Code of Maine Rules
90 - INDEPENDENT AGENCIES
590 - MAINE HEALTH DATA ORGANIZATION
Chapter 241 - UNIFORM REPORTING SYSTEM FOR HOSPITAL INPATIENT DATA SETS AND HOSPITAL OUTPATIENT DATA SETS
Appendix 590-241-C-2 - Maine Health Data Organization

Data Element #

Data Element Name

UB-04 Form Locator

CMS-1500

HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/Segment ID/Code Value/Reference Designator

OP7101

Record Type

NA

NA

NA

OP7102

Sequence Number

NA

NA

NA

OP7103

Patient Control Number

3A

26

837/2300/CLM/01

OP7104

Principal Diagnosis

67

21A

837/2300/HI/ABK/01-2

OP7107

Reason for Visit Diagnosis - 1

70A

NA

837/2300/HI/APR/01-2

OP7108

Reason for Visit Diagnosis - 2

70B

NA

837/2300/HI/APR/02-2

OP7109

Reason for Visit Diagnosis - 3

70C

NA

837/2300/HI/APR/03-2

OP7110

Principal Procedure Code

74

NA

837/2300/HI/BBR/01-2

OP7111

Principal Procedure Date

74

NA

837/2300/HI/D8/01-4

Data Element #

Data Element Name

UB-04 Form Locator

CMS-1500

HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator

OP7201

Record Type

NA

NA

NA

OP7202

Sequence Number

NA

NA

NA

OP7203

Patient Control Number

3A

26

837/2300/CLM/01

OP7204

Other Procedure Code - 1

74A

NA

837/2300/HI/BBQ/01-2

OP7205

Other Procedure Date - 1

74A

NA

837/2300/HI/D8/01-4

OP7206

Other Procedure Code - 2

74B

NA

837/2300/HI/BBQ/02-2

OP7207

Other Procedure Date - 2

74B

NA

837/2300/HI/D8/02-4

OP7208

Other Procedure Code - 3

74C

NA

837/2300/HI/BBQ/03-2

OP7209

Other Procedure Date - 3

74C

NA

837/2300/HI/D8/03-4

OP7210

Other Procedure Code - 4

74D

NA

837/2300/HI/BBQ/04-2

OP7211

Other Procedure Date - 4

74D

NA

837/2300/HI/D8/04-4

OP7212

Other Procedure Code - 5

74E

NA

837/2300/HI/BBQ/05-2

OP7213

Other Procedure Date - 5

74E

NA

837/2300/HI/D8/05-4

OP7214

Other Procedure Code - 6

NA

NA

837/2300/HI/BBQ/06-2

OP7215

Other Procedure Date - 6

NA

NA

837/2300/HI/D8/06-4

OP7216

Other Procedure Code - 7

NA

NA

837/2300/HI/BBQ/07-2

OP7217

Other Procedure Date - 7

NA

NA

837/2300/HI/D8/07-4

OP7218

Other Procedure Code - 8

NA

NA

837/2300/HI/BBQ/08-2

OP7219

Other Procedure Date - 8

NA

NA

837/2300/HI/D8/08-4

Data Element #

Data Element Name

UB-04 Form Locator

CMS-1500

HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator

OP7301

Record Type

NA

NA

NA

OP7302

Sequence Number

NA

NA

NA

OP7303

Patient Control Number

3A

26

837/2300/CLM/01

OP7304

External Cause of Injury - 1

72A

NA

837/2300/HI/ABN/01-2

OP7306

External Cause of Injury - 2

72B

NA

837/2300/HI/ABN/02-2

OP7308

External Cause of Injury - 3

72C

NA

837/2300/HI/ABN/03-2

OP7310

External Cause of Injury - 4

NA

NA

837/2300/HI/ABN/04-2

OP7312

External Cause of Injury - 5

NA

NA

837/2300/HI/ABN/05-2

OP7314

External Cause of Injury - 6

NA

NA

837/2300/HI/ABN/06-2

OP7316

External Cause of Injury - 7

NA

NA

837/2300/HI/ABN/07-2

OP7318

External Cause of Injury - 8

NA

NA

837/2300/HI/ABN/08-2

OP7320

External Cause of Injury - 9

NA

NA

837/2300/HI/ABN/09-2

OP7322

External Cause of Injury - 10

NA

NA

837/2300/HI/ABN/10-2

OP7324

External Cause of Injury - 11

NA

NA

837/2300/HI/ABN/11-2

OP7326

External Cause of Injury - 12

NA

NA

837/2300/HI/ABN/12-2

Data Element #

Data Element Name

UB-04 Form Locator

CMS-1500

HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/Segment ID/Code Value/Reference Designator

OP7401

Record Type

NA

NA

NA

OP7402

Sequence Number

NA

NA

NA

OP7403

Patient Control Number

3A

26

837/2300/CLM/01

OP7404

Other Diagnosis Code - 1

67A

21B

837I/2300/HI/ABF/01-2

837P/2300/HI/ABF/02-2

OP7406

Other Diagnosis Code - 2

67B

21C

837I/2300/HI/ABF/02-2

837P/2300/HI/ABF/03-2

OP7408

Other Diagnosis Code - 3

67C

21D

837I/2300/HI/ABF/03-2

837P/2300/HI/ABF/04-2

OP7410

Other Diagnosis Code - 4

67D

21E

837I/2300/HI/ABF/04-2

837P/2300/HI/ABF/05-2

OP7412

Other Diagnosis Code - 5

67E

21F

837I/2300/HI/ABF/05-2

837P/2300/HI/ABF/06-2

OP7414

Other Diagnosis Code - 6

67F

21G

837I/2300/HI/ABF/06-2

837P/2300/HI/ABF/07-2

OP7416

Other Diagnosis Code - 7

67G

21H

837I/2300/HI/ABF/07-2

837P/2300/HI/ABF/08-2

OP7418

Other Diagnosis Code - 8

67H

21I

837I/2300/HI/ABF/08-2

837P/2300/HI/ABF/09-2

OP7420

Other Diagnosis Code - 9

67I

21J

837I/2300/HI/ABF/09-2

837P/2300/HI/ABF/10-2

OP7422

Other Diagnosis Code - 10

67J

21K

837I/2300/HI/ABF/10-2

837P/2300/HI/ABF/11-2

OP7424

Other Diagnosis Code - 11

67K

21L

837I/2300/HI/ABF/11-2

837P/2300/HI/ABF/12-2

OP7426

Other Diagnosis Code - 12

67L

NA

837I/2300/HI/ABF/12-2

Data Element #

Data Element Name

UB-04 Form Locator

CMS-1500

HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/Segment ID/Code Value/Reference Designator

OP8001

Record Type

NA

NA

NA

OP8002

Sequence

NA

NA

NA

OP8003

Patient Control Number

3A

26

837/2300/CLM/01

OP8004

Attending Provider NPI

76

NA

837/2310A/NM1/71/1/XX/09

OP8005

Operating Physician NPI

77

NA

837/2310B/NM1/72/1/XX/09

OP8006

Attending Provider Last Name

76

NA

837/2310A/NM1/71/1/03

OP8007

Attending Provider First Name

76

NA

837/2310A/NM1/71/1/04

OP8008

Attending Provider Middle Initial

76

NA

837/2310A/NM1/71/1/05

OP8009

Operating Physician Last Name

77

NA

837/2310B/NM1/72/1/03

OP8010

Operating Physician First Name

77

NA

837/2310B/NM1/72/1/04

OP8011

Operating Physician Middle Initial

77

NA

837/2310B/NM1/72/1/05

OP8012

Billing Provider NPI

56

NA

837/2010AA/NM1/XX/09

OP9001

Record Type

NA

NA

NA

OP9003

Patient Control Number

3A

26

837/2300/CLM/01

OP9004

Total Ancillary Charges - Revenue Centers

NA

28

This is the total of the SV2 segments with the exception of Revenue Code 0001

Data Element #

Data Element Name

UB-04 Form Locator

CMS-1500

HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator

OP9901

Record Type

NA

NA

NA