|
| 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 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 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 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 |
| 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 |
| 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 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) |
| SERVICE PROVIDER ID QUALIFIER |
| SERVICE PROVIDER ID |
| SERVICE PROVIDER TAXONOMY |
| SERVICE PROVIDER IN-NETWORK |
| SERVICE PROVIDER FROM LINES |
| 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 |
| 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 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 |
| 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 |
| 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 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 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 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 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 |
| 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 |
| 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 |
