|
| Name of the paper form field associated with the incoming claim error. |
| May contain organization-specific values: No |
| Category Entries: |
| Received Date |
| Box 1 - Medicare |
| Box 1 - Medicaid |
| Box 1 - Tricare |
| Box 1 - Champva |
| Box 1 - Group Health Plan |
| Box 1 - FECA Blk Lung |
| Box 1 - Other |
| Box 1A - Insured ID |
| Box 2 - Patient Name |
| Box 3 - Patient DOB |
| Box 3 - Sex M |
| Box 3 - Sex F |
| Box 4 - Insured Name |
| Box 5 - Patient Address |
| Box 5 - Patient City |
| Box 5 - Patient State |
| Box 5 - Patient ZIP |
| Box 5 - Patient Phone |
| Box 6 - Relationship Self |
| Box 6 - Relationship Spouse |
| Box 6 - Relationship Child |
| Box 6 - Relationship Other |
| Box 7 - Insured Address |
| Box 7 - Insured City |
| Box 7 - Insured State |
| Box 7 - Insured ZIP |
| Box 7 - Insured Phone |
| Box 8 - Reserved (NUCC) |
| Box 9 - Other Insured Name |
| Box 9A - Other Insured Policy |
| Box 9B - Reserved (NUCC) |
| Box 9C - Reserved (NUCC) |
| Box 9D - Other Insurance Plan |
| Box 10A - Employment Y |
| Box 10A - Employment N |
| Box 10B - Auto Accident Y |
| Box 10B - Auto Accident N |
| Box 10B - Accident State |
| Box 10C - Other Accident Y |
| Box 10C - Other Accident N |
| Box 10D - Claim Codes |
| Box 11 - Insured Policy/Group |
| Box 11A - Insured DOB |
| Box 11A - Sex M |
| Box 11A - Sex F |
| Box 11B - Other Claim ID Qual |
| Box 11B - Other Claim ID |
| Box 11C - Insurance Plan Name |
| Box 11D - Other Health Plan Y |
| Box 11D - Other Health Plan N |
| Box 12 - Patient Signature |
| Box 13 - Insured Signature |
| Box 14 - Onset Date |
| Box 14 - Onset Qual |
| Box 15 - Other Date Qual |
| Box 15 - Other Date |
| Box 16 - Unable to Work From |
| Box 16 - Unable to Work To |
| Box 17 - Referring Qual |
| Box 17 - Referring Name |
| Box 17A - Other ID Qual |
| Box 17A - Other ID |
| Box 17B - Referring NPI |
| Box 18 - Hospitalization From |
| Box 18 - Hospitalization To |
| Box 19 - Additional Info |
| Box 20 - Outside Lab Y |
| Box 20 - Outside Lab N |
| Box 20 - Lab Charges |
| Box 21 - ICD Indicator |
| Box 21 - Diagnosis |
| Box 22 - Resubmission Code |
| Box 22 - Original Ref No |
| Box 23 - Prior Auth |
| Box 24A/1 (Shaded) |
| Box 24A/2 (Shaded) |
| Box 24B (Shaded) |
| Box 24C (Shaded) |
| Box 24D/1 (Shaded) |
| Box 24D/2 (Shaded) |
| Box 24E (Shaded) |
| Box 24F (Shaded) |
| Box 24G (Shaded) |
| Box 24H (Shaded) |
| Box 24I (Shaded) |
| Box 24J (Shaded) |
| Box 24A - From Date |
| Box 24A - To Date |
| Box 24B - Place of Service |
| Box 24C - EMG |
| Box 24D - CPT/HCPCS |
| Box 24D - Modifier |
| Box 24E - Diagnosis Pointer |
| Box 24F - Charges |
| Box 24G - Days/Units |
| Box 24H - EPSDT |
| Box 24J - Rendering NPI |
| Box 25 - Federal TIN |
| Box 25 - TIN SSN |
| Box 25 - TIN EIN |
| Box 26 - Patient Acct No |
| Box 27 - Accept Assignment Y |
| Box 27 - Accept Assignment N |
| Box 28 - Total Charge |
| Box 29 - Amount Paid |
| Box 30 - Reserved (NUCC) |
| Box 31 - Provider Signature |
| Box 32 - Service Facility |
| Box 32A - Service Facility NPI |
| Box 32B - Service Facility Other ID |
| Box 33 - Billing Phone |
| Box 33 - Billing Name/Address |
| Box 33A - Billing NPI |
| Box 33B - Billing Other ID |
| FL 1 - Billing Provider Name |
| FL 1 - Billing Provider Address |
| FL 1 - Billing Provider City/State/ZIP |
| FL 1 - Billing Provider Phone |
| FL 2 - Pay-To Name |
| FL 2 - Pay-To Address |
| FL 2 - Pay-To City/State/ZIP |
| FL 2 - Pay-To Phone |
| FL 3A - Patient Control No |
| FL 3B - Medical Record No |
| FL 4 - Type of Bill |
| FL 5 - Federal Tax ID |
| FL 6 - Statement From Date |
| FL 6 - Statement To Date |
| FL 7 - Reserved |
| FL 8A - Patient ID |
| FL 8B - Patient Name |
| FL 9A - Patient Street |
| FL 9B - Patient City |
| FL 9C - Patient State |
| FL 9D - Patient ZIP |
| FL 9E - Patient Country |
| FL 10 - Patient Birth Date |
| FL 11 - Patient Sex |
| FL 12 - Admission Date |
| FL 13 - Admission Hour |
| FL 14 - Type of Admission |
| FL 15 - Point of Origin |
| FL 16 - Discharge Hour |
| FL 17 - Patient Status |
| FL 18-28 - Condition Code |
| FL 29 - Accident State |
| FL 30 - Reserved |
| FL 31-34 - Occurrence Code |
| FL 31-34 - Occurrence Date |
| FL 35-36 - Occurrence Span Code |
| FL 35-36 - Occurrence Span From |
| FL 35-36 - Occurrence Span To |
| FL 37A - Reserved |
| FL 37B - Reserved |
| FL 38 - Responsible Party |
| FL 39-41 - Value Code |
| FL 39-41 - Value Amount Whole |
| FL 39-41 - Value Amount Cents |
| FL 42 - Revenue Code |
| FL 43 - Description |
| FL 44 - HCPCS/Rate |
| FL 45 - Service Date |
| FL 46 - Service Units |
| FL 47 - Total Charges |
| FL 48 - Non-Covered Charges |
| FL 49 - Reserved |
| Summary Revenue Code |
| Page Number |
| Page Count |
| Creation Date |
| Total Charges Total |
| Non-Covered Total |
| FL 49 Summary |
| FL 50A - Payer Name (Primary) |
| FL 50B - Payer Name (Secondary) |
| FL 50C - Payer Name (Tertiary) |
| FL 51A - Health Plan ID (Primary) |
| FL 51B - Health Plan ID (Secondary) |
| FL 51C - Health Plan ID (Tertiary) |
| FL 52A - Release of Info (Primary) |
| FL 52B - Release of Info (Secondary) |
| FL 52C - Release of Info (Tertiary) |
| FL 53A - Assignment of Benefits (Primary) |
| FL 53B - Assignment of Benefits (Secondary) |
| FL 53C - Assignment of Benefits (Tertiary) |
| FL 54A - Prior Payments (Primary) |
| FL 54B - Prior Payments (Secondary) |
| FL 54C - Prior Payments (Tertiary) |
| FL 55A - Estimated Amount Due (Primary) |
| FL 55B - Estimated Amount Due (Secondary) |
| FL 55C - Estimated Amount Due (Tertiary) |
| FL 56 - Billing NPI |
| FL 57A - Other Provider ID (Primary) |
| FL 57B - Other Provider ID (Secondary) |
| FL 57C - Other Provider ID (Tertiary) |
| FL 58A - Insured Name (Primary) |
| FL 58B - Insured Name (Secondary) |
| FL 58C - Insured Name (Tertiary) |
| FL 59A - Patient Relationship (Primary) |
| FL 59B - Patient Relationship (Secondary) |
| FL 59C - Patient Relationship (Tertiary) |
| FL 60A - Insured Unique ID (Primary) |
| FL 60B - Insured Unique ID (Secondary) |
| FL 60C - Insured Unique ID (Tertiary) |
| FL 61A - Group Name (Primary) |
| FL 61B - Group Name (Secondary) |
| FL 61C - Group Name (Tertiary) |
| FL 62A - Insurance Group No (Primary) |
| FL 62B - Insurance Group No (Secondary) |
| FL 62C - Insurance Group No (Tertiary) |
| FL 63A - Treatment Auth Code (Primary) |
| FL 63B - Treatment Auth Code (Secondary) |
| FL 63C - Treatment Auth Code (Tertiary) |
| FL 64A - Document Control No (Primary) |
| FL 64B - Document Control No (Secondary) |
| FL 64C - Document Control No (Tertiary) |
| FL 65A - Employer Name (Primary) |
| FL 65B - Employer Name (Secondary) |
| FL 65C - Employer Name (Tertiary) |
| FL 66 - Diagnosis Version Qual |
| FL 67 - Diagnosis |
| FL 68 - Reserved 1 |
| FL 68 - Reserved 2 |
| FL 69 - Admitting Diagnosis |
| FL 70A - Patient Reason Dx |
| FL 70B - Patient Reason Dx |
| FL 70C - Patient Reason Dx |
| FL 71 - PPS Code |
| FL 72A - External Cause |
| FL 72B - External Cause |
| FL 72C - External Cause |
| FL 73 - Reserved |
| FL 74 - Principal Proc Code |
| FL 74 - Principal Proc Date |
| FL 74 - Other Proc Code |
| FL 74 - Other Proc Date |
| FL 75 - Reserved |
| FL 76 - Attending NPI |
| FL 76 - Attending Secondary Qual |
| FL 76 - Attending Secondary ID |
| FL 76 - Attending Last Name |
| FL 76 - Attending First Name |
| FL 77 - Operating NPI |
| FL 77 - Operating Secondary Qual |
| FL 77 - Operating Secondary ID |
| FL 77 - Operating Last Name |
| FL 77 - Operating First Name |
| FL 78 - Other Provider Qual |
| FL 78 - Other Provider NPI |
| FL 78 - Other Provider Secondary Qual |
| FL 78 - Other Provider Secondary ID |
| FL 78 - Other Provider Last Name |
| FL 78 - Other Provider First Name |
| FL 79 - Other Provider Qual |
| FL 79 - Other Provider NPI |
| FL 79 - Other Provider Secondary ID |
| FL 79 - Other Provider Secondary Qual |
| FL 79 - Other Provider Last Name |
| FL 79 - Other Provider First Name |
| FL 80 - Remarks |
| FL 81 - Code-Code Qual |
| FL 81 - Code-Code Code |
| FL 81 - Code-Code Value |
| Box 24A-G (Shaded) |
| Attachment Present |
