Section II - Medical Data Call Structure

The Medical Data Call is not aggregated at the bill level. Instead, each line of a bill is reported as a separate record. While certain data elements will be repeated on each line, others are distinct per line. These two classifications of data elements are called Bill Header and Bill Detail.

Bill Header data elements identify the information that is common to all lines of a bill. Therefore, the data in these elements is the same for all records from the same bill.

Note: A bill is identified by the combination of Claim Number and Bill Identification Number.

Bill Header data elements include:

• Carrier Code
• Policy Number Identifier
• Policy Effective Date
• Claim Number Identifier
• Jurisdiction State Code
• Claimant Gender Code
• Birth Year
• Accident Date
• Bill Identification Number
• Service From Date
• Service To Date
• Provider Taxonomy Code
• Provider Identification Number
• Provider Postal (ZIP) Code
• Network Service Code
• Place of Service Code
• Provider Postal (ZIP+4) Code

These elements are typically located on the header (top) section of standard bill forms such as CMS-1500 or UB-04. For specific locations of the data information on these standard forms (if applicable), refer to the Source column of the Medical Data Call Record Layout table in the Record Layouts section of this manual.

Bill Detail data elements provide the line level information and, therefore, can differ among the individual records of a bill.

Bill Detail data elements include:

• Transaction Code
• Transaction Date
• Line Identification Number
• Service Date
• Paid Procedure Code
• Paid Procedure Code Modifier
• Amount Charged by Provider
• Paid Amount
• Primary ICD Diagnostic Code
• Secondary ICD Diagnostic Code
• Quantity/Number of Units per Procedure Code
• Secondary Procedure Code

Note: Some detail data elements, such as ICD Diagnostic Codes, can act like Bill Header data elements because they may be the same for all lines. However, it is possible for these codes to vary per line.

These elements are typically located on the detail (lower) section of standard bill forms, such as CMS-1500 or UB-04. For specific locations of the data information on these standard forms (if applicable), refer to the Source column of the Medical Data Call Record Layout table in the Record Layouts section of this manual.

Key fields identify unique claims. These elements are required to be reported the same for all records related to a claim (refer to Section III – Record Layouts – D. Key Field Change Record in this manual for details regarding making key field changes.

Key fields for the Medical Data Call include:

• Carrier Code
• Policy Number Identifier
• Policy Effective Date
• Claim Number Identifier
• Bill Identification Number
• Line Identification Number

The key fields are also used to link the cancellation or replacement records to the original record. If a record is reported with one or more of the key fields either missing or invalid, the record would be deemed unusable (refer to Section V – Reporting Rules, B. Record Replacements, Cancellations, and Key Field Changes.)

Consistent Reporting of Multi-Data Type Fields

Consistently reporting the field values that PCRB uses for linking within each data type and across all data types enables PCRB to use all data elements for the same policy and associated claims. Below are the fields by data type:

Data Type

Note: An “X” denotes that the data element is applicable for the data type.

The field values that PCRB uses for linking within each data type and across all data types must be reported in accordance with their reporting rules and be consistent across data types for the life of the policy and the life of the claim. Claim numbers and accident dates must be reported consistently from one valuation to the next.

The data types are:

• Policy Data
• Unit Statistical Data
• Financial Call #4
• Medical Data Call
• Indemnity Data Call

Note: PCRB recognizes that some data providers (or their TPAs/service providers) may report a different carrier code for related entities under their established statistical group, financial group, or pool group. The difference in carrier codes may be reported for these exceptions.

Subsequent Changes to Multi-Data Type Fields

When data linking fields are updated through Key Field Changes (KFCs), corrections or replacements based on their appropriate data type, similar updates may be needed to other data types. This ensures the continued accurate linking of policy fields and unique identification of claims.

Definitions of Data Elements

Below are the data elements and their definitions in accordance with PCRB’s Statistical Plan Manual and related guidebooks.

*Exposure State Code and Accident State Code are not Medical Data Call data elements.