Code of Maine Rules
90 - INDEPENDENT AGENCIES
590 - MAINE HEALTH DATA ORGANIZATION (MHDO)
Chapter 243 - UNIFORM REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS
Appendix 590-243-D-2 - Maine Health Data Organization Medical Claims File Mapping to National Standards

Universal Citation: 90 ME Code Rules ยง 590-243-D-2
Current through 2024-13, March 27, 2024

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

MC001

Submitter

N/A

N/A

N/A

MC002

Payer

N/A

N/A

N/A

MC003

Insurance Type/Product Code

N/A

N/A

835/2100/CLP/06

MC004

Payer Claim Control Number

N/A

N/A

835/2100/CLP/07

MC005

Line Counter

N/A

N/A

837/2400/LX/01

MC005A

Version Number

N/A

N/A

N/A

MC006

Insured Group or Policy Number

62 (A-C)

11

837/2000B/SBR/03

MC007

Subscriber Social Security Number

N/A

N/A

835/2100/NM1/MI/09

MC008

Plan Specific Contract Number

60 (A-C)

1a

835/2100/NM1/MI/09

MC009

Member Suffix or Sequence Number

N/A

N/A

N/A

MC010

Member Identification Code

N/A

N/A

835/2100/NM1/34/09

MC011

Individual Relationship Code

59 (A-C)

6

837/2000B/SBR/02, 837/2000C/PAT/01

MC012

Member Gender

11

3

837/2010BA/DMG/03, 837/2010CA/DMG/03

MC013

Member Date of Birth

10

3

837/2010BA/DMG/D8/02, 837/2010CA/DMG/D8/02

MC014

Member City Name

9b

5

837/2010BA/N4/01, 837/2010CA/N4/01

MC015

Member State or Province

9c

5

837/2010BA/N4/02, 837/2010CA/N4/02

MC016

Member ZIP Code

9d

5

837/2010BA/N4/03, 837/2010CA/N4/03

MC017

Date Service Approved

N/A

N/A

835/Header Financial Information/BPR/16

MC018

Admission Date

12

18

837/2300/DTP/435/03

MC019

Admission Hour

13

N/A

837/2300/DTP/435/03

MC020

Priority (Type) of Admission or Visit

14

N/A

837/2300/CL1/01

MC021

Point of Origin for Admission or Visit

15

N/A

837/2300/CL1/02

MC022

Discharge Hour

16

N/A

837/2300/DTP/096/03

MC023

Patient Discharge Status

17

N/A

837/2300/CL1/03

MC024

Rendering Provider Number

57

N/A

835/2100/REF/1A/02, 835/2100/REF/1B/02, 835/2100/REF/1C/02, 835/2100/REF/1D/02, 835/2100/REF/G2/02, 835/2100/NM1/BD/09, 835/2100/NM1/BS/09, 835/2100/NM1/MC/09, 835/2100/NM1/PC/09

MC025

Rendering Provider Tax ID Number

5

25 (only if EIN)

835/2100/NM1/FI/09

MC026

National Provider ID - Rendering Provider

56

24J

professional:

837/2420A/NM1/XX/09; 837/2310B/NM1/XX/09;

institutional:

837/2010AA/NM1/XX/09

MC027

Rendering Provider Entity Type Qualifier

N/A

N/A

professional:

837/2420A/NM1/82/02; 837/2310B/NM1/82/02;

institutional:

837/2010AA/NM1/85/02

MC028

Rendering Provider First Name

N/A

31

professional:

837/2420A/NM1/82/04; 837/2310B/NM1/82/04;

institutional:

N/A

MC029

Rendering Provider Middle Name

N/A

31

professional:

837/2420A/NM1/82/05; 837/2310B/NM1/82/05;

institutional:

N/A

MC030

Rendering Provider Last Name or Organization Name

1

31

professional:

837/2420A/NM1/82/1/03; 837/2310B/NM1/82/1/03;

institutional:

837/2010AA/NM1/85/2/03

MC031

Rendering Provider Suffix

N/A

31

professional:

837/2420A/NM1/82/07; 837/2310B/NM1/82/07;

institutional:

N/A

MC032

Rendering Provider Specialty

N/A

N/A

professional:

837/2420A/PRV/PXC/03; 837/2310B/PRV/PXC /03;

institutional:

837/2000A/PRV/PXC/03

MC033

Placeholder

N/A

N/A

N/A

MC034

Placeholder

N/A

N/A

N/A

MC035

Placeholder

N/A

N/A

N/A

MC036

Type of Bill - Institutional

4

N/A

837/2300/CLM/05-1

MC037

Place of Service - Professional

N/A

24B

837/2300/CLM/05-1

MC038

Claim Status

N/A

N/A

835/2100/CLP/02

MC039

Admitting Diagnosis

69

N/A

837/2300/HI/BJ/01-2

MC040

E-Code

72

N/A

837/2300/HI/BN/01-2

MC041

Principal Diagnosis

67

21.1

837/2300/HI/BK/01-2

MC042

Other Diagnosis - 1

67A

21.2

837/2300/HI/BF/01-2

MC043

Other Diagnosis - 2

67B

21.3

837/2300/HI/BF/02-2

MC044

Other Diagnosis - 3

67C

21.4

837/2300/HI/BF/03-2

MC045

Other Diagnosis - 4

67D

N/A

837/2300/HI/BF/04-2

MC046

Other Diagnosis - 5

67E

N/A

837/2300/HI/BF/05-2

MC047

Other Diagnosis - 6

67F

N/A

837/2300/HI/BF/06-2

MC048

Other Diagnosis - 7

67G

N/A

837/2300/HI/BF/07-2

MC049

Other Diagnosis - 8

67H

N/A

837/2300/HI/BF/08-2

MC050

Other Diagnosis - 9

67I

N/A

837/2300/HI/BF/09-2

MC051

Other Diagnosis -10

67J

N/A

837/2300/HI/BF/10-2

MC052

Other Diagnosis -11

67K

N/A

837/2300/HI/BF/11-2

MC053

Other Diagnosis -12

67L

N/A

837/2300/HI/BF/12-2

MC054

Revenue Code

42

N/A

835/2110/SVC/NU/01-2, 835/2110/SVC/04

MC055

Procedure Code

44

24D

835/2110/SVC/HC/01-2, 835/2110/SVC/HP/01-2

MC056

Procedure Modifier - 1

44

24D

835/2110/SVC/HC/01-3

MC057

Procedure Modifier - 2

44

24D

835/2110/SVC/HC/01-4

MC057A

Procedure Modifier - 3

44

24D

835/2110/SVC/HC/01-5

MC057B

Procedure Modifier - 4

44

24D

835/2110/SVC/HC/01-6

MC058

ICD-9-CM Procedure Code

74

N/A

837/2300/HI/BR/01-2

MC059

Date of Service - From

45

24A

837/2400/DTP/472/D8

MC060

Date of Service - Thru

N/A

24A

837/2400/DTP/472/D8

MC061

Quantity

46

24G

835/2110/SVC/05

MC062

Charge Amount

47

24F

835/2110/SVC/02

MC063

Paid Amount

N/A

N/A

835/2110/SVC/03

MC064

Prepaid Amount

N/A

N/A

835/2110/CAS/CO/03

MC065

Co-pay Amount

N/A

N/A

835/2110/CAS/PR/3-03

MC066

Coinsurance Amount

N/A

N/A

835/2110/CAS/PR/2-03

MC067

Deductible Amount

N/A

N/A

835/2110/CAS/PR/1-03

MC068

Patient Account/Control Number

3a

26

837/2300/CLM/01

MC069

Discharge Date

6

18

837/2300/DTP/434/03

MC070

Placeholder

N/A

N/A

N/A

MC071

DRG

N/A

N/A

837/2300/HI/DR/01-2

MC072

DRG Version

N/A

N/A

N/A

MC073

APC

N/A

N/A

835/2110/REF/APC/02

MC074

APC Version

N/A

N/A

N/A

MC075

Drug Code

N/A

N/A

837/2410/LIN/N4/03

MC076

Billing Provider Number

57

33b

837/2010BB/REF/G2/02

MC077

National Provider ID - Billing Provider

56

33a

837/2010AA/NM1/85/ /XX/09

MC078

Billing Provider Last Name

1

33

837/2010AA/NM1/85/ /03

MC079

Billing Provider Tax ID Number

NA

NA

837/2010AA/REF/EI/02

MC080

Billing Provider Address Line 1

1

33

837/2010AA/N3/01

MC081

Billing Provider Address Line 2

1

33

837/2010AA/N3/02

MC082

Billing Provider City Name

1

33

837/2010AA/N4/01

MC083

Billing Provider State or Province

1

33

837/2010AA/N4/02

MC084

Billing Provider Zip Code

1

33

837/2010AA/N4/03

MC085

Service Facility Location Name

1

32

professional:

837/2310C/NM1/77/2/03;

institutional:

837/2310E/NM1/77/2/03

MC086

National Provider ID - Service Facility

56

32a

professional:

837/2310C/NM1/77/2/XX/09;

institutional:

837/2310E/NM1/77/2/XX/09

MC087

Service Facility Location Address Line 1

1

32

professional:

837/2310C/N3/01;

institutional: 837/2310E/N3/01

MC088

Service Facility Location Address Line 2

1

32

professional:

837/2310C/N3/02;

institutional:

837/2310E/N3/02

MC089

Service Facility Location City Name

1

32

professional:

837/2310C/N4/01;

institutional:

837/2310E/N4/01

MC090

Service Facility Location Address State or Province

1

32

professional:

837/2310C/N4/02;

institutional:

837/2310E/N4/02

MC091

Service Facility Location Address Zip Code

1

32

professional:

837/2310C/N4/03;

institutional:

837/2310E/N4/03

MC092

Service Facility Number

57

32b

professional:

837/2310C/REF/G2/02;

institutional:

837/2310E /REF/G2/02

MC093

Service Facility Location Country Code

(1)

(32)

professional:

837/2310C/N4/04;

institutional:

837/2310E/N4/04

MC094

Billing Provider Country Code

(1)

(33)

837/2010AA/N4/04

MC101

Subscriber Last Name

58(A-C)

4

837/2010BA/NM1/ /03

MC102

Subscriber First Name

58(A-C)

4

837/2010BA/NM1/ /04

MC103

Subscriber Middle Name

N/A

4

837/2010BA/NM1/ /05

MC104

Member Last Name

8b

2

837/2010CA/NM1/ /03, 837/2010BA/NM1/ /03

MC105

Member First Name

8b

2

837/2010CA/NM1/ /04, 837/2010BA/NM1/ /04

MC106

Member Middle Name

8b

2

837/2010CA/NM1/ /05, 837/2010BA/NM1/ /05

MC107

Attending Provider Number

N/A

N/A

professional: N/A

institutional:

837/2310A/REF/G2/02

MC108

National Provider ID - Attending Provider

76

N/A

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

MC109

Attending Provider First Name

76

N/A

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

MC110

Attending Provider Middle Name

N/A

N/A

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

MC111

Attending Provider Last Name

76

N/A

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

MC112

Attending Provider Suffix

N/A

N/A

837/2310A/NM1/71/1/07

MC113

Attending Provider Specialty

N/A

N/A

837/2310A/PRV/AT/PXC/03

MC114

Operating Provider Number

N/A

N/A

professional: N/A

institutional:

837/2310B/REF/G2/02; 837/2420A/REF/G2/02

MC115

National Provider ID - Operating Provider

77

N/A

professional: N/A

institutional:

837/2420A/NM1/72/1/XX/09; 837/2420A/NM1/72/1/XX/09

MC116

Operating Provider First Name

77

N/A

professional: N/A

institutional:

837/2420A/NM1/72/1/04; 837/2420A/NM1/72/1/04

MC117

Operating Provider Middle Name

N/A

N/A

professional: N/A

institutional:

837/2420A/NM1/72/1/05; 837/2420A/NM1/72/1/05

MC118

Operating Provider Last Name

77

N/A

professional: N/A

institutional:

837/2420A/NM1/72/1/03; 837/2420A/NM1/72/1/03

MC119

Operating Provider Suffix

N/A

N/A

professional: N/A

institutional:

837/2420A/NM1/72/1/07; 837/2420A/NM1/72/1/07

MC120

Referring Provider Number

N/A

N/A

professional:

837/2310A/REF/G2/02; 837/2420F/REF/G2/02

institutional:

837/2310F/REF/G2/02; 837/2420D/REF/G2/02

MC121

National Provider ID - Referring Provider

78 or 79

17b

professional:

837/2310A/NM1/DN/1/XX/09; 837/2420F/NM1/DN/1/XX/09

institutional:

837/2310F/NM1/DN/1/XX/09; 837/2420D/NM1/DN/1/XX/09

MC122

Referring Provider First Name

78 or 79

17

professional:

837/2310A/NM1/DN/1/04; 837/2420F/NM1/DN/1/04

institutional:

837/2310F/NM1/DN/1/04; 837/2420D/NM1/DN/1/04

MC123

Referring Provider Middle Name

N/A

17

professional:

837/2310A/NM1/DN/1/05; 837/2420F/NM1/DN/1/05

institutional:

837/2310F/NM1/DN/1/05; 837/2420D/NM1/DN/1/05

MC124

Referring Provider Last Name

78 or 79

17

professional:

837/2310A/NM1/DN/1/03; 837/2420F/NM1/DN/1/03

institutional:

837/2310F/NM1/DN/1/03; 837/2420D/NM1/DN/1/03

MC125

Referring Provider Suffix

N/A

17

professional:

837/2310A/NM1/DN/1/07; 837/2420F/NM1/DN/1/07

institutional:

837/2310F/NM1/DN/1/07; 837/2420D/NM1/DN/1/07

MC200

Principal Diagnosis

67

N/A

837/2300/HI/ABK/01-2

MC201

Present On Admission Indicator

67 (pos 8)

N/A

837/2300/HI/01-9

MC202

Admitting Diagnosis

69

N/A

837/2300/HI/ABJ/01-2

MC203

Reason for Visit Diagnosis - 1

70A

N/A

837/2300/HI/APR/01-2

MC204

Reason for Visit Diagnosis - 2

70B

N/A

837/2300/HI/APR/02-2

MC205

Reason for Visit Diagnosis - 3

70C

N/A

837/2300/HI/APR/03-2

MC206

External Cause of Injury - 1

72A

N/A

837/2300/HI/ABN/01-2

MC207

Present On Admission Indicator - 1

72A (pos 8)

N/A

837/2300/HI/01-9

MC208

External Cause of Injury - 2

72B

N/A

837/2300/HI/ABN/02-2

MC209

Present On Admission Indicator - 2

72B (pos 8)

N/A

837/2300/HI/02-9

MC210

External Cause of Injury - 3

72C

N/A

837/2300/HI/ABN/03-2

MC211

Present On Admission Indicator - 3

72C (pos 8)

N/A

837/2300/HI/03-9

MC212

External Cause of Injury - 4

N/A

N/A

837/2300/HI/ABN/04-2

MC213

Present On Admission Indicator - 4

N/A

N/A

837/2300/HI/04-9

MC214

External Cause of Injury - 5

N/A

N/A

837/2300/HI/ABN/05-2

MC215

Present On Admission Indicator - 5

N/A

N/A

837/2300/HI/05-9

MC216

External Cause of Injury - 6

N/A

N/A

837/2300/HI/ABN/06-2

MC217

Present On Admission Indicator - 6

N/A

N/A

837/2300/HI/06-9

MC218

External Cause of Injury - 7

N/A

N/A

837/2300/HI/ABN/07-2

MC219

Present On Admission Indicator - 7

N/A

N/A

837/2300/HI/07-9

MC220

External Cause of Injury - 8

N/A

N/A

837/2300/HI/ABN/08-2

MC221

Present On Admission Indicator - 8

N/A

N/A

837/2300/HI/08-9

MC222

External Cause of Injury - 9

N/A

N/A

837/2300/HI/ABN/09-2

MC223

Present On Admission Indicator - 9

N/A

N/A

837/2300/HI/09-9

MC224

External Cause of Injury - 10

N/A

N/A

837/2300/HI/ABN/10-2

MC225

Present On Admission Indicator - 10

N/A

N/A

837/2300/HI/10-9

MC226

External Cause of Injury - 11

N/A

N/A

837/2300/HI/ABN/11-2

MC227

Present On Admission Indicator - 11

N/A

N/A

837/2300/HI/11-9

MC228

External Cause of Injury - 12

N/A

N/A

837/2300/HI/ABN/12-2

MC229

Present On Admission Indicator - 12

N/A

N/A

837/2300/HI/12-9

MC230

External Cause of Injury - 13

N/A

N/A

837/2300/HI/ABN/01-2

MC231

Present On Admission Indicator - 13

N/A

N/A

837/2300/HI/01-9

MC232

External Cause of Injury - 14

N/A

N/A

837/2300/HI/ABN/02-2

MC233

Present On Admission Indicator - 14

N/A

N/A

837/2300/HI/02-9

MC234

External Cause of Injury - 15

N/A

N/A

837/2300/HI/ABN/03-2

MC235

Present On Admission Indicator - 15

N/A

N/A

837/2300/HI/03-9

MC236

External Cause of Injury - 16

N/A

N/A

837/2300/HI/ABN/04-2

MC237

Present On Admission Indicator - 16

N/A

N/A

837/2300/HI/04-9

MC238

External Cause of Injury - 17

N/A

N/A

837/2300/HI/ABN/05-2

MC239

Present On Admission Indicator - 17

N/A

N/A

837/2300/HI/05-9

MC240

External Cause of Injury - 18

N/A

N/A

837/2300/HI/ABN/06-2

MC241

Present On Admission Indicator - 18

N/A

N/A

837/2300/HI/06-9

MC242

External Cause of Injury - 19

N/A

N/A

837/2300/HI/ABN/07-2

MC243

Present On Admission Indicator - 19

N/A

N/A

837/2300/HI/07-9

MC244

External Cause of Injury - 20

N/A

N/A

837/2300/HI/ABN/08-2

MC245

Present On Admission Indicator - 20

N/A

N/A

837/2300/HI/08-9

MC246

External Cause of Injury - 21

N/A

N/A

837/2300/HI/ABN/09-2

MC247

Present On Admission Indicator - 21

N/A

N/A

837/2300/HI/09-9

MC248

External Cause of Injury - 22

N/A

N/A

837/2300/HI/ABN/10-2

MC249

Present On Admission Indicator - 22

N/A

N/A

837/2300/HI/10-9

MC250

External Cause of Injury - 23

N/A

N/A

837/2300/HI/ABN/11-2

MC251

Present On Admission Indicator - 23

N/A

N/A

837/2300/HI/11-9

MC252

External Cause of Injury - 24

N/A

N/A

837/2300/HI/ABN/12-2

MC253

Present On Admission Indicator - 24

N/A

N/A

837/2300/HI/12-9

MC254

Other Diagnosis - 1

67A

21A

837/2300/HI/ABF/01-2

MC255

Present On Admission Indicator - 1

67A (pos 8)

N/A

837/2300/HI/01-9

MC256

Other Diagnosis - 2

67B

21B

837/2300/HI/ABF/02-2

MC257

Present On Admission Indicator - 2

67B (pos 8)

N/A

837/2300/HI/02-9

MC258

Other Diagnosis - 3

67C

21C

837/2300/HI/ABF/03-2

MC259

Present On Admission Indicator - 3

67C (pos 8)

N/A

837/2300/HI/03-9

MC260

Other Diagnosis - 4

67D

21D

837/2300/HI/ABF/04-2

MC261

Present On Admission Indicator - 4

67D (pos 8)

N/A

837/2300/HI/04-9

MC262

Other Diagnosis - 5

67E

21E

837/2300/HI/ABF/05-2

MC263

Present On Admission Indicator - 5

67E (pos 8)

N/A

837/2300/HI/05-9

MC264

Other Diagnosis - 6

67F

21F

837/2300/HI/ABF/06-2

MC265

Present On Admission Indicator - 6

67F (pos 8)

N/A

837/2300/HI/06-9

MC266

Other Diagnosis - 7

67G

21G

837/2300/HI/ABF/07-2

MC267

Present On Admission Indicator - 7

67G (pos 8)

N/A

837/2300/HI/07-9

MC268

Other Diagnosis - 8

67H

21H

837/2300/HI/ABF/08-2

MC269

Present On Admission Indicator - 8

67H (pos 8)

N/A

837/2300/HI/08-9

MC270

Other Diagnosis - 9

67I

21I

837/2300/HI/ABF/09-2

MC271

Present On Admission Indicator - 9

67I (pos 8)

N/A

837/2300/HI/09-9

MC272

Other Diagnosis - 10

67J

21J

837/2300/HI/ABF/10-2

MC273

Present On Admission Indicator - 10

67J (pos 8)

N/A

837/2300/HI/10-9

MC274

Other Diagnosis - 11

67K

21K

837/2300/HI/ABF/11-2

MC275

Present On Admission Indicator - 11

67K (pos 8)

N/A

837/2300/HI/11-9

MC276

Other Diagnosis - 12

67L

21L

837/2300/HI/ABF/12-2

MC277

Present On Admission Indicator - 12

67L (pos 8)

N/A

837/2300/HI/12-9

MC278

Other Diagnosis - 13

N/A

N/A

837/2300/HI/ABF/01-2

MC279

Present On Admission Indicator - 13

N/A

N/A

837/2300/HI/01-9

MC280

Other Diagnosis - 14

N/A

N/A

837/2300/HI/ABF/02-2

MC281

Present On Admission Indicator - 14

N/A

N/A

837/2300/HI/02-9

MC282

Other Diagnosis - 15

N/A

N/A

837/2300/HI/ABF/03-2

MC283

Present On Admission Indicator - 15

N/A

N/A

837/2300/HI/03-9

MC284

Other Diagnosis - 16

N/A

N/A

837/2300/HI/ABF/04-2

MC285

Present On Admission Indicator - 16

N/A

N/A

837/2300/HI/04-9

MC286

Other Diagnosis - 17

N/A

N/A

837/2300/HI/ABF/05-2

MC287

Present On Admission Indicator - 17

N/A

N/A

837/2300/HI/05-9

MC288

Other Diagnosis - 18

N/A

N/A

837/2300/HI/ABF/06-2

MC289

Present On Admission Indicator - 18

N/A

N/A

837/2300/HI/06-9

MC290

Other Diagnosis - 19

N/A

N/A

837/2300/HI/ABF/07-2

MC291

Present On Admission Indicator - 19

N/A

N/A

837/2300/HI/07-9

MC292

Other Diagnosis - 20

N/A

N/A

837/2300/HI/ABF/08-2

MC293

Present On Admission Indicator - 20

N/A

N/A

837/2300/HI/08-9

MC294

Other Diagnosis - 21

N/A

N/A

837/2300/HI/ABF/09-2

MC295

Present On Admission Indicator - 21

N/A

N/A

837/2300/HI/09-9

MC296

Other Diagnosis - 22

N/A

N/A

837/2300/HI/ABF/10-2

MC297

Present On Admission Indicator - 22

N/A

N/A

837/2300/HI/10-9

MC298

Other Diagnosis - 23

N/A

N/A

837/2300/HI/ABF/11-2

MC299

Present On Admission Indicator - 23

N/A

N/A

837/2300/HI/11-9

MC300

Other Diagnosis - 24

N/A

N/A

837/2300/HI/ABF/12-2

MC301

Present On Admission Indicator - 24

N/A

N/A

837/2300/HI/12-9

MC302

Principal Procedure Code

74

N/A

837/2300/HI/BBR/01-2

MC303

Other Procedure Code - 1

74A

N/A

837/2300/HI/BBQ/01-2

MC304

Other Procedure Code - 2

74B

N/A

837/2300/HI/BBQ/02-2

MC305

Other Procedure Code - 3

74C

N/A

837/2300/HI/BBQ/03-2

MC306

Other Procedure Code - 4

74D

N/A

837/2300/HI/BBQ/04-2

MC307

Other Procedure Code - 5

74E

N/A

837/2300/HI/BBQ/05-2

MC308

Other Procedure Code - 6

N/A

N/A

837/2300/HI/BBQ/06-2

MC309

Other Procedure Code - 7

N/A

N/A

837/2300/HI/BBQ/07-2

MC310

Other Procedure Code - 8

N/A

N/A

837/2300/HI/BBQ/08-2

MC311

Other Procedure Code - 9

N/A

N/A

837/2300/HI/BBQ/09-2

MC312

Other Procedure Code - 10

N/A

N/A

837/2300/HI/BBQ/10-2

MC313

Other Procedure Code - 11

N/A

N/A

837/2300/HI/BBQ/11-2

MC314

Other Procedure Code - 12

N/A

N/A

837/2300/HI/BBQ/12-2

MC315

Other Procedure Code - 13

N/A

N/A

837/2300/HI/BBQ/01-2

MC316

Other Procedure Code - 14

N/A

N/A

837/2300/HI/BBQ/02-2

MC317

Other Procedure Code - 15

N/A

N/A

837/2300/HI/BBQ/03-2

MC318

Other Procedure Code - 16

N/A

N/A

837/2300/HI/BBQ/04-2

MC319

Other Procedure Code - 17

N/A

N/A

837/2300/HI/BBQ/05-2

MC320

Other Procedure Code - 18

N/A

N/A

837/2300/HI/BBQ/06-2

MC321

Other Procedure Code - 19

N/A

N/A

837/2300/HI/BBQ/07-2

MC322

Other Procedure Code - 20

N/A

N/A

837/2300/HI/BBQ/08-2

MC323

Other Procedure Code - 21

N/A

N/A

837/2300/HI/BBQ/09-2

MC324

Other Procedure Code - 22

N/A

N/A

837/2300/HI/BBQ/10-2

MC325

Other Procedure Code - 23

N/A

N/A

837/2300/HI/BBQ/11-2

MC326

Other Procedure Code - 24

N/A

N/A

837/2300/HI/BBQ/12-2

MC327

Member Address Line 1

9a

5

837/2010BA/N3/01, 837/2010CA/N3/01

MC328

Member Address Line 2

9a

5

837/2010BA/N3/02, 837/2010CA/N3/02

MC329

Member Country Code

9e

N/A

837/2010BA/N4/04, 837/2010CA/N4/04

MC330

In-Plan Network Indicator

N/A

N/A

N/A

MC331

Payment Arrangement Type Indicator

N/A

N/A

N/A

MC899

Record Type

N/A

N/A

N/A

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