|
1 |
BENE_ID |
Encrypted CCW Beneficiary ID |
| 2 |
CLM_ID |
Claim ID |
| 3 |
NCH_NEAR_LINE_REC_IDENT_CD |
NCH Near Line Record Identification Code (RIC) |
| 4 |
NCH_CLM_TYPE_CD |
NCH Claim Type Code |
| 5 |
CLM_FROM_DT |
Claim From Date (FFS) |
| 6 |
CLM_THRU_DT |
Claim Through Date (FFS) |
| 7 |
NCH_WKLY_PROC_DT |
NCH Weekly Claim Processing Date |
| 8 |
FI_CLM_PROC_DT |
FI Claim Process Date |
| 9 |
CLAIM_QUERY_CODE |
Claim Query Code |
| 10 |
PRVDR_NUM |
Provider Number |
| 11 |
PRVDR_FULL_CCN_NUM |
Full CMS Certification Number for Provider |
| 12 |
CLM_FAC_TYPE_CD |
Claim Facility Type Code (FFS) |
| 13 |
OWNG_PRVDR_TIN_NUM |
Owning Provider Tax Identification Number (TIN) |
| 14 |
CLM_SRVC_CLSFCTN_TYPE_CD |
Claim Service Classification Type Code (FFS) |
| 15 |
CLM_FREQ_CD |
Claim Frequency Code (FFS) |
| 16 |
FI_NUM |
FI or MAC Number |
| 17 |
CLM_MDCR_NON_PMT_RSN_CD |
Claim Medicare Non-Payment Reason Code |
| 18 |
CLM_PMT_AMT |
Claim (Medicare) Payment Amount |
| 19 |
NCH_PRMRY_PYR_CLM_PD_AMT |
NCH Primary Payer (if not Medicare) Claim Paid Amount |
| 20 |
NCH_PRMRY_PYR_CD |
NCH Primary Payer Code (if not Medicare) |
| 21 |
FI_CLM_ACTN_CD |
FI or MAC Claim Action Code |
| 22 |
PRVDR_STATE_CD |
NCH Provider SSA State Code |
| 23 |
ORG_NPI_NUM |
Organization (or group) NPI Number |
| 24 |
SRVC_LOC_NPI_NUM |
Claim Service Location NPI Number |
| 25 |
AT_PHYSN_UPIN |
Claim Attending Physician UPIN Number |
| 26 |
AT_PHYSN_NPI |
Claim Attending Physician NPI Number (FFS) |
| 27 |
AT_PHYSN_SPCLTY_CD |
Claim Attending Physician Specialty Code |
| 28 |
OP_PHYSN_UPIN |
Claim Operating Physician UPIN Number |
| 29 |
OP_PHYSN_NPI |
Claim Operating Physician NPI Number (FFS) |
| 30 |
OP_PHYSN_SPCLTY_CD |
Claim Operating Physician Specialty Code |
| 31 |
OT_PHYSN_UPIN |
Claim Other Physician UPIN Number |
| 32 |
OT_PHYSN_NPI |
Claim Other Physician NPI Number (FFS) |
| 33 |
OT_PHYSN_SPCLTY_CD |
Claim Other Physician Specialty Code |
| 34 |
RNDRNG_PHYSN_NPI |
Rendering Physician NPI (FFS) |
| 35 |
RNDRNG_PHYSN_SPCLTY_CD |
Claim or Revenue Center Rendering Physician Specialty Code |
| 36 |
RFRG_NPI |
Claim Referring Physician NPI Number |
| 37 |
RFRG_SPCLTY_CD |
Claim Referring Physician Specialty Code |
| 38 |
CLM_MCO_PD_SW |
Claim MCO Paid Switch |
| 39 |
PTNT_DSCHRG_STUS_CD |
Patient Discharge Status Code (FFS) |
| 40 |
CLM_TOT_CHRG_AMT |
Claim Total Charge Amount |
| 41 |
NCH_BENE_BLOOD_DDCTBL_LBLTY_AM |
NCH Beneficiary Blood Deductible Liability Amount |
| 42 |
NCH_PROFNL_CMPNT_CHRG_AMT |
Professional Component Charge Amount |
| 43 |
NCH_BLOOD_PNTS_FRNSHD_QTY |
NCH Blood Pints Furnished Quantity |
| 44 |
PRNCPAL_DGNS_CD |
Claim Principal Diagnosis Code (FFS) |
| 45 |
ICD_DGNS_CD1 |
Claim Diagnosis Code I (FFS) |
| 46 |
ICD_DGNS_CD2 |
Claim Diagnosis Code II (FFS) |
| 47 |
ICD_DGNS_CD3 |
Claim Diagnosis Code III (FFS) |
| 48 |
ICD_DGNS_CD4 |
Claim Diagnosis Code IV (FFS) |
| 49 |
ICD_DGNS_CD5 |
Claim Diagnosis Code V (FFS) |
| 50 |
ICD_DGNS_CD6 |
Claim Diagnosis Code VI (FFS) |
| 51 |
ICD_DGNS_CD7 |
Claim Diagnosis Code VII (FFS) |
| 52 |
ICD_DGNS_CD8 |
Claim Diagnosis Code VIII (FFS) |
| 53 |
ICD_DGNS_CD9 |
Claim Diagnosis Code IX (FFS) |
| 54 |
ICD_DGNS_CD10 |
Claim Diagnosis Code X (FFS) |
| 55 |
ICD_DGNS_CD11 |
Claim Diagnosis Code XI (FFS) |
| 56 |
ICD_DGNS_CD12 |
Claim Diagnosis Code XII (FFS) |
| 57 |
ICD_DGNS_CD13 |
Claim Diagnosis Code XIII (FFS) |
| 58 |
ICD_DGNS_CD14 |
Claim Diagnosis Code XIV (FFS) |
| 59 |
ICD_DGNS_CD15 |
Claim Diagnosis Code XV (FFS) |
| 60 |
ICD_DGNS_CD16 |
Claim Diagnosis Code XVI (FFS) |
| 61 |
ICD_DGNS_CD17 |
Claim Diagnosis Code XVII (FFS) |
| 62 |
ICD_DGNS_CD18 |
Claim Diagnosis Code XVIII (FFS) |
| 63 |
ICD_DGNS_CD19 |
Claim Diagnosis Code XIX (FFS) |
| 64 |
ICD_DGNS_CD20 |
Claim Diagnosis Code XX (FFS) |
| 65 |
ICD_DGNS_CD21 |
Claim Diagnosis Code XXI (FFS) |
| 66 |
ICD_DGNS_CD22 |
Claim Diagnosis Code XXII (FFS) |
| 67 |
ICD_DGNS_CD23 |
Claim Diagnosis Code XXIII (FFS) |
| 68 |
ICD_DGNS_CD24 |
Claim Diagnosis Code XXIV (FFS) |
| 69 |
ICD_DGNS_CD25 |
Claim Diagnosis Code XXV (FFS) |
| 70 |
FST_DGNS_E_CD |
First Claim Diagnosis E Code (FFS) |
| 71 |
ICD_DGNS_E_CD1 |
Claim Diagnosis E Code I (FFS) |
| 72 |
ICD_DGNS_E_CD2 |
Claim Diagnosis E Code II (FFS) |
| 73 |
ICD_DGNS_E_CD3 |
Claim Diagnosis E Code III (FFS) |
| 74 |
ICD_DGNS_E_CD4 |
Claim Diagnosis E Code IV (FFS) |
| 75 |
ICD_DGNS_E_CD5 |
Claim Diagnosis E Code V (FFS) |
| 76 |
ICD_DGNS_E_CD6 |
Claim Diagnosis E Code VI (FFS) |
| 77 |
ICD_DGNS_E_CD7 |
Claim Diagnosis E Code VII (FFS) |
| 78 |
ICD_DGNS_E_CD8 |
Claim Diagnosis E Code VIII (FFS) |
| 79 |
ICD_DGNS_E_CD9 |
Claim Diagnosis E Code IX (FFS) |
| 80 |
ICD_DGNS_E_CD10 |
Claim Diagnosis E Code X (FFS) |
| 81 |
ICD_DGNS_E_CD11 |
Claim Diagnosis E Code XI |
| 82 |
ICD_DGNS_E_CD12 |
Claim Diagnosis E Code XII |
| 83 |
ICD_PRCDR_CD1 |
Claim Procedure Code I (FFS) |
| 84 |
PRCDR_DT1 |
Claim Procedure Code I Date (FFS) |
| 85 |
ICD_PRCDR_CD2 |
Claim Procedure Code II (FFS) |
| 86 |
PRCDR_DT2 |
Claim Procedure Code II Date (FFS) |
| 87 |
ICD_PRCDR_CD3 |
Claim Procedure Code III (FFS) |
| 88 |
PRCDR_DT3 |
Claim Procedure Code III Date (FFS) |
| 89 |
ICD_PRCDR_CD4 |
Claim Procedure Code IV (FFS) |
| 90 |
PRCDR_DT4 |
Claim Procedure Code IV Date (FFS) |
| 91 |
ICD_PRCDR_CD5 |
Claim Procedure Code V (FFS) |
| 92 |
PRCDR_DT5 |
Claim Procedure Code V Date (FFS) |
| 93 |
ICD_PRCDR_CD6 |
Claim Procedure Code VI (FFS) |
| 94 |
PRCDR_DT6 |
Claim Procedure Code VI Date (FFS) |
| 95 |
ICD_PRCDR_CD7 |
Claim Procedure Code VII (FFS) |
| 96 |
PRCDR_DT7 |
Claim Procedure Code VII Date (FFS) |
| 97 |
ICD_PRCDR_CD8 |
Claim Procedure Code VIII (FFS) |
| 98 |
PRCDR_DT8 |
Claim Procedure Code VIII Date (FFS) |
| 99 |
ICD_PRCDR_CD9 |
Claim Procedure Code IX (FFS) |
| 100 |
PRCDR_DT9 |
Claim Procedure Code IX Date (FFS) |
| 101 |
ICD_PRCDR_CD10 |
Claim Procedure Code X (FFS) |
| 102 |
PRCDR_DT10 |
Claim Procedure Code X Date (FFS) |
| 103 |
ICD_PRCDR_CD11 |
Claim Procedure Code XI (FFS) |
| 104 |
PRCDR_DT11 |
Claim Procedure Code XI Date (FFS) |
| 105 |
ICD_PRCDR_CD12 |
Claim Procedure Code XII (FFS) |
| 106 |
PRCDR_DT12 |
Claim Procedure Code XII Date (FFS) |
| 107 |
ICD_PRCDR_CD13 |
Claim Procedure Code XIII (FFS) |
| 108 |
PRCDR_DT13 |
Claim Procedure Code XIII Date (FFS) |
| 109 |
ICD_PRCDR_CD14 |
Claim Procedure Code XIV |
| 110 |
PRCDR_DT14 |
Claim Procedure Code XIV Date |
| 111 |
ICD_PRCDR_CD15 |
Claim Procedure Code XV |
| 112 |
PRCDR_DT15 |
Claim Procedure Code XV Date |
| 113 |
ICD_PRCDR_CD16 |
Claim Procedure Code XVI |
| 114 |
PRCDR_DT16 |
Claim Procedure Code XVI Date |
| 115 |
ICD_PRCDR_CD17 |
Claim Procedure Code XVII |
| 116 |
PRCDR_DT17 |
Claim Procedure Code XVII Date |
| 117 |
ICD_PRCDR_CD18 |
Claim Procedure Code XVIII |
| 118 |
PRCDR_DT18 |
Claim Procedure Code XVIII Date |
| 119 |
ICD_PRCDR_CD19 |
Claim Procedure Code XIX |
| 120 |
PRCDR_DT19 |
Claim Procedure Code XIX Date |
| 121 |
ICD_PRCDR_CD20 |
Claim Procedure Code XX |
| 122 |
PRCDR_DT20 |
Claim Procedure Code XX Date |
| 123 |
ICD_PRCDR_CD21 |
Claim Procedure Code XXI |
| 124 |
PRCDR_DT21 |
Claim Procedure Code XXI Date |
| 125 |
ICD_PRCDR_CD22 |
Claim Procedure Code XXII |
| 126 |
PRCDR_DT22 |
Claim Procedure Code XXII Date |
| 127 |
ICD_PRCDR_CD23 |
Claim Procedure Code XXIII |
| 128 |
PRCDR_DT23 |
Claim Procedure Code XXIII Date |
| 129 |
ICD_PRCDR_CD24 |
Claim Procedure Code XXIV |
| 130 |
PRCDR_DT24 |
Claim Procedure Code XXIV Date |
| 131 |
ICD_PRCDR_CD25 |
Claim Procedure Code XXV |
| 132 |
PRCDR_DT25 |
Claim Procedure Code XXV Date |
| 133 |
RSN_VISIT_CD1 |
Reason for Visit Diagnosis Code I (FFS) |
| 134 |
RSN_VISIT_CD2 |
Reason for Visit Diagnosis Code II (FFS) |
| 135 |
RSN_VISIT_CD3 |
Reason for Visit Diagnosis Code III (FFS) |
| 136 |
NCH_BENE_PTB_DDCTBL_AMT |
NCH Beneficiary Part B Deductible Amount |
| 137 |
NCH_BENE_PTB_COINSRNC_AMT |
NCH Beneficiary Part B Coinsurance Amount |
| 138 |
CLM_OP_PRVDR_PMT_AMT |
Claim Outpatient Provider Payment Amount |
| 139 |
CLM_OP_BENE_PMT_AMT |
Claim Outpatient Payment Amount to Beneficiary |
| 140 |
DOB_DT |
Date of Birth from Claim |
| 141 |
GNDR_CD |
Gender Code from Claim |
| 142 |
BENE_RACE_CD |
Beneficiary Race Code (FFS) |
| 143 |
BENE_CNTY_CD |
County Code from Claim (SSA) |
| 144 |
BENE_STATE_CD |
Beneficiary Residence (SSA) State Code (FFS) |
| 145 |
BENE_MLG_CNTCT_ZIP_CD |
Zip Code of Residence from Claim |
| 146 |
CLM_MDCL_REC |
Claim Medical Record Number (FFS) |
| 147 |
CLM_TRTMT_AUTHRZTN_NUM |
Claim Treatment Authorization Number |
| 148 |
CLM_PRCR_RTRN_CD |
Claim Pricer Return Code |
| 149 |
CLM_PRCR_VRSN_CD |
Claim Pricer Version Code |
| 150 |
CLM_SRVC_FAC_ZIP_CD |
Claim service facility ZIP code (where service was provided) |
| 151 |
CLM_OP_TRANS_TYPE_CD |
Claim Outpatient transaction type |
| 152 |
CLM_OP_ESRD_MTHD_CD |
Claim Outpatient End Stage Renal Disease (ESRD) Method of Reimbursement Code |
| 153 |
CLM_NEXT_GNRTN_ACO_IND_CD1 |
Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - Population-Based Payment (PBP) |
| 154 |
CLM_NEXT_GNRTN_ACO_IND_CD2 |
Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - Telehealth |
| 155 |
CLM_NEXT_GNRTN_ACO_IND_CD3 |
Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - Post Discharge HH visits |
| 156 |
CLM_NEXT_GNRTN_ACO_IND_CD4 |
Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - 3-day SNF waiver |
| 157 |
CLM_NEXT_GNRTN_ACO_IND_CD5 |
Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - Capitation |
| 158 |
ACO_ID_NUM |
Claim Accountable Care Organization (ACO) Identification Number |
| 159 |
CLM_BENE_ID_TYPE_CD |
Claim Beneficiary Identifier Type Code |
| 160 |
CLM_RSDL_PYMT_IND_CD |
Claim Residual Payment Indicator Code |
| 161 |
PRVDR_VLDTN_TYPE_CD |
Provider Validation Type Code |
| 162 |
RR_BRD_EXCLSN_IND_SW |
Railroad Board Exclusion Indicator Switch |
| 163 |
CLM_MODEL_REIMBRSMT_AMT |
Claim Model Reimbursement Amount |
| 164 |
CLM_ADJUST_GRP_CD |
Claim Adjustment Group Code |
| 165 |
CLM_ADJUST_RSN_CD |
Claim Adjustment Reason Code |
| 166 |
ESRD_TRTMT_CHS_IND_CD |
End-Stage Renal Disease (ESRD) Treatment Choices Demonstration Indicator Code |
| 167 |
CLM_OP_PPS_IND |
Claim Outpatient Prospective Payment System (OPPS) Indicator |
| 168 |
CLM_CLNCL_TRIL_NUM |
Clinical Trial Number |
