For the following file layouts, please contact the CPSA Information Systems Department at: [email protected] or at [email protected] to receive the most updated version.
837I
837P
Referral
834 (Intake, Change, Closure)
Demographic
A.1 Encounter Weekly Response File & Quarterly Resync File Layout
Version: 4.6
Version Date: 05/27/2011
Column
Position Column Name Type Size Comments/Changes
1 File_Type varchar 8 Identifies if file is a Snapshot (S) of encounters from Provider or a Change (C) to previously submitted encounters. Values for Direct Providers can also be:
EDI, Paper, Replcmnt, or VOID
2 Encounter_Type char 4 Identifies if the record is HCFA (HCFA) or a UB92 (UB92)
3 Record_Type char 1 Identifies the record as an Accepted (A), Denied (D), or InProgress (I) encounter.
4 Provider_File_Number varchar 255 The filename of the providers electronic 837 submission
5 CPSA_Batch_Number int Internal CPSA batch number
6 Receive_Date date 10 The date the file is received by CPSA. Format:
MM/DD/YYYY
7 Processed_Date date 10 The date the file is processed by CPSA. Format:
MM/DD/YYYY
8 Provider_Encounter varchar 38 Providers internal claim/encounter number
9 Claim char 10 CPSA claim/encounter number
10 Member_First_Name varchar 30
11 Member_Last_Name varchar 30
12 Birth_Date date 10 Format: MM/DD/YYYY
13 CIS_ID char 10
14 Agency varchar 30 Agency/Network name
15 Provider_Name char 30 For medical encounters (HCFA), the
PROVIDER_NAME represents the last name of the rendering provider.
For hospital encounters (UB92), the
PROVIDER_NAME represents the name of the institution.
16 Provider_ID varchar 8 The hospital or provider AHCCCS id
17 Specialty char 4 The provider specialty code from the claim (HCFA
and UB92)
18 Service_Start date 10 This is the service from date. Format:
MM/DD/YYYY
19 Service_End date 10 This is the service end date. Format:
MM/DD/YYYY
Column
Position Column Name Type Size Comments/Changes
20 Place_of_Service varchar 3 For medical encounters (HCFA, this field represents the PLACE OF SERVICE (2 char). The standard HIPAA code set for PLACE OF SERVICE is utilized.
For hospital encounters UB92), this field represents the BILL TYPE. The standard HIPAA code sets for hospital BILL TYPE are utilized.
21 Service_Code varchar 6 For medical encounters (HCFA), this field represents the CPT CODE (6 char). The standard HIPAA code set for CPT CODES is utilized.
For hospital encounters (UB92), this field represents the REVENUE CODE (4 char). The standard HIPAA code set for REVENUE CODES is utilized.
22 Modifier char 2 The standard HIPAA code set for MODIFIERS is
utilized.
23 Diagnostic_Code char 6 The primary diagnostic code for the claim/encounter.
24 Units int
25 Billed_Amount money The amount billed by the provider/institution.
26 Allowed_Amount money The amount allowed by CPSA for the services provided.
27 Denied_Reason_Code char 4 Snapshot File: For the Snapshot file, the DENIED REASON CODE represents values defined in CPSA's EDIT REFERENCE GUIDE.
Changes File: For the Changes file, the DENIED REASON CODE represents values defined in the CIS EDIT RESOLUTION MANUAL.
28 Pended_Reason_Code char 4 Snapshot / Changes File: The PENDED REASON
CODE represents values defined in CPSA's EDIT REFERENCE GUIDE.
29 Submitting_SiteID varchar 9 The submitting provider's Site ID (or new three letter acronym assigned to each network)
30 Rendering_SiteID varchar 9 The rendering provider's Site ID
31 Fund_Source varchar 35 The members fund source (i.e. TXIX, TXXI, or non-title)
32 BHC varchar 35 The members Behavioral Health Category (General
Mental Health, SMI, Child, Substance Abuse, etc.) 33 Network/Provider Finding n/a Findings returned to CPSA by the Network or
Provider
34 Date Resubmitted to CPSA n/a The date that the Network's findings were returned to CPSA
35 File Name n/a The name of the 837p or 837i file that the encounter
was returned in
36 CPSA Findings n/a Information from CPSA regarding the denied
encounter
Column
Position Column Name Type Size Comments/Changes
38 Rendering_Provider_NPI char 10 Rendering Provider NPI (HCFA)/Facility NPI (UB) 39 Attending_Physician_NPI char 10 Attending Physician NPI (UB)
40 COB1_Policy_ID varchar 30 COB1 - Policy ID
41 COB1_Policy_Name varchar 60 COB1 - Policy Name
42 COB1_Filing_Indicator varchar 3 COB1 - Claim Filing Indicator Code (see Filing Indicator Table)
43 COB1_Allowed_Amount money COB1 - Allowed Amount
44 COB1_Deductable_Amount money COB1 - Other Payer Responsibility Amount
45 COB1_Paid_Amount money COB1 - Payer Paid Amount
46 COB2_Policy_ID varchar 30 COB2 - Policy ID
47 COB2_Policy_Name varchar 60 COB2 - Policy Name
48 COB2_Filing_Indicator varchar 3 COB2 - Claim Filing Indicator Code (see Filing Indicator Table)
49 COB2_Allowed_Amount money COB2 - Allowed Amount
50 COB2_Deductable_Amount money COB2 - Other Payer Responsibility Amount
51 COB2_Paid_Amount money COB2 - Payer Paid Amount
52 COB3_Policy_ID varchar 30 COB3 - Policy ID
53 COB3_Policy_Name varchar 60 COB3 - Policy Name
54 COB3_Filing_Indicator varchar 3 COB3 - Claim Filing Indicator Code (see Filing Indicator Table)
55 COB3_Allowed_Amount money COB3 - Allowed Amount
56 COB3_Deductable_Amount money COB3 - Other Payer Responsibility Amount
57 COB3_Paid_Amount money COB3 - Payer Paid Amount
58 BLMT_flag varchar 10 Indicates when a claim was submitted with a billing limitation override request. Values: "F" = True, otherwise blank.
59 HOSP_AdmitDate date 10 Hospitalization Admission Date. Format:
MM/DD/YYYY
60 Diagnostic_Code_2 char 6 The secondary diagnostic code for the claim/encounter
61 Diagnostic_Code_3 char 6 Additional diagnostic code for the claim/encounter 62 Diagnostic_Code_4 char 6 Additional diagnostic code for the claim/encounter 63 Diagnostic_Code_5 char 6 Additional diagnostic code for the claim/encounter 64 Diagnostic_Code_6 char 6 Additional diagnostic code for the claim/encounter 65 Diagnostic_Code_7 char 6 Additional diagnostic code for the claim/encounter 66 Diagnostic_Code_8 char 6 Additional diagnostic code for the claim/encounter 67 Diagnostic_Code_9 char 6 Additional diagnostic code for the claim/encounter 68 Diagnostic_Code_10 char 6 Additional diagnostic code for the claim/encounter
Column
Position Column Name Type Size Comments/Changes
69 Mbr_Network_Assignment varchar 50 Name of Members Network Assignment at time of adjudication