Code of Maine Rules
90 - INDEPENDENT AGENCIES
590 - MAINE HEALTH DATA ORGANIZATION
Chapter 243 - UNIFORM REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS
Appendix 590-243-G-2 - Maine Health Data Organization Capitated Payments File Mapping to National Standards

Universal Citation: 90 ME Code Rules ยง 590-243-G-2
Current through 2024-38, September 18, 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

CF001

Submitter

N/A

N/A

N/A

CF002

Payor

N/A

N/A

N/A

CF003

Insurance Type/Product Code

N/A

N/A

835/2100/CLP/06

CF004

Subscriber Social Security Number

N/A

N/A

835/2100/NM1/MI/09

CF005

Member Identification Code

N/A

N/A

835/2100/NM1/34/09

CF006

Plan Specific Contract Number

60 (A-C)

1a

835/2100/NM1/MI/09

CF007

Member Suffix or Sequence Number

N/A

N/A

N/A

CF008

Carrier Specific Unique Member (CSUM) ID

N/A

N/A

N/A

CF009

Insured Group or Policy Number

62 (A-C)

11

837/2000B/SBR/03

CF010

Monetary Amount/Provider Adjustment Amount

N/A

N/A

835/PLB/CT/04

CF011

Payment Subcategory

N/A

N/A

N/A

CF012

Performance Period Year

N/A

N/A

N/A

CF013

Performance Period Month

N/A

N/A

N/A

CF014

Withhold Amount

N/A

N/A

835/PLB/E3/04

CF015

Member Gender

11

3

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

CF016

Member Date of Birth

10

3

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

CF017

Rendering Provider Specialty

N/A

N/A

professional:

837/2420A/PRV/PXC/03;

837/2310B/PRV/PXC/03;

institutional:

837/2000A/PRV/PXC/03

CF018

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

CF019

Rendering Provider Tax ID

5

25 (only if EIN)

835/2100/NM1/FI/09

CF020

National Provider ID - Rendering Provider

56

24J

835/PLB/01;

professional:

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

institutional:

837/2010AA/NM1/XX/09

CF021

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

CF022

Rendering Provider First Name

N/A

31

professional:

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

institutional:

N/A

CF023

Billing Provider Number

57

33b

837/2010BB/REF/G2/02

CF024

Billing Provider Tax ID

NA

NA

837/2010AA/REF/EI/02

CF025

National Provider ID - Billing Provider

56

33a

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

CF026

Billing Provider Last Name or Organization Name

1

33

837/2010AA/NM1/85/ /03

CF027

Member First Name

8b

2

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

CF028

Member Middle Name

8b

2

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

CF029

Member Last Name

8b

2

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

CF030

Member Address Line 1

9a

5

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

CF031

Member Address Line 2

9a

5

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

CF032

Member City Name

9b

5

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

CF033

Member State or Province

9c

5

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

CF034

Member ZIP Code

9d

5

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

CF035

Substance Use Disorder (SUD) Indicator

N/A

N/A

N/A

CF899

Record Type

N/A

N/A

N/A

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