Section III - Record Layouts - Pennsylvania Compensation Rating Bureau

A. Overview

In order for the PCRB to properly receive data submissions, data providers are required to comply with specific requirements regarding record layouts, data elements, and link data when reporting the Medical Data Call. Data files are transmitted in specific record layouts to allow for efficient processing. This allows the data contained within the record layouts to be formatted, sorted, and customized according to the user’s specifications.

The record layouts that comprise the Medical Data Call are provided in this section of the manual.

B. Medical Data Call Record

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Report one Medical Data Call Record for each medical transaction (line) of a bill. For specific data element reporting instructions, refer to the Data Dictionary section of this manual.

Medical Data Call Record Layout

Field No.	Field Title/ Description	Class	Position	Bytes	Header/ Detail	Source
1	Carrier Code *	N	1-5	5	H	Payer
2	Policy Number Identifier*	AN	6-23	18	H	CMS 11
3	Policy Effective Date*	N	24–31	8	H	Payer
4	Claim Number Identifier *	AN	32–43	12	H	Payer
5	Transaction Code	N	44–45	2	D	Payer
6	Jurisdiction State Code	N	46–47	2	H	Payer
7	Claimant Gender Code	AN	48	1	H	CMS 3 UB 11
8	Birth Year	N	49–52	4	H	CMS 3 UB 10
9	Accident Date	N	53–60	8	H	CMS 14
10	Transaction Date	N	61–68	8	D	Payer
11	Bill Identification Number *	AN	69–98	30	H	Payer
12	Line Identification Number *	AN	99–128	30	D	Payer
13	Service Date	N	129–136	8	D	CMS 24A UB 45
14	Service From Date	N	137–144	8	H	CMS 18 UB 6
15	Service To Date	N	145–152	8	H	CMS 18 UB 6
16	Paid Procedure Code	AN	153–177	25	D	CMS 24D UB 42 UB 44 or Payer
17	Paid Procedure Code Modifier First Paid Procedure Code Modifier Second Paid Procedure Code Modifier	AN	178–185 (178-181) (182-185)	8 (4) (4)	D	CMS 24D UB 44 or Payer
18	Amount Charged by Provider	N	186–196	11	D	CMS 24F UB 47
19	Paid Amount	N	197–207	11	D	Payer
20	Primary ICD Diagnostic Code	AN	208–221	14	H/D	CMS 21 A (D) UB 67 (H)
21	Secondary ICD Diagnostic Code	AN	222–235	14	H/D	CMS 21 B (D) UB 67 A (H)
22	Provider Taxonomy Code	AN	236-255	20	H	Provider or Payer
23	Provider Identification Number	AN	256–270	15	H	CMS 32A UB 56
24	Provider Postal (ZIP) Code	AN	271–273	3	H	CMS 32 UB 1
25	Network Service Code	A	274	1	H	Provider or Payer
26	Quantity/Number of Units per Procedure Code	N	275–281	7	D	CMS 24G UB 46
27	Place of Service Code	AN	282–289	8	H	CMS 24B UB4**
28	Secondary Procedure Code	AN	290–314	25	D	UB 42
29	Provider Postal (ZIP+4) Code	AN	315–323	9	H	CMS 32 UB 1
30	Reserved for Future Use		324–350	27

* This data element is considered a key field and must be reported the same as on the original record for all records related to a medical transaction (line). Refer to Key Fields in the Medical Data Call Structure section of this manual.
** Refer to Place of Service Crosswalk in the Appendix.

Source Notes:

CMS: Data is located on form CMS-1500. The field number on the form where the data is located is also provided.
Payer: Data is not on a form; it is provided by the entity that pays the bill.
Provider: Data is not on a form; it is provided by the healthcare provider.
UB: Data is located on form UB-04. The field number on the form where the data is located is also provided.

C. File Control Record

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One, and only one, File Control Record is required for each file submitted. The File Control Record should be placed at the end of the file. The File Control Record for a Key Field Change submission should be reported as an Original (Submission File Type Code “O”).

File Control Record Layout

Field No.	Field Title/ Description	Class	Position	Bytes
1	Record Type Report “SUBCTRLREC” One File Control Record is required for each submission. Format: A 10	A	1-10	10
2	Submission File Type Code Report the code that identifies the type of file being submitted. O=Original R=Replacement Format: A, this field cannot be blank.	A	11	1
3	Carrier Group Code * Report the NCCI Carrier Group Code that corresponds to the Reporting Group for which the data provider has been certified to report on its behalf. Format: N 5	N	12-16	5
4	Reporting Quarter Code * Report the code that corresponds to the quarter when the medical transactions being reported occurred. 1 = First Quarter 2 = Second Quarter 3 = Third Quarter 4 = Fourth Quarter Format: N	N	17	1
5	Reporting Year * Report the year that corresponds to the year when the medical transactions being reported occurred. Format: YYYY	N	18-21	4
6	*Submission File Identifier †** Report the unique identifier created by the data provider to distinguish the file being submitted from previously submitted files. Format: A/N 30, this field must be left justified and contain blanks in all spaces to the right of the last character if the Submission File Identifier is less than 30 bytes.	AN	22-51	30
7	Submission Date ** Report the date the file was generated. Format: YYYYMMDD	N	52-59	8
8	Submission Time ** Report the time the file was generated in military time. Format: HHMMSS (HH = Hours, MM = Minutes, SS = Seconds)	N	60-65	6
9	Record Total Report the total number of records in the file, excluding the File Control Record. Medical Call Manager validates the record total excluding the Electronic Transmittal Record (E.T.R.) and the File Control Record. If the E.T.R. and/or File Control Record are included in the record total count, the system may generate the error message: “1 record - Rejected From Submission - Further Action Is Required.” No further action is required from data submitters if this error message is generated. Note: Blank rows will be removed during processing and not counted. If blank rows are included in the Record Total, the file will appear out of balance and reject. Format: N 11, this field must be right justified and left zero-filled	N	66-76	11
10	Reserved for Future Use		77-350	274

* If this is a replacement submission (Submission File Type Code, Position 11 is R-Replacement), then this field must be reported the same as the submission being replaced. For details, refer to File Replacements in the Reporting Rules section of this manual.
† Valid characters in the file name include 0 through 9, A through Z, dash ‘-‘, underscore ‘_’, or period ‘.’.
** For replacements (Submission File Type Code R), the combination of Submission Date and Submission Time must be after that of the file being replaced.

D. Key Field Change Record

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Each Key Field Change record—Transaction Code 04—should contain all four of the previous key fields, as they were reported, for a given claim and all four of these key fields as they should be reported going forward. Key Field Change transactions should only be included in Key Field Change files.

Once the Key Field Change file has been submitted to PCRB, all future Medical Data Call bill line transaction records must be submitted with the new key fields. These will then link the records with the previously submitted records that changed because of the Key Field Change file.

If the Key Field Change file was submitted in error, a new Key Field Change file can be submitted reflecting the correct data. The File Replacement option (using Submission File Type Code “R” for Replacement on the File Control Record) will not be allowed for the Key Field Change file type.

Medical Data Call—Transaction Code 04—Key Field Change Record Layout

Field No.	Field Title	Class	Position	Bytes
1	Previous Carrier Code	N	1-5	5
2	Previous Policy Number Identifier	AN	6-23	18
3	Previous Policy Effective Date	N	24-31	8
4	Previous Claim Number Identifier	AN	32-43	12
5	Transaction Code	N	44-45	2
6	Carrier Code	N	46-50	5
7	Policy Number Identifier	AN	51-68	18
8	Policy Effective Date	N	69-76	8
9	Claim Number Identifier	AN	77-88	12
10	Reserved for Future Use		89-350	262