Form CMS-10501 Data Submission Template

Healthcare Fraud Prevention Partnership (HFPP): Data Sharing and Information Exchange

Data Submission Template PRA Package 411

Generalized Claims Data Call Submission

OMB: 0938-1251

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DATA SUBMISSION TEMPLATE

OMB # 0938-1251/Expiration Date: XX/2020

Date Submitted






Partner Name






Contact Information



Submitter Name



Submitter Address



Submitter Email Address



Submitter Telephone Number






Submission Information

Default Response (change as needed)

Alternatives

Media

Portal upload

Encrypted CD/DVD/Hard drive

Frequency

Monthly

Quarterly, Semi-annual

Estimated date of initial submission



File format

Pipe-delimited CSV format

See Instructions

Data element differences

No

If Yes, enter on next sheet

Member/beneficiary identification type

Full SSN

See Instructions


11/23/2016 8:18 AM



TTP DEFAULT FORMATS FOR PROFESSIONAL CLAIMS

Seq

Professional Data Elements

Data Element Description

Data Type Format

Expected Values

1

Payer Name

Name of entity Providing source data

VARCHAR(40)


2

File Type

The type of file being reported. (i.e. professional; Institutional; Pharmacy, Dental)

CHAR(2)

Professional=P

Institutional-I Pharmacy =RX

Dental=D

3

Line of Business

Payer Identifier and Line of Business

VARCHAR(40)

e.g., Medicare, Medicaid, Private,

P&C

4

Claim Number

A unique number assigned by the payment system that identifies an original claim or an adjusted claim.

VARCHAR(20)


5

Claim Line Number

Line number on the claim

INTEGER(3)


6

Member ID

A unique identification number for the member.

VARCHAR(20)


7

Member Social

Security Number

Member's social security number (full 9 or last 4 numbers).

INTEGER


8

Member Sex

The sex of the member

CHAR(1)

Male= M

Female=F

Unidentified=U

9

Member Date of Birth

Member’s Date of Birth.

DATE

MM/DD/YYYY

10

Member State

Member’s state

CHAR(2)

State Abbreviation

11

Member Zip Code

Member’s zip code

INTEGER(5)


12

Member DOD

Member’s Date of Death.

DATE

MM/DD/YYYY

13

Rendering Provider

Legal Business Name

Official name of rendering provider organization or if individual, in format LAST SUFFIX, FIRST MIDDLE

VARCHAR(100)


14

Rendering Provider

Doing Business As

Name

Name provider renders services under or is known to public by for organizations or

if individual, in format LAST SUFFIX, FIRST MIDDLE

VARCHAR(100)


15

Rendering Provider

NPI

The NPI for the provider who treated the member (as opposed to the provider “billing” for the service).

INTEGER(10)


16

Rendering Provider

TIN

Taxpayer Identification Number for provider who treated the member

INTEGER(10)


17

Rendering Provider

EIN

The EIN for the provider who treated the

member

INTEGER(10)


18

Rendering Provider

Taxonomy

The taxonomy code for the provider who treated the member (as opposed to the provider “billing” for the service).

VARCHAR(10)


19

Rendering Provider

Specialty

Code that describes the area of specialty for the provider treating the member

VARCHAR

Please provide your specialty code definitions


Seq

Professional Data Elements

Data Element Description

Data Type Format

Expected Values

20

Rendering Provider

Practice Address Line

1

US Address line 1 at which provider renders service

VARCHAR(100)


21

Rendering Provider

Practice Address Line

2

US Address line 2 at which provider renders service

VARCHAR(50)


22

Rendering Provider

Practice City

US City in which provider renders service

VARCHAR(50)


23

Rendering Provider

Practice State

US State in which provider renders service

CHAR(2)

State Abbreviation

24

Rendering Provider

Practice Zip

USPS Zip Code in which provider renders service

INTEGER(5)


25

Billing Provider Legal

Business Name

Official name of billing provider organization or if individual, in format LAST SUFFIX, FIRST MIDDLE

VARCHAR(100)


26

Billing Provider Doing

Business As Name

Name billing provider is known to public

by for organizations or if individual, in format LAST SUFFIX, FIRST MIDDLE

VARCHAR(100)


27

Billing Provider TIN

Billing Provider Taxpayer Identification

Number

INTEGER(10)


28

Billing Provider

Address Line 1

US Address line 1 that represents the entity billing address

VARCHAR(100)


29

Billing Provider

Address Line 2

US Address line 2 that represents the entity billing address

VARCHAR(50)


30

Billing Provider City

US City for billing entity

VARCHAR(50)


31

Billing Provider State

US State for billing entity

CHAR(2)

State Abbreviation

32

Billing Provider Zip

USPS Zip Code for billing entity

INTEGER(5)


33

Referring Provider

Legal Business Name

Official name of referring provider organization or if individual, in format LAST SUFFIX, FIRST MIDDLE

VARCHAR(100)


34

Referring Provider

Doing Business As

Name

Name referring provider provides services under or is known to public by for organizations or if individual, in format LAST SUFFIX, FIRST MIDDLE

VARCHAR(100)


35

Referring Provider NPI

NPI of Referring provider

INTEGER(10)


36

Referring Provider TIN

Referring Taxpayer Identification

Number

INTEGER(10)


37

Referring Provider EIN

The EIN for the provider who referred the

member

INTEGER(10)


38

Referring Provider

Practice Address Line

1

US Address line 1 at which provider referred service

VARCHAR(100)


39

Referring Provider

Practice Address Line

2

US Address line 2 at which provider referred service

VARCHAR(50)


40

Referring Provider

Practice City

US City in which provider referred service

VARCHAR(50)


41

Referring Provider

Practice State

US State in which provider referred service

CHAR(2)

State Abbreviation


Seq

Professional Data Elements

Data Element Description

Data Type Format

Expected Values

42

Referring Provider

Practice Zip

USPS Zip Code in which provider referred service

INTEGER(5)


43

Service/Procedure

Code

The code per CPT, HCPCS or NDC used to indicate the service provided during the period covered by this claim.

VARCHAR(11)


44

Service/Procedure

Code Modifier

The modifier for the service code on this claim record. Modifier can be used to

enhance the Service Code

VARCHAR(2)


45

Modifier (2)

The 2nd modifier for the service code on this claim record. Modifier can be used to enhance the Service Code

VARCHAR(2)


46

Modifier (3)

The 3rd modifier for the service code on this claim record. Modifier can be used to enhance the Service Code

VARCHAR(2)


47

Modifier (4)

The 4th modifier for the service code on this claim record. Modifier can be used to enhance the Service Code

VARCHAR(2)


48

Total Units/Quantity of Service

The number of units of service received by the recipient or units dispensed as shown on the claim record.

DECIMAL (5,2)


49

Diagnosis Code 1

The ICD-9-CM/ ICD-10 code for the primary principal diagnosis for this claim. The principal diagnosis is the condition established after study to be chiefly responsible for the admission.

VARCHAR(8)


50

Diagnosis Code 2

Second ICD-9-CM/ ICD-10-CM code found on the claim.

VARCHAR(8)


51

Diagnosis Code 3

The third ICD-9-CM/ ICD-10 -CM codes that appear on the claim.

VARCHAR(8)


52

Diagnosis Code 4

The fourth ICD-9-CM/ ICD-10-CM codes that appear on the claim.

VARCHAR(8)


53

Diagnosis Type Code

Indicates if diagnosis code is ICD9-CM or

ICD-10-CM

VARCHAR(8)

ICD9-CM or ICD10-CM

54

Place of Service

Code indicating where the service was performed

VARCHAR


55

Beginning Date of

Service

The first date of services received during an encounter with a provider, the date the service covered by this claim was received.

DATE

MM/DD/YYYY

56

Ending Date of Service

The last date of services received during an encounter with a provider, the date the service covered by this claim was received.

DATE

MM/DD/YYYY

57

Type of Service

A code indicating the type of service being billed. (if available-i.e.

Transportation Services; Hospice, PCS etc. represented by a code)

VARCHAR

Please provide code definitions

58

Charged Amount

The total charge for this claim as submitted by the provider.

INTEGER



Seq

Professional Data Elements

Data Element Description

Data Type Format

Expected Values

59

Amount Paid

The amount paid on this claim or adjustment.

INTEGER


60

COB Amount

Coordination of Benefits amounts paid

INTEGER


61

Claim Submission

Date

The date on which the claim was submitted for payment

DATE

MM/DD/YYYY

62

Payment Adjudication

Date

The date on which the payment status of the claim was paid

DATE

MM/DD/YYYY

63

Adjustment Indicator

Code indicating the type of adjustment record claim represented. (i.e. original claim, void, resubmittal, credit adjustment, debit adjustment, gross adjustment)

VARCHAR

Please provide code definitions


Seq

Professional Data Element

Data Element Description

Format

Expected Values

Source

1

Payer Name

Name of entity Providing source data

VARCHAR(40)


Data call

2

File Type

The type of file being reported. (i.e. professional;

Institutional; Pharmacy,

Dental)

CHAR(2)

Professional=P

Institutional-I

Pharmacy =RX

Dental=D


3

Line of Business

Payer Identifier and Line of Business

VARCHAR(40)

e.g., Medicare, Medicaid, Private, P&C

4

Claim Number

A unique number assigned by the payment system that identifies an original claim or an adjusted claim.

VARCHAR(20)


5

Claim Line Number

Line number on the claim

INTEGER(3)


6

Member ID

A unique identification number for the member.

VARCHAR(20)


7

Member Social Security Number

Member's social security number (full 9 or last 4 numbers).

INTEGER


8

Member Sex

The sex of the member

CHAR(1)

Male= M

Female=F

Unidentified=U

9

Member Date of Birth

Member’s Date of Birth.

DATE

MM/DD/YYYY

10

Member State

Member’s state

CHAR(2)

State Abbreviation

11

Member Zip Code

Member’s zip code

INTEGER(5)


12

Member DOD

Member’s Date of Death.

DATE

MM/DD/YYYY

13

Rendering Provider Legal Business

Name

Official name of rendering provider organization or if individual, in format LAST

SUFFIX, FIRST MIDDLE

VARCHAR(100)

Example:

Smith, John Allan for an individual

14

Rendering Provider Doing Business As Name

Name provider renders services under or is known to public by for organizations or if individual, in format

LAST SUFFIX, FIRST

MIDDLE

VARCHAR(100)

Example:

Smith, John Allan for an individual

15

Rendering Provider NPI

The NPI for the provider who treated the member (as opposed to the provider

billing” for the service).

INTEGER(10)


16

Rendering Provider TIN

Taxpayer Identification Number for provider who treated the member

INTEGER(10)


17

Rendering Provider EIN

The EIN for the provider who treated the member

INTEGER(10)


18

Rendering Provider Taxonomy

The taxonomy code for the provider who treated the member (as opposed to the provider “billing” for the service).

VARCHAR(10)


19

Rendering Provider Specialty

Code that describes the area of specialty for the provider treating the member

VARCHAR

Please provide your specialty code definitions


Seq

Professional Data Element

Data Element Description

Format

Expected Values

Source

20

Rendering Provider Practice Address Line 1

US Address line 1 at which provider renders service

VARCHAR(100)



21

Rendering Provider Practice Address Line 2

US Address line 2 at which provider renders service

VARCHAR(50)


22

Rendering Provider Practice City

US City in which provider renders service

VARCHAR(50)


23

Rendering Provider Practice State

US State in which provider renders service

CHAR(2)

State Abbreviation

24

Rendering Provider Practice Zip

USPS Zip Code in which provider renders service

INTEGER(5)


25

Billing Provider Legal Business Name

Official name of billing provider organization or if individual, in format LAST

SUFFIX, FIRST MIDDLE

VARCHAR(100)

Example:

Smith, John Allan for an individual

26

Billing Provider Doing Business As

Name

Name billing provider is known to public by for organizations or if individual, in format LAST

SUFFIX, FIRST MIDDLE

VARCHAR(100)


27

Billing Provider TIN

Billing Provider Taxpayer Identification Number

INTEGER(10)


28

Billing Provider Address Line 1

US Address line 1 that represents the entity billing address

VARCHAR(100)


29

Billing Provider Address Line 2

US Address line 2 that represents the entity billing address

VARCHAR(50)


30

Billing Provider City

US City for billing entity

VARCHAR(50)


31

Billing Provider State

US State for billing entity

CHAR(2)

State Abbreviation

32

Billing Provider Zip

USPS Zip Code for billing entity

INTEGER(5)


33

Referring Provider Legal Business

Name

Official name of referring provider organization or if individual, in format LAST

SUFFIX, FIRST MIDDLE

VARCHAR(100)

Example:

Smith, John Allan for an individual

34

Referring Provider Doing Business As

Name

Name referring provider provides services under or is known to public by for organizations or if individual, in format LAST

SUFFIX, FIRST MIDDLE

VARCHAR(100)

Example:

Smith, John Allan for an individual

35

Referring Provider NPI

NPI of Referring provider

INTEGER(10)


36

Referring Provider TIN

Referring Taxpayer Identification Number

INTEGER(10)


37

Referring Provider EIN

The EIN for the provider who referred the member

INTEGER(10)


38

Referring Provider Practice Address Line 1

US Address line 1 at which provider referred service

VARCHAR(100)


39

Referring Provider Practice Address Line 2

US Address line 2 at which provider referred service

VARCHAR(50)



Seq

Professional Data Element

Data Element Description

Format

Expected Values

Source

40

Referring Provider Practice City

US City in which provider referred service

VARCHAR(50)



41

Referring Provider Practice State

US State in which provider referred service

CHAR(2)

State Abbreviation

42

Referring Provider Practice Zip

USPS Zip Code in which provider referred service

INTEGER(5)


43

Service/Procedure Code

The code per CPT, HCPCS or NDC used to indicate the service provided during the period covered by this claim.

VARCHAR(11)


44

Service/Procedure Code Modifier

The modifier for the service code on this claim record. Modifier can be used to enhance the Service Code

VARCHAR(2)


45

Modifier (2)

The 2nd modifier for the service code on this claim record. Modifier can be used to enhance the Service Code

VARCHAR(2)


46

Modifier (3)

The 3rd modifier for the service code on this claim record. Modifier can be used to enhance the Service Code

VARCHAR(2)


47

Modifier (4)

The 4th modifier for the service code on this claim record. Modifier can be used to enhance the Service Code

VARCHAR(2)


48

Total Units/Quantity of Service

The number of units of service received by the recipient or units dispensed as shown on the claim record.

DECIMAL (5,2)


49

Diagnosis Code 1

The ICD-9-CM/ ICD-10 code for the primary principal diagnosis for this claim. The principal diagnosis is the condition established after study to be chiefly responsible for the admission.

VARCHAR(8)


50

Diagnosis Code 2

Second ICD-9-CM/ ICD-10-

CM code found on the claim.

VARCHAR(8)


51

Diagnosis Code 3

The third ICD-9-CM/ ICD10 -CM codes that appear on the claim.

VARCHAR(8)


52

Diagnosis Code 4

The fourth ICD-9-CM/ ICD10-CM codes that appear on the claim.

VARCHAR(8)


53

Diagnosis Type Code

Indicates if diagnosis code is

ICD9-CM or ICD-10-CM

VARCHAR(8)

ICD9-CM or ICD10-CM

54

Place of Service

Code indicating where the service was performed

VARCHAR


55

Beginning Date of Service

The first date of services received during an encounter with a provider, the date the service covered by this claim was received.

DATE

MM/DD/YYYY


Seq

Professional Data Element

Data Element Description

Format

Expected Values

Source

56

Ending Date of Service

The last date of services received during an encounter with a provider, the date the service covered by this claim was received.

DATE

MM/DD/YYYY


57

Type of Service

A code indicating the type of service being billed. (if available-i.e. Transportation Services; Hospice, PCS etc. represented by a code)

VARCHAR

Please provide code definitions

58

Charged Amount

The total charge for this claim as submitted by the provider.

INTEGER


59

Amount Paid

The amount paid on this claim or adjustment.

INTEGER


60

COB Amount

Coordination of Benefits amounts paid

INTEGER


61

Claim Submission Date

The date on which the claim was submitted for payment

DATE

MM/DD/YYYY

62

Payment Adjudication Date

The date on which the payment status of the claim was paid

DATE

MM/DD/YYYY

63

Adjustment Indicator

Code indicating the type of adjustment record claim represented. (i.e. original claim, void, resubmittal, credit adjustment, debit adjustment, gross adjustment)

VARCHAR

Please provide code definitions

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1251. The time required to complete this information collection is estimated to average 120 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.



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AuthorCARRICO, Timothy
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File Created2021-01-22

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