definition: Code(s) and related dollar or unit amount(s) identify data of a monetary

nature that are necessary for the processing of this claim.

Validation: Must be a valid code as listed in Pub 100-4, Medicare Claims Processing

Manual, Chapter 25, Completing and Processing CMS-1450 Data Set.

Remarks:

• The codes are two alpha-numeric digits, and each value allows

up to nine numeric digits (0000000.00).

• Negative amounts are not allowed except in the last entry.

• Whole numbers or non-dollar amounts are right justified to the left of the

dollars and cents delimiter.

• Some values are reported as cents, so refer to specific codes for

instructions.

• If more than one value code is shown for a billing period, codes are shown in

ascending numeric sequence.

• Use the first line before the second, etc.

Requirement: Required if available on claim record

Data Element: Claim Final Allowed Amount

Definition: Final Allowed Amount for this claim.

Validation: N/A

Remarks: The Gross Allowed charges on the claim. This represents the amount paid to

the provider plus any beneficiary responsibility (co-pay and deductible)

Requirement: Required

Data Element: Claim Deductible Amount

Definition: Amount of deductible applicable to the claim.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Claim State

Definition: 2 character indicator showing the state where the service is furnished.

Validation: Must be a valid USPS state abbreviation

Remarks: N/A

Requirement: Required

Data Element: Claim Zip Code

Definition: Zip code of the physical location where the services were furnished.

Validation: Must be a valid USPS zip code.

Remarks: N/A

Requirement: Required

Data Element: Beneficiary State

Definition: 2 character indicator showing the state of beneficiary residence.

Validation: Must be a valid USPS state abbreviation

Remarks: N/A

Requirement: Required

Data Element: Beneficiary Zip Code

Definition: Zip code associated with the beneficiary residence.

Validation: Must be a valid USPS zip code.

Remarks: N/A

Requirement: Required

Data Element: PWK Filler

Definition: PWK space -- use to be determined

Validation: N/A

Remarks: N/A

Requirement: Required when available on claim.

Data Element: Patient Reason for Visit 1-3

Definition: An ICD--CM code on the institutional claim indicating the beneficiary's reason

for visit.

Validation: Must be a valid ICD-CM diagnosis code.

• CMS accepts only CMS approved ICD-CM diagnostic and

procedural codes. The CMS approves only changes issued by the Federal

ICD-CM Coordination and Maintenance Committee.

• Diagnosis codes must be full ICD-CM diagnoses codes,

including the full number of digits (five for ICD-9-CM, seven

for ICD-10- CM) where applicable.

Remarks: Report the full ICD-CM codes for up to 3 conditions responsible for the

patient’s visit.

Requirement: For OP claims, this field is populated for those claims that are required to

process

through OP PPS Pricer. The type of bills (TOB) required to process through

are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers,

hospitals located in American Samoa, Guam and Saipan and Critical Access

Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any

outpatient type of bill with a condition code '07' and certain HCPCS. These

claim types could have lines that are not required to price under OPPS rules

so those lines would not have data in this field. Additional exception: Virgin

Island hospitals and hospitals that furnish only inpatient Part B services.

Data Element: Patient Reason for Visit Version Indicator Code 1-3

Definition: The ICD-CM diagnosis version code identifying the version of diagnosis code

submitted.

Validation:

• Version ICD9 use Version Code ‘9’

• Version ICD10 use Version Code ‘0’

Remarks: N/A

Requirement: Patient Reason for Visit Version codes must be submitted to

correspond to patient reason for visit codes 1-3.

Data Element: Present on Admission/External Cause of Injury Indicator

Definition: The code used to indicate a condition was present at the time the beneficiary

was admitted to a general acute care facility.

Validation: Position 1 for Principle Diagnosis, positions 2-25 for the 24 Secondary

Diagnosis for the Present on Admission (POA) Indicator, Positions 26 – 37 for

the 12 External Cause of Injury.

Remarks: N/A

Requirement: Required

Data Element: External Cause of Injury Diagnosis Codes 1-12

Definition: The ICD-CM code used to identify the external cause of injury,

poisoning, or other adverse effect.

Validation: Must be a valid ICD--CM diagnosis code.

• CMS accepts only CMS approved ICD-CM diagnostic and procedural codes.

The CMS approves only changes issued by the Federal ICD-CM Coordination

and Maintenance Committee.

• Diagnosis codes must be full ICD-CM diagnoses codes, including the full

number of digits (five for ICD-9-CM, seven for ICD-10- CM) where applicable.

Remarks: Report the full ICD-CM codes for up to 12 conditions resulting from external

causes.

Requirement: Required if available on the claim record.

Data Element: External Cause of Injury Version Indicator Code 1-12

Definition: The ICD-CM diagnosis version code identifying the version of diagnosis code

identified as external cause of injury.

Validation:

• Version ICD9 use Version Code ‘9’

• Version ICD10 use Version Code ‘0

Remarks: N/A

Requirement: External Cause of Injury version codes 1-12 should be submitted to

correspond to external cause of injury diagnosis codes 1-12.

Data Element: Service Facility Zip Code

Definition: Zip Code used to identify were the service was furnished.

Validation: Must be a valid Zip Code

Remarks: N/A

Requirement: Required, if available on claim record.

Data Element: RAC Adjustment Indicator

Definition: Indicator used to identify RAC requested adjustments, which occur as a

result of post-payment review activities done by the Recovery Audit

Contractors (RAC).

Validation: ‘R’ identifies a RAC-requested adjustment

Remarks: N/A

Requirement: Required when RAC adjustment indicator was furnished to CWF.

Data Element: Split/Adjustment Indicator

Definition: Count of number of adjustments (with different DCNs) of the claim that are

included in the resolution file.

Validation: ‘0’ is used when only one DCN associated with the sampled claim is included

in the resolution file.

When the resolution file contains multiple adjustments associated with a

single claim, this field will provide a count of records.

• When the resolution file contains 2 DCNs related to a single

claim, one of the records would contain a split/adjustment

indicator of 1 and the second record would contain a

split/adjustment indicator of 2.

Remarks: This indicator does not apply when multiple records are submitted for a single

claim record because of size restrictions.

CERT recognizes that Part A claims are not split. For Part A this field will

identify adjustments only.

Requirement: Required when the resolution file contains multiple versions of a single

claim.

Data Element: Referring Physician NPI

Definition: NPI assigned to the Referring Physician—the physician who requests an

item or service for the beneficiary for which payment may be made

under the Medicare program.

Validation: N/A

Remarks: Enter zeros if there is no referring physician

Requirement: Required when available on the claim record

NOTES:

• Referring physician - is a physician who requests an item or service for the

beneficiary for which payment may be made under the Medicare program.

• Ordering physician - is a physician or, when appropriate, a non- physician

practitioner who orders non-physician services for the patient.

Data Element: Referring Physician Last Name

Definition: Last name of the referring physician.

Validation: N/A

Remarks: Enter zeros if there is no referring/ordering provider

Requirement: Required when available on the claim record.

Data Element: Referring Physician Specialty

Definition: Code indicating the primary specialty of the referring physician.

Validation: N/A

Remarks: Enter zeros if the referring physician specialty is not available

Requirement: Required when available on the claim record.

Data Element: Claim Rendering Physician Specialty

Definition: Code indicating the primary specialty of the claim rendering physician.

Validation: N/A

Remarks: Enter zeros if the rendering physician specialty is not available

Requirement: Required when available on the claim record.

Data Element: Overpay Indicator

Definition: Code indicating whether or not an overpayment exists on an OIG or UPIC

tracked adjustment claims.

Validation:

• Y indicates an overpayment exists on an OIG or UPIC claim

• N indicates an overpayment does not exist on an

OIG or UPIC claim.

• Default value is blank for claims that are not OIG or UPIC tracked claims.

Remarks: This field is populated only when there is a value present in the FSSCIDRP-

OVERPAY-CODE field

Requirement: Required when available on the claim record.

Data Element: Overpay Code

Definition: Code that identifies an overpayment on an OIG or UPIC tracked adjustment

claim.

Validation: Any of the user-defined values present in the online parm PRMOIGAA,

PRMOIG00 through PRMOIG20 records.

Remarks: This field is populated only when the claim is an OIG or UPIC tracked

adjustment claim.

Requirement: Required when available on the claim record.

Data Element: Claim Demonstration Identification Number 2

Definition: The number assigned to identify a demonstration project.

Validation: Must be numeric or zeroes

Remarks: This field contains the value from the second

populated demonstration field.

Requirement: Required when available on the claim

Data Element: Claim Demonstration Identification Number 3

Definition: The number assigned to identify a demonstration project.

Validation: Must be numeric or zeroes

Remarks: This field contains the value from the third populated demonstration field.

Requirement: Required when available on the claim

Data Element: Claim Demonstration Identification Number 4

Definition: The number assigned to identify a demonstration project.

Validation: Must be numeric or zeroes.

Remarks: This field contains the value from the fourth populated demonstration field.

Requirement: Required when available on the claim.

Data Element: Beneficiary MBI

Definition: Beneficiary’s Medicare Beneficiary Identifier

Validation: Comply with CMS Standards

• 11-character, fixed length alpha-numeric string

• Different, visibly distinguishable from HICN/RRB numbers

• Contain no more than 2 consecutive numbers

• Contain no more than 2 consecutive alphabetic characters

• Must limit the possibility of letters being interpreted as numbers (i.e.,

alphabetic characters [A…Z]; excluding S, L, O, I, B, Z)

• Must not contain lowercase letters

• Must not contain any special characters

Remarks: Do not include hyphens or spaces

Requirement: Required

Data Element: HICN/MBI Indicator

Definition: Indicator that identifies if the provider submitted the claim with a HICN or

MBI

Validation:

M = MBI submitted on the claim

H = HICN submitted on the claim

Remarks: N/A

Requirement: Required

Data Element: Filler

Definition: Additional space -- use to be determined

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Total Line Item Count

Definition: Number indicating number of service lines on the claim

Validation: Must be a number 001 - 450

Remarks: N/A

Requirement: Required

Data Element: Record Line Item Count

Definition: Number indicating number of service lines on this record

Validation: Must be a number 001 - 100

Remarks: N/A

Requirement: Required

Claim Line Item Fields

Data Element: Revenue Center Code

Definition: Code assigned to each cost center for which a charge is billed.

Validation: Must be a valid NUBC-approved code.

Must be a valid code as listed in Pub 100-4, Medicare Claims Processing

Manual, Chapter 25, Completing and Processing CMS-1450 Data Set.

Remarks: Include an entry for revenue code ‘0001’

Requirement: Required

Data Element: NF-RUG-III Code

Definition: Skilled Nursing Facility Resource Utilization Group Version III (RUG-III)

descriptor. This is the rate code/assessment type that identifies (1) RUG-III

group the beneficiary was classified into as of the Minimum Data Set (MDS)

assessment reference date and (2) the type of assessment for payment

purposes.

Validation: N/A

Remarks: N/A

Requirement: Required for SNF inpatient bills

Data Element: APC Adjustment Code

Definition: The Ambulatory Payment Classification (APC) Code or Home Health

Prospective Payment System (HIPPS) code. The APC codes are the basis for

the calculation of payment of services made for hospital outpatient services,

certain PTB services furnished to inpatients who have no Part A coverage,

CMHCs, and limited services provided by CORFs, Home Health Agencies or to

hospice patients for the treatment of a non-terminal illness.

This field may contain a HIPPS code. If a HHPPS HIPPS code is down coded,

the down coded HIPPS will be reported in this field.

The HIPPS code identifies (1) the three case-mix dimensions of the Home

Health Resource Group (HHRG) system, clinical, functional and utilization,

from which a beneficiary is assigned to one of the 80 HHRG categories and

(2) it identifies whether or not the elements of the code were computed or

derived. The HHRGs, represented by the HIPPS coding, is the basis of

payment for each episode.

Validation: N/A

Remarks: Left justify the APC Adjustment Code

Requirement: Required if present on claim record

Data Element: HCPCS Procedure Code or HIPPS Code

Definition: The HCPCS/CPT-4 code that describes the service or Health Insurance PPS

(HIPPS) code.

Validation: Must be a valid HCPCS/CPT-4 or HIPPS code

Remarks: Healthcare Common Procedure Coding System (HCPCS) is a collection of

codes that represent procedures, supplies, products and services which may

be provided to Medicare beneficiaries and to individuals enrolled in private

health insurance programs

When revenue center code = '0022' (SNF PPS), '0023' (HH PPS), or '0024'

(IRF

PPS); this field contains the Health Insurance PPS (HIPPS) code.

The HIPPS code for SNF PPS contains the rate code/assessment type that

identifies RUG-III group the beneficiary was classified into as of the RAI MDS

assessment reference date and (2) the type of assessment for payment

purposes.

The HIPPS code for Home Health PPS identifies (1) the three case-mix

dimensions of the HHRG system, clinical, functional and utilization, from

which a beneficiary is assigned to one of the 80 HHRG categories and (2) it

identifies whether or not the elements of the code were computed or derived.

The HHRGs, represented by the HIPPS coding, will be the basis of payment

for each episode.

The HIPPS code (CMG Code) for IRF PPS identifies the clinical characteristics

of the beneficiary. The HIPPS rate/CMG code (AXXYY - DXXYY) must contain

five digits. The first position of the code is an A, B, C, or 'D'. The HIPPS code

beginning with an 'A' in front of the CMG is defined as without co-morbidity.

The 'B' in front of the CMG is defined as with co-morbidity for Tier 1. The 'C' is

defined as co-morbidity for Tier 2 and 'D' is defined as co-morbidity for Tier 3.

The 'XX' in the HIPPS rate code is the Rehabilitation Impairment Code (RIC).

The 'YY' is the sequential number system within the RIC.

Requirement: Required if present on claim record

Data Element: HCPCS Modifier 1

HCPCS Modifier 2

HCPCS Modifier 3

HCPCS Modifier 4

HCPCS Modifier 5

Definition: Codes identifying special circumstances related to the service

Validation: N/A

Remarks: N/A

Requirement: Required if available

Data Element: Line Item Date

Definition: The date the service was initiated

Validation: Must be a valid date.

Remarks: Format is CCYYMMDD

Requirement: Required if on bill and included in the shared system

Data Element: Line Submitted Charge

Definition: Actual charge submitted by the provider or supplier for the service or

equipment

Validation: N/A

Remarks: This is a required field. CR3997 provided direction on how to populate this

field if data is not available in the claim record.

Requirement: Required

Data Element: Line Medicare Initial Allowed Charge

Definition: Amount Medicare allowed for the service or equipment before any reduction or

denial.

Validation: Must be a numeric value.

Remarks: This is a required field. Use the value in FISS field FSSCPDCL-REV-COV-CHRG-

AMT to populate this field (per CMS Change Request 3912).

Requirement: Required

Data Element: ANSI Reason Code 1-14

Definition: Codes showing the reason for any adjustments to this line, such as denials or

reductions of payment from the amount billed.

Validation: Must be valid ANSI ASC claim adjustment codes and applicable group codes.

Remarks: Format is GGRRRRRR where: G is the group code and RRRRRR is the

adjustment reason code.

Requirement: Report all ANSI Reason Codes included on the bill.

Data Element: Manual Medical Review Indicator

Definition: Code indicating whether or not the service received complex manual medical

review. Complex review goes beyond routine review. It includes the request

for, collection of, and evaluation of medical records or any other

documentation in addition to the documentation on the claim, attached to the

claim, or contained in the MAC’s history file. The review must require

professional medical expertise and must be for the purpose of preventing

payments of non-covered or incorrectly coded services. That includes reviews

for the purpose of determining if services were medically necessary.

Professionals must perform the review, i.e., at a minimum, a Licensed

Practical Nurse must perform the review. Review requiring use of the MAC's

history file does not make the review a complex review. A review is not

considered complex if a medical record is requested from a provider and not

received. If sufficient documentation accompanies a claim to allow complex

review to be done without requesting additional documentation, count the

review as complex. For instance if all relative pages from the patient's

medical record are submitted with the claim, complex MR could be conducted

without requesting additional documentation.

Validation: Must be ‘Y’ or ’N’

Remarks: Set to ‘Y’ if service was subjected to complex manual medical review, else ’N’.

Requirement: Required

Data Element: Resolution Code

Definition: Code indicating how the MAC resolved the line.

Automated Review (AM): An automated review occurs when a claim/line item

passes through the MAC's claims processing system or any adjunct system

containing medical review edits.

Routine Manual Review (MR): Routine review uses human intervention, but

only to the extent that the claim reviewer reviews a claim or any attachment

submitted by the provider. It includes review that involves review of any of

the MAC's internal documentation, such as claims history file or policy

documentation. It does not include review that involves review of medical

records or other documentation requested from a provider. A review is

considered routine if a medical record is requested from a provider and not

received. Include prior authorization reviews in this category.

Complex Manual Review (MC): Complex review goes beyond routine review.

It includes the request for, collection of, and evaluation of medical records or

any other documentation in addition to the documentation on the claim,

attached to the claim, or contained in the MAC’s history file. The review must

require professional medical expertise and must be for the purpose of

preventing payments of non- covered or incorrectly coded services.

Professionals must perform the review, i.e., at a minimum; a Licensed

Practical Nurse must perform the review. Review requiring use of the MAC's

history file does not make the review a complex review. A review is not

considered complex if a medical record is requested from a provider and not

received. If sufficient documentation accompanies a claim to allow complex

review to be done without requesting additional documentation, the review is

complex. For instance if all relevant pages from the patient's medical record

are submitted with the claim, complex MR could be conducted without

requesting additional documentation.

Validation: Must be ‘APP’, ‘APPMR’, ’APPMC’, ’DENMR’, ‘DENMC’, ’DEO’, ‘RTP’,

‘REDMR’, ‘REDMC’, ‘REO’, ‘DENAM’, ‘REDAM’,’INACT’.

Remarks:

Resolution Code Description

APP Approved as a valid submission without

manual medical review.

APPAM Approved after automated medical review

APPMR Approved after manual medical review routine

APPMC Approved after manual medical review complex. If

this code is selected, set the Manual Medial

Review Indicator to 'Y.

DENAM Denied after automated medical review

DENMR Denied for medical review reasons or for

insufficient documentation of medical necessity,

manual medical review routine

DENMC Denied for medical review reasons or for

insufficient documentation medical necessity,

manual medical review complex. If this codes

is selected, set the Manual Medial Review

Indicator to 'Y.'

DEO Denied for non-medical reasons, other

than denied as unprocessable.

RTP Denied as unprocessable (return/reject)

REDAM Reduced after medical review

REDMR Reduced for medical review reasons or for

insufficient

documentation of medical necessity, manual

medical review routine

REDMC Reduced for medical review reasons or for

insufficient documentation of medical necessity,

manual medical review complex. If this code is

selected, set the Manual Medial

Review Indicator to 'Y.'

REO Reduced for non-medical review reasons.

INACT Claim is inactive as identified by “I” Status

Requirement: Required

Data Element: Final Allowed Charge

Definition: Final amount paid to the provider for this service or equipment plus patient

responsibility.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Cash Deductible

Definition: The amount of cash deductible the beneficiary paid for the line item service.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Special Action/Override Code

Definition: Code used to identify special actions taken in determining payment of this line

item.

Validation: Must be valid

Remarks: N/A

Requirement: Required

Data Element: Units

Definition: The total number of services or time periods provided for the line item.

Validation: N/A

Remarks: Zero filled to maintain the relative position of the decimal point. The last

three positions should contain the value to the right of the decimal in the

number of services. Put a zero in the last three positions for whole numbers.

For example if the number of units is 10, this field would be filled as

0000010000.

Requirement: Required

Data Element: Rendering Physician NPI

Definition: NPI assigned to the Rendering Physician.

Validation: N/A

Remarks: Left justify

Requirement: Required when available on claim record.

Data Element: Rendering Physician Last Name

Definition: Last Name (Surname) of the rendering physician.

Validation: Must be present

Remarks: N/A

Requirement: Required when available on claim record

Data Element: National Drug Code (NDC) field

Definition: To be assigned at a later date.

Validation: N/A

Remarks: Left justify

Requirement: Required when available on claim record.

Data Element: National Drug Code (NDC) Quantity Qualifier

Definition: To be assigned at a later date.

Validation: Must be present.

Remarks: N/A

Requirement: Required when available on claim record.

Data Element: National Drug Code (NDC) Quantity

Definition: To be assigned at a later date.

Validation: Must be present.

Remarks: Zero filled to maintain the relative position of the decimal point.

For example, if the number of units is 10, this field would be filled as

0000010000.

Requirement: Required when available on claim record.

Data Element: PWK Filler

Definition: PWK space -- use to be determined.

Validation: N/A

Remarks: N/A

Requirement: Required when available on claim

Data Element: Rendering Physician Specialty

Definition: Code indicating the primary specialty of the rendering physician.

Validation: N/A

Remarks: Enter zeros if the rendering physician specialty is not available

Requirement: Required when available on the claim record.

Data Element: Prior Authorization Program Indicator

Definition: Prior Authorization Program Indicator issued by CMS to identify to which PA

program the service belongs

Validation:  Four character alphanumeric

• The first character identifies the line of business

• A for Part A,

• B for Part B,

• D for DME,

• H for Home Health and Hospice

• Followed by a three digit number.

Remarks: N/A

Requirement: Required for claims containing services subject to a prior authorization

program.

Data Element: Unique Tracking Number (UTN)

Definition: Unique Tracking Number (UTN) assigned to the prior authorization request for

the service or item.

Validation: UTN shall be 14 characters and use the following format:

• First two characters = MAC identifier (e.g., RR for Railroad, 0F for Jurisdiction

F, 05 for Jurisdiction 5, etc.).

• Third character = line of business (e.g., A for Part A, B for Part

B, D for DME, H for Home Health and Hospice).

• Remaining numerical characters = a unique sequence number assigned by

the Shared System.

Remarks: N/A

Requirement: Required for claims containing services covered by an affirmed prior

authorization.

Data Element: Prior Auth Affirmed

Definition: Code to identify if the prior authorization for the service(s) on this line was

affirmed.

Validation:

• Y indicates the prior authorization was affirmed.

 N indicates the prior authorization was not affirmed.

 Default value is blank for claims that are not part of prior authorization

demonstration.

Remarks: N/A

Requirement: Required for claims containing services subject to prior authorization in the

state

where the service was furnished.

Data Element: Filler

Definition: Additional space -- use to be determined

Validation: N/A

Remarks: N/A

Requirement: Required

Claims Resolution File

Claims Resolution Trailer Record (one record per file)

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number.

Validation: Must be a valid CMS contractor ID.

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single

processing environment, the Contractor ID will reflect the roll-up Contractor

ID specified by CMS.

Data Element: Record Type

Definition: Code indicating type of record.

Validation: N/A

Remarks: 3 = Trailer Record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Resolution file.

Validation: Claim Resolution files prior to 10/1/2007 did not contain this field.

Codes:

B = Record Format as of 10/1/2007

C = Record Format as of 1/1/2010

D = Record Format as of 10/1/2012

E = Record Format as of 7/1/2016

F = Record Format as of 10/1/2017

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor included in the file

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 ‘3’

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Number of Claims 9(9) 9 17 Zeroes

Validation: Must be ‘A’ or ‘R’.

Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.

Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should

be ‘R’.

All others will be contractor type ‘A’.

Remarks: A = A/B MAC (A) only

R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)

Requirement: Required

Data Element: Number of Claims

Definition: Number of claim records on this file

Validation: Must be equal to the number of claim records on the file

Remarks: Do not count header or trailer records

Requirement: Required

Claims Provider Address File

Claims Provider Address Header Record (one record per file)

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 ‘1’

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Provider Address Date X(8) 9 16 Spaces

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number

Validation: Must be a valid CMS contractor ID

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single

processing environment, the Contractor ID will reflect the roll-up Contractor

ID specified by CMS

Data Element: Record Type

Definition: Code indicating type of record

Validation: N/A

Remarks: 1 = Header record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Provider Address file

Validation: Claim Provider Address files prior to 10/1/2007 did not contain this field.

Codes:

B = Record Format as of 10/1/2007

C = Record Format as of 1/1/2010

D = Record Format as of 10/1/2012

E = Record Format as of 7/1/2016

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor included in the file

Validation: Must be ‘A’ or ‘R’

Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.

Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should

be ‘R’.

All others will be contractor type ‘A’.

Remarks: A = A/B MAC (A) only

R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)

Requirement: Required

Data Element: Provider Address Date

Definition: Date the Provider Address File was created.

Validation: Must be a valid date not equal to a Provider Address date

sent on any previous claims Provider Address file

Remarks: Format is CCYYMMDD. May use shared system batch processing date

Requirement: Required

Provider Address File

Provider Address Detail Record

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 Spaces

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Sequence Number X(1) 9 9 Spaces

Provider Number X(15) 10 24 Spaces

Provider Name X(60) 25 84 Spaces

Provider Address 1 X(25) 85 109 Spaces

Provider Address 2 X(25) 110 134 Spaces

Provider City X(15) 135 149 Spaces

Provider State Code X(2) 150 151 Spaces

Provider Zip Code X(9) 152 160 Spaces

Provider Phone Number X(10) 161 170 Spaces

Provider Phone Number Extension X(10) 171 180 Spaces

Provider FAX Number X(10) 181 190 Spaces

Provider Type X(1) 191 191 Spaces

Provider Address Type 9(3) 192 194 1

Provider E-mail Address X(75) 195 269 Spaces

Provider Federal Tax number or EIN 9(10) 270 279 Zeroes

Filler X(16) 280 295 Spaces

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number

Validation: Must be a valid CMS contractor ID

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single

processing environment, the Contractor ID will reflect the roll-up Contractor ID

specified by CMS

Data Element: Record Type

Definition: Code indicating type of record

Validation: N/A

Remarks: 2 = Detail record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Provider Address file

Validation: Claim Provider Address files prior to 10/1/2007 did not contain this field.

Codes:

B = Record Format as of 10/1/2007

C = Record Format as of 1/1/2010

D = Record Format as of 10/1/2012

E = Record Format as of 10/1/2017

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor included in the file

Validation: Must be ‘A’ or ‘R’.

Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.

Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should

be ‘R’.

All others will be contractor type ‘A’.

Data Element: Sequence Number

Definition: Number occurrence number of addresses when there are multiple addresses

for a provider.

Validation: Must be between 1 and 3

Remarks: Enter 1 if there is only one address for a provider

Requirement: Required

Data Element: Provider Number

Definition: Number assigned by Medicare to identify the provider

Validation: N/A

Remarks: Left justify

Requirement: Required

Data Element: Provider Name

Definition: Provider's name

Validation: N/A

Remarks: This is the business name associated with the provider number. Must be

formatted into a name for mailing (e. g., Roger A Smith M.D. or Medical

Associates, Inc.)

Requirement: Required

Data Element: Provider Address 1

Definition: First line of provider's address

Validation: N/A

Remarks: This is the first line of the address associated with the provider number

indicated in the record.

Requirement: Required for all Billing Provider Numbers. Furnish as available

for other types of provider numbers.

Data Element: Provider Address 2

Definition: Second line of provider’s address

Validation: N/A

Remarks: This is the line of the address associated with the provider number indicated

in the record.

Requirement: Required for all Billing Provider Numbers. Furnish as available for other types

of provider numbers.

Data Element: Provider City

Definition: Provider’s city name

Validation: N/A

Remarks: This is the city of the provider number

Requirement: Required for Billing Provider Numbers. Furnish as available for other types of

provider numbers.

Data Element: Provider State Code

Definition: Provider's state code

Validation: Must be a valid state code

Remarks: This is the state associated with the address of the provider number.

Requirement: Required for Billing Provider Numbers. Furnish as available for other types of

provider numbers.

Data Element: Provider Zip Code

Definition: Provider's zip code

Validation: Must be a valid postal zip code

Remarks: This is the zip code associated with the address furnished for the provider

number identified in this record.

 Provide 9-digit zip code if available, otherwise provide 5-digit zip code.

Requirement: Required for Billing Provider Numbers. Furnish as available for other types of

provider numbers.

Data Element: Provider Phone Number

Definition: Provider's phone number

Validation: Must be a valid phone number

Remarks: N/A

Requirement: Required if available

Data Element: Provider Phone Number Extension

Definition: Provider's phone number extension

Validation: Must be a valid phone number

Remarks: N/A

Requirement: Required if available

Data Element: Provider Fax Number

Definition: Provider’s fax number

Validation: Must be a valid fax number

Remarks: N/A

Requirement: Required if available

Data Element: Provider Type

Definition: 1=Billing Provider Number (OSCAR)

2=Attending Physician Number (UPIN)

3=Operating Physician Number (UPIN)

4=Other Physician Number (UPIN)

5=Billing Provider NPI

6=Attending Physician NPI

7=Operating Physician NPI

8=Rendering Physician NPI

Validation: Must be 1-8.

Remarks: This field identifies the type of provider number whose name, address, phone

number and identification information are included in the record.

Requirement: Required

Data Element: Provider Address Type

Definition: The type of Provider Address furnished.

Validation: 1 = Master Address (FISS)

2 = Remittance Address (FISS)

3 = Check Address (FISS) (APASS)

4 = MSP Other Address (FISS)

5 = Medical Review Address (FISS) (APASS)

6 = Other Address (FISS) (APASS)

7 = Chain Address (APASS)

8 = Correspondence Address

9 = Medical Record Address

Remarks: The first “address type” for each provider will always be a “1.”

Subsequent occurrences of addresses for the same provider will have the

“address type” to correspond to the address submitted. When your files

contain only one address for the provider, submit only one provider address

record. Submit additional address records for a single provider number only

when your files contain addresses that differ from the Master or Legal

address.

 Correspondence Address—The Correspondence Address as indicated on the

855A. This is the address and telephone number where Medicare can directly

get in touch with the enrolling provider. This address cannot be that of the

billing agency, management service organization, or staffing company.

 Medical Record Address—the Location of Patients’ Medical Records as

indicated on the 855A. This information is required if the Patients’ Medical

Records are stored at a location other than the Master Address (practice

location). Post Office Boxes and Drop Boxes are not acceptable as the

physical address where patient’s medical records are maintained.

Requirement: Required Billing Provider Numbers. Furnish as available for

other types of provider numbers.

Data Element: Provider E-Mail Address

Definition: Provider’s e-mail address.

Validation: Must be a valid e-mail address.

Remarks: N/A

Requirement: Required if available.

Data Element: Provider Federal Tax Number or EIN

Definition: The number assigned to the billing provider by the Federal government for

tax report purposes. The Federal Tax Number is also known as a tax

identification number (TIN) or employer identification number (EIN).

Validation: Must be present

Remarks: N/A

Requirement: Required for all Billing Provider Numbers. For all other types of provider

numbers, the tax number is required when available

Data Element: Filler

Definition: Additional space -- use to be determined

Validation: N/A

Remarks: N/A

Requirement: Required

Claims Provider Address File

Claims Provider Address Trailer Record (one record per file)

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 ‘3’

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Number of Records 9(9) 9 17 Zeroes

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number.

Validation: Must be a valid CMS contractor ID.

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single

processing environment, the Contractor ID will reflect the roll-up Contractor

ID specified by CMS.

Data Element: Record Type

Definition: Code indicating type of record

Validation: N/A

Remarks: 3 = Trailer Record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Universe file

Validation: Claim Universe files prior to 10/1/2007 did not contain this field.

Codes:

B = Record Format as of 10/1/2007

C = Record Format as of 1/1/2010

D = Record Format as of 10/1/2012

E = Record Format as of 10/1/2017

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor included in the file

Validation: Must be ‘A’ or ‘R’

Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.

Where the TYPE of BILL, 1st/2nd positions = 81 or 82, contractor Type should

be ‘R’.

All others will be contractor type ‘A’.

Remarks: A = A/B MAC (A) only

R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)

Requirement: Required

Data Element: Number of Records

Definition: Number of provider address records on this file

Validation: Must be equal to the number of provider address records on the file

Remarks: Do not count header or trailer records

Requirement: Required

Exhibit 36.2

(Rev. 726, Issued: 06-16-17, Effective: 10-01-17, Implementation: 01-02-18 - For VMS and MCS for Business Requirements 11 through 22 and 22.1; 10-02-17 - For FISS)

Claims Universe File

Claims Universe Header Record (one record per file)

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 ‘1’

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Universe Date X(8) 9 16 Spaces

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number.

Validation: Must be a valid CMS contractor ID.

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (B): when multiple workloads share a single

processing environment, the Contractor ID will reflect the contractor

ID of the primary workload.

Data Element: Record Type

Definition: Code indicating type of record.

Validation: N/A

Remarks: 1 = Header record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Universe file.

Validation: Claim Universe files prior to 7/1/2007 did not contain this field.

Codes:

B = Record Format as of 7/1/2007

C = Record Format as of 10/1/2017

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor

Validation: Must be ‘B’ or ‘D’

Remarks: B = A/B MAC (B)

D = DME MAC

Requirement: Required

Data Element: Universe Date

Definition: Date the universe of claims entered the shared system.

Validation: Must be a valid date not equal to a universe date sent on any previous

claims universe file.

Remarks: Format is CCYYMMDD.

 Shared System logic may use shared system batch processing date as long as

the date is not equal to the universe date sent on any previous claims universe

file.

Requirement: Required

Claims Universe File

Claims Universe Claim Detail Record

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 "2"

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Claim Control Number X(15) 9 23 Spaces

Beneficiary HICN X(12) 24 35 Spaces

Billing Provider NPI X(10) 36 45 Spaces

Claim Submitted Charge Amount S9(7)v99 46 54 Zeroes

Claim Demonstration Number X(2) 55 56 Spaces

Claim State X(2) 57 58 Spaces

Beneficiary State X(2) 59 60 Spaces

Billing Provider Specialty X(2) 61 62 Spaces

Beneficiary MBI X(11) 63 73 Spaces

HICN/MBI Indicator X(1) 74 74 Spaces

Filler X(3) 75 77 Spaces

Line Item Count 9(2) 78 79 Zeroes

Claims Universe File

Claims Universe Claim Line Item Detail Record

*Line Item group: The following group of Fields occurs from 1 to 52 Times (depending on Line

Item Count).

*From and Thru values relate to the 1st line item

Field Name Picture From Thru Initialization

Performing Provider Number X(15) 80 94 Spaces

Performing Provider Specialty X(2) 95 96 Spaces

HCPCS Procedure Code X(5) 97 101 Spaces

From Date of Service X(8) 102 109 Spaces

To Date of Service X(8) 110 117 Spaces

Line Submitted Charge S9(7)v99 118 126 Zeroes

Performing Provider NPI X(10) 127 136 Spaces

DATA ELEMENT DETAIL

Claim Header Fields

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number

Validation: Must be a valid CMS contractor ID

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (B): when multiple workloads share a single

processing environment, the Contractor ID will reflect the contractor

ID of the primary workload.

Data Element: Record Type

Definition: Code indicating type of record

Validation: N/A

Remarks: 2 = claim record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Universe file

Validation: Claim Universe files prior to 7/1/2007 did not contain this field.

Codes:

B = Record Format as of 7/1/2007

C = Record Format as of 10/1/2017

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor

Validation: Must be ‘B’ or ‘D’

Remarks: B = A/B MAC (B)

D = DME MAC

Requirement: Required

Data Element: Claim Control Number

Definition: Number assigned by the shared system to uniquely identify the claim.

Validation: The required format for the Claim Control Number is different for each

claim type.

DME: must be 15 digits with a leading 1 as filler.

Part B: must be 15 digits, with two leading zeros as filler.

Remarks: N/A

Requirement: Required

Data Element: Beneficiary HICN

Definition: Beneficiary’s Health Insurance Claim Number.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Billing Provider NPI

Definition: NPI assigned to the Billing Provider.

Validation: N/A

Remarks: N/A.

Requirement: Required.

Data Element: Claim Submitted Charge Amount

Definition: The total submitted charges on the claim (the sum of line item

submitted charges).

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Claim Demonstration Number

Definition: Also known as Claim Demonstration Identification Number. The number

assigned to identify a demonstration Project. This field is also used to denote

special processing (a.k.a. Special Processing Number, SPN).

Validation: Must be a Valid Demo ID.

Remarks: N/A

Requirement: Required when available on claim.

Data Element: Claim State

Definition: State abbreviation identifying the state in which the service is furnished.

Validation: Must be a valid 2 digit state abbreviation as defined by the United States

Postal Service (USPS).

Remarks: When services on a single claim are furnished in multiple states, enter the state

identifier for the first detail line.

Requirement: Required for all Part B Claims. For DME claims, required if available.

Data Element: Beneficiary State

Definition: State abbreviation identifying the state in which the beneficiary resides.

Validation: Must be a valid 2 digit state abbreviation as defined by the United States

Postal Service (USPS).

Remarks: N/A

Requirement: Required, when available.

Data Element: Billing Provider Specialty

Definition: Code indicating the primary specialty of the Billing provider or supplier.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Beneficiary MBI

Definition: Beneficiary’s Medicare Beneficiary Identifier

Validation: Comply with CMS Standards

 11-character, fixed length alpha-numeric string.

 Different, visibly distinguishable from HICN/RRB numbers.

 Contain no more than 2 consecutive numbers.

 Contain no more than 2 consecutive alphabetic characters.

 Must limit the possibility of letters being interpreted as

numbers (i.e., alphabetic characters [A…Z]; excluding S, L, O, I, B, Z).

 Must not contain lowercase letters.

 Must not contain any special characters.

Remarks: Do not include hyphens or spaces.

Requirement: Required

Data Element: HICN/MBI Indicator

Definition: Indicator that identifies if the provider submitted the claim with a HICN or MBI.

Validation:

M = MBI submitted on the claim

H = HICN submitted on the claim

Remarks: N/A

Requirement: Required

Data Element: Filler

Definition: Additional space -- use to be determined

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Line Item Count

Definition: Number indicating number of service lines on the claim.

Validation: Must be a number 01 – 52.

Remarks: N/A

Requirement: Required

Claim Line Item Fields

Data Element: Performing Provider Number

Definition: Number assigned by the NSC or MAC to identify the provider who performed the

service or the supplier who supplied the medical equipment.

Validation: N/A

Remarks: Enter the PIN of the performing provider. When several different

providers of service or suppliers are billing on the same claim, show the

individual PIN in the corresponding line item.

Requirement: Required

Data Element: Performing Provider Specialty

Definition: Code indicating the primary specialty of the performing provider or

supplier.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: HCPCS Procedure Code

Definition: The HCPCS/CPT-4 code that describes the service.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: From Date of Service

Definition: The date the service was initiated.

Validation: Must be a valid date less than or equal to To Date of Service.

Remarks: Format is CCYYMMDD

Requirement: Required

Data Element: To Date of Service

Definition: The date the service ended.

Validation: Must be a valid date greater than or equal to From Date of Service.

Remarks: Format is CCYYMMDD

Requirement: Required

Data Element: Line Submitted Charge

Definition: Actual charge submitted by the provider or supplier for the service or

equipment.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Performing Provider NPI

Definition: NPI assigned to the Performing Provider.

Validation: N/A

Remarks: N/A.

Requirement: Required

Claims Universe File

Claims Universe Trailer Record (one record per file)

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 ‘3’

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Number of Claims 9(9) 9 17 Zeroes

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number.

Validation: Must be a valid CMS contractor ID.

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (B): when multiple workloads share a single processing

environment, the Contractor ID will reflect the contractor ID of the

primary workload.

Data Element: Record Type

Definition: Code indicating type of record

Validation: N/A

Remarks: 3 = Trailer Record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Universe file

Validation: Claim Universe files prior to 7/1/2007 did not contain this field.

Codes:

B = Record Format as of 7/1/2007

C = Record Format as of 10/1/2017

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor

Validation: Must be ‘B’ or ‘D’

Remarks: B = A/B MAC (B)

D = DME MAC

Requirement: Required

Data Element: Number of Claims

Definition: Number of claim records on this file

Validation: Must be equal to the number of claim records on the file

Remarks: Do not count header or trailer records

Requirement: Required

Claims Transaction File

Claims Transaction Header Record (one record per file)

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 ‘1’

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Transaction Date X(8) 9 16 Spaces

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number

Validation: Must be a valid CMS contractor ID

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (B): when multiple workloads share a single processing

environment, the Contractor ID will reflect the contractor ID of the

primary workload.

Data Element: Record Type

Definition: Code indicating type of record

Validation: N/A

Remarks: 1 = Header record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Transaction file

Validation: Claim Transaction files prior to 7/1/2007 did not contain this field.

Codes:

B = Record Format as of 7/1/2007

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor

Validation: Must be ‘B’ or ‘D’

Remarks: B = A/B MAC (B)

D = DME MAC

Requirement: Required

Data Element: Transaction Date

Definition: Date the Transaction File was created

Validation: Must be a valid date not equal to a Transaction date sent on any previous claims

Transaction file.

Remarks: Format is CCYYMMDD. May use shared system batch processing date.

Requirement: Required

Sampled Claims Transaction File

Sampled Claims Transaction File Detail Record

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 ‘2’

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Claim Control Number X(15) 9 23 Spaces

Beneficiary HICN X(12) 24 35 Spaces

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number.

Validation: Must be a valid CMS contractor ID.

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (B): when multiple workloads share a single processing

environment, the Contractor ID will reflect the contractor ID of the

primary workload.

Data Element: Record Type

Definition: Code indicating type of record

Validation: N/A

Remarks: 2 = claim record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Universe file.

Validation: Claim Universe files prior to 7/1/2007 did not contain this field.

Codes:

B = Record Format as of 7/1/2007

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor.

Validation: Must be ‘B’ or ‘D’

Remarks: B = A/B MAC (B)

D = DME MAC

Requirement: Required

Data Element: Claim Control Number

Definition: Number assigned by the shared system to uniquely identify the claim.

Validation: N/A

Remarks: Reflects the Claim Control Number selected from the Claim Universe file in

the sampling process.

Requirement: Required

Data Element: Beneficiary HICN

Definition: Beneficiary’s Health Insurance Claim Number

Validation: N/A

Remarks: Reflects the Beneficiary HICN on the claim record selected from the

Claim Universe file in the sampling process

Requirement: Required

Claims Transaction File

Claims Transaction Trailer Record (one record per file)

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 ‘3’

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Number of Claims 9(9) 9 17 Zeroes

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number

Validation: Must be a valid CMS contractor ID

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (B): when multiple workloads share a single processing

environment, the Contractor ID will reflect the contractor ID of the

primary workload.

Data Element: Record Type

Definition: Code indicating type of record.

Validation: N/A

Remarks: 3 = Trailer Record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Universe file.

Validation: Claim Universe files prior to 7/1/2007 did not contain this field.

Codes:

B = Record Format as of 7/1/2007

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor.

Validation: Must be ‘B’ or ‘D’

Remarks: B = A/B MAC (B)

D = DME MAC

Requirement: Required

Data Element: Number of Claims

Definition: Number of claim records on this file.

Validation: Must be equal to the number of claim records on the file.

Remarks: Do not count header or trailer records.

Requirement: Required

Claims Resolution File

Claims Resolution Header Record (one record per file)

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 ‘1’

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Resolution Date X(8) 9 16 Spaces

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number.

Validation: Must be a valid CMS contractor ID.

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (B): when multiple workloads share a single processing

environment, the Contractor ID will reflect the contractor ID of the

primary workload.

Data Element: Record Type

Definition: Code indicating type of record.

Validation: N/A

Remarks: 1 = Header record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Resolution file.

Validation: Claim Resolution files prior to 7/1/2007 did not contain this field.

Codes:

B = Record Format as of 7/1/2007

C = Record Format as of 1/1/2010

D = Record Format as of 7/1/2016

E = Record Format as of 10/1/2017

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor

Validation: Must be ‘B’ or ‘D’

Remarks: B = A/B MAC (B)

D = DME MAC

Requirement: Required

Data Element: Resolution Date

Definition: Date the Resolution Record was created.

Validation: Must be a valid date not equal to a Resolution date sent on any previous

claims Resolution file.

Remarks: Format is CCYYMMDD. May use shared system batch processing date.

Requirement: Required

Sampled Claims Resolution File

Sampled Claims Resolution Detail Record (one record per claim)

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 “2”

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Assignment Indicator X(1) 9 9 Spaces

Mode of Entry Indicator X(1) 10 10 Spaces

Original Claim Control Number X(15) 11 25 Spaces

Claim Control Number X(15) 26 40 Spaces

Beneficiary HICN X(12) 41 52 Spaces

Beneficiary Last Name X(60) 53 112 Spaces

Beneficiary First Name X(35) 113 147 Spaces

Beneficiary Middle Initial X(1) 148 148 Spaces

Beneficiary Date Of Birth X(8) 149 156 Spaces

Billing Provider Number X(15) 157 171 Spaces

Field Name Picture From Thru Initialization

Referring/Ordering UPIN X(6) 172 177 Spaces

Claim Allowed Amount S9(7)v99 178 186 Zeroes

Claim ANSI Reason Code 1 X(8) 187 194 Spaces

Claim ANSI Reason Code 2 X(8) 195 202 Spaces

Claim ANSI Reason Code 3 X(8) 203 210 Spaces

Claim Entry Date X(8) 211 218 Spaces

Claim Adjudicated Date X(8) 219 226 Spaces

Beneficiary Gender X(1) 227 227 Spaces

Billing Provider NPI X(10) 228 237 Spaces

Referring/Ordering Provider NPI X(10) 238 247 Spaces

Claim Paid Amount S9(7)v99 248 256 Zeroes

Beneficiary Paid Amount S9(7)v99 257 265 Zeroes

Claim Diagnosis Code 1 X(7) 266 272 Spaces

Claim Diagnosis Code 1Version

Indicator Code

X(1) 273 273 Spaces

Claim Diagnosis Code 2 X(7) 274 280 Spaces

Claim Diagnosis Code 2Version

Indicator Code

X(1) 281 281 Spaces

Claim Diagnosis Code 3 X(7) 282 288 Spaces

Claim Diagnosis Code 3Version

Indicator Code

X(1) 289 289 Spaces

Claim Diagnosis Code 4 X(7) 290 296 Spaces

Claim Diagnosis Code 4Version

Indicator Code

X(1) 297 297 Spaces

Claim Diagnosis Code 5 X(7) 298 304 Spaces

Claim Diagnosis Code 5Version

Indicator Code

X(1) 305 305 Spaces

Claim Diagnosis Code 6 X(7) 306 312 Spaces

Claim Diagnosis Code 6Version

Indicator Code

X(1) 313 313 Spaces

Claim Diagnosis Code 7 X(7) 314 320 Spaces

Claim Diagnosis Code 7Version

Indicator Code

X(1) 321 321 Spaces

Claim Diagnosis Code 8 X(7) 322 328 Spaces

Claim Diagnosis Code 8Version

Indicator Code

X(1) 329 329 Spaces

Claim Diagnosis Code 9 X(7) 330 336 Spaces

Claim Diagnosis Code 9Version

Indicator Code

X(1) 337 337 Spaces

Claim Diagnosis Code 10 X(7) 338 344 Spaces

Claim Diagnosis Code 10Version

Indicator Code

X(1) 345 345 Spaces

Claim Diagnosis Code 11 X(7) 346 352 Spaces

Claim Diagnosis Code 11Version

Indicator Code

X(1) 353 353 Spaces

Claim Diagnosis Code 12 X(7) 354 360 Spaces

Claim Diagnosis Code 12Version

Indicator Code

X(1) 361 361 Spaces

Claim Zip Code X(9) 362 370 Spaces

Claim Pricing State X(2) 371 372 Spaces

Field Name Picture From Thru Initialization

Beneficiary Zip Code X(9) 373 381 Spaces

Beneficiary State X(2) 382 383 Spaces

Claim Demonstration Number X(2) 384 385 Spaces

RAC Adjustment Indicator X(1) 386 386 Spaces

Split/Adjustment Indicator X(2) 387 388 Spaces

Facility NPI X(10) 389 398 Spaces

Claim PWK X(60) 399 458 Spaces

Claim Demonstration Identification

Number2

X(2) 459 460 Spaces

Claim Demonstration Identification

Number3

X(2) 461 462 Spaces

Claim Demonstration Identification

Number4

X(2) 463 464 Spaces

Beneficiary MBI X(11) 465 475 Spaces

HICN/MBI indicator X(1) 476 476 Spaces

Line Item Count 9(2) 477 478 Zeroes

Filler X(32) 479 510 Spaces

Sampled Claims Resolution File

Sampled Claims Resolution Line Item Detail Group

*The following group of fields occurs from 1 to 13 times (Depending on Line Item Count).

*From and Thru values relate to the 1st line item

Field Name Picture From Thru Initialization

Performing Provider Number X(15) 511 525 Spaces

Performing Provider Specialty X(2) 526 527 Spaces

HCPCS Procedure Code X(5) 528 532 Spaces

HCPCS Modifier 1 X(2) 533 534 Spaces

HCPCS Modifier 2 X(2) 535 536 Spaces

HCPCS Modifier 3 X(2) 537 538 Spaces

HCPCS Modifier 4 X(2) 539 540 Spaces

Number of Services S9(7)v999 541 550 Zeroes

Service From Date X(8) 551 558 Spaces

Service To Date X(8) 559 566 Spaces

Place of Service X(2) 567 568 Spaces

Type of Service X(1) 569 569 Spaces

Diagnosis Code X(7) 570 576 Spaces

Line Diagnosis Code Version

Indicator Code

X(1) 577 577 Spaces

CMN Control Number X(15) 578 592 Spaces

Line Submitted Charge S9(7)v99 593 601 Zeroes

Line Medicare Initial Allowed

S9(7)v99 602 610 Zeroes

ANSI Reason Code 1 X(8) 611 618 Spaces

ANSI Reason Code 2 X(8) 619 626 Spaces

ANSI Reason Code 3 X(8) 627 634 Spaces

ANSI Reason Code 4 X(8) 635 642 Spaces

ANSI Reason Code 5 X(8) 643 650 Spaces

ANSI Reason Code 6 X(8) 651 658 Spaces

ANSI Reason Code 7 X(8) 659 666 Spaces

Field Name Picture From Thru Initialization

Manual Medical Review Indicator X(1) 667 667 Space

Resolution Code X(5) 668 672 Spaces

Line Final Allowed Charge S9(7)v99 673 681 Zeroes

Performing Provider NPI X(10) 682 691 Spaces

Performing Provider UPIN X(6) 692 697 Spaces

Miles/Time/Units/Services Indicator

Code

X(1) 698 698 Spaces

Line Deductible Applied S9(7)v99 699 707 Zeroes

Line Co-Insurance S9(7)V99 708 716 Zeroes

Line Paid Amount S9(7)v99 717 725 Zeroes

Line MSP Code X(1) 726 726 Spaces

Line MSP Paid Amount S9(7)v99 727 735 Zeroes

Line Pricing Locality X(2) 736 737 Spaces

Line Zip Code X(9) 738 746 Spaces

Line Pricing State Code X(2) 747 748 Spaces

Ambulance Point of Pick up Zip

X(9) 749 757 Spaces

Ambulance Point of Drop Off Zip

Code

X(9) 758 766 Spaces

Line PWK X(60) 767 826 Spaces

Prior Authorization Program

X(4) 827 830 Spaces

Unique Tracking Number (UTN) X(14) 831 844 Spaces

Prior Authorization Affirmed

Indicator

X(1) 845 845 Spaces

Filler X(6) 846 851 Spaces

DATA ELEMENT DETAIL

Claim (Header) Fields

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number

Validation: Must be a valid CMS contractor ID

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (B): when multiple workloads share a single processing

environment, the Contractor ID will reflect the contractor ID of the

primary workload.

Data Element: Record Type

Definition: Code indicating type of record

Validation: N/A

Remarks: 2 = Claim record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Resolution file.

Validation: Claim Resolution files prior to 7/1/2007 did not contain this field.

Codes:

B = Record Format as of 7/1/2007

C = Record Format as of 1/1/2010

D = Record Format as of 7/1/2016

E = Record Format as of 10/1/2017

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor.

Validation: Must be ‘B’ or ‘D’

Remarks: B = A/B MAC (B)

D = DME MAC

Requirement: Required

Data Element: Assignment Indicator

Definition: Code indicating whether claim is assigned or non-assigned.

Validation: Must be ’A’ or ’N’

Remarks: A = Assigned

N = Non-assigned

Requirement: Required

Data Element: Mode of Entry Indicator

Definition: Code that indicates if the claim is paper or EMC.

Validation: Must be ’E’ or ‘P’

Remarks: E = EMC P = Paper

Use the same criteria to determine EMC or paper as that used for

workload reporting.

Requirement: Required

Data Element: Original Claim Control Number

Definition: The Claim Control Number the shared system assigned to the claim in

the Universe file. This number should be the same as the claim control

number for the claim in the Sample Claims Transactions file, and the claim control

number for the claim on the Universe file. If the shared system had to use a

crosswalk to pull the claim because the MAC or shared system changed the claim

control number during processing,

enter the number the shared system used to look up the number needed

to pull all records associated with the sample claim.

Validation: Must match the Claim Control Number identified in the Sampled

Claims Transaction File.

Remarks: N/A

Requirement: Required

Data Element: Claim Control Number

Definition: Number assigned by the shared system to uniquely identify the claim.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Beneficiary HICN

Definition: Beneficiary’s Health Insurance Claim Number.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Beneficiary Last Name

Definition: Last Name (Surname) of the beneficiary.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Beneficiary First Name

Definition: First (Given) Name of the beneficiary.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Beneficiary Middle Initial

Definition: First letter from Beneficiary Middle Name.

Validation: N/A

Remarks: N/A

Requirement: Required when available

Data Element: Beneficiary Date of Birth

Definition: Date on which beneficiary was born.

Validation: Must be a valid date

Remarks: MMDDCCYY on which the beneficiary was born.

Requirement: Required

Data Element: Billing Provider Number

Definition: Number assigned by the National Supplier Clearinghouse (NSC) or MAC

to identify the billing/pricing provider or supplier.

Validation: Must be present. Use the same requirements as for Item 33 in HCFA

1500.

• Enter the PIN, for the performing provider of service/supplier

who is not a member of a group practice.

• Enter the group PIN, for the performing provider of

service/supplier who is a member of a group practice.

• Suppliers billing the DME MAC will use the National Supplier

Clearinghouse (NSC) number in this item.

• If the same billing/pricing provider number does not apply to all

lines on the claim, enter the Billing provider number that applies

to the performing provider on the first line of the claim.

Remarks: N/A

Requirement: Required

Data Element: Referring/Ordering UPIN

Definition: UPIN assigned to identify the referring/ordering provider.

Validation: N/A

Remarks: Enter zeros if there is no referring/ordering provider.

• Referring physician - is a physician who requests an item or

service for the beneficiary for which payment may be made

under the Medicare program.

• Ordering physician - is a physician or, when appropriate, a non-physician practitioner who orders non-physician services for the patient.

Requirement: Required when available on the claim record.

Data Element: Claim Allowed Amount

Definition: Final Allowed Amount for this claim.

Validation: N/A

Remarks: The total allowed charges on the claim (the sum of line item allowed

charges)

Requirement: Required

Data Element: Claim ANSI Reason Code 1-3

Definition: Codes showing the reason for any adjustments to this claim, such as

denials or reductions of payment from the amount billed.

Validation: Must be valid ANSI ASC claim adjustment codes and applicable group

codes.

Remarks: Format is GGRRRRRR where: GG is the group code and RRRRRR is

the adjustment reason code.

Requirement: ANSI Reason Code 1 must be present on all claims. Codes 2 and 3 should

be sent, if available.

Data Element: Claim Entry Date

Definition: Date claim entered the shared claim processing system

Validation: Must be a valid date

Remarks: Format must be CCYYMMDD

Requirement: Required

Data Element: Claim Adjudicated Date

Definition: Date claim completed adjudication.

Validation: Must be a valid date. Format must be CCYYMMDD.

Remarks: This must represent the processed date that may be prior to the pay date if the

claim is held on the payment floor after a payment decision has been made.

Requirement: Required

Data Element: Beneficiary Gender

Definition: Gender of the Beneficiary.

Validation: M=Male

F=Female

U=Unknown

Remarks: N/A

Requirement: Required

Data Element: Billing Provider NPI

Definition: NPI assigned to the Billing Provider.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Referring/Ordering Provider NPI

Definition: NPI assigned to the Referring/Ordering Provider.

Validation: N/A

Remarks: Enter zeros if there is no referring/ordering provider.

• Referring physician - is a physician who requests an item or service

for the beneficiary for which payment may be made

under the Medicare program.

• Ordering physician - is a physician or, when appropriate, a non-physician practitioner who orders non-physician services for the patient.

Requirement: Required when available on the claim record.

Data Element: Claim Paid Amount

Definition: Net amount paid after co-insurance and deductible. Do not include

interest you paid in the amount reported.

Validation: N/A

Remarks: Amount of payment made from the Medicare trust fund for the services

covered by the claim record.

Requirement: Required

Data Element: Beneficiary Paid Amount

Definition: Amount paid by Beneficiary to the provider.

Validation: N/A

Remarks: N/A

Requirement: Required if available.

Data Element: Claim Diagnosis Code 1-12

Definition: The ICD-CM diagnosis code identifying the diagnosis, condition,

problem or other reason for the admission/encounter/visit shown in the medical

record to be chiefly responsible for the services provided.

Validation: Must be a valid ICD-CM diagnosis code.

• CMS accepts only CMS approved ICD-CM diagnostic and procedural

codes. The CMS approves only changes issued by the Federal ICD-CM

Coordination and Maintenance Committee.

• Diagnosis codes must be full ICD-CM diagnoses codes, including the full

number of digits (five for ICD-9-CM, seven for ICD-10-CM) where

applicable.

Remarks:

• These fields should be left justified and space filled. For instance if the

primary diagnosis on the claim is five positions long, this field should contain

the diagnosis with 2 spaces at the end.

• With the exception of claims submitted by ambulance suppliers (specialty

type 59), all claims submitted on HCFA 1500 by physician and non-physician

specialties (i.e., PA, NP, CNS, CRNA) use an ICD-CM code number and code

to the highest level of specificity for the date of service. Independent

laboratories enter a diagnosis only for limited coverage procedures. Since this

is a required field, resolution records for claims billed by Ambulance suppliers

and independent clinical laboratories must include the following filler

information when the diagnosis is not otherwise available:

• Ambulance supplier (specialty 59)—amb

• Independent Clinical Lab (specialty 69)--lab

Requirement: Claim Diagnosis 1 is required for ALL claims.

Claim diagnosis codes 2-12 should be submitted if contained on the

claim record. Enter spaces for the diagnosis code fields that are not

populated on the claim record in the Shared Processing System.

Data Element: Claim Diagnosis Version Indicator Code 1-12

Definition: The ICD--CM diagnosis version code identifying the version of

diagnosis code submitted.

Validation:  Version ICD9 use Version Code ‘9’

• Version ICD10 use Version Code ‘0’

• May be blank for claims billed by ambulance and independent

laboratory suppliers.

Remarks: With the exception of claims submitted by ambulance suppliers (specialty type

59), all claims submitted on HCFA 1500 by physician and non-physician

specialties (i.e., PA, NP, CNS, CRNA) use an ICD-CM code number and code to

the highest level of specificity for the date of service. Independent laboratories

enter a diagnosis only for limited coverage procedures.

Requirement: Claim Diagnosis Version Code 1 is required for ALL claims, except

those billed by ambulance and independent laboratories. Claim

diagnosis version codes 2-12 should be submitted to correspond to claim

level diagnosis codes 2-12.

Data Element: Claim Zip Code

Definition: Zip Code used to identify were the service was furnished.

Validation: Must be a valid Zip Code

• This field should be left justified and zero filled. When only a

five digit zip code is carried in the Shared Processing System, this field

will contain the five digit zip code followed by 4 zeros.

Remarks: For DME MAC Claims use the zip code for beneficiary residence.

For Part B Claims, use the zip code identified in item 32 of the HCFA

1500, except in the listed situations.

• For ambulance services, identify the zip code where the patient was

picked up.

• If the service was furnished in the patient’s home, use the zip code from

the patient’s home address.

• For electronic claims, if multiple zip codes are identified enter the zip

code for the line with the highest allowed amount. (If this logic is too

cumbersome to implement, we can live with enter the zip code from the

first line).

Requirement: Required

Data Element: Claim Pricing State

Definition: State where services were furnished.

Validation: Must be a valid 2 digit state abbreviation as defined by the United States

Postal Service (USPS).

Remarks: Furnish the state associated with the Claim Zip Code.

Requirement: Required

Data Element: Beneficiary Zip Code

Definition: Zip Code associated with the beneficiary residence.

Validation: Must be a valid Zip Code

• This field should be left justified and zero filled. When only a

five digit zip code is carried in the Shared Processing System,

this field will contain the five digit zip code followed by 4 zeros.

Remarks: Use the zip code for beneficiary residence.

Requirement: Required

Data Element: Beneficiary State

Definition: State abbreviation identifying the state in which the beneficiary resides.

Validation: Must be a valid 2 digit state abbreviation as defined by the United States Postal

Service (USPS).

Remarks: N/A

Requirement: Required

Data Element: Claim Demonstration Number

Definition: This element is also known as the Claim Demonstration Identification

Number. It is the number assigned to identify a demonstration Project. This

field is also used to denote special processing (a.k.a. Special Processing

Number, SPN).

Validation: Must be a Valid Demo ID.

Remarks: Must be populated with the value from the first populated demonstration

number on the claim.

Requirement: Required on every claim processed under a CMS demonstration project.

Data Element: RAC Adjustment Indicator

Definition: Indicator used to identify RAC requested adjustments, which occur as a

result of post-payment review activities done by the Recovery Audit

Contractors (RAC).

Validation: ‘R’ identifies a RAC-requested adjustment

Remarks: N/A

Requirement: Required when RAC adjustment indicator was furnished to CWF

Data Element: Split/Adjustment Indicator

Definition: Count of number of splits/replicates/adjustments (with different claim

control numbers (ICN/CCN)) of the sampled claim that are included in the

resolution file.

Validation: ‘00’ is used when only one claim control number (ICN/CCN) associated

with the sampled claim is included in the resolution file.

When the resolution file contains multiple adjustments/splits/replicates

associated with a single claim, this field will provide a count of records.

• For example, if the file contains the original, replicate and

adjustment claims, one record would have an indicator of 01,

one record would have an indicator of 02, and the third record

would have an indicator of 03.

Remarks: This indicator does not apply when multiple records are submitted for a

single claim record because of size restrictions.

This field is right justified and zero filled.

Requirement: Required when the resolution file contains multiple versions of a single claim.

Data Element: Facility NPI

Definition: The NPI of the facility at which the service was performed.

Validation: N/A

Remarks: N/A

Requirement: Required when available on the claim record.

Data Element: PWK

Definition: Space reserved for future use.

Validation: N/A

Remarks: N/A

Requirement: Required when available on the claim record.

Data Element: Claim Demonstration Number 2

Definition: This element is also known as the Claim Demonstration Identification

Number. It is the number assigned to identify a demonstration Project. This field is

also used to denote special processing (a.k.a. Special Processing Number,

SPN).

Validation: Must be a Valid Demo ID.

Remarks: Must be populated with the value from the second populated

demonstration number on the claim.

Requirement: Required when present on claim.

Data Element: Claim Demonstration Number 3

Definition: This element is also known as the Claim Demonstration Identification

Number. It is the number assigned to identify a demonstration Project. This field is

also used to denote special processing (a.k.a. Special Processing Number,

SPN).

Validation: Must be a Valid Demo ID.

Remarks: Must be populated with the value from the third populated demonstration

number on the claim.

Requirement: Required when present on claim

Data Element: Claim Demonstration Number 4

Definition: This element is also known as the Claim Demonstration Identification

Number. It is the number assigned to identify a demonstration Project. This field is

also used to denote special processing (a.k.a. Special Processing Number,

SPN).

Validation: Must be a Valid Demo ID

Remarks: Must be populated with the value from the fourth populated

demonstration number on the claim.

Requirement: Required when present on claim

Data Element: Beneficiary MBI

Definition: Beneficiary’s Medicare Beneficiary Identifier

Validation: Comply with CMS Standards

• 11-character, fixed length alpha-numeric string.

• Different, visibly distinguishable from

HICN/RRB

numbers.

• Contain no more than 2 consecutive numbers.

• Contain no more than 2 consecutive alphabetic characters

• Must limit the possibility of letters being

interpreted as

numbers (i.e., alphabetic characters [A…Z]; excluding S,

L, O, I, B, Z).

• Must not contain lowercase letters.

• Must not contain any special characters.

Remarks: Do not include hyphens or spaces.

Requirement: Required

Data Element: HICN/MBI Indicator

Definition: Indicator that identifies if the provider submitted the claim with a HICN

or MBI.

Validation:

M = MBI submitted on the claim

H = HICN submitted on the claim

Remarks: N/A

Requirement: Required

Data Element: Line Item Count

Definition: Number indicating number of service lines on the claim

Validation: Must be a number 01 – 52

Remarks: N/A

Requirement: Required

Data Element: Filler

Definition: Additional space -- use to be determined

Validation: N/A

Remarks: N/A

Requirement: Required

Claim Line Item Fields

Data Element: Performing Provider Number

Definition: Number assigned by the shared system to identify the provider who performed the

service or the supplier who supplied the medical equipment.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Performing Provider Specialty

Definition: Code indicating the primary specialty of the performing provider or

supplier.

Validation: Must be a valid Provider Specialty per IOM 10.4 ch26 10.8.

Remarks: N/A

Requirement: Required

Data Element: HCPCS Procedure Code

Definition: The HCPCS/CPT-4 code that describes the service.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: HCPCS Modifier 1-4

Definition: Codes identifying special circumstances related to the service.

Validation: N/A

Remarks: N/A

Requirement: Required if available

Data Element: Number of Services

Definition: The number of service rendered in days or units.

Validation: N/A

Remarks: Zero filled to maintain the relative position of the decimal point.

The last three positions should contain the value to the right of the

decimal in the number of services. Put a zero in the last three positions for

whole numbers. For example if the number of units is 10, this field would be

filled as 0000010000.

Requirement: Required

Data Element: Service from Date

Definition: The date the service was initiated.

Validation: Must be a valid date less than or equal to Service to Date.

Remarks: Format is CCYYMMDD

Requirement: Required

Data Element: Service to Date

Definition: The date the service ended.

Validation: Must be a valid date greater than or equal to Service from Date.

Remarks: Format is CCYYMMDD.

Requirement: Required

Data Element: Place of Service

Definition: Code that identifies where the service was performed.

Validation: N/A

Remarks: Must be a value in the range of 00-99.

Requirement: Required

Data Element: Type of Service

Definition: Code that classifies the service.

Validation: The code must match a valid CWF type of service code.

Remarks: N/A

Requirement: Required

Data Element: Diagnosis Code

Definition: Code identifying a diagnosed medical condition resulting in the line item service.

Validation: Must be a valid ICD-CM diagnosis code.

• CMS accepts only CMS approved ICD-CM diagnostic and procedural

codes. The CMS approves only changes issued by the Federal ICD-CM

Coordination and Maintenance Committee.

• Diagnosis codes must be full ICD-CM diagnoses codes, including the full

number of digits (five for ICD-9-CM, seven for ICD-10-CM) where

applicable.

Remarks: With the exception of claims submitted by ambulance suppliers (specialty type

59), all claims submitted on HCFA 1500 by physician and non-physician

specialties (i.e., PA, NP, CNS, CRNA) use an ICD-CM code number and code to

the highest level of specificity for the date of service. Independent laboratories

enter a diagnosis only for limited coverage procedures. Since this is a required

field, resolution records for claims billed by Ambulance suppliers and

independent clinical laboratories must include the following filler information

when the diagnosis is not otherwise available:

• Ambulance supplier (specialty 59)—amb

• Independent Clinical Lab (specialty 69)--lab

Requirement: Required

Data Element: Line Diagnosis Code Version Indicator Code

Definition: The ICD--CM diagnosis version code identifying the version of diagnosis code

submitted.

Validation: • Version ICD9 use Version Code ‘9’

• Version ICD10 use Version Code ‘0

• May be blank for claims billed by ambulance and independent

laboratory suppliers.

Remarks: With the exception of claims submitted by ambulance suppliers (specialty type

59), all claims submitted on HCFA 1500 by physician and non-physician

specialties (i.e., PA, NP, CNS, CRNA) use an ICD-CM code number and code to

the highest level of specificity for the date of service. Independent laboratories

enter a diagnosis only for limited coverage procedures.

Requirement: Diagnosis Version Code is required for ALL lines, except those billed by

ambulance and independent clinical laboratory suppliers.

Data Element: CMN Control Number

Definition: Number assigned by the shared system to uniquely identify a Certificate

of Medical Necessity.

Validation: N/A

Remarks: Enter a zero if no number is assigned.

Requirement: Required on DME claims

Data Element: Line Submitted Charge

Definition: Actual charge submitted by the provider or supplier for the service or

equipment.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Line Medicare Initial Allowed Charge

Definition: Amount Medicare allowed for the service or equipment before any

reduction or denial.

Validation: N/A

Remarks: This charge is the lower of the fee schedule or billed amount (i.e., Submitted

Charge), except for those services (e.g., ASC) that are always paid at the fee

schedule amount even if it is higher than the Submitted Charge. If there is no fee

schedule amount, then insert the Submitted Charge.

• Use MPFDB, Clinical Lab FS, Ambulance FS, ASC FS, drug and

injectable FS, or DME fee schedule as appropriate.

Requirement: Required

Data Element: ANSI Reason Code 1-7

Definition: Codes showing the reason for any adjustments to this line, such as denials or

reductions of payment from the amount billed.

Validation: Must be valid ANSI ASC claim adjustment codes and applicable group

codes.

Remarks: Format is GGRRRRRR where: GG is the group code and RRRRRR is

the adjustment reason code.

Requirement: ANSI Reason Code 1 must be present on all claims with resolutions of

'DENMR’, 'DENMC' ,'DEO’, 'RTP’, 'REDMR’, 'REDMC', or

'REO’,’APPAM’,’DENAM’,’REDAM’.

Data Element: Manual Medical Review Indicator

Definition: Code indicating whether or not the service received complex manual medical

review. Complex review goes beyond routine review. It includes the request for,

collection of, and evaluation of medical records or any other documentation in

addition to the documentation on the claim, attached to the claim, or contained in

the MAC’s history file. The review must require professional medical expertise

and must be for the purpose of preventing payments of non-covered or incorrectly

coded services. That includes reviews for the purpose of determining if services

were medically necessary. Professionals must perform the review, i.e., at a

minimum, a Licensed Practical Nurse must perform the review. Review requiring

use of the MAC's history file does not make the review a complex review. A

review is not considered complex if a medical record is requested from a provider

and not received. If sufficient documentation accompanies a claim to allow

complex review to be done without requesting additional documentation, count

the review as complex.

Validation: Must be 'Y’ or ’N’.

Remarks: Set to 'Y’ if service was subjected to complex manual medical review,

else ’N’.

Requirement: Required

Data Element: Resolution Code

Definition: Code indicating how the MAC resolved the line.

Automated Review (AM): An automated review occurs when a claim/line item

passes through the MAC's claims processing system or any adjunct system

containing medical review edits.

Routine Manual Review (MR): Routine review uses human intervention, but only

to the extent that the claim reviewer reviews a claim or any attachment submitted

by the provider. It includes review that involves review of any of the MAC's

internal documentation, such as claims history file or policy documentation. It

does not include review that involves review of medical records or other

documentation requested from a provider. A review is considered routine if a

medical record is requested from a provider and not received. Include prior

authorization reviews in this category.

Complex Manual Review (MC): Complex review goes beyond routine review. It

includes the request for, collection of, and evaluation of medical records or any

other documentation in addition to the documentation on the claim, attached to

the claim, or contained in the MAC’s history file. The review must require

professional medical expertise and must be for the purpose of preventing

payments of non-covered or incorrectly coded services. Professionals must

perform the review, i.e., at a minimum; a Licensed Practical Nurse must perform

the review. Review requiring use of the MAC's history file does not make the

review a complex review. A review is not considered complex if a medical record

is requested from a provider and not received. If sufficient documentation

accompanies a claim to allow complex review to be done without requesting

additional documentation, the review is complex. For instance if all relevant

pages from the patient's medical record are submitted with the claim, complex

MR could be conducted without requesting additional documentation.

Validation: Must be ‘APP’, ‘APPMR’, ’APPMC’, ’DENMR’, ‘DENMC’, ’DEO’,

’RTP’, ‘REDMR’, ‘REDMC’, 'REO’, ’DENAM’, ’REDAM’, ‘DELET’, or

‘TRANS’,

Remarks:

Resolutio

n Code

APP

Descriptio

APPA

APPM

DENA

DENM

Approved as a valid submission without manual

medical review.

Approved after automated medical review

Approved after manual medical review

routine

Approved after manual medical review complex. If

this code is selected, set the Manual Medial Review

Indicator to 'Y.

Denied after automated medical review

Denied for medical review reasons or for

insufficient documentation of medical necessity,

manual medical review routine

Denied for medical review reasons or for insufficient

Requirement: Required

Data Element: Line Final Allowed Charge

Definition: Final Amount allowed for this service or equipment after any reduction or denial.

Validation: N/A

Remarks: This represents the MAC’s value of the service/item gross of co-pays and

deductibles.

Requirement: Required

Data Element: Performing Provider NPI

Definition: NPI assigned to the Performing Provider.

Validation: N/A

Remarks: N/A.

Requirement: Required for providers that use HIPPA standard transactions.

Data Element: Performing Provider UPIN

Definition: Unique Physician Identifier Number (UPIN) that identifies the physician supplier

actually performing/providing the service.

Validation: N/A

Remarks: N/A

Requirement: Required, when available

Data Element: Miles/Time/Units/Services Indicator

Definition: Code indicating the units associated with services needing unit reporting on the

line item for the Part B claim.

Validation: Must be a valid Indicator as identified in IOM 10.4 ch26 10.10.

0- No allowed services

1- Ambulance transportation miles

2- Anesthesia Time Units

3- Services

Resolutio

n Code

Descriptio

DEO

RTP

REDA

REDM

REO

Review Indicator to 'Y.'

Denied for non-medical reasons, other than

denied as unprocessable.

Denied as unprocessable

(return/reject) Reduced after

medical review

Reduced for medical review reasons or for

insufficient documentation of medical necessity,

manual medical review routine

Reduced for medical review reasons or for insufficient

documentation of medical necessity, manual medical

review complex. If this code is selected, set the

Manual Medial Review Indicator to 'Y.'

Reduced for non-medical review reasons.

Claim deleted from processing system—AC

maintains record of claim on system

4- Oxygen units

5- Units of Blood

Remarks: N/A

Requirement: Required

Data Element: Line Deductible Applied

Definition: Amount of deductible applied for this service or equipment.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Line Co-Insurance Amount

Definition: Amount of co-insurance due for this service or equipment.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Line Paid Amount

Definition: Amount of payment made from the trust funds (after deductible and

coinsurance amounts have been paid) for the line item service on the

non-institutional claim.

Validation: N/A

Remarks: This represents the MAC’s value of the claim after co-pays and

deductibles.

Requirement: Required

Data Element: Line MSP Code

Definition: Code indicating primary payor for services on this line item.

Validation: A-Working Aged

B-ESRD

D-No-Fault

E-Workers' Compensation

F-Federal (Public Health)

G-Disabled

H-Black Lung

I-Veterans

L-Liability

Remarks: N/A

Requirement: Required, when contained on the claim record.

Data Element: Line MSP Paid Amount

Definition: The amount paid by the primary payer when the payer is primary to

Medicare (Medicare is secondary or tertiary).

Validation: N/A

Remarks: Amount paid by Primary Payer

Requirement: Required, when contained on the claim record.

Data Element: Line Pricing Locality

Definition: Code denoting the MAC-specific locality used for pricing this claim.

Validation: Must be a valid pricing locality.

• Enter ‘00’ for claims priced at a statewide locality.

Requirement: Required

Data Element: Line Zip Code

Definition: Zip Code used to determine claim pricing locality.

Validation: Must be a valid Zip Code

This field should be left justified and zero filled. When only a five digit

zip code is carried in the Shared Processing System, this field will

contain the five digit zip code followed by 4 zeros.

Remarks: For DME Claims use the zip code for beneficiary residence.

For Part B Claims, use the zip code identified in item 32 of the HCFA

1500, unless the service was furnished in the patient’s home. If the service

was furnished in the patient’s home, use the zip code from the patient’s home

address.

Requirement: Required

Data Element: Line Pricing State

Definition: State where services were furnished.

Validation: Must be a valid 2 digit state abbreviation as defined by the United States

Postal Service (USPS).

Remarks: Furnish the state associated with the Line Zip Code.

Requirement: Required

Data Element: Ambulance Point of Pick-up Zip Code

Definition: Zip Code identifying the ambulance point of pick up.

Validation: Must be a valid Zip Code.

Remarks: This field should be left justified and zero filled. When only a five digit

zip code is carried in the Shared Processing System, this field will

contain the five digit zip code followed by 4 zeros.

Requirement: Required for ambulance claims

Data Element: Ambulance Drop Off Zip Code

Definition: Zip Code identifying the ambulance drop off point.

Validation: Must be a valid Zip Code.

Remarks: This field should be left justified and zero filled. When only a five digit

zip code is carried in the Shared Processing System, this field will

contain the five digit zip code followed by 4 zeros.

Requirement: Required for ambulance claims

Data Element: PWK

Definition: Space reserved for future use.

Validation: N/A

Remarks: N/A

Requirement: Required when available on the claim record

Data Element: Prior Authorization Program Indicator

Definition: Prior Authorization Program Indicator issued by CMS to identify to

which PA program the service belongs

Validation:  Four character alphanumeric

• The first character identifies the line of business

• A for Part A,

• B for Part B,

• D for DME,

• H for Home Health and Hospice

• Followed by a three digit number

Remarks: N/A

Requirement: Required for claims containing services subject to a prior authorization

program.

Data Element: Unique Tracking Number (UTN)

Definition: Unique Tracking Number (UTN) assigned to the prior authorization

request for the service or item.

Validation: For Prior Authorization Claims/services the UTN shall be 14 characters

and use the following format:

• First two characters = MAC identifier (e.g. RR for Railroad, 0F for

Jurisdiction F, 05 for Jurisdiction 5, etc.).

• Third character = line of business (e.g. A for Part A, B for Part B, D for

DME, H for Home Health and Hospice).

• Remaining numerical characters = a unique sequence number assigned by

the Shared System.

For claims/services in the PMD Prior Authorization Project, the

UTN shall be 14 characters and use the following format:

• First character = DME MAC identifier (e.g. A for Jurisdiction A, B for

Jurisdiction B, etc.).

• Second and third characters = 00 (zero and zero).

• Remaining characters = a unique sequence number assigned by the Shared

System.

Remarks: N/A

Requirement: Required for claims containing services covered by an affirmed prior

authorization.

Data Element: Prior Auth Affirmed

Definition: Code to identify if the prior authorization for the service(s) on this line

was affirmed.

Validation:  Y indicates the prior authorization was affirmed.

 N indicates the prior authorization was not affirmed.

 Default value is blank for services that are not part of prior

authorization demonstration.

Remarks: N/A

Requirement: Required for claims containing services subject to prior authorization in

the state where the service was furnished.

Data Element: Filler

Definition: Additional space TBD.

Validation: N/A

Remarks: N/A

Requirement: None

Claims Resolution File

Claims Resolution Trailer Record (one record per file)

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 ‘3’

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Number of Claims 9(9) 9 1617 Zeroes

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number.

Validation: Must be a valid CMS contractor ID.

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (B): When multiple workloads share a single processing

environment, the Contractor ID will reflect the contractor ID of the

primary workload.

Data Element: Record Type

Definition: Code indicating type of record.

Validation: N/A

Remarks: 3 = Trailer Record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Resolution file.

Validation: Claim Resolution files prior to 7/1/2007 did not contain this field.

Codes:

B = Record Format as of 7/1/2007

C = Record Format as of 1/1/2010

D = Record Format as of 7/1/2016

E = Record Format as of 10/1/2017

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor.

Validation: Must be ‘B’ or ‘D’

Remarks: B = A/B MAC (B)

D = DME MAC

Requirement: Required

Data Element: Number of Claims

Definition: Number of claim records on this file.

Validation: Must be equal to the number of claim records on the file.

Remarks: Do not count header or trailer records.

Requirement: Required

Claims Provider Address File

Claims Provider Address Header Record (one record per file)

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 ‘1’

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Provider Address Date X(8) 9 16 Spaces

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number.

Validation: Must be a valid CMS contractor ID.

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (B): when multiple workloads share a single processing

environment, the Contractor ID will reflect the contractor ID of the

primary workload.

Data Element: Record Type

Definition: Code indicating type of record.

Validation: N/A

Remarks: 1 = Header record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Provider Address

file.

Validation: Claim Provider Address files prior to 7/1/2007 did not contain this field.

Codes:

B = Record Format as of 7/1/2007

C = Record Format as of 1/1/2010

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor.

Validation: Must be ‘B’ or ‘D’

Remarks: B = A/B MAC (B)

D = DME MAC

Requirement: Required

Data Element: Provider Address Date

Definition: Date the Provider Address File was created.

Validation: Must be a valid date not equal to a Provider Address date sent on any

previous claims Provider Address file.

Remarks: Format is CCYYMMDD. May use shared system batch processing date.

Requirement: Required

Provider Address File

Provider Address Detail Record

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 ’2’

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Provider Number/NPI X(15) 9 23 Spaces

Provider Name X(60) 24 83 Spaces

Provider Address 1 X(25) 84 108 Spaces

Provider Address 2 X(25) 109 133 Spaces

Provider City X(15) 134 148 Spaces

Provider State Code X(2) 149 150 Spaces

Provider Zip Code X(9) 151 159 Spaces

Provider Phone Number X(10) 160 169 Spaces

Provider Phone Number Extension X(10) 170 179 Spaces

Provider Fax Number X(10) 180 189 Spaces

Provider Type X(2) 190 191 Spaces

Provider Address Order X(2) 192 193 Spaces

Provider Address Type 9(3) 194 196 Zero

Provider E-mail Address X(75) 197 271 Spaces

Provider Federal Tax number or EIN 9(10) 272 281 Zeroes

Provider Taxonomy Code 9(10) 282 291 Zeroes

Provider License Number X(16) 292 307 Spaces

Provider License State X(2) 308 309 Spaces

Filler X(25) 310 334 Spaces

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number.

Validation: Must be a valid CMS contractor ID.

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (B): when multiple workloads share a single processing

environment, the Contractor ID will reflect the contractor ID of the

primary workload.

Data Element: Record Type

Definition: Code indicating type of record.

Validation: N/A

Remarks: 2 = claim record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Claim Universe file.

Validation: Claim Universe files prior to 7/1/2007 did not contain this field.

Codes:

B = Record Format as of 7/1/2007

C = Record Format as of 1/1/2010

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor.

Validation: Must be ‘B’ or ‘D’

Remarks: B = A/B MAC (B)

D = DME MAC

Requirement: Required

Data Element: Provider Number/NPI

Definition: Number assigned by the MAC/NSC or NPI agency to identify the provider.

Validation: N/A

Remarks: N/A

Requirement: Required

Data Element: Provider Name

Definition: Provider’s name.

Validation: N/A

Remarks: This is the name of the provider.

The provider name must be formatted into a business name for mailing

(e.g. Roger A Smith M.D. or Medical Associates, Inc).

Where possible this should contain the Legal Business Name as carried

in the Shared Processing System.

Requirement: Required

Data Element: Provider Address 1

Definition: 1st line of provider’s address.

Validation: N/A

Remarks: This is the address1 of the provider.

Requirement: Required

Data Element: Provider Address 2

Definition: 2nd line of provider’s address.

Validation: N/A

Remarks: This is the address2 of the provider.

Requirement: Required if available

Data Element: Provider City

Definition: Provider’s city name.

Validation: N/A

Remarks: This is the city of the provider’s address.

Requirement: Required

Data Element: Provider State Code

Definition: Provider’s state code.

Validation: Must be a valid state code.

Remarks: This is the state of the provider’s address.

Requirement: Required

Data Element: Provider Zip Code

Definition: Provider’s zip code.

Validation: Must be a valid postal zip code.

Remarks: This is the zip code of the provider’s address. Provide 9-digit zip code if

available, otherwise provide 5-digit zip code.

This field should be left justified and zero filled. When only a five digit

zip code is carried in the Shared Processing System, this field will

contain the five digit zip code followed by 4 zeros.

Requirement: Required

Data Element: Provider Phone Number

Definition: Provider’s telephone number..

Validation: Must be a valid telephone number.

Remarks: This is the phone number.

Requirement: None

Data Element: Provider Phone Number Extension

Definition: Provider’s telephone number Extension.

Validation: Must be a valid telephone number.

Remarks: This is the phone number.

Requirement: None

Data Element: Provider Fax Number

Definition: Provider’s fax number

Validation: Must be a valid fax number.

Remarks: This is the fax number of the provider.

Requirement: None

Data Element: Provider Type

Definition: 1=Billing/pricing provider number (Assigned by MAC or NSC).

2=Referring/ordering provider (UPIN)

3=Performing/rendering provider (Assigned by MAC or NSC)

4=Entity is both billing/pricing and performing/rendering provider

5=Entity is both referring/ordering and performing/rendering provider

6=Entity is all (billing/pricing AND referring/ordering AND

performing/rendering provider)

7=Billing/pricing provider number (NPI)

8=Referring/ordering provider (NPI)

9=Performing/rendering provider (NPI)

10=Entity is both billing/pricing and performing/rendering provider

(NPI)

11=Entity is both referring/ordering and performing/rendering provider

(NPI)

12=Entity is all (billing/pricing AND referring/ordering AND

performing/rendering provider) (NPI)

Validation: Must be a valid provider type.

Remarks: This field indicates for which provider number associated with a

sampled claim the address information is furnished.

Requirement: Required

Data Element: Address Order

Definition: The order in which the records of provider addresses for the provider are

entered into the provider address file detailed record. This field in

combination with the Contractor ID, Provider number, and Provider. Type

will make each record in the file unique.

Validation: Must be a valid number between 01 and 99

Remarks: This field indicated the order in which records containing the addresses

for a provider are entered into the detail file. For instance, if there are

three addresses for a provider, the record for the first address for that provider

with contain an ‘01’ in this field; and the record for the second address for that

provider will contain a ’02’ in this field.

Requirement: Required

Data Element: Provider Address Type

Definition: The type of Provider Address furnished.

Validation: 1 = Practice Address (MCS)

Provider address (VMS)

2 = Pay To Address (MCS)

Payee Address (VMS)

3 = Billing Address (VMS)

4 = Correspondence Address

5 = Medical Record Address

Remarks: The first “address type” for each provider will always be a “1.”

Subsequent occurrences of addresses for the same provider will have the

“address type” to correspond to the address submitted. When your files contain

only one address for the provider, submit only one provider address record.

Submit additional address records for a single provider number only when your files

contain addresses that differ from the

Master or Legal address.

• Correspondence Address—The Correspondence Address as indicated on the

855. This is the address and telephone number where

Medicare can directly get in touch with the enrolling provider. This

address cannot be that of the billing agency, management service

organization, or staffing company.

• Medical Record Address—the Location of Patients’ Medical Records as

indicated on the 855. This information is required if the Patients’ Medical

Records are stored at a location other than the Master

Address (practice location). Post Office Boxes and Drop Boxes are not

acceptable as the physical address where patient’s medical records are

maintained

Requirement: Required

Data Element: Provider E-Mail Address

Definition: Provider’s e-mail address

Validation: Must be a valid e-mail address

Remarks: N/A

Requirement: Required if available

Data Element: Provider Federal Tax Number or EIN

Definition: The number assigned to the provider by the Federal government for tax

report purposes. The Federal Tax Number is also known as a tax

identification number (TIN) or employer identification number (EIN).

Validation: Must be present.

Remarks: N/A

Requirement: Required for all provider numbers.

Data Element: Provider Taxonomy Code

Definition: The non- medical data code set used to classify health care providers

according to provider type or practitioner specialty in an electronic

environment, specifically within the American National Standards

Institute Accredited Standards Committee health care transaction.

Validation: Must be present

Remarks: If multiple taxonomy codes are available, furnish the first one listed.

Requirement: Required if available

Data Element: Provider License Number

Definition: The professional business license required to provide health care services.

Validation: Must be present

Remarks: N/A

Requirement: Required if available

Data Element: Provider License State

Definition: Identify the state that issued the providers professional business license.

Validation: Must be a valid 2 digit state abbreviation as defined by the United States

Postal Service (USPS).

Remarks: N/A

Requirement: Required if available.

Data Element: Filler

Definition: Additional space TBD.

Validation: N/A

Remarks: N/A

Requirement: N/A

Claims Provider Address File

Claims Provider Address Trailer Record (one record per file)

Field Name Picture From Thru Initialization

Contractor ID X(5) 1 5 Spaces

Record Type X(1) 6 6 ‘3’

Record Version Code X(1) 7 7 Spaces

Contractor Type X(1) 8 8 Spaces

Number of Records 9(9) 9 17 Zeroes

DATA ELEMENT DETAIL

Data Element: Contractor ID

Definition: Contractor’s CMS assigned number.

Validation: Must be a valid CMS contractor ID.

Remarks: N/A

Requirement: Required

NOTE: For A/B MAC (B): When multiple workloads share a single processing

environment, the Contractor ID will reflect the contractor ID of the

primary workload.

Data Element: Record Type

Definition: Code indicating type of record.

Validation: N/A

Remarks: 3 = Trailer Record

Requirement: Required

Data Element: Record Version Code

Definition: The code indicating the record version of the Provider Address file.

Validation: Provider Address files prior to 7/1/2007 did not contain this field.

Codes:

B = Record Format as of 7/1/2007

C = Record Format as of 1/1/2010

Remarks: N/A

Requirement: Required

Data Element: Contractor Type

Definition: Type of Medicare Contractor.

Validation: Must be ‘B’ or ‘D’

Remarks: B = A/B MAC (B)

D = DME MAC

Requirement: Required

Data Element: Number of Records

Definition: Number of provider records on this file.

Validation: Must be equal to the number of provider records on the file.

Remarks: Do not count header or trailer records.

Requirement: Required

Exhibit 37 - Office of Inspector General, Office of Investigations Data Use

Agreement

(Rev. 176, Issued: 11-24-06, Effective: 12-26-06, Implementation: 12-26-06)

DUA #:

(to be completed by CMS Staff)

OFFICE OF INSPECTOR GENERAL, OFFICE OF INVESTIGATIONS DATA USE

AGREEMENT

I, , representing the Office of Inspector General (OIG), Office of

Investigations (OI), will observe the following in the use of the Centers for Medicare & Medicaid Services (CMS) files

released to me:

A. Purpose:

B. The following CMS data file(s) is/are covered under this Agreement.

Description of Data/File Year(s) System of Record

(to be completed by CMS Staff)

1. The files will be used only for purposes authorized by the Inspector General Act of 1978 or other applicable law.

2. No information in the files released to the OIG will be used or disclosed except in strict accordance with all applicable

confidentiality laws and regulations. Where practicable and consistent with OIG oversight responsibilities, the OIG will

notify CMS of files extracted or derived from these files are disclosed pursuant to Federal disclosure and

confidentiality laws.

3. The information sought in this request is required to be produced to the Office of Investigations pursuant to the

Inspector General Act 1978, U.S.C. App. The information is also sought by the OIG in its capacity as a health

oversight agency, and this information is necessary to further health oversight activities. Disclosure is therefore

permitted under the Health Insurance Portability and Accountability Act (HIPAA) Standards for Privacy of

Individually Identifiable Health Information, 45 C.F.R. 164.501; 164.512(a); and 164.512(d).

4. will be designated as custodian of these files and will be

responsible for establishment and maintenance of security arrangements to prevent unauthorized use. If the

custodianship is transferred within the organization, CMS will be notified.

5. No listings or information from individual records, with identifiers will be published or otherwise released outside of

those deemed appropriate by OIG to perform the legal scope of OIG duties and responsibilities.

6. The OIG needs to retain these files for up to 10 years. CMS will contact the OIG representative at the end of 5 years to

confirm either that data will be destroyed or that OIG has a continuing need for the data. CMS will document its

tracking system to indicate OIG’s need for retention or destruction.

OIG Representative- Printed:

Phone Number:

Email Address:

Street Address:

City:

State:

Zip Code:

Signature:

Date:

Name of Custodian of Files, If Different:

Phone Number:

E-mail Address:

Street Address:

City:

State:

Zip Code:

CMS Representative- Printed:

Signature:

Date:

History

(Rev. 726, Issued: 06-16-17, Effective: 10-01-17, Implementation: 01-02-18 - For VMS and MCS for Business Requirements 11 through 22 and 22.1; 10-02-17 - For FISS)

Provenance

Source: cms.gov
Retrieved: 2026-08-25
Edition: iom-2026-08-25
Content hash: cbb3d6873e4163159bfa06bc1faafa5b6a0308cbbe5ce608322ed47c4deaf6e8

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