Volume II - Service Reporting & Mental Health Medicaid Billing (Rule 132)

2.1 Service Reporting/MH Billing Daily Record Format - Continued
2.2 Service Reporting Monthly Record Format
2.3 Service Reporting/MH Billing Daily Adjustment Record Format
2.4 Service Reporting Monthly Adjustment Record Format
2.5 MH Billing Client Eligibility Change Record Format
2.6 Service Reporting/MH Billing Trailer Record Format

2.1 Service Reporting/MH Billing Daily Record Format - Continued

Field Name	From	Thru	Length	Format	Description
Agency FEIN	1	9	9	numeric	Mandatory - The agency's nine digit Federal Employer Identification Number (FEIN).
Filler	10	11	2	alpha	Leave this field blank Value: spaces
Agency Satellite Code	12	13	2	numeric	Mandatory - An organizational subpart within an agency that has a unique physical location, but does not have a different FEIN assigned to it This code is assigned by DHS If no satellite code is assigned, report zeros in this field.
Client ID or Client's Age Group	14	22	9	numeric or alpha-numeric	Mandatory, if applicable - The agency client ID assigned by the agency to the registered client or the age group of the client if the client is not registered with the agency When SERVICE RECIPIENT CODE is "registered" (value 1) or "collateral" (value 3), report the client's ID. Use the agency client ID number assigned to the client by the agency and reported on the client's case registration (this may be the same number as the client's SSN number). All nine positions must be numeric Examples: 000234567 333445555 When SERVICE RECIPIENT CODE is "unregistered" (value 2), report the age group of the client (A for adults, C for children and adolescents) plus an 8 digit numeric identifier assigned by the agency Examples: A00000001 - Adults(age 18C00000001 - C & A(ages 00-17) When SERVICE RECIPIENT CODE is "community" (value 4) or "agency" (value 5), leave this field blank (value spaces).
Record Type	23	23	1	alpha	Mandatory - Report the value: D D - indicates DAILY record
Case ID Number	24	36	13	alpha	Mandatory - The DHS (formerly Department of Public Aid) eligibility Case ID number for the client Report 0000000000000 if the client has no Case ID Number. Report 9999999999999 if the client's Case ID Number is unknown.
Site Number	37	38	2	numeric or spaces	Mandatory, if applicable - The site number assigned by DHS that represents the unique or specific geographical site as the base for service delivery. Refer to your current DHS contract or Agency Plan 2.0/2.1. NOTE: Not used for DD programs. For DD service reporting, leave this field blank (value spaces).
Unit Code	39	40	2	numeric or spaces	Mandatory, if applicable - A unique number assigned to a component of the provider's service delivery organization to reflect a distinction of that component, such as location, client population to be served, staff or staff team providing the services, or source of funding for the service. Refer to your current DHS contract or Agency Plan 2.0/2.1. If unit code is not applicable, leave this field blank (value spaces.)
Program Code	41	43	3	numeric	Mandatory - The program number assigned by DHS that represents the program through which services were provided. Refer to your current DHS contract or Agency Plan 2.0/2.1.
Activity Code	44	45	2	numeric or alpha-numeric	Mandatory, for Mental Health programs - Indicates the specific service provided in the program. If the program provides more than one specific service, each must be reported separately. See the MH Billing Service Activity Codes listing for a detailed listing and descriptions. NOTE: Not used for DD programs. For DD service reporting, leave this field blank (value spaces)
Location Code	46	46	1	numeric or spaces	Mandatory, for Mental Health programs - Report the code for the location at which the service actually occurred. 0 - Own Agency 1 - Social Service Agency 2 - Long Term Care Facility 3 - Client's Residence 4 - Public Place 5 - Law Enforcement/Jail/Court 6 - School/Workplace 7 - General Hospital/Detox/Emergency Room 8 - State Operated Facility 9 - Other Optional, for Developmental Disability programs - This field may be blank (value spaces) when reporting for DD programs.
Billing Option	47	47	1	alpha	Mandatory - Report the appropriate code: D - Service Reporting Only (Use for all DD programs and not billable MH activities) C - MH Medicaid Clinic option (Invalid after 07-31-2004) N - MH Billable, Non-Medicaid R - MH Medicaid Rehab option T - MH Medicaid Targeted Case Management option
Filler	48	51	4	alpha	Leave this field blank. Value: spaces
Date of Service	52	59	8	numeric	Mandatory - The date on which the service was performed. Format: YYYYMMDD YYYY = century and year MM = month DD = day Example: 19990801
Staff ID #1	60	68	9	numeric or spaces	Mandatory, for Mental Health programs - The ID number of the professional staff member responsible for providing the services to this client. The staff ID number must be numeric - report 123 as 000000123 Optional, for DD programs; if not used, this field must be blank (value spaces).
Staff ID #2	69	77	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
Staff ID #3	78	86	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
Staff ID #4	87	95	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
Staff ID #5	96	104	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
Staff ID #6	105	113	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
Filler	114	133	20	alpha	Leave this field blank Value: spaces
Service Start Time	134	137	4	numeric or spaces	Optional, for Mental Health programs - The time at which the service began. If used, time must be reported using the 24 hour clock (Range: 0001-2400). If not used, leave this field blank (value spaces) NOTE: Not used for DD programs. For DD service reporting, leave this field blank (value spaces)
Total Dollars Spent on Client	138	143	6	numeric or spaces	Mandatory, if applicable - The dollars expended on behalf of a specific client for the service. These dollars can be reported with or without associated client service hours. Format: 9(4)v99 NOTE: This field is only used for MH program codes 131, 572, 573, and 574 when reporting designated activity codes; if not used, this field must be blank (value spaces).
Group ID	144	148	5	numeric or spaces	Optional - (for agency use only) If the service was performed in a group setting, report the Group ID. If not a group service, this field must be blank (value spaces).
Number of Staff in Group	149	150	2	numeric or spaces	Mandatory, if applicable - If the service was performed in a group setting, report the total number of staff involved in the group service. If not a group service, this field must be blank (value spaces).
Number of Clients in Group	151	153	3	numeric or spaces	Mandatory, if applicable - If the service was performed in a group setting, report the total number of clients involved in the group service. If not a group service, this field must be blank (value spaces).
Agency Optional Data	154	163	10	alpha	Optional - This area may be used by the agency for any miscellaneous data they desire to retain in this record.
Contractor FEIN	164	172	9	numeric or spaces	Optional - This field is to be used for special processing purposes only. The FEIN number of the agency who is actually being funded by DHS should be reported here (it must be a different FEIN than the FEIN reported in positions 1 - 9 of this record). If not used, this field must be blank (value spaces).
Service Recipient Code	173	173	1	numeric	Mandatory - Report the code that identifies the type of client served or the setting. 1 - Registered 2 - Unregistered 3 - Collateral 4 - Community 5 - Own Agency
Hours of Service	174	175	2	numeric	Mandatory - The duration of the service. Valid range: 00-24 (Report 00 when back billing MH programs. This is also done to accepted services which previously did not have MH Medicaid prior to 6/30/04.)
Minutes of Service	176	177	2	numeric	Mandatory - The duration of the service. Valid range: 00-59 (Report 00 when back billing MH programs. This is also done to accepted services which previously did not have MH Medicaid prior to 6/30/04.)
MH Billable Hours of Service	178	179	2	numeric or spaces	This field is used for MH billing only; if not used, this field must be blank (value spaces). Mandatory - The duration of the service that is billable to MH. Valid range: 00-24 NOTE: For activity codes 2D, 25, and 5L, this field must be "00".
MH Billable Minutes of Service	180	181	2	numeric or spaces	This field is used for MH billing only; if not used, this field must be blank (value spaces). Mandatory - The duration of the service that is billable to MH. Valid range: 00-59 NOTE: If no MH Billable Hours of Service were reported, the minimum value for this field is eight minutes of services. Exception: For activity codes 2D, 25, and 5L, this field represents the number of events. 2D & 25 - valid range 01-03 5L - must be 01
Location Description	182	198	17	alpha	This field is used for MH billing only; if not used, this field must be blank (value spaces). Mandatory, if applicable - When the service is provided off-site and a Location Code of 9 (Other) is reported, a description of where the service was provided must be reported.
Diagnosis Code	199	203	5	alpha	This field is used for MH billing only; if not used, this field must be blank (value spaces). Mandatory - Report the ICD-9-CM or DSM-IV diagnostic code which describes the condition primarily responsible for the client's treatment. (Refer to the MH Billing diagnosis codes listing for valid codes.) NOTE: Do not include the period imbedded in the diagnosis code. Example, for diagnosis code 295.10, report 29510 in the field.
Medicaid Site ID	204	206	3	numeric or spaces	This field is used for MH billing only; if not used, this field must be blank (value spaces). Mandatory - Report the three digit Department of Public Aid (DPA) site location number of the site the service was provided. NOTE: The Medicaid Site ID is assigned by DPA when the agency is enrolled for MH Medicaid and is the three digits which are appended to the agency's nine digit Federal Employer Identification Number (FEIN).
Charge Amount	207	213	7	numeric or spaces	This field is used for MH billing only; if not used, this field must be blank (value spaces). Mandatory - The total charge for the service, not deducting the TPL Amount if there is one. Format: 9(5)v99 Example: $10.50 should be reported as 0001050
Net Charge Amount	214	220	7	numeric or spaces	This field is used for MH billing only; if not used, this field must be blank (value spaces). Mandatory - The difference between the Charge Amount minus the Total TPL Amount. Format: 9(5)v99 Example: $10.50 should be reported as 0001050
Total Third Party Liability (TPL) Amount	221	227	7	numeric or spaces	This field is used for MH billing only; if not used, this field must be blank (value spaces). Mandatory - The sum of TPL Amount (occurrence 1) plus TPL Amount (occurrence 2) Format 9(5)v99 Example: $10.50 should be reported as 0001050
Third Party Liability (TPL) Data - up to 2 occurrences	228	269	42	alpha	This field is used for MH billing only; if not used, these fields must be blank (value spaces).
TPL Code	228 249	231 252	4	alpha	Report the TPL Code contained on the client's Medical Eligibility Card (MEC).
TPL Status Code	232 253	233 254	2	alpha	Report the appropriate code indicating the disposition of the third party billing.
TPL Amount	234 255	240 261	7	numeric	Report the amount of payment received from the third party resource. A dollar amount is required when TPL Status Code 01 is reported. Format: 9(5)v99 Example: $10.50 should be reported as 0001050
TPL Date	241 262	248 269	8	numeric	A TPL Date is required for all TPL status codes. NOTE: Refer to Appendix A for specific Third Party Liability (TPL) data specifications.
Agency Net Charge Amount	270	276	7	numeric or spaces	Leave this field blank. Value: spaces For MH billing only - This field is returned with the original Net Charge Amount the agency billed.
Net Approved Amount	277	283	7	numeric or spaces	Leave this field blank. Value: spaces For MH billing only - This field is returned with the actual amount approved by DPA and the DHS. Format: 9(5)v99 Example: $10.50 would be returned as 0001050
DHS Tracking Number	284	293	10	alpha	Leave this field blank. Value: spaces For MH billing only - This field is returned with DHS assigned number that is used in tracking the payment in the DHS accounting system.
DPA Voucher Number	294	304	11	alpha	Leave this field blank. Value: spaces For MH billing only - This field is returned with the DPA voucher number if the billing is approved.
Payment Fiscal Year	305	308	4	numeric or spaces	Leave this field blank. Value: spaces For MH billing only - This field is returned with the state fiscal year the bill is approved for payment.
Filler	309	335	27	alpha	Leave this field blank. Value: spaces
DPA Segment Indicator	336	336	1	alpha	Leave this field blank. Value: spaces For MH billing only - This field is returned with the DPA segment to which the billing was applied. A - DPA Medicaid Segment B - DPA Non-Medicaid Segment
Filler	337	356	20	alpha	Leave this field blank. Value: spaces
Submit Date	357	364	8	numeric	Mandatory - The date on which the record is being submitted to DHS. Format: YYYYMMDD YYYY - century and year MM - month DD - day Example: 19990801
Process Date	365	372	8	numeric or spaces	Leave this field blank. Value: spaces This field will be returned with the date the data was processed by DHS. Format: YYYYMMDD YYYY - century and year MM - month DD - day Example: 19990801
Acceptance Indicator	373	374	2	alpha	Leave this field blank. Value: spaces This field is returned with one of the following codes indicating the result of the processing. RJ - Rejected PD - Approved RD - Approved, MH rate reduced NV - Approved, MH payment not vouchered AR - Approved ROCS, Rejected MH billing SS - Suspended, action pending
Approval Date	375	382	8	numeric or spaces	Leave this field blank. Value: spaces For MH billing only - This field is returned with the date the data was approved by DHS. (Blank for service reporting only.) Format: YYYYMMDD YYYY - century and year MM - month DD - day Example: 19990801
Document Control Number	383	399	17	alpha	Leave this field blank. Value: spaces This field is returned with a unique assigned number. This number will need to be referenced when submitting adjustments to accepted data.
Prior FY Indicator	400	400	1	alpha	Leave this field blank. Value: spaces For MH billing only - This field is returned with a value of Y if the date the service was performed was in the prior state fiscal year and the lapse period for payment has passed.
Cycle Number	401	401	1	alpha	Leave this field blank. Value: spaces For MH billing only - This field is returned with the DHS processing data cycle number.
Warning Codes up to 3 warning codes (3 positions each)	402	410	9	alpha	Leave these fields blank. Value: spaces These fields are returned after DHS has processed the record. Up to three warning codes will be noted, indicating the reason the data was changed.
Reject Codes up to 5 error codes (3 positions each)	411	425	15	alpha	Leave these fields blank. Value: spaces These fields are returned after DHS has processed the record. If the record is rejected during processing by DHS, up to five error codes will be noted, indicating the reason the record was rejected by DHS.
Filler	426	439	14	alpha	Leave this field blank. Value: spaces
Software Indicator	440	440	1	alpha	Mandatory - Report the value: Z Z - indicates agency's own software created the file.
Filler	441	450	10	alpha	Leave this field blank. Value: spaces

2.2 Service Reporting Monthly Record Format

Field Name	From	Thru	Length	Format	Description
Agency FEIN	1	9	9	numeric	Mandatory - The agency's nine digit Federal Employer Identification Number (FEIN).
Filler	10	11	2	alpha	Leave this field blank. Value: spaces
Agency Satellite Code	12	13	2	numeric	Mandatory - An organizational subpart within an agency that has a unique physical location, but does not have a different FEIN assigned to it. This code is assigned by DHS. If no satellite code is assigned, report zeros in this field.
Client ID or Client's Age Group	14	22	9	numeric or alpha-numeric	Mandatory, if applicable - The agency client ID assigned by the agency to the registered client or the age group of the client if the client is not registered with the agency. When SERVICE RECIPIENT CODE is "registered" (value 1) or "collateral" (value 3), report the client's ID. Use the agency client ID number assigned to the client by the agency and reported on the client's case registration (this may be the same number as the client's SSN number). All nine positions must be numeric. Examples:. 000234567 333445555 When SERVICE RECIPIENT CODE is "unregistered" (value 2), report the age group of the client (A for adults, C for children and adolescents) plus a unique 8 digit numeric identifier assigned by the agency. Examples: A00000001 - Adults(age 18+) C00000001 - C & A(ages 00-17) When SERVICE RECIPIENT CODE is "community" (value 4) or "agency" (value 5), leave this field blank (value spaces).
Record Type	23	23	1	alpha	Mandatory - Report the value: M M - indicates MONTHLY record NOTE: The monthly record format is used for service reporting only; you cannot use this format for MH Medicaid billing.
Case ID Number	24	36	13	alpha	Mandatory - The DHS (formerly public aid) eligibility Case ID number for the client. Report 0000000000000 if the client has no Case ID Number. Report 9999999999999 if the client's Case ID Number is unknown.
Site Number	37	38	2	numeric or spaces	Mandatory, if applicable - The site number assigned by DHS that represents the unique or specific geographical site as the base for service delivery. Refer to your current DHS contract or Agency Plan 2.0/2.1. NOTE: Not used for DD programs. For DD service reporting, leave this field blank (value spaces).
Unit Code	39	40	2	numeric or spaces	Mandatory, if applicable - A unique number assigned to a component of the provider's service delivery organization to reflect a distinction of that component, such as location, client population to be served, staff or staff team providing the services, or source of funding for the service. Refer to your current DHS contract or Agency Plan 2.0/2.1. If unit code is not applicable, leave this field blank (value spaces).
Program Code	41	43	3	numeric	Mandatory - The program number assigned by DHS that represents the program through which services were provided. Refer to your current DHS contract or Agency Plan 2.0/2.1.
Activity Code	44	45	2	numeric or alpha-numeric	Mandatory, if applicable - Indicates the specific service provided in the program. If the program provides more than one specific service, each must be reported separately. For DD CILA (program 600) report the following activity code for service dates before 07/01/04: 88 - Residential Habilitation NOTE: For service dates after 06/30/04, not used for DD programs. For DD service reporting, leave this field blank (value spaces)
Location Code	46	46	1	numeric or spaces	Mandatory, for Mental Health programs - Report the code for the location at which the service actually occurred. 0 - Own Agency 1 - Social Service Agency 2 - Long Term Care Facility 3 - Client's Residence 4 - Public Place 5 - Law Enforcement/Jail/Court 6 - School/Workplace. 7 - General Hospital/Detox/Emergency Room 8 - State Operated Facility 9 - Other Optional, for Developmental Disability programs - This field may be blank (value spaces) when reporting for DD programs.
Billing Option	47	47	1	alpha	Mandatory - Report the value: D D - Service Reporting Only The monthly record format is used for service reporting only; you cannot use this format for MH billing.
Filler	48	51	4	alpha	Leave this field blank. Value: spaces
Date of Service	52	59	8	numeric	Mandatory - The month and year in which the service was performed. Format: YYYYMMDD YYYY = century and year MM = month DD = 00 (the actual day of service is reported in another area of the record) Example: 19990800
Staff ID #1	60	68	9	numeric or spaces	Mandatory, for Mental Health programs - The ID number of the professional staff member responsible for providing the services to this client. The staff ID number must be numeric - report 123 as 000000123. Optional, for DD programs; if not used this field must be blank (value spaces).
Staff ID #2	69	77	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
Staff ID #3	78	86	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
Staff ID #4	87	95	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
Staff ID #5	96	104	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
Staff ID #6	105	113	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
Filler	114	143	30	alpha	Leave this field blank. Value: spaces
Group ID	144	148	5	numeric or spaces	Optional - (for agency use only) If the service was performed in a group setting, report the Group ID. If not a group service, this field must be blank (value spaces).
Number of Staff in Group	149	150	2	numeric or spaces	Mandatory, if applicable - If the service was performed in a group setting, report the total number of staff involved in the group service. If not a group service, this field must be blank (value spaces).
Number of Clients in Group	151	153	3	numeric or spaces	Mandatory, if applicable - If the service was performed in a group setting, report the total number of clients involved in the group service. If not a group service, this field must be blank (value spaces).
Agency Optional Data	154	163	10	alpha	Optional - This area may be used by the agency for any miscellaneous data they desire to retain in this record.
Contractor FEIN	164	172	9	numeric or spaces	Optional - This field is to be used for special processing purposes only. The FEIN number of the agency who is actually being funded by DHS should be reported here (it must be a different FEIN than the FEIN reported in positions 1 - 9 of this record). If not used, this field must be blank (value spaces).
Service Recipient Code	173	173	1	numeric	Mandatory - Report the code that identifies the type of client served or the setting. 1 - Registered 2 - Unregistered 3 - Collateral 4 - Community 5 - Own Agency
Attendance or Hours and Minutes of Service 31 occurrences (up to 31 days in a month) length= 4 each	174	297	124	alpha or numeric	Mandatory - To report attendance, report one of the following codes in the first field position of the corresponding day of the month (the other 3 positions for that day must be spaces): P - Present A - Absent B - Bed-hold To report hours and minutes, report the duration of hours (valid range: 00-24) in the first two positions and the duration of minutes (valid range: 00-59) in the last two positions of the corresponding days of the month when the client received the service. Examples: report 3 hours as 0300 report 30 minutes as 0030 For months with less than 31 days, leave the remaining fields for those days blank (value spaces). Day/Position 01 (174 - 177) 02 (178 - 181) 03 (182 - 185) 04 (186 - 189) 05 (190 - 193) 06 (194 - 197) 07 (198 - 201) 08 (202 - 205) 09 (206 - 209) 10 (210 - 213) 11 (214 - 217) 12 (218 - 221) 13 (222 - 225) 14 (226 - 229) 15 (230 - 233) 16 (234 - 237) 17 (238 - 241) 18 (242 - 245) 19 (246 - 249) 20 (250 - 253) 21 (254 - 257) 22 (258 - 261) 23 (262 - 265) 24 (266 - 269) 25 (270 - 273) 26 (274 - 277) 27 (278 - 281) 28 (282 - 285) 29 (286 - 289) 30 (290 - 293) 31 (294 - 297)
Filler	298	356	59	alpha	Leave this field blank. Value: spaces
Submit Date	357	364	8	numeric	Mandatory - The date on which the record is being submitted to DHS. Format: YYYYMMDD YYYY - century and year MM - month DD - day Example: 19990801
Process Date	365	372	8	numeric or spaces	Leave this field blank. Value: spaces This field will be returned with the date the data was processed by DHS. Format: YYYYMMDD YYYY - century and year MM - month DD - day Example: 19990801
Acceptance Indicator	373	374	2	alpha	Leave this field blank. Value: spaces This field is returned with one of the following codes indicating the result of the processing. RJ - Rejected PD - Approved
Filler	375	382	8	alpha	Leave this field blank. Value: spaces
Document Control Number	383	399	17	alpha	Leave this field blank. Value: spaces This field is returned with a unique assigned number. This number will need to be referenced when submitting adjustments to accepted data.
Filler	400	401	2	alpha	Leave this field blank. Value: spaces
Warning Codes up to 3 warning codes (3 positions each)	402	410	9	alpha	Leave these fields blank. Value: spaces These fields are returned after DHS has processed the record. Up to three warning codes will be noted, indicating the reason the data was changed.
Reject Codes up to 5 error codes (3 positions each)	411	425	15	alpha	Leave these fields blank. Value: spaces These fields are returned after DHS has processed the record. If the record is rejected during processing by DHS, up to five error codes will be noted, indicating the reason the record was rejected by DHS.
Filler	426	439	14	alpha	Leave this field blank. Value: spaces
Software Indicator	440	440	1	alpha	Mandatory - Report the value: Z Z - indicates agency's own software created the file.
Filler	441	450	10	alpha	Leave this field blank. Value: spaces

2.3 Service Reporting/MH Billing Daily Adjustment Record Format

From	Thru	Length	Format	Description
1	9	9	numeric	Mandatory - The agency's nine digit Federal Employer Identification Number (FEIN) Report the same FEIN as indicated on the original approved reporting.
10	13	4	numeric	Mandatory - An organizational subpart within an agency that has a unique physical location, but does not have a different FEIN assigned to it (assigned by DHS). Report the same SATELLITE CODE as indicated on the original approved reporting.
14	22	9	numeric or alpha-numeric	Mandatory, if applicable - The agency client ID assigned by the agency to the registered client or the age group of the client if the client is not registered with the agency.
23	23	1	alpha	Mandatory - Report the value: S S - indicates ADJUSTMENT to the accepted DAILY record
24	36	13	alpha	Mandatory - The DHS (formerly public aid) eligibility Case ID number for the client. Report 0000000000000 if the client has no Case ID Number. Report 9999999999999 if the client's Case ID Number is unknown.
37	38	2	numeric or spaces	Mandatory, if applicable - The site number assigned by DHS that represents the unique or specific geographical site as the base for service delivery. Refer to your current DHS contract or Agency Plan 2.0/2.1. NOTE: Not used for DD programs. For DD service reporting, leave this field blank (value spaces).
39	40	2	numeric or spaces	Mandatory, if applicable - A unique number assigned to a component of the provider's service delivery organization to reflect a distinction of that component, such as location, client population to be served, staff or staff team providing the services, or source of funding for the service. Refer to your current DHS contract or Agency Plan 2.0/2.1. If unit code is not applicable, leave this field blank (value spaces).
41	43	3	numeric or alpha-numeric	Mandatory - The program number assigned by DHS that represents the program through which services were provided. Refer to your current DHS contract or Agency Plan 2.0/2.1.
44	59	16	alpha	Leave this field blank. Value: spaces
60	68	9	numeric or spaces	Mandatory, for Mental Health programs - The ID number of the professional staff member responsible for providing the services to this client. The staff ID number must be numeric - report 123 as 000000123. Optional, for DD programs; if not used, this field must be blank (value spaces).
69	77	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
78	86	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
87	95	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
96	104	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
105	113	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
114	133	20	alpha	Leave this field blank. Value: spaces
134	137	4	numeric or spaces	Mandatory, for Mental Health programs - The time at which the service began. Time must be reported using the 24 hour clock. Range: 0001 - 2400 NOTE: Not used for DD programs. For DD service reporting, leave this field blank (value spaces)
138	143	6	numeric or spaces	Mandatory, if applicable - The dollars expended on behalf of a specific client for the service. These dollars can be reported with or without associated client service hours. Format: 9(4)v99. NOTE: This field is only used for MH program codes 131, 572, 573, and 574 when reporting designated activity codes; if not used, this field must be blank (value spaces).
144	172	29	alpha	Leave this field blank Value: spaces
173	173	1	numeric	Mandatory - Report the code that identifies the type of client served or the setting. 1 - Registered 2 - Unregistered 3 - Collateral 4 - Community 5 - Own Agency
174	175	2	numeric	Mandatory - The duration of the service. Valid range: 00-24
176	177	2	numeric	Mandatory - The duration of the service. Valid range: 00-59
178	205	28	alpha	Leave this field blank. Value: spaces
206	216	11	numeric	This field is used for MH billing only; if not used, this field must be blank (value spaces). Mandatory, if applicable for MH billing - Report the exact DPA Voucher Number assigned to the original accepted MH billing claim.
217	218	2	numeric or spaces	This field is used for MH billing only; if not used, this field must be blank (value spaces). Mandatory, if applicable for MH billing - Report the hours reported on the original accepted claim. Must be numeric. Valid range: 00-24
219	220	2	numeric or spaces	This field is used for MH billing only; if not used, this field must be blank (value spaces). Mandatory, if applicable for MH billing - Report the minutes or events reported on the original accepted claim. Must be numeric. Valid range: 00-59
221	227	7	numeric or spaces	This field is used for MH billing only; if not used, this field must be blank (value spaces). Mandatory, if applicable for MH billing - Report all zeros to indicate payment should not have been made. Value = 0000000
228	269	42	spaces	Leave this field blank. Value: spaces
270	276	7	numeric or spaces	Leave this field blank. Value: spaces For MH billing only - This field is returned with the total amount the previously approved charge amount was decreased. This is the amount of credit due the DHS. Format: 9(5)v99.,Example: $10.50 would be displayed as 0001050
277	283	7	spaces	Leave this field blank. Value: spaces
284	293	10	alpha	Leave this field blank. Value: spaces For MH billing only - This field is returned with the DHS assigned number that is used in tracking the payment in the DHS accounting system.
294	304	11	alpha	Leave this field blank. Value: spaces For MH billing only - This field is returned with the DPA voucher number if the billing is approved.
305	308	4	numeric or spaces	Leave this field blank. Value: spaces For MH billing only - This field is returned with the State fiscal year the credit is applied to.
309	336	28	alpha	Leave this field blank. Value: spaces
337	353	17	alpha	Mandatory - Report the exact Document Control Number which was assigned by DHS to the original accepted service reporting/claim.
354	355	2	alpha	Mandatory - Report the appropriate code to identify the reason for the adjustment. 03 - Use this code to indicate data changes are being made to the original accepted service reporting. Valid data to change: DHS Case ID, Site Code, Unit Code, Program Code, Staff ID, Hours, Minutes, Service Recipient Code, Service Start Time, and Total Dollars Spent on Client..,04 - Use this code to VOID the original accepted service reporting and, if one exists, the MH billing claim.
356	356	1	alpha	Mandatory - This code is used to further describe the reason for the adjustment. Valid values: D - Use when Adjustment Type = 04, if the adjustment is voiding the original approved service reporting and MH billing claim. N - Use when Adjustment Type = 03
357	364	8	numeric	Mandatory - The date on which the record is being submitted to DHS. Format: YYYYMMDD YYYY - century and year MM - month DD - day Example: 19990801
365	372	8	numeric or spaces	Leave this field blank. Value: spaces This field will be returned with the date the data was processed by DHS. Format: YYYYMMDD YYYY - century and year MM - month DD - day Example: 19990801
373	374	2	alpha	Leave this field blank. Value: spaces This field is returned with one of the following codes indicating the result of the processing. RJ - Rejected PD - Approved SS - Suspended, action pending
375	382	8	numeric or spaces	Leave this field blank. Value: spaces For MH billing only, this field is returned with the date the data was approved by DHS. Format: YYYYMMDD YYYY - century and year MM - month DD - day Example: 19990801
383	399	17	alpha	Leave this field blank. Value: spaces For MH billing only, this field is returned with a unique assigned number. This number will need to be referenced when submitting adjustments to accepted data.
400	400	1	alpha	Leave this field blank. Value: spaces MH billing only, this field is returned with a value of Y if the date the service was performed was in the prior state fiscal year and the lapse period for payment has passed.
401	401	1	alpha	Leave this field blank. Value: spaces For MH billing only, this field is returned with the DHS processing data cycle number.
402	410	9	alpha	Leave these fields blank. Value: spaces These fields are returned after DHS has processed the record. Up to three warning codes will be noted, indicating the reason the data was changed.
411	425	15	alpha	Leave these fields blank. Value: spaces These fields are returned after DHS has processed the record. If the record is rejected during processing by DHS, up to five error codes will be noted, indicating the reason the record was rejected by DHS.
426	439	14	alpha	Leave this field blank. Value: spaces
440	440	1	alpha	Mandatory - Report the value: Z Z - indicates agency's own software created the file.
441	450	10	alpha	Leave this field blank. Value: spaces

2.4 Service Reporting Monthly Adjustment Record Format

Field Name	From	Thru	Length	Format	Description
Agency FEIN	1	9	9	numeric	Mandatory - The agency's nine digit Federal Employer Identification Number (FEIN). Report the same FEIN as indicated on the original approved reporting.
Filler	10	11	2	alpha	Leave this field blank. Value: spaces
Agency Satellite Code	12	13	2	numeric	Mandatory - An organizational subpart within an agency that has a unique physical location, but does not have a different FEIN assigned to it (assigned by DHS). Report the same SATELLITE CODE as indicated on the original approved reporting.
Client ID or Client's Age Group	14	22	9	numeric or alpha-numeric	Mandatory, if applicable - The agency client ID assigned by the agency to the registered client or the age group of the client if the client is not registered with the agency.
Record Type	23	23	1	alpha	Mandatory - Report the value: R R - indicates ADJUSTMENT to the accepted MONTHLY record NOTE: The monthly record format is used for service reporting only; you cannot use this format to adjust MH Medicaid billing.
Case ID Number	24	36	13	alpha	Mandatory - The DHS (formerly public aid) eligibility Case ID number for the client. Report 0000000000000 if the client has no Case ID Number. Report 9999999999999 if the client's Case ID Number is unknown.
Site Number	37	38	2	numeric or spaces	Mandatory, if applicable - The site number assigned by DHS that represents the unique or specific geographical site as the base for service delivery. Refer to your current DHS contract or Agency Plan 2.0/2.1. NOTE: Not used for DD programs. For DD service reporting, leave this field blank (value spaces).
Unit Code	39	40	2	numeric or spaces	Mandatory, if applicable - A unique number assigned to a component of the provider's service delivery organization to reflect a distinction of that component, such as location, client population to be served, staff or staff team providing the services, or source of funding for the service. Refer to your current DHS contract or Agency Plan 2.0/2.1. If unit code is not applicable, leave this field blank (value spaces).
Program Code	41	43	3	numeric	Mandatory - The program number assigned by DHS that represents the program through which services were provided. Refer to your current DHS contract or Agency Plan 2.0/2.1.
Filler	44	59	16	alpha	Leave this field blank. Value: spaces
Staff ID #1	60	68	9	numeric	Mandatory, for Mental Health programs - The ID number of the professional staff member responsible for providing the services to this client. The staff ID number must be numeric - report 123 as 000000123. Optional, for DD programs; if not used this field must be blank (value spaces).
Staff ID #2	69	77	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
Staff ID #3	78	86	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
Staff ID #4	87	95	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
Staff ID #5	96	104	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
Staff ID #6	105	113	9	numeric or spaces	Optional - If used, same description as for Staff ID #1 above; if not used, this field must be blank (value spaces).
Filler	114	172	59	alpha	Leave this field blank. Value: spaces
Service Recipient Code	173	173	1	numeric	Mandatory - Report the code that identifies the type of client served or the setting. 1 - Registered 2 - Unregistered 3 - Collateral 4 - Community 5 - Own Agency
Attendance or Hours and Minutes of Service 31 occurrences (up to 31 days in a month) length= 4 each Day/Position	174	297	124	alpha or numeric	Mandatory - To report attendance, report one of the following codes in the first field position of the corresponding day of the month (the other 3 positions for that day must be spaces): P - Present A - Absent B - Bed-hold To report hours and minutes, report the duration of hours (valid range: 00-24) in the first two positions and the duration of minutes (valid range: 00-59) in the last two positions of the corresponding days of the month when the client received the service. Examples: report 3 hours as 0300 report 30 minutes as 0030 For months with less than 31 days, leave the remaining fields for those days blank (value spaces). Note: This reporting will overlay the previous accepted reporting for each day of the month. Be sure to report for all days applicable, not just those being corrected.
1	174	177	4	alpha or numeric
2	178	181	4	alpha or numeric
3	182	185	4	alpha or numeric
4	186	189	4	alpha or numeric
5	190	193	4	alpha or numeric
6	194	197	4	alpha or numeric
7	198	201	4	alpha or numeric
8	202	205	4	alpha or numeric
9	206	209	4	alpha or numeric
10	210	213	4	alpha or numeric
11	214	217	4	alpha or numeric
12	218	221	4	alpha or numeric
13	222	225	4	alpha or numeric
14	226	229	4	alpha or numeric
15	230	233	4	alpha or numeric
16	234	237	4	alpha or numeric
17	238	241	4	alpha or numeric
18	242	245	4	alpha or numeric
19	246	249	4	alpha or numeric
20	250	253	4	alpha or numeric
21	254	257	4	alpha or numeric
22	258	261	4	alpha or numeric
23	262	265	4	alpha or numeric
24	266	269	4	alpha or numeric
25	270	273	4	alpha or numeric
26	274	277	4	alpha or numeric
27	278	281	4	alpha or numeric
28	282	285	4	alpha or numeric
29	286	289	4	alpha or numeric
30	290	293	4	alpha or numeric
31	294	297	4	alpha or numeric
Filler	298	336	39	alpha	Leave this field blank. Value: spaces
Original Document Control Number	337	353	17	alpha	Mandatory - Report the exact Document Control Number which was assigned by DHS to the original accepted service reporting/claim.
Adjustment Type	354	355	2	alpha	Mandatory - Report the appropriate code to identify the reason for the adjustment: 03 - Use this code to indicate data changes are being made to the original accepted service reporting. Valid data to change: DHS Case ID, Site Code, Unit Code, Program Code, Staff ID, Hours, Minutes, and Service Recipient Code. 04 - Use this code to VOID the original accepted service reporting.
Adjustment Purpose	356	356	1	alpha	Mandatory - This code is used to further describe the reason for the adjustment. Valid values: D - Use when Adjustment Type = 04, if the adjustment is voiding the original approved service reporting. N - Use when Adjustment Type = 03
Submit Date	357	364	8	numeric	Mandatory - The date on which the record is being submitted to DHS. Format: YYYYMMDD YYYY - century and year MM - month DD - day Example: 19990801
Process Date	365	372	8	alpha	Leave this field blank. Value: spaces This field will be returned with the date the data was processed by DHS. Format: YYYYMMDD YYYY - century and year MM - month DD - day Example: 19990801
Acceptance Indicator	373	374	2	alpha	Leave this field blank. Value: spaces This field is returned with one of the following codes indicating the result of the processing. RJ - Rejected PD - Approved
Filler	375	382	8	alpha	Leave this field blank. Value: spaces This field is returned with the date the data was approved by DHS. Format: YYYYMMDD YYYY - century and year MM - month DD - day Example: 19990801
Document Control Number	383	399	17	alpha	Leave this field blank. Value: spaces This field is returned with a unique assigned number. This number will need to be referenced when submitting adjustments to accepted data.
Filler	400	401	2	alpha	Leave this field blank. Value: spaces
Warning Codes up to 3 warning codes (3 positions each)	402	410	9	alpha	Leave these fields blank. Value: spaces These fields are returned after DHS has processed the record. Up to three warning codes will be noted, indicating the reason the data was changed.
Reject Codes up to 5 error codes (3 positions each)	411	425	15	alpha	Leave these fields blank. Value: spaces These fields are returned after DHS has processed the record. If the record is rejected during processing by DHS, up to five error codes will be noted, indicating the reason the record was rejected by DHS.
Filler	426	439	14	alpha	Leave this field blank. Value: spaces
Software Indicator	440	440	1	alpha	Mandatory - Report the value: Z Z - indicates agency's own software created the file.
Filler	441	450	10	alpha	Leave this field blank. Value: spaces

2.5 MH Billing Client Eligibility Change Record Format

Field Name	From	Thru	Length	Format	Description
Agency FEIN	1	9	9	numeric	The agency's Federal Employer Identification Number (FEIN).
Agency Satellite Code	10	13	4	numeric	The agency satellite code which was submitted on the original MH bill.
Client ID	14	22	9	numeric	The current agency client ID for the registered client.
Record Type	23	23	1	alpha	L - indicates a client eligibility change for the accepted MH bill.
Filler	24	283	260	alpha	Value: spaces
DHS Tracking Number	284	293	10	alpha	The DHS assigned number that is used in tracking the payment in the DHS accounting system.
Filler	294	304	11	alpha	Value: spaces
Payment Fiscal Year	305	308	4	numeric	The State fiscal year the eligibility change is applied.
Filler	309	364	27	alpha	Value: spaces
DPA Segment Indicator	336	336	1	alpha	The DPA segment to which the billing is now applied. A - DPA Medicaid Segment
Filler	337	364	28	alpha	Value: spaces
Process Date	365	372	8	numeric	The date the change was processed by DHS Format: YYYYMMDD
Filler	373	382	10	alpha	Value: spaces
Document Control Number	383	399	17	alpha	The Document Control Number which was assigned by DHS to the original accepted MH bill.
Filler	400	450	51	alpha	Value: spaces

2.6 Service Reporting/MH Billing Trailer Record Format

Field Name	From	Thru	Length	Format	Description
Agency FEIN	1	9	9	numeric	Mandatory - The agency's nine digit Federal Employer Identification Number (FEIN).
Filler	10	11	2	alpha	Leave this field blank. Value: spaces
Agency Satellite Code	12	13	2	numeric	Mandatory - An organizational subpart within an agency that has a unique physical location, but does not have a different FEIN assigned to it. This code is assigned by DHS. If no satellite code is assigned, report zeros in this field.
Trailer Nines	14	22	9	numeric	Mandatory - Report the value 999999999 in this field.
Record Type	23	23	1	alpha	Mandatory - Report the value: T T - indicates the TRAILER record
Record Count	24	31	8	numeric	Mandatory - Report the total number of records in the file, including the trailer record.
Agency Name	32	61	30	alpha	Mandatory - Report the agency name.
Total Hours Billed to MH	62	67	6	numeric	Mandatory - Report the total number of hours being billed to MH in the file. If none, report zeros in this field.
Total Minutes Billed to MH	68	73	6	numeric	Mandatory - Report the total number of minutes (DO NOT CONVERT TO HOURS) being billed to MH in the file. If none, report zeros in this field.
Filler	74	439	366	alpha	Leave this field blank. Value: spaces
Software Indicator	440	440	1	alpha	Mandatory - Report the value: Z Z - indicates agency's own software created the file
Filler	441	450	10	alpha	Leave this field blank. Value: spaces