Appendix B: Sample Data Elements (Pharmaceutical and Institutional)

Appendix B: Sample Data Elements (Pharmaceutical and Institutional)

Payer Name	Name of entity Providing source data
File Type	The type of file being reported. (i.e. professional; Institutional; Pharmacy, Dental)
Line of Business	Payer Identifier and Line of Business
Claim Number	A unique number assigned by the payment system that identifies an original claim or an adjusted claim.
Claim Line Number	Line number on the claim
Member ID	A unique identification number for the member.
Member Social Security Number	Member's social security number (full 9 or none).
Member Sex	The sex of the member
Member Date of Birth	Member’s Date of Birth.
Member State	Member’s state
Member Zip Code	Member’s zip code
Member DOD	Member’s Date of Death.
Rendering Provider Legal Business Name	Official name of rendering provider organization or if individual, in format LAST SUFFIX, FIRST MIDDLE
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
Rendering Provider NPI	The NPI for the provider who treated the member (as opposed to the provider “billing” for the service).
Rendering Provider TIN	Taxpayer Identification Number for provider who treated the member
Rendering Provider EIN	The EIN for the provider who treated the member
Rendering Provider Taxonomy	The taxonomy code for the provider who treated the member (as opposed to the provider “billing” for the service).
Rendering Provider Specialty	Code that describes the area of specialty for the provider treating the member
Rendering Provider Practice Address Line 1	US Address line 1 at which provider renders service
Rendering Provider Practice Address Line 2	US Address line 2 at which provider renders service
Rendering Provider Practice City	US City in which provider renders service
Rendering Provider Practice State	US State in which provider renders service
Rendering Provider Practice Zip	USPS Zip Code in which provider renders service
Billing Provider Legal Business Name	Official name of billing provider organization or if individual, in format LAST SUFFIX, FIRST MIDDLE
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
Billing Provider TIN	Billing Provider Taxpayer Identification Number
Billing Provider Address Line 1	US Address line 1 that represents the entity billing address
Billing Provider Address Line 2	US Address line 2 that represents the entity billing address
Billing Provider City	US City for billing entity
Billing Provider State	US State for billing entity
Billing Provider Zip	USPS Zip Code for billing entity
Referring Provider Legal Business Name	Official name of referring provider organization or if individual, in format LAST SUFFIX, FIRST MIDDLE
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
Referring Provider NPI	NPI of Referring provider
Referring Provider TIN	Referring Taxpayer Identification Number
Referring Provider EIN	The EIN for the provider who referred the member
Referring Provider Practice Address Line 1	US Address line 1 at which provider referred service
Referring Provider Practice Address Line 2	US Address line 2 at which provider referred service
Referring Provider Practice City	US City in which provider referred service
Referring Provider Practice State	US State in which provider referred service
Referring Provider Practice Zip	USPS Zip Code in which provider referred service
Service/Procedure Code	The code per CPT, HCPCS or NDC used to indicate the service provided during the period covered by this claim.
Service/Procedure Code Modifier	The modifier for the service code on this claim record. Modifier can be used to enhance the Service Code
Modifier (2)	The 2nd modifier for the service code on this claim record. Modifier can be used to enhance the Service Code
Modifier (3)	The 3rd modifier for the service code on this claim record. Modifier can be used to enhance the Service Code
Modifier (4)	The 4th modifier for the service code on this claim record. Modifier can be used to enhance the Service Code
Total Units/Quantity of Service	The number of units of service received by the recipient or units dispensed as shown on the claim record.
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.
Diagnosis Code 2	Second ICD-9-CM/ ICD-10-CM code found on the claim.
Diagnosis Code 3	The third ICD-9-CM/ ICD-10 -CM codes that appear on the claim.
Diagnosis Code 4	The fourth ICD-9-CM/ ICD-10-CM codes that appear on the claim.
Diagnosis Type Code	Indicates if diagnosis code is ICD9-CM or ICD-10-CM
Place of Service	Code indicating where the service was performed
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.
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.
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)
Charged Amount	The total charge for this claim as submitted by the provider.
Amount Paid	The amount paid on this claim or adjustment.
COB Amount	Coordination of Benefits amounts paid
Claim Submission Date	The date on which the claim was submitted for payment
Payment Adjudication Date	The date on which the payment status of the claim was paid
Adjustment Indicator	Code indicating the type of adjustment record claim represented. (i.e. original claim, void, resubmittal, credit adjustment, debit adjustment, gross adjustment)