CLM_VAL_AUDIT_TRAIL

Description: |
This table contains a list of the changes made by the user directly to the claim. Changes that occur because of changes to source data or configuration are not listed here. For multiple and related items, line numbers are included. For related multi items, the value position number within the line is included.

Primary Key

Column Name | Ordinal Position |
--- | --- | ---
RECORD_ID | 1 |
LINE | 2 |

Column Information

| Name | Type | Discontinued? |
--- | --- | --- | --- | ---
1 | RECORD_ID | NUMERIC | No |
The unique identifier for the claim value record.
2 | LINE | INTEGER | No |
The line number for the information associated with this record. Multiple pieces of information can be associated with this record.
3 | AUDIT_LINK | INTEGER | No |
A line number that can be used to link the audit details in this table to a user action in VALUE_EDIT_HISTORY.
4 | AUDIT_EVENT_C_NAME | VARCHAR | No |
The event category ID for the type of change the user made to the claim.
May contain organization-specific values: No
Category Entries:
Changed
Reset
Inserted Line
Deleted Line
Moved Line
5 | AUDIT_ITEM_C_NAME | VARCHAR | No |
The category ID of the item the user changed.
May contain organization-specific values: Yes
Category Entries:
SUBMITTER ENTITY TYPE QUAL
SUBMITTER LAST NAME
SUBMITTER FIRST NAME
SUBMITTER MIDDLE NAME
SUBMITTER IDENTIFIER
SUBMITTER CONTACT NAME
SUBMITTER CONTACT QUAL
SUBMITTER CONTACT INFORMATION
RECEIVER ENTITY TYPE QUAL
RECEIVER LAST NAME
RECEIVER IDENTIFIER
RECEIVER ENTITY TYPE QUAL OID
TRANSACTION SET CONTROL NUMBER
VERSION, RELEASE, OR INDUSTRY IDENTIFIER
TRANSACTION SET PURPOSE CODE
ORIGINATOR APPLICATION TRANSACTION IDENTIFIER
TRANSACTION SET CREATION DATE
TRANSACTION SET CREATION TIME
CLAIM IDENTIFIER
NCPDP RECORD TYPE
TRANSMISSION ACTION
SUBMISSION NUMBER
BCDA CLAIM GROUP IDENTIFIER
AUTHORIZATION INFORMATION
SECURITY INFORMATION
SENDER INTERCHANGE ID QUAL
INTERCHANGE SENDER ID
RECEIVER INTERCHANGE ID QUAL
INTERCHANGE RECEIVER ID
INTERCHANGE DATE
INTERCHANGE TIME
INTERCHANGE CONTROL NUMBER
ACKNOWLEDGMENT REQUESTED
INTERCHANGE USAGE INDICATOR
APPLICATION SENDER CODE
APPLICATION RECEIVER CODE
FUNCTIONAL GROUP CREATION DATE
FUNCTIONAL GROUP CREATION TIME
GROUP CONTROL NUMBER
RESPONSIBLE AGENCY CODE
VERSION RELEASE INDUSTRY IDENTIFIER CODE
BILLING PROVIDER ENTITY TYPE QUALIFIER
BILLING PROVIDER LAST OR ORGANIZATION NAME
BILLING PROVIDER FIRST NAME
BILLING PROVIDER MIDDLE NAME
BILLING PROVIDER NAME SUFFIX
BILLING PROVIDER NPI
BILLING PROVIDER TAXONOMY CODE
BILLING PROVIDER TAX ID QUALIFIER
BILLING PROVIDER TAX ID
BILLING PROVIDER UPIN
BILLING PROVIDER LICENSE NUMBER
BILLING PROVIDER CONTACT NAME
BILLING PROVIDER CURRENCY CODE
BILLING PROVIDER ENTITY IDENTIFIER CODE
BILLING PROVIDER SPECIALTY
BILLING PROVIDER SPECIALTY CODE SET
BILLING PROVIDER STREET ADDRESS LINE 1
BILLING PROVIDER STREET ADDRESS LINE 2
BILLING PROVIDER CITY
BILLING PROVIDER STATE
BILLING PROVIDER ZIP CODE
BILLING PROVIDER COUNTRY CODE
BILLING PROVIDER COUNTRY SUBDIVISION CODE
BILLING PROVIDER CONTACT QUALIFIER
BILLING PROVIDER CONTACT INFORMATION
PAY-TO ADDRESS NAME
PAY-TO ADDRESS ENTITY TYPE QUALIFIER
PAY-TO STREET ADDRESS LINE 1
PAY-TO STREET ADDRESS LINE 2
PAY-TO ADDRESS CITY
PAY-TO ADDRESS STATE
PAY-TO ADDRESS ZIP CODE
PAY-TO ADDRESS COUNTRY CODE
PAY-TO ADDRESS COUNTRY SUBDIVISION CODE
PAY-TO PLAN ENTITY TYPE QUAL
PAY-TO PLAN LAST OR ORGANIZATION NAME
PAY-TO PLAN PRIMARY ID QUAL
PAY-TO PLAN PRIMARY ID
PAY-TO PLAN SECONDARY ID QUAL
PAY-TO PLAN SECONDARY ID
PAY-TO PLAN TAX ID
PAY-TO PLAN STREET ADDRESS LINE 1
PAY-TO PLAN STREET ADDRESS LINE 2
PAY-TO PLAN CITY
PAY-TO PLAN STATE
PAY-TO PLAN ZIP CODE
PAY-TO PLAN COUNTRY CODE
PAY-TO PLAN COUNTRY SUBDIVISION CODE
CLAIM COVERAGE PAYER RESPONSIBILITY SEQUENCE CODE
PAYER NAME
CLAIM COVERAGE GROUP OR POLICY NUMBER
CLAIM COVERAGE GROUP NAME
CLAIM COVERAGE INSURANCE TYPE CODE
CLAIM COVERAGE CLAIM FILING INDICATOR CODE
PAYER PRIMARY IDENTIFIER TYPE
PAYER PRIMARY IDENTIFIER
PROVIDER ACCEPTS ASSIGNMENT FROM PAYER
INSURED AUTHORIZES PAYMENT TO PROVIDER
INSURED AUTHORIZES RELEASE OF INFORMATION TO PAYER
PAYER PHONE NUMBER
CLAIM COVERAGE PAYER PAID AMOUNT
CLAIM COVERAGE ESTIMATED AMOUNT DUE
PAYER COMPLEMENTARY INSURER ID
RELEASE OF INFORMATION DATE
LINE OF BUSINESS CODE
BENEFIT ID
PLAN TYPE
SUBSCRIBER ENTITY TYPE QUALIFIER
SUBSCRIBER LAST NAME
SUBSCRIBER FIRST NAME
SUBSCRIBER MIDDLE NAME
SUBSCRIBER NAME SUFFIX
SUBSCRIBER IDENTIFIER TYPE
SUBSCRIBER IDENTIFIER
SUBSCRIBER SOCIAL SECURITY NUMBER
SUBSCRIBER PROPERTY AND CASUALTY CLAIM NUMBER
SUBSCRIBER CONTACT NAME
SUBSCRIBER BIRTH DATE
SUBSCRIBER SEX
SUBSCRIBER PHONE NUMBER
SUBSCRIBER EMPLOYER
SUBSCRIBER SELF RELATIONSHIP CODE
SUBSCRIBER WORKERS' COMP NUMBER
SUBSCRIBER DEMOGRAPHIC CODE QUALIFIER
SUBSCRIBER DEMOGRAPHIC CODE
SUBSCRIBER EMPLOYER PHONE NUMBER
SUBSCRIBER STREET ADDRESS LINE 1
SUBSCRIBER STREET ADDRESS LINE 2
SUBSCRIBER CITY
SUBSCRIBER STATE
SUBSCRIBER ZIP CODE
SUBSCRIBER COUNTRY CODE
SUBSCRIBER COUNTRY SUBDIVISION CODE
SUBSCRIBER LOCATION IDENTIFIER
SUBSCRIBER CONTACT PHONE NUMBER
SUBSCRIBER CONTACT PHONE EXTENSION
PAYER STREET ADDRESS LINE 1
PAYER STREET ADDRESS LINE 2
PAYER CITY
PAYER STATE
PAYER ZIP CODE
PAYER COUNTRY CODE
PAYER COUNTRY SUBDIVISION CODE
PAYER SECONDARY IDENTIFIER QUALIFIER
PAYER SECONDARY IDENTIFIER
BILLING PROVIDER SECONDARY ID QUALIFIER
BILLING PROVIDER SECONDARY IDENTIFIER
BILLING PROVIDER SECONDARY ID QUALIFIER OID
PATIENT LAST NAME
PATIENT FIRST NAME
PATIENT MIDDLE NAME
PATIENT NAME SUFFIX
MEDICAL RECORD NUMBER
PATIENT COVERAGE MEMBER ID
PROPERTY AND CASUALTY PATIENT ID TYPE
PROPERTY AND CASUALTY PATIENT ID
PATIENT CONTACT NAME
MOTHER'S MEDICAL RECORD NUMBER
PATIENT RELATIONSHIP TO INSURED
PATIENT BIRTH DATE
PATIENT SEX
SIGNATURE ON FILE INDICATOR
PATIENT SIGNATURE SOURCE CODE
PATIENT DEATH DATE
PATIENT WEIGHT
PATIENT PREGNANCY INDICATOR
PATIENT WORKERS' COMP NUMBER
PATIENT MARITAL STATUS
PATIENT EMPLOYMENT STATUS
PATIENT PHONE NUMBER
PATIENT PERSONAL ID NUMBER
PATIENT DEMOGRAPHIC CODE QUALIFIER
PATIENT DEMOGRAPHIC CODE
PATIENT RELATIONSHIP TO INSURED CODE SET
PATIENT SEX ASSIGNED AT BIRTH
PATIENT STREET ADDRESS LINE 1
PATIENT STREET ADDRESS LINE 2
PATIENT CITY
PATIENT STATE
PATIENT ZIP CODE
PATIENT COUNTRY CODE
PATIENT COUNTRY SUBDIVISION CODE
PATIENT LOCATION IDENTIFIER
PATIENT RESIDENCE CODE
PATIENT CONTACT PHONE NUMBER
PATIENT CONTACT PHONE EXTENSION
PATIENT RACE OR ETHNICITY CODE
PATIENT LANGUAGE
PATIENT ID QUALIFIER
PATIENT ID
PATIENT ID TYPES OID
INVOICE NUMBER
INTERNAL CONTROL NUMBER (CLAIM CONTROL NUMBER)
TOTAL BILLED AMOUNT
BILL TYPE FACILITY CODE
BILL TYPE FREQUENCY CODE
ADMISSION TYPE
ADMISSION SOURCE
DISCHARGE DISPOSITION (PATIENT STATUS)
REFERRAL NUMBER
PRIOR AUTHORIZATION NUMBER
SPECIAL PROGRAM INDICATOR
CLAIM DELAY REASON
SERVICE AUTHORIZATION EXCEPTION CODE
PATIENT AMOUNT PAID
PATIENT ESTIMATED AMOUNT DUE
REPRICED CLAIM NUMBER
ADJUSTED REPRICED CLAIM NUMBER
CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES
PEER REVIEW ORGANIZATION APPROVAL NUMBER
AUTO ACCIDENT STATE
AUTO ACCIDENT COUNTRY
MAMMOGRAPHY CERTIFICATION NUMBER
CLIA NUMBER
DEMONSTRATION PROJECT IDENTIFIER
SPINAL MANIPULATION CONDITION CODE
EPSDT CERTIFICATION CONDITION CODE APPLIES
ORTHODONTIC TOTAL MONTHS
ORTHODONTIC MONTHS REMAINING
ADMISSION DIAGNOSIS QUALIFIER
ADMISSION DIAGNOSIS
DIAGNOSIS RELATED GROUP
ANESTHESIA RELATED SURGICAL PROCEDURE
OUTSIDE LAB
OUTSIDE LAB CHARGE AMOUNT
RESERVED FOR LOCAL USE (PAPER CMS)
MANDATORY MEDICARE CROSSOVER INDICATOR
CARE PLAN OVERSIGHT NUMBER
STATEMENT FROM DATE
STATEMENT TO DATE
ADMISSION DATE
ADMISSION TIME
DISCHARGE DATE
DISCHARGE TIME
ADMISSION DATE-HOUR QUALIFIER
DENTAL SERVICE FROM DATE
DENTAL SERVICE TO DATE
DENTAL SERVICE DATE QUALIFIER
INJURY OR ONSET OF ILLNESS DATE
INITIAL TREATMENT DATE
LAST SEEN DATE
ACUTE MANIFESTATION DATE
ACCIDENT DATE
LAST MENSTRUAL PERIOD DATE
LAST X-RAY DATE
HEARING AND VISION PRESCRIPTION DATE
DISABILITY START DATE
DISABILITY END DATE
LAST WORKED DATE
AUTHORIZED RETURN TO WORK DATE
ASSUMED CARE DATE
RELINQUISHED CARE DATE
ORTHODONTIC BANDING DATE
DENTAL SERVICE DATE
FIRST DATE OF SIMILAR ILLNESS DATE
CLAIM CREATION DATE
PROPERTY AND CASUALTY DATE OF FIRST CONTACT
REPRICER RECEIVED DATE
CLAIM ATTACHMENT REPORT TYPE
CLAIM ATTACHMENT TRANSMISSION CODE
CLAIM ATTACHMENT DOCUMENT CONTROL NUMBER
DISABILITY DATE-TIME QUALIFIER
DISABILITY TIME FORMAT QUALIFIER
MEDICARE DRUG COVERAGE CODE
PREDETERMINATION OF BENEFITS IDENTIFIER
CLAIM TYPE - INPATIENT VS OUTPATIENT
EXPIRY DATE OF THE PLAN REGISTRATION #
NCH CLAIM TYPE CODE
CMS ADJUSTMENT DELETION CODE
DECEASED INDICATOR
CLAIM NOTE QUALIFIER
CLAIM NOTE TEXT
AMBULANCE PATIENT WEIGHT
AMBULANCE TRANSPORT REASON CODE
AMBULANCE TRANSPORT DISTANCE
AMBULANCE ROUND TRIP PURPOSE DESCRIPTION
AMBULANCE STRETCHER PURPOSE DESCRIPTION
AMBULANCE TRANSPORT CONDITION CODE
AMBULANCE YES NO CONDITION CODE
VISION CONDITION QUALIFIER
VISION YES NO CONDITION CODE
VISION CONDITION CODE
EPSDT CONDITION INDICATOR
RELATED CAUSES CODE
INVESTIGATIONAL DEVICE EXEMPTION NUMBER
CONTRACT TYPE CODE
CONTRACT AMOUNT
CONTRACT PERCENTAGE
CONTRACT CODE
CONTRACT TERMS DISCOUNT PERCENTAGE
CONTRACT VERSION IDENTIFIER
CONTRACT NUMBER
FIXED FORMAT INFORMATION
CLAIM REMARK (BILLING NOTE)
RECORD INDICATOR
ADJUDICATION DATE
ADJUDICATION TIME
REJECT OVERRIDE CODE
CROSS REFERENCE INTERNAL CONTROL NUMBER
PROCESSOR PAYMENT CLARIFICATION CODE
ADJUSTMENT TYPE
MEMBER SUBMITTED CLAIM PAYMENT RELEASE DATE
CHECK DATE
DIAGNOSIS QUALIFIER
DIAGNOSIS
DIAGNOSIS PRESENT ON ADMISSION
DIAGNOSIS CODE SET OID
DIAGNOSIS RANK
DIAGNOSIS FROM HEADER
RX - DIAGNOSIS QUALIFIER
DIAGNOSIS PRESENT ON ADMISSION CODE
CMS DIAGNOSIS TYPE
PATIENT REASON FOR VISIT QUALIFIER
PATIENT REASON FOR VISIT DIAGNOSIS
EXTERNAL CAUSE OF INJURY QUALIFIER
EXTERNAL CAUSE OF INJURY DIAGNOSIS
EXTERNAL CAUSE OF INJURY PRESENT ON ADMISSION
PROCEDURE QUALIFIER
PROCEDURE
PROCEDURE DATE
PROCEDURE DESCRIPTION
PROCEDURE RANK
OCCURRENCE SPAN CODE
OCCURRENCE SPAN FROM DATE
OCCURRENCE SPAN TO DATE
OCCURRENCE CODE
OCCURRENCE DATE
VALUE CODE
VALUE AMOUNT (DEPRECATED)
VALUE AMOUNT
CONDITION CODE
PRICING METHODOLOGY
REPRICED ALLOWED AMOUNT
REPRICED SAVING AMOUNT
REPRICING ORGANIZATION IDENTIFIER
REPRICING PER DIEM OR FLAT RATE AMOUNT
REPRICED APPROVED DRG CODE
REPRICED APPROVED AMOUNT
REPRICED APPROVED REVENUE CODE
REPRICED APPROVED SERVICE UNIT MEASUREMENT CODE
REPRICED APPROVED SERVICE UNIT COUNT
REJECT REASON CODE
POLICY COMPLIANCE CODE
EXCEPTION CODE
ATTENDING PROVIDER LAST NAME
ATTENDING PROVIDER FIRST NAME
ATTENDING PROVIDER MIDDLE NAME
ATTENDING PROVIDER NAME SUFFIX
ATTENDING PROVIDER NPI
ATTENDING PROVIDER TAXONOMY CODE
ATTENDING PROVIDER SPECIALTY
ATTENDING PROVIDER SECONDARY ID QUALIFIER
ATTENDING PROVIDER SECONDARY ID
ATTENDING PROVIDER SECONDARY ID QUALIFIER OID
OPERATING PROVIDER LAST NAME
OPERATING PROVIDER FIRST NAME
OPERATING PROVIDER MIDDLE NAME
OPERATING PROVIDER NAME SUFFIX
OPERATING PROVIDER NPI
OPERATING PROVIDER TAXONOMY CODE
OPERATING PROVIDER FROM LINES
OPERATING PROVIDER SECONDARY ID QUALIFIER
OPERATING PROVIDER SECONDARY ID
OTHER OPERATING PROVIDER LAST NAME
OTHER OPERATING PROVIDER FIRST NAME
OTHER OPERATING PROVIDER MIDDLE NAME
OTHER OPERATING PROVIDER NAME SUFFIX
OTHER OPERATING PROVIDER NPI
OTHER OPERATING PROVIDER FROM LINES
OTHER OPERATING PROVIDER SECONDARY ID QUALIFIER
OTHER OPERATING PROVIDER SECONDARY ID
RENDERING PROVIDER ENTITY TYPE QUALIFIER
RENDERING PROVIDER LAST NAME
RENDERING PROVIDER FIRST NAME
RENDERING PROVIDER MIDDLE NAME
RENDERING PROVIDER NAME SUFFIX
RENDERING PROVIDER NPI
RENDERING PROVIDER TAXONOMY CODE
RENDERING PROVIDER FROM LINES
RENDERING PROVIDER SECONDARY ID QUALIFIER
RENDERING PROVIDER SECONDARY ID
REFERRING PROVIDER LAST NAME
REFERRING PROVIDER FIRST NAME
REFERRING PROVIDER MIDDLE NAME
REFERRING PROVIDER NAME SUFFIX
REFERRING PROVIDER NPI
REFERRING PROVIDER TAXONOMY CODE
REFERRING PROVIDER FROM LINES
REFERRING PROVIDER SECONDARY ID QUALIFIER
REFERRING PROVIDER SECONDARY ID
SUPERVISING PROVIDER LAST NAME
SUPERVISING PROVIDER FIRST NAME
SUPERVISING PROVIDER MIDDLE NAME
SUPERVISING PROVIDER NAME SUFFIX
SUPERVISING PROVIDER NPI
SUPERVISING PROVIDER SECONDARY ID QUALIFIER
SUPERVISING PROVIDER SECONDARY ID
ASSISTANT DENTAL SURGEON LAST NAME
ASSISTANT DENTAL SURGEON FIRST NAME
ASSISTANT DENTAL SURGEON MIDDLE NAME
ASSISTANT DENTAL SURGEON NAME SUFFIX
ASSISTANT DENTAL SURGEON NPI
ASSISTANT DENTAL SURGEON TAXONOMY CODE
ASSISTANT DENTAL SURGEON SECONDARY ID QUALIFIER
ASSISTANT DENTAL SURGEON SECONDARY ID
SERVICE FACILITY LOCATION NAME
SERVICE FACILITY LOCATION NPI
SERVICE FACILITY LOCATION CONTACT NAME
SERVICE FACILITY LOCATION CONTACT PHONE NUMBER
SERVICE FACILITY LOCATION CONTACT PHONE EXTENSION
SERVICE FACILITY LOCATION CMS CERTIFICATION NUMBER
SERVICE FACILITY LOCATION CMS PART D QUALIFIED
SERVICE FACILITY LOCATION STREET ADDRESS LINE 1
SERVICE FACILITY LOCATION STREET ADDRESS LINE 2
SERVICE FACILITY LOCATION CITY
SERVICE FACILITY LOCATION STATE
SERVICE FACILITY LOCATION ZIP CODE
SERVICE FACILITY LOCATION COUNTRY CODE
SERVICE FACILITY LOCATION COUNTRY SUBDIVISION CODE
SERVICE FACILITY LOCATION SECONDARY ID QUALIFIER
SERVICE FACILITY LOCATION SECONDARY ID
SERVICE FACILITY LOCATION SECONDARY ID QUALIFIER OID
AMBULANCE PICK-UP LOCATION STREET ADDRESS LINE 1
AMBULANCE PICK-UP LOCATION STREET ADDRESS LINE 2
AMBULANCE PICK-UP LOCATION CITY
AMBULANCE PICK-UP LOCATION STATE
AMBULANCE PICK-UP LOCATION ZIP CODE
AMBULANCE PICK-UP LOCATION COUNTRY CODE
AMBULANCE PICK-UP LOCATION COUNTRY SUBDIVISION CODE
AMBULANCE PICK-UP LOCATION COUNTY
AMBULANCE DROP-OFF LOCATION NAME
AMBULANCE DROP-OFF LOCATION STREET ADDRESS LINE 1
AMBULANCE DROP-OFF LOCATION STREET ADDRESS LINE 2
AMBULANCE DROP-OFF LOCATION CITY
AMBULANCE DROP-OFF LOCATION STATE
AMBULANCE DROP-OFF LOCATION ZIP CODE
AMBULANCE DROP-OFF LOCATION COUNTRY CODE
AMBULANCE DROP-OFF LOCATION COUNTRY SUBDIVISION CODE
AMBULANCE DROP-OFF LOCATION COUNTY
OTHER COVERAGE PAYER RESPONSIBILITY SEQUENCE CODE
OTHER COVERAGE PATIENT RELATIONSHIP TO INSURED
OTHER COVERAGE PATIENT MEMBER ID
OTHER COVERAGE GROUP OR POLICY NUMBER
OTHER COVERAGE GROUP NAME
OTHER COVERAGE INSURANCE TYPE CODE
OTHER COVERAGE CLAIM FILING INDICATOR CODE
OTHER COVERAGE INSURED AUTHORIZES PAYMENT TO PROVIDER
OTHER COVERAGE PATIENT SIGNATURE SOURCE CODE
OTHER CVG INSURED AUTHORIZES RELEASE OF INFORMATION
OTHER COVERAGE PAYER PAID AMOUNT
OTHER COVERAGE REMAINING PATIENT LIABILITY
OTHER COVERAGE TOTAL NON-COVERED AMOUNT
OTHER COVERAGE PAYER TRUE PAID AMOUNT
OTHER COVERAGE PAYER ADJUSTMENT AS PAID AMOUNT
OTHER COVERAGE PAYER ALLOWED AMOUNT
OTHER COVERAGE DERIVED AMOUNT INDICATOR
OTHER SUBSCRIBER ENTITY TYPE QUALIFIER
OTHER SUBSCRIBER LAST NAME
OTHER SUBSCRIBER FIRST NAME
OTHER SUBSCRIBER MIDDLE NAME
OTHER SUBSCRIBER NAME SUFFIX
OTHER SUBSCRIBER IDENTIFIER QUALIFIER
OTHER SUBSCRIBER IDENTIFIER
OTHER SUBSCRIBER SSN
OTHER SUBSCRIBER DATE OF BIRTH
OTHER SUBSCRIBER SEX
OTHER SUBSCRIBER EMPLOYER
OTHER SUBSCRIBER STREET ADDRESS LINE 1
OTHER SUBSCRIBER STREET ADDRESS LINE 2
OTHER SUBSCRIBER CITY
OTHER SUBSCRIBER STATE
OTHER SUBSCRIBER ZIP CODE
OTHER SUBSCRIBER COUNTRY CODE
OTHER SUBSCRIBER COUNTRY SUBDIVISION CODE
OTHER SUBSCRIBER SECONDARY ID QUAL
OTHER SUBSCRIBER SECONDARY ID
OTHER PAYER NAME
OTHER PAYER IDENTIFIER TYPE
OTHER PAYER IDENTIFIER
OTHER PAYER ADJUDICATION OR PAYMENT DATE
OTHER PAYER PRIOR AUTHORIZATION NUMBER
OTHER PAYER REFERRAL NUMBER
OTHER PAYER INTERNAL CONTROL NUMBER
OTHER PAYER CLAIM ADJUSTMENT INDICATOR ID
OTHER PAYER BILLING PROVIDER ENTITY TYPE QUALIFIER
OTHER PAYER STREET ADDRESS LINE 1
OTHER PAYER STREET ADDRESS LINE 2
OTHER PAYER CITY
OTHER PAYER STATE
OTHER PAYER ZIP CODE
OTHER PAYER COUNTRY CODE
OTHER PAYER COUNTRY SUBDIVISION CODE
OTHER PAYER SECONDARY IDENTIFIER TYPE
OTHER PAYER SECONDARY IDENTIFIER
OTHER PAYER ATTENDING PROVIDER SECONDARY ID QUAL
OTHER PAYER ATTENDING PROVIDER SECONDARY ID
OTHER PAYER OPERATING PHYSICIAN SECONDARY ID QUAL
OTHER PAYER OPERATING PHYSICIAN SECONDARY ID
OTHER PAYER OTHER OPERATING PHYSICIAN SEC ID QUAL
OTHER PAYER OTHER OPERATING PHYSICIAN SECONDARY ID
OTHER PAYER SERVICE FACILITY LOCATION SECONDARY ID QUAL
OTHER COVERAGE REASON CODE INFORMATION
OTHER PAYER SERVICE FACILITY LOCATION SECONDARY ID
OTHER PAYER RENDERING PROVIDER SECONDARY ID QUAL
OTHER PAYER RENDERING PROVIDER SECONDARY ID
OTHER PAYER REFERRING PROVIDER SECONDARY ID QUAL
OTHER PAYER REFERRING PROVIDER SECONDARY ID
OTHER PAYER SUPERVISING SECONDARY ID QUAL
OTHER PAYER SUPERVISING SECONDARY ID
OTHER PAYER REJECT CODE
OTHER PAYER BILLING PROVIDER SECONDARY ID QUALIFIER
OTHER PAYER BILLING PROVIDER SECONDARY IDENTIFIER
OTHER PAYER PAID AMOUNT
OTHER PAYER PATIENT RESPONSIBILITY AMOUNT
OTHER COVERAGE MIA COVERED DAYS
OTHER COVERAGE MIA LIFETIME PSYCHIATRIC DAYS
OTHER COVERAGE MIA DRG AMOUNT
OTHER COVERAGE MIA DISPROPORTIONATE SHARE (DSH) AMOUNT
OTHER COVERAGE MIA MSP PASS-THROUGH AMOUNT
OTHER COVERAGE MIA PPS CAPITAL AMOUNT
OTHER COVERAGE MIA PPS-CAPITAL FSP DRG AMOUNT
OTHER COVERAGE MIA PPS-CAPITAL HSP DRG AMOUNT
OTHER COVERAGE MIA PPS-CAPITAL DSH DRG AMOUNT
OTHER COVERAGE MIA OLD CAPITAL AMOUNT
OTHER COVERAGE MIA PPS-CAPITAL IME AMOUNT
OTHER COVERAGE MIA PPS-OPERATING HSP DRG AMOUNT
OTHER COVERAGE MIA COST REPORT DAY COUNT
OTHER COVERAGE MIA PPS-OPERATING FSP DRG AMOUNT
OTHER COVERAGE MIA PPS-CAPITAL OUTLIER AMOUNT
OTHER COVERAGE MIA CLAIM INDIRECT TEACHING AMOUNT
OTHER COVERAGE MIA NON-PAYABLE PROF COMP BILLED AMOUNT
OTHER COVERAGE MIA PPS-CAPITAL EXCEPTION AMOUNT
OTHER COVERAGE MIA REMARK CODE
OTHER COVERAGE MOA REIMBURSEMENT RATE
OTHER COVERAGE MOA HCPCS PAYABLE AMOUNT
OTHER COVERAGE MOA ESRD PAYMENT AMOUNT
OTHER COVERAGE MOA NON-PAYABLE PROF COMP BILLED AMOUNT
OTHER COVERAGE MOA REMARK CODE
OTHER PAYER ASSISTANT SURGEON ENTITY TYPE QUALIFIER
OTHER PAYER ASSISTANT SURGEON SECONDARY ID QUAL
OTHER PAYER ASSISTANT SURGEON SECONDARY ID
OTHER COVERAGE ADDITIONAL ITEM 1
OTHER COVERAGE ADDITIONAL ITEM 2
OTHER COVERAGE ADDITIONAL ITEM 3
OTHER COVERAGE ADDITIONAL ITEM 4
OTHER COVERAGE ADDITIONAL ITEM 5
OTHER COVERAGE ADDITIONAL ITEM 6
OTHER COVERAGE ADDITIONAL ITEM 7
OTHER COVERAGE ADDITIONAL ITEM 8
OTHER COVERAGE ADDITIONAL ITEM 9
OTHER COVERAGE ADDITIONAL ITEM 10
ADJUSTMENT TO CLAIM HEADER ID
REVERSAL TO CLAIM HEADER ID
ADJUSTMENT SEQUENCE
OTHER PAYER PCP REFERRING PROVIDER SECONDARY ID QUAL
OTHER PAYER PCP REFERRING PROVIDER SECONDARY ID
OTHER PROVIDER LAST NAME
OTHER PROVIDER FIRST NAME
OTHER PROVIDER MIDDLE NAME
OTHER PROVIDER NAME SUFFIX
OTHER PROVIDER NPI
OTHER PROVIDER SECONDARY ID QUALIFIER
OTHER PROVIDER SECONDARY ID
OTHER PROVIDER PROVIDER TYPE QUALIFIER
HOMEBOUND CONDITION QUALIFIER
HOMEBOUND CONDITION CODE
ORTHODONTIC TREATMENT INDICATOR
DENTAL PREDETERMINATION OF BENEFITS CODE
DIAGNOSIS RELATED GROUP SOI (SEVERITY OF ILLNESS)
DIAGNOSIS RELATED GROUP ROM (RISK OF MORTALITY)
DENTAL DATE OF LAST SRP
SERVICE PROVIDER ID QUALIFIER
SERVICE PROVIDER ID
SERVICE PROVIDER TAXONOMY
SERVICE PROVIDER IN-NETWORK
SERVICE PROVIDER FROM LINES
SERVICE PROVIDER NAME
PRESCRIBER ID QUALIFIER
PRESCRIBER ID
PRESCRIBER TAXONOMY
PRESCRIBER LAST NAME
REJECT CODE
CLAIM EXTENDED NOTE
PROVIDER OSCAR NUMBER
OUTPATIENT SERVICE TYPE CODE
TOOTH NUMBER
TOOTH STATUS CODE
TOOTH CODE LIST QUALIFIER CODE
CLAIM ADDITIONAL ITEM 1
CLAIM ADDITIONAL ITEM 2
CLAIM ADDITIONAL ITEM 3
CLAIM ADDITIONAL ITEM 4
CLAIM ADDITIONAL ITEM 5
CLAIM ADDITIONAL ITEM 6
CLAIM ADDITIONAL ITEM 7
CLAIM ADDITIONAL ITEM 8
CLAIM ADDITIONAL ITEM 9
CLAIM ADDITIONAL ITEM 10
HEADER ADDITIONAL ITEM TYPE
HEADER ADDITIONAL ITEM CODE
HEADER ADDITIONAL ITEM TYPE CAT
REMOVED LINE ITEM CONTROL NUMBERS
REMOVED DIAGNOSIS CODES
REMOVED PROCEDURE CODES
CLAIM FORMAT
CLAIM ADJUDICATION INSTANT
EDGE CHANGE TYPE
LINKED CLAIM CONTROL NUMBER
LINE CONTROL NUMBER
LINE FROM DATE
LINE TO DATE
LINE PROCEDURE CODE QUALIFIER
LINE PROCEDURE CODE
LINE PROCEDURE DESCRIPTION
LINE PROCEDURE MODIFIER
LINE QUANTITY QUALIFIER
LINE QUANTITY
LINE CHARGE AMOUNT
LINE DATE-RANGE QUALIFIER
LINE TOTAL PAID AMOUNT
ADJUSTED REPRICED LINE ITEM REFERENCE NUMBER
LINE SERVICE TAX AMOUNT
LINE FACILITY TAX AMOUNT
LINE REPRICED ITEM REFERENCE NUMBER
LINE SALES TAX AMOUNT
LINE POSTAGE CLAIMED AMOUNT
LINE QUANTITY TEXT
LINE REVENUE CODE
LINE REVENUE CODE DESCRIPTION
LINE RATE (FOR ACCOMMODATION REV CODES)
LINE NON-COVERED CHARGE AMOUNT
LINE CHARGE AMOUNT - PRE CONTRACT
GENERATED LINE FLAG
REVENUE APC CODE
LINE PLACE OF SERVICE CODE
LINE DIAGNOSIS POINTER
LINE EMERGENCY INDICATOR
LINE EPSDT INDICATOR
LINE FAMILY PLANNING INDICATOR
LINE COPAY STATUS CODE
LINE AMBULANCE PATIENT COUNT
LINE MAMMOGRAPHY CERTIFICATION NUMBER
LINE CLIA NUMBER
LINE TYPE OF SERVICE
LINE PURCHASED SERVICE CHARGE AMOUNT
LINE REFERRING CLIA NUMBER
LINE HOSPICE EMPLOYEE INDICATOR
LINE HOSPICE CONDITION INDICATOR
LINE OBSTETRIC ADDITIONAL UNITS
LINE IMMUNIZATION BATCH NUMBER
LINE PURCHASED SERVICE REFERENCE IDENTIFIER
LINE DIAGNOSIS POINTER RANK
SERVICE LINE NUMBER OVERRIDE
LINE ORAL CAVITY DESIGNATION CODE
LINE DENTAL PROSTHESIS, CROWN OR INLAY
LINE PRIOR PLACEMENT DATE QUALIFIER
LINE PRIOR PLACEMENT DATE
LINE APPLIANCE PLACEMENT DATE
LINE REPLACEMENT DATE
LINE TREATMENT START DATE
LINE TREATMENT COMPLETION DATE
LINE DME CMN TRANSMISSION CODE
LINE DME CERTIFICATION TYPE
LINE DME DURATION
LINE DME RECERTIFICATION DATE
LINE DME BEGIN THERAPY DATE
LINE DME CONDITION INDICATOR
LINE DME LAST CERTIFICATION DATE
LINE CONTRACT TYPE CODE
LINE CONTRACT AMOUNT
LINE CONTRACT PERCENTAGE
LINE CONTRACT CODE
LINE CONTRACT TERMS DISCOUNT PERCENTAGE
LINE CONTRACT VERSION IDENTIFIER
LINE ATTACHMENT REPORT TYPE
LINE ATTACHMENT TRANSMISSION CODE
LINE ATTACHMENT DOCUMENT CONTROL NUMBER
LINE DME PROCEDURE CODE
LINE DME LENGTH OF MEDICAL NECESSITY
LINE DME RENTAL PRICE
LINE DME PURCHASE PRICE
LINE DME RENTAL UNIT PRICE INDICATOR
LINE TEST DATE QUALIFIER
LINE TEST DATE
LINE TEST RESULT IDENTIFICATION CODE
LINE TEST RESULT QUALIFIER
LINE TEST RESULT
LINE PRIOR AUTHORIZATION NUMBER
LINE PRIOR AUTH OTHER PAYER IDENTIFIER
LINE REFERRAL NUMBER
LINE REFERRAL OTHER PAYER IDENTIFIER
LINE NDC OR UPN
LINE NDC OR UPN UNIT QUANTITY
LINE NDC OR UPN UNIT
LINE PRESCRIPTION OR DRUG NUMBER QUALIFIER
LINE PRESCRIPTION OR DRUG NUMBER
LINE NDC COST
FILL NUMBER
DAYS SUPPLY
DAW OR PRODUCT SELECTION CODE
LINE NOTE QUALIFIER
LINE NOTE TEXT
LINE THIRD PARTY ORGANIZATION NOTE
SECTION 340B PROGRAM PARTICIPANT
TOOTH CODE
TOOTH SURFACE CODE
LINE AMBULANCE PATIENT WEIGHT
LINE AMBULANCE TRANSPORT REASON CODE
LINE AMBULANCE TRANSPORT DISTANCE
LINE AMBULANCE ROUND TRIP PURPOSE DESCRIPTION
LINE AMBULANCE STRETCHER PURPOSE DESCRIPTION
LINE PRICING METHODOLOGY
LINE ALLOWED AMOUNT
LINE SAVINGS AMOUNT
LINE REPRICING ORGANIZATION IDENTIFICATION NUMBER
LINE PRICING RATE
LINE APPROVED DRG CODE
LINE APPROVED DRG AMOUNT
LINE APPROVED REVENUE CODE
LINE REPRICED APPROVED HCPCS QUALIFIER
LINE REPRICED APPROVED HCPCS CODE
LINE UNIT OR BASIS FOR MEASUREMENT CODE
LINE APPROVED SERVICE UNITS OR INPATIENT DAYS
LINE REJECT REASON CODE
LINE POLICY COMPLIANCE CODE
LINE EXCEPTION CODE
LINE DENIED?
LINE RENDERING PROVIDER ENTITY TYPE QUALIFIER
LINE RENDERING PROVIDER LAST NAME
LINE RENDERING PROVIDER FIRST NAME
LINE RENDERING PROVIDER MIDDLE NAME
LINE RENDERING PROVIDER NAME SUFFIX
LINE RENDERING PROVIDER NPI
LINE RENDERING PROVIDER TAXONOMY CODE
LINE RENDERING PROVIDER SECONDARY ID QUALIFIER
LINE RENDERING PROVIDER SECONDARY ID
LINE RENDERING PROVIDER SEC ID OTHER PAYER ID
LINE SERVICE FACILITY LOCATION NAME
LINE SERVICE FACILITY LOCATION NPI
LINE SERVICE FACILITY LOCATION IDENTIFIER
LINE SERVICE FACILITY LOCATION STREET ADDRESS LINE 1
LINE SERVICE FACILITY LOCATION STREET ADDRESS LINE 2
LINE SERVICE FACILITY LOCATION CITY
LINE SERVICE FACILITY LOCATION STATE
LINE SERVICE FACILITY LOCATION ZIP CODE
LINE SERVICE FACILITY LOCATION COUNTRY CODE
LINE SERVICE FACILITY LOCATION COUNTRY SUBDIVISION CODE
LINE SERVICE FACILITY LOCATION SECONDARY ID QUALIFIER
LINE SERVICE FACILITY LOCATION SECONDARY ID
LINE SERVICE FACILITY LOCATION SECONDARY ID OTHER PAYER
LINE SUPERVISING PROVIDER LAST NAME
LINE SUPERVISING PROVIDER FIRST NAME
LINE SUPERVISING PROVIDER MIDDLE NAME
LINE SUPERVISING PROVIDER NAME SUFFIX
LINE SUPERVISING PROVIDER NPI
LINE SUPERVISING PROVIDER SECONDARY ID QUALIFIER
LINE SUPERVISING PROVIDER SECONDARY ID
LINE SUPERVISING PROVIDER SEC ID OTHER PAYER ID
LINE ORDERING PROVIDER LAST NAME
LINE ORDERING PROVIDER FIRST NAME
LINE ORDERING PROVIDER MIDDLE NAME
LINE ORDERING PROVIDER NAME SUFFIX
LINE ORDERING PROVIDER NPI
LINE ORDERING PROVIDER CONTACT NAME
LINE LEVEL ORDERING PROVIDER TAXONOMY CODE
LINE ORDERING PROVIDER STREET ADDRESS LINE 1
LINE ORDERING PROVIDER STREET ADDRESS LINE 2
LINE ORDERING PROVIDER CITY
LINE ORDERING PROVIDER STATE
LINE ORDERING PROVIDER ZIP CODE
LINE ORDERING PROVIDER COUNTRY CODE
LINE ORDERING PROVIDER COUNTRY SUBDIVISION CODE
LINE ORDERING PROVIDER SECONDARY ID QUALIFIER
LINE ORDERING PROVIDER SECONDARY ID
LINE ORDERING PROVIDER SEC ID OTHER PAYER ID
LINE PURCHASED SERVICE PROVIDER ENTITY TYPE QUALIFIER
LINE PURCHASED SERVICE PROVIDER NPI
LINE PURCHASED SERVICE PROVIDER SECONDARY ID QUALIFIER
LINE PURCHASED SERVICE PROVIDER SECONDARY ID
LINE PURCHASED SERVICE PROVIDER SEC ID OTHER PAYER ID
LINE ASSISTANT DENTAL SURGEON ENTITY TYPE QUALIFIER
LINE ASSISTANT DENTAL SURGEON LAST NAME
LINE ASSISTANT DENTAL SURGEON FIRST NAME
LINE ASSISTANT DENTAL SURGEON MIDDLE NAME
LINE ASSISTANT DENTAL SURGEON NAME SUFFIX
LINE ASSISTANT DENTAL SURGEON NPI
LINE ASSISTANT DENTAL SURGEON TAXONOMY CODE
LINE ASSISTANT DENTAL SURGEON SECONDARY ID QUALIFIER
LINE ASSISTANT DENTAL SURGEON SECONDARY ID
LINE ASSISTANT DENTAL SURGEON SECONDARY ID OTHER PAYER
LINE OPERATING PHYSICIAN ENTITY TYPE QUAL
LINE OPERATING PHYSICIAN LAST NAME
LINE OPERATING PHYSICIAN FIRST NAME
LINE OPERATING PHYSICIAN MIDDLE NAME
LINE OPERATING PHYSICIAN NAME SUFFIX
LINE OPERATING PHYSICIAN ID
LINE OPERATING PHYSICIAN TAXONOMY
LINE OPERATING PHYSICIAN SECONDARY ID QUAL
LINE OPERATING PHYSICIAN SECONDARY ID
LINE OPERATING PHYSICIAN SECONDARY ID OTHER PAYER ID
LINE OTHER OPERATING PHYSICIAN ENTITY TYPE QUAL
LINE OTHER OPERATING PHYSICIAN LAST NAME
LINE OTHER OPERATING PHYSICIAN FIRST NAME
LINE OTHER OPERATING PHYSICIAN MIDDLE NAME
LINE OTHER OPERATING PHYSICIAN NAME SUFFIX
LINE OTHER OPERATING PHYSICIAN ID
LINE OTHER OPERATING PHYSICIAN SECONDARY ID QUAL
LINE OTHER OPERATING PHYSICIAN SECONDARY ID
LINE OTHER OPERATING PHYSICIAN SECONDARY ID OTHER PAYER
LINE REFERRING PROVIDER ENTITY TYPE QUAL
LINE REFERRING PROVIDER LAST NAME
LINE REFERRING PROVIDER FIRST NAME
LINE REFERRING PROVIDER MIDDLE NAME
LINE REFERRING PROVIDER NAME SUFFIX
LINE REFERRING PROVIDER ID
LINE REFERRING PROVIDER ENTITY IDENTIFIER CODE
LINE REFERRING PROVIDER SECONDARY ID QUAL
LINE REFERRING PROVIDER SECONDARY ID
LINE REFERRING PROVIDER SECONDARY ID OTHER PAYER ID
LINE ADJUDICATION OTHER PAYER IDENTIFIER
LINE ADJUDICATION PAID AMOUNT
LINE ADJUDICATION PROCEDURE CODE QUALIFIER
LINE ADJUDICATION PROCEDURE CODE
LINE ADJUDICATION PROCEDURE DESCRIPTION
LINE ADJUDICATION PROCEDURE MODIFIER
LINE ADJUDICATION QUANTITY
LINE ADJUDICATION BUNDLED LINE NUMBER
LINE ADJUDICATION OR PAYMENT DATE
LINE ADJUDICATION REVENUE CODE
LINE ADJUDICATION REMAINING PATIENT LIABILITY
LINE ADJUDICATION OTHER PAYER SEQUENCE CODE
LINE ADJUDICATION ALLOWED AMOUNT
LINE ADJUDICATION DERIVED AMOUNT INDICATOR
LINE REASON CODE INFORMATION
LINE AMBULANCE TRANSPORT CONDITION CODE
LINE AMBULANCE YES NO CONDITION CODE
LINE PRESCRIPTION DATE
LINE LAST CERTIFICATION DATE
LINE LAST SEEN DATE
LINE SHIPPED DATE
LINE LAST X-RAY DATE
LINE INITIAL TREATMENT DATE
LINE RECERTIFICATION DATE
PROCESSING INDICATOR CODE
PROCESSING INDICATOR CODE DESCRIPTION
LINE SUPPORTING DOCUMENTATION TYPE
LINE SUPPORTING DOCUMENTATION FORM IDENTIFIER
LINE SUPPORTING DOCUMENTATION QUESTION NUMBER
LINE SUPPORTING DOCUMENTATION QUESTION TYPE
LINE SUPPORTING DOCUMENTATION QUESTION RESPONSE
LINE FIXED FORMAT INFORMATION
LINE ORDERING PROVIDER CONTACT QUALIFIER
LINE ORDERING PROVIDER CONTACT INFORMATION
LINE AMBULANCE PICK-UP LOCATION STREET ADDRESS L
LINE AMBULANCE PICK-UP LOCATION ST ADDR LINE 2
LINE AMBULANCE PICK-UP LOCATION CITY
LINE AMBULANCE PICK-UP LOCATION STATE
LINE AMBULANCE PICK-UP LOCATION ZIP CODE
LINE AMBULANCE PICK-UP LOCATION COUNTRY CODE
LINE AMBULANCE PICK-UP LOCATION COUNTRY SUBDIVISION
LINE AMBULANCE PICK-UP LOCATION COUNTY
LINE AMBULANCE DROP-OFF LOCATION NAME
LINE AMBULANCE DROP-OFF LOCATION ADDRESS LINE 1
LINE AMBULANCE DROP-OFF LOCATION ADDRESS LINE 2
LINE AMBULANCE DROP-OFF LOCATION CITY
LINE AMBULANCE DROP-OFF LOCATION STATE
LINE AMBULANCE DROP-OFF LOCATION ZIP
LINE AMBULANCE DROP-OFF LOCATION COUNTRY CODE
LINE AMBULANCE DROP-OFF LOCATION COUNTRY SUBDIVISION
LINE AMBULANCE DROP-OFF LOCATION COUNTY
MEDICARE PAID AMOUNT
OTHER INSURANCE OR MEMBER PAID AMOUNT
INGREDIENT COST PAID
DISPENSING FEE PAID
PATIENT PAY AMOUNT
AMOUNT OF COPAY
AMOUNT OF COINSURANCE
AMOUNT OF DEDUCTIBLE
REGULATORY FEE AMOUNT PAID
PERCENTAGE TAX AMOUNT PAID
INCENTIVE AMOUNT PAID
OTHER PAYER AMOUNT RECOGNIZED
NET AMOUNT DUE
OTHER AMOUNT PAID QUALIFIER
OTHER AMOUNT PAID
FILL STATUS
LINE LIN QUALIFIER
LINE PREDETERMINATION OF BENEFITS IDENTIFIER
LINE OTHER PAYER PREDETERMINATION OF BENEFIT IDENT
LINE PRESCRIBING PROVIDER NPI
LINE PRESCRIBING PROVIDER TAXONOMY CODE
LINE START TIME
LINE END TIME
LINE ELAPSED TIME
LINE SERVICE PROVIDER NPI
LINE SERVICE PROVIDER TAXONOMY CODE
LINE SERVICE PROVIDER NAME
LINE PCP REFERRING PROVIDER LAST NAME
LINE PCP REFERRING PROVIDER FIRST NAME
LINE PCP REFERRING PROVIDER MIDDLE NAME
LINE PCP REFERRING PROVIDER NAME SUFFIX
LINE PCP REFERRING PROVIDER NPI
LINE PCP REFERRING PROVIDER SECONDARY ID QUAL
LINE PCP REFERRING PROVIDER SECONDARY ID
LINE PCP REFERRING PROVIDER SECONDARY ID OTHER PAYER ID
LINE SERVICE PROVIDER IN NETWORK
LINE ADDITIONAL ITEM 1
LINE ADDITIONAL ITEM 2
LINE ADDITIONAL ITEM 3
LINE ADDITIONAL ITEM 4
LINE ADDITIONAL ITEM 5
LINE ADDITIONAL ITEM 6
LINE ADDITIONAL ITEM 7
LINE ADDITIONAL ITEM 8
LINE ADDITIONAL ITEM 9
LINE ADDITIONAL ITEM 10
LINE ADDITIONAL ITEM TYPE
LINE ADDITIONAL ITEM CODE
LINE ADDITIONAL ITEM TYPE CAT
LINE THIRD PARTY ORGANIZATION NOTE (TAPESTRY REPRICING)
REFERENCE CLAIM - DESTINATION ORGANIZATION
REFERENCE CLAIM - SEND INSTANT
REFERENCE CLAIM - SENT ENCOUNTER
LINE CMS SERVICE CODE
LINE PRIMARY PAYER CODE
LINE HCPCS BETOS CODE
LINE CHARGE CODE
LINE CHARGE CODE QUANTITY
LINE CHARGE CODE AMOUNT
LINE CHARGE PRICE
PCP REFERRING PROVIDER LAST NAME
PCP REFERRING PROVIDER FIRST NAME
PCP REFERRING PROVIDER MIDDLE NAME
PCP REFERRING PROVIDER NAME SUFFIX
PCP REFERRING PROVIDER NPI
PCP REFERRING PROVIDER TAXONOMY CODE
PCP REFERRING PROVIDER SECONDARY ID QUALIFIER
PCP REFERRING PROVIDER SECONDARY ID
RX - BANK IDENTIFICATION NUMBER
RX - PROCESSOR CONTROL NUMBER
RX - PRIOR AUTHORIZATION TYPE
RX - PRESCRIPTION WRITTEN DATE
RX - SUBMISSION CLARIFICATION CODE
RX - PRESCRIPTION ORIGIN CODE
RX - PHARMACY SERVICE TYPE
RX - SPECIAL PACKAGING INDICATOR
RX - PRODUCT DESCRIPTION
RX - OTHER COVERAGE CODE
RX - SERVICE LEVEL
RX - QUANTITY PRESCRIBED
RX - REASON FOR SERVICE CODE
RX - PROFESSIONAL SERVICE CODE
RX - RESULT OF SERVICE CODE
RX - LEVEL OF EFFORT
RX - DOSAGE FORM DESCRIPTION CODE
RX - DISPENSING UNIT FORM INDICATOR
RX - ROUTE OF ADMINISTRATION
RX - COMPOUND INGREDIENT COMPONENT COUNT
RX - USUAL AND CUSTOMARY CHARGE
RX - COST DETERMINATION BASIS
RX - INGREDIENT COST SUBMITTED
RX - DISPENSING FEE SUBMITTED
RX - PROFESSIONAL SERVICE FEE SUBMITTED
RX - INCENTIVE AMOUNT SUBMITTED
RX - OTHER AMOUNT SUBMITTED
RX - GROSS AMOUNT DUE SUBMITTED
RX - COMPOUND INGREDIENT PRODUCT NAME
RX - COMPOUND LINE PRODUCT ID
RX - COMPOUND LINE PRODUCT ID QUALIFIER
RX - COMPOUND LINE INGREDIENT QUANTITY
RX - COMPOUND LINE INGREDIENT DRUG COST
RX - COMPOUND LINE COST DETERMINATION BASIS
CLAIM OUTCOME FHIR
OTHER ACCIDENT - EMERGENCY
STERILIZATION OR ABORTION
PAYEE NUMBER
CLAIM LEVEL TOS
CLAIM EPSDT INDICATOR
CLAIM FAMILY PLANNING INDICATOR
CLAIM EMERGENCY INDICATOR
STERILIZATION ABORTION CODE
POSSIBLE DISABILITY
PAYMENT SOURCE CODE - MEDICARE INVOLVEMENT
PAYMENT SOURCE CODE - OTHER INSURANCE INVOLVEMENT
PAYMENT SOURCE CODE - INSURANCE CODE
LOCATOR CODE
TOTAL BILLED AMOUNT - PRE CONTRACT
TPL PAYER CODE
TPL STATUS CODE
TPL AMOUNT
TPL DATE
LOOP OR SPLIT SEQUENCE CLAIMS
CLAIM ADJUSTMENT GROUP CODE
CLAIM ADJUSTMENT REASON CODE
CLAIM ADJUSTMENT AMOUNT
CLAIM ADJUSTMENT QUANTITY
BCDA ADJUDICATION AMOUNT TYPE
VALUE BASED PROGRAM IDENTIFIER
VALUE BASED PROGRAM NAME
VALUE BASED PROGRAM REMOVAL STATUS
CLAIM STATUS
DRG CODE SET
DRG VERSION
IS CLINICALLY INVALID?
DRG CODE SET IDENTIFIER
DRG CODE VERSION IDENTIFIER
MEDICARE NON PAYMENT REASON CODE
MEDICARE NON PAYMENT REASON CODE DESCRIPTION
CARRIER CLAIM PAYMENT DENIAL CODE
CARRIER CLAIM PAYMENT DENIAL CODE DESCRIPTION
PRIMARY PAYER CODE
PATIENT'S PAYER ENTERPRISE ID
BENEFIT PLAN NAME
CORPORATION NAME
NETWORK LEVEL
REGION NAME
LINE OF BUSINESS NAME
NON-CITIZEN NATIONALITY
NON-CITIZEN ID TYPE
NON-CITIZEN CARD NUMBER
NON-CITIZEN PATIENT ID
NON-CITIZEN CARD ISSUING OFFICE NAME
NON-CITIZEN CARD ISSUING OFFICE NUMBER
NON-CITIZEN CARD VALID FROM
NON-CITIZEN CARD VALID TO
NON-CITIZEN NATIONALITY
VISIT NUMBER
VISIT TYPE
INVOICE NUMBER HASH
CLAIM TRANSACTION TYPE
COPAY EXEMPT REASON
CLAIM REIMBURSABLE BASIS CODE
CLAIM DEBTOR
CREDIT FLAG
COPAY CORRECTION
COPAY PAID
CLAIM CHARGE TYPE
REFERRAL SOURCE TYPE
REFERRAL END DISPOSITION
RIGHTS ASSESSED BY
RIGHTS ASSESSMENT DATE
REFERRAL DATE
REFERRAL PERIOD ID
REFERRAL DIAGNOSES
REFERRAL DIAGNOSES QUALIFIER
REFERRAL DIAGNOSIS CODE SET OID
CONDITION - DIAGNOSIS
CONDITION - QUALIFIER
RUN REFERENCE NUMBER
EPIC VERSION
FORM VERSION
MESSAGE HEADER TYPE
CLAIM MESSAGE ID
SERVICE AREA CODE
DEPARTMENT ALTERNATE CODE
DEPARTMENT INTERNAL CODE
DEPARTMENT CODE
DEPARTMENT NAME
PRACTICE ACCOUNT NUMBER
PRACTICE ACCOUNT NUMBER
NET AMOUNT
VALUE ADDED TAX
ENCOUNTER TYPE
ENCOUNTER TRANSFER SOURCE
ENCOUNTER TRANSFER DESTINATION
ENCOUNTER START DATE
ENCOUNTER START TIME
ENCOUNTER END DATE
ENCOUNTER END TIME
ENCOUNTER END TYPE
DIAGNOSIS TYPE
DIAGNOSIS INFO TYPE
RESUBMISSION TYPE
RESUBMISSION COMMENT
ACTIVITY TRANSACTION CONTROL NUMBER
ACTIVITY VAT PERCENT
ACTIVITY CODE
ACTIVITY START DATE
OBSERVATION TYPE
OBSERVATION CODE
OBSERVATION VALUE
OBSERVATION VALUE TYPE
6 | AUDIT_OLD_LINE | INTEGER | No |
The previous line number for the item in AUDIT_ITEM_C that was changed. It will only be populated when the item is multiple response or part of a related group.
7 | AUDIT_OLD_POS | INTEGER | No |
The previous value position number for the item in AUDIT_ITEM_C that was changed. It will only be populated for related multi items.
8 | AUDIT_OLD_VAL | VARCHAR | No |
The value before the user's change.
9 | AUDIT_NEW_LINE | INTEGER | No |
The new line number for the item in AUDIT_ITEM_C that was changed. It will only be populated when the item is multiple response or part of a related group.
10 | AUDIT_NEW_POS | INTEGER | No |
The new value position number for the item in AUDIT_ITEM_C that was changed. It will only be populated for related multi items.
11 | AUDIT_NEW_VAL | VARCHAR | No |
The value after the user's change.