ISA-
Interchange Control Header
01 |
I01 |
Authorization Information Qualifier |
R |
|
|
00 03 |
02 |
I02 |
Authorization Information |
R |
|
03 |
I03 |
Security Information Qualifier |
R |
|
|
00 01 |
04 |
I04 |
Security Information |
R |
|
05 |
I05 |
Interchange ID Qualifier |
R |
|
|
01 14 20 27 28 29 30 33 ZZ |
06 |
I06 |
Interchange Sender ID |
R |
|
07 |
I05 |
Interchange ID Qualifier |
R |
|
|
01 14 20 27 28 29 30 33 ZZ |
08 |
I07 |
Interchange Receiver ID |
R |
|
09 |
I08 |
Interchange Date |
R |
|
10 |
I09 |
Interchange Time |
R |
|
11 |
I10 |
Interchange Control Standards Identifier |
R |
|
|
U |
12 |
I11 |
Interchange Control Version Number |
R |
|
|
00401 |
13 |
I12 |
Interchange Control Number |
R |
|
14 |
I13 |
Acknowledgment Requested |
R |
|
|
0 1 |
15 |
I14 |
Usage Indicator |
R |
|
|
P T |
16 |
I15 |
Component Element Separator |
R |
|
GS-
Functional Group Header
01 |
479 |
Functional Identifier Code |
R |
|
|
HC |
02 |
142 |
Application Sender's Code |
R |
|
03 |
124 |
Application Receiver's Code |
R |
|
04 |
373 |
Date |
R |
|
05 |
337 |
Time |
R |
|
06 |
28 |
Group Control Number |
R |
|
07 |
455 |
Responsible Agency Code |
R |
|
|
X |
08 |
480 |
Version / Release / Industry Identifier Code |
R |
|
|
004010X096A1 |
ST-
Transaction Set Header
01 |
143 |
Transaction Set Identifier Code |
R |
|
|
837 |
02 |
329 |
Transaction Set Control Number |
R |
|
BHT-
Beginning of Hierarchical Transaction
01 |
1005 |
Hierarchical Structure Code |
R |
|
|
0019 |
02 |
353 |
Transaction Set Purpose Code |
R |
|
|
00 18 |
03 |
127 |
Originator Application Transaction Identifier |
R |
|
04 |
373 |
Transaction Set Creation Date |
R |
|
05 |
337 |
Transaction Set Creation Time |
R |
|
06 |
640 |
Claim or Encounter Identifier |
R |
|
|
CH RP |
REF-
Transaction Type Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
87 |
02 |
127 |
Transmission Type Code |
R |
|
|
004010X096DA1 004010X096A1 |
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Submitter Name
01 |
98 |
Entity Identifier Code |
R |
|
|
41 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 2 |
03 |
1035 |
Submitter Last or Organization Name |
R |
|
04 |
1036 |
Submitter First Name |
S |
|
05 |
1037 |
Submitter Middle Name |
S |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Name Suffix |
N |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
46 |
09 |
67 |
Submitter Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
PER-
Submitter EDI Contact Information
01 |
366 |
Contact Function Code |
R |
|
|
IC |
02 |
93 |
Submitter Contact Name |
R |
|
03 |
365 |
Communication Number Qualifier |
R |
|
|
ED EM FX TE |
04 |
364 |
Communication Number |
R |
|
05 |
365 |
Communication Number Qualifier |
S |
|
|
ED EM EX FX TE |
06 |
364 |
Communication Number |
S |
|
07 |
365 |
Communication Number Qualifier |
S |
|
|
ED EM EX FX TE |
08 |
364 |
Communication Number |
S |
|
09 |
443 |
Contact Inquiry Reference |
N |
|
NM1-
Receiver Name
01 |
98 |
Entity Identifier Code |
R |
|
|
40 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
2 |
03 |
1035 |
Receiver Name |
R |
|
04 |
1036 |
Name First |
N |
|
05 |
1037 |
Name Middle |
N |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Name Suffix |
N |
|
08 |
66 |
Information Receiver Identification Number |
R |
|
|
46 |
09 |
67 |
Receiver Primary Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
HL-
Billing/Pay-To Provider Hierarchical Level
01 |
628 |
Hierarchical ID Number |
R |
|
02 |
734 |
Hierarchical Parent ID Number |
N |
|
03 |
735 |
Hierarchical Level Code |
R |
|
|
20 |
04 |
736 |
Hierarchical Child Code |
R |
|
|
1 |
PRV-
Billing/Pay-To Provider Specialty Information
01 |
1221 |
Provider Code |
R |
|
|
BI PT |
02 |
128 |
Reference Identification Qualifier |
R |
|
|
ZZ |
03 |
127 |
Provider Taxonomy Code |
R |
|
04 |
156 |
State or Province Code |
N |
|
|
External Source: states |
N |
|
C035 |
Provider Specialty Information |
|
06 |
1223 |
Provider Organization Code |
N |
|
CUR-
Foreign Currency Information
01 |
98 |
Entity Identifier Code |
R |
|
|
85 |
02 |
100 |
Currency Code |
R |
|
|
External Source: currency |
03 |
280 |
Exchange Rate |
N |
|
04 |
98 |
Entity Identifier Code |
N |
|
05 |
100 |
Currency Code |
N |
|
|
External Source: currency |
06 |
669 |
Currency Market/Exchange Code |
N |
|
07 |
374 |
Date/Time Qualifier |
N |
|
08 |
373 |
Date |
N |
|
09 |
337 |
Time |
N |
|
10 |
374 |
Date/Time Qualifier |
N |
|
11 |
373 |
Date |
N |
|
12 |
337 |
Time |
N |
|
13 |
374 |
Date/Time Qualifier |
N |
|
14 |
373 |
Date |
N |
|
15 |
337 |
Time |
N |
|
16 |
374 |
Date/Time Qualifier |
N |
|
17 |
373 |
Date |
N |
|
18 |
337 |
Time |
N |
|
19 |
374 |
Date/Time Qualifier |
N |
|
20 |
373 |
Date |
N |
|
21 |
337 |
Time |
N |
|
NM1-
Billing Provider Name
01 |
98 |
Entity Identifier Code |
R |
|
|
85 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
2 |
03 |
1035 |
Billing Provider Last or Organizational Name |
R |
|
04 |
1036 |
Name First |
N |
|
05 |
1037 |
Name Middle |
N |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Name Suffix |
N |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
24 34 XX |
09 |
67 |
Billing Provider Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
N3-
Billing Provider Address
01 |
166 |
Billing Provider Address Line |
R |
|
02 |
166 |
Billing Provider Address Line |
S |
|
N4-
Billing Provider City/State/ZIP Code
01 |
19 |
Billing Provider City Name |
R |
|
02 |
156 |
Billing Provider State or Province Code |
R |
|
|
External Source: states |
03 |
116 |
Billing Provider Postal Zone or ZIP Code |
R |
|
04 |
26 |
Country Code |
S |
|
|
External Source: country |
05 |
309 |
Location Qualifier |
N |
|
06 |
310 |
Location Identifier |
N |
|
REF-
Billing Provider Secondary Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
0B 1A 1B 1C 1D 1G 1H 1J B3 BQ EI FH G2 G5 LU SY X5 |
02 |
127 |
Billing Provider Additional Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Credit/Debit Card Billing Information
01 |
128 |
Reference Identification Qualifier |
R |
|
|
06 8U EM IJ LU RB ST TT |
02 |
127 |
Billing Provider Credit Card Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
PER-
Billing Provider Contact Information
01 |
366 |
Contact Function Code |
R |
|
|
IC |
02 |
93 |
Billing Provider Contact Name |
R |
|
03 |
365 |
Communication Number Qualifier |
R |
|
|
EM FX TE |
04 |
364 |
Communication Number |
R |
|
05 |
365 |
Communication Number Qualifier |
S |
|
|
EM EX FX TE |
06 |
364 |
Communication Number |
S |
|
07 |
365 |
Communication Number Qualifier |
S |
|
|
EM EX FX TE |
08 |
364 |
Communication Number |
S |
|
09 |
443 |
Contact Inquiry Reference |
N |
|
NM1-
Pay-To Provider Name
01 |
98 |
Entity Identifier Code |
R |
|
|
87 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
2 |
03 |
1035 |
Pay-to Provider Last or Organizational Name |
R |
|
04 |
1036 |
Name First |
N |
|
05 |
1037 |
Name Middle |
N |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Name Suffix |
N |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
24 34 XX |
09 |
67 |
Pay-to Provider Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
N3-
Pay-To Provider Address
01 |
166 |
Pay-to Provider Address Line |
R |
|
02 |
166 |
Pay-to Provider Address Line |
S |
|
N4-
Pay-To Provider City/State/ZIP Code
01 |
19 |
Pay-to Provider City Name |
R |
|
02 |
156 |
Pay-to Provider State Code |
R |
|
|
External Source: states |
03 |
116 |
Pay-to Provider Postal Zone or ZIP Code |
R |
|
04 |
26 |
Pay-to Provider Country Code |
S |
|
|
External Source: country |
05 |
309 |
Location Qualifier |
N |
|
06 |
310 |
Location Identifier |
N |
|
REF-
Pay-To Provider Secondary Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
0B 1A 1B 1C 1D 1G 1H 1J B3 BQ EI FH G2 G5 LU SY X5 |
02 |
127 |
Pay-to Provider Additional Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
HL-
Subscriber Hierarchical Level
01 |
628 |
Hierarchical ID Number |
R |
|
02 |
734 |
Hierarchical Parent ID Number |
R |
|
03 |
735 |
Hierarchical Level Code |
R |
|
|
22 |
04 |
736 |
Hierarchical Child Code |
R |
|
|
0 1 |
SBR-
Subscriber Information
01 |
1138 |
Payer Responsibility Sequence Number Code |
R |
|
|
P S T |
02 |
1069 |
Patients Relationship to Insured |
S |
|
|
18 |
03 |
127 |
Insured Group or Policy Number |
S |
|
04 |
93 |
Insured Group Name |
S |
|
05 |
1336 |
Insurance Type Code |
N |
|
06 |
1143 |
Coordination of Benefits Code |
N |
|
07 |
1073 |
Yes/No Condition or Response Code |
N |
|
08 |
584 |
Employment Status Code |
N |
|
09 |
1032 |
Claim Filing Indicator Code |
S |
|
|
09 10 11 12 13 14 15 16 AM BL CH CI DS HM LI LM MA MB MC OF TV VA WC ZZ |
NM1-
Subscriber Name
01 |
98 |
Entity Identifier Code |
R |
|
|
IL |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 2 |
03 |
1035 |
Subscriber Last Name |
R |
|
04 |
1036 |
Subscriber First Name |
S |
|
05 |
1037 |
Subscriber Middle Name |
S |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Subscriber Name Suffix |
S |
|
08 |
66 |
Identification Code Qualifier |
S |
|
|
MI ZZ |
09 |
67 |
Subscriber Primary Identifier |
S |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
N3-
Subscriber Address
01 |
166 |
Subscriber Address Line |
R |
|
02 |
166 |
Subscriber Address Line |
S |
|
N4-
Subscriber City/State/ZIP Code
01 |
19 |
Subscriber City Name |
R |
|
02 |
156 |
Subscriber State Code |
R |
|
|
External Source: states |
03 |
116 |
Subscriber Postal Zone or ZIP Code |
R |
|
04 |
26 |
Country Code |
S |
|
|
External Source: country |
05 |
309 |
Location Qualifier |
N |
|
06 |
310 |
Location Identifier |
N |
|
DMG-
Subscriber Demographic Information
01 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
02 |
1251 |
Subscriber Birth Date |
R |
|
03 |
1068 |
Subscriber Gender Code |
R |
|
|
F M U |
04 |
1067 |
Marital Status Code |
N |
|
05 |
1109 |
Race or Ethnicity Code |
N |
|
06 |
1066 |
Citizenship Status Code |
N |
|
07 |
26 |
Country Code |
N |
|
|
External Source: country |
08 |
659 |
Basis of Verification Code |
N |
|
09 |
380 |
Quantity |
N |
|
REF-
Subscriber Secondary Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
1W 23 IG SY |
02 |
127 |
Subscriber Supplemental Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Property and Casualty Claim Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
Y4 |
02 |
127 |
Property Casualty Claim Number |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Credit/Debit Card Account Holder Name
01 |
98 |
Entity Identifier Code |
R |
|
|
AO |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 2 |
03 |
1035 |
Credit or Debit Card Holder Last or Organizational Name |
R |
|
04 |
1036 |
Credit or Debit Card Holder First Name |
S |
|
05 |
1037 |
Credit or Debit Card Holder Middle Name |
S |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Credit or Debit Card Holder Name Suffix |
S |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
MI |
09 |
67 |
Credit or Debit Card Number |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
REF-
Credit/Debit Card Information
01 |
128 |
Reference Identification Qualifier |
R |
|
|
AB BB |
02 |
127 |
Credit or Debit Card Authorization Number |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Payer Name
01 |
98 |
Entity Identifier Code |
R |
|
|
PR |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
2 |
03 |
1035 |
Payer Name |
R |
|
04 |
1036 |
Name First |
N |
|
05 |
1037 |
Name Middle |
N |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Name Suffix |
N |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
PI XV |
09 |
67 |
Payer Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
N3-
Payer Address
01 |
166 |
Payer Address Line |
R |
|
02 |
166 |
Payer Address Line |
S |
|
N4-
Payer City/State/ZIP Code
01 |
19 |
Payer City Name |
R |
|
02 |
156 |
Payer State Code |
R |
|
|
External Source: states |
03 |
116 |
Payer Postal Zone or ZIP Code |
R |
|
04 |
26 |
Payer Country Code |
S |
|
|
External Source: country |
05 |
309 |
Location Qualifier |
N |
|
06 |
310 |
Location Identifier |
N |
|
REF-
Payer Secondary Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
2U FY NF TJ |
02 |
127 |
Payer Additional Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Responsible Party Name
01 |
98 |
Entity Identifier Code |
R |
|
|
QD |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 2 |
03 |
1035 |
Responsible Party Last or Organization Name |
R |
|
04 |
1036 |
Responsible Party First Name |
S |
|
05 |
1037 |
Responsible Party Middle Name |
S |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Responsible Party Suffix Name |
S |
|
08 |
66 |
Identification Code Qualifier |
N |
|
09 |
67 |
Identification Code |
N |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
N3-
Responsible Party Address
01 |
166 |
Responsible Party Address Line |
R |
|
02 |
166 |
Responsible Party Address Line |
S |
|
N4-
Responsible Party City/State/ZIP Code
01 |
19 |
Responsible Party City Name |
R |
|
02 |
156 |
Responsible Party State Code |
R |
|
|
External Source: states |
03 |
116 |
Responsible Party Postal Zone or ZIP Code |
R |
|
04 |
26 |
Responsible Party Country Code |
S |
|
|
External Source: country |
05 |
309 |
Location Qualifier |
N |
|
06 |
310 |
Location Identifier |
N |
|
CLM-
Claim Information
01 |
1028 |
Patient Account Number |
R |
|
02 |
782 |
Total Claim Charge Amount |
R |
|
03 |
1032 |
Claim Filing Indicator Code |
N |
|
04 |
1343 |
Non-Institutional Claim Type Code |
N |
|
R |
|
C023 |
Type of Bill |
|
01 |
1331 |
Facility Type Code |
R |
|
02 |
1332 |
Facility Code Qualifier |
R |
|
|
A |
03 |
1325 |
Claim Frequency Code |
R |
|
|
0 1 2 3 4 5 6 7 8 9 A B C D E F G H I J K L M N O X Y Z |
06 |
1073 |
Provider or Supplier Signature Indicator |
R |
|
|
N Y |
07 |
1359 |
Medicare Assignment Code |
S |
|
|
A C |
08 |
1073 |
Benefits Assignment Certification Indicator |
R |
|
|
N Y |
09 |
1363 |
Release of Information Code |
R |
|
|
A I M N O Y |
10 |
1351 |
Patient Signature Source Code |
N |
|
N |
|
C024 |
Property and Casualty Related Causes Codes |
|
12 |
1366 |
Special Program Indicator |
N |
|
|
01 02 03 05 07 08 09 |
13 |
1073 |
Yes/No Condition or Response Code |
N |
|
14 |
1338 |
Level of Service Code |
N |
|
15 |
1073 |
Yes/No Condition or Response Code |
N |
|
16 |
1360 |
Provider Agreement Code |
N |
|
17 |
1029 |
Claim Status Code |
N |
|
18 |
1073 |
Explanation of Benefits Indicator |
R |
|
|
N Y |
19 |
1383 |
Claim Submission Reason Code |
N |
|
20 |
1514 |
Delay Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 |
DTP-
Discharge Hour
01 |
374 |
Date Time Qualifier |
R |
|
|
096 |
02 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
TM |
03 |
1251 |
Discharge Hour |
R |
|
DTP-
Statement Dates
01 |
374 |
Date Time Qualifier |
R |
|
|
434 |
02 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 RD8 |
03 |
1251 |
Statement From or To Date |
R |
|
DTP-
Admission Date/Hour
01 |
374 |
Date Time Qualifier |
R |
|
|
435 |
02 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
DT |
03 |
1251 |
Admission Date and Hour |
R |
|
CL1-
Institutional Claim Code
01 |
1315 |
Admission Type Code |
S |
|
02 |
1314 |
Admission Source Code |
S |
|
03 |
1352 |
Patient Status Code |
S |
|
04 |
1345 |
Nursing Home Residential Status Code |
N |
|
PWK-
Claim Supplemental Information
01 |
755 |
Attachment Report Type Code |
R |
|
|
AS B2 B3 B4 CT DA DG DS EB MT NN OB OZ PN PO PZ RB RR RT |
02 |
756 |
Attachment Transmission Code |
R |
|
|
AA BM EL EM FX |
03 |
757 |
Report Copies Needed |
N |
|
04 |
98 |
Entity Identifier Code |
N |
|
05 |
66 |
Identification Code Qualifier |
S |
|
|
AC |
06 |
67 |
Attachment Control Number |
S |
|
07 |
352 |
Attachment Description |
S |
|
N |
|
C002 |
Actions Indicated |
|
09 |
1525 |
Request Category Code |
N |
|
CN1-
Contract Information
01 |
1166 |
Contract Type Code |
R |
|
|
01 02 03 04 05 06 09 |
02 |
782 |
Contract Amount |
S |
|
03 |
332 |
Contract Percentage |
S |
|
04 |
127 |
Contract Code |
S |
|
05 |
338 |
Terms Discount Percentage |
S |
|
06 |
799 |
Contract Version Identifier |
S |
|
AMT-
Payer Estimated Amount Due
01 |
522 |
Amount Qualifier Code |
R |
|
|
C5 |
02 |
782 |
Estimated Claim Due Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Patient Estimated Amount Due
01 |
522 |
Amount Qualifier Code |
R |
|
|
F3 |
02 |
782 |
Patient Responsibility Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Patient Paid Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
F5 |
02 |
782 |
Patient Amount Paid |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Credit/Debit Card Maximum Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
MA |
02 |
782 |
Credit or Debit Card Maximum Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
REF-
Adjusted Repriced Claim Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
9C |
02 |
127 |
Adjusted Repriced Claim Reference Number |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Repriced Claim Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
9A |
02 |
127 |
Repriced Claim Reference Number |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Claim Identification Number For Clearinghouses and Other Transmission Intermediaries
01 |
128 |
Reference Identification Qualifier |
R |
|
|
D9 |
02 |
127 |
Value Added Network Trace Number |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Document Identification Code
01 |
128 |
Reference Identification Qualifier |
R |
|
|
DD |
02 |
127 |
Document Control Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Original Reference Number (ICN/DCN)
01 |
128 |
Reference Identification Qualifier |
R |
|
|
F8 |
02 |
127 |
Claim Original Reference Number |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Investigational Device Exemption Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
LX |
02 |
127 |
Investigational Device Exemption Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Service Authorization Exception Code
01 |
128 |
Reference Identification Qualifier |
R |
|
|
4N |
02 |
127 |
Service Authorization Exception Code |
R |
|
|
1 2 3 4 5 6 7 |
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Peer Review Organization (PRO) Approval Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
G4 |
02 |
127 |
Peer Review Authorization Number |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Prior Authorization or Referral Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
9F G1 |
02 |
127 |
Prior Authorization Number |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Medical Record Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
EA |
02 |
127 |
Medical Record Number |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Demonstration Project Identifier
01 |
128 |
Reference Identification Qualifier |
R |
|
|
P4 |
02 |
127 |
Demonstration Project Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
K3-
File Information
01 |
449 |
Fixed Format Information |
R |
|
02 |
1333 |
Record Format Code |
N |
|
N |
|
C001 |
Composite Unit of Measure |
|
NTE-
Claim Note
01 |
363 |
Note Reference Code |
R |
|
|
ALG DCP DGN DME MED NTR ODT RHB RLH RNH SET SFM SPT UPI |
02 |
352 |
Claim Note Text |
R |
|
NTE-
Billing Note
01 |
363 |
Note Reference Code |
R |
|
|
ADD |
02 |
352 |
Billing Note Text |
R |
|
CR6-
Home Health Care Information
01 |
923 |
Prognosis Indicator |
R |
|
|
1 2 3 4 5 6 7 8 |
02 |
373 |
Service From Date |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
RD8 |
04 |
1251 |
Home Health Certification Period |
S |
|
05 |
373 |
Diagnosis Date |
R |
|
06 |
1073 |
Skilled Nursing Facility Indicator |
R |
|
|
N U Y |
07 |
1073 |
Medicare Coverage Indicator |
R |
|
|
N Y |
08 |
1322 |
Certification Type Indicator |
R |
|
|
I R S |
09 |
373 |
Surgery Date |
S |
|
10 |
235 |
Product or Service ID Qualifier |
S |
|
|
HC ID |
11 |
1137 |
Surgical Procedure Code |
S |
|
12 |
373 |
Physician Order Date |
S |
|
13 |
373 |
Last Visit Date |
S |
|
14 |
373 |
Physician Contact Date |
S |
|
15 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
RD8 |
16 |
1251 |
Last Admission Period |
S |
|
17 |
1384 |
Patient Discharge Facility Type Code |
R |
|
|
A B C D E F G H L M O R S T |
18 |
373 |
Diagnosis Date |
S |
|
19 |
373 |
Diagnosis Date |
S |
|
20 |
373 |
Diagnosis Date |
S |
|
21 |
373 |
Diagnosis Date |
S |
|
CRC-
Home Health Functional Limitations
01 |
1136 |
Code Category |
R |
|
|
75 |
02 |
1073 |
Certification Condition Indicator |
R |
|
|
N Y |
03 |
1321 |
Functional Limitation Code |
R |
|
|
AA AL BL CO DY EL HL LB OL PA SL |
04 |
1321 |
Functional Limitation Code |
S |
|
|
AA AL BL CO DY EL HL LB OL PA SL |
05 |
1321 |
Functional Limitation Code |
S |
|
|
AA AL BL CO DY EL HL LB OL PA SL |
06 |
1321 |
Functional Limitation Code |
S |
|
|
AA AL BL CO DY EL HL LB OL PA SL |
07 |
1321 |
Functional Limitation Code |
S |
|
|
AA AL BL CO DY EL HL LB OL PA SL |
CRC-
Home Health Activities Permitted
01 |
1136 |
Certification Condition Indicator |
R |
|
|
76 |
02 |
1073 |
Functional Limitation Code |
R |
|
|
N Y |
03 |
1321 |
Activities Permitted Code |
R |
|
|
BR CA CB CR EP IH NR PW TR UT WA WR |
04 |
1321 |
Activities Permitted Code |
S |
|
|
BR CA CB CR EP IH NR PW TR UT WA WR |
05 |
1321 |
Activities Permitted Code |
S |
|
|
BR CA CB CR EP IH NR PW TR UT WA WR |
06 |
1321 |
Activities Permitted Code |
S |
|
|
BR CA CB CR EP IH NR PW TR UT WA WR |
07 |
1321 |
Activities Permitted Code |
S |
|
|
BR CA CB CR EP IH NR PW TR UT WA WR |
CRC-
Home Health Mental Status
01 |
1136 |
Certification Condition Indicator |
R |
|
|
77 |
02 |
1073 |
Functional Limitation Code |
R |
|
|
N Y |
03 |
1321 |
Mental Status Code |
R |
|
|
AG CM DI DP FO LE MC OT |
04 |
1321 |
Mental Status Code |
S |
|
|
AG CM DI DP FO LE MC OT |
05 |
1321 |
Mental Status Code |
S |
|
|
AG CM DI DP FO LE MC OT |
06 |
1321 |
Mental Status Code |
S |
|
|
AG CM DI DP FO LE MC OT |
07 |
1321 |
Mental Status Code |
S |
|
|
AG CM DI DP FO LE MC OT |
HI-
Principal, Admitting, E-Code and Patient Reason for Visit Diagnosis Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BK |
02 |
1271 |
Industry Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BJ ZZ |
02 |
1271 |
Industry Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BN |
02 |
1271 |
Industry Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
HI-
Diagnosis Related Group (DRG) Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
DR |
02 |
1271 |
Diagnosis Related Group (DRG) Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
HI-
Other Diagnosis Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
HI-
Principal Procedure Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BP BR |
02 |
1271 |
Principal Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Date Time Period |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
HI-
Other Procedure Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
HI-
Occurrence Span Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
HI-
Occurrence Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
HI-
Value Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
n Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
HI-
Condition Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
HI-
Treatment Code Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
QTY-
Claim Quantity
01 |
673 |
Quantity Qualifier |
R |
|
|
CA CD LA NA |
02 |
380 |
Claim Days Count |
R |
|
R |
|
C001 |
Composite Unit of Measure |
|
01 |
355 |
Unit or Basis for Measurement Code |
R |
|
|
DA |
02 |
1018 |
Exponent |
N |
|
03 |
649 |
Multiplier |
N |
|
04 |
355 |
Unit or Basis for Measurement Code |
N |
|
05 |
1018 |
Exponent |
N |
|
06 |
649 |
Multiplier |
N |
|
07 |
355 |
Unit or Basis for Measurement Code |
N |
|
08 |
1018 |
Exponent |
N |
|
09 |
649 |
Multiplier |
N |
|
10 |
355 |
Unit or Basis for Measurement Code |
N |
|
11 |
1018 |
Exponent |
N |
|
12 |
649 |
Multiplier |
N |
|
13 |
355 |
Unit or Basis for Measurement Code |
N |
|
14 |
1018 |
Exponent |
N |
|
15 |
649 |
Multiplier |
N |
|
04 |
61 |
Free-Form Message |
N |
|
HCP-
Claim Pricing/Repricing Information
01 |
1473 |
Pricing Methodology |
R |
|
|
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 |
02 |
782 |
Repriced Allowed Amount |
R |
|
03 |
782 |
Repriced Saving Amount |
S |
|
04 |
127 |
Repricing Organization Identifier |
S |
|
05 |
118 |
Repricing Per Diem or Flat Rate Amount |
S |
|
06 |
127 |
Repriced Approved DRG Code |
S |
|
07 |
782 |
Repriced Approved Amount |
S |
|
08 |
234 |
Repriced Approved Revenue Code |
S |
|
09 |
235 |
Product or Service ID Qualifier |
S |
|
|
HC |
10 |
234 |
Repriced Approved HCPCS Code |
S |
|
11 |
355 |
Unit or Basis for Measurement Code |
S |
|
|
DA UN |
12 |
380 |
Repriced Approved Service Unit Count |
S |
|
13 |
901 |
Rejection Message |
S |
|
|
T1 T2 T3 T4 T5 T6 |
14 |
1526 |
Policy Compliance Code |
S |
|
|
1 2 3 4 5 |
15 |
1527 |
Exception Reason Code |
S |
|
|
1 2 3 4 5 6 |
CR7-
Home Health Care Plan Information
01 |
921 |
Discipline Type Code |
R |
|
|
AI MS OT PT SN ST |
02 |
1470 |
Visits Prior to Recertification Date Count |
R |
|
03 |
1470 |
Total Visits Projected This Certification Count |
R |
|
HSD-
Health Care Services Delivery
01 |
673 |
Visits |
S |
|
|
VS |
02 |
380 |
Number of Visits |
S |
|
03 |
355 |
Frequency Period |
S |
|
|
DA MO Q1 WK |
04 |
1167 |
Frequency Count |
S |
|
05 |
615 |
Duration of Visits Units |
S |
|
|
7 35 |
06 |
616 |
Duration of Visits, Number of Units |
S |
|
07 |
678 |
Ship, Delivery or Calendar Pattern Code |
S |
|
|
1 2 3 4 5 6 7 8 9 A B C D E F G H J K L N O S SA SB SC SD SG SL SP SX SY SZ W |
08 |
679 |
Delivery Pattern Time Code |
S |
|
|
D E F |
NM1-
Attending Physician Name
01 |
98 |
Entity Identifier Code |
R |
|
|
71 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 2 |
03 |
1035 |
Attending Physician Last Name |
R |
|
04 |
1036 |
Attending Physician First Name |
S |
|
05 |
1037 |
Attending Physician Middle Name |
S |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Attending Physician Name Suffix |
S |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
24 34 XX |
09 |
67 |
Attending Physician Primary Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
PRV-
Attending Physician Specialty Information
01 |
1221 |
Provider Code |
R |
|
|
AT SU |
02 |
128 |
Reference Identification Qualifier |
R |
|
|
ZZ |
03 |
127 |
Provider Taxonomy Code |
R |
|
04 |
156 |
State or Province Code |
N |
|
|
External Source: states |
N |
|
C035 |
Provider Specialty Information |
|
06 |
1223 |
Provider Organization Code |
N |
|
REF-
Attending Physician Secondary Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
0B 1A 1B 1C 1D 1G 1H EI G2 LU N5 SY X5 |
02 |
127 |
Attending Physician Secondary Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Operating Physician Name
01 |
98 |
Entity Identifier Code |
R |
|
|
72 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 |
03 |
1035 |
Operating Physician Last Name |
R |
|
04 |
1036 |
Operating Physician First Name |
R |
|
05 |
1037 |
Operating Physician Middle Name |
S |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Operating Physician Name Suffix |
S |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
24 34 XX |
09 |
67 |
Operating Physician Primary Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
PRV-
Operating Physician Specialty Information
01 |
1221 |
Provider Code |
R |
|
|
OP |
02 |
128 |
Reference Identification Qualifier |
R |
|
|
ZZ |
03 |
127 |
Provider Taxonomy Code |
R |
|
04 |
156 |
State or Province Code |
N |
|
N |
|
C035 |
Provider Specialty Information |
|
06 |
1223 |
Provider Organization Code |
N |
|
REF-
Operating Physician Secondary Identification
1 |
128 |
Reference Identification Qualifier |
R |
|
|
0B 1A 1B 1C 1D 1G 1H EI G2 LU N5 SY X5 |
02 |
127 |
Operating Physician Secondary Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Other Provider Name
01 |
98 |
Entity Identifier Code |
R |
|
|
73 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 2 |
03 |
1035 |
Other Physician Last Name |
R |
|
04 |
1036 |
Other Physician First Name |
S |
|
05 |
1037 |
Other Provider Middle Name |
S |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Other Provider Name Suffix |
S |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
24 34 XX |
09 |
67 |
Other Physician Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
PRV-
Other Provider Specialty Information
01 |
1221 |
Provider Code |
R |
|
|
OT PE |
02 |
128 |
Reference Identification Qualifier |
R |
|
|
ZZ |
03 |
127 |
Provider Taxonomy Code |
R |
|
04 |
156 |
State or Province Code |
N |
|
N |
|
C035 |
Provider Specialty Information |
|
06 |
1223 |
Provider Organization Code |
N |
|
REF-
Other Provider Secondary Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
0B 1A 1B 1C 1D 1G 1H EI G2 LU N5 SY X5 |
02 |
127 |
Other Provider Secondary Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Service Facility Name
01 |
98 |
Entity Identifier Code |
R |
|
|
FA |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
2 |
03 |
1035 |
Laboratory or Facility Name |
R |
|
04 |
1036 |
Name First |
N |
|
05 |
1037 |
Name Middle |
N |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Name Suffix |
N |
|
08 |
66 |
Identification Code Qualifier |
S |
|
|
24 34 XX |
09 |
67 |
Laboratory or Facility Primary Identifier |
S |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
PRV-
Service Facility Specialty Information
01 |
1221 |
Provider Code |
R |
|
|
RP |
02 |
128 |
Reference Identification Qualifier |
R |
|
|
ZZ |
03 |
127 |
Provider Taxonomy Code |
R |
|
04 |
156 |
State or Province Code |
N |
|
N |
|
C035 |
Provider Specialty Information |
|
06 |
1223 |
Provider Organization Code |
N |
|
N3-
Service Facility Address
01 |
166 |
Laboratory or Facility Address Line |
R |
|
02 |
166 |
Laboratory or Facility Address Line |
S |
|
N4-
Service Facility City/State/Zip Code
01 |
19 |
Laboratory or Facility City Name |
R |
|
02 |
156 |
Laboratory or Facility State or Province Code |
R |
|
|
External Source: states |
03 |
116 |
Laboratory or Facility Postal Zone or Zip Code |
R |
|
04 |
26 |
Laboratory/Facility Country Code |
S |
|
|
External Source: country |
05 |
309 |
Location Qualifier |
N |
|
06 |
310 |
Location Identifier |
N |
|
REF-
Service Facility Secondary Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
0B 1A 1B 1C 1D 1G 1H 1J EI FH G2 G5 LU N5 X5 |
02 |
127 |
Laboratory or Facility Secondary Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
SBR-
Other Subscriber Information
01 |
1138 |
Payer Responsibility Sequence Number Code |
R |
|
|
P S T |
02 |
1069 |
Individual Relationship Code |
R |
|
|
01 04 05 07 10 15 17 18 19 20 21 22 23 24 29 32 33 36 39 40 41 43 53 G8 |
03 |
127 |
Insured Group or Policy Number |
S |
|
04 |
93 |
Other Insured Group Name |
S |
|
05 |
1336 |
Insurance Type Code |
N |
|
06 |
1143 |
Coordination of Benefits Code |
N |
|
07 |
1073 |
Condition or Response Code |
N |
|
08 |
584 |
Employment Status Code |
N |
|
09 |
1032 |
Claim Filing Indicator Code |
S |
|
|
09 10 11 12 13 14 15 16 AM BL CH CI DS HM LI LM MA MB MC OF TV VA WC ZZ |
CAS-
Claim Level Adjustment
01 |
1033 |
Claim Adjustment Group Code |
R |
|
|
CO CR OA PI PR |
02 |
1034 |
Adjustment Reason Code |
R |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
03 |
782 |
Adjustment Amount |
R |
|
04 |
380 |
Adjustment Quantity |
S |
|
05 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
06 |
782 |
Adjustment Amount |
S |
|
07 |
380 |
Adjustment Quantity |
S |
|
08 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
09 |
782 |
Adjustment Amount |
S |
|
10 |
380 |
Adjustment Quantity |
S |
|
11 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
12 |
782 |
Adjustment Amount |
S |
|
13 |
380 |
Adjustment Quantity |
S |
|
14 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
15 |
782 |
Adjustment Amount |
S |
|
16 |
380 |
Adjustment Quantity |
S |
|
17 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
18 |
782 |
Adjustment Amount |
S |
|
19 |
380 |
Adjustment Quantity |
S |
|
AMT-
Payer Prior Payment
01 |
522 |
Amount Qualifier Code |
R |
|
|
C4 |
02 |
782 |
Other Payer Patient Paid Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Coordination of Benefits (COB) Total Allowed Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
B6 |
02 |
782 |
Allowed Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Coordination of Benefits (COB) Total Submitted Charges
01 |
522 |
Amount Qualifier Code |
R |
|
|
T3 |
02 |
782 |
Coordination of Benefits Total Submitted Charge Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Diagnostic Related Group (DRG) Outlier Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
ZZ |
02 |
782 |
Claim DRG Outlier Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Coordination of Benefits (COB) Total Medicare Paid Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
N1 |
02 |
782 |
Total Medicare Paid Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Medicare Paid Amount - 100%
01 |
522 |
Amount Qualifier Code |
R |
|
|
KF |
02 |
782 |
Medicare Paid at 100% Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Medicare Paid Amount - 80%
01 |
522 |
Amount Qualifier Code |
R |
|
|
PG |
02 |
782 |
Medicare Paid at 80% Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Coordination of Benefits (COB) Medicare A Trust Fund Paid Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
AA |
02 |
782 |
Paid From Part A Medicare Trust Fund Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Coordination of Benefits (COB) Medicare B Trust Fund Paid Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
B1 |
02 |
782 |
Paid From Part B Medicare Trust Fund Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Coordination of Benefits (COB) Total Non-Covered Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
A8 |
02 |
782 |
Non-Covered Charge Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Coordination of Benefits (COB) Total Denied Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
YT |
02 |
782 |
Claim Total Denied Charge Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
DMG-
Other Subscriber Demographic Information
01 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
02 |
1251 |
Other Insured Birth Date |
R |
|
03 |
1068 |
Other Insured Gender Code |
R |
|
|
F M U |
04 |
1067 |
Marital Status Code |
N |
|
05 |
1109 |
nicity Code |
N |
|
06 |
1066 |
Citizenship Status Code |
N |
|
07 |
26 |
Country Code |
N |
|
|
External Source: country |
08 |
659 |
Basis of Verification Code |
N |
|
09 |
380 |
Quantity |
N |
|
OI-
Other Insurance Coverage Information
01 |
1032 |
Claim Filing Indicator Code |
N |
|
02 |
1383 |
Claim Submission Reason Code |
N |
|
03 |
1073 |
Benefits Assignment Certification Indicator |
R |
|
|
N Y |
04 |
1351 |
Patient Signature Source Code |
N |
|
05 |
1360 |
Provider Agreement Code |
N |
|
06 |
1363 |
Release of Information Code |
R |
|
|
A I M N O Y |
MIA-
Medicare Inpatient Adjudication Information
01 |
380 |
Covered Days or Visits Count |
R |
|
02 |
380 |
Lifetime Reserve Days Count |
S |
|
03 |
380 |
Lifetime Psychiatric Days Count |
S |
|
04 |
782 |
Claim DRG Amount |
S |
|
05 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
06 |
782 |
Claim Disproportionate Share Amount |
S |
|
07 |
782 |
Claim MSP Pass-through Amount |
S |
|
08 |
782 |
Claim PPS Capital Amount |
S |
|
09 |
782 |
PPS-Capital FSP DRG Amount |
S |
|
10 |
782 |
PPS-Capital HSP DRG Amount |
S |
|
11 |
782 |
PPS-Capital DSH DRG Amount |
S |
|
12 |
782 |
Old Capital Amount |
S |
|
13 |
782 |
PPS-Capital IME Amount |
S |
|
14 |
782 |
PPS-Operating Hospital Specific DRG Amount |
S |
|
15 |
380 |
Cost Report Day Count |
S |
|
16 |
782 |
PPS-Operating Federal Specific DRG Amount |
S |
|
17 |
782 |
Claim PPS Capital Outlier Amount |
S |
|
18 |
782 |
Claim Indirect Teaching Amount |
S |
|
19 |
782 |
Nonpayable Professional Component Amount |
S |
|
20 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
21 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
22 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
23 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
24 |
782 |
PPS-Capital Exception Amount |
S |
|
MOA-
Medicare Outpatient Adjudication Information
01 |
954 |
Reimbursement Rate |
S |
|
02 |
782 |
Claim HCPCS Payable Amount |
S |
|
03 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
04 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
05 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
06 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
07 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
08 |
782 |
Claim ESRD Payment Amount |
S |
|
09 |
782 |
Nonpayable Professional Component Amount |
S |
|
NM1-
Other Subscriber Name
01 |
98 |
Entity Identifier Code |
R |
|
|
IL |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 2 |
03 |
1035 |
Other Insured Last Name |
R |
|
04 |
1036 |
Other Insured First Name |
S |
|
05 |
1037 |
Other Insured Middle Name |
S |
|
06 |
1038 |
fix |
N |
|
07 |
1039 |
Other Insured Name Suffix |
S |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
MI ZZ |
09 |
67 |
Other Insured Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
N3-
Other Subscriber Address
01 |
166 |
Other Insured Address Line |
R |
|
02 |
166 |
Other Insured Address Line |
S |
|
N4-
Other Subscriber City/State/ZIP Code
01 |
19 |
Other Insured City Name |
R |
|
02 |
156 |
Other Insured State Code |
R |
|
|
External Source: states |
03 |
116 |
Other Insured Postal Zone or Zip Code |
R |
|
04 |
26 |
Subscriber Country Code |
S |
|
|
External Source: country |
05 |
309 |
Location Qualifier |
N |
|
06 |
310 |
Location Identifier |
N |
|
REF-
Other Subscriber Secondary Information
01 |
128 |
Reference Identification Qualifier |
R |
|
|
1W 23 IG SY |
02 |
127 |
Other Insured Additional Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Other Payer Name
01 |
98 |
Entity Identifier Code |
R |
|
|
PR |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
2 |
03 |
1035 |
Other Payer Last or Organization Name |
R |
|
04 |
1036 |
Name First |
N |
|
05 |
1037 |
Name Middle |
N |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Name Suffix |
N |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
PI XV |
09 |
67 |
Other Payer Primary Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
N3-
Other Payer Address
01 |
166 |
Other Payer Address Line |
R |
|
02 |
166 |
Other Payer Address Line |
S |
|
N4-
Other Payer City/State/ZIP Code
01 |
19 |
Other Payer City Name |
R |
|
02 |
156 |
Other Payer State Code |
R |
|
|
External Source: states |
03 |
116 |
Other Payer Postal Zone or Zip Code |
R |
|
04 |
26 |
Payer Country Code |
S |
|
|
External Source: country |
05 |
309 |
Location Qualifier |
N |
|
06 |
310 |
Location Identifier |
N |
|
DTP-
Claim Adjudication Date
01 |
374 |
Date Time Qualifier |
R |
|
|
573 |
02 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
03 |
1251 |
Adjudication or Payment Date |
R |
|
REF-
Other Payer Secondary Identification and Reference Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
2U F8 FY NF TJ |
02 |
127 |
Other Payer Secondary Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Other Payer Prior Authorization or Referral Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
9F G1 |
02 |
127 |
Other Payer Prior Authorization or Referral Number |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Other Payer Patient Information
01 |
98 |
Entity Identifier Code |
R |
|
|
QC |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 |
03 |
1035 |
Name Last or Organization Name |
N |
|
04 |
1036 |
Name First |
N |
|
05 |
1037 |
Name Middle |
N |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Name Suffix |
N |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
EI MI |
09 |
67 |
Other Payer Patient Primary Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
REF-
Other Payer identification Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
1W IG SY |
02 |
127 |
Other Payer Patient Secondary Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Other Payer Attending Provider
01 |
98 |
Entity Identifier Code |
R |
|
|
71 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 2 |
03 |
1035 |
Name Last or Organization Name |
N |
|
04 |
1036 |
Name First |
N |
|
05 |
1037 |
Name Middle |
N |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Name Suffix |
N |
|
08 |
66 |
Identification Code Qualifier |
N |
|
09 |
67 |
Identification Code |
N |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
REF-
Other Payer Attending Provider Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
1A 1B 1C 1D 1G 1H EI G2 LU N5 |
02 |
127 |
Other Payer Attending Provider Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Other Payer Operating Provider
01 |
98 |
Entity Identifier Code |
R |
|
|
72 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 |
03 |
1035 |
Name Last or Organization Name |
N |
|
04 |
1036 |
Name First |
N |
|
05 |
1037 |
Name Middle |
N |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Name Suffix |
N |
|
08 |
66 |
Identification Code Qualifier |
N |
|
09 |
67 |
Identification Code |
N |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
REF-
Other Payer Operating Provider Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
1A 1B 1C 1D 1G 1H EI G2 LU N5 |
02 |
127 |
Other Payer Operating Provider Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Other Payer Other Provider
01 |
98 |
Entity Identifier Code |
R |
|
|
73 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 2 |
03 |
1035 |
Name Last or Organization Name |
N |
|
04 |
1036 |
Name First |
N |
|
05 |
1037 |
Name Middle |
N |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Name Suffix |
N |
|
08 |
66 |
Identification Code Qualifier |
N |
|
09 |
67 |
Identification Code |
N |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
fier Code |
N |
|
REF-
Other Payer Other Provider Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
1A 1B 1C 1D 1G 1H EI G2 LU N5 SY |
02 |
127 |
Other Payer Other Provider Identifier |
R |
|
03 |
352 |
on |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Other Payer Service Facility Provider
01 |
98 |
Entity Identifier Code |
R |
|
|
FA |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
2 |
03 |
1035 |
Name Last or Organization Name |
N |
|
04 |
1036 |
Name First |
N |
|
05 |
1037 |
Name Middle |
N |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Name Suffix |
N |
|
08 |
66 |
ode Qualifier |
N |
|
09 |
67 |
Identification Code |
N |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
REF-
Other Payer Service Facility Provider Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
1B 1C 1D EI G2 LU N5 |
02 |
127 |
Other Payer Service Facility Provider Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
LX-
Service Line Number
SV2-
Institutional Service Line
01 |
234 |
Service Line Revenue Code |
R |
|
S |
|
C003 |
Service Line Procedure Code |
|
01 |
235 |
Product or Service ID Qualifier |
R |
|
|
HC IV N4 ZZ |
02 |
234 |
Procedure Code |
R |
|
03 |
1339 |
HCPCS Modifier 1 |
S |
|
04 |
1339 |
HCPCS Modifier 2 |
S |
|
05 |
1339 |
HCPCS Modifier 3 |
S |
|
06 |
1339 |
HCPCS Modifier 4 |
S |
|
07 |
352 |
Description |
N |
|
03 |
782 |
Line Item Charge Amount |
R |
|
04 |
355 |
Unit or Basis for Measurement Code |
R |
|
|
DA F2 UN |
05 |
380 |
Service Unit Count |
R |
|
06 |
1371 |
Service Line Rate |
S |
|
07 |
782 |
Line Item Denied Charge or Non-Covered Charge Amount |
S |
|
08 |
1073 |
Yes/No Condition or Response Code |
N |
|
09 |
1345 |
Status Code |
N |
|
10 |
1337 |
Level of Care Code |
N |
|
PWK-
Line Supplemental Information
01 |
755 |
Attachment Report Type Code |
R |
|
|
AS B2 B3 B4 CT DA DG DS EB MT NN OB OZ PN PO PZ RB RR RT |
02 |
756 |
Attachment Transmission Code |
R |
|
|
AA AB AD AF AG BM EL EM FX |
03 |
757 |
Report Copies Needed |
N |
|
04 |
98 |
Entity Identifier Code |
N |
|
05 |
66 |
Identification Code Qualifier |
S |
|
|
AC |
06 |
67 |
Attachment Control Number |
S |
|
07 |
352 |
Description |
N |
|
N |
|
C002 |
Actions Indicated |
|
09 |
1525 |
Request Category Code |
N |
|
DTP-
Service Line Date
01 |
374 |
Date Time Qualifier |
R |
|
|
472 |
02 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 RD8 |
03 |
1251 |
Service Date |
R |
|
DTP-
Assessment Date
01 |
374 |
Date Time Qualifier |
R |
|
|
866 |
02 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
03 |
1251 |
Assessment Date |
R |
|
AMT-
Service Tax Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
GT |
02 |
782 |
Service Tax Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Facility Tax Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
N8 |
02 |
782 |
Facility Tax Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
HCP-
Line Pricing/Repricing Information R0113 P0910 P1112
01 |
1473 |
Pricing Methodology |
R |
|
|
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 |
02 |
782 |
Repriced Allowed Amount |
R |
|
03 |
782 |
Repriced Saving Amount |
S |
|
04 |
127 |
Repriced Organizational Identifier |
S |
|
05 |
118 |
Repricing Per Diem or Flat Rate Amount |
S |
|
06 |
127 |
Repriced Approved Ambulatory Patient Group Code |
S |
|
07 |
782 |
Repriced Approved Ambulatory Patient Group Amount |
S |
|
08 |
234 |
Repriced Approved Revenue Code |
S |
|
09 |
235 |
Product/ Service ID Qualifier |
S |
|
|
HC |
10 |
234 |
Procedure Code |
S |
|
11 |
355 |
Unit or Basis for Measurement Code |
S |
|
|
DA UN |
12 |
380 |
Repricing Approved Service Unit Count |
S |
|
13 |
901 |
Reject Reason Code |
S |
|
|
T1 T2 T3 T4 T5 T6 |
14 |
1526 |
Policy Compliance Code |
S |
|
|
1 2 3 4 5 |
15 |
1527 |
Exception Code |
S |
|
|
1 2 3 4 5 6 |
LIN-
Drug Identification P0405 P0607 P0809 P1011 P1213 P1415 P1617 P1819 P2021 P2223 P2425 P2627 P2829 P3031
01 |
350 |
Assigned Identification |
N |
|
02 |
235 |
Product/Service ID Qualifier |
R |
|
|
N4 |
03 |
234 |
Product/Service ID |
R |
|
04 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
05 |
234 |
Product/Service ID |
N |
|
06 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
07 |
234 |
Product/Service ID |
N |
|
08 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
09 |
234 |
Product/Service ID |
N |
|
10 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
11 |
234 |
Product/Service ID |
N |
|
12 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
13 |
234 |
Product/Service ID |
N |
|
14 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
15 |
234 |
Product/Service ID |
N |
|
16 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
17 |
234 |
Product/Service ID |
N |
|
18 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
19 |
234 |
Product/Service ID |
N |
|
20 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
21 |
234 |
Product/Service ID |
N |
|
22 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
23 |
234 |
Product/Service ID |
N |
|
24 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
25 |
234 |
Product/Service ID |
N |
|
26 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
27 |
234 |
Product/Service ID |
N |
|
28 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
29 |
234 |
Product/Service ID |
N |
|
30 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
31 |
234 |
Product/Service ID |
N |
|
CTP-
Drug Pricing P0405 C0607 C0902 C1002 C1103
01 |
687 |
Class of Trade Code |
N |
|
02 |
236 |
Price Identifier Code |
N |
|
03 |
212 |
Unit Price |
R |
|
04 |
380 |
Quantity |
R |
|
R |
|
C001 |
Composite Unit of Measure |
|
01 |
355 |
Unit or Basis for Measurement Code |
R |
|
|
F2 GR ML UN |
02 |
1018 |
Exponent |
N |
|
03 |
649 |
Multiplier |
N |
|
04 |
355 |
Unit or Basis for Measurement Code |
N |
|
05 |
1018 |
Exponent |
N |
|
06 |
649 |
Multiplier |
N |
|
07 |
355 |
Unit or Basis for Measurement Code |
N |
|
08 |
1018 |
Exponent |
N |
|
09 |
649 |
Multiplier |
N |
|
10 |
355 |
Unit or Basis for Measurement Code |
N |
|
11 |
1018 |
Exponent |
N |
|
12 |
649 |
Multiplier |
N |
|
13 |
355 |
Unit or Basis for Measurement Code |
N |
|
14 |
1018 |
Exponent |
N |
|
15 |
649 |
Multiplier |
N |
|
06 |
648 |
Price Multiplier Qualifier |
N |
|
07 |
649 |
Multiplier |
N |
|
08 |
782 |
Monetary Amount |
N |
|
09 |
639 |
Basis of Unit Price Code |
N |
|
10 |
499 |
Condition Value |
N |
|
11 |
289 |
Multiple Price Quantity |
N |
|
REF-
Prescription Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
XZ |
02 |
127 |
Reference Identification |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Attending Physician Name
01 |
98 |
Entity Identifier Code |
R |
|
|
71 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 2 |
03 |
1035 |
Attending Physician Last Name |
R |
|
04 |
1036 |
Attending Physician First Name |
S |
|
05 |
1037 |
Attending Physician Middle Name |
S |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Attending Physician Name Suffix |
S |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
24 34 XX |
09 |
67 |
Attending Physician Primary Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
PRV-
Attending Physician Specialty Information
01 |
1221 |
Provider Code |
R |
|
|
AT |
02 |
128 |
Reference Identification Qualifier |
R |
|
|
ZZ |
03 |
127 |
Provider Taxonomy Code |
R |
|
04 |
156 |
State or Province Code |
N |
|
N |
|
C035 |
Provider Specialty Information |
|
06 |
1223 |
Provider Organization Code |
N |
|
REF-
Attending Physician Secondary Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
0B 1A 1B 1C 1D 1G 1H EI G2 LU N5 SY X5 |
02 |
127 |
Attending Physician Secondary Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Operating Physician Name
01 |
98 |
Entity Identifier Code |
R |
|
|
72 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 |
03 |
1035 |
Operating Physician Last Name |
R |
|
04 |
1036 |
Operating Physician First Name |
R |
|
05 |
1037 |
Operating Physician Middle Name |
S |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Operating Physician Name Suffix |
S |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
24 34 XX |
09 |
67 |
Operating Physician Primary Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
PRV-
Operating Physician Specialty Information
01 |
1221 |
Provider Code |
R |
|
|
OP |
02 |
128 |
Reference Identification Qualifier |
R |
|
|
ZZ |
03 |
127 |
Provider Taxonomy Code |
R |
|
04 |
156 |
State or Province Code |
N |
|
N |
|
C035 |
Provider Specialty Information |
|
06 |
1223 |
Provider Organization Code |
N |
|
REF-
Operating Physician Secondary Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
0B 1A 1B 1C 1D 1G 1H EI G2 LU N5 SY X5 |
02 |
127 |
Operating Physician Secondary Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Other Provider Name
01 |
98 |
Entity Identifier Code |
R |
|
|
73 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 2 |
03 |
1035 |
Other Physician Last Name |
R |
|
04 |
1036 |
Other Physician First Name |
S |
|
05 |
1037 |
Other Provider Middle Name |
S |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Other Provider Name Suffix |
S |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
24 34 XX |
09 |
67 |
Other Provider Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
PRV-
Other Provider Specialty Information
01 |
1221 |
Provider Code |
R |
|
|
OT PE |
02 |
128 |
Reference Identification Qualifier |
R |
|
|
ZZ |
03 |
127 |
Provider Taxonomy Code |
R |
|
04 |
156 |
State or Province Code |
N |
|
N |
|
C035 |
Provider Specialty Information |
|
06 |
1223 |
Provider Organization Code |
N |
|
REF-
Other Provider Secondary Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
0B 1A 1B 1C 1D 1G 1H EI G2 LU N5 SY X5 |
02 |
127 |
Other Provider Secondary Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
SVD-
Service Line Adjudication Information
01 |
67 |
Payer Identifier |
R |
|
02 |
782 |
Service Line Paid Amount |
R |
|
S |
|
C003 |
Composite Medical Procedure Identifier |
|
01 |
235 |
Product or Service ID Qualifier |
R |
|
|
HC IV ZZ |
02 |
234 |
Procedure Code |
R |
|
03 |
1339 |
Procedure Modifier |
S |
|
04 |
1339 |
Procedure Modifier |
S |
|
05 |
1339 |
Procedure Modifier |
S |
|
06 |
1339 |
Procedure Modifier |
S |
|
07 |
352 |
Procedure Code Description |
S |
|
04 |
234 |
Service Line Revenue Code |
R |
|
05 |
380 |
Adjustment Quantity |
R |
|
06 |
554 |
Bundled or Unbundled Line Number |
S |
|
CAS-
Service Line Adjustment
01 |
1033 |
Claim Adjustment Group Code |
R |
|
|
CO CR OA PI PR |
02 |
1034 |
Adjustment Reason Code |
R |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
03 |
782 |
Adjustment Amount |
R |
|
04 |
380 |
Adjustment Quantity |
S |
|
05 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
06 |
782 |
Adjustment Amount |
S |
|
07 |
380 |
Adjustment Quantity |
S |
|
08 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
09 |
782 |
Adjustment Amount |
S |
|
10 |
380 |
Adjustment Quantity |
S |
|
11 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
12 |
782 |
Adjustment Amount |
S |
|
13 |
380 |
Adjustment Quantity |
S |
|
14 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
15 |
782 |
Adjustment Amount |
S |
|
16 |
380 |
Adjustment Quantity |
S |
|
17 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
18 |
782 |
Adjustment Amount |
S |
|
19 |
380 |
Adjustment Quantity |
S |
|
DTP-
Service Adjudication Date
01 |
374 |
Date Time Qualifier |
R |
|
|
573 |
02 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
03 |
1251 |
Service Adjudication or Payment Date |
R |
|
HL-
Patient Hierarchical Level
01 |
628 |
Hierarchical ID Number |
R |
|
02 |
734 |
Hierarchical Parent ID Number |
R |
|
03 |
735 |
Hierarchical Level Code |
R |
|
|
23 |
04 |
736 |
Hierarchical Child Code |
R |
|
|
0 |
PAT-
Patient Information
01 |
1069 |
Patients Relationship to Insured |
R |
|
|
01 04 05 07 10 15 17 19 20 21 22 23 24 29 32 33 36 39 40 41 43 53 G8 |
02 |
1384 |
Patient Location Code |
N |
|
03 |
584 |
Employment Status Code |
N |
|
04 |
1220 |
Student Status Code |
N |
|
05 |
1250 |
Date Time Period Format Qualifier |
N |
|
06 |
1251 |
Date Time Period |
N |
|
07 |
355 |
Unit or Basis for Measurement Code |
N |
|
08 |
81 |
Patient Weight |
N |
|
09 |
1073 |
Pregnancy Indicator |
N |
|
NM1-
Patient Name
01 |
98 |
Entity Identifier Code |
R |
|
|
QC |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 |
03 |
1035 |
Patient Last Name |
R |
|
04 |
1036 |
Patient First Name |
R |
|
05 |
1037 |
Patient Middle Name |
S |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Patient Name Suffix |
S |
|
08 |
66 |
Identification Code Qualifier |
S |
|
|
MI ZZ |
09 |
67 |
Patient Primary Identifier |
S |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
N3-
Patient Address
01 |
166 |
Patient Address Line |
R |
|
02 |
166 |
Patient Address Line |
S |
|
N4-
Patient City/State/ZIP Code
01 |
19 |
Patient City Name |
R |
|
02 |
156 |
Patient State Code |
R |
|
|
External Source: states |
03 |
116 |
Patient Postal Zone or ZIP Code |
R |
|
04 |
26 |
Country Code |
S |
|
|
External Source: country |
05 |
309 |
Location Qualifier |
N |
|
06 |
310 |
Location Identifier |
N |
|
DMG-
Patient Demographic Information
01 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
02 |
1251 |
Patient Birth Date |
R |
|
03 |
1068 |
Patient Gender Code |
R |
|
|
F M U |
04 |
1067 |
Marital Status Code |
N |
|
05 |
1109 |
Race or Ethnicity Code |
N |
|
06 |
1066 |
Citizenship Status Code |
N |
|
07 |
26 |
Country Code |
N |
|
|
External Source: country |
08 |
659 |
Basis of Verification Code |
N |
|
09 |
380 |
Quantity |
N |
|
REF-
Patient Secondary Identification Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
1W 23 IG SY |
02 |
127 |
Patient Secondary Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Property and Casualty Claim Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
Y4 |
02 |
127 |
Property Casualty Claim Number |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
CLM-
Claim Information
01 |
1028 |
Patient Account Number |
R |
|
02 |
782 |
Total Claim Charge Amount |
R |
|
03 |
1032 |
Claim Filing Indicator Code |
N |
|
04 |
1343 |
Non-Institutional Claim Type Code |
N |
|
R |
|
C023 |
Type of Bill |
|
01 |
1331 |
Facility Type Code |
R |
|
02 |
1332 |
Facility Code Qualifier |
R |
|
|
A |
03 |
1325 |
Claim Frequency Code |
R |
|
|
0 1 2 3 4 5 6 7 8 9 A B C D E F G H I J K L M N O X Y Z |
06 |
1073 |
Provider or Supplier Signature Indicator |
R |
|
|
N Y |
07 |
1359 |
Medicare Assignment Code |
S |
|
|
A C |
08 |
1073 |
Benefits Assignment Certification Indicator |
R |
|
|
N Y |
09 |
1363 |
Release of Information Code |
R |
|
|
A I M N O Y |
10 |
1351 |
Patient Signature Source Code |
N |
|
N |
|
C024 |
Property and Casualty Related Causes Codes |
|
12 |
1366 |
Special Program Indicator |
N |
|
|
01 02 03 05 07 08 09 |
13 |
1073 |
Yes/No Condition or Response Code |
N |
|
14 |
1338 |
Level of Service Code |
N |
|
15 |
1073 |
Yes/No Condition or Response Code |
N |
|
16 |
1360 |
Provider Agreement Code |
N |
|
17 |
1029 |
Claim Status Code |
N |
|
18 |
1073 |
Explanation of Benefits Indicator |
R |
|
|
N Y |
19 |
1383 |
Claim Submission Reason Code |
N |
|
20 |
1514 |
Delay Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 |
DTP-
Discharge Hour
01 |
374 |
Date Time Qualifier |
R |
|
|
096 |
02 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
TM |
03 |
1251 |
Discharge Hour |
R |
|
DTP-
Statement Dates
01 |
374 |
Date Time Qualifier |
R |
|
|
434 |
02 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 RD8 |
03 |
1251 |
Statement From or To Date |
R |
|
DTP-
Admission Date/Hour
01 |
374 |
Date Time Qualifier |
R |
|
|
435 |
02 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
DT |
03 |
1251 |
Admission Date and Hour |
R |
|
CL1-
Institutional Claim Code
01 |
1315 |
Admission Type Code |
S |
|
02 |
1314 |
Admission Source Code |
S |
|
03 |
1352 |
Patient Status Code |
S |
|
04 |
1345 |
Nursing Home Residential Status Code |
N |
|
PWK-
Claim Supplemental Information
01 |
755 |
Attachment Report Type Code |
R |
|
|
AS B2 B3 B4 CT DA DG DS EB MT NN OB OZ PN PO PZ RB RR RT |
02 |
756 |
Attachment Transmission Code |
R |
|
|
AA BM EL EM FX |
03 |
757 |
Report Copies Needed |
N |
|
04 |
98 |
Entity Identifier Code |
N |
|
05 |
66 |
Identification Code Qualifier |
S |
|
|
AC |
06 |
67 |
Attachment Control Number |
S |
|
07 |
352 |
Attachment Description |
S |
|
N |
|
C002 |
Actions Indicated |
|
09 |
1525 |
Request Category Code |
N |
|
CN1-
Contract Information
01 |
1166 |
Contract Type Code |
R |
|
|
01 02 03 04 05 06 09 |
02 |
782 |
Contract Amount |
S |
|
03 |
332 |
Contract Percentage |
S |
|
04 |
127 |
Contract Code |
S |
|
05 |
338 |
Terms Discount Percentage |
S |
|
06 |
799 |
Contract Version Identifier |
S |
|
AMT-
Payer Estimated Amount Due
01 |
522 |
Amount Qualifier Code |
R |
|
|
C5 |
02 |
782 |
Estimated Claim Due Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Patient Estimated Amount Due
01 |
522 |
Amount Qualifier Code |
R |
|
|
F3 |
02 |
782 |
Patient Responsibility Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Patient Paid Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
F5 |
02 |
782 |
Patient Amount Paid |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Credit/Debit Card Maximum Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
MA |
02 |
782 |
Credit or Debit Card Maximum Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
REF-
Adjusted Repriced Claim Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
9C |
02 |
127 |
Adjusted Repriced Claim Reference Number |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Repriced Claim Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
9A |
02 |
127 |
Repriced Claim Reference Number |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Claim Identification Number For Clearinghouses and Other Transmission Intermediaries
01 |
128 |
Reference Identification Qualifier |
R |
|
|
D9 |
02 |
127 |
Value Added Network Trace Number |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Document Identification Code
01 |
128 |
Reference Identification Qualifier |
R |
|
|
DD |
02 |
127 |
Document Control Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Original Reference Number (ICN/DCN)
01 |
128 |
Reference Identification Qualifier |
R |
|
|
F8 |
02 |
127 |
Claim Original Reference Number |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Investigational Device Exemption Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
LX |
02 |
127 |
Investigational Device Exemption Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Service Authorization Exception Code
01 |
128 |
Reference Identification Qualifier |
R |
|
|
4N |
02 |
127 |
Service Authorization Exception Code |
R |
|
|
1 2 3 4 5 6 7 |
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Peer Review Organization (PRO) Approval Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
G4 |
02 |
127 |
Peer Review Authorization Number |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Prior Authorization or Referral Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
9F G1 |
02 |
127 |
Prior Authorization Number |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Medical Record Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
EA |
02 |
127 |
Medical Record Number |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Demonstration Project Identifier
01 |
128 |
Reference Identification Qualifier |
R |
|
|
P4 |
02 |
127 |
Demonstration Project Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
K3-
File Information
01 |
449 |
Fixed Format Information |
R |
|
02 |
1333 |
Record Format Code |
N |
|
N |
|
C001 |
Composite Unit of Measure |
|
NTE-
Claim Note
01 |
363 |
Note Reference Code |
R |
|
|
ALG DCP DGN DME MED NTR ODT RHB RLH RNH SET SFM SPT UPI |
02 |
352 |
Claim Note Text |
R |
|
NTE-
Billing Note
01 |
363 |
Note Reference Code |
R |
|
|
ADD |
02 |
352 |
Billing Note Text |
R |
|
CR6-
Home Health Care Information
01 |
923 |
Prognosis Indicator |
R |
|
|
1 2 3 4 5 6 7 8 |
02 |
373 |
Service From Date |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
RD8 |
04 |
1251 |
Home Health Certification Period |
S |
|
05 |
373 |
Diagnosis Date |
R |
|
06 |
1073 |
Skilled Nursing Facility Indicator |
R |
|
|
N U Y |
07 |
1073 |
Medicare Coverage Indicator |
R |
|
|
N Y |
08 |
1322 |
Certification Type Indicator |
R |
|
|
I R S |
09 |
373 |
Surgery Date |
S |
|
10 |
235 |
Product or Service ID Qualifier |
S |
|
|
HC ID |
11 |
1137 |
Surgical Procedure Code |
S |
|
12 |
373 |
Physician Order Date |
S |
|
13 |
373 |
Last Visit Date |
S |
|
14 |
373 |
Physician Contact Date |
S |
|
15 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
RD8 |
16 |
1251 |
Last Admission Period |
S |
|
17 |
1384 |
Patient Discharge Facility Type Code |
R |
|
|
A B C D E F G H L M O R S T |
18 |
373 |
Diagnosis Date |
S |
|
19 |
373 |
Diagnosis Date |
S |
|
20 |
373 |
Diagnosis Date |
S |
|
21 |
373 |
Diagnosis Date |
S |
|
CRC-
Home Health Functional Limitations
01 |
1136 |
Code Category |
R |
|
|
75 |
02 |
1073 |
Certification Condition Indicator |
R |
|
|
N Y |
03 |
1321 |
Functional Limitation Code |
R |
|
|
AA AL BL CO DY EL HL LB OL PA SL |
04 |
1321 |
Functional Limitation Code |
S |
|
|
AA AL BL CO DY EL HL LB OL PA SL |
05 |
1321 |
Functional Limitation Code |
S |
|
|
AA AL BL CO DY EL HL LB OL PA SL |
06 |
1321 |
Functional Limitation Code |
S |
|
|
AA AL BL CO DY EL HL LB OL PA SL |
07 |
1321 |
Functional Limitation Code |
S |
|
|
AA AL BL CO DY EL HL LB OL PA SL |
CRC-
Home Health Activities Permitted
01 |
1136 |
Certification Condition Indicator |
R |
|
|
76 |
02 |
1073 |
Functional Limitation Code |
R |
|
|
N Y |
03 |
1321 |
Activities Permitted Code |
R |
|
|
BR CA CB CR EP IH NR PW TR UT WA WR |
04 |
1321 |
Activities Permitted Code |
S |
|
|
BR CA CB CR EP IH NR PW TR UT WA WR |
05 |
1321 |
Activities Permitted Code |
S |
|
|
BR CA CB CR EP IH NR PW TR UT WA WR |
06 |
1321 |
Activities Permitted Code |
S |
|
|
BR CA CB CR EP IH NR PW TR UT WA WR |
07 |
1321 |
Activities Permitted Code |
S |
|
|
BR CA CB CR EP IH NR PW TR UT WA WR |
CRC-
Home Health Mental Status
01 |
1136 |
Certification Condition Indicator |
R |
|
|
77 |
02 |
1073 |
Functional Limitation Code |
R |
|
|
N Y |
03 |
1321 |
Mental Status Code |
R |
|
|
AG CM DI DP FO LE MC OT |
04 |
1321 |
Mental Status Code |
S |
|
|
AG CM DI DP FO LE MC OT |
05 |
1321 |
Mental Status Code |
S |
|
|
AG CM DI DP FO LE MC OT |
06 |
1321 |
Mental Status Code |
S |
|
|
AG CM DI DP FO LE MC OT |
07 |
1321 |
Mental Status Code |
S |
|
|
AG CM DI DP FO LE MC OT |
HI-
Principal, Admitting, E-Code and Patient Reason for Visit Diagnosis Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BK |
02 |
1271 |
Industry Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BJ ZZ |
02 |
1271 |
Industry Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BN |
02 |
1271 |
Industry Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
HI-
Diagnosis Related Group (DRG) Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
DR |
02 |
1271 |
Diagnosis Related Group (DRG) Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
HI-
Other Diagnosis Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BF |
02 |
1271 |
Other Diagnosis |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
HI-
Principal Procedure Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BP BR |
02 |
1271 |
Principal Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Date Time Period |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
N |
|
C022 |
Health Care Code Information |
|
HI-
Other Procedure Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BO BQ |
02 |
1271 |
Procedure Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
S |
|
|
D8 |
04 |
1251 |
Procedure Date |
S |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
HI-
Occurrence Span Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BI |
02 |
1271 |
Occurrence Span Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
HI-
Occurrence Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BH |
02 |
1271 |
Occurrence Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
04 |
1251 |
Occurrence or Occurrence Span Code Associated Date |
R |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
HI-
Value Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
n Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BE |
02 |
1271 |
Value Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Value Code Associated Amount |
R |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
HI-
Condition Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
BG |
02 |
1271 |
Condition Code |
R |
|
|
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
HI-
Treatment Code Information
R |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
S |
|
C022 |
Health Care Code Information |
|
01 |
1270 |
Code List Qualifier Code |
R |
|
|
TC |
02 |
1271 |
Treatment Code |
R |
|
03 |
1250 |
Date Time Period Format Qualifier |
N |
|
04 |
1251 |
Date Time Period |
N |
|
05 |
782 |
Monetary Amount |
N |
|
06 |
380 |
Quantity |
N |
|
07 |
799 |
Version Identifier |
N |
|
QTY-
Claim Quantity
01 |
673 |
Quantity Qualifier |
R |
|
|
CA CD LA NA |
02 |
380 |
Claim Days Count |
R |
|
R |
|
C001 |
Composite Unit of Measure |
|
01 |
355 |
Unit or Basis for Measurement Code |
R |
|
|
DA |
02 |
1018 |
Exponent |
N |
|
03 |
649 |
Multiplier |
N |
|
04 |
355 |
Unit or Basis for Measurement Code |
N |
|
05 |
1018 |
Exponent |
N |
|
06 |
649 |
Multiplier |
N |
|
07 |
355 |
Unit or Basis for Measurement Code |
N |
|
08 |
1018 |
Exponent |
N |
|
09 |
649 |
Multiplier |
N |
|
10 |
355 |
Unit or Basis for Measurement Code |
N |
|
11 |
1018 |
Exponent |
N |
|
12 |
649 |
Multiplier |
N |
|
13 |
355 |
Unit or Basis for Measurement Code |
N |
|
14 |
1018 |
Exponent |
N |
|
15 |
649 |
Multiplier |
N |
|
04 |
61 |
Free-Form Message |
N |
|
HCP-
Claim Pricing/Repricing Information
01 |
1473 |
Pricing Methodology |
R |
|
|
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 |
02 |
782 |
Repriced Allowed Amount |
R |
|
03 |
782 |
Repriced Saving Amount |
S |
|
04 |
127 |
Repricing Organization Identifier |
S |
|
05 |
118 |
Repricing Per Diem or Flat Rate Amount |
S |
|
06 |
127 |
Repriced Approved DRG Code |
S |
|
07 |
782 |
Repriced Approved Amount |
S |
|
08 |
234 |
Repriced Approved Revenue Code |
S |
|
09 |
235 |
Product or Service ID Qualifier |
S |
|
|
HC |
10 |
234 |
Repriced Approved HCPCS Code |
S |
|
11 |
355 |
Unit or Basis for Measurement Code |
S |
|
|
DA UN |
12 |
380 |
Repriced Approved Service Unit Count |
S |
|
13 |
901 |
Rejection Message |
S |
|
|
T1 T2 T3 T4 T5 T6 |
14 |
1526 |
Policy Compliance Code |
S |
|
|
1 2 3 4 5 |
15 |
1527 |
Exception Reason Code |
S |
|
|
1 2 3 4 5 6 |
CR7-
Home Health Care Plan Information
01 |
921 |
Discipline Type Code |
R |
|
|
AI MS OT PT SN ST |
02 |
1470 |
Visits Prior to Recertification Date Count |
R |
|
03 |
1470 |
Total Visits Projected This Certification Count |
R |
|
HSD-
Health Care Services Delivery
01 |
673 |
Visits |
S |
|
|
VS |
02 |
380 |
Number of Visits |
S |
|
03 |
355 |
Frequency Period |
S |
|
|
DA MO Q1 WK |
04 |
1167 |
Frequency Count |
S |
|
05 |
615 |
Duration of Visits Units |
S |
|
|
7 35 |
06 |
616 |
Duration of Visits, Number of Units |
S |
|
07 |
678 |
Ship, Delivery or Calendar Pattern Code |
S |
|
|
1 2 3 4 5 6 7 8 9 A B C D E F G H J K L N O S SA SB SC SD SG SL SP SX SY SZ W |
08 |
679 |
Delivery Pattern Time Code |
S |
|
|
D E F |
NM1-
Attending Physician Name
01 |
98 |
Entity Identifier Code |
R |
|
|
71 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 2 |
03 |
1035 |
Attending Physician Last Name |
R |
|
04 |
1036 |
Attending Physician First Name |
S |
|
05 |
1037 |
Attending Physician Middle Name |
S |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Attending Physician Name Suffix |
S |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
24 34 XX |
09 |
67 |
Attending Physician Primary Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
PRV-
Attending Physician Specialty Information
01 |
1221 |
Provider Code |
R |
|
|
AT SU |
02 |
128 |
Reference Identification Qualifier |
R |
|
|
ZZ |
03 |
127 |
Provider Taxonomy Code |
R |
|
04 |
156 |
State or Province Code |
N |
|
|
External Source: states |
N |
|
C035 |
Provider Specialty Information |
|
06 |
1223 |
Provider Organization Code |
N |
|
REF-
Attending Physician Secondary Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
0B 1A 1B 1C 1D 1G 1H EI G2 LU N5 SY X5 |
02 |
127 |
Attending Physician Secondary Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Operating Physician Name
01 |
98 |
Entity Identifier Code |
R |
|
|
72 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 |
03 |
1035 |
Operating Physician Last Name |
R |
|
04 |
1036 |
Operating Physician First Name |
R |
|
05 |
1037 |
Operating Physician Middle Name |
S |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Operating Physician Name Suffix |
S |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
24 34 XX |
09 |
67 |
Operating Physician Primary Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
PRV-
Operating Physician Specialty Information
01 |
1221 |
Provider Code |
R |
|
|
OP |
02 |
128 |
Reference Identification Qualifier |
R |
|
|
ZZ |
03 |
127 |
Provider Taxonomy Code |
R |
|
04 |
156 |
State or Province Code |
N |
|
N |
|
C035 |
Provider Specialty Information |
|
06 |
1223 |
Provider Organization Code |
N |
|
REF-
Operating Physician Secondary Identification
1 |
128 |
Reference Identification Qualifier |
R |
|
|
0B 1A 1B 1C 1D 1G 1H EI G2 LU N5 SY X5 |
02 |
127 |
Operating Physician Secondary Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Other Provider Name
01 |
98 |
Entity Identifier Code |
R |
|
|
73 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 2 |
03 |
1035 |
Other Physician Last Name |
R |
|
04 |
1036 |
Other Physician First Name |
S |
|
05 |
1037 |
Other Provider Middle Name |
S |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Other Provider Name Suffix |
S |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
24 34 XX |
09 |
67 |
Other Physician Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
PRV-
Other Provider Specialty Information
01 |
1221 |
Provider Code |
R |
|
|
OT PE |
02 |
128 |
Reference Identification Qualifier |
R |
|
|
ZZ |
03 |
127 |
Provider Taxonomy Code |
R |
|
04 |
156 |
State or Province Code |
N |
|
N |
|
C035 |
Provider Specialty Information |
|
06 |
1223 |
Provider Organization Code |
N |
|
REF-
Other Provider Secondary Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
0B 1A 1B 1C 1D 1G 1H EI G2 LU N5 SY X5 |
02 |
127 |
Other Provider Secondary Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Service Facility Name
01 |
98 |
Entity Identifier Code |
R |
|
|
FA |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
2 |
03 |
1035 |
Laboratory or Facility Name |
R |
|
04 |
1036 |
Name First |
N |
|
05 |
1037 |
Name Middle |
N |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Name Suffix |
N |
|
08 |
66 |
Identification Code Qualifier |
S |
|
|
24 34 XX |
09 |
67 |
Laboratory or Facility Primary Identifier |
S |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
PRV-
Service Facility Specialty Information
01 |
1221 |
Provider Code |
R |
|
|
RP |
02 |
128 |
Reference Identification Qualifier |
R |
|
|
ZZ |
03 |
127 |
Provider Taxonomy Code |
R |
|
04 |
156 |
State or Province Code |
N |
|
N |
|
C035 |
Provider Specialty Information |
|
06 |
1223 |
Provider Organization Code |
N |
|
N3-
Service Facility Address
01 |
166 |
Laboratory or Facility Address Line |
R |
|
02 |
166 |
Laboratory or Facility Address Line |
S |
|
N4-
Service Facility City/State/Zip Code
01 |
19 |
Laboratory or Facility City Name |
R |
|
02 |
156 |
Laboratory or Facility State or Province Code |
R |
|
|
External Source: states |
03 |
116 |
Laboratory or Facility Postal Zone or Zip Code |
R |
|
04 |
26 |
Laboratory/Facility Country Code |
S |
|
|
External Source: country |
05 |
309 |
Location Qualifier |
N |
|
06 |
310 |
Location Identifier |
N |
|
REF-
Service Facility Secondary Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
0B 1A 1B 1C 1D 1G 1H 1J EI FH G2 G5 LU N5 X5 |
02 |
127 |
Laboratory or Facility Secondary Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
SBR-
Other Subscriber Information
01 |
1138 |
Payer Responsibility Sequence Number Code |
R |
|
|
P S T |
02 |
1069 |
Individual Relationship Code |
R |
|
|
01 04 05 07 10 15 17 18 19 20 21 22 23 24 29 32 33 36 39 40 41 43 53 G8 |
03 |
127 |
Insured Group or Policy Number |
S |
|
04 |
93 |
Other Insured Group Name |
S |
|
05 |
1336 |
Insurance Type Code |
N |
|
06 |
1143 |
Coordination of Benefits Code |
N |
|
07 |
1073 |
Condition or Response Code |
N |
|
08 |
584 |
Employment Status Code |
N |
|
09 |
1032 |
Claim Filing Indicator Code |
S |
|
|
09 10 11 12 13 14 15 16 AM BL CH CI DS HM LI LM MA MB MC OF TV VA WC ZZ |
CAS-
Claim Level Adjustment
01 |
1033 |
Claim Adjustment Group Code |
R |
|
|
CO CR OA PI PR |
02 |
1034 |
Adjustment Reason Code |
R |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
03 |
782 |
Adjustment Amount |
R |
|
04 |
380 |
Adjustment Quantity |
S |
|
05 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
06 |
782 |
Adjustment Amount |
S |
|
07 |
380 |
Adjustment Quantity |
S |
|
08 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
09 |
782 |
Adjustment Amount |
S |
|
10 |
380 |
Adjustment Quantity |
S |
|
11 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
12 |
782 |
Adjustment Amount |
S |
|
13 |
380 |
Adjustment Quantity |
S |
|
14 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
15 |
782 |
Adjustment Amount |
S |
|
16 |
380 |
Adjustment Quantity |
S |
|
17 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
18 |
782 |
Adjustment Amount |
S |
|
19 |
380 |
Adjustment Quantity |
S |
|
AMT-
Payer Prior Payment
01 |
522 |
Amount Qualifier Code |
R |
|
|
C4 |
02 |
782 |
Other Payer Patient Paid Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Coordination of Benefits (COB) Total Allowed Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
B6 |
02 |
782 |
Allowed Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Coordination of Benefits (COB) Total Submitted Charges
01 |
522 |
Amount Qualifier Code |
R |
|
|
T3 |
02 |
782 |
Coordination of Benefits Total Submitted Charge Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Diagnostic Related Group (DRG) Outlier Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
ZZ |
02 |
782 |
Claim DRG Outlier Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Coordination of Benefits (COB) Total Medicare Paid Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
N1 |
02 |
782 |
Total Medicare Paid Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Medicare Paid Amount - 100%
01 |
522 |
Amount Qualifier Code |
R |
|
|
KF |
02 |
782 |
Medicare Paid at 100% Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Medicare Paid Amount - 80%
01 |
522 |
Amount Qualifier Code |
R |
|
|
PG |
02 |
782 |
Medicare Paid at 80% Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Coordination of Benefits (COB) Medicare A Trust Fund Paid Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
AA |
02 |
782 |
Paid From Part A Medicare Trust Fund Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Coordination of Benefits (COB) Medicare B Trust Fund Paid Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
B1 |
02 |
782 |
Paid From Part B Medicare Trust Fund Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Coordination of Benefits (COB) Total Non-Covered Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
A8 |
02 |
782 |
Non-Covered Charge Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Coordination of Benefits (COB) Total Denied Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
YT |
02 |
782 |
Claim Total Denied Charge Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
DMG-
Other Subscriber Demographic Information
01 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
02 |
1251 |
Other Insured Birth Date |
R |
|
03 |
1068 |
Other Insured Gender Code |
R |
|
|
F M U |
04 |
1067 |
Marital Status Code |
N |
|
05 |
1109 |
nicity Code |
N |
|
06 |
1066 |
Citizenship Status Code |
N |
|
07 |
26 |
Country Code |
N |
|
|
External Source: country |
08 |
659 |
Basis of Verification Code |
N |
|
09 |
380 |
Quantity |
N |
|
OI-
Other Insurance Coverage Information
01 |
1032 |
Claim Filing Indicator Code |
N |
|
02 |
1383 |
Claim Submission Reason Code |
N |
|
03 |
1073 |
Benefits Assignment Certification Indicator |
R |
|
|
N Y |
04 |
1351 |
Patient Signature Source Code |
N |
|
05 |
1360 |
Provider Agreement Code |
N |
|
06 |
1363 |
Release of Information Code |
R |
|
|
A I M N O Y |
MIA-
Medicare Inpatient Adjudication Information
01 |
380 |
Covered Days or Visits Count |
R |
|
02 |
380 |
Lifetime Reserve Days Count |
S |
|
03 |
380 |
Lifetime Psychiatric Days Count |
S |
|
04 |
782 |
Claim DRG Amount |
S |
|
05 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
06 |
782 |
Claim Disproportionate Share Amount |
S |
|
07 |
782 |
Claim MSP Pass-through Amount |
S |
|
08 |
782 |
Claim PPS Capital Amount |
S |
|
09 |
782 |
PPS-Capital FSP DRG Amount |
S |
|
10 |
782 |
PPS-Capital HSP DRG Amount |
S |
|
11 |
782 |
PPS-Capital DSH DRG Amount |
S |
|
12 |
782 |
Old Capital Amount |
S |
|
13 |
782 |
PPS-Capital IME Amount |
S |
|
14 |
782 |
PPS-Operating Hospital Specific DRG Amount |
S |
|
15 |
380 |
Cost Report Day Count |
S |
|
16 |
782 |
PPS-Operating Federal Specific DRG Amount |
S |
|
17 |
782 |
Claim PPS Capital Outlier Amount |
S |
|
18 |
782 |
Claim Indirect Teaching Amount |
S |
|
19 |
782 |
Nonpayable Professional Component Amount |
S |
|
20 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
21 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
22 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
23 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
24 |
782 |
PPS-Capital Exception Amount |
S |
|
MOA-
Medicare Outpatient Adjudication Information
01 |
954 |
Reimbursement Rate |
S |
|
02 |
782 |
Claim HCPCS Payable Amount |
S |
|
03 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
04 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
05 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
06 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
07 |
127 |
Remark Code |
S |
|
|
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156 |
08 |
782 |
Claim ESRD Payment Amount |
S |
|
09 |
782 |
Nonpayable Professional Component Amount |
S |
|
NM1-
Other Subscriber Name
01 |
98 |
Entity Identifier Code |
R |
|
|
IL |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 2 |
03 |
1035 |
Other Insured Last Name |
R |
|
04 |
1036 |
Other Insured First Name |
S |
|
05 |
1037 |
Other Insured Middle Name |
S |
|
06 |
1038 |
fix |
N |
|
07 |
1039 |
Other Insured Name Suffix |
S |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
MI ZZ |
09 |
67 |
Other Insured Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
N3-
Other Subscriber Address
01 |
166 |
Other Insured Address Line |
R |
|
02 |
166 |
Other Insured Address Line |
S |
|
N4-
Other Subscriber City/State/ZIP Code
01 |
19 |
Other Insured City Name |
R |
|
02 |
156 |
Other Insured State Code |
R |
|
|
External Source: states |
03 |
116 |
Other Insured Postal Zone or Zip Code |
R |
|
04 |
26 |
Subscriber Country Code |
S |
|
|
External Source: country |
05 |
309 |
Location Qualifier |
N |
|
06 |
310 |
Location Identifier |
N |
|
REF-
Other Subscriber Secondary Information
01 |
128 |
Reference Identification Qualifier |
R |
|
|
1W 23 IG SY |
02 |
127 |
Other Insured Additional Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Other Payer Name
01 |
98 |
Entity Identifier Code |
R |
|
|
PR |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
2 |
03 |
1035 |
Other Payer Last or Organization Name |
R |
|
04 |
1036 |
Name First |
N |
|
05 |
1037 |
Name Middle |
N |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Name Suffix |
N |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
PI XV |
09 |
67 |
Other Payer Primary Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
N3-
Other Payer Address
01 |
166 |
Other Payer Address Line |
R |
|
02 |
166 |
Other Payer Address Line |
S |
|
N4-
Other Payer City/State/ZIP Code
01 |
19 |
Other Payer City Name |
R |
|
02 |
156 |
Other Payer State Code |
R |
|
|
External Source: states |
03 |
116 |
Other Payer Postal Zone or Zip Code |
R |
|
04 |
26 |
Payer Country Code |
S |
|
|
External Source: country |
05 |
309 |
Location Qualifier |
N |
|
06 |
310 |
Location Identifier |
N |
|
DTP-
Claim Adjudication Date
01 |
374 |
Date Time Qualifier |
R |
|
|
573 |
02 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
03 |
1251 |
Adjudication or Payment Date |
R |
|
REF-
Other Payer Secondary Identification and Reference Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
2U F8 FY NF TJ |
02 |
127 |
Other Payer Secondary Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
REF-
Other Payer Prior Authorization or Referral Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
9F G1 |
02 |
127 |
Other Payer Prior Authorization or Referral Number |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Other Payer Patient Information
01 |
98 |
Entity Identifier Code |
R |
|
|
QC |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 |
03 |
1035 |
Name Last or Organization Name |
N |
|
04 |
1036 |
Name First |
N |
|
05 |
1037 |
Name Middle |
N |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Name Suffix |
N |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
EI MI |
09 |
67 |
Other Payer Patient Primary Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
REF-
Other Payer identification Number
01 |
128 |
Reference Identification Qualifier |
R |
|
|
1W IG SY |
02 |
127 |
Other Payer Patient Secondary Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Other Payer Attending Provider
01 |
98 |
Entity Identifier Code |
R |
|
|
71 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 2 |
03 |
1035 |
Name Last or Organization Name |
N |
|
04 |
1036 |
Name First |
N |
|
05 |
1037 |
Name Middle |
N |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Name Suffix |
N |
|
08 |
66 |
Identification Code Qualifier |
N |
|
09 |
67 |
Identification Code |
N |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
REF-
Other Payer Attending Provider Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
1A 1B 1C 1D 1G 1H EI G2 LU N5 |
02 |
127 |
Other Payer Attending Provider Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Other Payer Operating Provider
01 |
98 |
Entity Identifier Code |
R |
|
|
72 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 |
03 |
1035 |
Name Last or Organization Name |
N |
|
04 |
1036 |
Name First |
N |
|
05 |
1037 |
Name Middle |
N |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Name Suffix |
N |
|
08 |
66 |
Identification Code Qualifier |
N |
|
09 |
67 |
Identification Code |
N |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
REF-
Other Payer Operating Provider Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
1A 1B 1C 1D 1G 1H EI G2 LU N5 |
02 |
127 |
Other Payer Operating Provider Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Other Payer Other Provider
01 |
98 |
Entity Identifier Code |
R |
|
|
73 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 2 |
03 |
1035 |
Name Last or Organization Name |
N |
|
04 |
1036 |
Name First |
N |
|
05 |
1037 |
Name Middle |
N |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Name Suffix |
N |
|
08 |
66 |
Identification Code Qualifier |
N |
|
09 |
67 |
Identification Code |
N |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
fier Code |
N |
|
REF-
Other Payer Other Provider Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
1A 1B 1C 1D 1G 1H EI G2 LU N5 SY |
02 |
127 |
Other Payer Other Provider Identifier |
R |
|
03 |
352 |
on |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Other Payer Service Facility Provider
01 |
98 |
Entity Identifier Code |
R |
|
|
FA |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
2 |
03 |
1035 |
Name Last or Organization Name |
N |
|
04 |
1036 |
Name First |
N |
|
05 |
1037 |
Name Middle |
N |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Name Suffix |
N |
|
08 |
66 |
ode Qualifier |
N |
|
09 |
67 |
Identification Code |
N |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
REF-
Other Payer Service Facility Provider Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
1B 1C 1D EI G2 LU N5 |
02 |
127 |
Other Payer Service Facility Provider Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
LX-
Service Line Number
SV2-
Institutional Service Line
01 |
234 |
Service Line Revenue Code |
R |
|
S |
|
C003 |
Service Line Procedure Code |
|
01 |
235 |
Product or Service ID Qualifier |
R |
|
|
HC IV N4 ZZ |
02 |
234 |
Procedure Code |
R |
|
03 |
1339 |
HCPCS Modifier 1 |
S |
|
04 |
1339 |
HCPCS Modifier 2 |
S |
|
05 |
1339 |
HCPCS Modifier 3 |
S |
|
06 |
1339 |
HCPCS Modifier 4 |
S |
|
07 |
352 |
Description |
N |
|
03 |
782 |
Line Item Charge Amount |
R |
|
04 |
355 |
Unit or Basis for Measurement Code |
R |
|
|
DA F2 UN |
05 |
380 |
Service Unit Count |
R |
|
06 |
1371 |
Service Line Rate |
S |
|
07 |
782 |
Line Item Denied Charge or Non-Covered Charge Amount |
S |
|
08 |
1073 |
Yes/No Condition or Response Code |
N |
|
09 |
1345 |
Status Code |
N |
|
10 |
1337 |
Level of Care Code |
N |
|
PWK-
Line Supplemental Information
01 |
755 |
Attachment Report Type Code |
R |
|
|
AS B2 B3 B4 CT DA DG DS EB MT NN OB OZ PN PO PZ RB RR RT |
02 |
756 |
Attachment Transmission Code |
R |
|
|
AA AB AD AF AG BM EL EM FX |
03 |
757 |
Report Copies Needed |
N |
|
04 |
98 |
Entity Identifier Code |
N |
|
05 |
66 |
Identification Code Qualifier |
S |
|
|
AC |
06 |
67 |
Attachment Control Number |
S |
|
07 |
352 |
Description |
N |
|
N |
|
C002 |
Actions Indicated |
|
09 |
1525 |
Request Category Code |
N |
|
DTP-
Service Line Date
01 |
374 |
Date Time Qualifier |
R |
|
|
472 |
02 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 RD8 |
03 |
1251 |
Service Date |
R |
|
DTP-
Assessment Date
01 |
374 |
Date Time Qualifier |
R |
|
|
866 |
02 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
03 |
1251 |
Assessment Date |
R |
|
AMT-
Service Tax Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
GT |
02 |
782 |
Service Tax Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
AMT-
Facility Tax Amount
01 |
522 |
Amount Qualifier Code |
R |
|
|
N8 |
02 |
782 |
Facility Tax Amount |
R |
|
03 |
478 |
Credit/Debit Flag Code |
N |
|
HCP-
Line Pricing/Repricing Information R0113 P0910 P1112
01 |
1473 |
Pricing Methodology |
R |
|
|
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 |
02 |
782 |
Repriced Allowed Amount |
R |
|
03 |
782 |
Repriced Saving Amount |
S |
|
04 |
127 |
Repriced Organizational Identifier |
S |
|
05 |
118 |
Repricing Per Diem or Flat Rate Amount |
S |
|
06 |
127 |
Repriced Approved Ambulatory Patient Group Code |
S |
|
07 |
782 |
Repriced Approved Ambulatory Patient Group Amount |
S |
|
08 |
234 |
Repriced Approved Revenue Code |
S |
|
09 |
235 |
Product/ Service ID Qualifier |
S |
|
|
HC |
10 |
234 |
Procedure Code |
S |
|
11 |
355 |
Unit or Basis for Measurement Code |
S |
|
|
DA UN |
12 |
380 |
Repricing Approved Service Unit Count |
S |
|
13 |
901 |
Reject Reason Code |
S |
|
|
T1 T2 T3 T4 T5 T6 |
14 |
1526 |
Policy Compliance Code |
S |
|
|
1 2 3 4 5 |
15 |
1527 |
Exception Code |
S |
|
|
1 2 3 4 5 6 |
LIN-
Drug Identification P0405 P0607 P0809 P1011 P1213 P1415 P1617 P1819 P2021 P2223 P2425 P2627 P2829 P3031
01 |
350 |
Assigned Identification |
N |
|
02 |
235 |
Product/Service ID Qualifier |
R |
|
|
N4 |
03 |
234 |
Product/Service ID |
R |
|
04 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
05 |
234 |
Product/Service ID |
N |
|
06 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
07 |
234 |
Product/Service ID |
N |
|
08 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
09 |
234 |
Product/Service ID |
N |
|
10 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
11 |
234 |
Product/Service ID |
N |
|
12 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
13 |
234 |
Product/Service ID |
N |
|
14 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
15 |
234 |
Product/Service ID |
N |
|
16 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
17 |
234 |
Product/Service ID |
N |
|
18 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
19 |
234 |
Product/Service ID |
N |
|
20 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
21 |
234 |
Product/Service ID |
N |
|
22 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
23 |
234 |
Product/Service ID |
N |
|
24 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
25 |
234 |
Product/Service ID |
N |
|
26 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
27 |
234 |
Product/Service ID |
N |
|
28 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
29 |
234 |
Product/Service ID |
N |
|
30 |
235 |
Product/Service ID Qualifier |
N |
|
|
N4 |
31 |
234 |
Product/Service ID |
N |
|
CTP-
Drug Pricing P0405 C0607 C0902 C1002 C1103
01 |
687 |
Class of Trade Code |
N |
|
02 |
236 |
Price Identifier Code |
N |
|
03 |
212 |
Unit Price |
R |
|
04 |
380 |
Quantity |
R |
|
R |
|
C001 |
Composite Unit of Measure |
|
01 |
355 |
Unit or Basis for Measurement Code |
R |
|
|
F2 GR ML UN |
02 |
1018 |
Exponent |
N |
|
03 |
649 |
Multiplier |
N |
|
04 |
355 |
Unit or Basis for Measurement Code |
N |
|
05 |
1018 |
Exponent |
N |
|
06 |
649 |
Multiplier |
N |
|
07 |
355 |
Unit or Basis for Measurement Code |
N |
|
08 |
1018 |
Exponent |
N |
|
09 |
649 |
Multiplier |
N |
|
10 |
355 |
Unit or Basis for Measurement Code |
N |
|
11 |
1018 |
Exponent |
N |
|
12 |
649 |
Multiplier |
N |
|
13 |
355 |
Unit or Basis for Measurement Code |
N |
|
14 |
1018 |
Exponent |
N |
|
15 |
649 |
Multiplier |
N |
|
06 |
648 |
Price Multiplier Qualifier |
N |
|
07 |
649 |
Multiplier |
N |
|
08 |
782 |
Monetary Amount |
N |
|
09 |
639 |
Basis of Unit Price Code |
N |
|
10 |
499 |
Condition Value |
N |
|
11 |
289 |
Multiple Price Quantity |
N |
|
NM1-
Attending Physician Name
01 |
98 |
Entity Identifier Code |
R |
|
|
71 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 2 |
03 |
1035 |
Attending Physician Last Name |
R |
|
04 |
1036 |
Attending Physician First Name |
S |
|
05 |
1037 |
Attending Physician Middle Name |
S |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Attending Physician Name Suffix |
S |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
24 34 XX |
09 |
67 |
Attending Physician Primary Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
PRV-
Attending Physician Specialty Information
01 |
1221 |
Provider Code |
R |
|
|
AT |
02 |
128 |
Reference Identification Qualifier |
R |
|
|
ZZ |
03 |
127 |
Provider Taxonomy Code |
R |
|
04 |
156 |
State or Province Code |
N |
|
N |
|
C035 |
Provider Specialty Information |
|
06 |
1223 |
Provider Organization Code |
N |
|
REF-
Attending Physician Secondary Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
0B 1A 1B 1C 1D 1G 1H EI G2 LU N5 SY X5 |
02 |
127 |
Attending Physician Secondary Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Operating Physician Name
01 |
98 |
Entity Identifier Code |
R |
|
|
72 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 |
03 |
1035 |
Operating Physician Last Name |
R |
|
04 |
1036 |
Operating Physician First Name |
R |
|
05 |
1037 |
Operating Physician Middle Name |
S |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Operating Physician Name Suffix |
S |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
24 34 XX |
09 |
67 |
Operating Physician Primary Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
PRV-
Operating Physician Specialty Information
01 |
1221 |
Provider Code |
R |
|
|
OP |
02 |
128 |
Reference Identification Qualifier |
R |
|
|
ZZ |
03 |
127 |
Provider Taxonomy Code |
R |
|
04 |
156 |
State or Province Code |
N |
|
N |
|
C035 |
Provider Specialty Information |
|
06 |
1223 |
Provider Organization Code |
N |
|
REF-
Operating Physician Secondary Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
0B 1A 1B 1C 1D 1G 1H EI G2 LU N5 SY X5 |
02 |
127 |
Operating Physician Secondary Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
NM1-
Other Provider Name
01 |
98 |
Entity Identifier Code |
R |
|
|
73 |
02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 2 |
03 |
1035 |
Other Physician Last Name |
R |
|
04 |
1036 |
Other Physician First Name |
S |
|
05 |
1037 |
Other Provider Middle Name |
S |
|
06 |
1038 |
Name Prefix |
N |
|
07 |
1039 |
Other Provider Name Suffix |
S |
|
08 |
66 |
Identification Code Qualifier |
R |
|
|
24 34 XX |
09 |
67 |
Other Provider Identifier |
R |
|
10 |
706 |
Entity Relationship Code |
N |
|
11 |
98 |
Entity Identifier Code |
N |
|
PRV-
Other Provider Specialty Information
01 |
1221 |
Provider Code |
R |
|
|
OT PE |
02 |
128 |
Reference Identification Qualifier |
R |
|
|
ZZ |
03 |
127 |
Provider Taxonomy Code |
R |
|
04 |
156 |
State or Province Code |
N |
|
N |
|
C035 |
Provider Specialty Information |
|
06 |
1223 |
Provider Organization Code |
N |
|
REF-
Other Provider Secondary Identification
01 |
128 |
Reference Identification Qualifier |
R |
|
|
0B 1A 1B 1C 1D 1G 1H EI G2 LU N5 SY X5 |
02 |
127 |
Other Provider Secondary Identifier |
R |
|
03 |
352 |
Description |
N |
|
N |
|
C040 |
Reference Identifier |
|
SVD-
Service Line Adjudication Information
01 |
67 |
Payer Identifier |
R |
|
02 |
782 |
Service Line Paid Amount |
R |
|
S |
|
C003 |
Composite Medical Procedure Identifier |
|
01 |
235 |
Product or Service ID Qualifier |
R |
|
|
HC IV ZZ |
02 |
234 |
Procedure Code |
R |
|
03 |
1339 |
Procedure Modifier |
S |
|
04 |
1339 |
Procedure Modifier |
S |
|
05 |
1339 |
Procedure Modifier |
S |
|
06 |
1339 |
Procedure Modifier |
S |
|
07 |
352 |
Procedure Code Description |
S |
|
04 |
234 |
Service Line Revenue Code |
R |
|
05 |
380 |
Adjustment Quantity |
R |
|
06 |
554 |
Bundled or Unbundled Line Number |
S |
|
CAS-
Service Line Adjustment
01 |
1033 |
Claim Adjustment Group Code |
R |
|
|
CO CR OA PI PR |
02 |
1034 |
Adjustment Reason Code |
R |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
03 |
782 |
Adjustment Amount |
R |
|
04 |
380 |
Adjustment Quantity |
S |
|
05 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
06 |
782 |
Adjustment Amount |
S |
|
07 |
380 |
Adjustment Quantity |
S |
|
08 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
09 |
782 |
Adjustment Amount |
S |
|
10 |
380 |
Adjustment Quantity |
S |
|
11 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
12 |
782 |
Adjustment Amount |
S |
|
13 |
380 |
Adjustment Quantity |
S |
|
14 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
15 |
782 |
Adjustment Amount |
S |
|
16 |
380 |
Adjustment Quantity |
S |
|
17 |
1034 |
Adjustment Reason Code |
S |
|
|
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1 |
18 |
782 |
Adjustment Amount |
S |
|
19 |
380 |
Adjustment Quantity |
S |
|
DTP-
Service Adjudication Date
01 |
374 |
Date Time Qualifier |
R |
|
|
573 |
02 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
D8 |
03 |
1251 |
Service Adjudication or Payment Date |
R |
|
SE-
Transaction Set Trailer
01 |
96 |
Transaction Segment Count |
R |
|
02 |
329 |
Transaction Set Control Number |
R |
|
GE-
Functional Group Trailer
01 |
97 |
Number of Transaction Sets Included |
R |
|
02 |
28 |
Group Control Number |
R |
|
TA1-
Interchange Acknowledgement
01 |
I12 |
Interchange Control Number |
R |
|
02 |
I08 |
Interchange Date |
R |
|
03 |
I09 |
Interchange Time |
R |
|
04 |
I17 |
Interchange Acknowledgement Code |
R |
|
|
A E R |
05 |
I18 |
Interchange Note Code |
R |
|
|
000 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 018 019 020 021 022 023 024 025 026 027 028 029 030 031 |
IEA-
Interchange Control Trailer
01 |
I16 |
Number of Included Functional Groups |
R |
|
2 |
I12 |
Interchange Control Number |
R |
|