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The record layouts for all eight file files is contained in this spreadsheet. Filter on the FILE NAME column to see a particular file's record segments. Filter on the FILE SEGMENT column (column "G") to view the layout for a particular record segment.
T-MSIS v2.0 Record Layouts |
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| DE_NO |
DATA_ELEMENT_NAME |
SIZE |
START POSITION |
STOP POSITION |
FILE NAME |
FILE SEGMENT (with RECORD-ID) |
| CIP001 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| CIP002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| CIP003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| CIP004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| CIP005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| CIP006 |
FILE-NAME |
X(8) |
32 |
39 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| CIP007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| CIP008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| CIP009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| CIP010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| CIP011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| CIP012 |
SSN-INDICATOR |
X(1) |
67 |
67 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| CIP013 |
TOT-REC-CNT |
9(11) |
68 |
78 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| CIP275 |
SEQUENCE-NUMBER |
X(4) |
79 |
82 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| CIP014 |
STATE-NOTATION |
X(500) |
83 |
582 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| CIP015 |
FILLER |
X(1518) |
583 |
2100 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| CIP016 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP019 |
ICN-ORIG |
X(50) |
22 |
71 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP020 |
ICN-ADJ |
X(50) |
72 |
121 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP021 |
SUBMITTER-ID |
X(12) |
122 |
133 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
134 |
153 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP023 |
CROSSOVER-INDICATOR |
X(1) |
154 |
154 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP024 |
TYPE-OF-HOSPITAL |
X(2) |
155 |
156 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP025 |
1115A-DEMONSTRATION-IND |
X(1) |
157 |
157 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP026 |
ADJUSTMENT-IND |
X(1) |
158 |
158 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP027 |
ADJUSTMENT-REASON-CODE |
X(3) |
159 |
161 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP028 |
ADMISSION-TYPE |
X(1) |
162 |
162 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP029 |
DRG-DESCRIPTION |
X(20) |
163 |
182 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP030 |
ADMITTING-DIAGNOSIS-CODE |
X(7) |
183 |
189 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP031 |
ADMITTING-DIAGNOSIS-CODE-FLAG |
X(1) |
190 |
190 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP032 |
DIAGNOSIS-CODE-1 |
X(7) |
191 |
197 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP033 |
DIAGNOSIS-CODE-FLAG-1 |
X(1) |
198 |
198 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP034 |
DIAGNOSIS-POA-FLAG-1 |
X(1) |
199 |
199 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP035 |
DIAGNOSIS-CODE-2 |
X(7) |
200 |
206 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP036 |
DIAGNOSIS-CODE-FLAG-2 |
X(1) |
207 |
207 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP037 |
DIAGNOSIS-POA-FLAG-2 |
X(1) |
208 |
208 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP038 |
DIAGNOSIS-CODE-3 |
X(7) |
209 |
215 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP039 |
DIAGNOSIS-CODE-FLAG-3 |
X(1) |
216 |
216 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP040 |
DIAGNOSIS-POA-FLAG-3 |
X(1) |
217 |
217 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP041 |
DIAGNOSIS-CODE-4 |
X(7) |
218 |
224 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP042 |
DIAGNOSIS-CODE-FLAG-4 |
X(1) |
225 |
225 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP043 |
DIAGNOSIS-POA-FLAG-4 |
X(1) |
226 |
226 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP044 |
DIAGNOSIS-CODE-5 |
X(7) |
227 |
233 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP045 |
DIAGNOSIS-CODE-FLAG-5 |
X(1) |
234 |
234 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP046 |
DIAGNOSIS-POA-FLAG-5 |
X(1) |
235 |
235 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP047 |
DIAGNOSIS-CODE-6 |
X(7) |
236 |
242 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP048 |
DIAGNOSIS-CODE-FLAG-6 |
X(1) |
243 |
243 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP049 |
DIAGNOSIS-POA-FLAG-6 |
X(1) |
244 |
244 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP050 |
DIAGNOSIS-CODE-7 |
X(7) |
245 |
251 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP051 |
DIAGNOSIS-CODE-FLAG-7 |
X(1) |
252 |
252 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP052 |
DIAGNOSIS-POA-FLAG-7 |
X(1) |
253 |
253 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP053 |
DIAGNOSIS-CODE-8 |
X(7) |
254 |
260 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP054 |
DIAGNOSIS-CODE-FLAG-8 |
X(1) |
261 |
261 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP055 |
DIAGNOSIS-POA-FLAG-8 |
X(1) |
262 |
262 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP056 |
DIAGNOSIS-CODE-9 |
X(7) |
263 |
269 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP057 |
DIAGNOSIS-CODE-FLAG-9 |
X(1) |
270 |
270 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP058 |
DIAGNOSIS-POA-FLAG-9 |
X(1) |
271 |
271 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP059 |
DIAGNOSIS-CODE-10 |
X(7) |
272 |
278 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP060 |
DIAGNOSIS-CODE-FLAG-10 |
X(1) |
279 |
279 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP061 |
DIAGNOSIS-POA-FLAG-10 |
X(1) |
280 |
280 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP062 |
DIAGNOSIS-CODE-11 |
X(7) |
281 |
287 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP063 |
DIAGNOSIS-CODE-FLAG-11 |
X(1) |
288 |
288 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP064 |
DIAGNOSIS-POA-FLAG-11 |
X(1) |
289 |
289 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP065 |
DIAGNOSIS-CODE-12 |
X(7) |
290 |
296 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP066 |
DIAGNOSIS-CODE-FLAG-12 |
X(1) |
297 |
297 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP067 |
DIAGNOSIS-POA-FLAG-12 |
X(1) |
298 |
298 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP068 |
DIAGNOSIS-RELATED-GROUP |
X(4) |
299 |
302 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP069 |
DIAGNOSIS-RELATED-GROUP-IND |
X(4) |
303 |
306 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP070 |
PROCEDURE-CODE-1 |
X(8) |
307 |
314 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP071 |
PROCEDURE-CODE-MOD-1 |
X(2) |
315 |
316 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP072 |
PROCEDURE-CODE-FLAG-1 |
X(2) |
317 |
318 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP073 |
PROCEDURE-CODE-DATE-1 |
9(8) |
319 |
326 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP074 |
PROCEDURE-CODE-2 |
X(8) |
327 |
334 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP075 |
PROCEDURE-CODE-MOD-2 |
X(2) |
335 |
336 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP076 |
PROCEDURE-CODE-FLAG-2 |
X(2) |
337 |
338 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP077 |
PROCEDURE-CODE-DATE-2 |
9(8) |
339 |
346 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP078 |
PROCEDURE-CODE-3 |
X(8) |
347 |
354 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP079 |
PROCEDURE-CODE-MOD-3 |
X(2) |
355 |
356 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP080 |
PROCEDURE-CODE-FLAG-3 |
X(2) |
357 |
358 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP081 |
PROCEDURE-CODE-DATE-3 |
9(8) |
359 |
366 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP082 |
PROCEDURE-CODE-4 |
X(8) |
367 |
374 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP083 |
PROCEDURE-CODE-MOD-4 |
X(2) |
375 |
376 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP084 |
PROCEDURE-CODE-FLAG-4 |
X(2) |
377 |
378 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP085 |
PROCEDURE-CODE-DATE-4 |
9(8) |
379 |
386 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP086 |
PROCEDURE-CODE-5 |
X(8) |
387 |
394 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP087 |
PROCEDURE-CODE-MOD-5 |
X(2) |
395 |
396 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP088 |
PROCEDURE-CODE-FLAG-5 |
X(2) |
397 |
398 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP089 |
PROCEDURE-CODE-DATE-5 |
9(8) |
399 |
406 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP090 |
PROCEDURE-CODE-6 |
X(8) |
407 |
414 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP091 |
PROCEDURE-CODE-MOD-6 |
X(2) |
415 |
416 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP092 |
PROCEDURE-CODE-FLAG-6 |
X(2) |
417 |
418 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP093 |
PROCEDURE-CODE-DATE-6 |
9(8) |
419 |
426 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP094 |
ADMISSION-DATE |
9(8) |
427 |
434 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP095 |
ADMISSION-HOUR |
X(2) |
435 |
436 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP096 |
DISCHARGE-DATE |
9(8) |
437 |
444 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP097 |
DISCHARGE-HOUR |
X(2) |
445 |
446 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP098 |
ADJUDICATION-DATE |
9(8) |
447 |
454 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP099 |
MEDICAID-PAID-DATE |
9(8) |
455 |
462 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP100 |
TYPE-OF-CLAIM |
X(1) |
463 |
463 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP101 |
TYPE-OF-BILL |
X(4) |
464 |
467 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP102 |
CLAIM-STATUS |
X(3) |
468 |
470 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP103 |
CLAIM-STATUS-CATEGORY |
X(3) |
471 |
473 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP104 |
SOURCE-LOCATION |
X(2) |
474 |
475 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP105 |
CHECK-NUM |
X(15) |
476 |
490 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP106 |
CHECK-EFF-DATE |
9(8) |
491 |
498 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP107 |
ALLOWED-CHARGE-SRC |
X(1) |
499 |
499 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP108 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
500 |
504 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP109 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
505 |
509 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP110 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
510 |
514 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP111 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
515 |
519 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP112 |
TOT-BILLED-AMT |
S9(11)V99 |
520 |
532 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP113 |
TOT-ALLOWED-AMT |
S9(11)V99 |
533 |
545 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP114 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
546 |
558 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP115 |
TOT-COPAY-AMT |
S9(11)V99 |
559 |
571 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP116 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
572 |
584 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP117 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
585 |
597 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP118 |
TOT-TPL-AMT |
S9(11)V99 |
598 |
610 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP119 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
611 |
623 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP121 |
OTHER-INSURANCE-IND |
X(1) |
624 |
624 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP122 |
OTHER-TPL-COLLECTION |
X(3) |
625 |
627 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP123 |
SERVICE-TRACKING-TYPE |
X(2) |
628 |
629 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP124 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
630 |
642 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP125 |
FIXED-PAYMENT-IND |
X(1) |
643 |
643 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP126 |
FUNDING-CODE |
X(2) |
644 |
645 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP127 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
646 |
647 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP128 |
MEDICARE-COMB-DED-IND |
X(1) |
648 |
648 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP129 |
PROGRAM-TYPE |
X(2) |
649 |
650 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP130 |
PLAN-ID-NUMBER |
X(12) |
651 |
662 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP131 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
663 |
672 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP132 |
PAYMENT-LEVEL-IND |
X(1) |
673 |
673 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP133 |
MEDICARE-REIM-TYPE |
X(2) |
674 |
675 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP134 |
NON-COV-DAYS |
S9(5) |
676 |
680 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP135 |
NON-COV-CHARGES |
S9(11)V99 |
681 |
693 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP136 |
MEDICAID-COV-INPATIENT-DAYS |
S9(7) |
694 |
700 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP137 |
CLAIM-LINE-COUNT |
9(4) |
701 |
704 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP138 |
FORCED-CLAIM-IND |
X(1) |
705 |
705 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP139 |
HEALTH-CARE-ACQUIRED-CONDITION-IND |
X(1) |
706 |
706 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP140 |
OCCURRENCE-CODE-01 |
X(2) |
707 |
708 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP141 |
OCCURRENCE-CODE-02 |
X(2) |
709 |
710 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP142 |
OCCURRENCE-CODE-03 |
X(2) |
711 |
712 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP143 |
OCCURRENCE-CODE-04 |
X(2) |
713 |
714 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP144 |
OCCURRENCE-CODE-05 |
X(2) |
715 |
716 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP145 |
OCCURRENCE-CODE-06 |
X(2) |
717 |
718 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP146 |
OCCURRENCE-CODE-07 |
X(2) |
719 |
720 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP147 |
OCCURRENCE-CODE-08 |
X(2) |
721 |
722 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP148 |
OCCURRENCE-CODE-09 |
X(2) |
723 |
724 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP149 |
OCCURRENCE-CODE-10 |
X(2) |
725 |
726 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP150 |
OCCURRENCE-CODE-EFF-DATE-01 |
9(8) |
727 |
734 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP151 |
OCCURRENCE-CODE-EFF-DATE-02 |
9(8) |
735 |
742 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP152 |
OCCURRENCE-CODE-EFF-DATE-03 |
9(8) |
743 |
750 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP153 |
OCCURRENCE-CODE-EFF-DATE-04 |
9(8) |
751 |
758 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP154 |
OCCURRENCE-CODE-EFF-DATE-05 |
9(8) |
759 |
766 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP155 |
OCCURRENCE-CODE-EFF-DATE-06 |
9(8) |
767 |
774 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP156 |
OCCURRENCE-CODE-EFF-DATE-07 |
9(8) |
775 |
782 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP157 |
OCCURRENCE-CODE-EFF-DATE-08 |
9(8) |
783 |
790 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP158 |
OCCURRENCE-CODE-EFF-DATE-09 |
9(8) |
791 |
798 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP159 |
OCCURRENCE-CODE-EFF-DATE-10 |
9(8) |
799 |
806 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP160 |
OCCURRENCE-CODE-END-DATE-01 |
9(8) |
807 |
814 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP161 |
OCCURRENCE-CODE-END-DATE-02 |
9(8) |
815 |
822 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP162 |
OCCURRENCE-CODE-END-DATE-03 |
9(8) |
823 |
830 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP163 |
OCCURRENCE-CODE-END-DATE-04 |
9(8) |
831 |
838 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP164 |
OCCURRENCE-CODE-END-DATE-05 |
9(8) |
839 |
846 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP165 |
OCCURRENCE-CODE-END-DATE-06 |
9(8) |
847 |
854 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP166 |
OCCURRENCE-CODE-END-DATE-07 |
9(8) |
855 |
862 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP167 |
OCCURRENCE-CODE-END-DATE-08 |
9(8) |
863 |
870 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP168 |
OCCURRENCE-CODE-END-DATE-09 |
9(8) |
871 |
878 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP169 |
OCCURRENCE-CODE-END-DATE-10 |
9(8) |
879 |
886 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP170 |
BIRTH-WEIGHT-GRAMS |
S9(6)V999 |
887 |
895 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP171 |
PATIENT-CONTROL-NUM |
X(20) |
896 |
915 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP172 |
ELIGIBLE-LAST-NAME |
X(30) |
916 |
945 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP173 |
ELIGIBLE-FIRST-NAME |
X(30) |
946 |
975 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP174 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
976 |
976 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP175 |
DATE-OF-BIRTH |
9(8) |
977 |
984 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP176 |
HEALTH-HOME-PROV-IND |
X(1) |
985 |
985 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP177 |
WAIVER-TYPE |
X(2) |
986 |
987 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP178 |
WAIVER-ID |
X(20) |
988 |
1007 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP179 |
BILLING-PROV-NUM |
X(30) |
1008 |
1037 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP180 |
BILLING-PROV-NPI-NUM |
X(10) |
1038 |
1047 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP181 |
BILLING-PROV-TAXONOMY |
X(12) |
1048 |
1059 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP182 |
BILLING-PROV-TYPE |
X(2) |
1060 |
1061 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP183 |
BILLING-PROV-SPECIALTY |
X(2) |
1062 |
1063 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP184 |
ADMITTING-PROV-NPI-NUM |
X(10) |
1064 |
1073 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP185 |
ADMITTING-PROV-NUM |
X(30) |
1074 |
1103 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP186 |
ADMITTING-PROV-SPECIALTY |
X(2) |
1104 |
1105 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP187 |
ADMITTING-PROV-TAXONOMY |
X(12) |
1106 |
1117 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP188 |
ADMITTING-PROV-TYPE |
X(2) |
1118 |
1119 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP189 |
REFERRING-PROV-NUM |
X(30) |
1120 |
1149 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP190 |
REFERRING-PROV-NPI-NUM |
X(10) |
1150 |
1159 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP191 |
REFERRING-PROV-TAXONOMY |
X(12) |
1160 |
1171 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP192 |
REFERRING-PROV-TYPE |
X(2) |
1172 |
1173 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP193 |
REFERRING-PROV-SPECIALTY |
X(2) |
1174 |
1175 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP194 |
DRG-OUTLIER-AMT |
S9(11)V99 |
1176 |
1188 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP195 |
DRG-REL-WEIGHT |
X(8) |
1189 |
1196 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP196 |
MEDICARE-HIC-NUM |
X(12) |
1197 |
1208 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP197 |
OUTLIER-CODE |
X(2) |
1209 |
1210 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP198 |
OUTLIER-DAYS |
S9(5) |
1211 |
1215 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP199 |
PATIENT-STATUS |
X(2) |
1216 |
1217 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP201 |
BMI |
S9(5)V9 |
1218 |
1223 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP202 |
REMITTANCE-NUM |
X(30) |
1224 |
1253 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP203 |
SPLIT-CLAIM-IND |
X(1) |
1254 |
1254 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP204 |
BORDER-STATE-IND |
X(1) |
1255 |
1255 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP206 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
1256 |
1268 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP207 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
1269 |
1276 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP208 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
1277 |
1289 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP209 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
1290 |
1297 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP210 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
1298 |
1310 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP211 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
1311 |
1318 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP212 |
CLAIM-DENIED-INDICATOR |
X(1) |
1319 |
1319 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP213 |
COPAY-WAIVED-IND |
X(1) |
1320 |
1320 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP214 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
1321 |
1370 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP216 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
1371 |
1383 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP217 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
1384 |
1391 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP218 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
1392 |
1404 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP219 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
1405 |
1412 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP220 |
MEDICAID-AMOUNT-PAID-DSH |
S9(11)V99 |
1413 |
1425 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP221 |
HEALTH-HOME-PROVIDER-NPI |
X(10) |
1426 |
1435 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP222 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
1436 |
1447 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP223 |
OPERATING-PROV-TAXONOMY |
X(12) |
1448 |
1459 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP224 |
UNDER-DIRECTION-OF-PROV-NPI |
X(10) |
1460 |
1469 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP225 |
UNDER-DIRECTION-OF-PROV-TAXONOMY |
X(12) |
1470 |
1481 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP226 |
UNDER-SUPERVISION-OF-PROV-NPI |
X(10) |
1482 |
1491 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP227 |
UNDER-SUPERVISION-OF-PROV-TAXONOMY |
X(12) |
1492 |
1503 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP228 |
MEDICARE-PAID-AMT |
S9(11)V99 |
1504 |
1516 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP229 |
STATE-NOTATION |
X(500) |
1517 |
2016 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP289 |
PROV-LOCATION-ID |
X(5) |
2017 |
2021 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP230 |
FILLER |
X(79) |
2022 |
2100 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| CIP231 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP232 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP233 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP234 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP235 |
ICN-ORIG |
X(50) |
42 |
91 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP236 |
ICN-ADJ |
X(50) |
92 |
141 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP237 |
LINE-NUM-ORIG |
X(3) |
142 |
144 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP238 |
LINE-NUM-ADJ |
X(3) |
145 |
147 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP239 |
LINE-ADJUSTMENT-IND |
X(1) |
148 |
148 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP240 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
149 |
151 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP241 |
SUBMITTER-ID |
X(12) |
152 |
163 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP242 |
CLAIM-LINE-STATUS |
X(3) |
164 |
166 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP243 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
167 |
174 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP244 |
ENDING-DATE-OF-SERVICE |
9(8) |
175 |
182 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP245 |
REVENUE-CODE |
X(4) |
183 |
186 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP248 |
IMMUNIZATION-TYPE |
X(2) |
187 |
188 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP249 |
IP-LT-QUANTITY-OF-SERVICE-ACTUAL |
S9(6)V999 |
189 |
197 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP250 |
IP-LT-QUANTITY-OF-SERVICE-ALLOWED |
S9(6)V999 |
198 |
206 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP251 |
REVENUE-CHARGE |
S9(11)V99 |
207 |
219 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP252 |
ALLOWED-AMT |
S9(11)V99 |
220 |
232 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP253 |
TPL-AMT |
S9(11)V99 |
233 |
245 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP254 |
MEDICAID-PAID-AMT |
S9(11)V99 |
246 |
258 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP255 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
259 |
271 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP256 |
BILLING-UNIT |
X(2) |
272 |
273 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP257 |
TYPE-OF-SERVICE |
X(3) |
274 |
276 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP260 |
SERVICING-PROV-NUM |
X(30) |
277 |
306 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP261 |
SERVICING-PROV-NPI-NUM |
X(10) |
307 |
316 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP262 |
SERVICING-PROV-TAXONOMY |
X(12) |
317 |
328 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP263 |
SERVICING-PROV-TYPE |
X(2) |
329 |
330 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP264 |
SERVICING-PROV-SPECIALTY |
X(2) |
331 |
332 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP265 |
OPERATING-PROV-NPI-NUM |
X(10) |
333 |
342 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP266 |
OTHER-TPL-COLLECTION |
X(3) |
343 |
345 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP267 |
PROV-FACILITY-TYPE |
X(9) |
346 |
354 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP268 |
BENEFIT-TYPE |
X(3) |
355 |
357 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP269 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
358 |
359 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP270 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
360 |
363 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP271 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
364 |
366 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP272 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
367 |
379 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP273 |
STATE-NOTATION |
X(500) |
380 |
879 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP279 |
HCPCS-RATE |
X(14) |
880 |
893 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP284 |
NATIONAL-DRUG-CODE |
X(12) |
894 |
905 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP285 |
NDC-UNIT-OF-MEASURE |
X(2) |
906 |
907 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP278 |
NDC-QUANTITY |
S9(6)V999 |
908 |
916 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP286 |
ADJUDICATION-DATE |
9(8) |
917 |
924 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP287 |
SELF-DIRECTION-TYPE |
X(3) |
925 |
927 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP288 |
PRE-AUTHORIZATION-NUM |
X(18) |
928 |
945 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CIP274 |
FILLER |
X(1155) |
946 |
2100 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| CLT001 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| CLT002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| CLT003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| CLT004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| CLT005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| CLT006 |
FILE-NAME |
X(8) |
32 |
39 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| CLT007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| CLT008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| CLT009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| CLT010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| CLT011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| CLT012 |
SSN-INDICATOR |
X(1) |
67 |
67 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| CLT013 |
TOT-REC-CNT |
9(11) |
68 |
78 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| CLT227 |
SEQUENCE-NUMBER |
X(4) |
79 |
82 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| CLT014 |
STATE-NOTATION |
X(500) |
83 |
582 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| CLT015 |
FILLER |
X(1318) |
583 |
1900 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| CLT016 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT019 |
ICN-ORIG |
X(50) |
22 |
71 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT020 |
ICN-ADJ |
X(50) |
72 |
121 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT021 |
SUBMITTER-ID |
X(12) |
122 |
133 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
134 |
153 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT023 |
CROSSOVER-INDICATOR |
X(1) |
154 |
154 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT024 |
1115A-DEMONSTRATION-IND |
X(1) |
155 |
155 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT025 |
ADJUSTMENT-IND |
X(1) |
156 |
156 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT026 |
ADJUSTMENT-REASON-CODE |
X(3) |
157 |
159 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT027 |
ADMITTING-DIAGNOSIS-CODE |
X(7) |
160 |
166 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT028 |
ADMITTING-DIAGNOSIS-CODE-FLAG |
X(1) |
167 |
167 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT029 |
DIAGNOSIS-CODE-1 |
X(7) |
168 |
174 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT030 |
DIAGNOSIS-CODE-FLAG-1 |
X(1) |
175 |
175 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT031 |
DIAGNOSIS-POA-FLAG-1 |
X(1) |
176 |
176 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT032 |
DIAGNOSIS-CODE-2 |
X(7) |
177 |
183 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT033 |
DIAGNOSIS-CODE-FLAG-2 |
X(1) |
184 |
184 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT034 |
DIAGNOSIS-POA-FLAG-2 |
X(1) |
185 |
185 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT035 |
DIAGNOSIS-CODE-3 |
X(7) |
186 |
192 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT036 |
DIAGNOSIS-CODE-FLAG-3 |
X(1) |
193 |
193 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT037 |
DIAGNOSIS-POA-FLAG-3 |
X(1) |
194 |
194 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT038 |
DIAGNOSIS-CODE-4 |
X(7) |
195 |
201 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT039 |
DIAGNOSIS-CODE-FLAG-4 |
X(1) |
202 |
202 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT040 |
DIAGNOSIS-POA-FLAG-4 |
X(1) |
203 |
203 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT041 |
DIAGNOSIS-CODE-5 |
X(7) |
204 |
210 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT042 |
DIAGNOSIS-CODE-FLAG-5 |
X(1) |
211 |
211 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT043 |
DIAGNOSIS-POA-FLAG-5 |
X(1) |
212 |
212 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT044 |
ADMISSION-DATE |
9(8) |
213 |
220 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT045 |
ADMISSION-HOUR |
X(2) |
221 |
222 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT046 |
DISCHARGE-DATE |
9(8) |
223 |
230 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT047 |
DISCHARGE-HOUR |
X(2) |
231 |
232 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT048 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
233 |
240 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT049 |
ENDING-DATE-OF-SERVICE |
9(8) |
241 |
248 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT050 |
ADJUDICATION-DATE |
9(8) |
249 |
256 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT051 |
MEDICAID-PAID-DATE |
9(8) |
257 |
264 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT052 |
TYPE-OF-CLAIM |
X(1) |
265 |
265 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT053 |
TYPE-OF-BILL |
X(4) |
266 |
269 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT054 |
CLAIM-STATUS |
X(3) |
270 |
272 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT055 |
CLAIM-STATUS-CATEGORY |
X(3) |
273 |
275 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT056 |
SOURCE-LOCATION |
X(2) |
276 |
277 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT057 |
CHECK-NUM |
X(15) |
278 |
292 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT058 |
CHECK-EFF-DATE |
9(8) |
293 |
300 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT059 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
301 |
305 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT060 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
306 |
310 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT061 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
311 |
315 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT062 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
316 |
320 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT063 |
TOT-BILLED-AMT |
S9(11)V99 |
321 |
333 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT064 |
TOT-ALLOWED-AMT |
S9(11)V99 |
334 |
346 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT065 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
347 |
359 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT066 |
TOT-COPAY-AMT |
S9(11)V99 |
360 |
372 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT067 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
373 |
385 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT068 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
386 |
398 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT069 |
TOT-TPL-AMT |
S9(11)V99 |
399 |
411 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT070 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
412 |
424 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT071 |
OTHER-INSURANCE-IND |
X(1) |
425 |
425 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT072 |
OTHER-TPL-COLLECTION |
X(3) |
426 |
428 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT073 |
SERVICE-TRACKING-TYPE |
X(2) |
429 |
430 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT074 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
431 |
443 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT075 |
FIXED-PAYMENT-IND |
X(1) |
444 |
444 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT076 |
FUNDING-CODE |
X(2) |
445 |
446 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT077 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
447 |
448 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT078 |
MEDICARE-COMB-DED-IND |
X(1) |
449 |
449 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT079 |
PROGRAM-TYPE |
X(2) |
450 |
451 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT080 |
PLAN-ID-NUMBER |
X(12) |
452 |
463 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT081 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
464 |
473 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT082 |
PAYMENT-LEVEL-IND |
X(1) |
474 |
474 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT083 |
MEDICARE-REIM-TYPE |
X(2) |
475 |
476 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT084 |
NON-COV-DAYS |
S9(5) |
477 |
481 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT085 |
NON-COV-CHARGES |
S9(11)V99 |
482 |
494 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT086 |
MEDICAID-COV-INPATIENT-DAYS |
S9(5) |
495 |
499 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT087 |
CLAIM-LINE-COUNT |
9(4) |
500 |
503 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT090 |
FORCED-CLAIM-IND |
X(1) |
504 |
504 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT091 |
HEALTH-CARE-ACQUIRED-CONDITION-IND |
X(1) |
505 |
505 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT092 |
OCCURRENCE-CODE-01 |
X(2) |
506 |
507 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT093 |
OCCURRENCE-CODE-02 |
X(2) |
508 |
509 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT094 |
OCCURRENCE-CODE-03 |
X(2) |
510 |
511 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT095 |
OCCURRENCE-CODE-04 |
X(2) |
512 |
513 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT096 |
OCCURRENCE-CODE-05 |
X(2) |
514 |
515 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT097 |
OCCURRENCE-CODE-06 |
X(2) |
516 |
517 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT098 |
OCCURRENCE-CODE-07 |
X(2) |
518 |
519 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT099 |
OCCURRENCE-CODE-08 |
X(2) |
520 |
521 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT100 |
OCCURRENCE-CODE-09 |
X(2) |
522 |
523 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT101 |
OCCURRENCE-CODE-10 |
X(2) |
524 |
525 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT102 |
OCCURRENCE-CODE-EFF-DATE-01 |
9(8) |
526 |
533 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT103 |
OCCURRENCE-CODE-EFF-DATE-02 |
9(8) |
534 |
541 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT104 |
OCCURRENCE-CODE-EFF-DATE-03 |
9(8) |
542 |
549 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT105 |
OCCURRENCE-CODE-EFF-DATE-04 |
9(8) |
550 |
557 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT106 |
OCCURRENCE-CODE-EFF-DATE-05 |
9(8) |
558 |
565 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT107 |
OCCURRENCE-CODE-EFF-DATE-06 |
9(8) |
566 |
573 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT108 |
OCCURRENCE-CODE-EFF-DATE-07 |
9(8) |
574 |
581 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT109 |
OCCURRENCE-CODE-EFF-DATE-08 |
9(8) |
582 |
589 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT110 |
OCCURRENCE-CODE-EFF-DATE-09 |
9(8) |
590 |
597 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT111 |
OCCURRENCE-CODE-EFF-DATE-10 |
9(8) |
598 |
605 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT112 |
OCCURRENCE-CODE-END-DATE-01 |
9(8) |
606 |
613 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT113 |
OCCURRENCE-CODE-END-DATE-02 |
9(8) |
614 |
621 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT114 |
OCCURRENCE-CODE-END-DATE-03 |
9(8) |
622 |
629 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT115 |
OCCURRENCE-CODE-END-DATE-04 |
9(8) |
630 |
637 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT116 |
OCCURRENCE-CODE-END-DATE-05 |
9(8) |
638 |
645 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT117 |
OCCURRENCE-CODE-END-DATE-06 |
9(8) |
646 |
653 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT118 |
OCCURRENCE-CODE-END-DATE-07 |
9(8) |
654 |
661 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT119 |
OCCURRENCE-CODE-END-DATE-08 |
9(8) |
662 |
669 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT120 |
OCCURRENCE-CODE-END-DATE-09 |
9(8) |
670 |
677 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT121 |
OCCURRENCE-CODE-END-DATE-10 |
9(8) |
678 |
685 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT122 |
PATIENT-CONTROL-NUM |
X(20) |
686 |
705 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT123 |
ELIGIBLE-LAST-NAME |
X(30) |
706 |
735 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT124 |
ELIGIBLE-FIRST-NAME |
X(30) |
736 |
765 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT125 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
766 |
766 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT126 |
DATE-OF-BIRTH |
9(8) |
767 |
774 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT127 |
HEALTH-HOME-PROV-IND |
X(1) |
775 |
775 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT128 |
WAIVER-TYPE |
X(2) |
776 |
777 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT129 |
WAIVER-ID |
X(20) |
778 |
797 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT130 |
BILLING-PROV-NUM |
X(30) |
798 |
827 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT131 |
BILLING-PROV-NPI-NUM |
X(10) |
828 |
837 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT132 |
BILLING-PROV-TAXONOMY |
X(12) |
838 |
849 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT133 |
BILLING-PROV-TYPE |
X(2) |
850 |
851 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT134 |
BILLING-PROV-SPECIALTY |
X(2) |
852 |
853 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT135 |
REFERRING-PROV-NUM |
X(30) |
854 |
883 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT136 |
REFERRING-PROV-NPI-NUM |
X(10) |
884 |
893 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT137 |
REFERRING-PROV-TAXONOMY |
X(12) |
894 |
905 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT138 |
REFERRING-PROV-TYPE |
X(2) |
906 |
907 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT139 |
REFERRING-PROV-SPECIALTY |
X(2) |
908 |
909 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT140 |
MEDICARE-HIC-NUM |
X(12) |
910 |
921 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT141 |
PATIENT-STATUS |
X(2) |
922 |
923 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT143 |
BMI |
S9(5)V9 |
924 |
929 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT144 |
REMITTANCE-NUM |
X(30) |
930 |
959 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT145 |
LTC-RCP-LIAB-AMT |
S9(11)V99 |
960 |
972 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT146 |
DAILY-RATE |
S9(5)V99 |
973 |
979 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT147 |
ICF-IID-DAYS |
S9(5) |
980 |
984 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT148 |
LEAVE-DAYS |
S9(5) |
985 |
989 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT149 |
NURSING-FACILITY-DAYS |
S9(5) |
990 |
994 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT150 |
SPLIT-CLAIM-IND |
X(1) |
995 |
995 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT151 |
BORDER-STATE-IND |
X(1) |
996 |
996 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT153 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
997 |
1009 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT154 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
1010 |
1017 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT155 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
1018 |
1030 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT156 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
1031 |
1038 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT157 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
1039 |
1051 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT158 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
1052 |
1059 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT159 |
CLAIM-DENIED-INDICATOR |
X(1) |
1060 |
1060 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT160 |
COPAY-WAIVED-IND |
X(1) |
1061 |
1061 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT161 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
1062 |
1111 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT163 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
1112 |
1124 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT164 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
1125 |
1132 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT165 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
1133 |
1145 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT166 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
1146 |
1153 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT167 |
HEALTH-HOME-PROVIDER-NPI |
X(12) |
1154 |
1165 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT168 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
1166 |
1177 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT169 |
UNDER-DIRECTION-OF-PROV-NPI |
X(12) |
1178 |
1189 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT170 |
UNDER-DIRECTION-OF-PROV-TAXONOMY |
X(12) |
1190 |
1201 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT171 |
UNDER-SUPERVISION-OF-PROV-NPI |
X(12) |
1202 |
1213 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT172 |
UNDER-SUPERVISION-OF-PROV-TAXONOMY |
X(12) |
1214 |
1225 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT174 |
ADMITTING-PROV-NPI-NUM |
X(10) |
1226 |
1235 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT175 |
ADMITTING-PROV-NUM |
X(30) |
1236 |
1265 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT176 |
ADMITTING-PROV-SPECIALTY |
X(2) |
1266 |
1267 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT177 |
ADMITTING-PROV-TAXONOMY |
X(12) |
1268 |
1279 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT178 |
ADMITTING-PROV-TYPE |
X(2) |
1280 |
1281 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT179 |
MEDICARE-PAID-AMT |
S9(11)V99 |
1282 |
1294 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT173 |
STATE-NOTATION |
X(500) |
1295 |
1794 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT237 |
PROV-LOCATION-ID |
X(5) |
1795 |
1799 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT183 |
FILLER |
X(101) |
1800 |
1900 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| CLT184 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT185 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT186 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT187 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT188 |
ICN-ORIG |
X(50) |
42 |
91 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT189 |
ICN-ADJ |
X(50) |
92 |
141 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT190 |
LINE-NUM-ORIG |
X(3) |
142 |
144 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT191 |
LINE-NUM-ADJ |
X(3) |
145 |
147 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT192 |
LINE-ADJUSTMENT-IND |
X(1) |
148 |
148 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT193 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
149 |
151 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT194 |
SUBMITTER-ID |
X(12) |
152 |
163 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT195 |
CLAIM-LINE-STATUS |
X(3) |
164 |
166 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT196 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
167 |
174 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT197 |
ENDING-DATE-OF-SERVICE |
9(8) |
175 |
182 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT198 |
REVENUE-CODE |
X(4) |
183 |
186 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT201 |
IMMUNIZATION-TYPE |
X(2) |
187 |
188 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT202 |
IP-LT-QUANTITY-OF-SERVICE-ACTUAL |
S9(6)V999 |
189 |
197 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT203 |
IP-LT-QUANTITY-OF-SERVICE-ALLOWED |
S9(6)V999 |
198 |
206 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT204 |
REVENUE-CHARGE |
S9(11)V99 |
207 |
219 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT205 |
ALLOWED-AMT |
S9(11)V99 |
220 |
232 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT206 |
TPL-AMT |
S9(11)V99 |
233 |
245 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT207 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
246 |
258 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT208 |
MEDICAID-PAID-AMT |
S9(11)V99 |
259 |
271 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT209 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
272 |
284 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT210 |
BILLING-UNIT |
X(2) |
285 |
286 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT211 |
TYPE-OF-SERVICE |
X(3) |
287 |
289 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT212 |
SERVICING-PROV-NUM |
X(30) |
290 |
319 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT213 |
SERVICING-PROV-NPI-NUM |
X(10) |
320 |
329 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT214 |
SERVICING-PROV-TAXONOMY |
X(12) |
330 |
341 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT215 |
SERVICING-PROV-TYPE |
X(2) |
342 |
343 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT216 |
SERVICING-PROV-SPECIALTY |
X(2) |
344 |
345 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT217 |
OTHER-TPL-COLLECTION |
X(3) |
346 |
348 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT218 |
BENEFIT-TYPE |
X(3) |
349 |
351 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT219 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
352 |
353 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT221 |
PROV-FACILITY-TYPE |
X(9) |
354 |
362 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT224 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
363 |
366 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT225 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
367 |
369 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT226 |
STATE-NOTATION |
X(500) |
370 |
869 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT228 |
NATIONAL-DRUG-CODE |
X(12) |
870 |
881 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT229 |
NDC-UNIT-OF-MEASURE |
X(2) |
882 |
883 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT230 |
NDC-QUANTITY |
S9(6)V999 |
884 |
892 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT231 |
HCPCS-RATE |
X(14) |
893 |
906 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT233 |
ADJUDICATION-DATE |
9(8) |
907 |
914 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT234 |
SELF-DIRECTION-TYPE |
X(3) |
915 |
917 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT235 |
PRE-AUTHORIZATION-NUM |
X(18) |
918 |
935 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| CLT238 |
FILLER |
X(965) |
936 |
1900 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| COT001 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| COT002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| COT003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| COT004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| COT005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| COT006 |
FILE-NAME |
X(8) |
32 |
39 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| COT007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| COT008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| COT009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| COT010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| COT011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| COT012 |
SSN-INDICATOR |
X(1) |
67 |
67 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| COT013 |
TOT-REC-CNT |
9(11) |
68 |
78 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| COT216 |
SEQUENCE-NUMBER |
X(4) |
79 |
82 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| COT014 |
STATE-NOTATION |
X(500) |
83 |
582 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| COT015 |
FILLER |
X(1168) |
583 |
1750 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| COT016 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT019 |
ICN-ORIG |
X(50) |
22 |
71 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT020 |
ICN-ADJ |
X(50) |
72 |
121 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT021 |
SUBMITTER-ID |
X(12) |
122 |
133 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
134 |
153 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT023 |
CROSSOVER-INDICATOR |
X(1) |
154 |
154 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT024 |
1115A-DEMONSTRATION-IND |
X(1) |
155 |
155 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT025 |
ADJUSTMENT-IND |
X(1) |
156 |
156 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT026 |
ADJUSTMENT-REASON-CODE |
X(3) |
157 |
159 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT027 |
DIAGNOSIS-CODE-1 |
X(7) |
160 |
166 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT028 |
DIAGNOSIS-CODE-FLAG-1 |
X(1) |
167 |
167 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT029 |
DIAGNOSIS-POA-FLAG-1 |
X(1) |
168 |
168 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT030 |
DIAGNOSIS-CODE-2 |
X(7) |
169 |
175 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT031 |
DIAGNOSIS-CODE-FLAG-2 |
X(1) |
176 |
176 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT032 |
DIAGNOSIS-POA-FLAG-2 |
X(1) |
177 |
177 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT033 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
178 |
185 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT034 |
ENDING-DATE-OF-SERVICE |
9(8) |
186 |
193 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT035 |
ADJUDICATION-DATE |
9(8) |
194 |
201 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT036 |
MEDICAID-PAID-DATE |
9(8) |
202 |
209 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT037 |
TYPE-OF-CLAIM |
X(1) |
210 |
210 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT038 |
TYPE-OF-BILL |
X(4) |
211 |
214 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT039 |
CLAIM-STATUS |
X(3) |
215 |
217 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT040 |
CLAIM-STATUS-CATEGORY |
X(3) |
218 |
220 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT041 |
SOURCE-LOCATION |
X(2) |
221 |
222 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT042 |
CHECK-NUM |
X(15) |
223 |
237 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT043 |
CHECK-EFF-DATE |
9(8) |
238 |
245 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT044 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
246 |
250 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT045 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
251 |
255 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT046 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
256 |
260 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT047 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
261 |
265 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT048 |
TOT-BILLED-AMT |
S9(11)V99 |
266 |
278 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT049 |
TOT-ALLOWED-AMT |
S9(11)V99 |
279 |
291 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT050 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
292 |
304 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT051 |
TOT-COPAY-AMT |
S9(11)V99 |
305 |
317 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT052 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
318 |
330 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT053 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
331 |
343 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT054 |
TOT-TPL-AMT |
S9(11)V99 |
344 |
356 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT056 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
357 |
369 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT057 |
OTHER-INSURANCE-IND |
X(1) |
370 |
370 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT058 |
OTHER-TPL-COLLECTION |
X(3) |
371 |
373 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT059 |
SERVICE-TRACKING-TYPE |
X(2) |
374 |
375 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT060 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
376 |
388 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT061 |
FIXED-PAYMENT-IND |
X(1) |
389 |
389 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT062 |
FUNDING-CODE |
X(2) |
390 |
391 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT063 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
392 |
393 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT064 |
MEDICARE-COMB-DED-IND |
X(1) |
394 |
394 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT065 |
PROGRAM-TYPE |
X(2) |
395 |
396 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT066 |
PLAN-ID-NUMBER |
X(12) |
397 |
408 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT067 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
409 |
418 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT068 |
PAYMENT-LEVEL-IND |
X(1) |
419 |
419 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT069 |
MEDICARE-REIM-TYPE |
X(2) |
420 |
421 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT070 |
CLAIM-LINE-COUNT |
9(4) |
422 |
425 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT072 |
FORCED-CLAIM-IND |
X(1) |
426 |
426 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT073 |
HEALTH-CARE-ACQUIRED-CONDITION-IND |
X(1) |
427 |
427 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT074 |
OCCURRENCE-CODE-01 |
X(2) |
428 |
429 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT075 |
OCCURRENCE-CODE-02 |
X(2) |
430 |
431 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT076 |
OCCURRENCE-CODE-03 |
X(2) |
432 |
433 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT077 |
OCCURRENCE-CODE-04 |
X(2) |
434 |
435 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT078 |
OCCURRENCE-CODE-05 |
X(2) |
436 |
437 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT079 |
OCCURRENCE-CODE-06 |
X(2) |
438 |
439 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT080 |
OCCURRENCE-CODE-07 |
X(2) |
440 |
441 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT081 |
OCCURRENCE-CODE-08 |
X(2) |
442 |
443 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT082 |
OCCURRENCE-CODE-09 |
X(2) |
444 |
445 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT083 |
OCCURRENCE-CODE-10 |
X(2) |
446 |
447 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT084 |
OCCURRENCE-CODE-EFF-DATE-01 |
9(8) |
448 |
455 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT085 |
OCCURRENCE-CODE-EFF-DATE-02 |
9(8) |
456 |
463 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT086 |
OCCURRENCE-CODE-EFF-DATE-03 |
9(8) |
464 |
471 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT087 |
OCCURRENCE-CODE-EFF-DATE-04 |
9(8) |
472 |
479 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT088 |
OCCURRENCE-CODE-EFF-DATE-05 |
9(8) |
480 |
487 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT089 |
OCCURRENCE-CODE-EFF-DATE-06 |
9(8) |
488 |
495 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT090 |
OCCURRENCE-CODE-EFF-DATE-07 |
9(8) |
496 |
503 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT091 |
OCCURRENCE-CODE-EFF-DATE-08 |
9(8) |
504 |
511 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT092 |
OCCURRENCE-CODE-EFF-DATE-09 |
9(8) |
512 |
519 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT093 |
OCCURRENCE-CODE-EFF-DATE-10 |
9(8) |
520 |
527 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT094 |
OCCURRENCE-CODE-END-DATE-01 |
9(8) |
528 |
535 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT095 |
OCCURRENCE-CODE-END-DATE-02 |
9(8) |
536 |
543 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT096 |
OCCURRENCE-CODE-END-DATE-03 |
9(8) |
544 |
551 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT097 |
OCCURRENCE-CODE-END-DATE-04 |
9(8) |
552 |
559 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT098 |
OCCURRENCE-CODE-END-DATE-05 |
9(8) |
560 |
567 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT099 |
OCCURRENCE-CODE-END-DATE-06 |
9(8) |
568 |
575 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT100 |
OCCURRENCE-CODE-END-DATE-07 |
9(8) |
576 |
583 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT101 |
OCCURRENCE-CODE-END-DATE-08 |
9(8) |
584 |
591 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT102 |
OCCURRENCE-CODE-END-DATE-09 |
9(8) |
592 |
599 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT103 |
OCCURRENCE-CODE-END-DATE-10 |
9(8) |
600 |
607 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT104 |
PATIENT-CONTROL-NUM |
X(20) |
608 |
627 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT105 |
ELIGIBLE-LAST-NAME |
X(30) |
628 |
657 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT106 |
ELIGIBLE-FIRST-NAME |
X(30) |
658 |
687 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT107 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
688 |
688 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT108 |
DATE-OF-BIRTH |
9(8) |
689 |
696 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT109 |
HEALTH-HOME-PROV-IND |
X(1) |
697 |
697 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT110 |
WAIVER-TYPE |
X(2) |
698 |
699 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT111 |
WAIVER-ID |
X(20) |
700 |
719 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT112 |
BILLING-PROV-NUM |
X(30) |
720 |
749 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT113 |
BILLING-PROV-NPI-NUM |
X(10) |
750 |
759 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT114 |
BILLING-PROV-TAXONOMY |
X(12) |
760 |
771 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT115 |
BILLING-PROV-TYPE |
X(2) |
772 |
773 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT116 |
BILLING-PROV-SPECIALTY |
X(2) |
774 |
775 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT117 |
REFERRING-PROV-NUM |
X(30) |
776 |
805 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT118 |
REFERRING-PROV-NPI-NUM |
X(10) |
806 |
815 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT119 |
REFERRING-PROV-TAXONOMY |
X(12) |
816 |
827 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT120 |
REFERRING-PROV-TYPE |
X(2) |
828 |
829 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT121 |
REFERRING-PROV-SPECIALTY |
X(2) |
830 |
831 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT122 |
MEDICARE-HIC-NUM |
X(12) |
832 |
843 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT123 |
PLACE-OF-SERVICE |
X(2) |
844 |
845 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT125 |
BMI |
S9(5)V9 |
846 |
851 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT126 |
REMITTANCE-NUM |
X(30) |
852 |
881 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT127 |
DAILY-RATE |
S9(5)V99 |
882 |
888 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT128 |
BORDER-STATE-IND |
X(1) |
889 |
889 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT130 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
890 |
902 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT131 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
903 |
910 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT132 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
911 |
923 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT133 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
924 |
931 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT134 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
932 |
944 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT135 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
945 |
952 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT136 |
CLAIM-DENIED-INDICATOR |
X(1) |
953 |
953 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT137 |
COPAY-WAIVED-IND |
X(1) |
954 |
954 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT138 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
955 |
1004 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT140 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
1005 |
1017 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT141 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
1018 |
1025 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT142 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
1026 |
1038 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT143 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
1039 |
1046 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT144 |
DATE-CAPITATED-AMOUNT-REQUESTED |
9(8) |
1047 |
1054 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT145 |
CAPITATED-PAYMENT-AMT-REQUESTED |
S9(11)V99 |
1055 |
1067 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT146 |
HEALTH-HOME-PROVIDER-NPI |
X(10) |
1068 |
1077 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT147 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
1078 |
1089 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT148 |
UNDER-DIRECTION-OF-PROV-NPI |
X(10) |
1090 |
1099 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT149 |
UNDER-DIRECTION-OF-PROV-TAXONOMY |
X(12) |
1100 |
1111 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT150 |
UNDER-SUPERVISION-OF-PROV-NPI |
X(10) |
1112 |
1121 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT151 |
UNDER-SUPERVISION-OF-PROV-TAXONOMY |
X(12) |
1122 |
1133 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT152 |
STATE-NOTATION |
X(500) |
1134 |
1633 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT226 |
PROV-LOCATION-ID |
X(5) |
1634 |
1638 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT153 |
FILLER |
X(112) |
1639 |
1750 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| COT154 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT155 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT156 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT157 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT158 |
ICN-ORIG |
X(50) |
42 |
91 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT159 |
ICN-ADJ |
X(50) |
92 |
141 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT160 |
LINE-NUM-ORIG |
X(3) |
142 |
144 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT161 |
LINE-NUM-ADJ |
X(3) |
145 |
147 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT162 |
LINE-ADJUSTMENT-IND |
X(1) |
148 |
148 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT163 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
149 |
151 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT164 |
SUBMITTER-ID |
X(12) |
152 |
163 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT165 |
CLAIM-LINE-STATUS |
X(3) |
164 |
166 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT166 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
167 |
174 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT167 |
ENDING-DATE-OF-SERVICE |
9(8) |
175 |
182 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT168 |
REVENUE-CODE |
X(4) |
183 |
186 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT169 |
PROCEDURE-CODE |
X(8) |
187 |
194 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT170 |
PROCEDURE-CODE-DATE |
9(8) |
195 |
202 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT171 |
PROCEDURE-CODE-FLAG |
X(2) |
203 |
204 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT172 |
PROCEDURE-CODE-MOD-1 |
X(2) |
205 |
206 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT173 |
IMMUNIZATION-TYPE |
X(2) |
207 |
208 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT174 |
BILLED-AMT |
S9(11)V99 |
209 |
221 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT175 |
ALLOWED-AMT |
S9(11)V99 |
222 |
234 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT176 |
COPAY-AMT |
S9(11)V99 |
235 |
247 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT177 |
TPL-AMT |
S9(11)V99 |
248 |
260 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT178 |
MEDICAID-PAID-AMT |
S9(11)V99 |
261 |
273 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT179 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
274 |
286 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT182 |
MEDICARE-PAID-AMT |
S9(11)V99 |
287 |
299 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT183 |
OT-RX-CLAIM-QUANTITY-ACTUAL |
S9(6)V999 |
300 |
308 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT184 |
OT-RX-CLAIM-QUANTITY-ALLOWED |
S9(6)V999 |
309 |
317 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT186 |
TYPE-OF-SERVICE |
X(3) |
318 |
320 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT187 |
HCBS-SERVICE-CODE |
X(1) |
321 |
321 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT188 |
HCBS-TAXONOMY |
X(5) |
322 |
326 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT189 |
SERVICING-PROV-NUM |
X(30) |
327 |
356 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT190 |
SERVICING-PROV-NPI-NUM |
X(10) |
357 |
366 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT191 |
SERVICING-PROV-TAXONOMY |
X(12) |
367 |
378 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT192 |
SERVICING-PROV-TYPE |
X(2) |
379 |
380 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT193 |
SERVICING-PROV-SPECIALTY |
X(2) |
381 |
382 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT194 |
OTHER-TPL-COLLECTION |
X(3) |
383 |
385 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT195 |
TOOTH-DESIGNATION-SYSTEM |
X(2) |
386 |
387 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT196 |
TOOTH-NUM |
X(2) |
388 |
389 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT197 |
TOOTH-QUAD-CODE |
X(2) |
390 |
391 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT198 |
TOOTH-SURFACE-CODE |
X(1) |
392 |
392 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT199 |
ORIGINATION-ADDR-LN1 |
X(60) |
393 |
452 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT200 |
ORIGINATION-ADDR-LN2 |
X(60) |
453 |
512 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT201 |
ORIGINATION-CITY |
X(28) |
513 |
540 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT202 |
ORIGINATION-STATE |
X(2) |
541 |
542 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT203 |
ORIGINATION-ZIP-CODE |
X(9) |
543 |
551 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT204 |
DESTINATION-ADDR-LN1 |
X(60) |
552 |
611 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT205 |
DESTINATION-ADDR-LN2 |
X(60) |
612 |
671 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT206 |
DESTINATION-CITY |
X(28) |
672 |
699 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT207 |
DESTINATION-STATE |
X(2) |
700 |
701 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT208 |
DESTINATION-ZIP-CODE |
X(9) |
702 |
710 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT209 |
BENEFIT-TYPE |
X(3) |
711 |
713 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT210 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
714 |
715 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT211 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
716 |
719 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT212 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
720 |
722 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT213 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
723 |
735 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT214 |
STATE-NOTATION |
X(500) |
736 |
1235 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT217 |
NATIONAL-DRUG-CODE |
X(12) |
1236 |
1247 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT227 |
PROCEDURE-CODE-MOD-2 |
X(2) |
1248 |
1249 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT218 |
PROCEDURE-CODE-MOD-3 |
X(2) |
1250 |
1251 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT219 |
PROCEDURE-CODE-MOD-4 |
X(2) |
1252 |
1253 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT220 |
HCPCS-RATE |
X(14) |
1254 |
1267 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT221 |
ADJUDICATION-DATE |
9(8) |
1268 |
1275 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT222 |
SELF-DIRECTION-TYPE |
X(3) |
1276 |
1278 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT223 |
PRE-AUTHORIZATION-NUM |
X(18) |
1279 |
1296 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT224 |
NDC-UNIT-OF-MEASURE |
X(2) |
1297 |
1298 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT225 |
NDC-QUANTITY |
S9(6)V999 |
1299 |
1307 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| COT215 |
FILLER |
X(443) |
1308 |
1750 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| CRX001 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| CRX002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| CRX003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| CRX004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| CRX005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| CRX006 |
FILE-NAME |
X(8) |
32 |
39 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| CRX007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| CRX008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| CRX009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| CRX010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| CRX011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| CRX012 |
SSN-INDICATOR |
X(1) |
67 |
67 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| CRX013 |
TOT-REC-CNT |
9(11) |
68 |
78 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| CRX155 |
SEQUENCE-NUMBER |
X(4) |
79 |
82 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| CRX014 |
STATE-NOTATION |
X(500) |
83 |
582 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| CRX015 |
FILLER |
X(868) |
583 |
1450 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| CRX016 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX019 |
ICN-ORIG |
X(50) |
22 |
71 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX020 |
ICN-ADJ |
X(50) |
72 |
121 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX021 |
SUBMITTER-ID |
X(12) |
122 |
133 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
134 |
153 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX023 |
CROSSOVER-INDICATOR |
X(1) |
154 |
154 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX024 |
1115A-DEMONSTRATION-IND |
X(1) |
155 |
155 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX025 |
ADJUSTMENT-IND |
X(1) |
156 |
156 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX026 |
ADJUSTMENT-REASON-CODE |
X(3) |
157 |
159 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX027 |
ADJUDICATION-DATE |
9(8) |
160 |
167 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX028 |
MEDICAID-PAID-DATE |
9(8) |
168 |
175 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX029 |
TYPE-OF-CLAIM |
X(1) |
176 |
176 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX030 |
CLAIM-STATUS |
X(3) |
177 |
179 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX031 |
CLAIM-STATUS-CATEGORY |
X(3) |
180 |
182 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX032 |
SOURCE-LOCATION |
X(2) |
183 |
184 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX033 |
CHECK-NUM |
X(15) |
185 |
199 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX034 |
CHECK-EFF-DATE |
9(8) |
200 |
207 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX035 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
208 |
212 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX036 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
213 |
217 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX037 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
218 |
222 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX038 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
223 |
227 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX039 |
TOT-BILLED-AMT |
S9(11)V99 |
228 |
240 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX040 |
TOT-ALLOWED-AMT |
S9(11)V99 |
241 |
253 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX041 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
254 |
266 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX042 |
TOT-COPAY-AMT |
S9(11)V99 |
267 |
279 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX043 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
280 |
292 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX044 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
293 |
305 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX045 |
TOT-TPL-AMT |
S9(11)V99 |
306 |
318 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX047 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
319 |
331 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX048 |
OTHER-INSURANCE-IND |
X(1) |
332 |
332 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX049 |
OTHER-TPL-COLLECTION |
X(3) |
333 |
335 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX050 |
SERVICE-TRACKING-TYPE |
X(2) |
336 |
337 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX051 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
338 |
350 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX052 |
FIXED-PAYMENT-IND |
X(1) |
351 |
351 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX053 |
FUNDING-CODE |
X(2) |
352 |
353 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX054 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
354 |
355 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX055 |
PROGRAM-TYPE |
X(2) |
356 |
357 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX056 |
PLAN-ID-NUMBER |
X(12) |
358 |
369 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX057 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
370 |
379 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX058 |
PAYMENT-LEVEL-IND |
X(1) |
380 |
380 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX059 |
MEDICARE-REIM-TYPE |
X(2) |
381 |
382 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX060 |
CLAIM-LINE-COUNT |
9(4) |
383 |
386 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX061 |
FORCED-CLAIM-IND |
X(1) |
387 |
387 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX062 |
PATIENT-CONTROL-NUM |
X(20) |
388 |
407 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX063 |
ELIGIBLE-LAST-NAME |
X(30) |
408 |
437 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX064 |
ELIGIBLE-FIRST-NAME |
X(30) |
438 |
467 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX065 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
468 |
468 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX066 |
DATE-OF-BIRTH |
9(8) |
469 |
476 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX067 |
HEALTH-HOME-PROV-IND |
X(1) |
477 |
477 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX068 |
WAIVER-TYPE |
X(2) |
478 |
479 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX069 |
WAIVER-ID |
X(20) |
480 |
499 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX070 |
BILLING-PROV-NUM |
X(30) |
500 |
529 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX071 |
BILLING-PROV-NPI-NUM |
X(10) |
530 |
539 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX072 |
BILLING-PROV-TAXONOMY |
X(12) |
540 |
551 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX073 |
BILLING-PROV-SPECIALTY |
X(2) |
552 |
553 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX074 |
PRESCRIBING-PROV-NUM |
X(30) |
554 |
583 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX075 |
PRESCRIBING-PROV-NPI-NUM |
X(10) |
584 |
593 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX076 |
PRESCRIBING-PROV-TAXONOMY |
X(12) |
594 |
605 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX077 |
PRESCRIBING-PROV-TYPE |
X(2) |
606 |
607 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX078 |
PRESCRIBING-PROV-SPECIALTY |
X(2) |
608 |
609 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX079 |
MEDICARE-HIC-NUM |
X(12) |
610 |
621 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX081 |
REMITTANCE-NUM |
X(30) |
622 |
651 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX082 |
BORDER-STATE-IND |
X(1) |
652 |
652 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX084 |
DATE-PRESCRIBED |
9(8) |
653 |
660 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX085 |
PRESCRIPTION-FILL-DATE |
9(8) |
661 |
668 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX086 |
COMPOUND-DRUG-IND |
X(1) |
669 |
669 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX087 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
670 |
682 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX089 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
683 |
695 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX090 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
696 |
703 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX088 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
704 |
711 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX092 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
712 |
724 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX093 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
725 |
732 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX094 |
CLAIM-DENIED-INDICATOR |
X(1) |
733 |
733 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX095 |
COPAY-WAIVED-IND |
X(1) |
734 |
734 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX096 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
735 |
784 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX098 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
785 |
797 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX099 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
798 |
805 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX100 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
806 |
818 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX101 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
819 |
826 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX102 |
DISPENSING-PRESCRIPTION-DRUG-PROV-NPI |
X(10) |
827 |
836 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX103 |
DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY |
X(12) |
837 |
848 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX104 |
HEALTH-HOME-PROVIDER-NPI |
X(10) |
849 |
858 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX105 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
859 |
870 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX106 |
STATE-NOTATION |
X(500) |
871 |
1370 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX156 |
DISPENSING-PRESCRIPTION-DRUG-PROV-NUM |
X(30) |
1371 |
1400 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX160 |
MEDICARE-COMB-DED-IND |
X(1) |
1401 |
1401 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX161 |
PROV-LOCATION-ID |
X(5) |
1402 |
1406 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX107 |
FILLER |
X(44) |
1407 |
1450 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| CRX108 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX109 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX110 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX111 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX112 |
ICN-ORIG |
X(50) |
42 |
91 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX113 |
ICN-ADJ |
X(50) |
92 |
141 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX114 |
LINE-NUM-ORIG |
X(3) |
142 |
144 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX115 |
LINE-NUM-ADJ |
X(3) |
145 |
147 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX116 |
LINE-ADJUSTMENT-IND |
X(1) |
148 |
148 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX117 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
149 |
151 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX118 |
SUBMITTER-ID |
X(12) |
152 |
163 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX119 |
CLAIM-LINE-STATUS |
X(3) |
164 |
166 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX120 |
NATIONAL-DRUG-CODE |
X(12) |
167 |
178 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX121 |
BILLED-AMT |
S9(11)V99 |
179 |
191 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX122 |
ALLOWED-AMT |
S9(11)V99 |
192 |
204 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX123 |
COPAY-AMT |
S9(5)V99 |
205 |
211 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX124 |
TPL-AMT |
S9(11)V99 |
212 |
224 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX125 |
MEDICAID-PAID-AMT |
S9(11)V99 |
225 |
237 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX126 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
238 |
250 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX127 |
MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
251 |
263 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX128 |
MEDICARE-COINS-AMT |
S9(11)V99 |
264 |
276 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX129 |
MEDICARE-PAID-AMT |
S9(11)V99 |
277 |
289 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX131 |
OT-RX-CLAIM-QUANTITY-ALLOWED |
S9(6)V999 |
290 |
298 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX132 |
OT-RX-CLAIM-QUANTITY-ACTUAL |
S9(6)V999 |
299 |
307 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX133 |
UNIT-OF-MEASURE |
X(2) |
308 |
309 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX134 |
TYPE-OF-SERVICE |
X(3) |
310 |
312 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX135 |
HCBS-SERVICE-CODE |
X(1) |
313 |
313 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX136 |
HCBS-TAXONOMY |
X(5) |
314 |
318 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX137 |
OTHER-TPL-COLLECTION |
X(3) |
319 |
321 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX138 |
DAYS-SUPPLY |
S9(5) |
322 |
326 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX139 |
NEW-REFILL-IND |
X(2) |
327 |
328 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX140 |
BRAND-GENERIC-IND |
X(1) |
329 |
329 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX141 |
DISPENSE-FEE |
S9(6)V99 |
330 |
337 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX142 |
PRESCRIPTION-NUM |
X(12) |
338 |
349 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX143 |
DRUG-UTILIZATION-CODE |
X(6) |
350 |
355 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX144 |
DTL-METRIC-DEC-QTY |
S9(7)V999 |
356 |
365 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX145 |
COMPOUND-DOSAGE-FORM |
X(2) |
366 |
367 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX146 |
REBATE-ELIGIBLE-INDICATOR |
X(1) |
368 |
368 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX147 |
IMMUNIZATION-TYPE |
X(2) |
369 |
370 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX148 |
BENEFIT-TYPE |
X(3) |
371 |
373 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX149 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
374 |
375 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX150 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
376 |
379 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX151 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
380 |
382 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX152 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
383 |
395 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX153 |
STATE-NOTATION |
X(500) |
396 |
895 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX157 |
ADJUDICATION-DATE |
9(8) |
896 |
903 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX158 |
SELF-DIRECTION-TYPE |
X(3) |
904 |
906 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX159 |
PRE-AUTHORIZATION-NUM |
X(18) |
907 |
924 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| CRX154 |
FILLER |
X(526) |
925 |
1450 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| ELG001 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| ELG002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| ELG003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| ELG004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| ELG005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| ELG006 |
FILE-NAME |
X(8) |
32 |
39 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| ELG007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| ELG008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| ELG009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| ELG010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| ELG011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| ELG012 |
SSN-INDICATOR |
X(1) |
67 |
67 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| ELG013 |
TOT-REC-CNT |
9(11) |
68 |
78 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| ELG247 |
SEQUENCE-NUMBER |
X(4) |
79 |
82 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| ELG014 |
STATE-NOTATION |
X(500) |
83 |
582 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| ELG015 |
FILLER |
X(418) |
583 |
1000 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| ELG016 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| ELG017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| ELG018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| ELG019 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| ELG020 |
ELIGIBLE-FIRST-NAME |
X(30) |
42 |
71 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| ELG021 |
ELIGIBLE-LAST-NAME |
X(30) |
72 |
101 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| ELG022 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
102 |
102 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| ELG023 |
SEX |
X(1) |
103 |
103 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| ELG024 |
DATE-OF-BIRTH |
9(8) |
104 |
111 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| ELG025 |
DATE-OF-DEATH |
9(8) |
112 |
119 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| ELG026 |
PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE |
9(8) |
120 |
127 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| ELG027 |
PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE |
9(8) |
128 |
135 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| ELG028 |
STATE-NOTATION |
X(500) |
136 |
635 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| ELG029 |
FILLER |
X(365) |
636 |
1000 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| ELG030 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG031 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG032 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG033 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG034 |
MARITAL-STATUS |
X(2) |
42 |
43 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG035 |
MARITAL-STATUS-OTHER-EXPLANATION |
X(50) |
44 |
93 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG036 |
SSN |
9(9) |
94 |
102 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG037 |
SSN-VERIFICATION-FLAG |
X(1) |
103 |
103 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG038 |
INCOME-CODE |
X(2) |
104 |
105 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG039 |
VETERAN-IND |
X(1) |
106 |
106 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG040 |
CITIZENSHIP-IND |
X(1) |
107 |
107 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG041 |
CITIZENSHIP-VERIFICATION-FLAG |
X(1) |
108 |
108 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG042 |
IMMIGRATION-STATUS |
X(1) |
109 |
109 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG043 |
IMMIGRATION-VERIFICATION-FLAG |
X(1) |
110 |
110 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG044 |
IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE |
9(8) |
111 |
118 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG045 |
PRIMARY-LANGUAGE-ENGL-PROF-CODE |
X(1) |
119 |
119 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG046 |
PRIMARY-LANGUAGE-CODE |
X(3) |
120 |
122 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG047 |
HOUSEHOLD-SIZE |
X(2) |
123 |
124 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG049 |
PREGNANCY-IND |
X(1) |
125 |
125 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG050 |
MEDICARE-HIC-NUM |
X(12) |
126 |
137 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG051 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
138 |
149 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG054 |
CHIP-CODE |
X(1) |
150 |
150 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG057 |
VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE |
9(8) |
151 |
158 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG058 |
VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE |
9(8) |
159 |
166 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG059 |
STATE-NOTATION |
X(500) |
167 |
666 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG060 |
FILLER |
X(334) |
667 |
1000 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| ELG061 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| ELG062 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| ELG063 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| ELG064 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| ELG065 |
ELIGIBLE-ADDR-TYPE |
X(2) |
42 |
43 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| ELG066 |
ELIGIBLE-ADDR-LN1 |
X(60) |
44 |
103 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| ELG067 |
ELIGIBLE-ADDR-LN2 |
X(60) |
104 |
163 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| ELG068 |
ELIGIBLE-ADDR-LN3 |
X(60) |
164 |
223 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| ELG069 |
ELIGIBLE-CITY |
X(28) |
224 |
251 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| ELG070 |
ELIGIBLE-STATE |
X(2) |
252 |
253 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| ELG071 |
ELIGIBLE-ZIP-CODE |
X(9) |
254 |
262 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| ELG072 |
ELIGIBLE-COUNTY-CODE |
X(3) |
263 |
265 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| ELG073 |
ELIGIBLE-PHONE-NUM |
X(10) |
266 |
275 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| ELG074 |
TYPE-OF-LIVING-ARRANGEMENT |
X(100) |
276 |
375 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| ELG075 |
ELIGIBLE-ADDR-EFF-DATE |
9(8) |
376 |
383 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| ELG076 |
ELIGIBLE-ADDR-END-DATE |
9(8) |
384 |
391 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| ELG077 |
STATE-NOTATION |
X(500) |
392 |
891 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| ELG078 |
FILLER |
X(109) |
892 |
1000 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| ELG079 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG080 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG081 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG082 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG083 |
MSIS-CASE-NUM |
X(12) |
42 |
53 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG084 |
MEDICAID-BASIS-OF-ELIGIBILITY |
X(2) |
54 |
55 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG085 |
DUAL-ELIGIBLE-CODE |
X(2) |
56 |
57 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG086 |
PRIMARY-ELIGIBILITY-GROUP-IND |
X(1) |
58 |
58 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG087 |
ELIGIBILITY-GROUP |
X(2) |
59 |
60 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG088 |
LEVEL-OF-CARE-STATUS |
X(3) |
61 |
63 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG089 |
SSDI-IND |
X(1) |
64 |
64 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG090 |
SSI-IND |
X(1) |
65 |
65 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG091 |
SSI-STATE-SUPPLEMENT-STATUS-CODE |
X(3) |
66 |
68 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG092 |
SSI-STATUS |
X(3) |
69 |
71 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG093 |
STATE-SPEC-ELIG-GROUP |
X(6) |
72 |
77 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG094 |
CONCEPTION-TO-BIRTH-IND |
X(1) |
78 |
78 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG095 |
ELIGIBILITY-CHANGE-REASON |
X(2) |
79 |
80 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG096 |
MAINTENANCE-ASSISTANCE-STATUS |
X(1) |
81 |
81 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG097 |
RESTRICTED-BENEFITS-CODE |
X(1) |
82 |
82 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG098 |
TANF-CASH-CODE |
X(1) |
83 |
83 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG099 |
ELIGIBILITY-DETERMINANT-EFF-DATE |
9(8) |
84 |
91 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG100 |
ELIGIBILITY-DETERMINANT-END-DATE |
9(8) |
92 |
99 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG101 |
STATE-NOTATION |
X(500) |
100 |
599 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG102 |
FILLER |
X(401) |
600 |
1000 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| ELG103 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| ELG104 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| ELG105 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| ELG106 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| ELG107 |
HEALTH-HOME-SPA-NAME |
X(100) |
42 |
141 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| ELG108 |
HEALTH-HOME-ENTITY-NAME |
X(100) |
142 |
241 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| ELG109 |
HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE |
9(8) |
242 |
249 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| ELG110 |
HEALTH-HOME-SPA-PARTICIPATION-END-DATE |
9(8) |
250 |
257 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| ELG111 |
HEALTH-HOME-ENTITY-EFF-DATE |
9(8) |
258 |
265 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| ELG112 |
STATE-NOTATION |
X(500) |
266 |
765 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| ELG113 |
FILLER |
X(235) |
766 |
1000 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| ELG114 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| ELG115 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| ELG116 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| ELG117 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| ELG118 |
HEALTH-HOME-SPA-NAME |
X(100) |
42 |
141 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| ELG119 |
HEALTH-HOME-ENTITY-NAME |
X(100) |
142 |
241 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| ELG120 |
HEALTH-HOME-PROV-NUM |
X(30) |
242 |
271 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| ELG121 |
HEALTH-HOME-SPA-PROVIDER-EFF-DATE |
9(8) |
272 |
279 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| ELG122 |
HEALTH-HOME-SPA-PROVIDER-END-DATE |
9(8) |
280 |
287 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| ELG123 |
HEALTH-HOME-ENTITY-EFF-DATE |
9(8) |
288 |
295 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| ELG124 |
STATE-NOTATION |
X(500) |
296 |
795 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| ELG125 |
FILLER |
X(205) |
796 |
1000 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| ELG126 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| ELG127 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| ELG128 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| ELG129 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| ELG130 |
HEALTH-HOME-CHRONIC-CONDITION |
X(1) |
42 |
42 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| ELG131 |
HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION |
X(50) |
43 |
92 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| ELG132 |
HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE |
9(8) |
93 |
100 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| ELG133 |
HEALTH-HOME-CHRONIC-CONDITION-END-DATE |
9(8) |
101 |
108 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| ELG134 |
STATE-NOTATION |
X(500) |
109 |
608 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| ELG135 |
FILLER |
X(392) |
609 |
1000 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| ELG136 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| ELG137 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| ELG138 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| ELG139 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| ELG140 |
LOCKIN-PROV-NUM |
X(30) |
42 |
71 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| ELG141 |
LOCKIN-PROV-TYPE |
X(2) |
72 |
73 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| ELG142 |
LOCKIN-EFF-DATE |
9(8) |
74 |
81 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| ELG143 |
LOCKIN-END-DATE |
9(8) |
82 |
89 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| ELG144 |
STATE-NOTATION |
X(500) |
90 |
589 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| ELG145 |
FILLER |
X(411) |
590 |
1000 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| ELG146 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| ELG147 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| ELG148 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| ELG149 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| ELG150 |
MFP-LIVES-WITH-FAMILY |
X(1) |
42 |
42 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| ELG151 |
MFP-QUALIFIED-INSTITUTION |
X(2) |
43 |
44 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| ELG152 |
MFP-QUALIFIED-RESIDENCE |
X(2) |
45 |
46 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| ELG153 |
MFP-REASON-PARTICIPATION-ENDED |
X(2) |
47 |
48 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| ELG154 |
MFP-REINSTITUTIONALIZED-REASON |
X(2) |
49 |
50 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| ELG155 |
MFP-ENROLLMENT-EFF-DATE |
9(8) |
51 |
58 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| ELG156 |
MFP-ENROLLMENT-END-DATE |
9(8) |
59 |
66 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| ELG157 |
STATE-NOTATION |
X(500) |
67 |
566 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| ELG158 |
FILLER |
X(434) |
567 |
1000 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| ELG159 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| ELG160 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| ELG161 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| ELG162 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| ELG163 |
STATE-PLAN-OPTION-TYPE |
X(2) |
42 |
43 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| ELG164 |
STATE-PLAN-OPTION-EFF-DATE |
9(8) |
44 |
51 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| ELG165 |
STATE-PLAN-OPTION-END-DATE |
9(8) |
52 |
59 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| ELG166 |
STATE-NOTATION |
X(500) |
60 |
559 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| ELG167 |
FILLER |
X(441) |
560 |
1000 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| ELG168 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| ELG169 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| ELG170 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| ELG171 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| ELG172 |
WAIVER-ID |
X(20) |
42 |
61 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| ELG173 |
WAIVER-TYPE |
X(2) |
62 |
63 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| ELG174 |
WAIVER-ENROLLMENT-EFF-DATE |
9(8) |
64 |
71 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| ELG175 |
WAIVER-ENROLLMENT-END-DATE |
9(8) |
72 |
79 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| ELG176 |
STATE-NOTATION |
X(500) |
80 |
579 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| ELG177 |
FILLER |
X(421) |
580 |
1000 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| ELG178 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| ELG179 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| ELG180 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| ELG181 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| ELG182 |
LTSS-LEVEL-CARE |
X(1) |
42 |
42 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| ELG183 |
LTSS-PROV-NUM |
X(30) |
43 |
72 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| ELG184 |
LTSS-ELIGIBILITY-EFF-DATE |
9(8) |
73 |
80 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| ELG185 |
LTSS-ELIGIBILITY-END-DATE |
9(8) |
81 |
88 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| ELG186 |
STATE-NOTATION |
X(500) |
89 |
588 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| ELG187 |
FILLER |
X(412) |
589 |
1000 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| ELG188 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| ELG189 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| ELG190 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| ELG191 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| ELG192 |
MANAGED-CARE-PLAN-ID |
X(12) |
42 |
53 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| ELG193 |
ENROLLED-MANAGED-CARE-PLAN-TYPE |
X(2) |
54 |
55 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| ELG194 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
56 |
65 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| ELG195 |
NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE |
X(1) |
66 |
66 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| ELG196 |
MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE |
9(8) |
67 |
74 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| ELG197 |
MANAGED-CARE-PLAN-ENROLLMENT-END-DATE |
9(8) |
75 |
82 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| ELG198 |
STATE-NOTATION |
X(500) |
83 |
582 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| ELG199 |
FILLER |
X(418) |
583 |
1000 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| ELG200 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| ELG201 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| ELG202 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| ELG203 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| ELG204 |
ETHNICITY-CODE |
X(1) |
42 |
42 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| ELG205 |
ETHNICITY-DECLARATION-EFF-DATE |
9(8) |
43 |
50 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| ELG206 |
ETHNICITY-DECLARATION-END-DATE |
9(8) |
51 |
58 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| ELG207 |
STATE-NOTATION |
X(500) |
59 |
558 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| ELG208 |
FILLER |
X(442) |
559 |
1000 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| ELG209 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| ELG210 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| ELG211 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| ELG212 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| ELG213 |
RACE |
X(3) |
42 |
44 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| ELG214 |
RACE-OTHER |
X(25) |
45 |
69 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| ELG215 |
CERTIFIED-AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR |
X(1) |
70 |
70 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| ELG216 |
RACE-DECLARATION-EFF-DATE |
9(8) |
71 |
78 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| ELG217 |
RACE-DECLARATION-END-DATE |
9(8) |
79 |
86 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| ELG218 |
STATE-NOTATION |
X(500) |
87 |
586 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| ELG219 |
FILLER |
X(414) |
587 |
1000 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| ELG220 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| ELG221 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| ELG222 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| ELG223 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| ELG224 |
DISABILITY-TYPE-CODE |
X(2) |
42 |
43 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| ELG225 |
DISABILITY-TYPE-EFF-DATE |
9(8) |
44 |
51 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| ELG226 |
DISABILITY-TYPE-END-DATE |
9(8) |
52 |
59 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| ELG227 |
STATE-NOTATION |
X(500) |
60 |
559 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| ELG228 |
FILLER |
X(441) |
560 |
1000 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| ELG229 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| ELG230 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| ELG231 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| ELG232 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| ELG233 |
1115A-DEMONSTRATION-IND |
X(1) |
42 |
42 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| ELG234 |
1115A-EFF-DATE |
9(8) |
43 |
50 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| ELG235 |
1115A-END-DATE |
9(8) |
51 |
58 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| ELG236 |
STATE-NOTATION |
X(500) |
59 |
558 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| ELG237 |
FILLER |
X(442) |
559 |
1000 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| ELG238 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| ELG239 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| ELG240 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| ELG241 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| ELG242 |
HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE |
X(3) |
42 |
44 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| ELG243 |
HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE |
9(8) |
45 |
52 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| ELG244 |
HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE |
9(8) |
53 |
60 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| ELG245 |
STATE-NOTATION |
X(500) |
61 |
560 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| ELG246 |
FILLER |
X(440) |
561 |
1000 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| ELG248 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
| ELG249 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
| ELG250 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
| ELG251 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
| ELG252 |
ENROLLMENT-TYPE |
X(1) |
42 |
42 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
| ELG253 |
ENROLLMENT-EFF-DATE |
9(8) |
43 |
50 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
| ELG254 |
ENROLLMENT-END-DATE |
9(8) |
51 |
58 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
| ELG255 |
STATE-NOTATION |
X(500) |
59 |
558 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
| ELG256 |
FILLER |
X(442) |
559 |
1000 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
| MCR001 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| MCR002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| MCR003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| MCR004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| MCR005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| MCR006 |
FILE-NAME |
X(8) |
32 |
39 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| MCR007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| MCR008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| MCR009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| MCR010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| MCR011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| MCR013 |
TOT-REC-CNT |
9(11) |
67 |
77 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| MCR112 |
SEQUENCE-NUMBER |
X(4) |
78 |
81 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| MCR014 |
STATE-NOTATION |
X(500) |
82 |
581 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| MCR012 |
FILLER |
X(419) |
582 |
1000 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| MCR016 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| MCR017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| MCR018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| MCR019 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| MCR020 |
MANAGED-CARE-CONTRACT-EFF-DATE |
9(8) |
34 |
41 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| MCR021 |
MANAGED-CARE-CONTRACT-END-DATE |
9(8) |
42 |
49 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| MCR022 |
MANAGED-CARE-NAME |
X(55) |
50 |
104 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| MCR023 |
MANAGED-CARE-PROGRAM |
X(1) |
105 |
105 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| MCR024 |
MANAGED-CARE-PLAN-TYPE |
X(2) |
106 |
107 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| MCR025 |
REIMBURSEMENT-ARRANGEMENT |
X(2) |
108 |
109 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| MCR026 |
MANAGED-CARE-PROFIT-STATUS |
X(2) |
110 |
111 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| MCR027 |
CORE-BASED-STATISTICAL-AREA-CODE |
X(1) |
112 |
112 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| MCR028 |
PERCENT-BUSINESS |
9(3) |
113 |
115 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| MCR029 |
MANAGED-CARE-SERVICE-AREA |
X(1) |
116 |
116 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| MCR030 |
MANAGED-CARE-MAIN-REC-EFF-DATE |
9(8) |
117 |
124 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| MCR031 |
MANAGED-CARE-MAIN-REC-END-DATE |
9(8) |
125 |
132 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| MCR032 |
STATE-NOTATION |
X(500) |
133 |
632 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| MCR033 |
FILLER |
X(368) |
633 |
1000 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| MCR034 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR035 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR036 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR037 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR038 |
MANAGED-CARE-LOCATION-ID |
X(15) |
34 |
48 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR039 |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE |
9(8) |
49 |
56 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR040 |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE |
9(8) |
57 |
64 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR041 |
MANAGED-CARE-ADDR-TYPE |
X(1) |
65 |
65 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR042 |
MANAGED-CARE-ADDR-LN1 |
X(60) |
66 |
125 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR043 |
MANAGED-CARE-ADDR-LN2 |
X(60) |
126 |
185 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR044 |
MANAGED-CARE-ADDR-LN3 |
X(60) |
186 |
245 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR045 |
MANAGED-CARE-CITY |
X(28) |
246 |
273 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR046 |
MANAGED-CARE-STATE |
X(2) |
274 |
275 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR047 |
MANAGED-CARE-ZIP-CODE |
X(9) |
276 |
284 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR048 |
MANAGED-CARE-COUNTY |
X(3) |
285 |
287 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR049 |
MANAGED-CARE-TELEPHONE |
X(10) |
288 |
297 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR050 |
MANAGED-CARE-EMAIL |
X(60) |
298 |
357 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR051 |
MANAGED-CARE-FAX-NUMBER |
X(10) |
358 |
367 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR052 |
STATE-NOTATION |
X(500) |
368 |
867 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR053 |
FILLER |
X(133) |
868 |
1000 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| MCR054 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| MCR055 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| MCR056 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| MCR057 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| MCR058 |
MANAGED-CARE-SERVICE-AREA-NAME |
X(30) |
34 |
63 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| MCR059 |
MANAGED-CARE-SERVICE-AREA-EFF-DATE |
9(8) |
64 |
71 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| MCR060 |
MANAGED-CARE-SERVICE-AREA-END-DATE |
9(8) |
72 |
79 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| MCR061 |
STATE-NOTATION |
X(500) |
80 |
579 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| MCR062 |
FILLER |
X(421) |
580 |
1000 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| MCR063 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| MCR064 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| MCR065 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| MCR066 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| MCR067 |
OPERATING-AUTHORITY |
X(2) |
34 |
35 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| MCR068 |
WAIVER-ID |
X(20) |
36 |
55 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| MCR069 |
MANAGED-CARE-OP-AUTHORITY-EFF-DATE |
9(8) |
56 |
63 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| MCR070 |
MANAGED-CARE-OP-AUTHORITY-END-DATE |
9(8) |
64 |
71 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| MCR071 |
STATE-NOTATION |
X(500) |
72 |
571 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| MCR072 |
FILLER |
X(429) |
572 |
1000 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| MCR073 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| MCR074 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| MCR075 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| MCR076 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| MCR077 |
MANAGED-CARE-PLAN-POP |
9(2) |
34 |
35 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| MCR078 |
MANAGED-CARE-PLAN-POP-EFF-DATE |
9(8) |
36 |
43 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| MCR079 |
MANAGED-CARE-PLAN-POP-END-DATE |
9(8) |
44 |
51 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| MCR080 |
STATE-NOTATION |
X(500) |
52 |
551 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| MCR081 |
FILLER |
X(449) |
552 |
1000 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| MCR082 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| MCR083 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| MCR084 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| MCR085 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| MCR086 |
ACCREDITATION-ORGANIZATION |
X(2) |
34 |
35 |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| MCR087 |
DATE-ACCREDITATION-ACHIEVED |
9(8) |
36 |
43 |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| MCR088 |
DATE-ACCREDITATION-END |
9(8) |
44 |
51 |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| MCR089 |
STATE-NOTATION |
X(500) |
52 |
551 |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| MCR090 |
FILLER |
X(449) |
552 |
1000 |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| MCR091 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| MCR092 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| MCR093 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| MCR094 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| MCR095 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
34 |
43 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| MCR096 |
NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE |
X(1) |
44 |
44 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| MCR097 |
NATIONAL-HEALTH-CARE-ENTITY-NAME |
X(50) |
45 |
94 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| MCR098 |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE |
9(8) |
95 |
102 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| MCR099 |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE |
9(8) |
103 |
110 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| MCR100 |
STATE-NOTATION |
X(500) |
111 |
610 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| MCR101 |
FILLER |
X(390) |
611 |
1000 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| MCR102 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| MCR103 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| MCR104 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| MCR105 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| MCR106 |
CHPID |
X(10) |
34 |
43 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| MCR107 |
SHPID |
X(10) |
44 |
53 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| MCR108 |
CHPID-SHPID-RELATIONSHIP-EFF-DATE |
9(8) |
54 |
61 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| MCR109 |
CHPID-SHPID-RELATIONSHIP-END-DATE |
9(8) |
62 |
69 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| MCR110 |
STATE-NOTATION |
X(500) |
70 |
569 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| MCR111 |
FILLER |
X(431) |
570 |
1000 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| PRV001 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| PRV002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| PRV003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| PRV004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| PRV005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| PRV006 |
FILE-NAME |
X(8) |
32 |
39 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| PRV007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| PRV008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| PRV009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| PRV010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| PRV011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| PRV013 |
TOT-REC-CNT |
9(11) |
67 |
77 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| PRV138 |
SEQUENCE-NUMBER |
X(4) |
78 |
81 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| PRV014 |
STATE-NOTATION |
X(500) |
82 |
581 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| PRV012 |
FILLER |
X(519) |
582 |
1100 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| PRV016 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV019 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV020 |
PROV-ATTRIBUTES-EFF-DATE |
9(8) |
52 |
59 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV021 |
PROV-ATTRIBUTES-END-DATE |
9(8) |
60 |
67 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV022 |
PROV-DOING-BUSINESS-AS-NAME |
X(100) |
68 |
167 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV023 |
PROV-LEGAL-NAME |
X(100) |
168 |
267 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV024 |
PROV-ORGANIZATION-NAME |
X(60) |
268 |
327 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV025 |
PROV-TAX-NAME |
X(100) |
328 |
427 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV026 |
FACILITY-GROUP-INDIVIDUAL-CODE |
X(2) |
428 |
429 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV027 |
TEACHING-IND |
X(1) |
430 |
430 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV028 |
PROV-FIRST-NAME |
X(30) |
431 |
460 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV029 |
PROV-MIDDLE-INITIAL |
X(1) |
461 |
461 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV030 |
PROV-LAST-NAME |
X(30) |
462 |
491 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV031 |
SEX |
X(1) |
492 |
492 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV032 |
OWNERSHIP-CODE |
X(2) |
493 |
494 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV033 |
PROV-PROFIT-STATUS |
X(2) |
495 |
496 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV034 |
DATE-OF-BIRTH |
9(8) |
497 |
504 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV035 |
DATE-OF-DEATH |
9(8) |
505 |
512 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV036 |
ACCEPTING-NEW-PATIENTS-IND |
X(1) |
513 |
513 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV037 |
STATE-NOTATION |
X(500) |
514 |
1013 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV038 |
FILLER |
X(87) |
1014 |
1100 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| PRV039 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV040 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV041 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV042 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV043 |
PROV-LOCATION-ID |
X(5) |
52 |
56 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV044 |
PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE |
9(8) |
57 |
64 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV045 |
PROV-LOCATION-AND-CONTACT-INFO-END-DATE |
9(8) |
65 |
72 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV046 |
PROV-ADDR-TYPE |
X(1) |
73 |
73 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV047 |
ADDR-LN1 |
X(60) |
74 |
133 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV048 |
ADDR-LN2 |
X(60) |
134 |
193 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV049 |
ADDR-LN3 |
X(60) |
194 |
253 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV050 |
ADDR-CITY |
X(28) |
254 |
281 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV051 |
ADDR-STATE |
X(2) |
282 |
283 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV052 |
ADDR-ZIP-CODE |
X(9) |
284 |
292 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV053 |
ADDR-TELEPHONE |
X(10) |
293 |
302 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV054 |
ADDR-EMAIL |
X(60) |
303 |
362 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV055 |
ADDR-FAX-NUM |
X(10) |
363 |
372 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV056 |
ADDR-BORDER-STATE-IND |
X(1) |
373 |
373 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV057 |
ADDR-COUNTY |
X(3) |
374 |
376 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV058 |
STATE-NOTATION |
X(500) |
377 |
876 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV059 |
FILLER |
X(224) |
877 |
1100 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| PRV060 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| PRV061 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| PRV062 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| PRV063 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| PRV064 |
PROV-LOCATION-ID |
X(5) |
52 |
56 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| PRV065 |
PROV-LICENSE-EFF-DATE |
9(8) |
57 |
64 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| PRV066 |
PROV-LICENSE-END-DATE |
9(8) |
65 |
72 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| PRV067 |
LICENSE-TYPE |
X(1) |
73 |
73 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| PRV068 |
LICENSE-ISSUING-ENTITY-ID |
X(60) |
74 |
133 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| PRV069 |
LICENSE-OR-ACCREDITATION-NUMBER |
X(20) |
134 |
153 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| PRV070 |
STATE-NOTATION |
X(500) |
154 |
653 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| PRV071 |
FILLER |
X(447) |
654 |
1100 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| PRV072 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| PRV073 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| PRV074 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| PRV075 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| PRV076 |
PROV-LOCATION-ID |
X(5) |
52 |
56 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| PRV077 |
PROV-IDENTIFIER-TYPE |
X(1) |
57 |
57 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| PRV078 |
PROV-IDENTIFIER-ISSUING-ENTITY-ID |
X(18) |
58 |
75 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| PRV079 |
PROV-IDENTIFIER-EFF-DATE |
9(8) |
76 |
83 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| PRV080 |
PROV-IDENTIFIER-END-DATE |
9(8) |
84 |
91 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| PRV081 |
PROV-IDENTIFIER |
X(12) |
92 |
103 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| PRV082 |
STATE-NOTATION |
X(500) |
104 |
603 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| PRV083 |
FILLER |
X(497) |
604 |
1100 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| PRV084 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| PRV085 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| PRV086 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| PRV087 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| PRV088 |
PROV-CLASSIFICATION-TYPE |
X(1) |
52 |
52 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| PRV089 |
PROV-CLASSIFICATION-CODE |
X(20) |
53 |
72 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| PRV090 |
PROV-TAXONOMY-CLASSIFICATION-EFF-DATE |
9(8) |
73 |
80 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| PRV091 |
PROV-TAXONOMY-CLASSIFICATION-END-DATE |
9(8) |
81 |
88 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| PRV092 |
STATE-NOTATION |
X(500) |
89 |
588 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| PRV093 |
FILLER |
X(512) |
589 |
1100 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| PRV094 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| PRV095 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| PRV096 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| PRV097 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| PRV098 |
PROV-MEDICAID-EFF-DATE |
9(8) |
52 |
59 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| PRV099 |
PROV-MEDICAID-END-DATE |
9(8) |
60 |
67 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| PRV100 |
PROV-MEDICAID-ENROLLMENT-STATUS-CODE |
X(2) |
68 |
69 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| PRV101 |
STATE-PLAN-ENROLLMENT |
X(1) |
70 |
70 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| PRV102 |
PROV-ENROLLMENT-METHOD |
X(1) |
71 |
71 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| PRV103 |
APPL-DATE |
9(8) |
72 |
79 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| PRV104 |
STATE-NOTATION |
X(500) |
80 |
579 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| PRV105 |
FILLER |
X(521) |
580 |
1100 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| PRV106 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| PRV107 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| PRV108 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| PRV109 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| PRV110 |
SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY |
X(12) |
52 |
63 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| PRV111 |
PROV-AFFILIATED-GROUP-EFF-DATE |
9(8) |
64 |
71 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| PRV112 |
PROV-AFFILIATED-GROUP-END-DATE |
9(8) |
72 |
79 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| PRV113 |
STATE-NOTATION |
X(500) |
80 |
579 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| PRV114 |
FILLER |
X(521) |
580 |
1100 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| PRV115 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| PRV116 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| PRV117 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| PRV118 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| PRV119 |
AFFILIATED-PROGRAM-TYPE |
X(1) |
52 |
52 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| PRV120 |
AFFILIATED-PROGRAM-ID |
X(50) |
53 |
102 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| PRV121 |
PROV-AFFILIATED-PROGRAM-EFF-DATE |
9(8) |
103 |
110 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| PRV122 |
PROV-AFFILIATED-PROGRAM-END-DATE |
9(8) |
111 |
118 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| PRV123 |
STATE-NOTATION |
X(500) |
119 |
618 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| PRV124 |
FILLER |
X(482) |
619 |
1100 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| PRV125 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| PRV126 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| PRV127 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| PRV128 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| PRV129 |
PROV-LOCATION-ID |
X(5) |
52 |
56 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| PRV130 |
BED-TYPE-EFF-DATE |
9(8) |
57 |
64 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| PRV131 |
BED-TYPE-END-DATE |
9(8) |
65 |
72 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| PRV134 |
BED-TYPE-CODE |
X(1) |
73 |
73 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| PRV135 |
BED-COUNT |
9(5) |
74 |
78 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| PRV136 |
STATE-NOTATION |
X(500) |
79 |
578 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| PRV137 |
FILLER |
X(522) |
579 |
1100 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| TPL001 |
RECORD-ID |
X(8) |
1 |
8 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| TPL002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| TPL003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| TPL004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| TPL005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| TPL006 |
FILE-NAME |
X(8) |
32 |
39 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| TPL007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| TPL008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| TPL009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| TPL010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| TPL011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| TPL012 |
SSN-INDICATOR |
X(1) |
67 |
67 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| TPL013 |
TOT-REC-CNT |
9(11) |
68 |
78 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| TPL088 |
SEQUENCE-NUMBER |
X(4) |
79 |
82 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| TPL014 |
STATE-NOTATION |
X(500) |
83 |
582 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| TPL015 |
FILLER |
X(318) |
583 |
900 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| TPL016 |
RECORD-ID |
X(8) |
1 |
8 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| TPL017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| TPL018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| TPL019 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| TPL020 |
TPL-HEALTH-INSURANCE-COVERAGE-IND |
X(1) |
42 |
42 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| TPL021 |
TPL-OTHER-COVERAGE-IND |
X(1) |
43 |
43 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| TPL022 |
ELIGIBLE-FIRST-NAME |
X(30) |
44 |
73 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| TPL023 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
74 |
74 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| TPL024 |
ELIGIBLE-LAST-NAME |
X(30) |
75 |
104 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| TPL025 |
ELIG-PRSN-MAIN-EFF-DATE |
9(8) |
105 |
112 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| TPL026 |
ELIG-PRSN-MAIN-END-DATE |
9(8) |
113 |
120 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| TPL027 |
STATE-NOTATION |
X(500) |
121 |
620 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| TPL028 |
FILLER |
X(280) |
621 |
900 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| TPL029 |
RECORD-ID |
X(8) |
1 |
8 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| TPL030 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| TPL031 |
RECORD-NUMBER |
9(11) |
11 |
21 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| TPL032 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| TPL033 |
INSURANCE-CARRIER-ID-NUM |
X(12) |
42 |
53 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| TPL034 |
INSURANCE-PLAN-ID |
X(20) |
54 |
73 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| TPL035 |
GROUP-NUM |
X(16) |
74 |
89 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| TPL036 |
MEMBER-ID |
X(20) |
90 |
109 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| TPL037 |
INSURANCE-PLAN-TYPE |
X(2) |
110 |
111 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| TPL089 |
COVERAGE-TYPE |
X(2) |
112 |
113 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| TPL038 |
ANNUAL-DEDUCTIBLE-AMT |
S9(11)V99 |
114 |
126 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| TPL044 |
POLICY-OWNER-FIRST-NAME |
X(30) |
127 |
156 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| TPL045 |
POLICY-OWNER-LAST-NAME |
X(30) |
157 |
186 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| TPL046 |
POLICY-OWNER-SSN |
X(9) |
187 |
195 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| TPL047 |
POLICY-OWNER-CODE |
X(2) |
196 |
197 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| TPL048 |
INSURANCE-COVERAGE-EFF-DATE |
9(8) |
198 |
205 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| TPL049 |
INSURANCE-COVERAGE-END-DATE |
9(8) |
206 |
213 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| TPL050 |
STATE-NOTATION |
X(500) |
214 |
713 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| TPL051 |
FILLER |
X(187) |
714 |
900 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| TPL052 |
RECORD-ID |
X(8) |
1 |
8 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| TPL053 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| TPL054 |
RECORD-NUMBER |
9(11) |
11 |
21 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| TPL055 |
INSURANCE-CARRIER-ID-NUM |
X(12) |
22 |
33 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| TPL056 |
INSURANCE-PLAN-ID |
X(20) |
34 |
53 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| TPL057 |
INSURANCE-PLAN-TYPE |
X(2) |
54 |
55 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| TPL058 |
COVERAGE-TYPE |
X(2) |
56 |
57 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| TPL059 |
INSURANCE-CATEGORIES-EFF-DATE |
9(8) |
58 |
65 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| TPL060 |
INSURANCE-CATEGORIES-END-DATE |
9(8) |
66 |
73 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| TPL061 |
STATE-NOTATION |
X(500) |
74 |
573 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| TPL062 |
FILLER |
X(327) |
574 |
900 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| TPL063 |
RECORD-ID |
X(8) |
1 |
8 |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| TPL064 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| TPL065 |
RECORD-NUMBER |
9(11) |
11 |
21 |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| TPL066 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| TPL067 |
TYPE-OF-OTHER-THIRD-PARTY-LIABILITY |
X(1) |
42 |
42 |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| TPL068 |
OTHER-TPL-EFF-DATE |
9(8) |
43 |
50 |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| TPL069 |
OTHER-TPL-END-DATE |
9(8) |
51 |
58 |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| TPL070 |
STATE-NOTATION |
X(500) |
59 |
558 |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| TPL071 |
FILLER |
X(342) |
559 |
900 |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| TPL072 |
RECORD-ID |
X(8) |
1 |
8 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL073 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL074 |
RECORD-NUMBER |
9(11) |
11 |
21 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL075 |
INSURANCE-CARRIER-ID-NUM |
X(12) |
22 |
33 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL076 |
TPL-ENTITY-ADDR-TYPE |
X(2) |
34 |
35 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL077 |
INSURANCE-CARRIER-ADDR-LN1 |
X(60) |
36 |
95 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL078 |
INSURANCE-CARRIER-ADDR-LN2 |
X(60) |
96 |
155 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL079 |
INSURANCE-CARRIER-ADDR-LN3 |
X(60) |
156 |
215 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL080 |
INSURANCE-CARRIER-CITY |
X(28) |
216 |
243 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL081 |
INSURANCE-CARRIER-STATE |
X(2) |
244 |
245 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL082 |
INSURANCE-CARRIER-ZIP-CODE |
X(9) |
246 |
254 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL083 |
INSURANCE-CARRIER-PHONE-NUM |
X(10) |
255 |
264 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL084 |
TPL-ENTITY-CONTACT-INFO-EFF-DATE |
9(8) |
265 |
272 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL085 |
TPL-ENTITY-CONTACT-INFO-END-DATE |
9(8) |
273 |
280 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL086 |
STATE-NOTATION |
X(500) |
281 |
780 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL090 |
INSURANCE-CARRIER-NAIC-CODE |
X(10) |
781 |
790 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL091 |
INSURANCE-CARRIER-NAME |
X(30) |
791 |
820 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL092 |
NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE |
X(1) |
821 |
821 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL093 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
822 |
831 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL094 |
NATIONAL-HEALTH-CARE-ENTITY-NAME |
X(50) |
832 |
881 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| TPL087 |
FILLER |
X (19) |
882 |
900 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |