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MEDS III Data Element Dictionary

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Version 3.4
December 2014

Prepared by:

Provider Network - MEDS Compliance Unit
Bureau of Managed Care Fiscal Oversight
Division of Health Plan Contracting and Oversight
Office of Health Insurance Programs
New York State Department of Health
Phone: (518) 474-5050
Email: omcmeds@health.ny.gov
HCS Home Page: https://commerce.health.state.ny.us/

MEDS III DATA ELEMENT DICTIONARY

INTRODUCTION
ENCOUNTER TYPE ASSIGNMENT BY CATEGORY OF SERVICE
MEDS III DATA ELEMENT REPORTING
ENCOUNTER TYPE ASSIGNMENT BY COS: REQUIREMENTS BY MEDS III DATA ELEMENT
HEADER RECORD
- DATA ELEMENT NAME: RECORD TYPE
  DATA ELEMENT NAME: PROVIDER TRANSMISSION SUPPLIER NUMBER (TSN)
  DATA ELEMENT NAME: INPUT SERIAL NUMBER
  DATA ELEMENT NAME: TSN CERTIFICATION
  DATA ELEMENT NAME: VENDOR SOFTWARE NUMBER
  DATA ELEMENT NAME: VENDOR SOFTWARE UPDATE LEVEL
  DATA ELEMENT NAME: TEST / PROD INDICATOR
  DATA ELEMENT NAME: PLAN IDENTIFICATION NUMBER
  DATA ELEMENT NAME: SUBMITTER NAME
  DATA ELEMENT NAME: SUBMITTER ADDRESS1
  DATA ELEMENT NAME: SUBMITTER ADDRESS2
  DATA ELEMENT NAME: SUBMITTER CITY
  DATA ELEMENT NAME: SUBMITTER STATE
  DATA ELEMENT NAME: SUBMITTER ZIP
  DATA ELEMENT NAME: SUBMITTER FAX NUMBER
  DATA ELEMENT NAME: SUBMITTER PHONE NUMBER
  DATA ELEMENT NAME: MEDS VERSION NUMBER
COMMON DETAIL
- DATA ELEMENT NAME: RECORD TYPE
  DATA ELEMENT NAME: ENCOUNTER TYPE INDICATOR (ETI)
  DATA ELEMENT NAME: ENCOUNTER CONTROL NUMBER (ECN)
  DATA ELEMENT NAME: PREVIOUS TRANSACTION CONTROL NUMBER (TCN)
  DATA ELEMENT NAME: TRANSACTION STATUS CODE
  DATA ELEMENT NAME: CLIENT IDENTIFICATION NUMBER (CIN)
  DATA ELEMENT NAME: BENEFICIARY IDENTIFICATION NUMBER
  DATA ELEMENT NAME: PROVIDER PROFESSION CODE
  DATA ELEMENT NAME: PROVIDER LICENSE NUMBER
  DATA ELEMENT NAME: PROVIDER IDENTIFICATION NUMBER
  DATA ELEMENT NAME: PROVIDER SERVICE LOCATION
  DATA ELEMENT NAME: CATEGORY OF SERVICE
  DATA ELEMENT NAME: TOTAL CHARGED AMOUNT
  DATA ELEMENT NAME: TOTAL PAID AMOUNT
  DATA ELEMENT NAME: MEDICARE TOTAL PAID AMOUNT
  DATA ELEMENT NAME: OTHER INSURANCE TOTAL PAID AMOUNT
  DATA ELEMENT NAME: OTHER PAYER NAME
  DATA ELEMENT NAME: OTHER INSURANCE TYPE CODE
  DATA ELEMENT NAME: MEDICARE TOTAL DEDUCTIBLE PAID
  DATA ELEMENT NAME: MEDICARE TOTAL CO-INSURANCE PAID
  DATA ELEMENT NAME: MEDICARE TOTAL COPAY PAID
  DATA ELEMENT NAME: OTHER INSURANCE TOTAL DEDUCTIBLE PAID
  DATA ELEMENT NAME: OTHER INSURANCE TOTAL CO-INSURANCE PAID
  DATA ELEMENT NAME: OTHER INSURANCE TOTAL COPAY PAID
  DATA ELEMENT NAME: FILLER
INSTITUTIONAL
- DATA ELEMENT NAME: PROVIDER SPECIALTY CODE
  DATA ELEMENT NAME: HOSPITAL INPATIENT CLAIM/ENCOUNTER INDICATOR
  DATA ELEMENT NAME: NYS DIAGNOSIS RELATED GROUP CODE
  DATA ELEMENT NAME: TYPE OF BILL DIGITS 1 & 2 CODE
  DATA ELEMENT NAME: TYPE OF BILL CODE DIGIT 3 CODE
  DATA ELEMENT NAME: STATEMENT COVERS PERIOD FROM
  DATA ELEMENT NAME: STATEMENT COVERS PERIOD THRU
  DATA ELEMENT NAME: TYPE OF ADMISSION
  DATA ELEMENT NAME: SOURCE OF ADMISSION
  DATA ELEMENT NAME: PATIENT STATUS OR DISPOSITION CODE
  DATA ELEMENT NAME: MEDICAL RECORD NUMBER
  DATA ELEMENT NAME: NEONATE BIRTH WEIGHT CODE [UP TO 2]
  DATA ELEMENT NAME: NEONATE BIRTH WEIGHT IN GRAMS (VALUE CODE AMOUNT) [UP TO 2]
  DATA ELEMENT NAME: SERVICE DATE [UP TO 10]
  DATA ELEMENT NAME: REVENUE CODE [UP TO 10]
  DATA ELEMENT NAME: CPT/HCPCS CODE [UP TO 10]
  DATA ELEMENT NAME: PROCEDURE MODIFIER CODE 1 [UP TO 10]
  DATA ELEMENT NAME: PROCEDURE MODIFIER CODE 2 [UP TO 10]
  DATA ELEMENT NAME: PROCEDURE MODIFIER CODE 3 [UP TO 10]
  DATA ELEMENT NAME: PROCEDURE MODIFIER CODE 4 [UP TO 10]
  DATA ELEMENT NAME: QUANTITY OR UNITS SUBMITTED [UP TO 10]
  DATA ELEMENT NAME: NDC (FORMULARY) CODE [UP TO 10]
  DATA ELEMENT NAME: NDC (FORMULARY) UNITS [UP TO 10]
  DATA ELEMENT NAME: CHARGED AMOUNT [UP TO 10]
  DATA ELEMENT NAME: MEDICARE PAID AMOUNT
  DATA ELEMENT NAME: PAID AMOUNT
  DATA ELEMENT NAME: NON-INPATIENT CLAIM/ENCOUNTER INDICATOR
  DATA ELEMENT NAME: ICD VERSION CODE
  DATA ELEMENT NAME: PRINCIPAL/PRIMARY DIAGNOSIS CODE
  DATA ELEMENT NAME: OTHER DIAGNOSIS CODES [UP TO 8]
  DATA ELEMENT NAME: OTHER DIAGNOSIS CODES [9 TO 24]
  DATA ELEMENT NAME: ADMIT DIAGNOSIS
  DATA ELEMENT NAME: EXTERNAL DIAGNOSIS CODE (E CODE)
  DATA ELEMENT NAME: PRESENT ON ADMISSION CODE (POA) [UP TO 25]
  DATA ELEMENT NAME: PRINCIPAL PROCEDURE CODE
  DATA ELEMENT NAME: OTHER PROCEDURE CODES [UP TO 5]
  DATA ELEMENT NAME: OTHER PROCEDURE CODES [6 TO 24]
  DATA ELEMENT NAME: PROCEDURE DATE [UP TO 25]
  DATA ELEMENT NAME: ATTENDING PROVIDER PROFESSION CODE
  DATA ELEMENT NAME: ATTENDING PROVIDER LICENSE NUMBER
  DATA ELEMENT NAME: ATTENDING PROVIDER IDENTIFICATION NUMBER
  DATA ELEMENT NAME: SURGEON PROFESSION CODE
  DATA ELEMENT NAME: SURGEON LICENSE NUMBER
  DATA ELEMENT NAME: SURGEON PROVIDER IDENTIFICATION NUMBER
  DATA ELEMENT NAME: ADMISSION DATE
  DATA ELEMENT NAME: DISCHARGE DATE
  DATA ELEMENT NAME: FILLER
PHARMACY SEGMENT
DENTAL SEGMENT
- DATA ELEMENT NAME: PROVIDER SPECIALTY CODE
  DATA ELEMENT NAME: SERVICE START DATE
  DATA ELEMENT NAME: SERVICE END DATE
  DATA ELEMENT NAME: PLACE OF SERVICE/PLACE OF TREATMENT
  DATA ELEMENT NAME: PROCEDURE CODE [UP TO 10]
  DATA ELEMENT NAME: PROCEDURE MODIFIER CODE 1 [UP TO 10]
  DATA ELEMENT NAME: PROCEDURE MODIFIER CODE 2 [UP TO 10]
  DATA ELEMENT NAME: PROCEDURE MODIFIER CODE 3 [UP TO 10]
  DATA ELEMENT NAME: PROCEDURE MODIFIER CODE 4 [UP TO 10]
  DATA ELEMENT NAME: TOOTH NUMBER OR LETTER [UP TO 10]
  DATA ELEMENT NAME: DENTAL NUMBER OF UNITS/VISITS [UP TO 10]
  DATA ELEMENT NAME: CHARGED AMOUNT [UP TO 10]
  DATA ELEMENT NAME: MEDICARE PAID AMOUNT [UP TO 10]
  DATA ELEMENT NAME: PAID AMOUNT [UP TO 10]
  DATA ELEMENT NAME: DENTAL CLAIM/ENCOUNTER INDICATOR
  DATA ELEMENT NAME: FILLER
PROFESSIONAL SEGMENT
- DATA ELEMENT NAME: PROVIDER SPECIALTY CODE
  DATA ELEMENT NAME: ICD VERSION CODE
  DATA ELEMENT NAME: DIAGNOSIS CODES [UP TO 4]
  DATA ELEMENT NAME: PLACE OF SERVICE/PLACE OF TREATMENT [UP TO 10]
  DATA ELEMENT NAME: SERVICE START DATE
  DATA ELEMENT NAME: SERVICE END DATE
  DATA ELEMENT NAME: CPT/HCPCS PROCEDURE CODES [UP TO 10]
  DATA ELEMENT NAME: PROCEDURE MODIFIER CODE 1 [UP TO 10]
  DATA ELEMENT NAME: PROCEDURE MODIFIER CODE 2
  DATA ELEMENT NAME: PROCEDURE MODIFIER CODE 3
  DATA ELEMENT NAME: PROCEDURE MODIFIER CODE 4
  DATA ELEMENT NAME: NUMBER OF UNITS/VISITS [UP TO 10]
  DATA ELEMENT NAME: NDC (FORMULARY) CODE [UP TO 10]
  DATA ELEMENT NAME: NDC (FORMULARY) UNITS [UP TO 10]
  DATA ELEMENT NAME: CHARGED AMOUNT [UP TO 10]
  DATA ELEMENT NAME: MEDICARE PAID AMOUNT
  DATA ELEMENT NAME: PAID AMOUNT [UP TO 10]
  DATA ELEMENT NAME: PROFESSIONAL CLAIM/ENCOUNTER INDICATOR [UP TO 10]
  DATA ELEMENT NAME: FILLER

APPENDIX A - PROVIDER PROFESSION CODES
APPENDIX B - PROVIDER SPECIALTY CODES
APPENDIX C - CODES AND VALUES FOR TOOTH NUMBER OR LETTER
APPENDIX D - MEDS III SUPPLEMENTAL MANUAL ON APPLICABLE EDITS
APPENDIX E - TRANSACTION LAYOUT WITH RECORD POSITIONS

I. Introduction

This MEDS III Data Element Dictionary contains descriptive information for the data elements that are required for submission by health care organizations as part of the redesigned Medicaid Encounter Data System (MEDS III). This document contains requirements by MEDS III Category of Service (COS), the transaction layout for data submission, descriptions of the individual data elements and an Appendices section.

An encounter is a professional face-to-face contact or transaction between an enrollee and a provider who delivers services. An encounter is comprised of the procedure(s) or service(s) rendered during the contact. An encounter should be operationalized in an information system as each unique occurrence of recipient and provider. Up to ten separate dates of service can be reported on one encounter line. All claim detail lines should be rolled up under the same encounter control number when possible. If a claim contains more than ten service lines, a second (continuation) encounter should be created with its own unique encounter control number to report the additional lines. Encounters for all incurred services in the plan's benefit package must be reported. Referrals to services outside of the benefit package, which are covered by another payer, should not be reported.

In general, the enrollee must be physically present for an encounter to be recorded. The exception to this criterion is laboratory services. Provider consultation with another provider about an enrollee in the absence of the enrollee or the act of referring the enrollee to another provider in the plan's network is not considered an encounter (the encounter resulting from the referral would be reported by that provider), nor is provider consultation with a third party for the purpose of developing and obtaining services for an enrollee.

There are four Encounter Types for which records are to be submitted:

Institutional: Encounters extracted from electronic media 837I format or UB-92 paper claims (Encounter Type = 'I'). Institutional encounters are reflective of both inpatient (COS 11) and non-inpatient services.
Pharmacy: Encounters extracted from NCPDP format (Encounter Type = 'D').
Dental: Encounters extracted from electronic media 837D format or ADA paper claims (Encounter Type = 'T').
Professional: Encounters extracted from electronic media 837P format or CMS-1500 paper claims (Encounter Type = 'P').

Similar to the legacy MEDS system, each encounter will consist of a common segment and a detail segment (Institutional, Pharmacy, Dental or Professional).

All managed care plan types will report encounter data, however, not all segments will apply to every plan type. All services defined in a plan's benefit package should be reported. Both paid and administratively denied services should be reported.

Each descriptive data element page in this data dictionary contains the following information:

MEDS III Transaction Segment: The MEDS III Transaction Segment that the data element applies to: Common Detail, Institutional, Pharmacy, Dental or Professional.

Data Element Name: The name of the MEDS III data element being described.

Submission Status: Whether the data element is optional, situational upon other information (e.g., other payer data) or required for reporting. If required for reporting, the MEDS Categories of Service (COS) that the data element applies to are listed.

Encounter Record Position(s): The positions on the transaction layout where the data should be reported.

Format - Length: The format (Character, Numeric, Date) and length of the data element. Effective Date: This version of the data dictionary is dated 2/26/2015 forward.

Version Number - Date: This version of the data dictionary is Version 3.3 - February 2014. MEDS III DE#/ DW#: eMedNY Data Element Number and Data Warehouse numbers (if applicable).

Definition: A description of the data element.

Mapping: The form based and electronic media mapping for the data element (if applicable). Codes and Values: Valid codes and values for the data element.

Edit Applications: Edits applicable to the input record.

Reporting

Encounters submitted more than two years after the date of service will be rejected.

Encounter files must be submitted in accordance with the model contract and should include encounters incurred and processed by health organizations, as well as records that were previously submitted and rejected.

There are currently no size limits for production files. However, test files are limited in size up to 1,000 encounters and (15) fifteen submissions per day based on user ID.

Connectivity Options

Electronic submissions are available through eMedNY eXchange, file transfer protocol (FTP) or eMedNY FTS via SOAP.

Information requests for MEDS III data submissions should be directed to CSC Provider Relations staff at: MEDSSupport@csc.com

In order to utilize the MEDS III testing and production environments, a health plan must have established components of the following:

An active New York State Medicaid Provider ID (MMIS ID);
An active Provider Transmission Supplier Number (TSN); and
An active eMedNY eXchange or FTP account.

Connectivity Options

Access Method
Internet batch file submission via eMedNY eXchange	Batch files may be conducted via eMedNY's website.
Dial-up batch file submission using File Transfer Protocol (FTP) over Transmission Control Protocol/Internet Protocol (TCP/IP)	Dial-up batch submissions using FTP may be conducted by using 866-488-3006 and connecting to 172.27.16.79. FTP connection should be established through MS-DOS for best results. Users will have to change the setting to 'binary' by using the 'bin' command. Follow the FTP instructions to ensure that the file is named properly. See MEVS Batch Authorization Manual.
eMedNY File Transfer Service (FTS) using Service Oriented Architecture (SOA) with the Simple Object Access Protocol (SOAP)	Access to the eMedNY FTS via SOAP must be obtained through an enrollment process that results in the creation of an eMedNY SOAP Certificate and a SOAP Administrator. Contact CSC Provider Relations Staff at: MEDSSupport@csc.com

Submission
Plans are allowed to submit files on a daily basis. The list below indicates 2014-2015 extract dates of that month's data feed to NYSDOH. Anything accepted after the extract date will be included in the department's next month data feed. Test data are not included in the department's data feed. Also, please remember to account for a minimum of a seven (7) day lag in processing.

2015 Data Extract Schedule:
December 25, 2014
January 22, 2015
February 19, 2015
March 19, 2015
April 23, 2015
May 21, 2015
June 18, 2015
July 23, 2015
August 20, 2015
September 24, 2015
October 22, 2015
November 19, 2015
December 24, 2015

Edits
Data elements will be edited for missing or invalid data elements, duplicate encounters and valid enrollment in MMC. A Supplemental Manual of current encounter edit numbers, descriptions and severity is included as Appendix D. The following describes 'Tier One Edits', or fatal edits which will stop a file from being processed.

Tier One Edits

Tier One Error	Message Returned
Record is not 3000 bytes	'Incomplete " ", Header Record' - will give the size and record that is not 3000 bytes
Required records missing (H1, D1, and a T1)	Required " " record missing' - will include the record type missing
Required records not in sequence (H1, D1, and a T1)	'Record " " is of unknown type or invalid sequence' - will include the record type in error
Test/Prod indicator is incorrect - must be PROD	'Specified mode " " does not match' 'Test/Prod Indicator'
The carriage return (CR) is too short/long or misaligned	'Misaligned ASCII " ", "CR" in record " " column " " ' 'Unexpected ASCII " ", "CR" in record " " column " " '
Newline/linefeed (NL) in record	'Unexpected ASCII " ", "NL" in record " " column " " '
Non-printable characters in file	'Non-ASCII character'
End of file not in the correct place	'Premature end-of-file'
No records are found	'FILE CONTAINS NO CLAIM RECORDS'
H1 record is found when unexpected	'UNEXPECTED H1 RECORD RECEIVED' 'AT RECORD #:'
H1 record is not found when expected (after user record)	'EXPECTED H1 CONTROL RECORD NOT RECEIVED' 'AT RECORD #:'
D1 record is found, and it is expected, and the encounter type is other than I, D, T, or P	'INVALID D1 RECORD RECEIVED' 'AT RECORD #:'
D1 record is found when unexpected	'UNEXPECTED D1 RECORD RECEIVED' 'AT RECORD #:'
D1 record is not found when expected	'EXPECTED D1 CONTROL RECORD NOT RECEIVED' 'AT RECORD #:'
T1 record is found when unexpected	'UNEXPECTED T1 RECORD RECEIVED' 'AT RECORD #:'
Record is other than H1, D1, or T1	'RECEIVED RECORD NOT H1/D1/T1''AT RECORD #:'
Provider Check Digit	The Provider Identification is Invalid
Provider Zip Code	The Provider Service Location is Invalid/Non-Numeric

Response Reports
Plans will receive a transmission file confirming the acceptance or rejection of each encounter file submitted. Files will stay within the plan's eMedNY Exchange mailbox for a period of twenty-eight (28) days. Responses returned via FTP will remain in the plan's FTP directory for twenty-eight (28) days or until downloaded. Plans will also receive a response file for all encounter files submitted during the processing cycle. When submitting to the Provider Test Environment (PTE) the processing cycle happens daily and the plan will receive a response file the following day after a test file is processed. When submitting to the Production System the processing cycle pulls encounter files in daily and processes them in a weekly cycle. Therefore, you will receive your response file 7 days after processing. The response file provides valuable feedback to the Plan on the quality of the encounter data submitted. The plan will receive information on whether the record was accepted or rejected as well as up to 24 edits.

Response File Layout

Data Element Width Record Positions

Encounter Control Number 11 1-11
Claim Line Number 04 12-15
Edit Status Code 01 16
Claim Edit Code 05 17-21
COS Code 04 22-25
Transaction Control Number (TCN) 16 26-41
Plan ID 08 42-49
TSN 03 50-52
Filler 28 53-80

Data Element	Width	Record Positions
Encounter Control Number	11	1-11
Claim Line Number	04	12-15
Edit Status Code	01	16
Claim Edit Code	05	17-21
COS Code	04	22-25
Transaction Control Number (TCN)	16	26-41
Plan ID	08	42-49
TSN	03	50-52
Filler	28	53-80

Encounter Control Number
Encounter Control Number is a Managed Care Organization (MCO) assigned number used to uniquely identify an encounter transaction.

Claim Line Number
Claim Line Number specifies the line number of the service.

Line numbers 01 through 10 will be used to identify service line errors in the encounter record. A value of 00 with an Edit Status Code of P will indicate the entire record has been accepted, with no edits.
A value of 00 and an Edit Status Code of 2 will indicate the entire record has been rejected. The error is identified through the Claim Edit Code.

Edit Status Code Edit Status Code specifies the disposition of an edit that has been posted to a claim. Valid codes and values include:

Edit Status Code	Edit Severity
2	H=Hard Edit (Rejected)
3	S=Soft Edit (Accept)
P	Record passed through with no edits.

Claim Edit Code
Claim Edit Code is a unique code attached to a claim as the result of logic applied during the claim adjudication cycle. The most current list of applicable edit codes, descriptions and severity status, by Encounter Type Indicator, Claim Type and Category of Service is listed as Appendix D, and is also available in the MEDS III Supplemental Manual on Applicable Edits.

MEDS Category of Service Code
MEDS Category of Service Code categorizes provider services for the processing and reporting.

Code	Value
01	Physician Services
03	Podiatry
04	Psychology
05	Eye Care / Vision
06	Rehabilitation Therapy
07	Nursing
11	Inpatient
12	Institutional LTC
13	Dental
14	Pharmacy
15	Home Health Care/Non-Institutional Long Term Care
16	Laboratories
19	Transportation
22	DME and Hearing Aids
28	Intermediate Care Facilities
41	NPs/Midwives
73	Hospice
75	Clinical Social Worker
85	Freestanding Clinic
87	Hospital OP/ER Room

Transaction Control Number
Transaction Control Number is a unique identifier assigned to each claim or encounter transaction received. This number is essential to adjust or void records.

Reconciling the Response Report

The plan should use the response report data elements to appropriately tag the encounter status for their internal data system, and resubmit rejected or edited records as appropriate.

Plans should use the [Encounter Control Number (ECN), Line Number, Edit Status Code, Claim Edit Number, Category of Service (COS), and Transaction Control Number (TCN)] to match the status of each line of your encounter.

Since the Response File will report errors on a service line level, Plans should be aware of four general rules about feedback reports:

Rule # 1: If the encounter record passes through without any edits, one record line is reported with an edit status code of 'P' at line number '0000'. The Plan should store the associated TCN and the Accepted status in their data system. Any changes to these records should be handled as an adjustment.

Rule # 2: If the encounter record rejects at the header level (line number '0000' and Edit Status Code = '2') the entire encounter is rejected. Plans should correct all errors identified and resubmit the encounter as an original.

Rule # 3: If the encounter record includes both accepted and rejected service lines (line number(s) = '01' - '10' and Edit Status Codes of '2' and '3') the encounter record has been partially accepted. The Plan should store the associated TCN and the accepted and rejected status at each service line. All corrections to the encounter should be handled as an adjustment to the original encounter.

Rule # 4: For every adjusted encounter the Plan will receive two response lines back. The eMedNY claim system creates a 'void' line that removes the original encounter. It then creates a new replacement/adjustment line. The first TCN, which represents the 'void' line, will always end in '1'. Plans should disregard this TCN. The second TCN, which represents the 'replacement/adjustment' line, will always end in '2'. Plans should store this TCN with the new encounter record.

Additional MEDS III Information and Reference Materials

MEDS Home Page on the HCS:
For up to date information on MEDS III reporting requirements and associated activities, please visit the MEDS Home Page on the Health Commerce System (HCS) internet site at the following link: https://commerce.health.state.ny.us/hcsportal/appmanager/hcs/home.

CSC Contact Information:
Provider Services, Suite 270, 2nd Floor MEDSSupport@csc.com
Fax: (518) 257-4637
www.csc.com

Visit the Help Desk at: http://www.emedny.org/HIPAA/

MEDS-L Discussion Group:
To join the MEDS-L Listserv discussion group, please contact the MEDS Unit at omcmeds@health.ny.gov.

Please contact us at:

Provider Network - MEDS Compliance Unit
Bureau of Managed Care Fiscal Oversight
Division of Health Plan Contracting and Oversight
Office Health Insurance Programs
New York State Department of Health
Corning Tower, Room 2040
Empire State Plaza
Albany, New York 12237

Phone: (518) 474-5050
Fax: (518) 486-7899
Email: omcmeds@health.ny.gov

II. ENCOUNTER TYPE ASSIGNMENT BY CATEGORY OF SERVICE

For MEDS III submissions, the Category of Service (COS) must be applicable to the encounter type being reported. The table below indicates submission standards for encounter types by MEDS COS. (The Encounter Type Indicator is reflective of the form or electronic media in which the encounter is being submitted to the health organization.)

Category of Service		Encounter Type		Form Type/ EDI
Code	Value	Code	Value	Form Type/ EDI
01	Physician Services	P	Professional	CMS-1500 / 837P
03	Podiatry	P	Professional	CMS-1500 / 837P
04	Psychology	P	Professional	CMS-1500 / 837P
05	Eye Care / Vision*	P	Professional	CMS-1500 / 837P
06	Rehabilitation Therapy	I	Institutional	UB-92 / 837I
07	Nursing	P	Professional	CMS-1500 / 837P
11	Inpatient	I	Institutional	UB-92 / 837I
12	Institutional LTC	I	Institutional	UB-92 / 837I
13	Dental	T	Dental	ADA / 837D
14	Pharmacy	D	Pharmacy/DME	NCPDP
15	Home Health Care/Non- Institutional Long Term Care	I	Institutional	UB-92 / 837I
16	Laboratories**	P	Professional	CMS-1500 / 837P
19	Transportation	P	Professional	CMS-1500 / 837P
22	DME and Hearing Aids	P	Professional	CMS-1500 / 837P
28	Intermediate Care Facilities	I	Institutional	UB-92 / 837I
41	NPs/Midwives	P	Professional	CMS-1500 / 837P
73	Hospice	I	Institutional	UB-92 / 837I
75	Clinical Social Worker	P	Professional	CMS-1500 / 837P
85	Freestanding Clinic	I	Institutional	UB-92 / 837I
87	Hospital OP/ER Room	I	Institutional	UB-92 / 837I

* Eye glasses should be reported using a HCPCS code and COS 05 Eye Care/Vision.

**If laboratory data is submitted on a UB-92 form, these services should be reported under COS 85 (Freestanding Clinic) or COS 87 (Hospital Outpatient) with an Encounter Type Indicator of 'I' and a provider specialty code of '599' All Laboratories.

III. MEDS III DATA ELEMENT REPORTING

Header Record Segment

Record Positions	Data Element - Header	Data Type	Field Length	Submission Status	Description
1-2	Record Type	Character	2	Required	H1=Header
3-6	Provider Transmission Supplier Number (TSN)	Character	4	Required	Provider Transmission Supplier Number (TSN) is a unique number assigned to the health organization submitting encounter records. The TSN should be left-justified and space-filled.
7-12	Input Serial Number	Character	6	Required
13-21	TSN Certification	Character	9	Required	This field should contain the word "CERTIFIED".
22-26	Vendor Software Number	Character	5	Optional
27-28	Vendor Software Update Level	Character	2	Optional
29-32	Test / Prod Indicator	Character	4	Required	This field must contain either the word "TEST" or "PROD".
33-40	Plan Identification Number	Character	8	Required	The health organization's MMIS ID number
41-61	Submitter Name	Character	21	Required	Submitter Name is the name of the health organization as used on official State records.
62-79	Submitter Address 1	Character	18	Required	Submitter Address Line is the street address for the health organization submitting encounter data.
80-97	Submitter Address 2	Character	18	Required
98-112	Submitter Address City	Character	15	Required	Submitter Address City is the city in which the health organization does business or to which correspondence should be sent.
113-114	Submitter Address State	Character	2	Required	Submitter Address State/Province Code is the two character standard state postal code (i.e., NY)
115-123	Submitter Zip	Character	9	Required	This element specifies the health organizations geographic area denoted by the postal ZIP code.
124-134	Submitter Fax Number	Character	11	Required	Submitter Fax Number is the facsimile number for the health organization.
135-145	Submitter Phone Number	Character	11	Required	Phone Number is the telephone number of the health organization, including 1 and the area code and seven-digit number.
146-148	MEDS Version Number	Character	3	Required	Will contain "003"
149-3000	FILLER	Character	2852	Required	Space fill positions 149-3000.

Common Detail Segment

Record Positions	Data Element - Common Detail	Format	Field Length	Submission Status	Description
1-2	Record Type	Character	2	Required	D1=Detail
3	Encounter Type Indicator (ETI)	Character	1	Required	The code that indicates the type of encounter being reported: I=Institutional; D=Pharmacy; T=Dental; P=Professional.
4-14	Encounter Control Number (ECN)	Character	11	Required	Encounter Control Number is a health organization assigned number used to uniquely identify an encounter transaction.
15-30	Previous Transaction Control Number (TCN)	Character	16	Situational	Transaction Control Number (TCN) is a unique identifier assigned by CSC to each encounter transaction received. The TCN is used for internal control purposes and by plans to adjust or void records identified as failing soft edits.
31	Transaction Status Code	Character	1	Required	Transaction Status Code identifies a transaction as an original encounter or a voids or adjustment to a previously submitted encounter.
32-39	Client Identification Number	Character	8	Required	The CIN is assigned by the state to an enrollee upon determination that an individual is eligible for Medicaid services.
40-64	Beneficiary Identification Number	Character	25	Optional	Beneficiary Identification Number is an identifier given to an individual by the health organization for their internal purposes.
65-67	Provider Profession Code	Character	3	Required	Provider Profession Code specifies the profession of a Provider on the state license file.
68-75	Provider License Number	Character	8	Required	Provider License Number is an identifying number issued by the state licensing board, authorizing a provider to practice within that state under the specific license type applicable to the provider.
76-85	Provider Identification Number (NPI or MMIS ID)	Character	10	Required	National Provider Identification Number (NPI) is a unique number assigned to each provider. If the provider type in not recognized by NPI, you would report the unique MMIS Provider Id recognized in the Medicaid program.
86-94	Provider Service Location	ZIP+4	9	Required	The Zip Code + 4 of the Service Location of the Provider on the encounter.
95-96	Category of Service (COS) Code	Character	2	Required	Category of Service is a two-digit code that classifies the services in the encounter.
97-107	Total Charged Amount	Numeric	11	Required	The total amount charged for each listed service.
108-118	Total Paid Amount	Numeric	11	Required	The total amount Medicaid paid for each listed service.
119-129	Medicare Total Paid Amount	Numeric	11	Required	The total amount Medicare paid for listed services that are received by dual eligible Medicaid/Medicare enrollees or beneficiaries. This is the Medicare Total Paid Amount on the Header Level.
130-140	Other Insurance Total Paid Amount	Numeric	11	Situational	Total amount paid by insurance other than Medicaid (if applicable). Medicare cost data should be reported the Medicare paid amount data fields.
141-175	Other Payer Name	Character	35	Situational	Other Payer Name identifies the secondary payer on the encounter (if applicable).
176-177	Other Insurance Type Code	Character	2	Situational	A code indicating insurance payers other than Medicaid (if applicable).
178-188	Medicare Total Deductible Paid	Numeric	11	Required	The amount the beneficiary is required to pay for health care or prescriptions before Medicare paid for the treatment.
189-199	Medicare Total Co-Insurance Paid	Numeric	11	Required	The amount the beneficiary is required to pay for healthcare services which is a set percentage of the covered costs after the deductible has been paid before Medicare paid for the treatment.
200-210	Medicare Total Copay Paid	Numeric	11	Required	The specified amount the beneficiary is required to pay out-of-pocket for healthcare services at the time the service is rendered before Medicare paid for the treatment.
211-221	Other Insurance Total Deductible Paid	Numeric	11	Required	The amount the beneficiary is required to pay for health care or prescriptions before the Other Payer paid for the treatment.
222-232	Other Insurance Total Co-Insurance Paid	Numeric	11	Required	The amount the beneficiary is required to pay for healthcare services which is a set percentage of the covered costs after the deductible has been paid before the Other Payer paid for the treatment.
233-243	Other Insurance Total Copay Paid	Numeric	11	Required	The specified amount the beneficiary is required to pay out-of-pocket for healthcare services at the time the service is rendered before the Other Payer paid for the treatment.
244-257	FILLER	Character	14	Required	Space-fill positions 244 to 257.
Individual Record Type Segments (i.e. Institutional, Pharmacy, Professional, Dental) fill positions 258-3000

Institutional Segment

Record Positions	Data Element - Institutional	Format	Field Length	Submission Status	Description
258-260	Provider Specialty Code	Character	3	Required: COS 06, 12, 15, 28, 73, 85, 87	A code that identifies a provider's medical, dental, clinic or program type specialty.
261	Hospital Inpatient Claim/Encounter Indicator	Character	1	Required: COS 11	Indicates whether the service provided was a capitated service within the health organization's contract ("E"); a within plan claim ("C") or an administratively denied service ("A").
262-265	New York State Diagnosis Related Group Code	Character	4	Required: COS 11	The NYS APR-DRG code assigned by the providing hospital to the inpatient stay for billing purposes.
266-267	Type of Bill Digits 1 & 2 Code	Character	2	Required: COS 06, 11, 12, 15, 28, 73, 85, 87	The first two digits of a three-digit alphanumeric code. The first digit identifies the type of facility. The second classifies the type of care.
268	Type of Bill Digit 3 Code	Character	1	Required: COS 06, 11, 12, 15, 28, 73, 85, 87	The third digit of a three-digit alphanumeric code. The third digit indicates the sequence of the bill in the particular episode of care. It is referred to as the "frequency" code.
269-276	Statement Covers Period From	Date CCYYMMDD	8	Required: COS 06, 12, 15, 28, 73, 85, 87	The begin date of the encounter period.
277-284	Statement Covers Period Thru	Date CCYYMMDD	8	Required: COS 06, 12, 15, 28, 73, 85, 87	The end date of the encounter period.
285	Type of Admission	Character	1	Required: COS 11	One-digit alphanumeric code indicating priority of the admission.
286	Source of Admission	Character	1	Required: COS 11	One-digit alphanumeric code indicating the source of the admission or outpatient registration.
287-288	Patient Status or Disposition Code	Character	2	Required: COS 11, 12, 28, 73	A two-digit, alphanumeric code indicating the patient's destination or status upon discharge.
289-308	Medical Record Number	Character	20	Required:	The number assigned to the patient's medical/health record by the provider.
309-310	Neonate Birth Weight Value Code [up to 2]	Character	2	Required: COS 11	All newborn encounters will have a birth weight code of "54".
318-319	Neonate Birth Weight Value Code [up to 2]	Character	2	Required: COS 11
311-317	Neonate Birth Weight in Grams (Value Code Amount) [up to 2]	Numeric	7	Required: COS 11	The birth weight of the neonate in grams.
320-326	Neonate Birth Weight in Grams (Value Code Amount) [up to 2]	Numeric	7	Required: COS 11	The birth weight of the neonate in grams.
327-334	Service Date [up to 10]	Date CCYYMMDD	8	Required: COS 06, 12, 15, 28, 73, 85, 87	The associated Service Date for the reported CPT/HCPCS or Revenue code(s) describing non- inpatient procedure(s) performed.
420-427
513-520
606-613
699-706
792-799
885-892
978-985
1071-1078
1164-1171
335-338	Revenue Code [up to 10]	Character	4	Required: COS 06, 11, 12, 15, 28, 73, 85, 87	The revenue code assigned for each cost center for which a separate charge is billed.
428-431
521-524
614-617
707-710
800-803
893-896
986-989
1079-1082
1172-1175
339-343	CPT/HCPCS Code [up to 10]	Character	5	Required COS 06, 11, 12, 15, 28, 73, 85, 87	432-436
525-529
618-622
711-715
804-808
897-901
990-994
1083-1087
1176-1180
344-345	Procedure Modifier Code 1 [up to 10]	Character	2	Required: COS 06, 12, 15, 28, 73, 85, 87	Procedure Modifier Codes are used in conjunction with the CPT procedure code to uniquely describe the service(s) rendered by a provider during an encounter. Fields for reporting a single modifier on each of the up to ten procedures or services are available.
437-438
530-531
623-624
716-717
809-810
902-903
995-996
1088-1089
1181-1182
346-347	Procedure Modifier Code 2 [up to 10]	Character	2	Required: COS 06, 12, 15, 28, 73, 85, 87	Procedure Modifier Codes are used in conjunction with the CPT procedure code to uniquely describe the service(s) rendered by a provider during an encounter. Fields for reporting a single modifier on each of the up to ten procedures or services are available.
439-440
532-533
625-626
718-719
811-812
904-905
997-998
1090-1091
1183-1184
348-349	Procedure Modifier Code 3 [up to 10]	Character	2	Required: COS 06, 12, 15, 28, 73, 85, 87	Procedure Modifier Codes are used in conjunction with the CPT procedure code to uniquely describe the service(s) rendered by a provider during an encounter. Fields for reporting a single modifier on each of the up to ten procedures or services are available.
441-442
534-535
627-628
720-721
813-814
906-907
999-1000
1092-1093
1185-1186
350-351	Procedure Modifier Code 4 [up to 10]	Character	2	Required: COS 06, 12, 15, 28, 73, 85, 87	Procedure Modifier Codes are used in conjunction with the CPT procedure code to uniquely describe the service(s) rendered by a provider during an encounter. Fields for reporting a single modifier on each of the up to ten procedures or services are available.
443-444
536-537
629-630
722-723
815-816
908-909
1001-1002
1094-1095
1187-1188
352-362	Quantity or Units Submitted [up to 10]	Numeric	11	Required: COS 06, 12, 15, 28, 73, 85, 87	When revenue codes are assigned, this data element quantifies services by revenue category (e.g., number of days of a particular accommodation, pints of blood.) However, when CPT/HCPCS codes are assigned, units are equal to the number of times the procedure/service being reported was performed.
445-455
538-548
631-641
724-734
817-827
910-920
1003-1013
1096-1106
1189-1199
363-373	NDC (Formulary) Code [up to 10]	Character	11	Required: COS 06, 12, 15, 28, 73, 85	An 11-digit national drug identification number assigned by the Federal Drug Administration (or the HCPCS code) used to identify Durable Medical Equipment, Hearing Aids, OTC medications or other pharmacy products without an NDC code.
456-466
549-559
642-652
735-745
828-838
921-931
1014-1024
1107-1117
1200-1210
374-385	NDC (Formulary) Units [up to 10]	Numeric	12	Required: COS 06, 12, 15, 28, 73, 85	The dispensing quantity based upon the unit of measure as defined by the National Drug Code.
467-478
560-571
653-664
746-757
839-850
932-943
1025-1036
1118-1129
1211-1222
386-396	Charged Amount [up to 10]	Numeric	11	Required: COS 06, 12, 15, 28, 73, 85, 87	The amount charged for each listed service corresponding to the procedures defined in the CPT/HCPCS data element.
479-489
572-582
665-675
758-768
851-861
944-954
1037-1047
1130-1140
1223-1233
397-407	Medicare Paid Amount [up to 10]	Numeric	11	Required: COS 06, 12, 15, 28, 73, 85, 87	The amount Medicare paid for each listed service line that is received by dual eligible Medicaid/Medicare enrollees or beneficiaries. A service line is identified through either CPT/HCPCS procedure codes or revenue codes. This is the Medicare Paid Amount on the service line.
490-500
583-593
676-686
769-779
862-872
955-965
1048-1058
1141-1151
1234-1244
408-418	Paid Amount [up to 10]	Numeric	11	Required: COS 06, 12, 15, 28, 73, 85, 87	The amount Medicaid paid for each listed service corresponding to the procedures defined in the CPT/HCPCS data element.
501-511
594-604
687-697
780-790
873-883
966-976
1059-1069
1152-1162
1245-1255
419	Non-Inpatient Claim/Encounter Indicator [up to 10]	Character	1	Required: COS 06, 12, 15, 28, 73, 85, 87	Indicates whether the service provided was a capitated service within the health organization's contract ("E"); a within plan claim ("C") or an administratively denied service ("A").
512
605
698
791
884
977
1070
1163
1256
1257	ICD Version Code	Character	1	Required: COS 06, 11, 12, 15, 28, 73, 85, 87	A one-digit code to indicate whether the reported diagnosis is ICD-9 or ICD-10.
1258-1264	Principal/Primary Diagnosis Code	Character	7	Required: COS 06, 11, 12, 15, 28, 73, 85, 87	The ICD-9-CM or ICD-10 diagnosis code that indicates the primary condition for an inpatient stay.
1265-1271	Other Diagnosis Codes [up to 8]	Character	7	Required: COS 06, 11, 12, 15, 28, 73, 85, 87	Up to eight additional ICD-9-CM or ICD-10 diagnosis codes, indicating additional significant condition(s) during the encounter.
1272-1278
1279-1285
1286-1292
1293-1299
1300-1306
1307-1313
1314-1320
1321-1327	Other Diagnosis Codes [9 to 24]	Character	7	Required: COS 06, 11, 12, 15, 28, 73, 85, 87	Up to sixteen additional ICD-9-CM or ICD-10 diagnosis codes, indicating additional significant condition(s) during the encounter.
1328-1334
1335-1341
1342-1348
1349-1355
1356-1362
1363-1369
1370-1376
1377-1383
1384-1390
1391-1397
1398-1404
1405-1411
1412-1418
1419-1425
1426-1432
1433-1439	Admit Diagnosis	Character	7	Required: COS 11	The diagnosis that describes the patient's condition upon admission to the hospital.
1440-1446	External Diagnosis Code (E Code)	Character	7	Required: COS 11	The ICD-9-CM or ICD-10 code for the external cause of an injury, poisoning, or adverse effect.
1447	Present on Admission Code [up to 25]	Character	1	Required: COS 11	Up to 25 instances of a one-digit indicator for inpatient diagnoses that denotes whether or not each diagnosis was present at the time of admission.
1448
1449
1450
1451
1452
1453
1454
1455
1456
1457
1458
1459
1460
1461
1462
1463
1464
1465
1466
1467
1468
1469
1470
1471
1472-1478	Principal Procedure Code	Character	7	Required: COS 11	The ICD-9-CM or ICD-10 procedure code identifying the principal procedure performed during an inpatient stay.
1487-1493	Other Procedure Codes [up to 5]	Character	7	Required: COS 11	ICD-9-CM or ICD-10 Procedure Codes identifying the procedures performed during an inpatient stay
1502-1508
1517-1523
1532-1538
1547-1553
1562-1568	Other Procedure Codes [6 to 24]	Character	7	Required: COS 11	ICD-9-CM or ICD-10 Procedure Codes identifying the procedures performed during an inpatient stay
1577-1583
1592-1598
1607-1613
1622-1628
1637-1643
1652-1658
1667-1673
1682-1688
1697-1703
1712-1718
1727-1733
1742-1748
1757-1763
1772-1778
1787-1793
1802-1808
1817-1823
1832-1838
1479-1486	Procedure Date [1 to 25]	Date CCYYMMDD	8	Required: COS 11	ICD-9-CM or ICD-10 Procedure Codes identifying the procedures performed during an inpatient stay.
1494-1501
1509-1516
1524-1531
1539-1546
1554-1561
1569-1576
1584-1591
1599-1606
1614-1621
1629-1636
1644-1651
1659-1666
1674-1681
1689-1696
1704-1711
1719-1726
1734-1741
1749-1756
1764-1771
1779-1786
1794-1801
1809-1816
1824-1831
1839-1846
1847-1849	Attending Provider Profession Code	Character	3	Required: COS 06, 11, 12, 15, 28, 73, 85, 87	The profession code issued by the state of the attending provider for inpatient encounters and the servicing provider for non-Inpatient encounters.
1850-1857	Attending Provider License Number	Character	8	Required COS 06, 11, 12, 15, 28, 73, 85, 87	The professional license number issued by the state of the attending provider for inpatient encounters and the servicing provider for non- Inpatient encounters.
1858-1867	Attending Provider ID	Character	10	Required COS 06, 11, 12, 15, 28, 73, 85, 87	The NPI of the attending provider for inpatient encounters and the servicing provider for non- Inpatient encounters. If the provider type is not recognized by NPI, then report the state Medicaid Id.
1868-1870	Surgeon Profession Code	Character	3	Required: COS 11	The profession code issued by the State Department of Education that identifies the type of license of the surgeon performing the primary procedure or the surgery.
1871-1878	Surgeon License Number	Character	8	Required: COS 11	The professional license number, issued by the State Department of Education that identifies the surgeon.
1879-1888	Surgeon Provider ID	Character	10	Required: COS 11	The NPI number of the surgeon.
1889-1896	Admission Date	Date CCYYMMDD	8	Required: COS 11, 12, 28	The admit date for the institutional stay.
1897-1904	Discharge Date	Date CCYYMMDD	8	Required: COS 11,12,28	The date of discharge from an inpatient stay at a hospital.
1905-3000	FILLER	Character	1096	Required	Space-fill positions 1905 to 3000.

Pharmacy Segment

Record Positions	Data Element - Pharmacy	Format	Field Length	Submission Status	Description
258	Prescription Origin Code	Character	1	Required: COS 14	A one (1) digit indicator that identifies the method which the provider used to transmit the prescription or order to the pharmacy.
259-270	Prescription Number	Character	12	Required: COS 14	The prescription number assigned by the pharmacy.
271-273	Prescribing Provider Profession Code	Character	3	Required: COS 14	The profession code issued by the State Department of Education that identifies the type of license of the prescribing provider.
274-281	Prescribing Provider License Number	Character	8	Required: COS 14	The professional license number, issued by the State Department of Education that identifies the prescribing provider.
282-291	Prescribing Provider ID	Character	10	Required: COS 14	The NPI number of the prescribing provider.
292-299	Prescription Ordered Date	Date CCYYMMDD	8	Required: COS 14	The date the prescription was issued by the referring provider.
300-307	Date Filled	Date CCYYMMDD	8	Required: COS 14	The date the prescription was filled.
308-310	Drug Days Supply Count	Numeric	3	Required: COS 14	Represents the number of days supply currently dispensed with this prescription service.
311-321	National Drug Code (NDC) or Product Code [up to 25]	Character	11	Required: COS 14	An 11-digit national drug identification number assigned by the Federal Drug Administration (or the HCPCS code) used to identify Durable Medical Equipment, Hearing Aids, OTC medications or other pharmacy products without an NDC code.
357-367
403-413
449-459
495-505
541-551
587-597
633-643
679-689
725-735
771-781
817-827
863-873
909-919
955-965
1001-1011
1047-1057
1093-1103
1139-1149
1185-1195
1231-1241
1277-1287
1323-1333
1369-1379
1415-1425
322-333	Quantity Dispensed [up to 25]	Numeric	12	Required: COS 14	The dispensing quantity based upon the unit of measure as defined by the National Drug Code.
368-379
414-425
460-471
506-517
552-563
598-609
644-655
690-701
736-747
782-793
828-839
874-885
920-931
966-977
1012-1023
1058-1069
1104-1115
1150-1161
1196-1207
1242-1253
1288-1299
1334-1345
1380-1391
1426-1437
334-344	Amount Charged [up to 25]	Numeric	11	Required: COS 14	The amount charged for the prescription or ingredient.
380-390
426-436
472-482
518-528
564-574
610-620
656-666
702-712
748-758
794-804
840-850
886-896
932-942
978-988
1024-1034
1070-1080
1116-1126
1162-1172
1208-1218
1254-1264
1300-1310
1346-1356 1392-1402 1438-1448
1392-1402
1438-1448
345-355	Amount Paid [up to 25]	Numeric	11	Required: COS 14	The amount paid for the prescription or ingredient.
391-401
437-447
483-493
529-539
575-585
621-631
667-677
713-723
759-769
805-815
851-861
897-907
943-953
989-999
1035-1045
1081-1091
1127-1137
1173-1183
1219-1229
1265-1275
1311-1321
1357-1367
1403-1413
1449-1459
356	Pharmacy Claim/Encounter Indicator [up to 25]	Character	1	Required: COS 14	"E" = Capitated encounter; "C" = Within plan claim; "A" = Administratively denied service
402
448
494
540
586
632
678
724
770
816
862
908
954
1000
1046
1092
1138
1184
1230
1276
1322
1368
1414
1460
1461-1462	Refill Indicator	Character	2	Required: COS 14	The number indicating whether the prescription is an original or refill.
1463-1464	Number of Refills Authorized	Character	2	Required: COS 14	The number of refills authorized by the prescriber.
1465	Dispensed As Written	Character	1	Required: COS 14	The code indicates whether or not a prescription is dispensed based on the prescriber's instructions.
1466	ICD Version Code	Character	1	Required: COS 14	A one-digit code to indicate whether the reported Diagnosis Code is ICD-9 or ICD-10.
1467-1473	Diagnosis Code	Character	7	Required: COS 14	Diagnosis codes are to be recorded for diagnosed medical conditions for which the recipient receives services during the encounter, or which may have been present at the time of the encounter and recorded by the provider.
1474-1485	Prescription Serial Number	Character	12	Required: COS 14	The serial number on the official NYS Prescription Form.
1486-1487	Submission Clarification Code	Character	2	Required: COS 14	Submission Clarification Code is the code indicating that the pharmacist is clarifying the submission
1488-1498	Dispensing Fee	Numeric	11	Required: COS 14	Pharmacy Dispensing Fee is that portion of the claim payment amount that is directly related to cost of dispensing the drug.
1499	Mail Order Pharmacy Indicator	Character	1	Required: COS 14	A one-digit indicator of whether or not the script was from a mail order pharmacy.
1500-3000	FILLER	Character	1501	Required	Space-fill record positions 1500 to 3000.

Dental Segment

Record Positions	Data Element - Dental	Format	Field Length	Submission Status	Description
258-260	Provider Specialty Code	Character	3	Required: COS 13	A provider's specialty code identifies a provider's medical, dental, clinic or program type specialty.
261-268	Service Start Date [up to 10]	Date CCYYMMDD	8	Required: COS 13	The date the service began.
339-346
417-424
495-502
573-580
651-658
729-736
807-814
885-892
963-970
269-276	Service End Date [up to 10]	Date CCYYMMDD	8	Required: COS 13	The date the service ended.
347-354
425-432
503-510
581-588
659-666
737-744
815-822
893-900
971-978
277-278	Place of Service/Place of Treatment [up to 10]	Character	2	Required: COS 13	Indicates where the dental service took place.
355-356
433-434
511-512
589-590
667-668
745-746
823-824
901-902
979-980
279-283	Procedure Codes [up to 10]	Character	5	Required: COS 13	Procedure Codes identifying the procedures performed during the dental visit.
357-361
435-439
513-517
591-595
669-673
747-751
825-829
903-907
981-985
284-285	Procedure Modifier Code 1 [up to 10]	Character	2	Required: COS 13	Procedure Modifier Codes are used in conjunction with the CPT procedure code to uniquely describe the service(s) rendered by a provider during an encounter. Fields for reporting a single modifier on each of the up to ten procedures or services are available.
362-363
440-441
518-519
596-597
674-675
752-753
830-831
908-909
986-987
286-287	Procedure Modifier Code 2 [up to 10]	Character	2	Required: COS 13	Procedure Modifier Codes are used in conjunction with the CPT procedure code to uniquely describe the service(s) rendered by a provider during an encounter. Fields for reporting a single modifier on each of the up to ten procedures or services are available.
364-365
442-443
520-521
598-599
676-677
754-755
832-833
910-911
988-989
288-289	Procedure Modifier Code 3 [up to 10]	Character	2	Required: COS 13	Procedure Modifier Codes are used in conjunction with the CPT procedure code to uniquely describe the service(s) rendered by a provider during an encounter. Fields for reporting a single modifier on each of the up to ten procedures or services are available.
366-367
444-445
522-523
600-601
678-679
756-757
834-835
912-913
990-991
290-291	Procedure Modifier Code 4 [up to 10]	Character	2	Required: COS 13	Procedure Modifier Codes are used in conjunction with the CPT procedure code to uniquely describe the service(s) rendered by a provider during an encounter. Fields for reporting a single modifier on each of the up to ten procedures or services are available.
368-369
446-447
524-525
602-603
680-681
758-759
836-837
914-915
992-993
292-293	Tooth Number or Letter [up to 10]	Character	2	Required: COS 13	The tooth that the service was performed on.
370-371
448-449
526-527
604-605
682-683
760-761
838-839
916-917
994-995
294-304	Dental Number of Units/Visits [up to 10]	Numeric	11	Required: COS 13	The number of times a procedure or service was provided during the encounter; or the number of units, visits, or days a procedure or service was rendered during an episode of care defined by Service Start and End Dates.
372-382
450-460
528-538
606-616
684-694
762-772
840-850
918-928
996-1006
305-315	Charged Amount [up to 10]	Numeric	11	Required: COS 13	The Amount Charged for each listed service.
383-393
461-471
539-549
617-627
695-705
773-783
851-861
929-939
1007- 1017
316-326	Medicare Paid Amount	Numeric	11	Required: COS 13	The amount Medicare paid for each listed service line that is received by dual eligible Medicaid/Medicare enrollees or beneficiaries. A service line is identified through either CPT/HCPCS procedure codes or revenue codes. This is the Medicare Paid Amount on the service line.
394-404
472-482
550-560
628-638
706-716
784-794
862-872
940-950
1018- 1028
327-337	Paid Amount [up to 10]	Numeric	11	Required: COS 13	The amount paid by Medicaid for each listed service.
405-415
483-493
561-571
639-649
717-727
795-805
873-883
951-961
1029- 1039
338	Dental Claim/Encounter Indicator [up to 10]	Character	1	Required: COS 13	Indicates whether the service provided was a capitated service within the health organization's contract ("E"); a within plan claim ("C") or an administratively denied service ("A").
416
494
572
650
728
806
884
962
1040
1041- 3000	FILLER	Character	1960	Required	Space-fill positions 1041 to 3000.

Professional Segment

Record Positions	Data Element - Professional	Format	Field Length	Submission Status	Description
258-260	Provider Specialty Code	Character	3	Required: COS 01, 03, 04, 05, 07, 16, 22, 41, 75	The code identifying a provider's medical, dental, clinic or program type specialty.
261	ICD Version Code	Character	1	Required: COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75	A one-digit code to indicate whether the reported diagnosis is ICD-9 or ICD-10.
262-268	Diagnosis Codes [up to 4]	Character	7	Required: COS 01, 03, 04, 05, 07, 16, 22, 41, 75	Up to four diagnosis codes are to be recorded for diagnosed medical conditions for which the recipient receives services during the encounter, or which may have been present at the time of the encounter and recorded by the provider.
269-275
276-282
283-289
290-291	Place of Service/Place of Treatment [up to 10]	Character	2	Required: COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75	Indicates location where service occurred.
388-389
486-487
584-585
682-683
780-781
878-879
976-977
1074-1075
1172-1173
292-299	Service Start Date [up to 10]	Date CCYYMMDD	8	Required: COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75	The date the service began.
390-397
488-495
586-593
684-691
782-789
880-887
978-985
1076-1083
1174-1181
300-307	Service End Date [up to 10]	Date CCYYMMDD	8	Required: COS 01, 03, 04, 05, 07, 16, 19, 22, 28, 41, 73, 75	The date the service ended.
398-405
496-503
594-601
692-699
790-797
888-895
986-993
1084-1091
1182-1189
308-312	Procedure Codes [up to 10]	Character	5	Required: COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75	The CPT/HCPCS procedure code that describes the service(s) rendered during the professional encounter(s).
406-410
504-508
602-606
700-704
798-802
896-900
994-998
1092-1096
1190-1194
313-314	Procedure Modifier Code 1 [up to 10]	Character	2	Required: COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75	Procedure Modifier Codes are used in conjunction with the CPT procedure code to uniquely describe the service(s) rendered by a provider during an encounter. Fields for reporting a single modifier on each of the up to ten procedures or services are available.
411-412
509-510
607-608
705-706
803-804
901-902
999-1000
1097-1098
1195-1196
315-316	Procedure Modifier Code 2 [up to 10]	Character	2	Required: COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75	Procedure Modifier Codes are used in conjunction with the CPT procedure code to uniquely describe the service(s) rendered by a provider during an encounter. Fields for reporting a single modifier on each of the up to ten procedures or services are available.
413-414
511-512
609-610
707-708
805-806
903-904
1001-1002
1099-1100
1197-1198
317-318	Procedure Modifier Code 3 [up to 10]	Character	2	Required: COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75	Procedure Modifier Codes are used in conjunction with the CPT procedure code to uniquely describe the service(s) rendered by a provider during an encounter. Fields for reporting a single modifier on each of the up to ten procedures or services are available.
415-416
513-514
611-612
709-710
807-808
905-906
1003-1004
1101-1102
1199-1200
319-320	Procedure Modifier Code 4 [up to 10]	Character	2	Required: COS 01	Procedure Modifier Codes are used in conjunction with the CPT procedure code to uniquely describe the service(s) rendered by a provider during an encounter. Fields for reporting a single modifier on each of the up to ten procedures or services are available.
417-418
515-516
613-614
711-712
809-810
907-908
1005-1006
1103-1104
1201-1202
321-331	Professional Number of Units/Visits [up to 10]	Numeric	11	Required: COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75	The number of times a procedure or service was provided during the encounter; or the number of units, visits, or days a procedure or service was rendered during an episode of care defined by Service Start and End Dates.
419-429
517-527
615-625
713-723
811-821
909-919
1007-1017
1105-1115
1203-1213
332-342	NDC (Formulary) Code [up to 10]	Character	11	Required: COS 01	An 11-digit national drug identification number assigned by the Federal Drug Administration used to identify OTC medications.
430-440
528-538
626-636
724-734
822-832
920-930
1018-1028
1116-1126
1214-1224
343-353	NDC (Formulary) Units [up to 10]	Numeric	11	Required: COS 01	An 11-digit national drug identification number assigned by the Federal Drug Administration (or the HCPCS code) used to identify Durable Medical Equipment, Hearing Aids, OTC medications or other pharmacy products without an NDC code.
441-451
539-549
637-647
735-745
833-843
931-941
1029-1039
1127-1137
1225-1235
354-364	Charged Amount [up to 10]	Numeric	11	Required: COS 01, 03, 04, 05, 07, 16, 19, 22, 28, 41, 73, 75	The amount charged for the reported claim line.
452-462
550-560
648-658
746-756
844-854
942-952
1040-1050
1138-1148
1236-1246
365-375	Medicare Paid Amount	Numeric	11	Required: COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75	The amount Medicare paid for each listed service line that is received by dual eligible Medicaid/Medicare enrollees or beneficiaries. A service line is identified through either CPT/HCPCS procedure codes or revenue codes. This is the Medicare Paid Amount on the service line.
463-473
561-571
659-669
757-767
855-865
953-963
1051-1061
1149-1159
1247-1257
376-386	Paid Amount [up to 10]	Numeric	11	Required: COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75	The amount paid by Medicaid for each listed service.
474-484
572-582
670-680
768-778
866-876
964-974
1062-1072
1160-1170
1258-1268
387	Professional Claim/Encounter Indicator [up to 10]	Character	1	Required: COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75	Indicates whether the service provided was a capitated service within the health organization's contract ("E"); a within plan claim ("C") or an administratively denied service ("A").
485
583
681
779
877
975
1073
1171
1269
1270-3000	FILLER	Character	1731	Required	Space-fill positions 1270 to 3000.

Trailer Record

Record Positions	Data Element - Trailer	Format	Field Length	Submission Status	Description
1-2	Record Type	Character	2	Required	T1=Trailer
3	Submission Record Count	Numeric	9	Required	The total number of records in the file, including the header and trailer records. Zero fill and right justify.
Space-fill Record Positions 12 to 3000

IV. ENCOUNTER TYPE ASSIGNMENT BY COS: REQUIREMENTS BY MEDS III DATA ELEMENT

R = Required for Reporting

	01	03	04	05	06	07	11	12	13	14	15	16	19	22	28	41	73	75	85	87
	MEDS Category of Service (COS)
Encounter Type:	P	P	P	P	I	P	I	I	T	D	I	P	P	P	I	P	I	P	I	I
Institutional Transaction Segment (Encounter Type = "I")
Provider Specialty Code					R			R			R				R		R		R	R
Hosp Inpatient Claim/Encounter Indicator							R
NYS DRG Code							R
Type of Bill Digits 1 & 2 Code					R		R	R			R				R		R		R	R
Type of Bill Digit 3 Code					R		R	R			R				R		R		R	R
Statement Covers Period From					R			R			R				R		R		R	R
Statement Covers Period Thru					R			R			R				R		R		R	R
Type of Admission							R
Source of Admission							R
Patient Status or Disposition Code							R	R							R		R
Medical Record Number							R
Neonate Birth Weight Value Code							R
Neonate Birth Weight in Grams							R
Service Date					R			R			R				R		R		R	R
Revenue Code					R		R	R			R				R		R		R	R
CPT/HCPCS Code					R			R			R				R		R		R	R
Procedure Modifier Code 1					R			R			R				R		R		R	R
Procedure Modifier Code 2					R			R			R				R		R		R	R
Procedure Modifier Code 3					R			R			R				R		R		R	R
Procedure Modifier Code 4					R			R			R				R		R		R	R
Quantity or Units Submitted					R			R			R				R		R		R	R
NDC (Formulary) Code					R			R			R				R		R		R	R
NDC (Formulary) Units					R			R			R				R		R		R	R
Charged Amount					R			R			R				R		R		R	R
Medicare Paid Amount					R			R			R				R		R		R	R
Paid Amount					R			R			R				R		R		R	R
Non-Inpatient Claim/Encounter Indicator					R			R			R				R		R		R	R
ICD Version Code					R		R	R			R				R		R		R	R
Principal/Primary Diagnosis Code					R		R	R			R				R		R		R	R
Other Diagnosis Codes					R		R	R			R				R		R		R	R
Admit Diagnosis							R
External Diagnosis Code (E Code)							R
Present on Admission Code							R
Principal Procedure Code							R
Procedure Date							R
Other Procedure Codes							R
Attending Provider Profession Code					R		R	R			R				R		R		R	R
Attending Provider License Number					R		R	R			R				R		R		R	R
Attending Provider ID					R		R	R			R				R		R		R	R
Surgeon Profession Code							R
Surgeon License Number							R
Surgeon Provider ID							R
Admission Date							R	R							R
Discharge Date							R	R							R
Pharmacy Transaction Segment (Encounter Type = "D")
Prescription Origin Code										R
Prescription Number										R
Prescribing Provider Profession Code										R
Prescribing Provider License Code										R
Prescribing Provider ID										R
Prescription Ordered Date										R
Date Filled										R
Drug Days Supply Count										R
National Drug Code (NDC) or Product Code										R
Quantity Dispensed										R
Amount Charged										R
Amount Paid										R
Pharmacy Claim/Encounter Indicator										R
Refill Indicator										R
Number of Refills Authorized										R
Dispensed As Written										R
ICD Version Code										R
Diagnosis Code										R
Prescription Serial Number										R
Submission Clarification Code										R
Dispensing Fee										R
Mail Order Pharmacy Indicator										R
Dental Transaction Segment (Encounter Type = "T")
Provider Specialty Code									R
Service Start Date									R
Service End Date									R
Place of Service/Place of Treatment									R
Procedure Codes									R
Procedure Modifier Code 1									R
Procedure Modifier Code 2									R
Procedure Modifier Code 3									R
Procedure Modifier Code 4									R
Tooth Number or Letter									R
Dental Number of Units/Visits									R
Charged Amount									R
Medicare Paid Amount									R
Paid Amount									R
Dental Claim/Encounter Indicator									R
Professional Transaction Segment (Encounter Type = "P")
Provider Specialty Code	R	R	R	R		R						R		R		R		R
ICD Version Code	R	R	R	R		R						R	R	R		R		R
Diagnosis Codes	R	R	R	R		R						R		R		R		R
Place of Service/Place of Treatment	R	R	R	R		R						R	R	R		R		R
Service Start Date	R	R	R	R		R						R	R	R		R		R
Service End Date	R	R	R	R		R						R	R	R		R		R
Procedure Codes	R	R	R	R		R						R	R	R		R		R
Procedure Modifier Code 1	R	R	R	R		R						R	R	R		R		R
Procedure Modifier Code 2	R	R	R	R		R						R	R	R		R		R
Procedure Modifier Code 3	R	R	R	R		R						R	R	R		R		R
Procedure Modifier Code 4	R	R	R	R		R						R	R	R		R		R
Professional Number of Units/Visits	R	R	R	R		R						R	R	R		R		R
NDC (Formulary) Code	R
NDC (Formulary) Units	R
Charged Amount	R	R	R	R		R						R	R	R	R	R	R	R
Medicare Paid Amount	R	R	R	R		R						R	R	R		R		R
Paid Amount	R	R	R	R		R						R	R	R		R		R
Professional Claim/Encounter Indicator	R	R	R	R		R						R	R	R		R		R

V. HEADER RECORD

MEDS III Transaction Segment: Header

Data Element Name: RECORD TYPE
Submission Status: Required for Header Record
Encounter Record Position(s): 1-2
Format - Length: Character - 2
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: NA

Definition: The Record Type identifies the data being submitted as either the header record, the detail section, or the trailer record.

Mapping

New York State Specific Data Element

Codes and Values

*Code*	*Value*
H1	Header

Edit Applications:

Must be a valid code of H1 for Header Record
Tier One Edit

MEDS III Transaction Segment: Header

Data Element Name: PROVIDER TRANSMISSION SUPPLIER NUMBER (TSN)
Submission Status: Required for Header Record
Encounter Record Position(s): 3-6
Format - Length: Character - 4
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 4312/E4312

Definition: Provider Transmission Supplier Number (TSN) is a unique number assigned to the health organization submitting encounter records. The TSN should be left-justified and space-filled.

Mapping

New York State Specific Data Element

Codes and Values

Left-justified and space-filled
Unique to health plan reporting

Edit Applications:

Must be a valid TSN/Plan Id combination

MEDS III Transaction Segment: Header

Data Element Name: INPUT SERIAL NUMBER
Submission Status: Required for Header Record
Encounter Record Position(s): 7-12
Format - Length: Character - 6
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: NA/E6203

Definition: This is a number assigned by the submitter for electronic submissions.

Mapping

New York State Specific Data Element

Codes and Values

Left-justified and space-filled
Unique to health plan reporting

Edit Applications:

None

MEDS III Transaction Segment: Header

Data Element Name: TSN CERTIFICATION
Submission Status: Required for Header Record
Encounter Record Position(s): 13-21
Format - Length: Character - 9
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: NA/C110

Definition: This field must contain the word 'CERTIFIED' (in UPPERCASE letters) to indicate the submitter is certified to submit electronically.

Mapping

New York State Specific Data Element

Codes and Values

Left-justified
'CERTIFIED' in UPPERCASE letters

Edit Applications:

None

MEDS III Transaction Segment: Header

Data Element Name: VENDOR SOFTWARE NUMBER
Submission Status: Optional
Encounter Record Position(s): 22-26
Format - Length: Character - 5
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: NA/E2843

Definition: Vendor Software Number

Mapping

New York State Specific Data Element

Codes and Values

Optional Plan Reported Data Element

Edit Applications:

None

MEDS III Transaction Segment: Header

Data Element Name: VENDOR SOFTWARE UPDATE LEVEL
Submission Status: Optional
Encounter Record Position(s): 27-28
Format - Length: Character - 2
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: NA/E2825

Definition: Vendor Software Update Level

Mapping

New York State Specific Data Element

Codes and Values

Optional Plan Reported Data Element

Edit Applications:

None

MEDS III Transaction Segment: Header

Data Element Name: TEST / PROD INDICATOR
Submission Status: Required for Header Record
Encounter Record Position(s): 29-32
Format - Length: Character - 4
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: NA/NA

Definition: This field must contain either the word 'TEST' to direct your submission to the Provider Test Environment (PTE) or 'PROD' for submitting files to production. If this field is left blank, the submission will not pass through our 'Tier One' editing process and the entire file will reject.

Mapping

New York State Specific Data Element

Codes and Values

Left-justified
Must contain either the word 'TEST' or 'PROD'

Edit Applications:

Tier One Edit: 'Specified mode ' ' does not match' 'Test/Prod Indicator'

MEDS III Transaction Segment: Header

Data Element Name: PLAN IDENTIFICATION NUMBER
Submission Status: Required for Header Record
Encounter Record Position(s): 33-40
Format - Length: Character - 8
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 4397/H056

Definition: The health organization's MMIS Identification Number.

Mapping

New York State Specific Data Element

Codes and Values

Left-justified with no embedded blanks and Space-filled
Must be a valid MMIS Plan Identification Number

Edit Applications:

00423 MMIS Plan ID Missing
00424 MMIS Plan ID Not On File
00425 MMIS Plan ID Not MC Capitation Provider

MEDS III Transaction Segment: Header

Data Element Name: SUBMITTER NAME
Submission Status: Required for Header Record
Encounter Record Position(s): 41-61
Format - Length: Character - 21
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: NA/NA

Definition: Name of submitting health organization.

Mapping

New York State Specific Data Element

Codes and Values

Name Used on Official State Records

Edit Applications:

None

MEDS III Transaction Segment: Header

Data Element Name: SUBMITTER ADDRESS1
Submission Status: Required for Header Record
Encounter Record Position(s): 62-79
Format - Length: Character - 18
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: NA/NA

Definition: Street address for submitting health organization.

Mapping

New York State Specific Data Element

Codes and Values

Valid Street Address

Edit Applications:

None

MEDS III Transaction Segment: Header

Data Element Name: SUBMITTER ADDRESS2
Submission Status: Required for Header Record
Encounter Record Position(s): 80-97
Format - Length: Character - 18
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: NA/NA

Definition: Street address for submitting health organization.

Mapping

New York State Specific Data Element

Codes and Values

Left-justified
Valid Street Address

Edit Applications:

None

MEDS III Transaction Segment: Header

Data Element Name: SUBMITTER CITY
Submission Status: Required for Header Record
Encounter Record Position(s): 98-112
Format - Length: Character - 15
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: NA/NA

Definition: City in which the submitting health organization correspondence should be sent.

Mapping

New York State Specific Data Element

Codes and Values

Left-justified
Valid City Name

Edit Applications:

None

MEDS III Transaction Segment: Header

Data Element Name: SUBMITTER STATE
Submission Status: Required for Header Record
Encounter Record Position(s): 113-114
Format - Length: Character - 2
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: NA/NA

Definition: Two-character standard state postal code in which the health organization does business.

Mapping

New York State Specific Data Element

Codes and Values

Valid two character state abbreviation (e.g., 'NY')

Edit Applications:

None

MEDS III Transaction Segment: Header

Data Element Name: SUBMITTER ZIP
Submission Status: Required for Header Record
Encounter Record Position(s): 115-123
Format - Length: Character - 9
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: NA/NA

Definition: The health organizations geographic area denoted by the postal zip code.

Mapping

New York State Specific Data Element

Codes and Values

Left-justified

Edit Applications:

None

MEDS III Transaction Segment: Header

Data Element Name: SUBMITTER FAX NUMBER
Submission Status: Required for Header Record
Encounter Record Position(s): 124-134
Format - Length: Character - 11
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: NA/NA

Definition: Facsimile number for the health organization.

Mapping

New York State Specific Data Element

Codes and Values

Left-justified

Edit Applications:

None

MEDS III Transaction Segment: Header

Data Element Name: SUBMITTER PHONE NUMBER
Submission Status: Required for Header Record
Encounter Record Position(s): 135-145
Format - Length: Character - 11
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: NA/NA

Definition: Phone number for the health organization, including 1 and the area code and seven digit number.

Mapping

New York State Specific Data Element

Codes and Values

Left-justified

Edit Applications:

None

MEDS III Transaction Segment: Header

Data Element Name: MEDS VERSION NUMBER
Submission Status: Required for Header Record
Encounter Record Position(s): 146-148
Format - Length: Character - 3
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: NA/NA

Definition: Version Number is '003'.

Mapping

New York State Specific Data Element

Codes and Values

Edit Applications:

None

VI. COMMON DETAIL

MEDS III Transaction Segment: Common Detail

Data Element Name: RECORD TYPE
Submission Status: Required: All COS
Encounter Record Position(s): 1-2
Format - Length: Character - 2
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: NA

Definition: The Record Type identifies the data being submitted as either the header record, the detail section, or the trailer record.

Mapping

New York State Specific Data Element

Codes and Values

*Code*	*Value*
H1	Header
D1	Detail
T1	Trailer

Edit Applications:

Must be a valid code of D1 for Common Detail Segment
Tier One Edit

MEDS III Transaction Segment: Common Detail

Data Element Name: ENCOUNTER TYPE INDICATOR (ETI)
Submission Status: Required: All COS
Encounter Record Position(s): 3
Format - Length: Character - 1
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 2764/H054

Definition: The Encounter Type Indicator (ETI) is a one-digit code indicating the type of encounter being reported. The ETI follows the four paper and electronic forms for institutional, pharmacy, dental and professional transactions.

Each of the four encounter types to be reported has different required data element sets and formats.

Mapping

New York State Specific Data Element

Codes and Values

Code must be valid, or the encounter file will reject and no further editing will occur.

*Code*	*Value*
I	Institutional
D	Pharmacy
T	Dental
P	Professional

Note: Institutional includes inpatient (COS 11) and other Categories of Service. Refer to Section II, Encounter Type Assignment by Category of Service, for more information on proper assignment.

Edit Applications:

Must be a valid code.
The combination of Encounter Type and Category of Service must be valid.
00901 Claim Type Unknown

MEDS III Transaction Segment: Common Detail

Data Element Name: ENCOUNTER CONTROL NUMBER (ECN)
Submission Status: Required: All COS
Encounter Record Position(s): 4-14
Format - Length: Character - 11
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1121/H073

Definition: Encounter Control Number (ECN) is the health organization assigned number used to uniquely identify an encounter transaction. CSC will include the ECN on edit feedback reports to health organizations. Other than editing the ECN for its presence on the encounter record and special characters, the assignment, composition, and validity of the ECN is the responsibility of the health organization.

The ECN is returned to the plan on the response report file, so the plan is able to reconcile the status of the encounter with the original file submitted.

Mapping

New York State Specific Data Element

Codes and Values

Must be left-justified with no embedded blanks and space-filled
Cannot equal zero or blanks
Must be numeric (0-9) and/or alphabetic (A-Z). Special Characters are invalid entries.

Edit Applications:

00400 Encounter Control Number Missing

MEDS III Transaction Segment: Common Detail

Data Element Name: PREVIOUS TRANSACTION CONTROL NUMBER (TCN)
Submission Status: Situational
Encounter Record Position(s): 15-30
Format - Length: Character/Numeric - 16
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 0537/H055 (TCN) H075 (Prev TCN)

Definition: This data element was formerly called the Previous Encounter Reference Number (ERN).

Transaction Control Number (TCN) is a unique identifier assigned by Computer Sciences Corporation (CSC) to each encounter transaction received. The TCN is used for internal control purposes and by plans to adjust or void records identified as failing edits. Records failing soft edits will be identified to the plans by the assigned TCN and unique, plan-assigned Encounter Control Number (ECN). The previous TCN and appropriate Transaction Status Code are used only to properly adjust or void a previously submitted record. When submitting a second adjustment of a record, use the TCN assigned to the adjustment record (i.e. not the original record).

Additionally, if the encounter record passes through the system without hitting any edits, the plan should store the associated TCN and the 'Accepted' status in their internal data system.

Mapping

New York State Specific Data Element

Codes and Values

Space-filled if the previous ERN is not recorded (i.e. the record is not being adjusted or voided).

Edit Applications:

00103 Adj / Void Fields Incomplete
00725 Hist Record Not Found Adjus/Void

MEDS III Transaction Segment: Common Detail

Data Element Name: TRANSACTION STATUS CODE
Submission Status: Required: All COS
Encounter Record Position(s): 31
Format - Length: Number - 1
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 0705/H066

Definition: The Transaction Status Code identifies an encounter transaction as an original encounter, a void or a replacement to a previously accepted encounter. This data element was formerly called the Adjustment/Void Code.

Health organizations may use the adjustment/void process to update previously submitted information, to correct data elements that had previously failed soft edits or to delete records that should not have been submitted.

Mapping

New York State Specific Data Element

Codes and Values

*Code*	*Value*
0	ORIGINAL ENCOUNTER
7	ADJUSTMENT ENCOUNTER - REPLACEMENT RECORD
8	VOID ENCOUNTER - DELETION RECORD

All new encounters will be submitted with a value of '0'
For adjustments, resubmit entire record, with the '7' code and Previous Transaction Control Number
For Voids, resubmit entire record with an '8' code and Previous TCN
To resubmit rejected records, resubmit the entire record with a value of '0', with the same Encounter Control Number, but without the TCN

Edit Applications:

00103 Adj / Void fields incomplete

MEDS III Transaction Segment: Common Detail

Data Element Name: CLIENT IDENTIFICATION NUMBER (CIN)
Submission Status: Required: All COS
Encounter Record Position(s): 32-39
Format - Length: Character - 8
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 0535/1010

Definition: The CIN is assigned to an enrollee upon determination that an individual is eligible for Medicaid services. All encounter records must contain a valid CIN. Newborn encounters should not be reported under the maternal CIN.

Mapping:

Paper Form :

Encounter Type	Form	Element
Institutional	UB-92	#60
Institutional	UB-04	#60
Pharmacy	UCF	ID
Dental	ADA	#15
Professional	CMS-1500	#1A

Electronic :

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Page No.
Institutional	837I	2010BA	NM1 NM1	08 09	66 67	MI	110
Dental	837D	2010CA	NM1	08 09	66 67	MI	137- 138
Professional	837P	2010CA	NM1	08 09	66 67	MI	159

Encounter Type	NCPDP Format
Pharmacy/DME	302-C2

Codes and Values :

The Medicaid CIN format consists of 2 letters, followed by 5 numbers, and ending with 1 letter (e.g. XY12345Z). CHPlus CIN is 8 numbers.

Edit Applications:

00074 Recipient ID Number Invalid
00140 Recipient ID Not On File
00689 Recipient Not Enrolled in Plan on Date of Service
00693 Recipient Never Enrolled in Managed Care
00694 Recipient Not Enrolled in MC on Date of Service
00696 Recipient Enrolled in Another MC Plan on Date of Service

MEDS III Transaction Segment: Common Detail

Data Element Name: BENEFICIARY IDENTIFICATION NUMBER
Submission Status: Optional
Encounter Record Position(s): 40-64
Format - Length: Character - 25
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 2767/H072

Definition: The Beneficiary Identification Number is a unique identification number assigned by the health organization to the member. The Beneficiary Identification Number may also be known as the subscriber identification number or a health insurance card identification number. The Beneficiary Identification Number should be identical to the Policy Number used for hospital claims and the Insured's Identification Number used in Professional service claims.

Mapping :

Paper Form :

Encounter Type	Form	Element
Institutional	UB-92	#60
Institutional	UB-04	#60
Pharmacy	UCF	ID
Dental	ADA	#15
Professional	CMS-1500	#1A

Electronic :

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Page No.
Institutional	837I	2300	CLM	01	1028	158
Dental	837D	2300	CLM	01	1028	150
Professional	837P	2300	CLM	01	1028	171

Encounter Type	NCPDP Format
Pharmacy/DME	ID

Codes and Values :

Left-justified
Space-fill if not applicable

Edit Applications:

None

MEDS III Transaction Segment: Common Detail

Data Element Name: PROVIDER PROFESSION CODE
Submission Status: Required: 01, 03, 04, 05, 06, 07, 13, 41, 75
Encounter Record Position(s): 65-67
Format - Length: Character - 3
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 2165/2165_3

Definition: Provider Profession Code specifies the three-digit profession of a provider on the State Education Department (SED) license file. The Profession Code is used in conjunction with the provider license number to identify providers licensed by SED.

Mapping:

New York State Specific Data Element

Codes and Values:

Provider Profession Codes and Values are contained within Appendix A. These codes are also available for download on the MEDS Home Page on the HCS.
Space-fill if not applicable.

Edit Applications:

Must be a valid code

Important Note:

Plans are now receiving the SED profession code for every provider on their Provider Network Data Submission. Please contact the Department's Provider Network and MEDS Compliance Unit at pnds@health.ny.gov if you have any questions or need more information. For up to date information on provider profession codes, plans can also visit the State Education Department website.

MEDS III Transaction Segment: Common Detail

Data Element Name: PROVIDER LICENSE NUMBER
Submission Status: Required: 01, 03, 04, 05, 06, 07, 13, 41, 75
Encounter Record Position(s): 68-75
Format - Length: Character - 8
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1570/W047

Definition: The Provider License Number, issued by the New York State Department of Education, is used to identify the health care provider rendering services or primarily responsible for the care provided during the encounter.

Mapping:

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Page No.
Institutional	837I	2010AA	REF	01 02	128 127	0B	83- 84
Dental	837D	2010AA	REF	01 02	128 127	0B	84
Professional	837P	2010AA	REF	01 02	128 127	0B	92

Codes and Values:

Right-justified
Do not zero fill - Space-fill if not applicable
Must be a valid professional license number issued by the New York State Department of Education

Edit Applications:

Must be a valid entry
Soft edit failures will be recorded if license number is not provided
00416 License Number Is Missing

Important Note:

There is a lookup tool for SED License status on the Provider Network Data System homepage on the HCS. This application supplements the SED license site lookup but gives plans more features and search flexibility. This lookup also returns SED profession code for those needing this information for MEDS submission purposes.

MEDS III Transaction Segment: Common Detail

Data Element Name: PROVIDER IDENTIFICATION NUMBER
Submission Status: Required: All COS
Encounter Record Position(s): 76-85
Format - Length: Character - 10
Effective Date: 9/1/2008
Version Number - Date: 2.7 - August 2008
MEDS III DE# / DW#: 1563/2001

Definition: Provider Identification Number is a unique National Provider ID (NPI) assigned to each health care provider that sees recipients. If the provider type is non-health care related the Provider Identification Number is a unique MMIS provider ID assigned to each provider that sees Medicaid recipients. This number is the primary way of identifying a provider.

Encounter Type	Provider Type
Professional	Servicing Provider
Dental	Servicing Provider
Institutional	Billing (Referring) Provider
Pharmacy/DME	Dispensing (Referring) Provider

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#51
Institutional	UB-04	#56-57
Pharmacy	UCF	Service Provider ID
Dental	ADA	#54
Professional	CMS-1500	#33

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Page No.
Institutional	837I	2010AA	NM1	08 09	66 67	XX	77
Dental	837D	2010AA	NM1	08 09	66 67	XX	78
Professional	837P	2010AA	NM1	08 09	66 67	XX	86
Encounter Type	NCPDP Format
Pharmacy/DME	202-B2 201-B1

Codes and Values:

NPI should be left-justified with no embedded blanks.
MMIS Id should be left-justified with two (2) trailing spaces.
Space-fill if not applicable.
The following Generic Provider IDs should be used to report encounters involving out-of-network providers (in state or out-of-state) when Provider IDs are unknown.

COS	COS Description	Generic Provider ID
01	Provider Services	01666119
03	Podiatry	01666119
04	Psychology	01666119
05	Eye Care/Vision	01666119
06	Rehabilitation Therapy	01666119
07	Nursing	01666119
11	Inpatient	01666086
12	Institutional Long Term Care	01666119
13	Dental	01666119
14	Pharmacy	01666137
15	Home Health Care / Non-Institutional Long Term Care	01666119
16	Laboratories	01666100
19	Transportation	01666077
22	DME and Hearing Aids	01666137
28	Intermediate Care Facilities	01666119
41	Nurse Providers/Midwives	01666119
73	Hospice	01666119
75	Clinical Social Worker	01666119
85	Freestanding Clinic	01666095
87	Non-Inpatient/Emergency Room	01666128

Edit Applications:

Must be a valid entry
00409 Inpatient MMIS Provider ID Is Not A Hospital (COS 11 Only)
00175 Servicing Provider Id Not on File (Professional and Dental)
00078 Referring Provider Identification Number Invalid (Institutional and Pharmacy)
02022 Missing Referring NPI (Institutional and Pharmacy)
02025 Missing Rendering NPI (Professional and Dental)
02032 Invalid Referring NPI (Institutional and Pharmacy)
02035 Invalid Rendering NPI (Professional and Dental)
Tier One Edit - Provider Check Digit

MEDS III Transaction Segment: Common Detail

Data Element Name: PROVIDER SERVICE LOCATION
Submission Status: Required: ALL COS
Encounter Record Position(s): 86-94
Format - Length: Zip+4 - 9
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: E9805/9805

Definition: Provider Service Location is the Zip+4 U.S. address postal code or an international postal code related to the address for the Provider ID and Locator Code.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-04	#1
Pharmacy	UCF	Zip Code
Dental	ADA	#56
Professional	CMS-1500	#32

Electronic:

Mapping Electronic Claim Element
	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Page No.
837I	2310E	N4	03	116	2010AA	N4	03	116	81
837D	2310C	N4	03	116	2010AA	N4	03	116	90
NCPDC	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
837P	2310C	N4	03	116	2010AA	N4	03	116	82
Primary Zip code loop					Secondary Zip code loop - used when Primary loop not present

Codes and Values:

Left-justified
Zip+4 codes are U.S. address postal codes
Must be valid U.S. postal codes with the format 123456789
Zero filled for non-U.S. address location

Edit Applications:

Tier One Edit - Provider Zip Code

MEDS III Transaction Segment: Common Detail

Data Element Name: CATEGORY OF SERVICE
Submission Status: Required: All COS
Encounter Record Position(s): 95-96
Format - Length: Numeric - 2
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 2694/H001_7

Definition: Category of Service is a two-digit alpha-numeric code which indicates the type of service being provided and/or the provider rendering the service.

Mapping:

New York State Specific Data Element

Codes and Values: Category of Service must be applicable to the encounter type being reported.

*Category of Service*		*Encounter Type*
*Code*	*Value*	*Code*	*Value*
01	Physician Services	P	Professional
03	Podiatry	P	Professional
04	Psychology	P	Professional
05	Eye Care / Vision	P	Professional
06	Rehabilitation Therapy	I	Institutional
07	Nursing	P	Professional
11	Inpatient	I	Institutional
12	Institutional LTC	I	Institutional
13	Dental	T	Dental
14	Pharmacy	D	Pharmacy/DME
15	Home Health Care/Non-Institutional LTC	I	Institutional
16	Laboratories	P	Professional
19	Transportation	P	Professional
22	DME and Hearing Aids	P	Professional
28	Intermediate Care Facilities	I	Institutional
41	NPs/Midwives	P	Professional
73	Hospice	I	Institutional
75	Clinical Social Worker	P	Professional
85	Freestanding Clinic	I	Institutional
87	Hospital OP/ER Room	I	Institutional

Edit Applications:

Must be a valid code
00408 Category Of Service Missing
00901 Claim Type Unknown

MEDS III Transaction Segment: Common Detail

Data Element Name: TOTAL CHARGED AMOUNT
Submission Status: Required: ALL COS
Encounter Record Position(s): 97-107
Format - Length: Numeric - 11
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: E1025/1025

Definition: The total amount charged for each listed service.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-04	#47
Pharmacy	UCF	Net Amount Due
Dental	ADA	#33
Professional	CMS-1500	#28

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Page No.
Institutional	837I	2300	CLM	02	782	159
Dental	837D	2300	CLM	02	782	151
Professional	837P	2300	CLM	02	782	172
Encounter Type	NCPDP Format
Pharmacy/DME	430-DU

Codes and Values:

Right-justified and zero filled
This amount is defined with two implied decimal places (e.g., $1,000.00 is reported as 100000)

Edit Applications:

Must be a valid format
Must be entered as a positive number
00036 M/I Usual and Customary

MEDS III Transaction Segment: Common Detail

Data Element Name: TOTAL PAID AMOUNT
Submission Status: Required: All COS
Encounter Record Position(s): 108-118
Format - Length: Numeric - 11
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1028/E1028

Definition: The total amount Medicaid paid for all listed services. The Total Amount Paid includes the sum of all plan claims (Claim/Encounter Indicator=”C”) and proxy encounters (Claim/Encounter Indicator=”E”).

Total Amount Paid should be calculated from the service lines reported. If the record submitted in a continuation encounter, the Total Paid Amount on the first encounter record would be for service lines 1 through 10 and the Total Paid Amount on the second encounter record would be for service lines 11 - 20, etc.

Mapping:

New York State Specific Data Element

Codes and Values:

Right-justified and zero filled
This amount is defined with two implied decimal places (e.g., $1,000.00 is reported as 100000)

Edit Applications:

Must be a valid format
Must be entered as a positive number

MEDS III Transaction Segment: Common Detail

Data Element Name: MEDICARE TOTAL PAID AMOUNT
Submission Status: Situational:
Required if member enrolled in Medicare.
Encounter Record Position(s): 119-129
Format - Length: Numeric - 11
Effective Date: 2/18/2010
Version Number - Date: 2.9 - April 2010
MEDSIII DE# / DW#: 1085/H3033_2

Definition: The total amount Medicare paid for listed services that are received by dual eligible Medicaid/Medicare enrollees or beneficiaries. This is the Medicare Total Paid Amount on the “Header Level”.

Medicare Total Amount Paid should be calculated from the Medicare Paid Amount service lines reported. If the record submitted in a continuation encounter, the Medicare Total Paid Amount on the first encounter record would be for service lines 1 through 10 and the Medicare Total Paid Amount on the second encounter record would be for service lines 11 - 20, etc.

Mapping:

New York State Specific Data Element

Codes and Values:

Right-justified and zero filled
This amount is defined with two implied decimal places (e.g., $1,000.00 is reported as 100000)

Edit Applications:

Must be a valid format
Must be entered as a positive number

Important Note:

This data element will be used to identify the first 20 days of a nursing home stay in which Medicare pays 100% of the cost. If the enrollee is not discharged within the first 20 days, then the remainder of the month would be reported as a separate encounter.

MEDS III Transaction Segment: Common Detail

Data Element Name: OTHER INSURANCE TOTAL PAID AMOUNT
Submission Status: Situational
Encounter Record Position(s): 130-140
Format - Length: Numeric - 11
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1085/3031

Definition: The total amount paid by insurance other than Medicaid. Medicare cost data should be reported the Medicare paid amount data fields.

Mapping:

New York State Specific Data Element

Codes and Values:

Right-justified and zero-filled
This amount is defined with two implied decimal places

Edit Applications:

Must be a valid format
Must be entered as a positive number

MEDS III Transaction Segment: Common Detail

Data Element Name: OTHER PAYER NAME
Submission Status: Situational
Encounter Record Position(s): 141-175
Format - Length: Character - 35
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1589/E1589

Definition: Other Payer Name identifies the secondary payer on the encounter. Medicare data should be reported the Medicare data fields.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#50B
Institutional	UB-04	#50B
Pharmacy	UCF
Dental	ADA	#11
Professional	CMS-1500

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Page No.
Institutional	837I	2010BC	NM1	03	1035	127
Dental	837D	2010BB	NM1	03	1035	118
Professional	837P	2010BB	NM1	03	1035	131

Codes and Values:

Free-form description of secondary payer
Space-fill if not applicable

Edit Applications:

None

MEDS III Transaction Segment: Common Detail

Data Element Name: OTHER INSURANCE TYPE CODE
Submission Status: Situational
Encounter Record Position(s): 176-177
Format - Length: Character - 2
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1455/E1455_2

Definition: The Other Insurance Type Code indicates payers other than Medicaid.

Mapping:

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Page No.
Institutional	837I	2000B	SBR	09	1032	104
Dental	837D	2000B	SBR	09	1032	101
Professional	837P	2000B	SBR	09	1032	112

Codes and Values:

Code	Value
09	Self-Pay
10	Central Certification
11	Other Non-Federal Programs
12	Preferred Provider Organizations (PPO)
13	Point of Service (POS)
14	Exclusive Provider Organization (EPO)
15	Indemnity Insurance
16	HMO Medicare Risk
AM	Automobile Medical
BL	Blue Cross/Blue Shield
CA	Capitated
CH	Champus
CI	Commercial Insurance Company
DS	Disability
HM	Health Maintenance Organization
LI	Liability
LM	Liability Medical
MA	Medicare; Part A
MB	Medicare; Part B
MC	Medicaid
OF	Other Federal Program
OI	Other Insurance
SC	Sub-Capitated

Code	Value
TV	Title V
VA	Veteran's Administration Plan
WC	Workers Compensation Health Plan
ZZ	Mutually Defined

Space-fill if not applicable

Edit Applications:

Must be a valid code

MEDS III Transaction Segment: Common Detail

Data Element Name: MEDICARE TOTAL DEDUCTIBLE PAID
Submission Status: Situational
Required if member enrolled in Medicare.
Encounter Record Position(s): 178-188
Format - Length: Numeric - 11
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: 3034/4141

Definition: The amount the beneficiary is required to pay for health care or prescriptions before Medicaid paid for the treatment.

Mapping:

New York State Specific Data Element

Codes and Values:

Right-justified and zero filled
This amount is defined with two implied decimal places (e.g., $1,000.00 is reported as 100000)

Edit Applications:

Must be a valid format
Must be entered as a positive number

MEDS III Transaction Segment: Common Detail

Data Element Name: MEDICARE TOTAL CO-INSURANCE PAID
Submission Status: Situational
Required if member enrolled in Medicare.
Encounter Record Position(s): 189-199
Format - Length: Numeric - 11
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: F445/2735

Definition: The amount the beneficiary is required to pay for healthcare services which is a set percentage of the covered costs after the deductible has been paid before Medicare paid for the treatment.

Mapping:

New York State Specific Data Element

Codes and Values:

Right-justified and zero filled
This amount is defined with two implied decimal places (e.g., $1,000.00 is reported as 100000)

Edit Applications:

Must be a valid format
Must be entered as a positive number

MEDS III Transaction Segment: Common Detail

Data Element Name: MEDICARE TOTAL COPAY PAID
Submission Status: Situational
Required if member enrolled in Medicare
Encounter Record Position(s): 200-210
Format - Length: Numeric - 11
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: S040

Definition: The specified amount the beneficiary is required to pay out-of-pocket for healthcare services at the time the service is rendered before Medicare paid for the treatment.

Mapping:

New York State Specific Data Element

Codes and Values:

Right-justified and zero filled
This amount is defined with two implied decimal places (e.g., $1,000.00 is reported as 100000)

Edit Applications:

Must be a valid format
Must be entered as a positive number

MEDS III Transaction Segment: Common Detail

Data Element Name: OTHER INSURANCE TOTAL DEDUCTIBLE PAID
Submission Status: Situational
Encounter Record Position(s): 211-221
Format - Length: Numeric - 11
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: E0482/0482

Definition: The amount the beneficiary is required to pay for health care or prescriptions before the Other Payer paid for the treatment.

Mapping:

New York State Specific data element

Codes and Values:

Right-justified and zero filled
This amount is defined with two implied decimal places (e.g., $1,000.00 is reported as 100000)

Edit Applications:

Must be a valid format
Must be entered as a positive number

MEDS III Transaction Segment: Common Detail

Data Element Name: OTHER INSURANCE TOTAL CO-INSURANCE PAID
Submission Status: Situational
Encounter Record Position(s): 222-232
Format - Length: Numeric - 11
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: E1013/1033

Definition: The amount the beneficiary is required to pay for healthcare services which is a set percentage of the covered costs after the deductible has been paid before the Other Payer paid for the treatment.

Mapping:

New York State Specific Data Element

Codes and Values:

Right-justified and zero filled
This amount is defined with two implied decimal places (e.g., $1,000.00 is reported as 100000)

Edit Applications:

Must be a valid format
Must be entered as a positive number

MEDS III Transaction Segment: Common Detail

Data Element Name: OTHER INSURANCE TOTAL COPAY PAID Submission Status: Situational
Encounter Record Position(s): 233-243
Format - Length: Numeric - 11
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: E0481/0481

Definition: The specified amount the beneficiary is required to pay out-of-pocket for healthcare services at the time the service is rendered before the Other Payer paid for the treatment.

Mapping:

New York State Specific Data Element

Codes and Values:

Right-justified and zero filled
This amount is defined with two implied decimal places (e.g., $1,000.00 is reported as 100000)

Edit Applications:

Must be a valid format
Must be entered as a positive number

MEDS III Transaction Segment: Common Detail

Data Element Name: FILLER
Submission Status: Situational
Encounter Record Position(s): 244-257
Format - Length: Character - 14
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012

Definition: Space-fill positions 244 to 257.

Mapping:

New York State Specific data element

Codes and Values:

Left-justified and space-filled

Edit Applications:

Tier One Edit - Record is not 3000 bytes.

VII. INSTITUTIONAL

Inpatient and Non-Inpatient Reporting Requirements By Data Element

There are two components to the Institutional segment of MEDS III reporting requirements: inpatient and non-inpatient. As the diagram above indicates, many of the Institutional data elements are required for inpatient COS 11 only. The intersection of the diagram above indicates the data elements that are required for both inpatient and non-inpatient reporting.

MEDS III Transaction Segment: Institutional

Data Element Name: PROVIDER SPECIALTY CODE
Submission Status: Required for COS 06, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 258-260
Format - Length: Character - 3
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1499/2048

Definition: The Provider Specialty Code identifies a provider's medical, dental, clinic or program type specialty.

Mapping:

New York State Specific Data Element

Codes and Values:

Refer to Appendix B for valid codes and values
Where applicable, specialty codes must be a valid three-digit MMIS specialty code
Space-fill if not applicable

Edit Applications:

Must be a valid code
00404 Provider Specialty Missing
00413 Provider Specialty Not On File

MEDS III Transaction Segment: Institutional

Data Element Name: HOSPITAL INPATIENT CLAIM/ENCOUNTER INDICATOR
Submission Status: Required for COS 11
Encounter Record Position(s): 261
Format - Length: Character - 1
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1983/E1983

Definition: Indicates whether the inpatient service provided was a capitated service within the health organization's contract (“E”); a within plan claim (“C”) or an administratively denied service (“A”).

Administratively denied encounters are those encounters, which reflect services normally paid for but were denied due to failure of at least one requirement of the agreement between provider and plan. An example could be that encounters must be submitted within 60 days of service date. A well-child encounter submitted 63 days after date of service would be administrative denied. (Claim received too late).

Mapping:

New York State Specific Data Element

Codes and Values:

Code	Value
E	Capitated Encounter or service not paid directly by the health organization
C	Within Plan Claim
A	Administrative Denial

Space-fill if not applicable

Edit Applications:

Must be a valid code
00437 Claim Encounter Ind Invalid

Please Note:

Sub-capitation vendor relationships should be reported as encounters.

MEDS III Transaction Segment: Institutional

Data Element Name: NYS DIAGNOSIS RELATED GROUP CODE
Submission Status: Required for COS 11
Encounter Record Position(s): 262-265
Format - Length: Character - 4
Effective Date: 12/01/2009
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 2053/3336

Definition: The NYS Diagnosis Related Group (APR-DRG) Code specifies the group of services received by a recipient during an inpatient stay. The APR-DRG data element is a four digits character field. The APR-DRG code is three digits and should be reported first (left justified). The Severity of illness (SOI) indicator is the last digit within the data element.

This code is generated by the NYS APR-DRG grouper module during claims processing and is derived using recipient information, diagnosis codes and procedure codes.

In instances where a plan-derived DRG differs from the provider submitted DRG, submit the plan- derived DRG.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#11, #35;39-41, #35;78, #35;84
Institutional	UB-04	#39-41, #35;78, #35;80

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Page No.
Institutional	837I	2300	HI HI	01 01	1 2		230

Codes and Values:

Follow the guidelines for APR-DRG codes
Values for Severity of Illness:

*Code*	*Value*
1	Minor
2	Moderate
3	Major
4	Severe

Left-justified
If there is no DRG to report, a plan must report "0000" for the DRG

Edit Applications:

Must be a valid code
00410 DRG Code Missing

MEDS III Transaction Segment: Institutional

Data Element Name: TYPE OF BILL DIGITS 1 & 2 CODE
Submission Status: Required for COS 06, 11, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 266-267
Format - Length: Character - 2
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 0394 / E0394

Definition: Type of Bill Digits 1 & 2 Code is the first two digits of a three-digit numeric code which identifies the specific type of bill (inpatient, outpatient, adjustments, voids, etc.). The first digit represents the Type of Facility; the second digit is the Bill Classification.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#4
Institutional	UB-04	#4

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Institutional	837I	2300	CLM	05	C023-1 C023-2	1331 1332	159

Codes and Values

*Code*	*Value*
11	HOSP-INP INCL MED PART A
12	HOSP-INP MED PART B ONLY
13	HOSP-OUT
14	HOSP-OTHER
15	HOSP-INTER CARE LEVEL I
16	HOSP-INTER CARE LEVEL II
17	HOSP-SUBACUTE INP
18	HOSP-SWING BEDS
21	SNF-INP INCL MED PART A
22	SNF-INP MED PART B ONLY
23	SNF-OUT
24	SNF-OTHER
25	SNF-INTER CARE LEVEL I
26	SNF-INTER CARE LEVEL II
27	SNF-SUBACUTE INP
28	SNF-SWING BEDS
32	HOME HLTH-INP MED PART B ONLY
33	HOME HLTH-OUTPATIENT
34	HOME HLTH-OTHER
41	NON-MED HCI-HOSP INP-INP INCL MED PART A
42	NON-MED HCI-HOSP INP-INP MED PART B ONLY
43	NON-MED HCI-HOSP INP-OUT
44	NON-MED HCI-HOSP INP-OTHER
45	NON-MED HCI-HOSP INP-INTER CARE LEVEL I
46	NON-MED HCI-HOSP INP-INTER CARE LEVEL II
47	NON-MED HCI-HOSP INP-SUBACUTE INP
48	NON-MED HCI-HOSP INP-SWING BEDS
51	NON-MED HCI-POST-HOSP EXT CS-INP INCL MED PART A
52	NON-MED HCI-POST-HOSP EXT CS-INP MED PART B ONLY
53	NON-MED HCI-POST-HOSP EXT CS-OUT
54	NON-MED HCI-POST-HOSP EXT CS-OTHER
55	NON-MED HCI-POST-HOSP EXT CS-INTER CARE LEVEL I
56	NON-MED HCI-POST-HOSP EXT CS-INTER CARE LEVEL II
57	NON-MED HCI-POST-HOSP EXT CS-SUBACUTE INP
58	NON-MED HCI-POST-HOSP EXT CS-SWING BEDS
61	INTER CARE-INP INCL MED PART A
62	INTER CARE-INP MED PART B ONLY
63	INTER CARE-OUT
64	INTER CARE-OTHER
65	INTER CARE-INTER CARE LEVEL I
66	INTER CARE-INTER CARE LEVEL II
67	INTER CARE-SUBACUTE INP
68	INTER CARE-SWING BEDS
71	CLINIC-RURAL HLTH
72	CLINIC-HOSP/INDEP DIALYSIS CNTR
73	CLINIC-FREE STANDING
74	CLINIC-ORF
75	CLINIC-CORF
76	CLINIC-COMMUNITY MENTAL HLTH CENTER
79	CLINIC-OTHER
81	SPEC FACI-HOSPICE (NON-HOSP BASED)
82	SPEC FACI-HOSPICE (HOSP BASED)
83	SPEC FACI-AMB SURG CNTR
84	SPEC FACI-FREE STANDING BIRTHING CENTER
85	SPEC FACI-CRITICAL ACCESS HOSP
86	SPEC FACI-RESIDENTIAL FACILITY
89	SPEC FACI-OTHER

Edit Applications:

Must be a valid code.
01718 Type of Bill is Invalid

MEDS III Transaction Segment: Institutional

Data Element Name: TYPE OF BILL CODE DIGIT 3 CODE
Submission Status: Required for COS 06, 11, 12, 15, 28,
73, 85, 87
Encounter Record Position(s): 268
Format - Length: Character - 1
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 0395/ E0395

Definition: Type of Bill Digit 3 Code is the last digit of the three Character Type of Bill code. It represents the frequency of the bill.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#4
Institutional	UB-04	#4

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Institutional	837I	2300	CLM	05	C023-3	1325	159

Codes and Values:

*Code*	*Value*
0	NON-PAYMENT/ZERO CLAIM
1	ADMIT THRU DISCHARGE CLAIM
2	INTERIM - FIRST CLAIM (NOT VALID FOR COS 11 ENCOUNTERS)
3	INTERIM - CONTINUING CLAIM (NOT VALID FOR COS 11 ENCOUNTERS)
4	INTERIM - LAST CLAIM (NOT VALID FOR COS 11 ENCOUNTERS)
5	LATE CHARGE(S) ONLY CLAIM
6	RESERVED
7	REPLACEMENT OF PRIOR CLAIM
8	VOID/CANCEL OF PRIOR CLAIM
9	FINAL CLAIM FOR A HOME HEALTH PPS EPISODE
A	ADMISSION/ELECTION NOTICE (A)

Edit Applications:

Must be a valid code
00436 Type of Bill Digit 3 Invalid

MEDS III Transaction Segment: Institutional

Data Element Name: STATEMENT COVERS PERIOD FROM
Submission Status: Required for COS 06, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 269-276
Format - Length: Date - CCYYMMDD
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1022/3013

Definition: Statement Covers Period From date is the first date that a service on an encounter was rendered.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#6
Institutional	UB-04	#6

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Pg No
Institutional	837I	2300	DTP	01 02 03	374 1250 1251	434 D8&RD8	167

Codes and Values:

Must be a valid date format CCYYMMDD

Valid Century (CC)	Valid Year (YY)
20	>=04

Valid Month Code (MM)	Valid Day Code (DD)
01, 03, 05, 07, 08, 10, 12	Greater than 00 and less than 32
04, 06, 09, 11	Greater than 00 and less than 31
02	Greater than 00 and less than 29 (less than 30 on a leap year)

Must be spaced-filled when not applicable (i.e., COS 06, 12, 15, 28, 73, 85, 87)

Edit Applications:

Must be on or before the Statement Covers Period - Thru Date
00018 Date Of Service/Fill Date Invalid
001292 Date of Service Two Years Prior to Date Received

MEDS III Transaction Segment: Institutional

Data Element Name: STATEMENT COVERS PERIOD THRU
Submission Status: Required for COS 06, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 277-284
Format - Length: Date - CCYYMMDD
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1023/3015

Definition: Statement Covers Period Thru date is the last date that a service on an encounter was rendered.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#6
Institutional	UB-04	#6

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Pg No
Institutional	837I	2300	DTP	01 02 03	374 1250 1251	434 D8&RD8	167

Codes and Values:

Must be a valid date format CCYYMMDD

Valid Century (CC)	Valid Year (YY)
20	>=04

Valid Month Code (MM)	Valid Day Code (DD)
01, 03, 05, 07, 08, 10, 12	Greater than 00 and less than 32
04, 06, 09, 11	Greater than 00 and less than 31
02	Greater than 00 and less than 29 (less than 30 on a leap year)

Must be spaced-filled when not applicable (i.e., COS 06, 12, 15, 28, 73, 85, 87)

Edit Applications:

Must be on or after the Statement Covers Period - From Date
Must be on or after the Admission Date
00655 Discharge Date Different Than Statement Thru Date
01004 Thru Service Date Invalid
01006 Thru Service Prior to From Service Date

MEDS III Transaction Segment: Institutional

Data Element Name: TYPE OF ADMISSION
Submission Status: Required for COS 11
Encounter Record Position(s): 285
Format - Length: Character - 1
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 4151/3101

Definition: One-digit alpha-numeric code indicating priority of the admission to a hospital.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#19
Institutional	UB-04	#14

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Institutional	837I	2300	CL1	01	n/a	1315	171

Codes and Values:

Code	Value
1	Emergency: The patient requires immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions.
2	Urgent: The patient requires immediate attention for the care and treatment of a physical or mental disorder. Generally the patient is admitted to the first available and suitable accommodation.
3	Elective: The patient's condition permits adequate time to schedule the admission based on the availability of a suitable accommodation.
4	Newborn: Use of this code necessitates the use of special codes in the Source of Admission
5	Trauma Center

Space-fill if not applicable

Edit Applications:

Must be a valid entry.
00603 Admission Type Code Invalid

MEDS III Transaction Segment: Institutional

Data Element Name: SOURCE OF ADMISSION
Submission Status: Required for COS 11
Encounter Record Position(s): 286
Format - Length: Character - 1
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 0138/E0138

Definition: Source of Admission specifies the source of an admission into a hospital.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#20
Institutional	UB-04	#15

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Institutional	837I	2300	CL1	02	n/a	1314	172

Codes and Values:

Code	Value
1	Non-Health Care Facility Point of Origin
2	Clinic Referral
4	Transfer from a Hospital
5	Transfer from a Skilled Nursing Facility or Intermediate Care Facility
6	Transfer from Another Health Care Facility
7	Emergency Room
8	Court/Law Enforcement
9	Information Not Available
B	Transfer from Another Home Health Agency
C	Readmission to Same Home Health Agency
D	Transfer from One Distinct Unit of the Hospital to another Distinct Unit of the same hospital
E	Transfer from Ambulatory Surgery Center
F	Transfer from Hospice and is Under a Hospice Plan of Care

If the Type of Admission is a Newborn, "4", the following coding scheme must be used for Source of Admission.

Code	Value
5	Born Inside this Hospital
6	Born Outside this Hospital

Space-fill if not applicable

Edit Applications:

Must be a valid entry
00435 Source of Admission Code Invalid

MEDS III Transaction Segment: Institutional

Data Element Name: PATIENT STATUS OR DISPOSITION CODE
Submission Status: Required for COS 11, 12, 28, 73
Encounter Record Position(s): 287-288
Format - Length: Character - 2
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 0168/3291

Definition: Patient Status Code describes a specific condition or status of an enrollee as of the last date of service on the encounter.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#22
Institutional	UB-04	#17

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Institutional	837I	2300	CL1	03	n/a	1352	172

Codes and Values:

Right-justified and zero-filled.
Must be a valid code in accordance with Patient Status or Disposition Codes

Code	Value
01	DISCHARGE / TRANSFER TO HOME/SELF CARE
02	TRANSFER TO A DRG HOSPITAL
03	DISCHARGE / TRANSFER TO SKILLED NURSING FACILITY
04	DISCHARGE/TRANSFER TO INTER CARE FACILITY/HRF
05	TRANSFERRED TO A NON-DRG HOSPITAL
06	DISCHARGE TO HOME UNDER CARE OF HOME HEALTH ORG.
07	LEFT AGAINST MEDICAL ADVICE
08	DISCHARGED TO HOME IV THERAPY
09	ADMITTED TO INPATIENT HOSPITAL
20	EXPIRED
21	DISCHARGE/TRANSFER TO COURT/LAW ENFORCEMENT
30	STILL A PATIENT/RESIDENT (NOT VALID FOR COS 11 ENCOUNTERS)
40	EXPIRED AT HOME
41	EXPIRED AT MEDICAL FACILITY
42	EXPIRED - PLACE UNKNOWN

Code	Value
43	DISCHARGED TO FEDERAL HOSPITAL
50	HOSPICE - HOME
51	HOSPICE - MEDICAL FACILITY
61	DISCHARGE/TRANSFER TO ALC
62	DISCHARGE/TRANSFER TO INPATIENT REHAB FACILITY
63	DISCHARGE/TRANSFER TO MCARE LTC HOSPITAL
64	DISCHARGE/TRANSFER TO SNF CERTIFIED UNDER MCAID
65	DISCHAGE /TRANSFER TO PSYCHIATRIC HOSPITAL
66	DISCHARGE/ TRANSFER TO A CRITICAL ACCESS HOSPITAL
70	DISCHARGE/ TRANSFER TO ANOTHER TYPE OF HEALTH CARE INSTITUTION

Space-fill if not applicable

Edit Applications:

Must be a valid entry
00021 Patient Status Code Invalid

MEDS III Transaction Segment: Institutional

Data Element Name: MEDICAL RECORD NUMBER
Submission Status: Required for COS 11
Encounter Record Position(s): 289-308
Format - Length: Character - 20
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1016/3253

Definition: Patient Medical Record Number is an identifier assigned by a provider to a client for the purposes of tracking, accounting or reference. The number used by the Medical Records Department to identify the patient's permanent medical/health record file.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#23
Institutional	UB-04	#3-B

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Institutional	837I	2300	REF	01 02	n/a	128 127	200-201

Codes and Values:

Left-justified with no embedded blanks
Space-fill if not applicable
Must not equal zero or blanks
Must be numeric (0-9) and/or alphabetic (A-Z); special characters are invalid

Edit Applications:

Must be a valid entry

MEDS III Transaction Segment: Institutional

Data Element Name: NEONATE BIRTH WEIGHT CODE [up to 2]
Submission Status: Required for COS 11 Encounter Record Position(s): 309-310; 318-319 Format - Length: Character - 2
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1093/3321

Definition: The MEDS III layout allows for up to two Value Codes and up to two Value Code Amounts. At this time, only neonatal birth weight will be using the Value Codes. All newborn encounters must have a value code of 54.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#39-41
Institutional	UB-04	#39-41

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Institutional	837I	2300	HI	01	C022 - 2	1271	281

Codes and Values:

Code	Value
54	Newborn Birth Weight In Grams

Space-fill if not applicable

Edit Applications:

If applicable, must be a valid code
00431 Neonate Brth Weight Cd Invalid

MEDS III Transaction Segment: Institutional

Data Element Name: NEONATE BIRTH WEIGHT IN GRAMS (VALUE CODE AMOUNT) [up to 2]
Submission Status: Required for COS 11 Encounter Record Position(s): 311-317; 320-326 Format - Length: Numeric - 7
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1094/3367

Definition: The birth weight of the neonate in grams.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#39-41
Institutional	UB-04	#39-41

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Institutional	837I	2300	HI	01	C022-5	782	280

Codes and Values:

Right-justified and zero-filled
Must be a valid number greater than '0099' and less than '8000'
Birth Weights of '0099' grams or less should be reported as '0100' grams
If this field is not applicable it must contain zeroes

Edit Applications:

Must be a valid entry
00434 Birthweight Not Reasonable

MEDS III Transaction Segment: Institutional

Data Element Name: SERVICE DATE [up to 10]
Submission Status: Required for COS 06, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 327-334; 420-427; 513-520; 606-613; 699-706; 792-799;
885-892; 978-985; 1071-1078; 1164-1171
Format - Length: Date CCYYMMDD - 8
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: 3013/1080

Definition: The associated Service Date for the reported CPT/HCPCS or Revenue code(s) describing non-inpatient procedure(s) performed.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#17
Institutional	UB-04	#45

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Page No.
Institutional	837I	2400	DTP	03	1251	457

Codes and Values:

Must be a valid date format CCYYMMDD

Valid Century (CC)	Valid Year (YY)
20	>=04

Valid Month Code (MM)	Valid Day Code (DD)
01, 03, 05, 07, 08, 10, 12	Greater than 00 and less than 32
04, 06, 09, 11	Greater than 00 and less than 31
02	Greater than 00 and less than 29 (less than 30 on a leap year)

Edit Applications:

Must be a valid, properly formatted date

MEDS III Transaction Segment: Institutional

Data Element Name: REVENUE CODE [up to 10]
Submission Status: Required for COS 06, 11, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 335-338; 428-431; 521-524; 614-617; 707-710; 800-803;
893-896; 986-989;1079-1082;1172-1175
Format - Length: Character - 4
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 0442/0442

Definition: Revenue Codes uniquely identify a provider's cost center.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#42
Institutional	UB-04	#42

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Institutional	837I	2400	SV2	01	n/a	234	446

Codes and Values:

Right-justified
Space-fill if not applicable
Valid values are assigned by the National Uniform Billing Committee (NUBC)
If this field is not applicable it must be space-filled

Edit Applications:

Must be a valid code
01705 Revenue Code Not On File

MEDS III Transaction Segment: Institutional

Data Element Name: CPT/HCPCS CODE [up to 10]
Submission Status: Required for COS 06, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 339-343;432-436;525-529;618-622;711-715;804-808;897-901;990-994;1083-1087;1176-1180
Format - Length: Character - 5
Effective Date: 1/1/2009
Version Number - Date: 2.8 - January 2009
MEDS III DE# / DW#: 2042/5055

Definition: The American Medical Association's Current Procedural Terminology 4th Edition (CPT-4) Code or the Healthcare Common Procedure Coding System (HCPCS) code, which applies to the non-inpatient procedure performed and associated with each line of service.

Procedure Codes uniquely describe the service(s) rendered by a provider during an encounter. Fields for reporting up to ten procedures or services are available. If more than ten procedures were performed during the encounter, submit a second encounter record with the additional procedures listed and using the same Encounter Control Number and identical information on all other elements that were included in the first record.

Injections and immunizations administered or DME provided during the encounter should be recorded using the appropriate procedure codes. Diagnostic tests performed during the encounter should be reported. Diagnostic testing performed on subsequent days should be reported as separate encounters.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#44
Institutional	UB-04	#44

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Institutional	837I	2400	SV2	02	C0003-1 C0003-2	235 234	446

Codes and Values:

Space-fill if not applicable
Entered exactly as shown in the American Medical Association's Current Procedural Terminology

4th Edition (CPT-4) or the Centers for Medicare and Medicaid Services HCPCS code for ambulatory surgery and emergency department procedures performed.

Not applicable for inpatient encounters

Edit Applications:

Must be a valid code
00070 Procedure Code Invalid
00170 Procedure Code Not On File
00710 Procedure Exceeds Service Limits

MEDS III Transaction Segment: Institutional

Data Element Name: PROCEDURE MODIFIER CODE 1 [up to 10]
Submission Status: Required for COS 06, 12, 15, 28, 73, 85,
Encounter Record Position(s): 344-345; 437-438;530-531;623-624;716-717;809-810;902-903;995-996;1088-1089;1181-1182 Format - Length: Character - 2
Effective Date: 1/1/2009
Version Number - Date: 2.8 - January 2009
MEDS III DE# / DW#: 3227_1

Definition: Procedure Modifier Codes are used in conjunction with the CPT procedure code to uniquely describe the service(s) rendered by a provider during an encounter. Fields for reporting a single modifier on each of the up to ten procedures or services are available.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#44
Institutional	UB-04	#44

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Institutional	837I	2400	SV2	02	3	1339	447

Codes and Values:

Space-fill if not applicable
Entered exactly as shown in the American Medical Association's Current Procedural Terminology
- 4th Edition (CPT-4)
Not applicable for inpatient encounters

Edit Applications:

00927 Modifier Invalid For Procedure Code

MEDS III Transaction Segment: Institutional

Data Element Name: PROCEDURE MODIFIER CODE 2 [up to 10]
Submission Status: Required for COS 06, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 346-347;439-440;532-533;625-626;718-719;811-812;904-
905;997-998;1090-1091;1183-1184
Format - Length: Character - 2
Effective Date: 4/1/2012
Version Number - Date: 3.2- April 2012
MEDS III DE# / DW#: 3227_1

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#44
Institutional	UB-04	#44

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Institutional	837I	2400	SV2	02	4	1339	447

Codes and Values:

Space-fill if not applicable
Entered exactly as shown in the American Medical Association's Current Procedural Terminology
- 4th Edition (CPT-4).
Not applicable for inpatient encounters

Edit Applications:

00927 Modifier Invalid For Procedure Code

MEDS III Transaction Segment: Institutional

Data Element Name: PROCEDURE MODIFIER CODE 3 [up to 10]
Submission Status: Required for COS 06, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 348-349;441-442;534-535;627-628;720-721;813-814;906-907;999-1000;1092-1093;1185-1186
Format - Length: Character - 2
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: 3227_1

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#44
Institutional	UB-04	#44

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Institutional	837I	2400	SV2	02	5	1339	448

Codes and Values:

Space-fill if not applicable
Entered exactly as shown in the American Medical Association's Current Procedural Terminology

4th Edition (CPT-4).

Not applicable for inpatient encounters

Edit Applications:

00927 Modifier Invalid For Procedure Code

MEDS III Transaction Segment: Institutional

Data Element Name: PROCEDURE MODIFIER CODE 4 [up to 10]
Submission Status: Required for COS 06, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 350-351;443-444;536-537;629-630;722-723;815-816;908-
909;1001-1002;1094-1095;1187-1188
Format - Length: Character - 2
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: 3227_1

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#44
Institutional	UB-04	#44

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Institutional	837I	2400	SV2	02	6	1339	448

Codes and Values:

Space-fill if not applicable
Entered exactly as shown in the American Medical Association's Current Procedural Terminology

4th Edition (CPT-4).

Not applicable for inpatient encounters

Edit Applications:

00927 Modifier Invalid For Procedure Code

MEDS III Transaction Segment: Institutional

Data Element Name: QUANTITY OR UNITS SUBMITTED [up to 10]
Submission Status: Required for COS 06, 12, 15, 28, 73, 85, 87,
Encounter Record Position(s): 352-362;445-455;538-548;631-641;724-734;817-827;910-
920;1003-1013;1096-1106;1189-1199
Format - Length: Numeric - 11
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1092/3029

Definition: Quantity or Units Submitted is the total number of units or quantity submitted by a provider for the service rendered. This element may contain days, metric units, visits, miles, injections, etc. Format and size may vary based on encounter type and nature of the quantity specified.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#46
Institutional	UB-04	#46

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Institutional	837I	2400	SV2	04 05		355 380	448

Codes and Values:

Right-justified and zero-filled with 2 implied decimal points (i.e. '1' would be reported as '00000000001'

Edit Applications:

00094 Number of Units Not Greater Than Zero
00180 Units Greater Than Maximum
00710 Procedure Code Exceeds Service Limits

MEDS III Transaction Segment: Institutional

Data Element Name: NDC (FORMULARY) CODE [up to 10]
Submission Status: Required for COS 06, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 363-373;456-466;549-559;642-652;735-745;828-838;921-
931;1014-1024;1107-1117;1200-1210
Format - Length: Character - 11
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: 1856/E1856

Definition: National Drug Code (NDC) is an 11-digit national drug identification number assigned by the Federal Drug Administration used to identify OTC medications. The NDC uniquely identifies a drug and includes information on the manufacturer, product code, and package size.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#43
Institutional	UB-04	#43

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Page No.
Institutional	837I	2400	SV2	04	355	448

Codes and Values:

Right-justified and zero filled.
Valid values for this data element are defined and maintained by First DataBank.

Edit Applications:

00544 NDC Code Non-Numeric
00561 Drug Code Not On file
01610 Missing or Invalid Alternate Product Code
02066 Drug Code Missing

MEDS III Transaction Segment: Institutional

Data Element Name: NDC (FORMULARY) UNITS [up to 10]
Submission Status: Required for COS 06, 12, 15, 28, 73, 85
Encounter Record Position(s): 374-385;467-478;560-571;653-664;746-757;839-850;932-
943;1025-1036;1118-1129;1211-1222
Format - Length: Numeric - 12
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: 4217/3251

Definition: NDC (Formulary) Unit is the dispensed quantity of a drug as submitted on a claim form. The dispensing quantity is based upon the unit of measure as defined by the National Drug Code. Quantity Dispensed was formerly called NDC Units.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#46
Institutional	UB-04	#46

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Institutional	837I	2410	CTP	04		380	449

Codes and Values:

Must be entered if a National Drug Code has been entered
Right-justified and zero filled with 3 implied decimal points
Must be a positive numeric value
Fractions must be reported to the nearest 1000th (.001)

Edit Applications:

Must be a valid entry
00528 Missing Or Invalid Quantity Dispensed

Examples:
2.755 units = 000000002755
2.5 units = 000000002500
25 units = 000000025000
250 units = 000000250000

MEDS III Transaction Segment: Institutional

Data Element Name: CHARGED AMOUNT [up to 10]
Submission Status: Required for COS 06, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 386-396;479-489;572-582;665-675;758-768;851-861;944-
954;1037-1047;1130-1140;1223-1233
Format - Length: Numeric - 11
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: 3199/3199

Definition: The amount charged for each listed service corresponding to the procedures defined in the CPT/HCPCS data element.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#47
Institutional	UB-04	#47

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Page No.
Institutional	837I	2400	SV2	02	782	159

Codes and Values:

Right-justified and zero filled
The amount is defined with two implied decimal places
Must be entered as a positive number

Edit Applications:

Must be a valid format
Must be entered as a positive number
00036 M/I Usual and Customary

MEDS III Transaction Segment: Institutional

Data Element Name: MEDICARE PAID AMOUNT
Submission Status: Required for COS 06, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 397-407;490-500;583-593;676-686;769-779;862-872;955-
965;1048-1058;1141-1151;1234-1244
Format - Length: Numeric - 11
Effective Date: 2/18/2010
Version Number - Date: 2.9 - April 2010
MEDS III DE# / DW#: 1085/L3033_2

Definition: The amount Medicare paid for each listed service line that is received by dual eligible Medicaid/Medicare enrollees or beneficiaries. A service line is identified through either HCPCS/CPT procedure codes or revenue codes. This is the Medicare Paid Amount on the service line.

Mapping:

New York State Specific Data Element

Codes and Values:

Right-justified and zero filled
The amount is defined with two implied decimal places
Must be entered as a positive number

Edit Applications:

Must be a valid entry

MEDS III Transaction Segment: Institutional

Data Element Name: PAID AMOUNT
Submission Status: Required for COS 06, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 408-418;501-511;594-604;687-697;780-790;873-883;966-
976;1059-1069;1152-1162;1245-1255
Format - Length: Numeric - 11
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1028/3157

Definition: The amount Medicaid paid for each listed service, corresponding to the procedures defined in the data element HCPCS Code.

Mapping:

New York State Specific Data Element

Codes and Values:

Right-justified and zero filled
The amount is defined with two implied decimal places
Must be entered as a positive number
On the service line level, the paid amount by Claim/Encounter Indicator should be as follows:

Claim/Encounter Indicator	Total Paid Amount
"E" - Encounter	Proxy Cost Amount
"C" - Within Plan Claim	Actual Cost Amount
"A" - Administrative Denial	Zero Dollars

Edit Applications:

Must be a valid entry

Important Note:

Plans should use internal proxy fee schedules when determining the proxy cost amount.

MEDS III Transaction Segment: Institutional

Data Element Name: NON-INPATIENT CLAIM/ENCOUNTER INDICATOR
Submission Status: Required for COS 06, 12, 15, 28, 73, 85, 87 Encounter Record Position(s): 419;512;605;698;791;884;977;1070;1163;
1256
Format - Length: Character - 1
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1983/1983

Definition: Indicates whether the non-inpatient service provided was a capitated service within the health organization's contract ("E"); a within plan claim ("C") or an administratively denied service ("A").

Administratively denied encounters are those encounters which reflect services performed normally paid for but were denied due to failure of at least one requirement of the agreement between provider and plan. An example could be where a contract requires that encounters must be submitted within 60 days of service date. A well-child encounter submitted 63 days after date of service would be administrative denied. (Claim received too late).

Mapping:

New York State Specific Data Element

Codes and Values:

*Code*	*Value*
E	Capitated Encounter, or service not paid directly by health organization.
C	Within Plan Claim
A	Administrative Denial

Space-fill if not applicable

Edit Applications:

Must be a valid code
00437 Claim Encounter Ind Invalid

MEDS III Transaction Segment: Institutional

Data Element Name: ICD VERSION CODE
Submission Status: Required for COS 06, 11, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 1257
Format - Length: Character - 1
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: E2498/2498

Definition: A one-digit code to indicate whether the reported diagnosis codes are ICD-9 or ICD-10.

Mapping:

New York State specific data element

Codes and Values:

If no diagnosis, leave blank (see below table).

Code	Description
	Not Available
1	ICD-9 Version
2	ICD-10 Version

Edit Applications:

Must be a valid value
02174 Version Code Not Valid

MEDS III Transaction Segment: Institutional

Data Element Name: PRINCIPAL/PRIMARY DIAGNOSIS CODE
Submission Status: Required for COS 06, 11, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 1258-1264
Format - Length: Character - 7
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 4183/3006

Definition: The ICD-9-CM or ICD-10-CM Principal Diagnosis Code uniquely specifies the condition established after study to be chiefly responsible for admission to an institution.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#67
Institutional	UB-04	#67

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Code	Page No.
Institutional	837I	2300	HI	01	C022-1 C022-2	1270 1271	BK	228

NOTE: The Principal/Primary Diagnosis Code is coded in the first occurrence of C022 Composite for the Principal/Primary Diagnosis Information HI segment.

Codes and Values:

Must be Left-justified and entered exactly as shown in the ICD-9-CM coding reference, excluding the decimal point, and Space-filled. The decimal point is implied because each ICD-9-CM or ICD- 10-CM code is unique.
Record the appropriate ICD-9-CM or ICD-10-CM code exactly as it appears in the manual. The diagnosis code must be the most specific/precise 3-digit, 4-digit or 5-digit code allowed for in the ICD-9-CM or ICD-10-CM coding format.
Leading and trailing zeros in a diagnostic code must be recorded (i.e. do not use blanks in place of zeros for any reason). In addition, zeros should not be added to a diagnostic code to fill in blank spaces.
External diagnosis codes (E Codes) are not valid as Principal Diagnosis Codes.

Edit Applications:

Must be a valid code
00039 Primary Diagnosis Code Blank
00146 Primary Diagnosis not on File

MEDS III Transaction Segment: Institutional

Data Element Name: OTHER DIAGNOSIS CODES [up to 8]
Submission Status: Required for COS 06, 11, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 1265-1271;1272-1278;1279-1285;1286-1292;1293-1299;1300-1306;1307-1313;1314-1320
Format - Length: Character - 7
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 4157/W657

Definition: Other Diagnosis Codes indicate additional significant condition(s) during an encounter.
Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#68-75
Institutional	UB-04	#67A- 67Q

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Code	Page No.
Institutional	837I	2300	HI	01	C022-1 C022-2	1270 1271	BF	232

NOTE: The Other Diagnosis codes are coded in two iterations of C022 Composite for the Other Diagnosis Information HI segment.

Codes and Values:

Left-justified and entered exactly as shown in the ICD-9-CM or ICD-10-CM coding reference, excluding the decimal point, and Space-filled. The decimal point is implied because each ICD-9- CM or ICD-10-CM code is unique.
Record the appropriate ICD-9-CM or ICD-10-CM code exactly as it appears in the manual. The diagnosis code must be the most specific/precise 3-digit, 4-digit or 5-digit code allowed for in the ICD-9-CM or ICD-10-CM coding format.
Leading and trailing zeros in a diagnostic code must be recorded (i.e. do not use blanks in place of zeros for any reason). In addition, zeros should not be added to a diagnostic code to fill in blank spaces.

Edit Applications:

Must be a valid code
If this field is not coded it must contain blanks
00412 Diagnosis Code Not On File

MEDS III Transaction Segment: Institutional

Data Element Name: OTHER DIAGNOSIS CODES [9 TO 24]
Submission Status: Required for COS 06, 11, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 1321-1327;1328-1334;1335-1341;1342-1348;1349-1355;1356-1362;1363-1369;1370-1376;1377-1383;1384-1390;1391-1397;1398-1404;1405-1411;1412-1418;1419-1425;1426-1432
Format - Length: Character - 7
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 4157/W657

Definition: Other Diagnosis Codes indicate additional significant condition(s) during an encounter.
Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#68-75
Institutional	UB-04	#67A- 67Q

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Code	Page No.
Institutional	837I	2300	HI	01	C022-1 C022-2	1270 1271	BF	232

NOTE: The Other Diagnosis codes are coded in two iterations of C022 Composite for the Other Diagnosis Information HI segment.

Codes and Values:

Left-justified and entered exactly as shown in the ICD-9-CM or ICD-10-CM coding reference, excluding the decimal point, and Space-filled. The decimal point is implied because each ICD-9- CM or ICD-10-CM code is unique.
Record the appropriate ICD-9-CM or ICD-10-CM code exactly as it appears in the manual. The diagnosis code must be the most specific/precise 3-digit, 4-digit or 5-digit code allowed for in the ICD-9-CM or ICD-10-CM coding format.
Leading and trailing zeros in a diagnostic code must be recorded (i.e. do not use blanks in place of zeros for any reason). In addition, zeros should not be added to a diagnostic code to fill in blank spaces.

Edit Applications:

Must be a valid code
If this field is not coded it must contain blanks
00412 Diagnosis Code Not On File

MEDS III Transaction Segment: Institutional

Data Element Name: ADMIT DIAGNOSIS
Submission Status: Required for COS 11
Encounter Record Position(s): 1433-1439
Format - Length: Character - 7
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 0411/3187

Definition: The diagnosis made by the Provider at the time of admission that describes the patient's condition upon admission to an institution. Since the Admitting Diagnosis is formulated before all tests and examinations are complete, it may have been stated in the form of a problem or symptom and it may differ from any of the final diagnoses recorded in the medical record.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#76
Institutional	UB-04	#69

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Comp- osite	Elem- ent ID	Code	Page No.
Institutional	837I	2300	HI	02	C022-1 C022-2	1270 1271	BJ/PR	228

NOTE: The Admitting Diagnosis Code is coded in the second occurrence of C022 Composite for the Principal Diagnosis Information HI segment.

Codes and Values:

Left-justified and entered exactly as shown in the ICD-9-CM or ICD-10-CM coding reference, excluding the decimal point, and Space-filled.
Must have been a valid ICD-9-CM or ICD-10-CM code excluding the decimal point. To be valid, ICD-9-CM or ICD-10-CM codes must have been entered at the most specific level to which they are classified in the ICD-9-CM or ICD-10-CM Tabular List. Three-digit codes further divided at the four-digit level must have been entered using all four digits. Four-digit codes further sub-classified at the five-digit level must be entered using all five digits.
E-codes are not valid as Admitting Diagnosis Codes.

Edit Applications:

00604 Admitting Diagnosis Code Missing
00412 Diagnosis Code Not On File

MEDS III Transaction Segment: Institutional

Data Element Name: EXTERNAL DIAGNOSIS CODE (E Code)
Submission Status: Required for COS 11
Encounter Record Position(s): 1440-1446
Format - Length: Character - 7
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 0411/5004

Definition: The External Diagnosis Code indicates the external cause of an injury, poisoning, or adverse effect.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#77
Institutional	UB-04	#70

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Code	Page No.
Institutional	837I	2300	HI	03	C022-1 C022-2	1270 1271	BN	229

NOTE: The External Cause-of-Injury Code is coded in the third occurrence of C022 Composite for the Principal Diagnosis Information HI segment.

Codes and Values:

Left-justified including the prefix letter "E" and all digits exactly as shown in the ICD-9-CM coding reference excluding the decimal point, and Space-filled.
Must have been a valid ICD-9-CM or ICD-10-CM "E" code excluding the decimal point. To be valid, the code must have been entered at the most specific level classified in the ICD-9-CM Tabular List. Three-digit codes further divided to the four-digit level must have been entered using all four digits plus the prefix letter "E". Failure to enter the prefix "E" and all required digits will cause the record to reject.
If this field is not applicable it must contain blanks.

Edit Applications:

Must contain a valid code
00412 Diagnosis Code Not On File

MEDS III Transaction Segment: Institutional

Data Element Name: PRESENT ON ADMISSION CODE (POA) [up to 25]
Submission Status: Required for COS 11 Encounter Record Position(s):
1447;1448;1449;1450;1451;1452;1453;1454;1455;1456;1457;1458;1459;1460;1461;1462;1463;1464;1465;1466;1467;1468;1469;1470;1471
Format - Length: Character - 1
Effective Date: 7/17/2008
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: E2254_1 - E2254_9

Definition: The POA code is a one-digit indicator for the inpatient diagnoses that denotes whether or not the diagnosis was present at the time of admission. Position one would be used for the primary diagnosis and positions two through twenty-five are used for the twenty-four other diagnoses.

Mapping:

Paper Form:

No mapping from paper form

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Pg No
Institutional	837I	2300	K3	01	449	204

Codes and Values:

Blanks are not permitted
Must be a valid code

*Code*	*Value*
Y	Diagnosis was POA
N	Diagnosis was not POA
U	Documentation insufficient to determine POA or not
W	Provider unable to determine whether POA or not
1	Exempt/ Diagnosis not on applicable list

Edit Applications:

Edit 02079 Missing or Invalid POA code

MEDS III Transaction Segment: Institutional

Data Element Name: PRINCIPAL PROCEDURE CODE
Submission Status: Required for COS 11
Encounter Record Position(s): 1472-1478
Format - Length: Character - 7
Effective Date: 3/1/2005
Version Number - Date: 1.2 - May 96
MEDS III DE# / DW#: 0606/5055

Definition: The ICD-9-CM or ICD-10-CM Principal Procedure Code is the primary procedure code on a claim reported to the health organization by the providing inpatient facility.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#80
Institutional	UB-04	#74

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Code	Page No.
Institutional	837I	2300	HI	01	C022-1 C022-2	1270 1271	BR	242

NOTE: The Principal Procedure Code is coded in the first occurrence of the C022 Composite for the Principal Procedure Information HI segment.

Codes and Values:

Left-justified and Space-filled
Enter exactly as shown in the ICD-9-CM coding reference, excluding the decimal point
If this field is not coded it must be Space-filled

Edit Applications:

Must contain a valid code if a procedure was performed
00405 Principal Procedure Code Missing
00170 Procedure Code Not on File

MEDS III Transaction Segment: Institutional

Data Element Name: OTHER PROCEDURE CODES [up to 5]
Submission Status: Required for COS 11
Encounter Record Position(s): 1487-1493;1502-1508;1517-1523;1532-1538;1547-1553
Format - Length: Character - 7
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 4159/5055

Definition: Procedure Codes uniquely identify the procedures performed. All significant procedures other than the Principal Procedure Code are to be reported here. They are reported in order of significance, starting with the most significant.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#80
Institutional	UB-04	#74A- 74E

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Code	Page No.
Institutional	837I	2300	HI	01	C022-1 C022-2	1270 1271	BQ	244

NOTE: The Other Procedure codes and dates are coded in two iterations of C022 Composite for the Other Procedure Information HI segment.

Codes and Values:

Left-justified and Space-filled
Enter exactly as shown in the ICD-9-CM or ICD-10-CM coding reference, excluding decimal points
If this field is not applicable it must be Space-filled

Edit Applications:

ICD-9-CM or ICD-10-CM procedure codes only
00170 Procedure Code Not on File

MEDS III Transaction Segment: Institutional

Data Element Name: OTHER PROCEDURE CODES [6 TO 24]
Submission Status: Required for COS 11
Encounter Record Position(s): 1562-1568;1577-1583;1592-1598;1607-1613;1622-
1628;1637-1643;1652-1658;1667-1673;1682-1688;1697-
1703;1712-1718;1727-1733;1742-1748;1757-1763;1772-
1778;1787-1793;1802-1808;1817-1823;1832-1838
Format - Length: Character - 7
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: 4159/5055

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#80
Institutional	UB-04	#74A- 74E

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Code	Page No.
Institutional	837I	2300	HI	01	C022-1 C022-2	1270 1271	BQ	244

Codes and Values:

Left-justified and Space-filled
Enter exactly as shown in the ICD-9-CM or ICD-10-CM coding reference, excluding decimal points
If this field is not applicable it must be space-filled

Edit Applications:

ICD-9-CM or ICD-10-CM procedure codes only

MEDS III Transaction Segment: Institutional

Data Element Name: PROCEDURE DATE [up to 25]
Submission Status: Required for COS 11
Encounter Record Position(s): 1479-1486;1494-1501;1509-1516;1524-1531;1539-
1546;1554-1561;1569-1576;1584-1591;1599-1606;1614-
1621;1629-1636;1644-1651;1659-1666;1674-1681;1689-
1696;1704-1711;1719-1726;1734-1741;1749-1756;1764-
1771;1779-1786;1794-1801;1809-1816;1824-1831;1839-
1846
Format - Length: Date CCYYMMDD - 8
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012 MEDS III DE# / DW#:

Definition: The associated Procedure Date for the reported ICD-9 or ICD-10 code(s) describing inpatient procedure(s) performed.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-04	#74

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Institutional	837I	2300	HI	01	4	1251	244

Codes and Values:

Blanks and characters are not permitted.
Must be a valid date format CCYYMMDD

Valid Century (CC)	Valid Year (YY)
20	>=04

Valid Month Code (MM)	Valid Day Code (DD)
01, 03, 05, 07, 08, 10, 12	Greater than 00 and less than 32
04, 06, 09, 11	Greater than 00 and less than 31
02	Greater than 00 and less than 29 (less than 30 on a leap year)

Edit Applications:

Must be a valid, properly formatted date
00600 Admission/Service Date Invalid
02210 ICD-9 Procedure Date After Service Date
02211 ICD-9 Procedure Without ICD-9 Date
00613 Principal Procedure Date Is Invalid

MEDS III Transaction Segment: Institutional

Data Element Name: ATTENDING PROVIDER PROFESSION CODE
Submission Status: Required for COS 06, 11, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 1847-1849
Format - Length: Character - 3
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 2165/2165_5

Definition: The NYS profession code of the attending provider for inpatient encounters (COS 11) and the servicing provider for non-inpatient encounters.

Mapping:

New York State Specific Data Element

Codes and Values:

Provider Profession Codes and Values are contained within Appendix A
Space-fill if not applicable

Edit Applications:

Must be a valid code

MEDS III Transaction Segment: Institutional

Data Element Name: ATTENDING PROVIDER LICENSE NUMBER
Submission Status: Required for COS 06, 11, 12, 15, 28, 73, 85, 87
Encounter Record Position(s): 1850-1857
Format - Length: Character - 8
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1570/3003_2

Definition: The NY professional license number of the attending provider for inpatient encounters (COS 11) and the servicing provider for non-inpatient encounters.

Mapping:

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Page No.
Institutional	837I	2420A	REF	01 02	128 127	0B	467

Codes and Values:

Right-justified
Do not zero fill - space-fill if not applicable
Must be a valid professional license number issued by the New York State Department of Education

Edit Applications:

Must be a valid entry
00416 License Number is Missing
00664 Attending Physician License Number Missing

MEDS III Transaction Segment: Institutional

Data Element Name: ATTENDING PROVIDER IDENTIFICATION NUMBER Submission Status: Required for COS 06, 11, 12, 15, 28, 73, 85, 87 Encounter Record Position(s): 1858-1867
Format - Length: Character - 10
Effective Date: 9/1/2008
Version Number - Date: 2.7 - August 2008
MEDS III DE# / DW#: 1563/W039

Definition: The National Provider Identification (NPI) number of the attending provider for inpatient encounters and the servicing provider for non-inpatient encounters. If the servicing provider is a non- healthcare provider, you should report the state MMIS ID.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#82
Institutional	UB-04	#76

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Page No.
Institutional	837I	2420A	NM1	01 02 08 09	98 1065 66 67	71 1 XX	463 463 464 464

Codes and Values:

NPI should be left-justified with no embedded blanks.
MMIS ID should be left-justified with two (2) trailing blanks.
Space-fill if not applicable.

Edit Applications:

Must be a valid entry
00432 Attend Prov Id Not on File
02023 Missing Attending NPI
02033 Invalid Attending NPI

MEDS III Transaction Segment: Institutional

Data Element Name: SURGEON PROFESSION CODE
Submission Status: Required for COS 11
Encounter Record Position(s): 1868-1870
Format - Length: Character - 3
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 2165/2165_6

Definition: The profession code issued by the State Department of Education that identifies the type of license of the surgeon.

Mapping:

New York State Specific Data Element

Codes and Values:

Provider Profession Codes and Values are contained within Appendix A
Space-fill if not applicable.

Edit Applications:

Must be a valid code.

MEDS III Transaction Segment: Institutional

Data Element Name: SURGEON LICENSE NUMBER
Submission Status: Required for COS 11
Encounter Record Position(s): 1871-1878
Format - Length: Character - 8
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1570/3100

Definition: The professional license number, issued by the NYS Department of Education, used to identify the surgeon.

Mapping:

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Page No.
Institutional	837I	2420C	REF	01 02	128 127	0B	481 482

Codes and Values:

Right-justified
Do not zero fill, space-fill if not applicable
Must be a valid professional license number issued by the NYS Department of Education.

Edit Applications:

If a surgery was performed, must be a valid entry
00416 License Number Is Missing

MEDS III Transaction Segment: Institutional

Data Element Name: SURGEON PROVIDER IDENTIFICATION NUMBER
Submission Status: Required for COS 11
Encounter Record Position(s): 1879-1888
Format - Length: Character - 10
Effective Date: 9/1/2008
Version Number - Date: 2.7 - August 2008
MEDS III DE# / DW#: 1563/W042

Definition: The National Provider Identification (NPI) number of the surgeon who performed the surgery.

Mapping:

Paper Form: (Other identification Number)

Encounter Type	Form	Element
Institutional	UB-92	#83
Institutional	UB-04	#77

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Page No.
Institutional	837I	2420C	NM1	01 02 08 09	98 1065 66 67	73 1 XX	477 477 478 478

Codes and Values:

NPI must be left-justified with no embedded blanks.
Space-fill if not applicable

Edit Applications:

If a surgery was performed, must be a valid entry
00433 Oper Prov Id Not on File
02024 Missing Operating NPI
02034 Invalid Operating NPI

MEDS III Transaction Segment: Institutional

Data Element Name: ADMISSION DATE
Submission Status: Required for COS 11, 12, 28
Encounter Record Position(s): 1889-1896
Format - Length: Date CCYYMMDD - 8
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1033/3011

Definition: The date of the patient's admission to the institution or facility.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#17
Institutional	UB-04	#12

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Page No.
Institutional	837I	2300	DTP	02	1250 1251	DT	169

Codes and Values:

Blanks and characters are not permitted
Must be a valid date format CCYYMMDD

Valid Century (CC)	Valid Year (YY)
20	>=04

Valid Month Code (MM)	Valid Day Code (DD)
01, 03, 05, 07, 08, 10, 12	Greater than 00 and less than 32
04, 06, 09, 11	Greater than 00 and less than 31
02	Greater than 00 and less than 29 (less than 30 on a leap year)

Edit Applications:

Must be on or before the Statement Covers Thru Date
Must be a valid, properly formatted date
00600 Admission Date Invalid

MEDS III Transaction Segment: Institutional

Data Element Name: DISCHARGE DATE
Submission Status: Required for COS 11, 12, 28
Encounter Record Position(s): 1897-1904
Format - Length: Date CCYYMMDD - 8
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1185/3108

Definition: The date of discharge from a stay in an inpatient hospital.

Inpatient encounters should be reported only after the patient is discharged. The entire inpatient stay, identified by actual admission and discharge dates should be reported as one encounter even if there are payers in addition to Medicaid managed care involved.

Mapping:

Paper Form:

Encounter Type	Form	Element
Institutional	UB-92	#6
Institutional	UB-04	#6

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Pg No
Institutional	837I	2300	DTP	01 02 03	374 1250 1251	434 D8&RD8	167

Codes and Values:

Blanks and characters are not permitted.
Must be a valid date format CCYYMMDD

Valid Century (CC)	Valid Year (YY)
20	>=04
Valid Month Code (MM)	Valid Day Code (DD)
01, 03, 05, 07, 08, 10, 12	Greater than 00 and less than 32
04, 06, 09, 11	Greater than 00 and less than 31
02	Greater than 00 and less than 29 (less than 30 on a leap year)

Edit Applications:

Must be a valid, properly formatted date
00625 Discharge Date Illogical
00652 Discharge Date Prior To Admission Date
00655 Discharge Date Different Than Statement Thru Date

MEDS III Transaction Segment: Institutional

Data Element Name: FILLER
Submission Status: Required
Encounter Record Position(s): 1905-3000
Format - Length: Character - 1096
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012

Definition: Space-fill positions 1905 to 3000.

Mapping:

New York State specific element

Codes and Values:

Left-justified and space-filled

Edit Applications:

Tier One Error - Record is not 3000 bytes

VIII. PHARMACY SEGMENT

MEDS III Transaction Segment: Pharmacy

Data Element Name: PRESCRIPTION ORIGIN CODE
Submission Status: Required for COS 14
Encounter Record Position(s): 258
Format - Length: Character - 1
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: E2371/2371

Definition: The Prescription Origin Code holds a value representing the medium used for submitting the prescription. It is a one-digit indicator that identifies the method in which the prescription was transmitted electronically to the pharmacy.

Mapping:

Encounter Type	Paper	Electronic
Encounter Type	Form	Element	Format	Element
Pharmacy	UCF	N/A	NCPDP	419-DJ

Codes and Values:

Code	Description
0	NOT SPECIFIED OR AVAILABLE
1	WRITTEN
2	TELEPHONE
3	ELECTRONIC
4	FACSIMILE

Edit Applications:

Must be a valid value
02116 Missing Prescription Origin Code
02117 Invalid Prescription Origin Code
02193 Controlled Substance Limit Exceeded

MEDS III Transaction Segment: Pharmacy

Data Element Name: PRESCRIPTION NUMBER
Submission Status: Required for COS 14
Encounter Record Position(s): 259-270
Format - Length: Character - 12
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: 3099/3099

Definition: Prescription Number is assigned to a prescription by the pharmacy when it is filled.

Mapping:

Encounter Type	Paper	Electronic
Encounter Type	Form	Element	Format	Element
Pharmacy	UCF	Prescription/ Service Reference #	NCPDP	402-D2

Codes and Values:

Must be right-justified and zero filled.
Cannot equal zero or blanks.
Must be numeric (0-9). Special Characters and Spaces are invalid entries.

Edit Applications:

00526 Missing or Invalid Prescription Number

MEDS III Transaction Segment: Pharmacy

Data Element Name: PRESCRIBING PROVIDER PROFESSION CODE
Submission Status: Required for COS 14
Encounter Record Position(s): 271-273
Format - Length: Character - 3
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 2165/2165_2

Definition: The profession code, issued by the NYS Department of Education, is used to identify the type of license of individual health care professionals providing the services or primarily responsible for the care provided during the encounter. The prescribing Provider profession code relates to the Provider who signed the prescription form.

Mapping:

New York State Specific Data Element

Codes and Values:

Provider Profession Codes and Values are contained within Appendix A
Space-fill if not applicable

Edit Applications:

Must be a valid code

MEDS III Transaction Segment: Pharmacy

Data Element Name: PRESCRIBING PROVIDER LICENSE NUMBER
Submission Status: Required for COS 14
Encounter Record Position(s): 274-281
Format - Length: Character - 8
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1570/3005

Definition: The State issued provider license number of the prescribing provider. Health organizations must submit the State license number or the MMIS identification number on all prescriptions written for Medicaid recipients. When a prescription is written by an unlicensed intern or resident, the supervising physician's NYS MMIS number or State license number must be provided.

Mapping:

Common Detail Section	Paper	Electronic
Common Detail Section	Form	Element	Format	Element
Pharmacy	UCF	Prescriber ID	NCPDP	466-EZ* 411-DB

* Element 466-EZ is a prescriber ID qualifier and will always equal 08.

Codes and Values:

Right-justified
Do not zero fill - space-fill if not applicable
Must be a valid professional license number issued by the New York State Department of Education.
Plans should not report a prescriber Drug Enforcement Agency (DEA) number in this field.

Applicable Edit Codes:

Must be a valid entry
00525 Prescribing License Number Missing

MEDS III Transaction Segment: Pharmacy

Data Element Name: PRESCRIBING PROVIDER IDENTIFICATION NUMBER
Submission Status: Required for COS 14
Encounter Record Position(s): 282-291
Format - Length: Character - 10
Effective Date: 9/1/2008
Version Number - Date: 2.7 - August 2008
MEDS III DE# / DW#: 1563/W048

Definition: The National Provider Identification number of the prescribing Provider. Health organizations must submit the State license number or the NPI on all prescriptions written for Medicaid recipients. When a prescription is written by an unlicensed intern or resident, the supervising physician's NPI number or State license number must be provided.

Mapping:

Common Detail Section	Paper	Electronic
Common Detail Section	Form	Element	Format	Element
Pharmacy	UCF	Service Provider ID	NCPDP	466-EZ* 411-DB

* The NCPDP qualifier (466-EZ) will always be equal to 05

Codes and Values:

NPI must be left-justified with no embedded spaces
Space-fill if not applicable

Applicable Edit Codes:

Must be a valid entry
00897 Prescriber Id Not on File
02029 Missing Prescribing NPI
02039 Invalid Prescribing NPI

MEDS III Transaction Segment: Pharmacy

Data Element Name: PRESCRIPTION ORDERED DATE
Submission Status: Required for COS 14
Encounter Record Position(s): 292-299
Format - Length: Date - CCYYMMDD
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 0860/3247

Definition: Prescription Ordered Date is the date that a service was ordered, or a prescription was written. (Formerly called Date Prescribed/Ordered)

Mapping:

Encounter Type	Paper	Electronic
Encounter Type	Form	Element	Format	Element
Pharmacy	UCF	Date Written	NCPDP	414-DE

Codes and Values:

Must be a valid date format CCYYMMDD

Valid Century (CC)	Valid Year (YY)
20	>=04

Valid Month Code (MM)	Valid Day Code (DD)
01, 03, 05, 07, 08, 10, 12	Greater than 00 and less than 32
04, 06, 09, 11	Greater than 00 and less than 31
02	Greater than 00 and less than 29 (less than 30 on a leap year)

Edit Applications:

Must be a valid date
00534 Date Ordered Invalid
00548 Fill Date Precedes Order Date

MEDS III Transaction Segment: Pharmacy

Data Element Name: DATE FILLED
Submission Status: Required for COS 14
Encounter Record Position(s): 300-307
Format - Length: Date - CCYYMMDD
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1022/3013

Definition: Date Filled is the date a prescription or order was filled.

Mapping:

Encounter Type	Paper	Electronic
Encounter Type	Form	Element	Format	Element
Pharmacy	UCF	Date of Service	NCPDP	401-D1

Codes and Values:

Must be a valid date format CCYYMMDD

Valid Century (CC)	Valid Year (YY)
20	>=04

Valid Month Code (MM)	Valid Day Code (DD)
01, 03, 05, 07, 08, 10, 12	Greater than 00 and less than 32
04, 06, 09, 11	Greater than 00 and less than 31
02	Greater than 00 and less than 29 (less than 30 on a leap year)

Edit Applications:

Must be a valid date
00018 Date Of Service/Fill Date Invalid
00020 Service/Fill Date Later Than Receipt Date
00548 Fill Date Precedes Order Date
001292 Date of Service Two Years Prior to Date Received

MEDS III Transaction Segment: Pharmacy

Data Element Name: DRUG DAYS SUPPLY COUNT
Submission Status: Required for COS 14
Encounter Record Position(s): 308-310
Format - Length: Numeric - 3
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 0819/3232

Definition: Drug Days Supply Count specifies the number of days supply dispensed with the prescription service.

Mapping:

Encounter Type	Paper	Electronic
Encounter Type	Form	Element	Format	Element
Pharmacy	UCF	Days Supply	NCPDP	405-D5

Codes and Values:

Must be entered if a National Drug Code has been entered.
Must be a positive whole number.
Right-justified and zero filled.
Leave blank when reporting DME/Hearing aid and alternate product encounter records.

Edit Applications:

Must be a valid entry.
00540 Number of Days Supply Invalid

MEDS III Transaction Segment: Pharmacy

Data Element Name: NATIONAL DRUG CODE (NDC) / PRODUCT CODE
Submission Status: Required for COS 14
Encounter Record Position(s): 311-321; 357-367; 403-413; 449-459; 495-505; 541-551;587-597; 633-643; 679-689; 725-735; 771-781; 817-827;863-873; 909-919; 955-965; 1001-1011; 1047-1057; 1093-1103; 1139-1149; 1185-1195; 1231-1241; 1277-1287; 1323-1333; 1369-1379; 1415-1425
Format - Length: Character - 11
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: NDC: 1856/E1856
Product Code: 1856/E1856

Definition: National Drug Code (NDC) uniquely identifies a drug and includes information on the manufacturer, product code, and package size.

The Product Code is the HCPCS Code used to identify Durable Medical Equipment, Hearing Aids, Over the Counter medications or other pharmacy products without an NDC code.

Mapping:

NDC Code:

Encounter Type	Paper	Electronic
Encounter Type	Form	Element	Format	Element
Pharmacy	UCF	Product ID	NCPDP	436-E1 407-D7

Codes and Values:

Right-justified and zero filled
Valid values for this data element are defined and maintained by First DataBank.

Edit Applications:

00544 NDC Code Non-Numeric
00561 Drug Code Not On file
01610 Missing or Invalid Alternate Product Code
02171 NDC Occurs More Than Once On The Compound

MEDS III Transaction Segment: Pharmacy

Data Element Name: QUANTITY DISPENSED
Submission Status: Required for COS 14
Encounter Record Position(s): 322-333; 368-379; 414-425; 460-471; 506-517; 552-563;598-609; 644-655; 690-701; 736-747; 782-793; 828-839; 874-885; 920-931; 966-977; 1012-1023; 1058-1069; 1104-1115; 1150-1161; 1196-1207; 1242-1253; 1288-1299; 1334-1345; 1380-1391; 1426-1437
Format - Length: Numeric - 12
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 4217/3251

Definition: Quantity Dispensed is the quantity of a drug as submitted on a claim form. The dispensing quantity is based upon the unit of measure as defined by the National Drug Code. Quantity Dispensed was formerly called NDC Units.

Mapping:

Encounter Type	Paper	Electronic
Encounter Type	Form	Element	Format	Element
Pharmacy	UCF	Quantity Dispense d	NCPDP	442-E7

Codes and Values:

Must be entered if a National Drug Code has been entered
Right-justified and zero filled with 3 implied decimal points
Must be a positive numeric value
Fractions must be reported to the nearest 1000th (.001)

Edit Applications:

Must be a valid entry
00528 Missing Or Invalid Quantity Dispensed

Examples:
2.755 units = 000000002755
2.5 units = 000000002500
25 units = 000000025000
250 units = 000000250000

MEDS III Transaction Segment: Pharmacy

Data Element Name: AMOUNT CHARGED [up to 25]
Submission Status: Required for COS 14
Encounter Record Position(s): 334-344; 380-390; 426-436; 472-482; 518-528; 564-574; 610-620; 656-666; 702-712; 748-758; 794-804; 840-850; 886-896; 932-942; 978-988; 1024-1034; 1070-1080; 1116-1126; 1162-1172; 1208-1218; 1254-1264; 1300-1310; 1346-1356; 1392-1402; 1438-1448
Format - Length: Numeric - 11
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: 3199/3199

Definition: The amount charged for the prescription or ingredient.

Mapping:

Encounter Type	Paper	Electronic
Encounter Type	Form	Element	Format	Element
Pharmacy	UCF	Ingredient Cost Submitted	NCPDP	409-D9

Codes and Values:

Right-justified and zero filled
This amount is defined with two implied decimal places (e.g., $1,000.00 is reported as 100000)

Edit Applications:

Must be a valid format
Must be entered as a positive number

MEDS III Transaction Segment: Pharmacy

Data Element Name: AMOUNT PAID [up to 25]
Submission Status: Required for COS 14
Encounter Record Position(s): 345-355; 391-401; 437-447; 483-493; 529-539; 575-585;621-631; 667-677; 713-723; 759-769; 805-815; 851-861; 897-907; 943-953; 989-999; 1035-1045; 1081-1091; 1127-1137; 1173-1183; 1219-1229; 1265-1275; 1311-1321; 1357-1367; 1403-1413; 1449-1459
Format - Length: Numeric - 11
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: 3157/1028

Definition: The amount paid for the prescription or ingredient.

Mapping:

New York State specific element

Codes and Values:

Right-justified and zero filled
This amount is defined with two implied decimal places (e.g., $1,000.00 is reported as 100000)

Edit Applications:

Must be a valid format
Must be entered as a positive number

MEDS III Transaction Segment: Pharmacy

Data Element Name: PHARMACY CLAIM/ENCOUNTER INDICATOR [up to 25]
Submission Status: Required for COS 14
Encounter Record Position(s): 356; 402; 448; 494; 540; 586; 632; 678; 724; 770; 816; 862; 908; 954; 1000; 1046; 1092; 1138; 1184; 1230; 1276; 1322; 1368; 1414; 1460
Format - Length: Character - 1
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1983/E1983

Definition: Indicates whether the service provided was a capitated service within the health organization's contract ("E"); a within plan claim ("C") or an administratively denied service ("A").

Mapping:

New York State Specific Data Element

Codes and Values:

*Code*	*Value*
E	Capitated Encounter, or service not paid directly by the health organization
C	Within Plan Claim
A	Administrative Denial

Edit Applications:

Must be a valid code
00437 Claim Encounter Ind Invalid

MEDS III Transaction Segment: Pharmacy

Data Element Name: REFILL INDICATOR
Submission Status: Required for COS 14
Encounter Record Position(s): 1461-1462
Format - Length: Character - 2
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: 3233/4237

Definition: The number indicating whether the prescription is an original or refill.

Mapping:

Encounter Type	Paper	Electronic
Encounter Type	Form	Element	Format	Element
Pharmacy	UCF	Fill Number	NCPDP	403-D3

Codes and Values:

Code	Description
00	ORIGINAL
01	1ST REFILL
02	2ND REFILL
03	3RD REFILL
04	4TH REFILL
05	5TH REFILL

Edit Applications:

Must be a valid value
00530 New/Refill Number Invalid

MEDS III Transaction Segment: Pharmacy

Data Element Name: NUMBER OF REFILLS AUTHORIZED
Submission Status: Required for COS 14
Encounter Record Position(s): 1463-1464
Format - Length: Number - 2
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: 3018/0851

Definition: The number of refills that have been authorized for a prescription by the provider beyond the original prescription. This number should be consistent for all encounters within the same prescribed period.

Mapping:

Encounter Type	Paper	Electronic
Encounter Type	Form	Element	Format	Element
Pharmacy	UCF	N/A	NCPDP	415-DF

Codes and Values:

Must be numeric; alphabetic and special characters are invalid

Edit Applications:

Must be a valid value
00531 Authorized Refills Number Invalid

MEDS III Transaction Segment: Pharmacy

Data Element Name: DISPENSED AS WRITTEN
Submission Status: Required for COS 14
Encounter Record Position(s): 1465
Format - Length: Number - 1
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: XXXX/3234

Definition: Dispensed As Written (DAW) product selection codes provide important information to the New York State Department of Health as to whether or not a prescription is dispensed based on the prescriber's instructions. The specific codes being used (see below) have been taken from the National Council on Prescription Drug Programs (NCPDP) Version 5.1 Data Dictionary, Field 408-D8 Product Selection Codes. It is important that plans report the appropriate selections as submitted or reported on the prescription form with prescriber's signature.

Mapping:

Encounter Type	Paper	Electronic
Encounter Type	Form	Element	Format	Element
Pharmacy	UCF	DAW Code	NCPDP	408-D8

Codes and Values:

Codes	Description
0	No product selection indicated
1	Substitution not allowed by provider
2	Substitution allowed- patient requested product dispensed
3	Substitution allowed- pharmacist selected product dispensed
4	Substitution allowed- generic drug not in stock
5	Substitution allowed- brand drug dispensed as generic
6	Override
7	Substitution not allowed- brand drug mandated by law
8	Substitution allowed- generic drug not available in marketplace
9	Other (Not Allowed)

Edit Applications:

Must be a valid entry
Code '9' is not a valid entry

MEDS III Transaction Segment: Pharmacy

Data Element Name: ICD VERSION CODE
Submission Status: Required for COS 14
Encounter Record Position(s): 1466
Format - Length: Character - 1
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: E2498/2498

Definition: A one-digit code to indicate whether the reported diagnoses are ICD-9 or ICD-10.

Mapping:

New York State specific element

Codes and Values:

If no diagnosis, leave blank (see below table).

Code	Description
Not Available
1	ICD-9 Version
2	ICD-10 Version

Edit Applications:

Must be a valid value
02174 Version Not Valid

MEDS III Transaction Segment: Pharmacy

Data Element Name: DIAGNOSIS CODE
Submission Status: Required for COS 14
Encounter Record Position(s): 1467-1473
Format - Length: Character - 7
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: 4157/W657

Definition: Diagnosis codes are to be recorded for diagnosed medical conditions for which the recipient receives services during the encounter, or which may have been present at the time of the encounter and recorded by the provider.

Mapping:

Encounter Type	Paper	Electronic
Encounter Type	Form	Element	Format	Element
Pharmacy	UCF	Diagnosis Code	NCPDP	424-DO

Codes and Values:

Filled or zero filled
Left-justified and entered exactly as shown in the ICD-9-CM or ICD-10-CM coding reference, excluding the decimal point, and Space-filled. The decimal point is implied because each ICD-9- CM or ICD-10-CM code is unique.
Record the appropriate ICD-9-CM or ICD-10-CM code exactly as it appears in the manual. The diagnosis code must be the most specific/precise 3-digit, 4-digit or 5-digit code allowed for in the ICD-9-CM or ICD-10-CM coding format.
Leading and trailing zeros in a diagnostic code must be recorded. In addition, zeros should not be added to a diagnostic code to fill in blank spaces.

Edit Applications:

Must be a valid code
If this field is not coded it must contain blanks

MEDS III Transaction Segment: Pharmacy

Data Element Name: PRESCRIPTION SERIAL NUMBER
Submission Status: Required for COS 14
Encounter Record Position(s): 1474-1485
Format - Length: Character - 12
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: E2011/2011

Definition: Prescription Serial Number is the number on the official New York State Prescription Form. It is a unique number used to identify an individual prescription sheet within a prescription pad.

Some valid Prescriptions can be dispensed when not written on Official Prescription Forms. For these specific situations, in lieu of the Prescription Serial Number, use the codes below.

Mapping:

Encounter Type	Paper	Electronic
Encounter Type	Form	Element	Format	Element
Pharmacy	UCF	N/A	NCPDP	454-EK

Codes and Values:

Blanks are not permitted
Must be a valid code

*Code*	*Value*
HHHHHHHHHHHH	Prescriptions on Hospital and their affiliated Clinics Prescription Pads
ZZZZZZZZZZZZ	Prescriptions written by Out of State prescribers
EEEEEEEEEEEE	Prescriptions submitted via fax or electronically
NNNNNNNNNNNN	Prescriptions for carve-out drugs for nursing home patients
888888888888	Unknown/Documentation insufficient to determine Serial Number
999999999999	Oral Prescriptions

Edit Applications:

02002 Prescription Serial Number Missing

MEDS III Transaction Segment: Pharmacy

Data Element Name: SUBMISSION CLARIFICATION CODE
Submission Status: Required for COS 14
Encounter Record Position(s): 1486-1487
Format - Length: Character - 2
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012 MEDS III DE# / DW#:

Definition: Submission Clarification Code is used to indicate whether or not the code indicating that the pharmacist is clarifying the submission. This code is required if the Date of Service contains the subsequent payer coverage date, the Submission Clarification Code is required with value "19" (split billing indicates the quantity dispensed is the remainder billed to a subsequent payer when Medicare Part A expires. It is used only in long-term care settings) for individual unit of use of medications.

Mapping:

New York State Specific data element

Codes and Values:

Blanks are not permitted
Must be a valid code

*Code*	*Value*
01	No Override
02	Other Override
05	Therapy Change
06	Starter Dose
07	Medically Necessary
08	Process Compound For Approved Ingredients
09	Encounters
19	Split Billing - Medicare Part A Expiration
20	340B - Indicates that prior to providing service, the pharmacy has determined the product to be billed was purchased pursuant to the rights available under Section 340B of the Public Health Act of 1992.
99	Other

Edit Applications:

NONE

MEDS III Transaction Segment: Pharmacy

Data Element Name: DISPENSING FEE
Submission Status: Required for COS 14
Encounter Record Position(s): 1488-1498
Format - Length: Numeric - 11
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: E0817/0817

Definition: Pharmacy Dispensing Fee is that portion of the cost to dispense the claim payment amount that is directly related to drug by the dispensing fee of the provider pharmacy.

Mapping:

New York State specific data element

Codes and Values:

Right-justified and zero filled
This amount is defined with two implied decimal places (e.g., $1,000.00 is reported as 100000)

Edit Applications:

Must be a valid format
Must be entered as a positive number

MEDS III Transaction Segment: Pharmacy

Data Element Name: MAIL ORDER PHARMACY INDICATOR
Submission Status: Required
Encounter Record Position(s): 1499
Format - Length: Character - 1
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012 MEDS III DE# / DW#:

Definition: Mail Order Pharmacy Indicator is a one-digit code to indicate whether or not the script was order either by telephone or online and delivered through the mail and not picked up directly from the neighborhood pharmacy.

Mapping:

New York State specific data element

Codes and Values:

*Code*	*Value*
1	Online Order
2	Telephone Order
3	Non-Online/Telephone Order

Edit Applications:

Must be a valid code

MEDS III Transaction Segment: Pharmacy

Data Element Name: FILLER
Submission Status: Required
Encounter Record Position(s): 1500-3000
Format - Length: Character - 1501
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012

Definition: Space-fill positions 1500 to 3000.

Mapping:

New York State Specific data element

Codes and Values:

Left-justified and space-filled

Edit Applications:

Tier One Edit - Record is not 3000 bytes.

IX. DENTAL SEGMENT

MEDS III Transaction Segment: Dental

Data Element Name: PROVIDER SPECIALTY CODE
Submission Status: Required for COS 13
Encounter Record Position(s): 258-260
Format - Length: Character - 3
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1499/2048

Definition: The Provider Specialty Code designates the State classification of provider specialties. It is based on a provider's certified medical specialty.

Mapping:

New York State Specific Data Element

Codes and Values:

See Appendix B for Valid Codes and Values

Edit Applications:

Must be a valid code
00404 Provider Specialty Missing
00413 Provider Specialty Not On File

MEDS III Transaction Segment: Dental

Data Element Name: SERVICE START DATE
Submission Status: Required for COS 13
Encounter Record Position(s): 261-268; 339-346; 417-424;495-502;573-580;651-658;729-
736;807-814;885-892;963-970
Format - Length: Date - CCYYMMDD
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1022/3013

Definition: The date the dental service was received or initiated.

Mapping:

Paper Form:

Encounter Type	Form	Element
Dental	ADA	#24

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Page No.
Institutional	837I	2300	DTP	02 03	1250 1251	D8 & RD8	167 168
Dental	837D	2300	DTP	02 03	1250 1251	D8 & RD8	164 165

Codes and Values:

Must be a valid date format CCYYMMDD

Valid Century (CC)	Valid Year (YY)
20	>=04

Valid Month Code (MM)	Valid Day Code (DD)
01, 03, 05, 07, 08, 10, 12	Greater than 00 and less than 32
04, 06, 09, 11	Greater than 00 and less than 31
02	Greater than 00 and less than 29 (less than 30 on a leap year)

Edit Applications:

00018 Date Of Service/Fill Date Invalid
00020 Service/Fill Date Later Than Receipt Date
01006 Thru Service Prior to From Service Date
001292 Date of Service Two Years Prior to Date Received

MEDS III Transaction Segment: Dental

Data Element Name: SERVICE END DATE
Submission on Status: Required for COS 13
Encounter Record Position(s): 269-276; 347-354; 425-432;503-510;581-588;659-666;737-744;815-822;893-900;971-978
Format - Length: Date - CCYYMMDD
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1023/3015

Definition: The date the dental service ended.

Mapping:

Paper Form:

Encounter Type	Form	Element
Dental	ADA	#24

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Page No.
Institutional	837I	2300	DTP	02 03	1250 1251	D8 & RD8	167 168
Dental	837D	2300	DTP	02 03	1250 1251	D8 & RD8	164 165

Codes and Values:

Must be a valid date format CCYYMMDD

Valid Century (CC)	Valid Year (YY)
20	>=04

Valid Month Code (MM)	Valid Day Code (DD)
01, 03, 05, 07, 08, 10, 12	Greater than 00 and less than 32
04, 06, 09, 11	Greater than 00 and less than 31
02	Greater than 00 and less than 29 (less than 30 on a leap year)

Edit Applications:

01004 Thru Service Date Invalid
01006 Thru Service Prior to From Service Date

MEDS III Transaction Segment: Dental

Data Element Name: PLACE OF SERVICE/PLACE OF TREATMENT
Submission Status: Required for COS 13
Encounter Record Position(s): 277-278; 355-356; 433-434;511-512;589-590;667-668;745-
746;823-824;901-902;979-980
Format - Length: Character - 2
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 4178/3016

Definition: Place of Service/Place of Treatment Code identifies the place(s) where a service was rendered by a provider.

Mapping:

Paper Form:

Encounter Type	Form	Element
Dental	ADA	#38

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Page No.
Institutional	837I	2300	CLM	05-1	1331	159
Dental	837D	2300	CLM	05-1	1331	151

Codes and Values:

*Code*	*Value*
03	SCHOOL
04	HOMELESS SHELTER
05	INDN HLTH FREE STND
06	INDN HLTH PROV BSD
07	TRIB 638 FREE STND
08	TRIB 638 PROV BSD
11	OFFICE
12	CLIENT'S HOME
13	ASSISTD LIVING FCLTY
14	GROUP HOME
15	MOBILE UNIT
16	HOSP-INTERCARE LVLII
17	HOSP-SUBACUTE INP
18	HOSP-SWING BEDS
20	URGENT CARE FACILITY
21	INPATIENT HOSPITAL
22	OUTPATIENT HOSPITAL
23	HOSP ER
24	AMB SURG CTR
25	BIRTHING CENTER
26	MILITARY TRTMNT FLTY
27	SNF-SUBACUTE INP
28	SNF-SWING BEDS
31	SNF
32	NURSING FACILITY
33	CUSTODIAL CARE FCLTY
34	HOSPICE
41	AMBULANCE - LAND
42	AMBLNCE AIR OR WATER
43	NON-MED HCI-HOSP I-O
44	NON-MED HCIHOSP OTHR
45	NON-MED HCIHOSP IC I
46	NON-MED HCIHOSP ICII
47	NON-MED HCIHOSP SUBA
48	NON-MED HCIHOSP SWNG
49	INDP CLINIC
50	FQHC
51	INPAT PSYCH FCLTY
52	PSYCH FCLTY PRT HSP
53	COMM MH CTR
54	ICF/MR
55	RES SUB AB TREAT FAC
56	PSYCH RES TREAT FAC
57	NO RES SUB ABS FCLTY
58	NO MED HCI POST HOSP
60	MASS IMMUN
61	CIRF
62	CORF
63	INTER CARE-OUT
64	INTER CARE-OTHR
65	ES RNAL DIS TRT FAC
66	INTER CARE-IC LVL II
67	INTER CARE-SUBAC INP
68	INTER CARE-SWING BED
71	ST OR LCL PHC
72	RRL HLTH CLNC
73	CLINIC-FREE STANDING
74	CLINIC-ORF
75	CLINIC-CORF
76	CLINIC-COMM MH
79	CLINIC-OTHER
81	IND LAB
82	SPC FAC-HOSPICE HB
83	SPC FAC-AMB SURG CTR
84	SPC FAC-FS BIRTH CTR
85	SPC FAC-CRITIC AH
86	SPC FAC-RES FAC
88	HMO
89	SPEC FACI-OTHER
99	OTHER

Edit Applications:

Must be a valid entry
00071 Place Of Service Code Invalid

MEDS III Transaction Segment: Dental

Data Element Name: PROCEDURE CODE [up to 10]
Submission Status: Required for COS 13
Encounter Record Position(s): 279-283; 357-361; 435-439;513-517;591-595;669-673;747-
751;825-829;903-907;981-985
Format - Length: Character - 5
Effective Date: 1/1/2009
Version Number - Date: 2.8 - January 2009
MEDS III DE# / DW#: 4159/5055

Definition: Procedure Codes identifying the procedures performed during the dental visit. Fields for reporting of up to ten procedures or services are available. If more than ten procedures were performed during the encounter, submit a second encounter record with the additional procedures listed and using a different Encounter Control Number and identical information on all other elements that were included in the first record (with the exception of Total Amount Paid).

Mapping:

Paper Form:

Encounter Type	Form	Element
Dental	ADA	#29

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Page No.
Institutional	837I	2400	SV2	02-1 02-2	235 234	HC	446 447
Dental	837D	2400	SV3	01-1 01-2	235 234	266- 267

Codes and Values:

Per the 837D, American Dental Association (i.e., CDT) codes may be used to report dental procedures. If CDT2 codes are used, the leading zero of the 5-digit ADA code must be replaced with a 'D" so that the code will conform to the HCPCS coding convention. CDT3 codes conform with HCPCS D codes.
Left-justified and entered exactly as shown in the CPT coding reference.

Edit Applications:

Must be a valid code
00070 Procedure Code Invalid
00170 Procedure Code Not On File
00710 Procedure Code Exceeds Service Limits

MEDS III Transaction Segment: Dental

Data Element Name: PROCEDURE MODIFIER CODE 1 [up to 10]
Submission Status: Required for COS 13
Encounter Record Position(s): 284-285; 362-363; 440-441;518-519;596-597;674-675;752-
753;830-831;908-909;986-987
Format - Length: Character - 2
Effective Date: 1/1/2009
Version Number - Date: 2.8 - January 2009
MEDS III DE# / DW#: 3227_1

Definition: Procedure Modifier Codes are used in conjunction with the CDT procedure code to uniquely describe the service(s) rendered by a provider during an encounter. Fields for reporting a single modifier on each of the up to ten procedures or services are available.

Mapping:

Paper Form:

Encounter Type	Form	Element
Dental	ADA	#29

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Institutional	837I	2400	SV2	02-3	1339	HC	447
Dental	837D	2400	SV3	01	3	1339	267

Codes and Values:

Space-fill if not applicable
Entered exactly as shown in the American Medical Association's Current Procedural Terminology - 4th Edition (CPT-4).
Not applicable for inpatient encounters

Edit Applications:

00927 Modifier Invalid For Procedure Code

MEDS III Transaction Segment: Dental

Data Element Name: PROCEDURE MODIFIER CODE 2 [up to 10]
Submission Status: Required for COS 13
Encounter Record Position(s): 286-287; 364-365; 442-443;520-521;598-599;676-677;754-
755;832-833;910-911;988-989
Format - Length: Character - 2
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: 3227_1

Mapping:

Paper Form:

Encounter Type	Form	Element
Dental	ADA	#29

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Dental	837D	2400	SV3	01	4	1339	267

Codes and Values:

Space-fill if not applicable
Entered exactly as shown in the American Medical Association's Current Procedural Terminology - 4th Edition (CPT-4).
Not applicable for inpatient encounters

Edit Applications:

00927 Modifier Invalid For Procedure Code

MEDS III Transaction Segment: Dental

Data Element Name: PROCEDURE MODIFIER CODE 3 [up to 10]
Submission Status: Required for COS 13
Encounter Record Position(s): 288-289; 366-367; 444-445;522-523;600-601;678-679;756-
757;834-835;912-913;990-991
Format - Length: Character - 2
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: 3227_1

Mapping:

Paper Form:

Encounter Type	Form	Element
Dental	ADA	#29

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Dental	837D	2400	SV3	01	5	1339	267

Codes and Values:

Space-fill if not applicable
Entered exactly as shown in the American Medical Association's Current Procedural Terminology - 4th Edition (CPT-4).
Not applicable for inpatient encounters

Edit Applications:

00927 Modifier Invalid For Procedure Code

MEDS III Transaction Segment: Dental

Data Element Name: PROCEDURE MODIFIER CODE 4 [up to 10]
Submission Status: Required for COS 13
Encounter Record Position(s): 290-291; 368-369; 446-447; 524-525;602-603;680-681;758-
759;836-837;914-915;992-993
Format - Length: Character - 2
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012
MEDS III DE# / DW#: 3227_1

Mapping:

Paper Form:

Encounter Type	Form	Element
Dental	ADA	#29

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Dental	837D	2400	SV3	01	6	1339	267

Codes and Values:

Space-fill if not applicable
Entered exactly as shown in the American Medical Association's Current Procedural Terminology - 4th Edition (CPT-4).
Not applicable for inpatient encounters

Edit Applications:

00927 Modifier Invalid For Procedure Code

MEDS III Transaction Segment: Dental

Data Element Name: TOOTH NUMBER OR LETTER [up to 10]
Submission Status: Required for COS 13
Encounter Record Position(s): 292-293; 370-371;448-449;526-527;604-605;682-683;760-
761;838-839;916-917;994-995
Format - Length: Character - 2
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1646/E4266

Definition: Dental Site Code specifies a tooth, oral cavity, quadrant, or arch.

Mapping:

Paper Form:

Encounter Type	Form	Element
Dental	ADA	#27

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Page No.
Dental	837D	2400	TOO	01 02	1270 1271	JP	271 272

Codes and Values:

See Appendix C for Valid Codes and Values
Space-fill if not applicable

Edit Applications:

Must be a valid entry
00931 Required Tooth For Procedure Invalid

MEDS III Transaction Segment: Dental

Data Element Name: DENTAL NUMBER OF UNITS/VISITS [up to 10]
Submission Status: Required for COS 13
Encounter Record Position(s): 294-304; 372-382;450-460;528-538;606-616;684-694;762-
772;840-850;918-928;996-1006
Format - Length: Numeric - 11
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1092/3029

Definition: A whole number indicating the number of times a procedure or service was provided during the dental encounter; or the number of units, visits, or days a procedure or service was rendered during an episode of care defined by Service Start and End Dates.

Mapping:

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Page No.
Institutional	837I	2400	SV2	04 05	355 380	UN	448
Dental	837D	2400	SV3	06	380	270

Codes and Values:

Right justified and zero filled with 2 implied decimal points ( i.e. '1' would be reported as '00000000001'
Must contain a whole number

Edit Applications:

Must be a valid entry
00094 Number of Units Not Greater than Zero
00180 Units Greater Than Maximum
00710 Procedure Code Exceeds Service Limits

MEDS III Transaction Segment: Dental

Data Element Name: CHARGED AMOUNT [up to 10]
Submission Status: Required for COS 13
Encounter Record Position(s): 305-315; 383-393;461-471;539-549;617-627;695-705;773-
783;851-861;929-939;1007-1017
Format - Length: Numeric - 11
Effective Date: 4/1/2012
Version Number - Date: 3.2 - April 2012 MEDS III DE# / DW#:

Definition: Charged Amount is the line level, charge amount submitted or billed by the provider. The total amount charged for each listed service corresponding to the procedures defined in the CPT data element.

Mapping:

Paper Form:

Encounter Type	Form	Element
Dental	ADA	#31

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Page No.
Dental	837D	2400	SV3	02	782	268

Codes and Values:

Right-justified and zero filled
This amount is defined with two implied decimal places (e.g., $1,000.00 is reported as 100000)

Edit Applications:

Must be a valid format
Must be entered as a positive number
00036 M/I Usual and Customary

MEDS III Transaction Segment: Dental

Data Element Name: MEDICARE PAID AMOUNT [up to 10]
Submission Status: Required for COS 13
Encounter Record Position(s): 316-326; 394-404;472-482;550-560;628-638;706-716;784-
794;863-872;940-950;1018-1028
Format - Length: Numeric - 11
Effective Date: 2/18/2010
Version Number - Date: 2.9 - April 2010
MEDS III DE# / DW#: 1085/L3033_2

Mapping:

New York State Specific Data Element

Codes and Values:

Right-justified and zero filled
The amount is defined with two implied decimal places
Must be entered as a positive number

Edit Applications:

Must be a valid entry

MEDS III Transaction Segment: Dental

Data Element Name: PAID AMOUNT [up to 10]
Submission Status: Required for COS 13
Encounter Record Position(s): 327-337; 405-415;483-493;561-571;639-649;717-727;795-
805;873-883;951-961;1029-1039
Format - Length: Numeric - 11
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1028/3157

Definition: The amount paid by Medicaid for each listed service.

Mapping:

New York State Specific Data Element

Codes and Values:

Right-justified and zero-filled
This amount is defined with two implied decimal places and must be entered as a positive number
On the service line level, the paid amount by Claim/Encounter Indicator should be as follows:

Claim/Encounter Indicator	Total Paid Amount
"E" - Encounter	Proxy Cost Amount
"C" - Within Plan Claim	Actual Cost Amount
"A" - Administrative Denial	Zero Dollars

Edit Applications:

Must be a valid entry

Important Note:

Plans should use internal proxy fee schedules when determining the proxy cost amount.

MEDS III Transaction Segment: Dental

Data Element Name: DENTAL CLAIM/ENCOUNTER INDICATOR
Submission Status: Required for COS 13
Encounter Record Position(s): 338; 416;494;572;650;728;806;884;962;1040 Format - Length: Character - 1
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1983/E1983

Definition: Indicates whether the dental service provided was a capitated service within the health organization's contract ("E"); a within plan claim ("C") or an administratively denied service ("A").

Mapping:

New York State Specific Data Element

Codes and Values:

*Code*	*Value*
E	Capitated Encounter, or service not paid directly by the health organization.
C	Within Plan Claim
A	Administrative Denial

Edit Applications:

Must be a valid code
00437 Claim Encounter Ind Invalid

MEDS III Transaction Segment: Dental

Data Element Name: FILLER
Submission Status: Required
Encounter Record Position(s): 1041-3000
Format - Length: Character - 1960
Effective Date: 4/1/2012
Version Number - Date: 3.2 – April 2012

Definition: Space-fill positions 1041 to 3000.

Mapping:

New York State Specific data element

Codes and Values:

Left-justified and space-filled

Edit Applications:

Tier One Edit – Record is not 3000 bytes.

PROFESSIONAL SEGMENT

MEDS III Transaction Segment: Professional

Data Element Name: PROVIDER SPECIALTY CODE
Submission Status: Required for COS 01, 03, 04, 05, 07, 16, 22, 41, 75
Encounter Record Position(s): 258-260
Format - Length: Character - 3
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1499/2048

Definition: The provider's Specialty Code identifies a provider's medical, dental, clinic or program type specialty.

Mapping:

New York State Specific Data Element

Codes and Values:

Refer to Appendix B for valid codes and values
Provider Specialty Code for podiatrist (COS 03) is always 778
Provider Specialty Code for laboratory (COS 16) is always 599
Provider Specialty Code for DME (COS 22) is either 307 or 969
Provider Specialty Code for non-emergency transportation services (COS 19) may be 671 Other Transportation

Edit Applications:

Must be a valid code
00404 Provider Specialty Missing
00413 Provider Specialty Not On File

MEDS III Transaction Segment: Professional

Data Element Name: ICD VERSION CODE
Submission Status: Required for COS 01, 03, 04, 05, 07, 16, 22, 41, 75
Encounter Record Position(s): 261
Format - Length: Character - 1
Effective Date: 4/1/2012
Version Number - Date: 3.2 – April 2012
MEDS III DE# / DW#: E2498/2498

Definition: A one-digit code to indicate whether the reported diagnoses are ICD-9 or ICD-10.

Mapping:

New York State specific data element

Codes and Values:

If no diagnosis, leave blank (see below table).

Code	Description
Not Available
1	ICD-9 Version
2	ICD-10 Version

Edit Applications:

Must be a valid value
02174 Version Code Not Valid

MEDS III Transaction Segment: Professional

Data Element Name: DIAGNOSIS CODES [up to 4]
Submission Status: Required for COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75
Encounter Record Position(s): 262-268;269-275;276-282;283-289 Format - Length: Character - 7
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 4183/W657

Definition: Up to four diagnosis codes are to be recorded for diagnosed medical conditions for which the recipient receives services during the encounter, or which may have been present at time of the encounter and recorded by the provider. V codes should be used to indicate well-child, routine check- ups and screening encounters where no diagnosed condition exists.

Mapping:

Paper Form:

Encounter Type	Form	Element
Professional	CMS-1500	#21

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Composite	Code	Page No.
Professional	837P	2300	H1	01-04	1270 1271	C022- 1 C022- 2	BK	266- 268

Codes and Values:

Record the appropriate ICD-9-CM or ICD-10 code exactly as it appears in the manual. The diagnosis code must be the most specific/precise 3-digit, 4-digit, or 5-digit code allowed for in the ICD-9-CM or ICD-10coding format.
Left-justified and entered exactly as shown in the ICD-9-CM or ICD-10coding reference, excluding the decimal point, and Space-filled. The decimal point is implied after third digit because each ICD-9-CM or ICD-10code is unique.
Leading and trailing zeros in a diagnostic code must be recorded (i.e. do not use blanks in place of zeros for any reason). In addition, zeros should not be added to a diagnostic code to fill in blank spaces.
For editing purposes, only the first four digits of the diagnostic code will be checked for validity against the ICD-9-CM or ICD-10 coding system.
Managed Long Term Care (MLTC) and PACE plans may use V689 – Encounters for Unspecified Administrative Purposes when reporting services that do not have a diagnosis.

Edit Applications:

00406 Diagnosis Code Missing
00412 Diagnosis Code Not On File

MEDS III Transaction Segment: Professional

Data Element Name: PLACE OF SERVICE/PLACE OF TREATMENT [UP TO 10]
Submission Status: Required for COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75
Encounter Record Position(s): 290-291;388-389;486-487;584-585;682-683;780-781;878-
879;976-977;1074-1075;1172-1173
Format - Length: Character - 2
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 4178/3016

Definition: Place of Service/Place of Treatment Code identifies the place(s) where a service was rendered by a provider.

Mapping:

Paper Form:

Encounter Type	Form	Element
Professional	CMS-1500	#24B

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Page No.
Professional	837P	2300	CLM	05-1	1331	173

Codes and Values:

*Code*	*Value*
03	SCHOOL
04	HOMELESS SHELTER
05	INDIAN HLTH SVCS FR-STND FCLTY
06	INDIAN HLTH SVCS PR-BSD FCLTY
07	TRIBAL 638 FRE-STNDNG FACILITY
08	TRIBAL 638 PROV BASED FACILITY
11	OFFICE
12	CLIENT'S HOME
13	ASSISTED LIVING FACILITY
14	GROUP HOME
15	MOBILE UNIT
20	URGENT CARE FACILITY
21	INPATIENT HOSPITAL
22	OUTPATIENT HOSPITAL
23	HOSPITAL EMERGENCY ROOM
24	AMBULATORY SURGICAL CENTER
25	BIRTHING CENTER
26	MILITARY TREATMENT FACILITY

*Code*	*Value*
31	SKILLED NURSING FACILITY
32	NURSING FACILITY
33	CUSTODIAL CARE FACILITY
34	HOSPICE
41	AMBULANCE – LAND
42	AMBULANCE - AIR OR WATER
49	INDEPENDENT CLINIC
50	FEDERALLY QUALIFIED HEALTH CENTER
51	INPATIENT PSYCHIATRIC FACILITY
52	PSYCHIATRIC FACILITY PARTIAL HOSPITALIZATION
53	COMUNITY MENTAL HEALTH CENTER
54	INTERMEDIATE CARE FACILITY/MENTALLY RETARDED
55	RESIDENTIAL SUBSTANCE ABUSE TREATMENT FACILITY
56	PSYCHIATRIC RESIDENTIAL TREATMENT CENTER
57	NON-RES SUBST ABS TRTMNT FCLTY
60	MASS IMMUNIZATION
61	COMPREHENSIVE INPATIENT REHABILITATION FACILITY
62	COMPREHENSIVE OUTPATIENT REHALILITATION FACILITY
65	END STAGE RENAL DISEASE TREATMENT FACILITY
71	STATE OR LOCAL PUBLIC HEALTH CLINIC
72	RURAL HEALTH CLINIC
81	INDEPENDENT LABORATORY
99	OTHER UNLISTED FACILITY

Edit Applications:

Must be a valid entry.
00071 Place Of Service Code Invalid

MEDS III Transaction Segment: Professional

Data Element Name: SERVICE START DATE
Submission Status: Required for COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75
Encounter Record Position(s): 292-299;390-397;488-495;586-593;684-691;782-789;880-887;978-985;1076-1083;1174-1181
Format - Length: Date - CCYYMMDD
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1022/3013

Definition: The date the service was received or initiated.

Mapping:

Paper Form:

Encounter Type	Form	Element
Professional	CMS-1500	#24A "From"

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Page No.
Professional	837P	2400	DTP	02 03	1250 1251	D8 & RD8	436

Codes and Values:

Must be a valid date format CCYYMMDD

Valid Century (CC)	Valid Year (YY)
20	>=04

Valid Month Code (MM)	Valid Day Code (DD)
01, 03, 05, 07, 08, 10, 12	Greater than 00 and less than 32
04, 06, 09, 11	Greater than 00 and less than 31
02	Greater than 00 and less than 29 (less than 30 on a leap year)

Edit Applications:

00018 Date Of Service/Fill Date Invalid
00020 Service/Fill Date Later Than Receipt Date
01006 Thru Service Prior to From Service Date
001292 Date of Service Two Years Prior to Date Received

MEDS III Transaction Segment: Professional

Data Element Name: SERVICE END DATE
Submission Status: Required for COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75
Encounter Record Position(s): 300-307;398-405;496-503;594-601;692-699;790-797;888-895;986-993;1084-1091;1182-1189
Format - Length: Date - CCYYMMDD
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1023/3015

Definition: The date on which the service ended.

Mapping:

Paper Form:

Encounter Type	Form	Element
Professional	CMS-1500	#24A "To"

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Page No.
Professional	837P	2400	DTP	02 03	1250 1251	D8 & RD8	436

Codes and Values:

Must be a valid date format CCYYMMDD

Valid Century (CC)	Valid Year (YY)
20	>=04

Valid Month Code (MM)	Valid Day Code (DD)
01, 03, 05, 07, 08, 10, 12	Greater than 00 and less than 32
04, 06, 09, 11	Greater than 00 and less than 31
02	Greater than 00 and less than 29 (less than 30 on a leap year)

Edit Applications:

00705 Duplicate Claim in History
01004 Thru Service Date Invalid
01006 Thru Service Prior to From Service Date

MEDS III Transaction Segment: Professional

Data Element Name: CPT/HCPCS PROCEDURE CODES [UP TO 10]
Submission Status: Required for COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75
Encounter Record Position(s): 308-312;406-410;504-508;602-606;700-704;798-802;896-
900;994-998;1092-1096;1190-1194
Format - Length: Character - 5
Effective Date: 1/1/2009
Version Number - Date: 2.8 - January 2009
MEDS III DE# / DW#: 2042/5055

Definition: The CPT/HCPCS procedure code that describes the service(s) rendered during Professional encounters. Fields for reporting of up to ten procedures or services are available. If more than ten procedures were performed during the encounter, submit a second encounter record with the additional procedures listed and using a different Encounter Control Number and identical information on all other elements that were included in the first record (with the exception of Total Amount Paid).

Mapping:

Paper Form:

Encounter Type	Form	Element
Professional	CMS-1500	#24D

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Code	Page No.
Professional	837P	2400	SV1	01-1 01-2	235 234	HC	401

Codes and Values:

Left-justified.
Must be a CPT/HCPCS Code.

Edit Applications:

Must be a valid entry.
00070 Procedure Code Invalid
00170 Procedure Code Not On File
00710 Procedure Code Exceeds Service Limits

MEDS III Transaction Segment: Professional

Data Element Name: PROCEDURE MODIFIER CODE 1 [UP TO 10]
Submission Status: Required for COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75
Encounter Record Position(s): 313-314;411-412;509-510;607-608;705-706;803-804;901-902;999-1000;1097-1098;1195-1196
Format - Length: Character - 2
Effective Date: 1/1/2009
Version Number - Date: 2.8 - January 2009
MEDS III DE# / DW#: 3227_1

Mapping:

Paper Form:

Encounter Type	Form	Element
Professional	CMS-1500	#44

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Professional	837P	2400	SV1	01	3	1339	401

Codes and Values:

Space-fill if not applicable.
Entered exactly as shown in the American Medical Association's Current Procedural Terminology - 4th Edition (CPT-4).
Not applicable for inpatient encounters

Edit Applications:

00927 Modifier Invalid For Procedure Code

MEDS III Transaction Segment: Professional

Data Element Name: PROCEDURE MODIFIER CODE 2
Submission Status: Required for COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75
Encounter Record Position(s): 315-316;413-414;511-512;609-610;707-708;805-806;903-904;1001-1002;1099-1100;1197-1198
Format - Length: Character - 2
Effective Date: 4/1/2012
Version Number - Date: 3.2 – April 2012
MEDS III DE# / DW#: 3227_1

Mapping:

Paper Form:

Encounter Type	Form	Element
Professional	CMS-1500	#44

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Professional	837P	2400	SV1	01	4	1339	402

Codes and Values:

Space-fill if not applicable.
Entered exactly as shown in the American Medical Association's Current Procedural Terminology - 4th Edition (CPT-4).
Not applicable for inpatient encounters

Edit Applications:

00927 Modifier Invalid For Procedure Code

MEDS III Transaction Segment: Professional

Data Element Name: PROCEDURE MODIFIER CODE 3
Submission Status: Required for COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75
Encounter Record Position(s): 317-318;415-416;513-514;611-612;709-710;807-808;905-906;1003-1004;1101-1102;1199-1200
Format - Length: Character - 2
Effective Date: 4/1/2012
Version Number - Date: 3.2 – April 2012
MEDS III DE# / DW#: 3227_1

Mapping:

Paper Form:

Encounter Type	Form	Element
Professional	CMS-1500	#44

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Professional	837P	2400	SV1	01	5	1339	402

Codes and Values:

Space-fill if not applicable.
Entered exactly as shown in the American Medical Association's Current Procedural Terminology - 4th Edition (CPT-4).
Not applicable for inpatient encounters

Edit Applications:

00927 Modifier Invalid For Procedure Code

MEDS III Transaction Segment: Professional

Data Element Name: PROCEDURE MODIFIER CODE 4
Submission Status: Required for COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75
Encounter Record Position(s): 319-320;417-418;515-516;613-614;711-712;809-810;907-
908;1005-1006;1103-1104;1201-1202
Format - Length: Character - 2
Effective Date: 4/1/2012
Version Number - Date: 3.2 – April 2012
MEDS III DE# / DW#: 3227_1

Mapping:

Paper Form:

Encounter Type	Form	Element
Professional	CMS-1500	#44

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Composite	Element ID	Page No.
Professional	837P	2400	SV1	01	5	1339	402

Codes and Values:

Space-fill if not applicable.
Entered exactly as shown in the American Medical Association's Current Procedural Terminology - 4th Edition (CPT-4).
Not applicable for inpatient encounters

Edit Applications:

00927 Modifier Invalid For Procedure Code

MEDS III Transaction Segment: Professional

Data Element Name: NUMBER OF UNITS/VISITS [UP TO 10]
Submission Status: Required for COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75
Encounter Record Position(s): 321-331;419-429;517-527;615-625;713-723;811-821;909-919;1007-1017;1105-1115;1203-1213
Format - Length: Numeric - 11
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1092/3029

Definition: A whole number indicating the number of times a procedure or service was provided during the encounter; or the number of units, visits, or days a procedure or service was rendered during an episode of care defined by Service Start and End Dates.

Mapping:

Paper Form:

Encounter Type	Form	Element
Professional	CMS-1500	#24G

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Elem- ent ID	Code	Page No.
Professional	837P	2400	SV1	03 04	355 380	UN	403

Codes and Values:

Right-justified and zero filled. ( i.e. '1' would be reported as '00000000001' )
Must be a non-zero number when an associated procedure has been recorded.

Edit Applications:

Must be a valid entry.
00094 Number of Units Not Greater Than Zero
00180 units Greater Than Maximum
00710 Procedure Code Exceeds Service Limits

MEDS III Transaction Segment: Professional

Data Element Name: NDC (FORMULARY) CODE [UP TO 10]
Submission Status: Required for COS 01
Encounter Record Position(s): 332-342;430-440;528-538;626-636;724-734;822-832;920-930;1018-1028;1116-1126;1214-1224
Format - Length: Character - 11
Effective Date: 4/1/2012
Version Number - Date: 3.2 – April 2012
MEDS III DE# / DW#: 1856/E1856

Mapping:

Paper Form:

Encounter Type	Form	Element
Professional	CMS-1500	#44

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Page No.
Institutional	837P	2410	CTP	04	380	426

Codes and Values:

Right-justified and zero filled.
Valid values for this data element are defined and maintained by First DataBank.

Edit Applications:

00544 NDC Code Non-Numeric
00561 Drug Code Not On file
01610 Missing or Invalid Alternate Product Code
02066 Drug Code Missing

MEDS III Transaction Segment: Professional

Data Element Name: NDC (FORMULARY) UNITS [UP TO 10]
Submission Status: Required for COS 01
Encounter Record Position(s): 343-353;441-451;539-549;637-647;735-745;833-843;931-941;1029-1039;1127-1137;1225-1235
Format - Length: Numeric - 11
Effective Date: 4/1/2012
Version Number - Date: 3.2 – April 2012
MEDS III DE# / DW#: 4217/3251

Definition: The dispensing quantity based upon the unit of measure as defined by the National Drug Code.

Mapping:

Paper Form:

Encounter Type	Form	Element
Professional	CMS-1500	#24G

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Page No.
Institutional	837P	2410	CTP	04	380	426

Codes and Values:

Must be entered if a National Drug Code has been entered
Right-justified and zero filled with 3 implied decimal points
Must be a positive numeric value
Fractions must be reported to the nearest 1000th (.001)

Edit Applications:

Must be a valid entry
00528 Missing Or Invalid Quantity Dispensed

Examples:
2.755 units = 00000002755
2.5 units = 00000002500
25 units = 00000025000
250 units = 00000250000

MEDS III Transaction Segment: Professional

Data Element Name: CHARGED AMOUNT [UP TO 10]
Submission Status: Required for COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75
Encounter Record Position(s): 354-364;452-462;550-560;648-658;746-756;844-854;942-952;1040-1050;1138-1148;1236-1246
Format - Length: Numeric - 11
Effective Date: 4/1/2012
Version Number - Date: 3.2 – April 2012
MEDS III DE# / DW#: 3199/3199

Definition: The total amount charged for each listed service.

Mapping:

Paper Form:

Encounter Type	Form	Element
Professional	CMS-1500	#24F

Electronic:

Encounter Type	EDI Format	X12 Mapping Loop	X12 Mapping Segment	Seg. Ele. (Ref)	Element ID	Page No.
Institutional	837P	2400	SV1	02	782	402

Codes and Values:

Right-justified and zero filled
This amount is defined with two implied decimal places (e.g., $1,000.00 is reported as 100000)

Edit Applications:

Must be a valid format
Must be entered as a positive number
00036 M/I Usual and Customary

MEDS III Transaction Segment: Professional

Data Element Name: MEDICARE PAID AMOUNT
Submission Status: Required for COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75
Encounter Record Position(s): 365-375;463-473;561-571;659-669;757-767;855-865;953-963;1051-1061;1149-1159;1247-1257
Format - Length: Numeric - 11
Effective Date: 2/18/2010
Version Number - Date: 2.9 – April 2010
MEDS III DE# / DW#: 1085/L3033_2

Mapping:

New York State Specific Data Element

Codes and Values:

Right-justified and zero filled.
The amount is defined with two implied decimal places
Must be entered as a positive number.

Edit Applications:

Must be a valid entry.

MEDS III Transaction Segment: Professional

Data Element Name: PAID AMOUNT [UP TO 10]
Submission Status: Required for COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75
Encounter Record Position(s): 376-386;474-484;572-582;670-680;768-778;866-876;964-974;1062-1072;1160-1170;1258-1268
Format - Length: Numeric - 11
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1028/3157

Definition: The amount Medicaid paid by insurer for each listed service.

Mapping:

New York State Specific Data Element

Codes and Values:

Right-justified and zero filled.
This amount is defined with two implied decimal places and must be entered as a positive number.
On the service line level, the paid amount by Claim/Encounter Indicator should be as follows:

Claim/Encounter Indicator	Total Paid Amount
"E" – Encounter	Proxy Cost Amount
"C" – Within Plan Claim	Actual Cost Amount
"A" – Administrative Denial	Zero Dollars

Edit Applications:

Must be a valid entry.

Important Note:

***Plans should use internal proxy fee schedules when determining the proxy cost amount***

MEDS III Transaction Segment: Professional

Data Element Name: PROFESSIONAL CLAIM/ENCOUNTER INDICATOR [UP TO 10]
Submission Status: Required for COS 01, 03, 04, 05, 07, 16, 19, 22, 41, 75
Encounter Record Position(s): 387;485;583;681;779;877;975;1073;1171;1269
Format - Length: Character - 1
Effective Date: 3/1/2005
Version Number - Date: 2.6 - July 2008
MEDS III DE# / DW#: 1983/E1983

Definition: Indicates whether the professional service provided was a capitated service within the health organization's contract ("E"); a within plan claim ("C") or an administratively denied service ("A").

Administratively denied encounters are those encounters which reflect services performed normally paid for but were denied due to failure of at least one requirement of the agreement between provider and plan. For example, a plan requires encounters be submitted within 60 days of the service date. A well-child encounter submitted 63 days after date of service would be administratively denied. (Claim received too late).

Mapping:

New York State Specific Data Element

Codes and Values:

*Code*	*Value*
E	Capitated Encounter, or service not paid directly by the health organization.
C	Within Plan Claim
A	Administrative Denial

Edit Applications:

Must be a valid entry.
00437 Claim Encounter Ind Invalid

MEDS III Transaction Segment: Professional

Data Element Name: FILLER
Submission Status: Required
Encounter Record Position(s): 1270-3000
Format - Length: Character - 1731
Effective Date: 4/1/2012
Version Number - Date: 3.2 – April 2012

Definition: Space-fill positions 1270 to 3000.

Mapping:

New York State Specific data element

Codes and Values:

Left-justified and space-filled

Edit Applications:

Tier One Edit – Record is not 3000 bytes.

APPENDIX A – Provider Profession Codes

This list is available for download on the MEDS Home Page on the HCS under the heading MEDS III.

*Code*	*Value*
009	Medical Physicist-Diagnostic Radiological
010	Licensed Practical Nurse
011	Medical Physicist-Medical Health
012	Medical Physicist-Medical Nuclear
013	Medical Physicist-Therapeutic Radiological
020	Pharmacist
021	Pharmacist, limited license (3 year)
022	Registered Professional Nurse
023	Registered Physician Assistant
024	Registered Specialist Assistant
025	Acupuncture
027	Massage Therapist
028	Midwife
030	Nurse Practitioner, Adult Health
031	Nurse Practitioner, College Health
032	Nurse Practitioner, Community Health
033	Nurse Practitioner, Family Health
034	Nurse Practitioner, Gerontology
035	Nurse Practitioner, Neonatology
036	Nurse Practitioner, Obstetrics & Gynecology
037	Nurse Practitioner, Oncology
038	Nurse Practitioner, Pediatrics
039	Nurse Practitioner, Perinatology
040	Nurse Practitioner, Psychiatry
041	Nurse Practitioner, School Health
042	Nurse Practitioner, Women's Health
043	Nurse Practitioner, Acute Care
044	Nurse Practitioner, Palliative Care
045	Nurse Practitioner, Holistic medicine
048	Dietitian/Nutritionist, Certified
049	Dental Assistant
050	Dentist
051	Dental Hygienist
052	Respiratory Therapist
053	Respiratory Therapy Technician
055	Ophthalmic Dispenser
056	Optometrist
057	Audiologist
058	Speech-Language Pathologist
059	Dentist, limited license (3 year)
060	Medicine
061	Medicine, limited license (3 year)
062	Physical Therapist
063	Occupational Therapist
064	Occupational Therapy Assistant
065	Podiatrist
066	Physical Therapy Assistant
067	Athletic Trainer
068	Psychologist
069	Dental Hygiene with Limited License
070	Chiropractor
072	Licensed Master Social Worker (no privileges)
073	Licensed Clinical Social Worker (R/P psychotherapy priv.)
080	Social Worker (obsolete split into 072, 073 eff. 9/1/2004)
081	Dental Parenteral Conscious Sedation (eff. 1/1/01)
082	Dental General Anesthesia (eff. 1/1/01)
083	Dental Enteral Conscious Sedation (eff. 1/1/01)
084	Dental Hygiene Anesthesia
088	Dental, Parenteral Conscious Sedation (prior to 1/1/01)
089	Dental Anesthesia (prior to 1/1/01)

APPENDIX B – Provider Specialty Codes

These provider specialty codes for MEDS III reporting are available for download on the MEDS Home Page on the HCS under the heading MEDS III.

Code	Provider Specialty/Service Description
007	ALCOHOLISM/SUBSTANCE ABUSE INPATIENT
010	ALLERGY AND IMMUNOLOGY
011	GENERAL HOSPITAL (ARTICLE 28)
017	OMH PSYCH CTR/OASAS ASA INPATIENT
018	PRIVATE PSYCH & ASA INPATIENT
020	ANESTHESIOLOGY
030	COLON AND RECTAL SURGERY
040	DERMATOLOGY
041	DERMATOPATHOLOGY
050	FAMILY PRACTICE
055	ADOLESCENT MEDICINE: FAMILY MEDICINE
056	ADOLESCENT MEDICINE: PEDIATRICS
057	BEHAVIORAL PEDIATRICS
058	INTERNAL MEDICINE AND PEDIATRICS
059	PEDIATRIC RHEUMATOLOGY
060	INTERNAL MEDICINE
061	PEDIATRIC INFECTIOUS DISEASE
062	CARDIOVASCULAR DISEASE
063	ENDOCRINOLOGY AND METABOLISM
064	GASTROENTEROLOGY
065	HEMATOLOGY - INTERNAL MED
066	INFECTIOUS DISEASES
067	NEPHROLOGY
068	PULMONARY DISEASES
069	RHEUMATOLOGY
070	NEUROLOGICAL SURGERY
071	SPINAL CORD INJURY MEDICINE
072	PEDIATRIC NEUROSURGERY
073	PEDIATRIC DERMATOLOGY
074	MEDICAL TOXICOLOGY
075	UNDERSEA & HYPERBARIC MEDICINE
076	PEDIATRIC REHABILITATION
080	NUCLEAR MEDICINE
081	MEDICAL NUCLEAR PHYSICS
083	NEUROMUSCULAR MEDICINE
084	NEURORADIOLOGY
085	NEUROTOLOGY
089	OBSTETRICS AND GYNECOLOGY
092	MATERNAL AND FETAL MEDICINE
093	REPRODUCTIVE ENDOCRINOLOGY
095	CERTIFIED DIABETES EDUCATOR
100	OPTHALMOLOGY
101	PEDIATRIC OPHTHALMOLOGY
102	CERTIFIED ASTHMA EDUCATOR
110	ORTHOPEDIC SURGERY
111	HAND SURGERY - ORTHOPEDIC SURGERY
112	HAND SURGERY - PLASTIC SURGERY
113	HAND SURGERY - SURGERY
114	PLASTIC SURGERY WITH THE HEAD & NECK
120	OTOLARYNGOLOGY
121	PEDIATRIC OTOLARYNGOLOGY
127	CLIA REGISTRATION/COMPLIANCE/ACCREDITATION
128	CLIA WAIVER
129	CLIA PHYSICIAN PERFORMED MICROSCOPY PROCEDURE
130	CLIA WAIVER/REGISTRATION
131	BLOOD BANKING
135	CLINICAL PATHOLOGY
136	FORENSIC PATHOLOGY
137	HEMATOLOGY - PSC PATH
138	CHEMICAL PATHOLOGY
139	MEDICAL MICROBIOLOGY
140	PATHOLOGY WITH MOLECULAR GENETIC SPEC
141	NEUROPATHOLOGY
142	ANATOMIC PATHOLOGY
143	DERMATOPATHOLOGY - PSC PATH
144	TRANSPLANT HEPATOLOGY
145	PEDIATRIC TRANSPLANT HEPATOLOGY
146	ANATOMIC AND CLINICAL PATHOLOGY
147	PEDIATRIC PATHOLOGY
148	RADIOISOTOPIC PATHOLOGY
149	PEDIATRIC EMERGENCY MEDICINE
150	PEDIATRICS
151	PEDIATRIC CARDIOLOGY
152	PEDIATRIC HEMATOLOGY - ONCOLOGY
153	PEDIATRIC SURGERY
154	PEDIATRIC NEPHROLOGY
155	PEDIATRIC NEONATAL - PERINATAL MEDICINE
156	PEDIATRIC ENDOCRINOLOGY
157	PEDIATRIC PULMONOLOGY
158	PREFERRED PHYSICIANS AND CHILDREN PROG
159	MEDICAID OBSTETRICAL & MATERNAL SVC PROG
160	PHYSICAL MEDICINE & REHABILITATION
161	PEDIATRIC CRITICAL CARE
162	OSTEOPATHIC MANIPULATIVE MEDICINE
163	PEDIATRIC GASTROENTOLOGY
164	CRITICAL CARE MED - ANESTHESIOLOGIST
165	CRITICAL CARE MEDICINE - INTERNAL
166	CRITICAL CARE MEDICINE - OBSTETRICS
167	CRITICAL CARE MEDICINE - SURGERY
169	MEDICAID OBSTERICAL & MATERNAL SERVICES PRGM (MOMS): HEALTH SUPPORTIVE SERVICES
170	PLASTIC SURGERY
171	CLINICAL MOLECULAR GENETICS
180	CLINICAL BIOCHEMICAL GENETICS
181	AEROSPACE
182	GENERAL PREVENTIVE MEDICINE
183	OCCUPATIONAL MEDICINE
184	PUBLIC HEALTH - PREVENTIVE MEDICINE
185	AEROSPACE MEDICINE
186	T.B. DIRECTLY OBSERVED THERAPY/PHYSICIAN
187	MEDICAL GENETICS
188	CLINICAL GENETICS
189	MOLECULAR GENETIC PATHOLOGY
190	PAIN MANAGEMENT-PSYCHIATRY & NEUROLOGY
191	CHILD PSYCHIATRY
192	PSYCHIATRY
193	CHILD NEUROLOGY
194	NEUROLOGY
195	PSYCHIATRY & NEUROLOGY
196	CLOZAPINE CASE MANAGER - PSYCH
197	GERIATRIC PSYCHIATRY
198	ADDICTION PSYCHIATRY
199	NERODEVELOPMENTAL DISABILITIES
200	RADIOLOGY
201	DIAGNOSTIC RADIOLOGY
202	DIAGNOSTIC ROENTGENOLOGY
205	THERAPEUTIC RADIOLOGY
206	RADIOLOGICAL PHYSICS
207	THERAPEUTIC RADIOLOGICAL PHYSICS
208	DIAGNOSTIC RADIOLOGICAL PHYSICS
210	GENERAL SURGERY
211	HOSPITALIST
220	THORACIC SURGERY
230	UROLOGY
231	PEDIATRIC UROLOGY
240	VASCULAR NEUROLOGY
241	ONCOLOGY
242	GYNECOLOGIC ONCOLOGY
243	VASCULAR MEDICINE
244	RADIOLOGIST ONCOLOGY
245	PEDIATRIC RADIOLOGY
246	VASCULAR&INTERVENTIONAL RADIOLOGY
247	MANAGED CARE - PHYSICIAN ENHANCED FEE
248	MANAGED CARE - DENTAL ENHANCED FEE
249	HIV PRIMARY CARE SERVICES
250	EMERGENCY MEDICINE
252	PRIMARY CARE INITIATIVE IN UNDERSERVED AREAS
253	SPECIALSTS PRIMARY CARE INIT - UNDERSRVD AREA
254	SPECIALISTS IN PHYSICIANS CASE MGMT PROGRAM
270	CHILD HEALTH ASSURANCE PROGRAM
280	CHIROPRACTIC
281	CLINICAL SOCIAL WORKER
282	CERTIFIED DRUG & ALCOHOL COUNSELOR
283	COUNSELOR
290	ACUPUNCTURIST
300	PHYSICAL THERAPY
301	OCCUPATIONAL THERAPY
302	SPEECH THERAPY
303	AIDS/HIV SERVICES
304	MEDICAL REHAB
305	PEDIATRIC SPECIALTY - ALL EXCEPT PRIMARY CARE
306	SCHOOL SUPPORTIVE HEALTH SERVICES PROGRAM
307	DURABLE MEDICAL EQUIPMENT
308	HIV PRIMARY CARE SERVICES - CLINIC SPECIALTY
309	MEDICALLY SUPERVISED SUBSTANCE ABUSE
310	OMH ADULT CLINIC (STATE OPR)
311	OMH CHILD CLINIC (STATE OPR)
312	OMH CONTINUING DAY TRTMT (STATE OPR)
313	OMH PARTIAL HOSPITALIZATION (STATE OPR)
314	OMH INTEN PSYCH REHAB TRTMT (STATE OPR)
315	OMH ADULT CLINIC
316	OMH CHILD CLINIC
317	OMH CONTINUING DAY TREATMENT
318	OMH PARTIAL HOSPITALIZATION
319	OMH INTENSIVE PSYCH REHAB TREATMENT
320	CLOZAPINE CASE MANAGER - CLINIC
321	COMPREHENSIVE SPECIALTY CLINIC SERVICES
322	OMH COMPREHENSIVE OUTPATIENT PROGRAM (COPS) CLINIC
323	OMH COMP OUTPAT PROG (COPS) CONTINUING DAY TRTMT
324	PRE-SCHOOL SUPPORTIVE HEALTH CARE
325	EARLY INTERVENTION
326	OMH/CR ADULT (VOLUNTARY)
327	OMH/CR CHILDREN (VOLUNTARY)
328	OMH FAMILY BASED TREATMENT
329	OMH/CR ADULT (STATE OPR)
330	OMH/CR CHILDREN (STATE OPR)
331	OMH TEACHING FAMILY HOME
332	OMR/DD CR (STATE OPR)
350	PPCP ASSOCIATED DENTAL CLINIC - ORAL SURGERY
351	PPCP ASSOCIATED DENTAL CLINIC - GENERAL DENTISTRY
352	PPCP ASSOCIATED COPS
353	PPCP ASSOCIATED OMH CLINICS
354	PPCP ASSOCIATED PSYCHIATRY, GENERAL
355	AIDS DAY HEALTH CARE SERVICES
356	HOME & COMMUNITY BASED SERVICE (HCBS) WAIVER
357	OUTPATIENT CHEMICAL DEPENDENCE WITHDRAWL
358	TBI SERVICES
359	RISPERDAL CONSTA ADMINISTRATION
365	MH RESIDENTIAL (NON-INPATIENT)
371	CASE MANAGEMENT
375	MH OUTPATIENT (NON-RESIDENTIAL)
376	MENTAL HEALTH PRACTITIONER
400	MICROBIOLOGY
401	FQ OUT-OF-STATE (NON-CMMA)
402	FQ PRIMARY
403	FQ SECONDARY
404	FQ AUTHORIZED
410	BACTERIOLOGY
411	BACTERIOLOGY - GENERAL
412	BACTERIOLOGY - LIMITED
413	BACTERIOLOGY - AEROBES ONLY
414	BACTERIOLOGY - NEISSERIA GONORRHOEAE SCREENG
415	BACTEROLOGY - GC SMEARS ONLY
416	BACTERIOLOGY-RESTRICTED (DENTAL)
419	MYCOBACTERIOLOGY - SMEARS AND CULTURE
420	MYCOBACTERIOLOGY - GENERAL
421	MYCOBACTERIOLOGY - LIMITED
422	MYCOBACTERIOLOGY - SMEARS ONLY
423	DIAGNOSTIC IMMUNOLOGY - COMPREHENSIVE
424	DIAGNOSTIC IMMUNOLOGY - OTHER
427	DIAGNOSTIC IMMUNOLOGY - GENERAL/LIMITED
429	DIAGNOSTIC IMMUNOLOGY - SPECIAL
430	HUMAN IMMUNODEFICIENCY VIRUS - RESTRICTED A
431	HUMAN IMMUNODEFICIENCY VIRUS - RESTRICTED B
432	HUMAN IMMUNODEFICIENCY VIRUS - COMPREHENSIVE
433	SEROLOGY - ROUTINE
434	SEROLOGY - LIMITED
435	CELLULAR IMMUNOLOGY - LIMITED I
436	CELLULAR IMMUNOLOGY - LIMITED II
437	SEROLGY - OTHER
438	CELLULAR IMMUNOLOGY - GENERAL
439	CELLULAR IMMUNOLOGY - LIMITED III
440	VIROLOGY - GENERAL I OR GENERAL II
441	VIROLOGY - LIMITED
442	VIROLOGY - RESTRICTED
450	MYCOLOGY - GENERAL
451	MYCOLOGY - LIMITED (YEAST ONLY)
460	PARASITOLOGY
461	PARASITOLOGY - STOOL
462	PARASITOLOGY - OTHER
463	PARASITOLOGY - BLOOD
470	URINE PREGNANCY TESTING
480	HEMATOLOGY
481	HEMATOLOGY - COMPREHENSIVE
482	HEMATOLOGY - GENERAL
483	HEMATOLOGY - COAGULATION ONLY
484	HEMATOLOGY - LIMITED
485	HEMATOLOGY - OTHER
486	CYTOHEMATOLOGY - LIMITED/DIAGNOSTIC
490	IMMUNOHEMATOLOGY
491	BLOOD SERVICES - DIAGNOSTIC IMMUNOHEMATOLOGY
492	IMMUNOHEMATOLOGY SPC 492
493	IMMUNOHEMATOLOGY SPC 493
510	CLINICAL CHEMISTRY - GENERAL
511	CLINICAL CHEMISTRY - LIMITED
512	TOXICOLOGY - ERYTHROCYTE PROTOPORPHYRIN-HEMAT
513	TOXICOLOGY - ERYTHROCYTE PROTOPORHYRIN-EXTRCT
514	TOXICOLOGY - DRUG ANALYSIS-QUAL (OR FORENSIC)
515	TOXICOLOGY - BLOOD LEAD
516	ENDOCRINOLOGY
517	CHEMLIMIT
518	QUALITATIVE TOXICOLOGY - REHABILITATION PROGS
519	CHEM RESERV
520	CHEM ALL
521	BLOOD PH AND GASES
522	CHEM IMD
523	THERAPEUTIC SUBSTANCE MONITORING/QUAN TOXICOL
524	URINALYSIS
530	PATHOLOGY SPC 530
531	HISTOPATHOLOGY - GENERAL/ORAL/DERMATOPATHALGY
532	PATHOLOGY SPC 532
533	PATHOLOGY SPC 533
540	CYTOPATHOLOGY
550	ONCOFETAL ANTIGEN - GENERAL
551	ONCOFETAL ANTIGEN - LIMITED
552	ONCOFETAL ANTIGEN - GENERAL, SERA ONLY
553	ONCOFETAL ANTIGEN - GENL, AMNIOTIC FLUID ONLY
560	GENETIC TESTING
561	BLOOD TRANSFUSION COLLECTION
562	BLOOD TRANSFUSION
570	MISCELLANEOUS
571	CYTOGENETICS - GENERAL
572	CYTOGENETICS - LIMITED
573	CYTOGENETICS - HEMATOLOGICAL DISORDERS
574	MISCELLANEOUS HIS
575	MISCELLANEOUS LIMITED HIS
576	MISCELLANEOUS MISCELLANEOUS
579	NURSE: MEDICALLY FRAGILE CHILDREN
580	HISTOCOMPATIBILITY - LIMITED
585	MISCELLANEOUS CLINIC CHEM
590	MISCELLANEOUS SPECIALTY TEST
599	LABORATORY
600	SPORTS MEDICINE - EMERGENCY
601	SPORTS MEDICINE - FAMILY MEDICINE
602	SPORTS MEDICINE - INTERNAL
603	SPORTS MEDICINE - PEDIATRICS
604	SPORTS MEDICINE - ORTHOPEDIC
615	PERSONAL EMERGENCY RESPONSE SYSTEM
616	MENTAL HEALTH INPATIENT
620	GERIATRICS - FAMILY MEDICINE
621	GERIATRICS - INTERNAL
630	PAIN MANAGEMENT
640	AUDIOLOGIST
650	GENERAL VASCULARY SURGERY
651	CARDIO-THORACIC
652	INTERVENTION CARDIOLOGY
653	CLINICAL CARDIAC ELECTROPHYSIOLOGY
655	AIDS SKILLED NURSING FACILITY
656	HEAD INJURY/TBI INJURY SNF
657	BEHAVIORAL HEALTH INTERVENTION SKILLED NURSING FACILITY (NEURO)
658	PEDIATRIC SKILLED NURSING FACILITY
659	VENT SKILLED NURSING FACILITY
660	INSTITUTIONAL LTC
661	SOCIAL AND ENVIRONMENTAL SUPPORTS
662	SOCIAL DAY CARE
663	NURSING HOME CARE SHORT TERM REHAB
664	ADULT DAY HEALTH CARE
665	NON-INSTITUTIONAL LTC
666	ASSISTED LIVING PROGRAM
667	HOME DELIVERED MEALS/CONGREGATE MEALS
668	HOME CARE - HOME HEALTH AIDE
669	HOSPICE CARE
670	AMBULANCE
671	OTHER TRANSPORTATION (NON-EMERGENT)
672	PARALEVEL1 PARAPROFESSIONAL SERVICES: LEVEL 1 HMMAKER/HOUSKP
673	PARALEVEL2 PARAPROFESSIONAL SERVICES: LEVEL 2 PERSONAL CARE
674	RESPIRATORY THERAPY
675	CONSUMER DIRECTED PERSONAL CARE: LEVEL 1
676	CONSUMER DIRECTED PERSONAL CARE: LEVEL 2
680	NURSING
711	PRESCRIPTION FOOTWEAR
714	LOW VISION SPECIALIST
715	OPTICIAN/CONTACT LENS PRIVILGE
716	OPTOMETRIST/DIAGNOSTIC PHARMEUTICALS
730	INBORN METABOLIC DISEASE CENTER
738	PORTABLE X-RAY COMPANIES
739	INDEPENDENT PHYSIOLOGICAL LABS
740	REGIONAL PERINATAL TRANSPORTATION PROV
741	TRANSPLANT SURGERY
749	ASA GENERAL OUTPATIENT
750	METHADONE MAINTENANCE (PHYSICIAN)
751	METHADONE MAINTENANCE PREFERRED PROV
754	ASA MEDICALLY MONITORED WITHDRAWAL
760	PHARMACY
762	HOME CARE SERVICES AGENCY LIMITED LICENSE
775	ALL SPECIALITIES
776	GENERAL PRACTICE ONLY - NO SPEC
777	ALL PHYSICIAN
778	PODIATRIST
779	NURSE PRAC
780	CLINICAL PSYCHLG
781	CERT SOCIAL WKRS
782	NURSE MIDWIVES
790	RESPITE
791	S/HMO (ELDERPLAN)
798	LONG TERM HOME HEALTH
799	NO SPECIALTY REQUIRED
800	GENERAL DENTIST
801	ORTHODONTURE
802	ENDODONTIST
803	ORAL PATHOLOGIST
804	PEDODONTIST
805	PROSTHODONTIST
806	PERIODONTIST
807	PUBLIC HEALTH
808	ORAL SURGEON
809	DENTAL ANESTHESIOLOGIST
810	PARENTERAL CONSCIOUS SEDATION
811	MAXILLOFACIAL SURGERY
815	DENTIST - FAMILY
816	ASSERTIVE COMMUNITY TREATMENT
817	ASSISTIVE TECHNOLOGY
818	COMMUNITY INTEGRATION COUNSELING
819	COMMUNITY TRANSITIONAL SERVICE PROVIDER
820	ENVIRONMENTAL MODIFICATIONS SERVICES
821	FREESTANDING BIRTH CENTER
822	INDEPENDENT LIVING SKILLS TRAINING PROVIDER
823	URGENT CARE
824	MOBILE MENTAL HEALTH TREATMENT PROVIDER
825	MOVING ASSISTANCE PROVIDER
826	PALLIATIVE CARE PROVIDER
827	PEER DELIVERED SERVICES
828	PEER MENTORING PROVIDER
829	PERSONALIZED RECOVERY ORIENTED SERVICES
830	POSITIVE BEHAVIORAL INTERVENTIONS AND SUPPORTS
831	SOCIAL DAY CARE TRANSPORTATION
832	STRUCTURED DAY PROGRAM
833	TELEHEALTH
834	HOME AND COMMUNITY SUPPORT SERVICES
835	HCBS PROVIDER TRAVEL
836	HCBS PSYCHOSOCIAL REHAB
837	HCBS PEER SUPPORT
838	OMH OTHER LICENSED PRACTITIONERS
839	HCBS COMMUNITY PSYCHIATRIC SUPPORTS AND TREATMENT
851	OTHER VISION CARE
852	PCCM ENHANCEMENT
853	PCCM QUALITY ENHANCEMENT
854	HABILITATION SUPPORT SERVICES
855	FAMILY SUPPORT AND TRAINING
856	SHORT-TERM CRISIS RESPITE
857	INTENSIVE CRISIS RESPITE
858	PRE-VOCATIONAL SERVICES
859	TRANSITIONAL EMPLOYMENT
860	INTENSIVE SUPPORTIVE EMPLOYMENT
861	ONGOING SUPPORTED EMPLOYMENT
862	EDUCATION SUPPORT SERVICES
899	HOSPITAL INPATIENT
900	HMO CO-PAYMENT
901	EMERGENCY ROOM
902	ENDOCRINE
903	DIABETES
904	OBSTETRICS
905	GYNECOLOGY
906	FAMILY PLANNING
907	ABORTION
908	CHILD HEALTH ASSURANCE PROGRAM (CHAP)
909	NUTRITION
910	ORAL SURGERY - CLINIC SPECIALTY
911	GENERAL DENTISTRY - CLINIC SPECIALTY
912	ORTHODONTICS
913	HEMODIALYSIS
914	GENERAL MEDICINE - CLINIC SPECIALTY
915	ALLERGY
916	ARTHRITIS
917	RHEUMATOLOGY - CLINIC SPECIALTY
918	PODIATRIST CENTER
919	EYE/VISION CENTER
920	PHYSICAL THERAPY - CLINIC SPECIALTY
921	SPEECH THERAPY- CLINIC SPECIALTY
922	METHADONE MAINTENANCE TREATMENT PROGRAM
923	OCCUPATIONAL THERAPY- CLINIC SPECIALTY
924	REHABILITATION MEDICINE- CLINIC SPECIALTY
925	HYPERTENSION - CLINIC SPECIALTY
926	HEMATOLOGY- CLINIC SPECIALTY
927	CARDIOLOGY
928	CARDIOVASCULAR- CLINIC SPECIALTY
929	PULMONARY-CLINIC SPECIALTY
930	GASTROENTEROLOGY - CLINIC SPECIALTY
931	NEUROLOGY- CLINIC SPECIALTY
932	NEUROSURGERY- CLINIC SPECIALTY
933	CANCER DETECTION
934	ONCOLOGY - THERAPY (RADIATION OR CHEMO)
935	EAR, NOSE & THROAT- CLINIC SPECIALTY
936	PEDIATRIC GENERAL MEDICINE- CLINIC SPECIALTY
937	PEDIATRIC ALLERGY- CLINIC SPECIALTY
938	PEDIATRIC NEUROLOGY- CLINIC SPECIALTY
939	PEDIATRIC HEMATOLOGY- CLINIC SPECIALTY
940	PEDIATRIC CARDIAC - CLINIC SPECIALTY
941	PEDIATRIC RENAL- CLINIC SPECIALTY
942	PEDIATRIC PULMONARY- CLINIC SPECIALTY
943	PEDIATRIC ORTHOPEDIC- CLINIC SPECIALTY
944	PEDIATRIC ENDOCRINE - CLINIC SPECIALTY
945	PSYCHIATRY - INDIVIDUAL
946	PSYCHIATRY - GROUP
947	PSYCHIATRY - HALF DAY CARE
948	PSYCHIATRY - FULL DAY CARE
949	ALCOHOLISM TREATMENT PROGRAM
950	ORTHOPEDIC- CLINIC SPECIALTY
951	SURGICAL, MINOR
952	SURGICAL, GENERAL
953	UROLOGY - CLINIC SPECIALTY
954	NEPHROLOGY - CLINIC SPECIALTY
955	GENITO-URINARY- CLINIC SPECIALTY
956	DERMATOLOGY - CLINIC SPECIALTY
957	CONTRACT CARRIER
958	OPTHALMOLOGY - CLINIC SPECIALTY
959	OUTPAT CHEM DEPENDENCY PROG FOR YOUTH
960	PEDIATRIC DERMATOLOGY - CLINIC SPECIALTY
961	PEDIATRIC DIABETES- CLINIC SPECIALTY
962	PEDIATRIC SURGERY - CLINIC SPECIALTY
963	CHILD PSYCHIATRY - CLINIC SPECIALTY
964	PSYCHIATRY-GENERAL- CLINIC SPECIALTY
965	TUBERCULOSIS- CLINIC SPECIALTY
966	INFECTIOUS DISEASES - CLINIC SPECIALTY
967	SPEECH & HEARING- CLINIC SPECIALTY
968	AMPUTEE CENTER
969	HOSP DME/ORTHOTIC/PROSTH APPLNC VENDOR
970	NURSING HOME HOSPITAL DAYCARE (NO CLAIM)
971	MH CLINIC TREATMENT (STATE OPR)
972	MH DAY TREATMENT (STATE OPR)
973	MH CONTINUING TREATMENT (STATE OPR)
974	MENTAL HEALTH CLINIC TREATMENT
975	MENTAL HEALTH DAY TREATMENT
976	MENTAL HEALTH CONTINUING TREATMENT
977	MR/DD CLINIC TREATMENT (STATE OPR)
978	PREFERRED PRIMARY CARE CLINIC
979	MR/DD CLINIC TREATMENT
980	T.B. DIRECTLY OBSERVED THERAPY/CLINIC
981	DIAG AND RESEARCH CLINIC MR (STATE OPR)
982	APNEA CENTER
983	SPECIALTY CLINIC - MENTAL RETARDATION
984	ALCOHOLISM CLINIC TREATMENT (STATE OPR)
985	ALCOHOLISM DAY REHAB (STATE OPR)
986	ALCOHOLISM CLINIC TREATMENT
987	ALCOHOLISM DAY REHABILIATION
988	COMPREHENSIVE ALCOHOLISM CARE
989	MEDICALLY SUPERVISED WITHDRAWAL-OUTPATIENT
990	COMP PHYSICAL EXAM (SCHOOL HEALTH PROJ)
991	ROUTINE VISIT (SCHOOL HEALTH PROJECT)
992	OMH COMPREHENSIVE PSYCHIATRIC EMERGENCY PROG
993	HOSP-BASED/FREESTANDING AMBULAT SURGERY
994	BLOOD PRODUCTS (ORDERED AMBULATORY)
995	GENETIC COUNSELING (ORDERED AMBULATORY)
996	HEARING SERVICES (ORDERED AMBULATORY)
997	OPERATING ROOM (ORDERED AMBULATORY)
998	RADIOLOGY (ORDERED AMBULATORY)
999	OTHER

APPENDIX C - Codes and Values for Tooth Number or Letter

Code	Value
01	PERMANENT THIRD MOLAR-UPPER RIGHT
02	PERMANENT SECOND MOLAR-UPPER RIGHT
03	PERMANENT FIRST MOLAR-UPPER RIGHT
04	PERMANENT SECOND PREMOLAR-UPPER RIGHT
05	PERMANENT FIRST PREMOLAR-UPPER RIGHT
06	PERMANENT CANINE-UPPER RIGHT
07	PERMANENT LATERAL INCISOR-UPPER RIGHT
08	PERMANENT CENTRAL INCISOR-UPPER RIGHT
09	PERMANENT CENTRAL INCISOR-UPPER LEFT
10	PERMANENT LATERAL INCISOR-UPPER LEFT
11	PERMANENT CANINE-UPPER LEFT
12	PERMANENT FIRST PREMOLAR-UPPER LEFT
13	PERMANENT SECOND PREMOLAR-UPPER LEFT
14	PERMANENT FIRST MOLAR-UPPER LEFT
15	PERMANENT SECOND MOLAR-UPPER LEFT
16	PERMANENT THIRD MOLAR-UPPER LEFT
17	PERMANENT THIRD MOLAR-LOWER LEFT
18	PERMANENT SECOND MOLAR-LOWER LEFT
19	PERMANENT FIRST MOLAR-LOWER LEFT
20	PERMANENT SECOND PREMOLAR-LOWER LEFT
21	PERMANENT FIRST PREMOLAR-LOWER LEFT
22	PERMANENT CANINE-LOWER LEFT
23	PERMANENT LATERAL INCISOR-LOWER LEFT
24	PERMANENT CENTRAL INCISOR-LOWER LEFT
25	PERMANENT CENTRAL INCISOR-LOWER RIGHT
26	PERMANENT LATERAL INCISOR-LOWER RIGHT
27	PERMANENT CANINE-LOWER RIGHT
28	PERMANENT FIRST PREMOLAR-LOWER RIGHT
29	PERMANENT SECOND PREMOLAR-LOWER RIGHT
30	PERMANENT FIRST MOLAR-LOWER RIGHT
31	PERMANENT SECOND MOLAR-LOWER RIGHT
32	PERMANENT THIRD MOLAR-LOWER RIGHT
51	SUPERNUMARY 01
52	SUPERNUMARY 02
53	SUPERNUMARY 03
54	SUPERNUMARY 04
55	SUPERNUMARY 05
56	SUPERNUMARY 06
57	SUPERNUMARY 07
58	SUPERNUMARY 08
59	SUPERNUMARY 09
60	SUPERNUMARY 10
61	SUPERNUMARY 11
62	SUPERNUMARY 12
63	SUPERNUMARY 13
64	SUPERNUMARY 14
65	SUPERNUMARY 15
66	SUPERNUMARY 16
67	SUPERNUMARY 17
68	SUPERNUMARY 18
69	SUPERNUMARY 19
70	SUPERNUMARY 20
71	SUPERNUMARY 21
72	SUPERNUMARY 22
73	SUPERNUMARY 23
74	SUPERNUMARY 24
75	SUPERNUMARY 25
76	SUPERNUMARY 26
77	SUPERNUMARY 27
78	SUPERNUMARY 28
79	SUPERNUMARY 29
80	SUPERNUMARY 30
81	SUPERNUMARY 31
82	SUPERNUMARY 32
A	PRIMARY SECOND MOLAR-UPPER RIGHT
AL	LOWER ARCH
AS	TOOTH CODES AS
AU	UPPER ARCH UPPER ARCH
B	PRIMARY FIRST MOLAR-UPPER RIGHT
BS	TOOTH CODES BS
C	PRIMARY CANINE-UPPER RIGHT
CS	TOOTH CODES CS
D	PRIMARY LATERAL INCISOR-UPPER RIGHT
DE	ALL DECIDUOUS
DS	TOOTH CODES DS
E	PRIMARY CENTRAL INCISOR-UPPER RIGHT
ES	TOOTH CODES ES
F	PRIMARY CENTRAL INCISOR-UPPER LRFT
FS	TOOTH CODES FS
G	PRIMARY LATERAL INCISOR-UPPER LEFT
GS	TOOTH CODES GS
H	PRIMARY CANINE-UPPER LEFT
HS	TOOTH CODES HS
I	PRIMARY FIRST MOLAR-UPPER LEFT
IS	TOOTH CODES IS
J	PRIMARY SECOND MOLAR-UPPER LEFT
JS	TOOTH CODES JS
K	PRIMARY SECOND MOLAR-LOWER LEFT
KS	TOOTH CODES KS
L	PRIMARY FIRST MOLAR-LOWER LEFT
LL	LOWER LEFT QUADRANT
LR	LOWER RIGHT QUADRANT
LS	TOOTH CODES LS
M	PRIMARY CANINE-LOWER LEFT
MS	TOOTH CODES MS
N	PRIMARY LATERAL INCISOR-LOWER LEFT
NS	TOOTH CODES NS
O	PRIMARY CENTRAL INCISOR-LOWER LEFT
OS	TOOTH CODES OS
P	PRIMARY CENTRAL INCISOR-LOWER LEFT
PE	ALL PERMANENT
PS	TOOTH CODES PS
Q	PRIMARY LATERAL INCISOR-LOWER LEFT
QS	TOOTH CODES QS
R	PRIMARY CANINE-LOWER RIGHT
RS	TOOTH CODES RS
S	PRIMARY FIRST MOLAR-LOWER RIGHT
SS	TOOTH CODES SS
T	PRIMARY SECOND MOLAR-LOWER RIGHT
TS	TOOTH CODES TS
UL	UPPER LEFT QUADRANT
UR	UPPER RIGHT QUADRANT

APPENDIX D - MEDS III SUPPLEMENTAL MANUAL ON APPLICABLE EDITS

Medicaid Encounter Data System III (MEDS III)
Supplemental Manual On Applicable Edits

MEDS III Categories of Service, Applicable Encounter Type Indicators and Form Type/EDI
Tier One Edits
Edit Logic
Edit Severity Matrix
Response Report Reconciliation

Prepared by:

Provider Network - MEDS Compliance Unit
Division of Health Plan Contracting and Oversight
New York State Department of Health
Phone: (518) 474-5050
Fax: (518) 486-7899
Email: omcmeds@health.ny.gov

February 2014

I. MEDS III Categories of Service, Applicable Encounter Type Indicators (ETI) and Form Type/EDI

*COS* *Code*	*COS Description*	*ETI*	*ETI Description*	*Form Type/EDI*
01	Physician Services	P	Professional	CMS-1500 / 837P
03	Podiatry	P	Professional	CMS-1500 / 837P
04	Psychology	P	Professional	CMS-1500 / 837P
05	Eye Care / Vision	P	Professional	CMS-1500 / 837P
06	Rehabilitation Therapy	I	Institutional	UB-92 / 837I
07	Nursing	P	Professional	CMS-1500 / 837P
11	Inpatient	I	Institutional	UB-92 / 837I
12	Institutional LTC	I	Institutional	UB-92 / 837I
13	Dental	T	Dental	ADA / 837D
14	Pharmacy	D	Pharmacy/DME	NCPDP
15	Home Health Care/Non- Institutional Long Term Care	I	Institutional	UB-92 / 837I
16	Laboratories	P	Professional	CMS-1500 / 837P
19	Transportation	P	Professional	CMS-1500 / 837P
22	DME and Hearing Aids	P	Professional	CMS-1500 / 837P
28	Intermediate Care Facilities	I	Institutional	UB-92 / 837I
41	NPs/Midwives	P	Professional	CMS-1500 / 837P
73	Hospice	I	Institutional	UB-92 / 837I
75	Clinical Social Worker	P	Professional	CMS-1500 / 837P
85	Freestanding Clinic	I	Institutional	UB-92 / 837I
87	Hospital OP/ER Room	I	Institutional	UB-92 / 837I

Additional Copies:
Additional copies of this manual may be obtained via download from the MEDS Home Page on the HCS.

CSC Contact Information:
CSC Provider Relations Staff at: MEDSSupport@csc.com
eMedNY Managed Care Manual

II. Tier One Edits

After submitting a file of encounter data to CSC via the eMedNY eXchange or FTP options, plans will receive notification that the file was received and processed. When an encounter file does not pass through the front end processing it is due to failing a 'Tier One' edit. When this occurs the entire file is rejected for one of the following 'Tier One' edits.

Tier One Error	Message Returned
Record is not 3000 bytes	'Incomplete " ", Header Record' - will give the size and record that is not 3000 bytes
Required records missing (H1, D1, and a T1)	Required " " record missing' - will include the record type missing
Required records not in sequence (H1, D1, and a T1)	'Record " " is of unknown type or invalid sequence' - will include the record type in error
Test/Prod indicator is incorrect - must be PROD	'Specified mode " " does not match' 'Test/Prod Indicator'
The carriage return (CR) is too short/long or misaligned	'Misaligned ASCII " ", "CR" in record " " column " " '
The carriage return (CR) is too short/long or misaligned	'Unexpected ASCII " ", "CR" in record " " column " " '
Newline/linefeed (NL) in record	'Unexpected ASCII " ", "NL" in record " " column " " '
Non-printable characters in file	'Non-ASCII character'
End of file not in the correct place	'Premature end-of-file'
No records are found	'FILE CONTAINS NO CLAIM RECORDS'
H1 record is found when unexpected	'UNEXPECTED H1 RECORD RECEIVED' 'AT RECORD #:'
H1 record is not found when expected (after user record)	'EXPECTED H1 CONTROL RECORD NOT RECEIVED' 'AT RECORD #:'
D1 record is found, and it is expected, and the encounter type is other than I, D, T, or P	'INVALID D1 RECORD RECEIVED'
	'AT RECORD #:'
D1 record is found when unexpected	'UNEXPECTED D1 RECORD RECEIVED' 'AT RECORD #:'
D1 record is not found when expected	'EXPECTED D1 CONTROL RECORD NOT RECEIVED' 'AT RECORD #:'
T1 record is found when unexpected	'UNEXPECTED T1 RECORD RECEIVED' 'AT RECORD #:'
Record is other than H1, D1, or T1	'RECEIVED RECORD NOT H1/D1/T1''AT RECORD #:'
Provider Check Digit	The Provider Identification is Invalid
Provider Zip Code	The Provider Service Location is Invalid/Non- Numeric

If the encounter transmission does not fail for any of the above listed 'Tier One' edits, plans will receive a message that the file was passed on for further processing. What this means is that the encounter file will now be processed in the CSC Claims System and a MEDS III Response File will be generated and sent back to the plan.

III. Edit Logic

**If the In-process pharmacy encounter Prescribing Physician Provider Number is an out of network NPI (Prescribing Provider Number is blank), then the Prescribing Physician Provider Number is ignored during History comparisons otherwise, Prescribing Physician Provider Number is matched between In- process and History pharmacy encounters.

Edit Number	Edit Description	Edit Logic
00018	DATE OF SERVICE/ FILL DATE INVALID	If Service Date is not a valid date (CCYYMMDD), the edit is failed.
00020	SERVICE/ FILL DATE LATER THAN RECEIPT DATE	If the Service Start Date or Service End Date is greater than the CSC processing date, the edit is failed.
00021	PATIENT STATUS CODE INVALID	If Patient Status or Disposition Code is not equal to: 01-09, 20, 30, 40-43, 50-51, 61-66, 70 the edit is failed.
00036	M/I USUAL AND CUSTOMARY	The Charged Amount is Missing or Invalid
00039	PRIMARY DIAGNOSIS CODE FAILED	If the Principal/Primary Diagnosis Code for institutional encounters is blank, the edit is failed.
00062	PROVIDER ID NUMBER INVALID	For Dental and Professional Encounters - If the Provider Identification Number is spaces, the edit is failed.
00070	PROCEDURE CODE INVALID	For Dental and Professional Encounters - For each service line reported, if the Procedure Code is blank, the edit is failed.
00070	PROCEDURE CODE INVALID	For Institutional-Outpatient Encounters - For each service line reported, if the HCPCS Code and Revenue Code are blank, the edit is failed.
00071	PLACE OF SERVICE CODE INVALID	If the Place of Service/Place of Treatment Code is not equal to: 03-08, 11-15, 20-26, 31-34, 41-42,49-57, 60- 62, 65, 71-72, 81, 99 the edit is failed.
00074	RECIPIENT ID NUMBER INVALID	If the CIN is not a valid CIN (CCNNNNNC), the edit is failed. (C = Character N = Number)
00076	M/I PROVIDER ID	Provider ID No. is non-numeric, or the eighth position of the provider identification number is not a valid check digit.
00078	REFERRING PROVIDER ID NUMBER INVALID	If the Provider Id does not match a Provider Id on the eMedNY Provider Reference File, the edit is failed.
00094	NUMBER OF UNITS NOT GREATER THAN ZERO	If the Quantity or Units Submitted is equal to zero, the edit is failed.
00103	ADJ/ VOID FIELDS INCOMPLETE	If the Transaction Status Code equals 7 or 8 and the Previous Transaction Control Number equals spaces or zeros, the edit is failed.
00132	PROVIDER ID NOF	Provider ID No. not on file
00140	RECIPIENT ID NOT ON FILE	If the CIN is not on the WMS (Client Demographic Table), the edit is failed.
00146	PRIMARY DIAGNOSIS NOT ON FILE	If Diagnosis Code is not on the eMedNY Reference Diagnosis Code Table, the edit is failed (i.e., must be a valid diagnosis code as reported in the coding manual.)
00162	CLIENT NOT ELIG ON SVC DT	Client not eligible on service date.
00170	PROCEDURE CODE NOT ON FILE	If the Procedure Code is not on the eMedNY Reference Procedure Code Table, the edit is failed (i.e., must be a valid CPT/HCPCS code as reported in the coding manual.).
00175	PROVIDER ID NOT ON FILE	If the Provider Id does not match a Provider Id on the eMedNY Provider Reference File, the edit is failed.
00180	UNITS GREATER THAN MAXIMUM	If the Procedure Units is greater than allowed amount on the eMedNY Procedure Reference File, the edit is failed.
00204	PROC NOT AVAILABLE ON DOS	The Procedure Code that was submitted is not valid for the Date of Service indicated.
00240	OVER TWO-YEAR-OLD CLAIM HELD FOR FUTURE ADJUDICATION	Over two-year-old claim held for future adjudication.
00262	MEDICARE PAID, NO MEDICARE ON FILE	If a Medicare paid amount is reported and the recipient is not shown to have Medicare insurance on file with eMedNY, the edit is failed.
00263	SERVICING PROVIDER LICENSE NUM	Servicing provider ID or license No. and profession code are required.
00400	ENCOUNTER CONTROL NUMBER MISSING	If the Encounter Control Number is blank, the edit is failed.
00401	BENEFICIARY ID MISSING	Beneficiary ID missing.
00402	DX CODE AND PROC CODE MISSING	Missing/incomplete/invalid diagnosis or condition.
00404	PROVIDER SPECIALTY MISSING	If the Provider Specialty Code is blank or equal to zero, the edit is failed.
00405	PRINCIPAL PROCEDURE CODE MISSING	If Procedure Code is blank or equal to zero, the edit is failed.
00406	DIAGNOSIS CODE MISSING	For Practitioner Encounters - If the first Diagnosis Code is blank, the edit is failed.
00406	DIAGNOSIS CODE MISSING	For Institutional Encounters - If the Primary Diagnosis Code is blank, the edit is failed.
00408	CATEGORY OF SERVICE (COS) MISSING	If the Category of Service is not equal to: 01, 03-07, 11-16, 19, 22, 28, 41, 73, 75, 85, 87 the edit is failed.
00409	INPATIENT MMIS PROVIDER ID IS NOT A HOSPITAL	If the Provider Type Code is not equal to: 012, 016, 028, 038 for referring Provider Id, the edit is failed. (The Provider Type Code is assigned by eMedNY according to the MMIS ID.)
00410	DRG CODE MISSING	For inpatient encounters, if the APR-DRG Code is blank, the edit is failed
00411	DRG CODE AND DX CODE MISSING	Missing/incomplete/invalid diagnosis or condition.
00412	DIAGNOSIS CODE NOT ON FILE	If the Diagnosis Code is not on the eMedNY Diagnosis Code Reference Table, the edit is failed.
00413	PROVIDER SPECIALTY NOT ON FILE	If the Provider Specialty Code is not on the eMedNY Provider Specialty Reference Table, the edit is failed.
00414	SVC/ADMIT DATE PRIOR TO 1/1/96	Service/Admittance date prior to 1/1/1996.
00415	COS NOT ALLWD TO SUB BLOCK ENC	Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.
00416	LICENSE NUMBER IS MISSING	If the Provider License Number is blank or equal to all zeros, the edit is failed.
00422	PRENATAL PROC CODE NOT ALLOW	Prenatal procedure code not allowed.
00423	MMIS PLAN ID MISSING	If the MMIS Plan Id is blank, the edit is failed.
00424	MMIS PLAN ID NOT ON FILE	If the MMIS Plan Id does not match a provider Id on the eMedNY Provider Reference File, the edit is failed.
00425	MMIS PLAN ID NOT HMO PROVIDER	If the Provider Type Code associated with the MMIS Plan Id is not 022, the edit is failed. (The Provider Type Code is assigned by eMedNY according to the MMIS ID.)
00431	NEONATE BIRTH WEIGHT CODE INVALID	For Inpatient Encounters- If the Recipient (CIN) Date of Birth and the Admit Date on the claim are equal and the Neonate Value Code is not equal to '54', the edit is failed.
00432	ATTEND PROV ID NOT ON FILE	If the Attending Provider Id does not match a Provider ID on the eMedNY Provider Reference File, the edit is failed.
00433	OPER PROV ID NOT ON FILE	If the Surgeon Provider Id does not match a Provider Id on the eMedNY Provider Reference File, the edit is failed.
00434	BIRTH WEIGHT NOT REASONABLE	If the Neonate Value Code equals '54', the Birth Weight must be between '0000099' and '0008000', else the edit is failed.
00435	SOURCE OF ADMISSION CODE INVALID	For Inpatient Encounters- If Source of Admission Code is not a valid value: '1-9', 'A-C', the edit is failed. For all other institutional encounters, if the Source of Admission Code does not equal spaces, the edit is failed.
00436	TYPE OF BILL DIGIT 3 INVALID	If the Type of Bill Code is greater than spaces and the third digit of the Type of Bill Code is not a valid value; '0-9', 'A' the edit is failed.
00437	CLAIM/ENCOUNTER IND INVALID	If the Claim/Encounter Indicator does not equal; 'A', 'C', or 'E', the edit is failed.
00525	PRESCRIBING LICENSE NUMBER MISSING	If the Prescribing License Number is blank or equal to zero, the edit is failed.
00526	M/I PRESCRIPTION NUMBER	Prescription Number Missing or Invalid
00528	MISSING OR INVALID QUANTITY DISPENSED	If the Quantity Dispensed is blank or equal to zero, the edit is failed.
00530	NEW/REFILL CODE INVALID	Missing or Invalid New or Refill Number
00531	AUTHORIZED REFILL INVALID	If the number of authorized refill is not valid or numeric.
00534	DATE ORDERED INVALID	If the Date Ordered is not a valid date (CCYYMMDD), the edit is failed.
00540	NUMBER OF DAYS SUPPLY INVALID	If the Days Supply is blank or equal to zero, the edit is failed.
00544	NDC CODE NON-NUMERIC	If the NDC Code is non-numeric or blank, the edit is failed.
00548	FILL DATE PRECEDES ORDER DATE	If the Fill Date is less than the Ordered Date, the edit is failed.
00561	DRUG CODE NOT ON FILE	If the NDC Code is not on the eMedNY Reference Drug Table, the edit is failed.
00600	ADMISSION DATE INVALID	If the Admission Date is not a valid date (CCYYMMDD), the edit is failed.
00603	ADMISSION TYPE CODE INVALID	If the Admission Type Code is not: 1-5, the edit is failed.
00604	ADMITTING DIAGNOSIS CODE MISSING	If Admit Diagnosis Code is blank, the edit is failed.
00613	PRINCIPAL PROCEDURE DATE INVALID	Principal Procedure Date for Institutional Claim is Invalid
00625	DISCHARGE DATE ILLOGICAL	If the Discharge Date is not a valid date (CCYYMMDD), the edit is failed.
00627	DISCHARGE STATUS INVALID	Discharge status invalid.
00652	DISCHARGE DATE PRIOR TO ADMISSION DATE	If Discharge Date is valid, but less than Admission Date, the edit is failed.
00653	STATEMENT FROM DATE PRIOR TO ADMISSION DATE	Statement from date prior to admission date.
00655	DISCHARGE DATE DIFFERENT THAN STATEMENT THRU DATE	If the Discharge Date is different than the Statement Thru Date, the edit is failed.
00664	ATTENDING PHYSICIAN LICENSE NUMBER MISSING	If Attending Physician License Number is blank or equal to zero, the edit is failed.
00689	RECIPIENT NOT ENROLLED IN PLAN ON DATE OF SERVICE	If recipient is not enrolled on Managed Care Master File in your Plan on date of service, the edit is failed.
00693	RECIPIENT NEVER ENROLLED IN MANAGED CARE	If the Recipient (CIN) is not on the Managed Care Master File, the edit is failed.
00694	RECIPIENT NOT ENROLLED IN MANAGED CARE ON DATE OF SERVICE	If the Recipient (CIN) is not on the Managed Care Master file on the date of service, the edit is failed.
00696	RECIPIENT ENROLLED IN ANOTHER MANAGED CARE PLAN ON DATE OF SERVICE	If the Recipient (CIN) is on the Managed Care Master file on the date of service, but enrolled in another MC Plan, the edit is failed.
00705	DUPLICATE CLAIM IN HISTORY	Encounters (Professional - Non-dental, Non-DME) COS 01, 03, 04, 05, 06, 07, 16, 19, 21, 41, 75 This edit will fail when the following fields are equal between the Claim and History Records: Claim Type Code Client Identification Number (CIN) Billing Provider Number Rendering Provider Number Procedure Code Service Dates Diagnosis Code (Primary) Provider Specialty Code
		Encounters (Dental) - COS 13 This edit will fail when the following fields are equal between the Claim and History Records: Claim Type Code Client Identification Number (CIN) Procedure Code Service Dates Billing Provider Number Rendering Provider Number Oral Cavity Designation Code Tooth Code Tooth Surface Code
		Encounters (DME) - COS 22 (DME and Hearing Aids) This edit will fail when the following fields are equal between the Claim and History Records: Claim Type Code Client Identification Number (CIN) Billing Provider Number Rendering Provider Number Procedure Code Service Dates
		Encounters (Inpatient) - COS 11 This edit will fail when the following fields are equal between the Claim and History Records: Claim Type Code Client Identification Number (CIN) Billing Provider Number Referring Provider Number Admission Date
		Encounters (Nursing Home, Child Care, ICF/DD, and Managed Care) - COS 12, 28, 73 This edit will fail when the following fields are equal between the Claim and History Records: Claim Type Code Client Identification Number (CIN) Billing Provider Number Referring Provider Number Procedure Code Specialty Code Diagnosis Code (Principal) Service Begin Date
		Encounters (Clinic and Home Health) - COS 15, 80, 85, 87 This edit will fail when the following fields are equal between the Claim and History Records: Claim Type Code Client Identification Number (CIN) Billing Provider Number Referring Provider Number Service Begin Date Service End Date Procedure Code Revenue Code
		Encounters (Pharmacy) - COS 14 This edit will fail when the following fields are equal between the Claim and History Records: Claim Type Code Client Identification Number (CIN) Billing Provider Number **Prescribing Physician Provider Number National Drug Code (NDC) Service Date (1022)
00710	PROCEDURE CODE EXCEEDS SERVICE LIMITS	If the procedure code reported has exceeded the established service limit, the edit is failed.
00725	HISTORY RECORD NOT FOUND ADJUSTMENT/VOID	If the Previous Transaction Control Number (TCN) is not valid, the edit is failed.
00736	DIAG CD BLANK - FULL ICD-9- CM	Diagnosis code blank, full ICD-9 CM code required.
00737	ICD-9-CM DIAG CODE ON PHYS CLM	The Diagnosis Code entered on the claim is not a valid Diagnosis code. Medicaid requires the 4th and 5th digit sub-classification when available.
00897	PRESCRIBER ID NOT ON FILE	If the Prescriber Id does not match a Provider Id on the eMedNY Provider Reference File, the edit is failed.
00901	CLAIM TYPE UNKNOWN	If the Claim/Encounter does not equal a valid claim type (i.e., correct ETI/MEDS III COS combination), the edit is failed.
00901	CLAIM TYPE UNKNOWN	The Encounter Type Indicator (ETI) must be equal to "I", "T", "D" or "P", and in the correct MEDS III Category of Service. Correct submission standards are detailed in the MEDS III Data Element Dictionary in Section II. Encounter Type Assignment by Category of Service.
00903	PROVIDER ID OR LICENSE NUMBER MISSING	For Institutional or Pharmacy Encounters- If the Provider Id and Provider License Number are blank, the edit is failed.
00927	MODIFIER INVALID FOR PROCEDURE CODE	If procedure modifier not allowable for procedure code, the edit is failed
00931	REQUIRED TOOTH FOR PROCEDURE INVALID	If the Procedure Code indicates a tooth number is required and Tooth Number or Letter not equal to a value in Appendix C of the MEDS III Data Element Dictionary, the edit is failed.
01004	THRU SERVICE DATE INVALID	If the Thru Service Date is not a valid date (CCYYMMDD), the edit is failed.
01006	THRU SERVICE PRIOR TO FROM SERVICE DATE	If the Thru Service Date is prior to From Service Date, the edit is failed.
01042	UNITS NOT CONSISTENT W/ SVC DT	Submitted units not consistent with dates of service.
01044	SVC DTS CANNOT SPAN MONTHS	Dates of service cannot span across months.
01046	SUBMTD UNITS NOT EVENLY DIVISB	Submitted units not evenly divisible.
01073	PROC CD FOR BLOCK BILL INVALID	Procedure code for block bill invalid.
01292	DATE OF SERVICE TWO YEARS PRIOR TO DATE RECEIVED	If the Date of Service/Begin Date is greater than 734 days (2 years) from the CSC processing date, the edit is failed.
01608	ERROR OVERFLOW	If the encounter record has more than 23 edits (combination of soft or hard), the edit is failed. This will fail the entire encounter.
01610	MISSING OR INVALID ALTERNATE PRODUCT CODE	If the Product Code is entered and the first 11 digits are not alphanumeric, the edit is failed.
01705	REVENUE CODE NOT ON FILE	If the Revenue Code is not found on the eMedNY Revenue Code Table, the edit is failed (i.e., must be a valid Revenue Code as reported in the coding manual.)
01714	REVENUE CODE MISSING	Missing/incomplete/invalid diagnosis or condition.
01718	TYPE OF BILL INVALID	If the Type of Bill is not equal to: 11-18, 21-28, 32-34, 41-48, 51-58, 61-68, 71-76, 79, 81-86, 89 the edit is failed.
01724	LINE DOS OUTSIDE FROM/THROUGH DATES	If the Line Service Begin Date is less than the Header Service Begin Date, the edit is failed.
		If the Line Service Begin Date is greater than the Header Service End Date, the edit is failed.
		If the Line Service End Date is greater than the Header Service End Date, the edit is failed.
		If the Line Service End Date is less than the Header Service Begin Date, the edit is failed.
01737	VALUE AMOUNT INVALID FOR SUBMITTED VALUE CODE	If the Neonate Value Amount is blank or equal to zero and a Neonate Value Code is present, the edit is failed.
02002	PRESCRIPTION SERIAL NUMBER MISSING	If Prescription Serial Number for Pharmacy Claim is blank
02022	MISSING REFERRING NPI	If Referring NPI is blank, and the Referring Group MMIS ID or License Number field is not equal to spaces, this edit is failed.
02023	MISSING ATTENDING NPI	If Attending NPI is blank, and the Attending MMIS ID or License Number field is not equal to spaces, this edit is failed.
02024	MISSING OPERATING NPI	If Operating NPI is blank, and the Operating MMIS ID or License Number field is not equal to spaces, this edit is failed.
02025	MISSING RENDERING NPI	If Rendering NPI is blank, and the Rendering MMIS ID or License Number field is not equal to spaces, this edit is failed.
02029	MISSING PRESCRIBING NPI	If Prescribing NPI is blank, and the Prescribing MMIS ID or License Number field is not equal to spaces this edit is failed.
02030	INVALID BILLING NPI	Billing national provider identifier is invalid.
02031	INVALID GROUP NPI	This edit is failed when the NPI of a group provider was invalid according to a "check digit" routine.
02032	INVALID REFERRING NPI	If Referring NPI check digit is invalid, this edit is failed.
02033	INVALID ATTENDING NPI	If Attending NPI check digit is invalid, this edit is failed.
02034	INVALID OPERATING NPI	If Operating NPI check digit is invalid, this edit is failed.
02035	INVALID RENDERING NPI	If Rendering NPI check digit is invalid, this edit is failed.
02036	INVALID SUPERVISING NPI	Invalid supervising NPI.
02037	INVALID OTHER NPI	Invalid other NPI.
02038	INVALID ASSISTANT SURGEON NPI	Invalid assistant surgeon NPI.
02039	INVALID PRESCRIBING NPI	If Prescribing NPI check digit is invalid, this edit is failed.
02066	DRUG CODE MISSING	If the drug code is missing or invalid, this edit is failed.
02070	INVALID ORDERING NPI	Invali ordering NPI.
02079	PRESENT ON ADMISSION CODE MISSING OR INVALID	If the either the Principal or Other Diagnoses is greater than spaces and POA Code equals spaces or invalid, the edit is failed.
02116	MISSING PRESCRIPTION ORIGIN CODE	If the Prescription Origin Code is Not Reported
02117	INVALID PRESCRIPTION ORIGIN CODE	If the reported Prescription Origin Code is not a valid value
02171	NDC OCCURS MORE THAN ONCE	If the NDC Occurs More Than Once in a Compound for Pharmacy Claim, the edit is failed.
02174	ICD VERSION CODE NOT VALID	If the reported ICD Version Code is a Not Valid Value, the edit is failed.
02193	CONTROLLED SUBSTANCE LIMIT EXCEEDED	If the Prescription Origin Code is 2 AND Drug Enforcement Agency (DEA) code on the Reference Drug Table is 2, 3 or 5 OR DEA code is 4 and the Therapeutic Class Code (State Formulary) is in Claims System list 1963 AND Drugs Day Supply Count (submitted) is greater than the maximum allowed quantity limit specified in Claims System Parameter 0038
02210	IDC-9 PROCEDURE CODE DATE AFTER SERVICE DATE	If the reported ICD-9 Procedure Date is After The Service Date, the edit is failed.
02211	ICD-9 PROCEDURE WITHOUT ICD-9 DATE	If the Reported Procedure is Sent Without a Service Date, the edit is failed.

IV. Edit Severity Matrix

This section details current edit severity programming within the CSC Encounter/Claim System Processing. The edits correspond to the logic indicated in Section III, and not all edits apply to all Encounter Type/Category of Service/Claim type record submissions.

Up to 24 edits may be assigned to an encounter record before the entire record is rejected.

Each edit is assigned a severity level as follows:

Code Edit Severity File Processing Implication

F Fatal Record
Error There is a fatal error in the encounter record. The claim system has stopped reading the encounter record, and the entire record
is rejected.
H Hard Edit (Deny) There is a vital error in the encounter record.

If the error is at the header level, the entire record will reject and should be resubmitted as an original encounter.

If the error is on the service line, the affected service line will reject (with an edit code and service line indicated in the response report. Please refer to Section V of this manual for more detail).

Subsequent service lines, if correctly submitted, will be accepted for further processing.
S Soft Edit (Accept) Edit indicates that the data provided is inaccurate. However, the record is accepted for further processing. The inaccurate information should be corrected and resubmitted as an
adjustment.
N Non-Edit Edit does not apply to the ETI/Clinic Type/MEDS COS combination.

III. Edit Severity Matrix

ETI: I=Institutional D T P=Professional
Claim Type: Clinic IP Nursing Home HH ICF Rx Dental Practitioner Eye Lab Trans DME
Edit Code COS: 06 85 87 11 12 73 15 28 14 13 01 03 04 07 41 75 05 16 19 22

00018 DATE OF SERVICE/FILL DATE INVALID F F F F F F F F F F F F
00020 SERVICE/FILL DATE LATER THAN RECEIPT DATE H H H H H H H H H H H H
00021 PATIENT STATUS CODE INVALID N H H N H N N N N N N N
00036 M/I USUAL AND CUSTOMARY S S S S S S S S S S S S
00039 PRIMARY DIAGNOSIS CODE BLANK H H S S S N N N N N N N
00062 PROVIDER ID NUMBER INVALID N N N N N N N N N N H N
00070 PROCEDURE CODE INVALID H N H H H N H H H H H H
00071 PLACE OF SERVICE CODE INVALID N N N N N N H H H H S H
00074 RECIPIENT ID NUMBER INVALID F F F F F F F F F F F F
00076 M/I PROVIDER ID N N N N N N N N N N N N
00078 REFERRING PROVIDER ID NUMBER INVALID H H H H H N N N N N N N
00094 NUMBER OF UNITS NOT GREATER THAN ZERO H N H H H N H H H H H H
00103 ADJUSTMENT / VOID FIELDS INCOMPLETE H H H H H H H H H H H H
00132 PROVIDER ID NOF N N N N N N N N N N N N
00140 RECIPIENT ID NOT ON FILE H H H H H H H H H H H H
00146 PRIMARY DIAGNOSIS NOT ON FILE H H S S S N N N N N N N
00162 CLIENT NOT ELIG ON SVC DT N N N N N N N N N N N N
00170 PROCEDURE CODE NOT ON FILE H H H H H N H H H H H H
00175 PROVIDER ID NOT ON FILE N N N N N N H H H H H H
00180 UNITS GREATER THAN MAXIMUM S N N S N N S S S N N S
00204 PROC NOT AVAILABLE ON DOS N N N N N N N N N N N N
00240 OVER TWO-YEAR-OLD CLAIM HELD FOR FUTURE ADJUDICATION N N N N N N N N N N N N
00262 MEDICARE PAID, NO MEDICARE ON FILE S S S S S S S S S S S S
00263 SERVICING PROVIDER LICENSE NUM N N N N N N N N N N N N
00400 ENCOUNTER CONTROL NUMBER MISSING S S S S S S S S S S S S
00401 BENEFICIARY ID MISSING N N N N N N N N N N N N
00402 DX CODE AND PROC CODE MISSING N N N N N N N N N N N N
00404 PROVIDER SPECIALTY MISSING H N H H H N H H H H H H
00405 PRINCIPAL PROCEDURE CODE MISSING N S N N N N N N N N N N
00406 DIAGNOSIS CODE MISSING H H H H H N N H H S S S
00408 CATEGORY OF SERVICE (COS) MISSING F F F F F F F F F F F F
00409 INPATIENT MMIS PROVIDER ID IS NOT A HOSPITAL N H N N N N N N N N N N
00410 DRG CODE MISSING N H N N N N N N N N N N
00411 DRG CODE AND DX CODE MISSING N N N N N N N N N N N N
00412 DIAGNOSIS CODE NOT ON FILE H H H H H N N H H S S S
00413 PROVIDER SPECIALTY NOT ON FILE H N H H H N H H H H H H
00414 SVC/ADMIT DATE PRIOR TO 1/1/96 N N N N N N N N N N N N
00415 COS NOT ALLWD TO SUB BLOCK ENC N N N N N N N N N N N N
00416 LICENSE NUMBER IS MISSING N N N N N N N N N N N N
00422 PRENATAL PROC CODE NOT ALLOW N N N N N N N N N N N N
00423 MMIS PLAN ID MISSING F F F F F F F F F F F F
00424 MMIS PLAN ID NOT ON FILE F F F F F F F F F F F F
00425 MMIS PLAN ID NOT HMO PROVIDER H H H H H H H H H H H H
00431 NEONATE BIRTH WEIGHT CODE INVALID N H N N N N N N N N N N
00432 ATTEND PROV ID NOT ON FILE H H H H H N N N N N N N
00433 OPER PROV ID NOT ON FILE N H N N N N N N N N N N
00434 BIRTH WEIGHT NOT REASONABLE N H N N N N N N N N N N
00435 SOURCE OF ADMISSION CD INVALID N H N N N N N N N N N N
00436 TYPE OF BILL DIGIT 3 INVALID H H H H H N N N N N N N
00437 CLAIM/ENCOUNTER IND INVALID H H H H H H H H H H H H
00525 PRESCRIBING LIC NO. MISSING N N N N N N N N N N N N
00526 M/I PRESCRIPTION # N N N N N S N N N N N N
00528 M/I QUANTITY DISPENSED S N N N N H N S N N N N
00530 NEW/REFILL CODE INVALID N N N N N S N N N N N N
00531 AUTHORIZED REFILL INVALID N N N N N S N N N N N N
00534 DATE ORDERED INVALID N N N N N H N N N N N N
00540 NO. OF DAYS SUPPLY INVALID N N N N N H N N N N N N
00544 NDC CODE NON- NUMERIC N N N N N H N N N N N N
00548 FILL DATE PRIOR ORDER DATE N N N N N H N N N N N N
00561 DRUG CODE NOT ON FILE H N N N N H N H N N N S
00600 ADMISSION DATE INVALID N H H N H N N N N N N N
00603 ADMIT TYPE CODE INVALID N H S N S N N N N N N N
00604 ADMITTING DIAGNOSIS CODE MISSING N S N N N N N N N N N N
00613 PRINCIPAL PROC DATE INVALID N S N N N N N N N N N N
00625 DISCHARGE DATE ILLOGICAL N H H N H N N N N N N N
00627 DISCHARGE STATUS INVALID N N N N N N N N N N N N
00652 DISCHARGE DATE PRIOR TO ADMIT DATE N H H N H N N N N N N N
00653 STATEMENT FROM DATE PRIOR TO A N N N N N N N N N N N N
00655 D/C DATE DIFF THAN THRU DATE N H N N N N N N N N N N
00664 ATTENDING PHYSICIAN LIC NO. MISSING N N N N S N N N N N N N
00689 RECIPIENT NOT ENROLLED IN PLAN ON DATE OF SERVICE H H H H H H H H H H H H
00693 RECIPIENT NEVER ENROLLED IN MNGD CARE H H H H H H H H H H H H
00694 RECIPIENT NOT ENROLLED IN MNGD CARE ON DATE OF SRVCE H H H H H H H H H H H H
00696 RECIPIENT ENROLLED IN ANOTHER MNGD CARE PLAN ON DATE OF SRVCE H H H H H H H S S S S S
00705 DUPLICATE CLAIM IN HISTORY H H H H H H H H H H H H
00710 PROCEDURE EXCEEDS SERVICE LIMITS S N N N N S S S S S S S
00725 HISTRY RECORD NOT FOUND ADJUSTMENT/VOID H H H H H H H H H H H H
00736 DIAG CD BLANK - FULL ICD-9-CM N N N N N N N N N N N N
00737 ICD-9-CM DIAG CODE ON PHYS CLM N N N N N N N N N N N N
00897 PRESCRIBER ID NOT ON FILE N N N N N S N N N N N N
00901 CLAIM TYPE UNKNOWN F F F F F F F F F F F F
00903 PROVIDER ID NUMBER MISSING H H H H H H N N N N N N
00927 MODIFIER INVALID FOR PROCEDURE CODE S N N S N N S S S S S S
00931 REQUIRED TOOTH FOR PROCEDURE INVALID N N N N N N S N N N N N
01004 THRU SERVICE DATE INVALID H N H H H N H H H H H H
01006 THRU SERVICE PRIOR TO FROM SERVICE DATE H N H H H N H H H H H H
01042 UNITS NOT CONSISTENT W/ SVC DT N N N N N N N N N N N N
01044 SVC DTS CANNOT SPAN MONTHS N N N N N N N N N N N N
01046 SUBMTD UNITS NOT EVENLY DIVISB N N N N N N N N N N N N
01073 PROC CD FOR BLOCK BILL INVALID N N N N N N N N N N N N
01292 DATE OF SERVICE TWO YEARS PRIOR TO DATE RECEIVED H H H H H N H H H H H H
01608 ERROR OVERFLOW H H H H H H H H H H H H
01610 MISSING OR INVALID ALTERNATE PRODUCT CODE N N N N N S N N N N N N
01705 REVENUE CODE NOT ON FILE H H H H H N N N N N N N
01714 REVENUE CODE MISSING N N N N N N N N N N N N
01718 TYPE OF BILL IS INVALID H H H H H N N N N N N N
01724 LINE DOS OUTSIDE FROM/THROUGH DATES H N N H H N N N N N N N
01737 VALUE AMOUNT INVALID FOR SUBMITTED VALUE CODE N H N N N N N N N N N N
02002 RX SERIAL NO MISSING N N N N N S N N N N N N
02022 MISSING REFERRING NPI S S S S S S N N N N N N
02023 MISSING ATTENDING NPI S S S S S N N N N N N N
02024 MISSING OPERATING NPI N S N N N N N N N N N N
02025 MISSING RENDERING NPI N N N N N N S S S S S S
02029 MISSING PRESCRIBING NPI N N N N N S N N N N N N
02030 INVALID BILLING NPI H H H H H H H H H H H H
02031 INVALID GROUP NPI N N N N N N H N N N N N
02032 INVALID REFERRING NPI S S S S S S N N N N N N
02033 INVALID ATTENDING NPI H H H H H N N N N N N N
02034 INVALID OPERATING NPI N S N N N N N N N N N N
02035 INVALID RENDERING NPI N N N N N N S S S S S S
02036 INVALID SUPERVISING NPI N N N N N N N H H N H H
02037 INVALID OTHER NPI N N N N N N H H H H H H
02038 INVALID ASSISTANT SURGEON NPI N N N N N N H N N N N N
02039 INVALID PRESCRIBING NPI N N N N N S N N N N N N
02066 DRUG CODE MISSING H N N N N N N H N N N S
02070 INVALID ORDERING NPI N N N N N N N N N N N N
02079 POA CODE MISSION OR INVALID N H N N N N N N N N N N
02116 MISSING RX ORIGIN CODE N N N N N S N N N N N N
02117 INVALID RX ORIGIN CODE N N N N N S N N N N N N
02171 NDC OCCURS MORE THAN ONCE N N N N N S N N N N N N
02174 ICD VERSION CODE INVALID S S S S S S N S S S S S
02193 CONTROLLED SUBSTANCE LIMIT EXCEEDED N N N N N S N N N N N N
02210 ICD-9 PROC DATE AFTER SERVICE DATE N S N N N N N N N N N N
02211 ICD-9 PROC WITHOUT DATE N S N N N N N N N N N N

Legend: F=Fatal; H=Hard Edit (Deny); S=Soft Edit (Accept); N=Non-Edit (Ignore)

V. Response File Reconciliation

Plans will receive a transmission file confirming the acceptance or rejection of each encounter file submitted. Files will stay within the plan's eMedNY Exchange mailbox for a period of twenty-eight (28) days. Responses returned via FTP will remain in the plan's FTP directory for twenty-eight (28) days or until downloaded. Plans will also receive a response file for all encounter files submitted during the processing cycle. When submitting to the Provider Test Environment (PTE) the processing cycle happens daily and the plan will receive a response file the following day after a test file is processed. When submitting to the Production System the processing cycle pulls encounter files in daily and processes them in a weekly cycle. Therefore, you will receive your response file 7 days after processing.

The response file provides valuable feedback to the plan on the quality of the encounter data submitted. The plan will receive information on whether the record was accepted or rejected as well as up to 24 edits.

Data Element Width Record Positions
Encounter Control Number 11 1-11
Claim Line Number 04 12-15
Edit Status Code 01 16
Claim Edit Code 05 17-21
COS Code ("EN" precedes code) 04 22-25
TCN 16 26-41
Plan ID 08 42-49
TSN 03 50-52
Filler 28 53-80

Plans should use information provided in the feedback report [Encounter Control Number (ECN), Claim Line Number, Edit Status Code, Claim Edit Number, Category of Service (COS Code), and Transaction Control Number (TCN)] to match the status of each line of the encounter record.

Since the Response File reports errors on the service line level, plans should be aware of four general rules about feedback reports:

Rule #1:

If the encounter record passes through without hitting any edits, the plan will receive one record line back with an edit status code of 'P' at line number '0000'. The plan should store the associated TCN and the Accepted status in their data system. Any changes to these records should be handled as an adjustment.

Example:

Plan ID '12345678' with a TSN of 'ABC' submits a professional service encounter with an ECN of '00000000001' and a COS of '01'. The encounter passes all edits. The feedback report will produce the following response:

000000000010000P EN01052200000154952012345678ABC

Using the feedback report layout allows the plan to match the result back to the reported encounter.

ECN = '00000000001'
Line Number = '0000'
Edit Status Code = 'P' [Paid/Accepted]
COS = 'EN01'
TCN = '0522000001549520'
Plan ID = '12345678'
TSN = 'ABC'

Plan ID '12345678' should tag encounter '00000000001' as an accepted encounter with a TCN of '0522000001549520' within their system. If the encounter needs to be adjusted in the future, the plan has stored the transaction control number (TCN) to identify the record.

Rule #2:

If the encounter record rejects at the header level (line = '0000' and edit status code = '2') the entire encounter record is rejected. Plans should correct all errors identified and resubmit the encounter as an original.

Example:

Plan '12345678' with a TSN of 'ABC' submits a professional services encounter with an ECN of '00000000002', a COS of '01', five different valid procedure codes, but did not submit the MMIS Provider Id. Everything else in the encounter record is correct. The feedback report will produce the following response.

000000000020000200175EN01052200000154954012345678ABC

Using the feedback report layout allows the plan to match the result back to the reported encounter.

ECN = '00000000002'
Line Number = '0000'
Edit Status Code = '2' [Deny/Rejected]
Claim Edit Code = '00175' [Servicing Provider Id Not on File]
COS = 'EN01'
TCN = '0522000001549540'
Plan ID = '12345678'
TSN = 'ABC'

Anything that fails at the Header level (line number= '00') will cause the entire encounter to reject. In this case the plan would not store the associated TCN because it will not be used after errors are corrected and the encounter is re-submitted as an original.

Rule #3:

If the encounter record includes both accepted and rejected service lines (line number(s) = '01' - '10' and edit status codes of '2' and '3') the encounter has been partially accepted. The plan should store the associated TCN and the accepted and rejected status of each service line. All corrections to the encounter would be handled as an adjustment to the original encounter.

Example:

Plan '12345678' with a TSN of 'ABC' submits a professional services encounter with an ECN of '00000000003', a COS of '01'. Within this encounter there are two service lines. One line reports a valid procedure code '99214', and the second line does not '9TY32'. Everything else within the encounter record is correct. The feedback report will produce the following response.

000000000030002200170EN01052200000154956012345678ABC

Using the feedback report layout allows the plan to match each result back to the reported encounter. The response file identifies when a record is accepted and when a record has errors. If the plan has submitted a multiple service line encounter and receives responses to only some service lines, the plan should assume the other service lines are accepted. In the example above, the plan will not receive a response line to the first procedure code of '99214' because it was accepted. However, for line '0002' the plan should receive the response line shown above, which is interpreted as follows:

ECN = '00000000003'
Line Number = '0002'
Edit Status Code = '2' [Deny/Rejected]
Claim Edit Code = '00170' [Procedure Code Not on File]
COS = 'EN01'
TCN = '0522000001549560'
Plan ID = '12345678'
TSN = 'ABC'

This record has been partially accepted in the claims system. Line '01' with the valid procedure code of '99214' was accepted. Line '02' with the invalid procedure code of '9TY32' was rejected. Plan '12345678' should incorporate the TCN '0522000001549560' and the status code for each claim line into their data system. Line '02' should be corrected, and the entire encounter should be re-submitted as an adjustment.

Rule #4:

For every adjusted encounter the plan will receive two response lines returned. The eMedNY claims system creates a 'void' line in the claim system that removes the original encounter. It then creates a new replacement/adjustment line. The first TCN, which represents the 'void' line, should always end in '1'. Plans should disregard this TCN. The second TCN, which represents the 'replacement/adjustment' line, will always end in '2'. Plans should store this TCN with the new encounter record.

Example:

Plan '12345678' with a TSN of 'ABC' decides to correct the professional services encounter (ECN '00000000003') that was partially accepted in Example 3. In order to correct the record, the plan changes the second procedure code from '9TY32' to '99215' and submits the adjusted record following the rules identified in the MEDS III Data Element Dictionary. The adjusted encounter is determined to be correct and is accepted for processing. The feedback report produces the following response.

000000000030000P EN01052200000154959112345678ABC
000000000030000P EN01052200000154959212345678ABC

The first response line indicates the removal of the original encounter was accepted.

ECN = '00000000003'
Line Number = '0000'
Edit Status Code = 'P' [Paid/Accepted]
COS = 'EN01'
TCN = '0522000001549591'
Plan ID = '12345678'
TSN = 'ABC'

The second response line indicates the 'adjusted' encounter was accepted.

ECN = '00000000003'
Line Number = '0000'
Edit Status Code = 'P' [Paid/Accepted]
COS = 'EN01'
TCN = '0522000001549592'
Plan ID = '12345678'
TSN = 'ABC'

MEDS-L

The Division of Health Plan Contracting & Oversight has created an email listserv group called MEDS-L. The purpose of the listserv is to provide a forum to interactively discuss issues related to encounter data reporting under the new MEDS III system.

The listserv is closed, restricted to health plans and associated parties that are involved with the submission of Medicaid encounter data.

If you wish to be added to the MEDS-L listserv please contact the MEDS Unit at omcmeds@health.ny.gov

APPENDIX E - Transaction Layout with Record Positions

The MEDS III transaction file will be a fixed width file of 3,000 characters. Filler should be added at the end of each record type so that the file width equals 3,000.

MEDS Data Element Name Length Start End

Header Record
Record Type 2 1 2
Provider Transmission Supplier Number (TSN) 4 3 6
Input Serial Number 6 7 12
TSN Certification Date 9 13 21
Vendor Software Number 5 22 26
Vendor Software Update Level 2 27 28
Test / Prod Indicator 4 29 32
Plan Identification Number 8 33 40
Submitter Name 21 41 61
Submitter Address 1 18 62 79
Submitter Address 2 18 80 97
Submitter Address City 15 98 112
Submitter Address State 2 113 114
Submitter Zip 9 115 123
Submitter Fax Number 11 124 134
Submitter Phone Number 11 135 145
MEDS Version Number 3 146 148
Common Detail Segment
Record Type 2 1 2
Encounter Type Indicator 1 3 3
Encounter Control Number 11 4 14
Previous Transaction Control Number 16 15 30
Transaction Status Code 1 31 31
Client Identification Number 8 32 39
Beneficiary Identification Number 25 40 64
Provider Profession Code 3 65 67
Provider License Number 8 68 75
Provider Identification Number 10 76 85
Provider Service Location 9 86 94
Category of Service (COS) Code 2 95 96
Total Charged Amount 11 97 107
Total Paid Amount 11 108 118
Medicare Total Paid Amount 11 119 129
Other Insurance Total Paid Amount 11 130 140
Other Payer Name 35 141 175
Other Insurance Type Code 2 176 177
Medicare Total Deductible Paid 11 178 188
Medicare Total Co-Insurance Paid 11 189 199
Medicare Total Copay Paid 11 200 210
Other Insurance Total Deductible Paid 11 211 221
Other Insurance Total Co-Insurance Paid 11 222 232
Other Insurance Total Copay Paid 11 233 243
FILLER 14 244 257
Institutional Segment
Provider Specialty Code 3 258 260
Hospital Inpatient Claim/Encounter Indicator 1 261 261
NYS DRG Code 4 262 265
Type of Bill Digits 1 & 2 Code 2 266 267
Type of Bill Digit 3 Code 1 268 268
Statement Covers Period From 8 269 276
Statement Covers Period Thru 8 277 284
Type of Admission 1 285 285
Source of Admission 1 286 286
Patient Status or Disposition Code 2 287 288
Medical Record Number 20 289 308
Neonate Birth Weight Value Code [1] 2 309 310
Neonate Birth Weight in Grams [1] 7 311 317
Neonate Birth Weight Value Code [2] 2 318 319
Neonate Birth Weight in Grams [2] 7 320 326
Service Date [1] 8 327 334
Revenue Code [1] 4 335 338
CPT/HCPCS Code [1] 5 339 343
Procedure Modifier Code 1 [1] 2 344 345
Procedure Modifier Code 2 [1] 2 346 347
Procedure Modifier Code 3 [1] 2 348 349
Procedure Modifier Code 4 [1] 2 350 351
Quantity or Units Submitted [1] 11 352 362
NDC (Formulary) Code [1] 11 363 373
NDC (Formulary) Units [1] 12 374 385
Charged Amount [1] 11 386 396
Medicare Paid Amount [1] 11 397 407
Paid Amount [1] 11 408 418
Non-Inpatient Claim/Encounter Indicator [1] 1 419 419
Service Date [2] 8 420 427
Revenue Code [2] 4 428 431
CPT/HCPCS Code [2] 5 432 436
Procedure Modifier Code 1 [2] 2 437 438
Procedure Modifier Code 2 [2] 2 439 440
Procedure Modifier Code 3 [2] 2 441 442
Procedure Modifier Code 4 [2] 2 443 444
Quantity or Units Submitted [2] 11 445 455
NDC (Formulary) Code [2] 11 456 466
NDC (Formulary) Units [2] 12 467 478
Charged Amount [2] 11 479 489
Medicare Paid Amount [2] 11 490 500
Paid Amount [2] 11 501 511
Non-Inpatient Claim/Encounter Indicator [2] 1 512 512
Service Date [3] 8 513 520
Revenue Code [3] 4 521 524
CPT/HCPCS Code [3] 5 525 529
Procedure Modifier Code 1 [3] 2 530 531
Procedure Modifier Code 2 [3] 2 532 533
Procedure Modifier Code 3 [3] 2 534 535
Procedure Modifier Code 4 [3] 2 536 537
Quantity or Units Submitted [3] 11 538 548
NDC (Formulary) Code [3] 11 549 559
NDC (Formulary) Units [3] 12 560 571
Charged Amount [3] 11 572 582
Medicare Paid Amount [3] 11 583 593
Paid Amount [3] 11 594 604
Non-Inpatient Claim/Encounter Indicator [3] 1 605 605
Service Date [4] 8 606 613
Revenue Code [4] 4 614 617
CPT/HCPCS Code [4] 5 618 622
Procedure Modifier Code 1 [4] 2 623 624
Procedure Modifier Code 2 [4] 2 625 626
Procedure Modifier Code 3 [4] 2 627 628
Procedure Modifier Code 4 [4] 2 629 630
Quantity or Units Submitted [4] 11 631 641
NDC (Formulary) Code [4] 11 642 652
NDC (Formulary) Units [4] 12 653 664
Charged Amount [4] 11 665 675
Medicare Paid Amount [4] 11 676 686
Paid Amount [4] 11 687 697
Non-Inpatient Claim/Encounter Indicator [4] 1 698 698
Service Date [5] 8 699 706
Revenue Code [5] 4 707 710
CPT/HCPCS Code [5] 5 711 715
Procedure Modifier Code 1 [5] 2 716 717
Procedure Modifier Code 2 [5] 2 718 719
Procedure Modifier Code 3 [5] 2 720 721
Procedure Modifier Code 4 [5] 2 722 723
Quantity or Units Submitted [5] 11 724 734
NDC (Formulary) Code [5] 11 735 745
NDC (Formulary) Units [5] 12 746 757
Charged Amount [5] 11 758 768
Medicare Paid Amount [5] 11 769 779
Paid Amount [5] 11 780 790
Non-Inpatient Claim/Encounter Indicator [5] 1 791 791
Service Date [6] 8 792 799
Revenue Code [6] 4 800 803
CPT/HCPCS Code [6] 5 804 808
Procedure Modifier Code 1 [6] 2 809 810
Procedure Modifier Code 2 [6] 2 811 812
Procedure Modifier Code 3 [6] 2 813 814
Procedure Modifier Code 4 [6] 2 815 816
Quantity or Units Submitted [6] 11 817 827
NDC (Formulary) Code [6] 11 828 838
NDC (Formulary) Units [6] 12 839 850
Charged Amount [6] 11 851 861
Medicare Paid Amount [6] 11 862 872
Paid Amount [6] 11 873 883
Non-Inpatient Claim/Encounter Indicator [6] 1 884 884
Service Date [7] 8 885 892
Revenue Code [7] 4 893 896
CPT/HCPCS Code [7] 5 897 901
Procedure Modifier Code 1 [7] 2 902 903
Procedure Modifier Code 2 [7] 2 904 905
Procedure Modifier Code 3 [7] 2 906 907
Procedure Modifier Code 4 [7] 2 908 909
Quantity or Units Submitted [7] 11 910 920
NDC (Formulary) Code [7] 11 921 931
NDC (Formulary) Units [7] 12 932 943
Charged Amount [7] 11 944 954
Medicare Paid Amount [7] 11 955 965
Paid Amount [7] 11 966 976
Non-Inpatient Claim/Encounter Indicator [7] 1 977 977
Service Date [8] 8 978 985
Revenue Code [8] 4 986 989
CPT/HCPCS Code [8] 5 990 994
Procedure Modifier Code 1 [8] 2 995 996
Procedure Modifier Code 2 [8] 2 997 998
Procedure Modifier Code 3 [8] 2 999 1000
Procedure Modifier Code 4 [8] 2 1001 1002
Quantity or Units Submitted [8] 11 1003 1013
NDC (Formulary) Code [8] 11 1014 1024
NDC (Formulary) Units [8] 12 1025 1036
Charged Amount [8] 11 1037 1047
Medicare Paid Amount [8] 11 1048 1058
Paid Amount [8] 11 1059 1069
Non-Inpatient Claim/Encounter Indicator [8] 1 1070 1070
Service Date [9] 8 1071 1078
Revenue Code [9] 4 1079 1082
CPT/HCPCS Code [9] 5 1083 1087
Procedure Modifier Code 1 [9] 2 1088 1089
Procedure Modifier Code 2 [9] 2 1090 1091
Procedure Modifier Code 3 [9] 2 1092 1093
Procedure Modifier Code 4 [9] 2 1094 1095
Quantity or Units Submitted [9] 11 1096 1106
NDC (Formulary) Code [9] 11 1107 1117
NDC (Formulary) Units [9] 12 1118 1129
Charged Amount [9] 11 1130 1140
Medicare Paid Amount [9] 11 1141 1151
Paid Amount [9] 11 1152 1162
Non-Inpatient Claim/Encounter Indicator [9] 1 1163 1163
Service Date [10] 8 1164 1171
Revenue Code [10] 4 1172 1175
CPT/HCPCS Code [10] 5 1176 1180
Procedure Modifier Code 1 [10] 2 1181 1182
Procedure Modifier Code 2 [10] 2 1183 1184
Procedure Modifier Code 3 [10] 2 1185 1186
Procedure Modifier Code 4 [10] 2 1187 1188
Quantity or Units Submitted [10] 11 1189 1199
NDC (Formulary) Code [10] 11 1200 1210
NDC (Formulary) Units [10] 12 1211 1222
Charged Amount [10] 11 1223 1233
Medicare Paid Amount [10] 11 1234 1244
Paid Amount [10] 11 1245 1255
Non-Inpatient Claim/Encounter Indicator [10] 1 1256 1256
ICD Version Code 1 1257 1257
Principal/Primary Diagnosis Code 7 1258 1264
Other Diagnosis Codes [1] 7 1265 1271
Other Diagnosis Codes [2] 7 1272 1278
Other Diagnosis Codes [3] 7 1279 1285
Other Diagnosis Codes [4] 7 1286 1292
Other Diagnosis Codes [5] 7 1293 1299
Other Diagnosis Codes [6] 7 1300 1306
Other Diagnosis Codes [7] 7 1307 1313
Other Diagnosis Codes [8] 7 1314 1320
Other Diagnosis Codes [9] 7 1321 1327
Other Diagnosis Codes [10] 7 1328 1334
Other Diagnosis Codes [11] 7 1335 1341
Other Diagnosis Codes [12] 7 1342 1348
Other Diagnosis Codes [13] 7 1349 1355
Other Diagnosis Codes [14] 7 1356 1362
Other Diagnosis Codes [15] 7 1363 1369
Other Diagnosis Codes [16] 7 1370 1376
Other Diagnosis Codes [17] 7 1377 1383
Other Diagnosis Codes [18] 7 1384 1390
Other Diagnosis Codes [19] 7 1391 1397
Other Diagnosis Codes [20] 7 1398 1404
Other Diagnosis Codes [21] 7 1405 1411
Other Diagnosis Codes [22] 7 1412 1418
Other Diagnosis Codes [23] 7 1419 1425
Other Diagnosis Codes [24] 7 1426 1432
Admit Diagnosis 7 1433 1439
External Diagnosis Code (E Code) 7 1440 1446
Present on Admission Code [1] 1 1447 1447
Present on Admission Code [2] 1 1448 1448
Present on Admission Code [3] 1 1449 1449
Present on Admission Code [4] 1 1450 1450
Present on Admission Code [5] 1 1451 1451
Present on Admission Code [6] 1 1452 1452
Present on Admission Code [7] 1 1453 1453
Present on Admission Code [8] 1 1454 1454
Present on Admission Code [9] 1 1455 1455
Present on Admission Code [10] 1 1456 1456
Present on Admission Code [11] 1 1457 1457
Present on Admission Code [12] 1 1458 1458
Present on Admission Code [13] 1 1459 1459
Present on Admission Code [14] 1 1460 1460
Present on Admission Code [15] 1 1461 1461
Present on Admission Code [16] 1 1462 1462
Present on Admission Code [17] 1 1463 1463
Present on Admission Code [18] 1 1464 1464
Present on Admission Code [19] 1 1465 1465
Present on Admission Code [20] 1 1466 1466
Present on Admission Code [21] 1 1467 1467
Present on Admission Code [22] 1 1468 1468
Present on Admission Code [23] 1 1469 1469
Present on Admission Code [24] 1 1470 1470
Present on Admission Code [25] 1 1471 1471
Principal Procedure Code 7 1472 1478
Procedure Date [1] 8 1479 1486
Other Procedure Codes [1] 7 1487 1493
Procedure Date [2] 8 1494 1501
Other Procedure Codes [2] 7 1502 1508
Procedure Date [3] 8 1509 1516
Other Procedure Codes [3] 7 1517 1523
Procedure Date [4] 8 1524 1531
Other Procedure Codes [4] 7 1532 1538
Procedure Date [5] 8 1539 1546
Other Procedure Codes [5] 7 1547 1553
Procedure Date [6] 8 1554 1561
Other Procedure Codes [6] 7 1562 1568
Procedure Date [7] 8 1569 1576
Other Procedure Codes [7] 7 1577 1583
Procedure Date [8] 8 1584 1591
Other Procedure Codes [8] 7 1592 1598
Procedure Date [9] 8 1599 1606
Other Procedure Codes [9] 7 1607 1613
Procedure Date [10] 8 1614 1621
Other Procedure Codes [10] 7 1622 1628
Procedure Date [11] 8 1629 1636
Other Procedure Codes [11] 7 1637 1643
Procedure Date [12] 8 1644 1651
Other Procedure Codes [12] 7 1652 1658
Procedure Date [13] 8 1659 1666
Other Procedure Codes [13] 7 1667 1673
Procedure Date [14] 8 1674 1681
Other Procedure Codes [14] 7 1682 1688
Procedure Date [15] 8 1689 1696
Other Procedure Codes [15] 7 1697 1703
Procedure Date [16] 8 1704 1711
Other Procedure Codes [16] 7 1712 1718
Procedure Date [17] 8 1719 1726
Other Procedure Codes [17] 7 1727 1733
Procedure Date [18] 8 1734 1741
Other Procedure Codes [18] 7 1742 1748
Procedure Date [19] 8 1749 1756
Other Procedure Codes [19] 7 1757 1763
Procedure Date [20] 8 1764 1771
Other Procedure Codes [20] 7 1772 1778
Procedure Date [21] 8 1779 1786
Other Procedure Codes [21] 7 1787 1793
Procedure Date [22] 8 1794 1801
Other Procedure Codes [22] 7 1802 1808
Procedure Date [23] 8 1809 1816
Other Procedure Codes [23] 7 1817 1823
Procedure Date [24] 8 1824 1831
Other Procedure Codes [24] 7 1832 1838
Procedure Date [25] 8 1839 1846
Attending Provider Profession Code 3 1847 1849
Attending Provider License Number 8 1850 1857
Attending Provider ID 10 1858 1867
Surgeon Profession Code 3 1868 1870
Surgeon License Number 8 1871 1878
Surgeon Provider ID 10 1879 1888
Admission Date 8 1889 1896
Discharge Date 8 1897 1904
FILLER 1096 1905 3000
Pharmacy Segment
Prescription Origin Code 1 258 258
Prescription Number 12 259 270
Prescribing Provider Profession Code 3 271 273
Prescribing Provider License Code 8 274 281
Prescribing Provider ID 10 282 291
Prescription Ordered Date 8 292 299
Date Filled 8 300 307
Drug Days Supply Count 3 308 310
National Drug Code (NDC) or Product Code [1] 11 311 321
Quantity Dispensed [1] 12 322 333
Amount Charged [1] 11 334 344
Amount Paid [1] 11 345 355
Pharmacy Claim/Encounter Indicator [1] 1 356 356
National Drug Code (NDC) or Product Code [2] 11 357 367
Quantity Dispensed [2] 12 368 379
Amount Charged [2] 11 380 390
Amount Paid [2] 11 391 401
Pharmacy Claim/Encounter Indicator [2] 1 402 402
National Drug Code (NDC) or Product Code [3] 11 403 413
Quantity Dispensed [3] 12 414 425
Amount Charged [3] 11 426 436
Amount Paid [3] 11 437 447
Pharmacy Claim/Encounter Indicator [3] 1 448 448
National Drug Code (NDC) or Product Code [4] 11 449 459
Quantity Dispensed [4] 12 460 471
Amount Charged [4] 11 472 482
Amount Paid [4] 11 483 493
Pharmacy Claim/Encounter Indicator [4] 1 494 494
National Drug Code (NDC) or Product Code [5] 11 495 505
Quantity Dispensed [5] 12 506 517
Amount Charged [5] 11 518 528
Amount Paid [5] 11 529 539
Pharmacy Claim/Encounter Indicator [5] 1 540 540
National Drug Code (NDC) or Product Code [6] 11 541 551
Quantity Dispensed [6] 12 552 563
Amount Charged [6] 11 564 574
Amount Paid [6] 11 575 585
Pharmacy Claim/Encounter Indicator [6] 1 586 586
National Drug Code (NDC) or Product Code [7] 11 587 597
Quantity Dispensed [7] 12 598 609
Amount Charged [7] 11 610 620
Amount Paid [7] 11 621 631
Pharmacy Claim/Encounter Indicator [7] 1 632 632
National Drug Code (NDC) or Product Code [8] 11 633 643
Quantity Dispensed [8] 12 644 655
Amount Charged [8] 11 656 666
Amount Paid [8] 11 667 677
Pharmacy Claim/Encounter Indicator [8] 1 678 678
National Drug Code (NDC) or Product Code [9] 11 679 689
Quantity Dispensed [9] 12 690 701
Amount Charged [9] 11 702 712
Amount Paid [9] 11 713 723
Pharmacy Claim/Encounter Indicator [9] 1 724 724
National Drug Code (NDC) or Product Code [10] 11 725 735
Quantity Dispensed [10] 12 736 747
Amount Charged [10] 11 748 758
Amount Paid [10] 11 759 769
Pharmacy Claim/Encounter Indicator [10] 1 770 770
National Drug Code (NDC) or Product Code [11] 11 771 781
Quantity Dispensed [11] 12 782 793
Amount Charged [11] 11 794 804
Amount Paid [11] 11 805 815
Pharmacy Claim/Encounter Indicator [11] 1 816 816
National Drug Code (NDC) or Product Code [12] 11 817 827
Quantity Dispensed [12] 12 828 839
Amount Charged [12] 11 840 850
Amount Paid [12] 11 851 861
Pharmacy Claim/Encounter Indicator [12] 1 862 862
National Drug Code (NDC) or Product Code [13] 11 863 873
Quantity Dispensed [13] 12 874 885
Amount Charged [13] 11 886 896
Amount Paid [13] 11 897 907
Pharmacy Claim/Encounter Indicator [13] 1 908 908
National Drug Code (NDC) or Product Code [14] 11 909 919
Quantity Dispensed [14] 12 920 931
Amount Charged [14] 11 932 942
Amount Paid [14] 11 943 953
Pharmacy Claim/Encounter Indicator [14] 1 954 954
National Drug Code (NDC) or Product Code [15] 11 955 965
Quantity Dispensed [15] 12 966 977
Amount Charged [15] 11 978 988
Amount Paid [15] 11 989 999
Pharmacy Claim/Encounter Indicator [15] 1 1000 1000
National Drug Code (NDC) or Product Code [16] 11 1001 1011
Quantity Dispensed [16] 12 1012 1023
Amount Charged [16] 11 1024 1034
Amount Paid [16] 11 1035 1045
Pharmacy Claim/Encounter Indicator [16] 1 1046 1046
National Drug Code (NDC) or Product Code [17] 11 1047 1057
Quantity Dispensed [17] 12 1058 1069
Amount Charged [17] 11 1070 1080
Amount Paid [17] 11 1081 1091
Pharmacy Claim/Encounter Indicator [17] 1 1092 1092
National Drug Code (NDC) or Product Code [18] 11 1093 1103
Quantity Dispensed [18] 12 1104 1115
Amount Charged [18] 11 1116 1126
Amount Paid [18] 11 1127 1137
Pharmacy Claim/Encounter Indicator 1 1138 1138
National Drug Code (NDC) or Product Code [19] 11 1139 1149
Quantity Dispensed [19] 12 1150 1161
Amount Charged [19] 11 1162 1172
Amount Paid [19] 11 1173 1183
Pharmacy Claim/Encounter Indicator 1 1184 1184
National Drug Code (NDC) or Product Code [20] 11 1185 1195
Quantity Dispensed [20] 12 1196 1207
Amount Charged [20] 11 1208 1218
Amount Paid [20] 11 1219 1229
Pharmacy Claim/Encounter Indicator [20] 1 1230 1230
National Drug Code (NDC) or Product Code [21] 11 1231 1241
Quantity Dispensed [21] 12 1242 1253
Amount Charged [21] 11 1254 1264
Amount Paid [21] 11 1265 1275
Pharmacy Claim/Encounter Indicator [21] 1 1276 1276
National Drug Code (NDC) or Product Code [22] 11 1277 1287
Quantity Dispensed [22] 12 1288 1299
Amount Charged [22] 11 1300 1310
Amount Paid [22] 11 1311 1321
Pharmacy Claim/Encounter Indicator [22] 1 1322 1322
National Drug Code (NDC) or Product Code [23] 11 1323 1333
Quantity Dispensed [23] 12 1334 1345
Amount Charged [23] 11 1346 1356
Amount Paid [23] 11 1357 1367
Pharmacy Claim/Encounter Indicator [23] 1 1368 1368
National Drug Code (NDC) or Product Code [24] 11 1369 1379
Quantity Dispensed [24] 12 1380 1391
Amount Charged [24] 11 1392 1402
Amount Paid [24] 11 1403 1413
Pharmacy Claim/Encounter Indicator [24] 1 1414 1414
National Drug Code (NDC) or Product Code [25] 11 1415 1425
Quantity Dispensed [25] 12 1426 1437
Amount Charged [25] 11 1438 1448
Amount Paid [25] 11 1449 1459
Pharmacy Claim/Encounter Indicator 1 1460 1460
Refill Indicator 2 1461 1462
Number of Refills Authorized 2 1463 1464
Dispensed As Written 1 1465 1465
ICD Version Code 1 1466 1466
Diagnosis Code 7 1467 1473
Prescription Serial Number 12 1474 1485
Submission Clarification Code 2 1486 1487
Dispensing Fee 11 1488 1498
Mail Order Pharmacy Indicator 1 1499 1499
FILLER 1501 1500 3000
Dental Segment
Provider Specialty Code 3 258 260
Service Start Date [1] 8 261 268
Service End Date [1] 8 269 276
Place of Service/Place of Treatment [1] 2 277 278
Procedure Code [1] 5 279 283
Procedure Modifier Code 1 [1] 2 284 285
Procedure Modifier Code 3 [1] 2 288 289
Procedure Modifier Code 4 [1] 2 290 291
Tooth Number or Letter [1] 2 292 293
Dental Number of Units/Visits [1] 11 294 304
Charged Amount [1] 11 305 315
Medicare Paid Amount [1] 11 316 326
Paid Amount [1] 11 327 337
Dental Claim/Encounter Indicator [1] 1 338 338
Service Start Date [2] 8 339 346
Service End Date [2] 8 347 354
Place of Service/Place of Treatment [2] 2 355 356
Procedure Code [2] 5 357 361
Procedure Modifier Code 2 [2] 2 364 365
Procedure Modifier Code 3 [2] 2 366 367
Procedure Modifier Code 4 [2] 2 368 369
Tooth Number or Letter [2] 2 370 371
Dental Number of Units/Visits [2] 11 372 382
Charged Amount [2] 11 383 393
Medicare Paid Amount [2] 11 394 404
Paid Amount [2] 11 405 415
Dental Claim/Encounter Indicator [2] 1 416 416
Service Start Date [3] 8 417 424
Service End Date [3] 8 425 432
Place of Service/Place of Treatment [3] 2 433 434
Procedure Code [3] 5 435 439
Procedure Modifier Code 1 [3] 2 440 441
Procedure Modifier Code 2 [3] 2 442 443
Procedure Modifier Code 3 [3] 2 444 445
Procedure Modifier Code 4 [3] 2 446 447
Tooth Number or Letter [3] 2 448 449
Dental Number of Units/Visits [3] 11 450 460
Charged Amount [3] 11 461 471
Medicare Paid Amount [3] 11 472 482
Paid Amount [3] 11 483 493
Dental Claim/Encounter Indicator [3] 1 494 494
Service Start Date [4] 8 495 502
Service End Date [4] 8 503 510
Place of Service/Place of Treatment [4] 2 511 512
Procedure Code [4] 5 513 517
Procedure Modifier Code 1 [4] 2 518 519
Procedure Modifier Code 2 [4] 2 520 521
Procedure Modifier Code 3 [4] 2 522 523
Procedure Modifier Code 4 [4] 2 524 525
Tooth Number or Letter [4] 2 526 527
Dental Number of Units/Visits [4] 11 528 538
Charged Amount [4] 11 539 549
Medicare Paid Amount [4] 11 550 560
Paid Amount [4] 11 561 571
Dental Claim/Encounter Indicator [4] 1 572 572
Service Start Date [5] 8 573 580
Service End Date [5] 8 581 588
Place of Service/Place of Treatment [5] 2 589 590
Procedure Code [5] 5 591 595
Procedure Modifier Code 1 [5] 2 596 597
Procedure Modifier Code 2 [5] 2 598 599
Procedure Modifier Code 3 [5] 2 600 601
Procedure Modifier Code 4 [5] 2 602 603
Tooth Number or Letter [5] 2 604 605
Dental Number of Units/Visits [5] 11 606 616
Charged Amount [5] 11 617 627
Medicare Paid Amount [5] 11 628 638
Paid Amount [5] 11 639 649
Dental Claim/Encounter Indicator [5] 1 650 650
Service Start Date [6] 8 651 658
Service End Date [6] 8 659 666
Place of Service/Place of Treatment [6] 2 667 668
Procedure Code [6] 5 669 673
Procedure Modifier Code 1 [6] 2 674 675
Procedure Modifier Code 2 [6] 2 676 677
Procedure Modifier Code 3 [6] 2 678 679
Procedure Modifier Code 4 [6] 2 680 681
Tooth Number or Letter [6] 2 682 683
Dental Number of Units/Visits [6] 11 684 694
Charged Amount [6] 11 695 705
Medicare Paid Amount [6] 11 706 716
Paid Amount [6] 11 717 727
Dental Claim/Encounter Indicator [6] 1 728 728
Service Start Date [7] 8 729 736
Service End Date [7] 8 737 744
Place of Service/Place of Treatment [7] 2 745 746
Procedure Code [7] 5 747 751
Procedure Modifier Code 1 [7] 2 752 753
Procedure Modifier Code 2 [7] 2 754 755
Procedure Modifier Code 3 [7] 2 756 757
Procedure Modifier Code 4 [7] 2 758 759
Tooth Number or Letter [7] 2 760 761
Dental Number of Units/Visits [7] 11 762 772
Charged Amount [7] 11 773 783
Medicare Paid Amount [7] 11 784 794
Paid Amount [7] 11 795 805
Dental Claim/Encounter Indicator [7] 1 806 806
Service Start Date [8] 8 807 814
Service End Date [8] 8 815 822
Place of Service/Place of Treatment [8] 2 823 824
Procedure Code [8] 5 825 829
Procedure Modifier Code 1 [8] 2 830 831
Procedure Modifier Code 2 [8] 2 832 833
Procedure Modifier Code 3 [8] 2 834 835
Procedure Modifier Code 4 [8] 2 836 837
Tooth Number or Letter [8] 2 838 839
Dental Number of Units/Visits [8] 11 840 850
Charged Amount [8] 11 851 861
Medicare Paid Amount [8] 11 862 872
Paid Amount [8] 11 873 883
Dental Claim/Encounter Indicator [8] 1 884 884
Service Start Date [9] 8 885 892
Service End Date [9] 8 893 900
Place of Service/Place of Treatment [9] 2 901 902
Procedure Code [9] 5 903 907
Procedure Modifier Code 1 [9] 2 908 909
Procedure Modifier Code 2 [9] 2 910 911
Procedure Modifier Code 3 [9] 2 912 913
Procedure Modifier Code 4 [9] 2 914 915
Tooth Number or Letter [9] 2 916 917
Dental Number of Units/Visits [9] 11 918 928
Charged Amount [9] 11 929 939
Medicare Paid Amount [9] 11 940 950
Paid Amount [9] 11 951 961
Dental Claim/Encounter Indicator [9] 1 962 962
Service Start Date [10] 8 963 970
Service End Date [10] 8 971 978
Place of Service/Place of Treatment [10] 2 979 980
Procedure Code [10] 5 981 985
Procedure Modifier Code 1 [10] 2 986 987
Procedure Modifier Code 2 [10] 2 988 989
Procedure Modifier Code 3 [10] 2 990 991
Procedure Modifier Code 4 [10] 2 992 993
Tooth Number or Letter [10] 2 994 995
Dental Number of Units/Visits [10] 11 996 1006
Charged Amount [10] 11 1007 1017
Medicare Paid Amount [10] 11 1018 1028
Paid Amount [10] 11 1029 1039
Dental Claim/Encounter Indicator [10] 1 1040 1040
FILLER 1960 1041 3000
Professional Segment
Provider Specialty Code 3 258 260
ICD Version Code 1 261 261
Diagnosis Codes [1] 7 262 268
Diagnosis Codes [2] 7 269 275
Diagnosis Codes [3] 7 276 282
Diagnosis Codes [4] 7 283 289
Place of Service/Place of Treatment [1] 2 290 291
Service Start Date [1] 8 292 299
Service End Date [1] 8 300 307
Procedure Code [1] 5 308 312
Procedure Modifier Code 1 [1] 2 313 314
Procedure Modifier Code 2 [1] 2 315 316
Procedure Modifier Code 3 [1] 2 317 318
Procedure Modifier Code 4 [1] 2 319 320
Professional Number of Units/Visits [1] 11 321 331
NDC (Formulary) Code [1] 11 332 342
NDC (Formulary) Units [1] 11 343 353
Charged Amount [1] 11 354 364
Medicare Paid Amount [1] 11 365 375
Paid Amount [1] 11 376 386
Professional Claim/Encounter Indicator [1] 1 387 387
Place of Service/Place of Treatment [2] 2 388 389
Service Start Date [2] 8 390 397
Service End Date [2] 8 398 405
Procedure Code [2] 5 406 410
Procedure Modifier Code 1 [2] 2 411 412
Procedure Modifier Code 2 [2] 2 413 414
Procedure Modifier Code 3 [2] 2 415 416
Procedure Modifier Code 4 [2] 2 417 418
Professional Number of Units/Visits [2] 11 419 429
NDC (Formulary) Code [2] 11 430 440
NDC (Formulary) Units [2] 11 441 451
Charged Amount [2] 11 452 462
Medicare Paid Amount [2] 11 463 473
Paid Amount [2] 11 474 484
Professional Claim/Encounter Indicator [2] 1 485 485
Place of Service/Place of Treatment [3] 2 486 487
Service Start Date [3] 8 488 495
Service End Date [3] 8 496 503
Procedure Code [3] 5 504 508
Procedure Modifier Code 1 [3] 2 509 510
Procedure Modifier Code 2 [3] 2 511 512
Procedure Modifier Code 3 [3] 2 513 514
Procedure Modifier Code 4 [3] 2 515 516
Professional Number of Units/Visits [3] 11 517 527
NDC (Formulary) Code [3] 11 528 538
NDC (Formulary) Units [3] 11 539 549
Charged Amount [3] 11 550 560
Medicare Paid Amount [3] 11 561 571
Paid Amount [3] 11 572 582
Professional Claim/Encounter Indicator [3] 1 583 583
Place of Service/Place of Treatment [4] 2 584 585
Service Start Date [4] 8 586 593
Service End Date [4] 8 594 601
Procedure Code [4] 5 602 606
Procedure Modifier Code 1 [4] 2 607 608
Procedure Modifier Code 2 [4] 2 609 610
Procedure Modifier Code 3 [4] 2 611 612
Procedure Modifier Code 4 [4] 2 613 614
Professional Number of Units/Visits [4] 11 615 625
NDC (Formulary) Code [4] 11 626 636
NDC (Formulary) Units [4] 11 637 647
Charged Amount [4] 11 648 658
Medicare Paid Amount [4] 11 659 669
Paid Amount [4] 11 670 680
Professional Claim/Encounter Indicator [4] 1 681 681
Place of Service/Place of Treatment [5] 2 682 683
Service Start Date [5] 8 684 691
Service End Date [5] 8 692 699
Procedure Code [5] 5 700 704
Procedure Modifier Code 1 [5] 2 705 706
Procedure Modifier Code 2 [5] 2 707 708
Procedure Modifier Code 3 [5] 2 709 710
Procedure Modifier Code 4 [5] 2 711 712
Professional Number of Units/Visits [5] 11 713 723
NDC (Formulary) Code [5] 11 724 734
NDC (Formulary) Units [5] 11 735 745
Charged Amount [5] 11 746 756
Medicare Paid Amount [5] 11 757 767
Paid Amount [5] 11 768 778
Professional Claim/Encounter Indicator [5] 1 779 779
Place of Service/Place of Treatment [6] 2 780 781
Service Start Date [6] 8 782 789
Service End Date [6] 8 790 797
Procedure Code [6] 5 798 802
Procedure Modifier Code 1 [6] 2 803 804
Procedure Modifier Code 2 [6] 2 805 806
Procedure Modifier Code 3 [6] 2 807 808
Procedure Modifier Code 4 [6] 2 809 810
Professional Number of Units/Visits [6] 11 811 821
NDC (Formulary) Code [6] 11 822 832
NDC (Formulary) Units [6] 11 833 843
Charged Amount [6] 11 844 854
Medicare Paid Amount [6] 11 855 865
Paid Amount [6] 11 866 876
Professional Claim/Encounter Indicator [6] 1 877 877
Place of Service/Place of Treatment [7] 2 878 879
Service Start Date [7] 8 880 887
Service End Date [7] 8 888 895
Procedure Code [7] 5 896 900
Procedure Modifier Code 1 [7] 2 901 902
Procedure Modifier Code 2 [7] 2 903 904
Procedure Modifier Code 3 [7] 2 905 906
Procedure Modifier Code 4 [7] 2 907 908
Professional Number of Units/Visits [7] 11 909 919
NDC (Formulary) Code [7] 11 920 930
NDC (Formulary) Units [7] 11 931 941
Charged Amount [7] 11 942 952
Medicare Paid Amount [7] 11 953 963
Paid Amount [7] 11 964 974
Professional Claim/Encounter Indicator [7] 1 975 975
Place of Service/Place of Treatment [8] 2 976 977
Service Start Date [8] 8 978 985
Service End Date [8] 8 986 993
Procedure Code [8] 5 994 998
Procedure Modifier Code 1 [8] 2 999 1000
Procedure Modifier Code 2 [8] 2 1001 1002
Procedure Modifier Code 3 [8] 2 1003 1004
Procedure Modifier Code 4 [8] 2 1005 1006
Professional Number of Units/Visits [8] 11 1007 1017
NDC (Formulary) Code [8] 11 1018 1028
NDC (Formulary) Units [8] 11 1029 1039
Charged Amount [8] 11 1040 1050
Medicare Paid Amount [8] 11 1051 1061
Paid Amount [8] 11 1062 1072
Professional Claim/Encounter Indicator [8] 1 1073 1073
Place of Service/Place of Treatment [9] 2 1074 1075
Service Start Date [9] 8 1076 1083
Service End Date [9] 8 1084 1091
Procedure Code [9] 5 1092 1096
Procedure Modifier Code 1 [9] 2 1097 1098
Procedure Modifier Code 2 [9] 2 1099 1100
Procedure Modifier Code 3 [9] 2 1101 1102
Procedure Modifier Code 4 [9] 2 1103 1104
Professional Number of Units/Visits [9] 11 1105 1115
NDC (Formulary) Code [9] 11 1116 1126
NDC (Formulary) Units [9] 11 1127 1137
Charged Amount [9] 11 1138 1148
Medicare Paid Amount [9] 11 1149 1159
Paid Amount [9] 11 1160 1170
Professional Claim/Encounter Indicator [9] 1 1171 1171
Place of Service/Place of Treatment [10] 2 1172 1173
Service Start Date [10] 8 1174 1181
Service End Date [10] 8 1182 1189
Procedure Code [10] 5 1190 1194
Procedure Modifier Code 1 [10] 2 1195 1196
Procedure Modifier Code 2 [10] 2 1197 1198
Procedure Modifier Code 3 [10] 2 1199 1200
Procedure Modifier Code 4 [10] 2 1201 1202
Professional Number of Units/Visits [10] 11 1203 1213
NDC (Formulary) Code [10] 11 1214 1224
NDC (Formulary) Units [10] 11 1225 1235
Charged Amount [10] 11 1236 1246
Medicare Paid Amount [10] 11 1247 1257
Paid Amount [10] 11 1258 1268
Professional Claim/Encounter Indicator [10] 1 1269 1269
FILLER 1731 1270 3000
Trailer
Record Type 2 1 2
Submission Record Count 9 3 11

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Code	Edit Severity	File Processing Implication
F	Fatal Record Error	There is a fatal error in the encounter record. The claim system has stopped reading the encounter record, and the entire record is rejected.
H	Hard Edit (Deny)	There is a vital error in the encounter record. If the error is at the header level, the entire record will reject and should be resubmitted as an original encounter. If the error is on the service line, the affected service line will reject (with an edit code and service line indicated in the response report. Please refer to Section V of this manual for more detail). Subsequent service lines, if correctly submitted, will be accepted for further processing.
S	Soft Edit (Accept)	Edit indicates that the data provided is inaccurate. However, the record is accepted for further processing. The inaccurate information should be corrected and resubmitted as an adjustment.
N	Non-Edit	Edit does not apply to the ETI/Clinic Type/MEDS COS combination.

	ETI:	I=Institutional								D	T	P=Professional
	Claim Type:	Clinic			IP	Nursing Home		HH	ICF	Rx	Dental	Practitioner						Eye	Lab	Trans	DME
Edit Code	COS:	06	85	87	11	12	73	15	28	14	13	01	03	04	07	41	75	05	16	19	22
00018	DATE OF SERVICE/FILL DATE INVALID	F			F	F		F	F	F	F	F						F	F	F	F
00020	SERVICE/FILL DATE LATER THAN RECEIPT DATE	H			H	H		H	H	H	H	H						H	H	H	H
00021	PATIENT STATUS CODE INVALID	N			H	H		N	H	N	N	N						N	N	N	N
00036	M/I USUAL AND CUSTOMARY	S			S	S		S	S	S	S	S						S	S	S	S
00039	PRIMARY DIAGNOSIS CODE BLANK	H			H	S		S	S	N	N	N						N	N	N	N
00062	PROVIDER ID NUMBER INVALID	N			N	N		N	N	N	N	N						N	N	H	N
00070	PROCEDURE CODE INVALID	H			N	H		H	H	N	H	H						H	H	H	H
00071	PLACE OF SERVICE CODE INVALID	N			N	N		N	N	N	H	H						H	H	S	H
00074	RECIPIENT ID NUMBER INVALID	F			F	F		F	F	F	F	F						F	F	F	F
00076	M/I PROVIDER ID	N			N	N		N	N	N	N	N						N	N	N	N
00078	REFERRING PROVIDER ID NUMBER INVALID	H			H	H		H	H	N	N	N						N	N	N	N
00094	NUMBER OF UNITS NOT GREATER THAN ZERO	H			N	H		H	H	N	H	H						H	H	H	H
00103	ADJUSTMENT / VOID FIELDS INCOMPLETE	H			H	H		H	H	H	H	H						H	H	H	H
00132	PROVIDER ID NOF	N			N	N		N	N	N	N	N						N	N	N	N
00140	RECIPIENT ID NOT ON FILE	H			H	H		H	H	H	H	H						H	H	H	H
00146	PRIMARY DIAGNOSIS NOT ON FILE	H			H	S		S	S	N	N	N						N	N	N	N
00162	CLIENT NOT ELIG ON SVC DT	N			N	N		N	N	N	N	N						N	N	N	N
00170	PROCEDURE CODE NOT ON FILE	H			H	H		H	H	N	H	H						H	H	H	H
00175	PROVIDER ID NOT ON FILE	N			N	N		N	N	N	H	H						H	H	H	H
00180	UNITS GREATER THAN MAXIMUM	S			N	N		S	N	N	S	S						S	N	N	S
00204	PROC NOT AVAILABLE ON DOS	N			N	N		N	N	N	N	N						N	N	N	N
00240	OVER TWO-YEAR-OLD CLAIM HELD FOR FUTURE ADJUDICATION	N			N	N		N	N	N	N	N						N	N	N	N
00262	MEDICARE PAID, NO MEDICARE ON FILE	S			S	S		S	S	S	S	S						S	S	S	S
00263	SERVICING PROVIDER LICENSE NUM	N			N	N		N	N	N	N	N						N	N	N	N
00400	ENCOUNTER CONTROL NUMBER MISSING	S			S	S		S	S	S	S	S						S	S	S	S
00401	BENEFICIARY ID MISSING	N			N	N		N	N	N	N	N						N	N	N	N
00402	DX CODE AND PROC CODE MISSING	N			N	N		N	N	N	N	N						N	N	N	N
00404	PROVIDER SPECIALTY MISSING	H			N	H		H	H	N	H	H						H	H	H	H
00405	PRINCIPAL PROCEDURE CODE MISSING	N			S	N		N	N	N	N	N						N	N	N	N
00406	DIAGNOSIS CODE MISSING	H			H	H		H	H	N	N	H						H	S	S	S
00408	CATEGORY OF SERVICE (COS) MISSING	F			F	F		F	F	F	F	F						F	F	F	F
00409	INPATIENT MMIS PROVIDER ID IS NOT A HOSPITAL	N			H	N		N	N	N	N	N						N	N	N	N
00410	DRG CODE MISSING	N			H	N		N	N	N	N	N						N	N	N	N
00411	DRG CODE AND DX CODE MISSING	N			N	N		N	N	N	N	N						N	N	N	N
00412	DIAGNOSIS CODE NOT ON FILE	H			H	H		H	H	N	N	H						H	S	S	S
00413	PROVIDER SPECIALTY NOT ON FILE	H			N	H		H	H	N	H	H						H	H	H	H
00414	SVC/ADMIT DATE PRIOR TO 1/1/96	N			N	N		N	N	N	N	N						N	N	N	N
00415	COS NOT ALLWD TO SUB BLOCK ENC	N			N	N		N	N	N	N	N						N	N	N	N
00416	LICENSE NUMBER IS MISSING	N			N	N		N	N	N	N	N						N	N	N	N
00422	PRENATAL PROC CODE NOT ALLOW	N			N	N		N	N	N	N	N						N	N	N	N
00423	MMIS PLAN ID MISSING	F			F	F		F	F	F	F	F						F	F	F	F
00424	MMIS PLAN ID NOT ON FILE	F			F	F		F	F	F	F	F						F	F	F	F
00425	MMIS PLAN ID NOT HMO PROVIDER	H			H	H		H	H	H	H	H						H	H	H	H
00431	NEONATE BIRTH WEIGHT CODE INVALID	N			H	N		N	N	N	N	N						N	N	N	N
00432	ATTEND PROV ID NOT ON FILE	H			H	H		H	H	N	N	N						N	N	N	N
00433	OPER PROV ID NOT ON FILE	N			H	N		N	N	N	N	N						N	N	N	N
00434	BIRTH WEIGHT NOT REASONABLE	N			H	N		N	N	N	N	N						N	N	N	N
00435	SOURCE OF ADMISSION CD INVALID	N			H	N		N	N	N	N	N						N	N	N	N
00436	TYPE OF BILL DIGIT 3 INVALID	H			H	H		H	H	N	N	N						N	N	N	N
00437	CLAIM/ENCOUNTER IND INVALID	H			H	H		H	H	H	H	H						H	H	H	H
00525	PRESCRIBING LIC NO. MISSING	N			N	N		N	N	N	N	N						N	N	N	N
00526	M/I PRESCRIPTION #	N			N	N		N	N	S	N	N						N	N	N	N
00528	M/I QUANTITY DISPENSED	S			N	N		N	N	H	N	S						N	N	N	N
00530	NEW/REFILL CODE INVALID	N			N	N		N	N	S	N	N						N	N	N	N
00531	AUTHORIZED REFILL INVALID	N			N	N		N	N	S	N	N						N	N	N	N
00534	DATE ORDERED INVALID	N			N	N		N	N	H	N	N						N	N	N	N
00540	NO. OF DAYS SUPPLY INVALID	N			N	N		N	N	H	N	N						N	N	N	N
00544	NDC CODE NON- NUMERIC	N			N	N		N	N	H	N	N						N	N	N	N
00548	FILL DATE PRIOR ORDER DATE	N			N	N		N	N	H	N	N						N	N	N	N
00561	DRUG CODE NOT ON FILE	H			N	N		N	N	H	N	H						N	N	N	S
00600	ADMISSION DATE INVALID	N			H	H		N	H	N	N	N						N	N	N	N
00603	ADMIT TYPE CODE INVALID	N			H	S		N	S	N	N	N						N	N	N	N
00604	ADMITTING DIAGNOSIS CODE MISSING	N			S	N		N	N	N	N	N						N	N	N	N
00613	PRINCIPAL PROC DATE INVALID	N			S	N		N	N	N	N	N						N	N	N	N
00625	DISCHARGE DATE ILLOGICAL	N			H	H		N	H	N	N	N						N	N	N	N
00627	DISCHARGE STATUS INVALID	N			N	N		N	N	N	N	N						N	N	N	N
00652	DISCHARGE DATE PRIOR TO ADMIT DATE	N			H	H		N	H	N	N	N						N	N	N	N
00653	STATEMENT FROM DATE PRIOR TO A	N			N	N		N	N	N	N	N						N	N	N	N
00655	D/C DATE DIFF THAN THRU DATE	N			H	N		N	N	N	N	N						N	N	N	N
00664	ATTENDING PHYSICIAN LIC NO. MISSING	N			N	N		N	S	N	N	N						N	N	N	N
00689	RECIPIENT NOT ENROLLED IN PLAN ON DATE OF SERVICE	H			H	H		H	H	H	H	H						H	H	H	H
00693	RECIPIENT NEVER ENROLLED IN MNGD CARE	H			H	H		H	H	H	H	H						H	H	H	H
00694	RECIPIENT NOT ENROLLED IN MNGD CARE ON DATE OF SRVCE	H			H	H		H	H	H	H	H						H	H	H	H
00696	RECIPIENT ENROLLED IN ANOTHER MNGD CARE PLAN ON DATE OF SRVCE	H			H	H		H	H	H	H	S						S	S	S	S
00705	DUPLICATE CLAIM IN HISTORY	H			H	H		H	H	H	H	H						H	H	H	H
00710	PROCEDURE EXCEEDS SERVICE LIMITS	S			N	N		N	N	S	S	S						S	S	S	S
00725	HISTRY RECORD NOT FOUND ADJUSTMENT/VOID	H			H	H		H	H	H	H	H						H	H	H	H
00736	DIAG CD BLANK - FULL ICD-9-CM	N			N	N		N	N	N	N	N						N	N	N	N
00737	ICD-9-CM DIAG CODE ON PHYS CLM	N			N	N		N	N	N	N	N						N	N	N	N
00897	PRESCRIBER ID NOT ON FILE	N			N	N		N	N	S	N	N						N	N	N	N
00901	CLAIM TYPE UNKNOWN	F			F	F		F	F	F	F	F						F	F	F	F
00903	PROVIDER ID NUMBER MISSING	H			H	H		H	H	H	N	N						N	N	N	N
00927	MODIFIER INVALID FOR PROCEDURE CODE	S			N	N		S	N	N	S	S						S	S	S	S
00931	REQUIRED TOOTH FOR PROCEDURE INVALID	N			N	N		N	N	N	S	N						N	N	N	N
01004	THRU SERVICE DATE INVALID	H			N	H		H	H	N	H	H						H	H	H	H
01006	THRU SERVICE PRIOR TO FROM SERVICE DATE	H			N	H		H	H	N	H	H						H	H	H	H
01042	UNITS NOT CONSISTENT W/ SVC DT	N			N	N		N	N	N	N	N						N	N	N	N
01044	SVC DTS CANNOT SPAN MONTHS	N			N	N		N	N	N	N	N						N	N	N	N
01046	SUBMTD UNITS NOT EVENLY DIVISB	N			N	N		N	N	N	N	N						N	N	N	N
01073	PROC CD FOR BLOCK BILL INVALID	N			N	N		N	N	N	N	N						N	N	N	N
01292	DATE OF SERVICE TWO YEARS PRIOR TO DATE RECEIVED	H			H	H		H	H	N	H	H						H	H	H	H
01608	ERROR OVERFLOW	H			H	H		H	H	H	H	H						H	H	H	H
01610	MISSING OR INVALID ALTERNATE PRODUCT CODE	N			N	N		N	N	S	N	N						N	N	N	N
01705	REVENUE CODE NOT ON FILE	H			H	H		H	H	N	N	N						N	N	N	N
01714	REVENUE CODE MISSING	N			N	N		N	N	N	N	N						N	N	N	N
01718	TYPE OF BILL IS INVALID	H			H	H		H	H	N	N	N						N	N	N	N
01724	LINE DOS OUTSIDE FROM/THROUGH DATES	H			N	N		H	H	N	N	N						N	N	N	N
01737	VALUE AMOUNT INVALID FOR SUBMITTED VALUE CODE	N			H	N		N	N	N	N	N						N	N	N	N
02002	RX SERIAL NO MISSING	N			N	N		N	N	S	N	N						N	N	N	N
02022	MISSING REFERRING NPI	S			S	S		S	S	S	N	N						N	N	N	N
02023	MISSING ATTENDING NPI	S			S	S		S	S	N	N	N						N	N	N	N
02024	MISSING OPERATING NPI	N			S	N		N	N	N	N	N						N	N	N	N
02025	MISSING RENDERING NPI	N			N	N		N	N	N	S	S						S	S	S	S
02029	MISSING PRESCRIBING NPI	N			N	N		N	N	S	N	N						N	N	N	N
02030	INVALID BILLING NPI	H			H	H		H	H	H	H	H						H	H	H	H
02031	INVALID GROUP NPI	N			N	N		N	N	N	H	N						N	N	N	N
02032	INVALID REFERRING NPI	S			S	S		S	S	S	N	N						N	N	N	N
02033	INVALID ATTENDING NPI	H			H	H		H	H	N	N	N						N	N	N	N
02034	INVALID OPERATING NPI	N			S	N		N	N	N	N	N						N	N	N	N
02035	INVALID RENDERING NPI	N			N	N		N	N	N	S	S						S	S	S	S
02036	INVALID SUPERVISING NPI	N			N	N		N	N	N	N	H						H	N	H	H
02037	INVALID OTHER NPI	N			N	N		N	N	N	H	H						H	H	H	H
02038	INVALID ASSISTANT SURGEON NPI	N			N	N		N	N	N	H	N						N	N	N	N
02039	INVALID PRESCRIBING NPI	N			N	N		N	N	S	N	N						N	N	N	N
02066	DRUG CODE MISSING	H			N	N		N	N	N	N	H						N	N	N	S
02070	INVALID ORDERING NPI	N			N	N		N	N	N	N	N						N	N	N	N
02079	POA CODE MISSION OR INVALID	N			H	N		N	N	N	N	N						N	N	N	N
02116	MISSING RX ORIGIN CODE	N			N	N		N	N	S	N	N						N	N	N	N
02117	INVALID RX ORIGIN CODE	N			N	N		N	N	S	N	N						N	N	N	N
02171	NDC OCCURS MORE THAN ONCE	N			N	N		N	N	S	N	N						N	N	N	N
02174	ICD VERSION CODE INVALID	S			S	S		S	S	S	N	S						S	S	S	S
02193	CONTROLLED SUBSTANCE LIMIT EXCEEDED	N			N	N		N	N	S	N	N						N	N	N	N
02210	ICD-9 PROC DATE AFTER SERVICE DATE	N			S	N		N	N	N	N	N						N	N	N	N
02211	ICD-9 PROC WITHOUT DATE	N			S	N		N	N	N	N	N						N	N	N	N

Legend: F=Fatal; H=Hard Edit (Deny); S=Soft Edit (Accept); N=Non-Edit (Ignore)

Data Element	Width	Record Positions
Encounter Control Number	11	1-11
Claim Line Number	04	12-15
Edit Status Code	01	16
Claim Edit Code	05	17-21
COS Code ("EN" precedes code)	04	22-25
TCN	16	26-41
Plan ID	08	42-49
TSN	03	50-52
Filler	28	53-80

ECN	= '00000000001'
Line Number	= '0000'
Edit Status Code	= 'P' [Paid/Accepted]
COS	= 'EN01'
TCN	= '0522000001549520'
Plan ID	= '12345678'
TSN	= 'ABC'

ECN	= '00000000002'
Line Number	= '0000'
Edit Status Code	= '2' [Deny/Rejected]
Claim Edit Code	= '00175' [Servicing Provider Id Not on File]
COS	= 'EN01'
TCN	= '0522000001549540'
Plan ID	= '12345678'
TSN	= 'ABC'

ECN	= '00000000003'
Line Number	= '0002'
Edit Status Code	= '2' [Deny/Rejected]
Claim Edit Code	= '00170' [Procedure Code Not on File]
COS	= 'EN01'
TCN	= '0522000001549560'
Plan ID	= '12345678'
TSN	= 'ABC'

Department of Health

MEDS III Data Element Dictionary

Version 3.4December 2014

Prepared by:

MEDS III DATA ELEMENT DICTIONARY

Table of Contents

I. Introduction

II. ENCOUNTER TYPE ASSIGNMENT BY CATEGORY OF SERVICE

III. MEDS III DATA ELEMENT REPORTING

IV. ENCOUNTER TYPE ASSIGNMENT BY COS: REQUIREMENTS BY MEDS III DATA ELEMENT

V. HEADER RECORD

MEDS III Transaction Segment: Header

MEDS III Transaction Segment: Header

MEDS III Transaction Segment: Header

MEDS III Transaction Segment: Header

MEDS III Transaction Segment: Header

MEDS III Transaction Segment: Header

MEDS III Transaction Segment: Header

MEDS III Transaction Segment: Header

MEDS III Transaction Segment: Header

MEDS III Transaction Segment: Header

MEDS III Transaction Segment: Header

MEDS III Transaction Segment: Header

MEDS III Transaction Segment: Header

MEDS III Transaction Segment: Header

MEDS III Transaction Segment: Header

MEDS III Transaction Segment: Header

MEDS III Transaction Segment: Header

VI. COMMON DETAIL

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

Important Note:

MEDS III Transaction Segment: Common Detail

Important Note:

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

Important Note:

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

MEDS III Transaction Segment: Common Detail

VII. INSTITUTIONAL

MEDS III Transaction Segment: Institutional

MEDS III Transaction Segment: Institutional

Please Note:

MEDS III Transaction Segment: Institutional

MEDS III Transaction Segment: Institutional

MEDS III Transaction Segment: Institutional

MEDS III Transaction Segment: Institutional

MEDS III Transaction Segment: Institutional

MEDS III Transaction Segment: Institutional

MEDS III Transaction Segment: Institutional

MEDS III Transaction Segment: Institutional

MEDS III Transaction Segment: Institutional

MEDS III Transaction Segment: Institutional

MEDS III Transaction Segment: Institutional

MEDS III Transaction Segment: Institutional

MEDS III Transaction Segment: Institutional

MEDS III Transaction Segment: Institutional

MEDS III Transaction Segment: Institutional

MEDS III Transaction Segment: Institutional

MEDS III Transaction Segment: Institutional

MEDS III Transaction Segment: Institutional

Version 3.4
December 2014