1 |
BENE_ID |
Encrypted CCW Beneficiary ID |
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2 |
CLM_ID |
Claim ID |
* |
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3 |
RIC_CD |
NCH Near Line Record Identification Code |
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* |
4 |
CLM_TYPE |
NCH Claim Type Code |
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* |
5 |
FROM_DT |
Claim From Date |
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6 |
THRU_DT |
Claim Through Date |
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7 |
WKLY_DT |
NCH Weekly Claim Processing Date |
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8 |
FI_CLM_PROC_DT |
FI Claim Process Date |
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9 |
QUERY_CD |
Claim Query Code |
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* |
10 |
PROVIDER |
Provider Number |
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* |
11 |
FAC_TYPE |
Claim Facility Type Code |
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* |
12 |
TYPESRVC |
Claim Service Classification Type Code |
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* |
13 |
FREQ_CD |
Claim Frequency Code |
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* |
14 |
FI_NUM |
FI Number |
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* |
15 |
NOPAY_CD |
Claim Medicare Non Payment Reason Code |
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* |
16 |
PMT_AMT |
Claim Payment Amount |
* |
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17 |
PRPAYAMT |
NCH Primary Payer Claim Paid Amount* |
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18 |
PRPAY_CD |
NCH Primary Payer Code |
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* |
19 |
PRSTATE |
NCH Provider State Code |
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* |
20 |
ORGNPINM |
Organization NPI Number |
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21 |
SRVC_LOC_NPI_NUM |
Claim Service Location NPI Number |
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22 |
AT_UPIN |
Claim Attending Physician UPIN Number |
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23 |
AT_NPI |
Claim Attending Physician NPI Number |
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24 |
AT_PHYSN_SPCLTY_CD |
Claim Attending Physician Specialty Code |
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* |
25 |
OP_UPIN |
Claim Operating Physician UPIN Number |
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26 |
OP_NPI |
Claim Operating Physician NPI Number |
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27 |
OP_PHYSN_SPCLTY_CD |
Claim Operating Physician Specialty Code |
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* |
28 |
OT_UPIN |
Claim Other Physician UPIN Number |
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29 |
OT_NPI |
Claim Other Physician NPI Number |
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30 |
OT_PHYSN_SPCLTY_CD |
Claim Other Physician Specialty Code |
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* |
31 |
RNDRNG_PHYSN_NPI |
Claim Rendering Physician NPI Number |
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32 |
RNDRNG_PHYSN_SPCLTY_CD |
Claim Rendering Physician Specialty Code |
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* |
33 |
RFR_PHYSN_NPI |
Claim Referring Physician NPI Number |
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34 |
RFR_PHYSN_SPCLTY_CD |
Claim Referring Physician Specialty Code |
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* |
35 |
MCOPDSW |
Claim MCO Paid Switch |
* |
* |
36 |
STUS_CD |
Patient Discharge Status Code |
|
* |
37 |
TOT_CHRG |
Claim Total Charge Amount |
* |
* |
38 |
BLDDEDAM |
NCH Beneficiary Blood Deductible Liability Amount |
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* |
39 |
PCCHGAMT |
NCH Professional Component Charge Amount |
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* |
40 |
PRNCPAL_DGNS_CD |
Claim Principal Diagnosis Code |
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41 |
ICD_DGNS_CD1 |
Claim Diagnosis Code I |
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42 |
ICD_DGNS_CD2 |
Claim Diagnosis Code II |
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43 |
ICD_DGNS_CD3 |
Claim Diagnosis Code III |
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44 |
ICD_DGNS_CD4 |
Claim Diagnosis Code IV |
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45 |
ICD_DGNS_CD5 |
Claim Diagnosis Code V |
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46 |
ICD_DGNS_CD6 |
Claim Diagnosis Code VI |
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47 |
ICD_DGNS_CD7 |
Claim Diagnosis Code VII |
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48 |
ICD_DGNS_CD8 |
Claim Diagnosis Code VIII |
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49 |
ICD_DGNS_CD9 |
Claim Diagnosis Code IX |
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50 |
ICD_DGNS_CD10 |
Claim Diagnosis Code X |
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51 |
ICD_DGNS_CD11 |
Claim Diagnosis Code XI |
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52 |
ICD_DGNS_CD12 |
Claim Diagnosis Code XII |
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53 |
ICD_DGNS_CD13 |
Claim Diagnosis Code XIII |
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54 |
ICD_DGNS_CD14 |
Claim Diagnosis Code XIV |
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55 |
ICD_DGNS_CD15 |
Claim Diagnosis Code XV |
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56 |
ICD_DGNS_CD16 |
Claim Diagnosis Code XVI |
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57 |
ICD_DGNS_CD17 |
Claim Diagnosis Code XVII |
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58 |
ICD_DGNS_CD18 |
Claim Diagnosis Code XVIII |
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59 |
ICD_DGNS_CD19 |
Claim Diagnosis Code XIX |
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60 |
ICD_DGNS_CD20 |
Claim Diagnosis Code XX |
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61 |
ICD_DGNS_CD21 |
Claim Diagnosis Code XXI |
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62 |
ICD_DGNS_CD22 |
Claim Diagnosis Code XXII |
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63 |
ICD_DGNS_CD23 |
Claim Diagnosis Code XXIII |
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64 |
ICD_DGNS_CD24 |
Claim Diagnosis Code XXIV |
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65 |
ICD_DGNS_CD25 |
Claim Diagnosis Code XXV |
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66 |
FST_DGNS_E_CD |
First Claim Diagnosis E Code |
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67 |
ICD_DGNS_E_CD1 |
Claim Diagnosis E Code I |
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68 |
ICD_DGNS_E_CD2 |
Claim Diagnosis E Code II |
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69 |
ICD_DGNS_E_CD3 |
Claim Diagnosis E Code III |
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70 |
ICD_DGNS_E_CD4 |
Claim Diagnosis E Code IV |
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71 |
ICD_DGNS_E_CD5 |
Claim Diagnosis E Code V |
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72 |
ICD_DGNS_E_CD6 |
Claim Diagnosis E Code VI |
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73 |
ICD_DGNS_E_CD7 |
Claim Diagnosis E Code VII |
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74 |
ICD_DGNS_E_CD8 |
Claim Diagnosis E Code VIII |
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75 |
ICD_DGNS_E_CD9 |
Claim Diagnosis E Code IX |
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76 |
ICD_DGNS_E_CD10 |
Claim Diagnosis E Code X |
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77 |
ICD_DGNS_E_CD11 |
Claim Diagnosis E Code XI |
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78 |
ICD_DGNS_E_CD12 |
Claim Diagnosis E Code XII |
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79 |
ICD_PRCDR_CD1 |
Claim Procedure Code I |
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80 |
PRCDR_DT1 |
Claim Procedure Code I Date |
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81 |
ICD_PRCDR_CD2 |
Claim Procedure Code II |
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82 |
PRCDR_DT2 |
Claim Procedure Code II Date |
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83 |
ICD_PRCDR_CD3 |
Claim Procedure Code III |
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84 |
PRCDR_DT3 |
Claim Procedure Code III Date |
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85 |
ICD_PRCDR_CD4 |
Claim Procedure Code IV |
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86 |
PRCDR_DT4 |
Claim Procedure Code IV Date |
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87 |
ICD_PRCDR_CD5 |
Claim Procedure Code V |
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88 |
PRCDR_DT5 |
Claim Procedure Code V Date |
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89 |
ICD_PRCDR_CD6 |
Claim Procedure Code VI |
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90 |
PRCDR_DT6 |
Claim Procedure Code VI Date |
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91 |
ICD_PRCDR_CD7 |
Claim Procedure Code VII |
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92 |
PRCDR_DT7 |
Claim Procedure Code VII Date |
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93 |
ICD_PRCDR_CD8 |
Claim Procedure Code VIII |
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94 |
PRCDR_DT8 |
Claim Procedure Code VIII Date |
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95 |
ICD_PRCDR_CD9 |
Claim Procedure Code IX |
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96 |
PRCDR_DT9 |
Claim Procedure Code IX Date |
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97 |
ICD_PRCDR_CD10 |
Claim Procedure Code X |
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98 |
PRCDR_DT10 |
Claim Procedure Code X Date |
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99 |
ICD_PRCDR_CD11 |
Claim Procedure Code XI |
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100 |
PRCDR_DT11 |
Claim Procedure Code XI Date |
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101 |
ICD_PRCDR_CD12 |
Claim Procedure Code XII |
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102 |
PRCDR_DT12 |
Claim Procedure Code XII Date |
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103 |
ICD_PRCDR_CD13 |
Claim Procedure Code XIII |
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104 |
PRCDR_DT13 |
Claim Procedure Code XIII Date |
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105 |
ICD_PRCDR_CD14 |
Claim Procedure Code XIV |
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106 |
PRCDR_DT14 |
Claim Procedure Code XIV Date |
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107 |
ICD_PRCDR_CD15 |
Claim Procedure Code XV |
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108 |
PRCDR_DT15 |
Claim Procedure Code XV Date |
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109 |
ICD_PRCDR_CD16 |
Claim Procedure Code XVI |
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110 |
PRCDR_DT16 |
Claim Procedure Code XVI Date |
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111 |
ICD_PRCDR_CD17 |
Claim Procedure Code XVII |
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112 |
PRCDR_DT17 |
Claim Procedure Code XVII Date |
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113 |
ICD_PRCDR_CD18 |
Claim Procedure Code XVIII |
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114 |
PRCDR_DT18 |
Claim Procedure Code XVIII Date |
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115 |
ICD_PRCDR_CD19 |
Claim Procedure Code XIX |
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116 |
PRCDR_DT19 |
Claim Procedure Code XIX Date |
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117 |
ICD_PRCDR_CD20 |
Claim Procedure Code XX |
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118 |
PRCDR_DT20 |
Claim Procedure Code XX Date |
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119 |
ICD_PRCDR_CD21 |
Claim Procedure Code XXI |
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120 |
PRCDR_DT21 |
Claim Procedure Code XXI Date |
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121 |
ICD_PRCDR_CD22 |
Claim Procedure Code XXII |
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122 |
PRCDR_DT22 |
Claim Procedure Code XXII Date |
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123 |
ICD_PRCDR_CD23 |
Claim Procedure Code XXIII |
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124 |
PRCDR_DT23 |
Claim Procedure Code XXIII Date |
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125 |
ICD_PRCDR_CD24 |
Claim Procedure Code XXIV |
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126 |
PRCDR_DT24 |
Claim Procedure Code XXIV Date |
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127 |
ICD_PRCDR_CD25 |
Claim Procedure Code XXV |
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128 |
PRCDR_DT25 |
Claim Procedure Code XXV Date |
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129 |
RSN_VISIT_CD1 |
Reason for Visit Diagnosis Code I |
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130 |
RSN_VISIT_CD2 |
Reason for Visit Diagnosis Code II |
|
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131 |
RSN_VISIT_CD3 |
Reason for Visit Diagnosis Code III |
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132 |
PTB_DED |
NCH Beneficiary Part B Deductible Amount |
|
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133 |
PTB_COIN |
NCH Beneficiary Part B Coinsurance Amount |
|
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134 |
PRVDRPMT |
Claim Outpatient Provider Payment Amount |
|
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135 |
BENEPMT |
Claim Outpatient Beneficiary Payment Amount |
|
* |
136 |
DOB_DT |
Date of Birth from Claim (Date) |
|
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137 |
GNDR_CD |
Gender Code from Claim |
|
* |
138 |
RACE_CD |
Race Code from Claim |
|
* |
139 |
CNTY_CD |
County Code from Claim (SSA) |
|
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140 |
STATE_CD |
State Code from Claim (SSA) |
|
* |
141 |
ZIP_CD |
Zip Code of Residence from Claim |
|
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142 |
CLM_MDCL_REC |
Claim Medical Record Number |
|
|
143 |
ACTIONCD |
FI or MAC Claim Action Code |
|
* |
144 |
BLDFRNSH |
NCH Blood Pints Furnished Quantity |
|
|
145 |
CLM_TRTMT_AUTHRZTN_NUM |
Claim Treatment Authorization Number |
|
* |
146 |
CLM_PRCR_RTRN_CD |
Claim Pricer Return Code |
|
* |
147 |
CLM_SRVC_FAC_ZIP_CD |
Claim service facility ZIP code (where service was provided) |
|
* |
148 |
CLM_OP_TRANS_TYPE_CD |
Claim Outpatient transaction type |
|
* |
149 |
CLM_OP_ESRD_MTHD_CD |
Claim Outpatient End Stage Renal Disease (ESRD) Method of Reimbursement Code |
|
* |
150 |
CLM_NEXT_GNRTN_ACO_IND_1_CD |
Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - Population based payments (PBP) |
|
* |
151 |
CLM_NEXT_GNRTN_ACO_IND_2_CD |
Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - Telehealth |
|
* |
152 |
CLM_NEXT_GNRTN_ACO_IND_3_CD |
Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - Post Discharge HH visits |
|
* |
153 |
CLM_NEXT_GNRTN_ACO_IND_4_CD |
Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - 3 day SNF waiver |
|
* |
154 |
CLM_NEXT_GNRTN_ACO_IND_5_CD |
Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - Capitation |
|
* |
155 |
ACO_ID_NUM |
Claim Accountable Care Organization (ACO) Identification Number |
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|