| Comparison of v1.1 versus v2.0 Size, Start Position and Stop Position on T-MSIS Record Layouts |
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The "NbrFalse" line shows how many spreadsheet rows have a V1.1 to V2.0 change.
NbrFalse |
0 |
4 |
6 |
90 |
90 |
0 |
27 |
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Filter on one of the "Comparison" columns to see those spreadsheet rows with V1.0 to V2.0 changes to the specified data element.
Comparison |
v2.0 DD |
v1.1 DD RL Tabs |
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Filter by color (red) to see all spreadsheet rows with changes in any of the data elements.
RowNo |
DE NO |
DATA ELEMENT NAME |
SIZE |
START POSITION |
STOP POSITION |
FILE NAME |
FILE SEGMENT (with RECORD-ID) |
DE_NO |
DATA_ELEMENT_NAME |
SIZE |
START POSITION |
STOP POSITION |
FILE NAME |
FILE SEGMENT (with RECORD-ID) |
DE NO |
DATA ELEMENT NAME |
SIZE |
START POSITION |
STOP POSITION |
FILE NAME |
FILE SEGMENT (with RECORD-ID) |
| 1 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP001 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP001 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 2 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 3 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 4 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 5 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 6 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP006 |
FILE-NAME |
X(8) |
32 |
39 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP006 |
FILE-NAME |
X(8) |
32 |
39 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 7 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 8 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 9 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 10 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 11 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 12 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP012 |
SSN-INDICATOR |
X(1) |
67 |
67 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP012 |
SSN-INDICATOR |
X(1) |
67 |
67 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 13 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP013 |
TOT-REC-CNT |
9(11) |
68 |
78 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP013 |
TOT-REC-CNT |
9(11) |
68 |
78 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 14 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP275 |
SEQUENCE-NUMBER |
X(4) |
79 |
82 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP275 |
SEQUENCE-NUMBER |
X(4) |
79 |
82 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 15 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP014 |
STATE-NOTATION |
X(500) |
83 |
582 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP014 |
STATE-NOTATION |
X(500) |
83 |
582 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 16 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP015 |
FILLER |
X(1518) |
583 |
2100 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP015 |
FILLER |
X(1518) |
583 |
2100 |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 17 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP016 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP016 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 18 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 19 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 20 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP019 |
ICN-ORIG |
X(50) |
22 |
71 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP019 |
ICN-ORIG |
X(50) |
22 |
71 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 21 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP020 |
ICN-ADJ |
X(50) |
72 |
121 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP020 |
ICN-ADJ |
X(50) |
72 |
121 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 22 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP021 |
SUBMITTER-ID |
X(12) |
122 |
133 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP021 |
SUBMITTER-ID |
X(12) |
122 |
133 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 23 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
134 |
153 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
134 |
153 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 24 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP023 |
CROSSOVER-INDICATOR |
X(1) |
154 |
154 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP023 |
CROSSOVER-INDICATOR |
X(1) |
154 |
154 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 25 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP024 |
TYPE-OF-HOSPITAL |
X(2) |
155 |
156 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP024 |
TYPE-OF-HOSPITAL |
X(2) |
155 |
156 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 26 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP025 |
1115A-DEMONSTRATION-IND |
X(1) |
157 |
157 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP025 |
1115A-DEMONSTRATION-IND |
X(1) |
157 |
157 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 27 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP026 |
ADJUSTMENT-IND |
X(1) |
158 |
158 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP026 |
ADJUSTMENT-IND |
X(1) |
158 |
158 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 28 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP027 |
ADJUSTMENT-REASON-CODE |
X(3) |
159 |
161 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP027 |
ADJUSTMENT-REASON-CODE |
X(3) |
159 |
161 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 29 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP028 |
ADMISSION-TYPE |
X(1) |
162 |
162 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP028 |
ADMISSION-TYPE |
X(1) |
162 |
162 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 30 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP029 |
DRG-DESCRIPTION |
X(20) |
163 |
182 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP029 |
DRG-DESCRIPTION |
X(20) |
163 |
182 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 31 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP030 |
ADMITTING-DIAGNOSIS-CODE |
X(7) |
183 |
189 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP030 |
ADMITTING-DIAGNOSIS-CODE |
X(7) |
183 |
189 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 32 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP031 |
ADMITTING-DIAGNOSIS-CODE-FLAG |
X(1) |
190 |
190 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP031 |
ADMITTING-DIAGNOSIS-CODE-FLAG |
X(1) |
190 |
190 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 33 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP032 |
DIAGNOSIS-CODE-1 |
X(7) |
191 |
197 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP032 |
DIAGNOSIS-CODE-1 |
X(7) |
191 |
197 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 34 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP033 |
DIAGNOSIS-CODE-FLAG-1 |
X(1) |
198 |
198 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP033 |
DIAGNOSIS-CODE-FLAG-1 |
X(1) |
198 |
198 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 35 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP034 |
DIAGNOSIS-POA-FLAG-1 |
X(1) |
199 |
199 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP034 |
DIAGNOSIS-POA-FLAG-1 |
X(1) |
199 |
199 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 36 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP035 |
DIAGNOSIS-CODE-2 |
X(7) |
200 |
206 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP035 |
DIAGNOSIS-CODE-2 |
X(7) |
200 |
206 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 37 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP036 |
DIAGNOSIS-CODE-FLAG-2 |
X(1) |
207 |
207 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP036 |
DIAGNOSIS-CODE-FLAG-2 |
X(1) |
207 |
207 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 38 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP037 |
DIAGNOSIS-POA-FLAG-2 |
X(1) |
208 |
208 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP037 |
DIAGNOSIS-POA-FLAG-2 |
X(1) |
208 |
208 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 39 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP038 |
DIAGNOSIS-CODE-3 |
X(7) |
209 |
215 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP038 |
DIAGNOSIS-CODE-3 |
X(7) |
209 |
215 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 40 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP039 |
DIAGNOSIS-CODE-FLAG-3 |
X(1) |
216 |
216 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP039 |
DIAGNOSIS-CODE-FLAG-3 |
X(1) |
216 |
216 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 41 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP040 |
DIAGNOSIS-POA-FLAG-3 |
X(1) |
217 |
217 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP040 |
DIAGNOSIS-POA-FLAG-3 |
X(1) |
217 |
217 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 42 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP041 |
DIAGNOSIS-CODE-4 |
X(7) |
218 |
224 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP041 |
DIAGNOSIS-CODE-4 |
X(7) |
218 |
224 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 43 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP042 |
DIAGNOSIS-CODE-FLAG-4 |
X(1) |
225 |
225 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP042 |
DIAGNOSIS-CODE-FLAG-4 |
X(1) |
225 |
225 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 44 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP043 |
DIAGNOSIS-POA-FLAG-4 |
X(1) |
226 |
226 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP043 |
DIAGNOSIS-POA-FLAG-4 |
X(1) |
226 |
226 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 45 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP044 |
DIAGNOSIS-CODE-5 |
X(7) |
227 |
233 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP044 |
DIAGNOSIS-CODE-5 |
X(7) |
227 |
233 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 46 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP045 |
DIAGNOSIS-CODE-FLAG-5 |
X(1) |
234 |
234 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP045 |
DIAGNOSIS-CODE-FLAG-5 |
X(1) |
234 |
234 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 47 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP046 |
DIAGNOSIS-POA-FLAG-5 |
X(1) |
235 |
235 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP046 |
DIAGNOSIS-POA-FLAG-5 |
X(1) |
235 |
235 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 48 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP047 |
DIAGNOSIS-CODE-6 |
X(7) |
236 |
242 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP047 |
DIAGNOSIS-CODE-6 |
X(7) |
236 |
242 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 49 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP048 |
DIAGNOSIS-CODE-FLAG-6 |
X(1) |
243 |
243 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP048 |
DIAGNOSIS-CODE-FLAG-6 |
X(1) |
243 |
243 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 50 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP049 |
DIAGNOSIS-POA-FLAG-6 |
X(1) |
244 |
244 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP049 |
DIAGNOSIS-POA-FLAG-6 |
X(1) |
244 |
244 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 51 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP050 |
DIAGNOSIS-CODE-7 |
X(7) |
245 |
251 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP050 |
DIAGNOSIS-CODE-7 |
X(7) |
245 |
251 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 52 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP051 |
DIAGNOSIS-CODE-FLAG-7 |
X(1) |
252 |
252 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP051 |
DIAGNOSIS-CODE-FLAG-7 |
X(1) |
252 |
252 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 53 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP052 |
DIAGNOSIS-POA-FLAG-7 |
X(1) |
253 |
253 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP052 |
DIAGNOSIS-POA-FLAG-7 |
X(1) |
253 |
253 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 54 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP053 |
DIAGNOSIS-CODE-8 |
X(7) |
254 |
260 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP053 |
DIAGNOSIS-CODE-8 |
X(7) |
254 |
260 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 55 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP054 |
DIAGNOSIS-CODE-FLAG-8 |
X(1) |
261 |
261 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP054 |
DIAGNOSIS-CODE-FLAG-8 |
X(1) |
261 |
261 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 56 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP055 |
DIAGNOSIS-POA-FLAG-8 |
X(1) |
262 |
262 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP055 |
DIAGNOSIS-POA-FLAG-8 |
X(1) |
262 |
262 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 57 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP056 |
DIAGNOSIS-CODE-9 |
X(7) |
263 |
269 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP056 |
DIAGNOSIS-CODE-9 |
X(7) |
263 |
269 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 58 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP057 |
DIAGNOSIS-CODE-FLAG-9 |
X(1) |
270 |
270 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP057 |
DIAGNOSIS-CODE-FLAG-9 |
X(1) |
270 |
270 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 59 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP058 |
DIAGNOSIS-POA-FLAG-9 |
X(1) |
271 |
271 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP058 |
DIAGNOSIS-POA-FLAG-9 |
X(1) |
271 |
271 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 60 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP059 |
DIAGNOSIS-CODE-10 |
X(7) |
272 |
278 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP059 |
DIAGNOSIS-CODE-10 |
X(7) |
272 |
278 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 61 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP060 |
DIAGNOSIS-CODE-FLAG-10 |
X(1) |
279 |
279 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP060 |
DIAGNOSIS-CODE-FLAG-10 |
X(1) |
279 |
279 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 62 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP061 |
DIAGNOSIS-POA-FLAG-10 |
X(1) |
280 |
280 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP061 |
DIAGNOSIS-POA-FLAG-10 |
X(1) |
280 |
280 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 63 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP062 |
DIAGNOSIS-CODE-11 |
X(7) |
281 |
287 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP062 |
DIAGNOSIS-CODE-11 |
X(7) |
281 |
287 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 64 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP063 |
DIAGNOSIS-CODE-FLAG-11 |
X(1) |
288 |
288 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP063 |
DIAGNOSIS-CODE-FLAG-11 |
X(1) |
288 |
288 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 65 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP064 |
DIAGNOSIS-POA-FLAG-11 |
X(1) |
289 |
289 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP064 |
DIAGNOSIS-POA-FLAG-11 |
X(1) |
289 |
289 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 66 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP065 |
DIAGNOSIS-CODE-12 |
X(7) |
290 |
296 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP065 |
DIAGNOSIS-CODE-12 |
X(7) |
290 |
296 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 67 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP066 |
DIAGNOSIS-CODE-FLAG-12 |
X(1) |
297 |
297 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP066 |
DIAGNOSIS-CODE-FLAG-12 |
X(1) |
297 |
297 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 68 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP067 |
DIAGNOSIS-POA-FLAG-12 |
X(1) |
298 |
298 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP067 |
DIAGNOSIS-POA-FLAG-12 |
X(1) |
298 |
298 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 69 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP068 |
DIAGNOSIS-RELATED-GROUP |
X(4) |
299 |
302 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP068 |
DIAGNOSIS-RELATED-GROUP |
X(4) |
299 |
302 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 70 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP069 |
DIAGNOSIS-RELATED-GROUP-IND |
X(4) |
303 |
306 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP069 |
DIAGNOSIS-RELATED-GROUP-IND |
X(4) |
303 |
306 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 71 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP070 |
PROCEDURE-CODE-1 |
X(8) |
307 |
314 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP070 |
PROCEDURE-CODE-1 |
X(8) |
307 |
314 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 72 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP071 |
PROCEDURE-CODE-MOD-1 |
X(2) |
315 |
316 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP071 |
PROCEDURE-CODE-MOD-1 |
X(2) |
315 |
316 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 73 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP072 |
PROCEDURE-CODE-FLAG-1 |
X(2) |
317 |
318 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP072 |
PROCEDURE-CODE-FLAG-1 |
X(2) |
317 |
318 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 74 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP073 |
PROCEDURE-CODE-DATE-1 |
9(8) |
319 |
326 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP073 |
PROCEDURE-CODE-DATE-1 |
9(8) |
319 |
326 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 75 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP074 |
PROCEDURE-CODE-2 |
X(8) |
327 |
334 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP074 |
PROCEDURE-CODE-2 |
X(8) |
327 |
334 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 76 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP075 |
PROCEDURE-CODE-MOD-2 |
X(2) |
335 |
336 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP075 |
PROCEDURE-CODE-MOD-2 |
X(2) |
335 |
336 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 77 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP076 |
PROCEDURE-CODE-FLAG-2 |
X(2) |
337 |
338 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP076 |
PROCEDURE-CODE-FLAG-2 |
X(2) |
337 |
338 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 78 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP077 |
PROCEDURE-CODE-DATE-2 |
9(8) |
339 |
346 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP077 |
PROCEDURE-CODE-DATE-2 |
9(8) |
339 |
346 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 79 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP078 |
PROCEDURE-CODE-3 |
X(8) |
347 |
354 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP078 |
PROCEDURE-CODE-3 |
X(8) |
347 |
354 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 80 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP079 |
PROCEDURE-CODE-MOD-3 |
X(2) |
355 |
356 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP079 |
PROCEDURE-CODE-MOD-3 |
X(2) |
355 |
356 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 81 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP080 |
PROCEDURE-CODE-FLAG-3 |
X(2) |
357 |
358 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP080 |
PROCEDURE-CODE-FLAG-3 |
X(2) |
357 |
358 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 82 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP081 |
PROCEDURE-CODE-DATE-3 |
9(8) |
359 |
366 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP081 |
PROCEDURE-CODE-DATE-3 |
9(8) |
359 |
366 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 83 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP082 |
PROCEDURE-CODE-4 |
X(8) |
367 |
374 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP082 |
PROCEDURE-CODE-4 |
X(8) |
367 |
374 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 84 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP083 |
PROCEDURE-CODE-MOD-4 |
X(2) |
375 |
376 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP083 |
PROCEDURE-CODE-MOD-4 |
X(2) |
375 |
376 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 85 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP084 |
PROCEDURE-CODE-FLAG-4 |
X(2) |
377 |
378 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP084 |
PROCEDURE-CODE-FLAG-4 |
X(2) |
377 |
378 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 86 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP085 |
PROCEDURE-CODE-DATE-4 |
9(8) |
379 |
386 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP085 |
PROCEDURE-CODE-DATE-4 |
9(8) |
379 |
386 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 87 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP086 |
PROCEDURE-CODE-5 |
X(8) |
387 |
394 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP086 |
PROCEDURE-CODE-5 |
X(8) |
387 |
394 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 88 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP087 |
PROCEDURE-CODE-MOD-5 |
X(2) |
395 |
396 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP087 |
PROCEDURE-CODE-MOD-5 |
X(2) |
395 |
396 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 89 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP088 |
PROCEDURE-CODE-FLAG-5 |
X(2) |
397 |
398 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP088 |
PROCEDURE-CODE-FLAG-5 |
X(2) |
397 |
398 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 90 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP089 |
PROCEDURE-CODE-DATE-5 |
9(8) |
399 |
406 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP089 |
PROCEDURE-CODE-DATE-5 |
9(8) |
399 |
406 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 91 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP090 |
PROCEDURE-CODE-6 |
X(8) |
407 |
414 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP090 |
PROCEDURE-CODE-6 |
X(8) |
407 |
414 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 92 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP091 |
PROCEDURE-CODE-MOD-6 |
X(2) |
415 |
416 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP091 |
PROCEDURE-CODE-MOD-6 |
X(2) |
415 |
416 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 93 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP092 |
PROCEDURE-CODE-FLAG-6 |
X(2) |
417 |
418 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP092 |
PROCEDURE-CODE-FLAG-6 |
X(2) |
417 |
418 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 94 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP093 |
PROCEDURE-CODE-DATE-6 |
9(8) |
419 |
426 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP093 |
PROCEDURE-CODE-DATE-6 |
9(8) |
419 |
426 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 95 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP094 |
ADMISSION-DATE |
9(8) |
427 |
434 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP094 |
ADMISSION-DATE |
9(8) |
427 |
434 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 96 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP095 |
ADMISSION-HOUR |
X(2) |
435 |
436 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP095 |
ADMISSION-HOUR |
X(2) |
435 |
436 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 97 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP096 |
DISCHARGE-DATE |
9(8) |
437 |
444 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP096 |
DISCHARGE-DATE |
9(8) |
437 |
444 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 98 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP097 |
DISCHARGE-HOUR |
X(2) |
445 |
446 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP097 |
DISCHARGE-HOUR |
X(2) |
445 |
446 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 99 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP098 |
ADJUDICATION-DATE |
9(8) |
447 |
454 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP098 |
ADJUDICATION-DATE |
9(8) |
447 |
454 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 100 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP099 |
MEDICAID-PAID-DATE |
9(8) |
455 |
462 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP099 |
MEDICAID-PAID-DATE |
9(8) |
455 |
462 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 101 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP100 |
TYPE-OF-CLAIM |
X(1) |
463 |
463 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP100 |
TYPE-OF-CLAIM |
X(1) |
463 |
463 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 102 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP101 |
TYPE-OF-BILL |
X(4) |
464 |
467 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP101 |
TYPE-OF-BILL |
X(4) |
464 |
467 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 103 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP102 |
CLAIM-STATUS |
X(3) |
468 |
470 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP102 |
CLAIM-STATUS |
X(3) |
468 |
470 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 104 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP103 |
CLAIM-STATUS-CATEGORY |
X(3) |
471 |
473 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP103 |
CLAIM-STATUS-CATEGORY |
X(3) |
471 |
473 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 105 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP104 |
SOURCE-LOCATION |
X(2) |
474 |
475 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP104 |
SOURCE-LOCATION |
X(2) |
474 |
475 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 106 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP105 |
CHECK-NUM |
X(15) |
476 |
490 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP105 |
CHECK-NUM |
X(15) |
476 |
490 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 107 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP106 |
CHECK-EFF-DATE |
9(8) |
491 |
498 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP106 |
CHECK-EFF-DATE |
9(8) |
491 |
498 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 108 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP107 |
ALLOWED-CHARGE-SRC |
X(1) |
499 |
499 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP107 |
ALLOWED-CHARGE-SRC |
X(1) |
499 |
499 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 109 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP108 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
500 |
504 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP108 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
500 |
504 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 110 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP109 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
505 |
509 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP109 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
505 |
509 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 111 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP110 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
510 |
514 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP110 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
510 |
514 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 112 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP111 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
515 |
519 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP111 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
515 |
519 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 113 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP112 |
TOT-BILLED-AMT |
S9(11)V99 |
520 |
532 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP112 |
TOT-BILLED-AMT |
S9(11)V99 |
520 |
532 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 114 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP113 |
TOT-ALLOWED-AMT |
S9(11)V99 |
533 |
545 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP113 |
TOT-ALLOWED-AMT |
S9(11)V99 |
533 |
545 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 115 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP114 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
546 |
558 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP114 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
546 |
558 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 116 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP115 |
TOT-COPAY-AMT |
S9(11)V99 |
559 |
571 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP115 |
TOT-COPAY-AMT |
S9(11)V99 |
559 |
571 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 117 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP116 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
572 |
584 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP116 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
572 |
584 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 118 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP117 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
585 |
597 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP117 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
585 |
597 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 119 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP118 |
TOT-TPL-AMT |
S9(11)V99 |
598 |
610 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP118 |
TOT-TPL-AMT |
S9(11)V99 |
598 |
610 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 120 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP119 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
611 |
623 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP119 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
611 |
623 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 121 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP121 |
OTHER-INSURANCE-IND |
X(1) |
624 |
624 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP121 |
OTHER-INSURANCE-IND |
X(1) |
624 |
624 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 122 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP122 |
OTHER-TPL-COLLECTION |
X(3) |
625 |
627 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP122 |
OTHER-TPL-COLLECTION |
X(3) |
625 |
627 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 123 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP123 |
SERVICE-TRACKING-TYPE |
X(2) |
628 |
629 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP123 |
SERVICE-TRACKING-TYPE |
X(2) |
628 |
629 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 124 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP124 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
630 |
642 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP124 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
630 |
642 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 125 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP125 |
FIXED-PAYMENT-IND |
X(1) |
643 |
643 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP125 |
FIXED-PAYMENT-IND |
X(1) |
643 |
643 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 126 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP126 |
FUNDING-CODE |
X(2) |
644 |
645 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP126 |
FUNDING-CODE |
X(2) |
644 |
645 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 127 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP127 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
646 |
647 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP127 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
646 |
647 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 128 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP128 |
MEDICARE-COMB-DED-IND |
X(1) |
648 |
648 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP128 |
MEDICARE-COMB-DED-IND |
X(1) |
648 |
648 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 129 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP129 |
PROGRAM-TYPE |
X(2) |
649 |
650 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP129 |
PROGRAM-TYPE |
X(2) |
649 |
650 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 130 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP130 |
PLAN-ID-NUMBER |
X(12) |
651 |
662 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP130 |
PLAN-ID-NUMBER |
X(12) |
651 |
662 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 131 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP131 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
663 |
672 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP131 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
663 |
672 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 132 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP132 |
PAYMENT-LEVEL-IND |
X(1) |
673 |
673 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP132 |
PAYMENT-LEVEL-IND |
X(1) |
673 |
673 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 133 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP133 |
MEDICARE-REIM-TYPE |
X(2) |
674 |
675 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP133 |
MEDICARE-REIM-TYPE |
X(2) |
674 |
675 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 134 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP134 |
NON-COV-DAYS |
S9(5) |
676 |
680 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP134 |
NON-COV-DAYS |
S9(5) |
676 |
680 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 135 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP135 |
NON-COV-CHARGES |
S9(11)V99 |
681 |
693 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP135 |
NON-COV-CHARGES |
S9(11)V99 |
681 |
693 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 136 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP136 |
MEDICAID-COV-INPATIENT-DAYS |
S9(7) |
694 |
700 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP136 |
MEDICAID-COV-INPATIENT-DAYS |
S9(7) |
694 |
700 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 137 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP137 |
CLAIM-LINE-COUNT |
9(4) |
701 |
704 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP137 |
CLAIM-LINE-COUNT |
9(4) |
701 |
704 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 138 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP138 |
FORCED-CLAIM-IND |
X(1) |
705 |
705 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP138 |
FORCED-CLAIM-IND |
X(1) |
705 |
705 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 139 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP139 |
HEALTH-CARE-ACQUIRED-CONDITION-IND |
X(1) |
706 |
706 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP139 |
HEALTH-CARE-ACQUIRED-CONDITION-IND |
X(1) |
706 |
706 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 140 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP140 |
OCCURRENCE-CODE-01 |
X(2) |
707 |
708 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP140 |
OCCURRENCE-CODE-01 |
X(2) |
707 |
708 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 141 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP141 |
OCCURRENCE-CODE-02 |
X(2) |
709 |
710 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP141 |
OCCURRENCE-CODE-02 |
X(2) |
709 |
710 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 142 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP142 |
OCCURRENCE-CODE-03 |
X(2) |
711 |
712 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP142 |
OCCURRENCE-CODE-03 |
X(2) |
711 |
712 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 143 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP143 |
OCCURRENCE-CODE-04 |
X(2) |
713 |
714 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP143 |
OCCURRENCE-CODE-04 |
X(2) |
713 |
714 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 144 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP144 |
OCCURRENCE-CODE-05 |
X(2) |
715 |
716 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP144 |
OCCURRENCE-CODE-05 |
X(2) |
715 |
716 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 145 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP145 |
OCCURRENCE-CODE-06 |
X(2) |
717 |
718 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP145 |
OCCURRENCE-CODE-06 |
X(2) |
717 |
718 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 146 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP146 |
OCCURRENCE-CODE-07 |
X(2) |
719 |
720 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP146 |
OCCURRENCE-CODE-07 |
X(2) |
719 |
720 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 147 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP147 |
OCCURRENCE-CODE-08 |
X(2) |
721 |
722 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP147 |
OCCURRENCE-CODE-08 |
X(2) |
721 |
722 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 148 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP148 |
OCCURRENCE-CODE-09 |
X(2) |
723 |
724 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP148 |
OCCURRENCE-CODE-09 |
X(2) |
723 |
724 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 149 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP149 |
OCCURRENCE-CODE-10 |
X(2) |
725 |
726 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP149 |
OCCURRENCE-CODE-10 |
X(2) |
725 |
726 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 150 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP150 |
OCCURRENCE-CODE-EFF-DATE-01 |
9(8) |
727 |
734 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP150 |
OCCURRENCE-CODE-EFF-DATE-01 |
9(8) |
727 |
734 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 151 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP151 |
OCCURRENCE-CODE-EFF-DATE-02 |
9(8) |
735 |
742 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP151 |
OCCURRENCE-CODE-EFF-DATE-02 |
9(8) |
735 |
742 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 152 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP152 |
OCCURRENCE-CODE-EFF-DATE-03 |
9(8) |
743 |
750 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP152 |
OCCURRENCE-CODE-EFF-DATE-03 |
9(8) |
743 |
750 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 153 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP153 |
OCCURRENCE-CODE-EFF-DATE-04 |
9(8) |
751 |
758 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP153 |
OCCURRENCE-CODE-EFF-DATE-04 |
9(8) |
751 |
758 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 154 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP154 |
OCCURRENCE-CODE-EFF-DATE-05 |
9(8) |
759 |
766 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP154 |
OCCURRENCE-CODE-EFF-DATE-05 |
9(8) |
759 |
766 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 155 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP155 |
OCCURRENCE-CODE-EFF-DATE-06 |
9(8) |
767 |
774 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP155 |
OCCURRENCE-CODE-EFF-DATE-06 |
9(8) |
767 |
774 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 156 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP156 |
OCCURRENCE-CODE-EFF-DATE-07 |
9(8) |
775 |
782 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP156 |
OCCURRENCE-CODE-EFF-DATE-07 |
9(8) |
775 |
782 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 157 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP157 |
OCCURRENCE-CODE-EFF-DATE-08 |
9(8) |
783 |
790 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP157 |
OCCURRENCE-CODE-EFF-DATE-08 |
9(8) |
783 |
790 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 158 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP158 |
OCCURRENCE-CODE-EFF-DATE-09 |
9(8) |
791 |
798 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP158 |
OCCURRENCE-CODE-EFF-DATE-09 |
9(8) |
791 |
798 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 159 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP159 |
OCCURRENCE-CODE-EFF-DATE-10 |
9(8) |
799 |
806 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP159 |
OCCURRENCE-CODE-EFF-DATE-10 |
9(8) |
799 |
806 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 160 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP160 |
OCCURRENCE-CODE-END-DATE-01 |
9(8) |
807 |
814 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP160 |
OCCURRENCE-CODE-END-DATE-01 |
9(8) |
807 |
814 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 161 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP161 |
OCCURRENCE-CODE-END-DATE-02 |
9(8) |
815 |
822 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP161 |
OCCURRENCE-CODE-END-DATE-02 |
9(8) |
815 |
822 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 162 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP162 |
OCCURRENCE-CODE-END-DATE-03 |
9(8) |
823 |
830 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP162 |
OCCURRENCE-CODE-END-DATE-03 |
9(8) |
823 |
830 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 163 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP163 |
OCCURRENCE-CODE-END-DATE-04 |
9(8) |
831 |
838 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP163 |
OCCURRENCE-CODE-END-DATE-04 |
9(8) |
831 |
838 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 164 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP164 |
OCCURRENCE-CODE-END-DATE-05 |
9(8) |
839 |
846 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP164 |
OCCURRENCE-CODE-END-DATE-05 |
9(8) |
839 |
846 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 165 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP165 |
OCCURRENCE-CODE-END-DATE-06 |
9(8) |
847 |
854 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP165 |
OCCURRENCE-CODE-END-DATE-06 |
9(8) |
847 |
854 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 166 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP166 |
OCCURRENCE-CODE-END-DATE-07 |
9(8) |
855 |
862 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP166 |
OCCURRENCE-CODE-END-DATE-07 |
9(8) |
855 |
862 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 167 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP167 |
OCCURRENCE-CODE-END-DATE-08 |
9(8) |
863 |
870 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP167 |
OCCURRENCE-CODE-END-DATE-08 |
9(8) |
863 |
870 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 168 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP168 |
OCCURRENCE-CODE-END-DATE-09 |
9(8) |
871 |
878 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP168 |
OCCURRENCE-CODE-END-DATE-09 |
9(8) |
871 |
878 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 169 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP169 |
OCCURRENCE-CODE-END-DATE-10 |
9(8) |
879 |
886 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP169 |
OCCURRENCE-CODE-END-DATE-10 |
9(8) |
879 |
886 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 170 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP170 |
BIRTH-WEIGHT-GRAMS |
S9(6)V999 |
887 |
895 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP170 |
BIRTH-WEIGHT-GRAMS |
S9(6)V999 |
887 |
895 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 171 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP171 |
PATIENT-CONTROL-NUM |
X(20) |
896 |
915 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP171 |
PATIENT-CONTROL-NUM |
X(20) |
896 |
915 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 172 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP172 |
ELIGIBLE-LAST-NAME |
X(30) |
916 |
945 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP172 |
ELIGIBLE-LAST-NAME |
X(30) |
916 |
945 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 173 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP173 |
ELIGIBLE-FIRST-NAME |
X(30) |
946 |
975 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP173 |
ELIGIBLE-FIRST-NAME |
X(30) |
946 |
975 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 174 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP174 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
976 |
976 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP174 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
976 |
976 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 175 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP175 |
DATE-OF-BIRTH |
9(8) |
977 |
984 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP175 |
DATE-OF-BIRTH |
9(8) |
977 |
984 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 176 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP176 |
HEALTH-HOME-PROV-IND |
X(1) |
985 |
985 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP176 |
HEALTH-HOME-PROV-IND |
X(1) |
985 |
985 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 177 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP177 |
WAIVER-TYPE |
X(2) |
986 |
987 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP177 |
WAIVER-TYPE |
X(2) |
986 |
987 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 178 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP178 |
WAIVER-ID |
X(20) |
988 |
1007 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP178 |
WAIVER-ID |
X(20) |
988 |
1007 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 179 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP179 |
BILLING-PROV-NUM |
X(30) |
1008 |
1037 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP179 |
BILLING-PROV-NUM |
X(30) |
1008 |
1037 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 180 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP180 |
BILLING-PROV-NPI-NUM |
X(10) |
1038 |
1047 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP180 |
BILLING-PROV-NPI-NUM |
X(10) |
1038 |
1047 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 181 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP181 |
BILLING-PROV-TAXONOMY |
X(12) |
1048 |
1059 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP181 |
BILLING-PROV-TAXONOMY |
X(12) |
1048 |
1059 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 182 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP182 |
BILLING-PROV-TYPE |
X(2) |
1060 |
1061 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP182 |
BILLING-PROV-TYPE |
X(2) |
1060 |
1061 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 183 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP183 |
BILLING-PROV-SPECIALTY |
X(2) |
1062 |
1063 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP183 |
BILLING-PROV-SPECIALTY |
X(2) |
1062 |
1063 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 184 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP184 |
ADMITTING-PROV-NPI-NUM |
X(10) |
1064 |
1073 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP184 |
ADMITTING-PROV-NPI-NUM |
X(10) |
1064 |
1073 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 185 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP185 |
ADMITTING-PROV-NUM |
X(30) |
1074 |
1103 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP185 |
ADMITTING-PROV-NUM |
X(30) |
1074 |
1103 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 186 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP186 |
ADMITTING-PROV-SPECIALTY |
X(2) |
1104 |
1105 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP186 |
ADMITTING-PROV-SPECIALTY |
X(2) |
1104 |
1105 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 187 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP187 |
ADMITTING-PROV-TAXONOMY |
X(12) |
1106 |
1117 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP187 |
ADMITTING-PROV-TAXONOMY |
X(12) |
1106 |
1117 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 188 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP188 |
ADMITTING-PROV-TYPE |
X(2) |
1118 |
1119 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP188 |
ADMITTING-PROV-TYPE |
X(2) |
1118 |
1119 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 189 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP189 |
REFERRING-PROV-NUM |
X(30) |
1120 |
1149 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP189 |
REFERRING-PROV-NUM |
X(30) |
1120 |
1149 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 190 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP190 |
REFERRING-PROV-NPI-NUM |
X(10) |
1150 |
1159 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP190 |
REFERRING-PROV-NPI-NUM |
X(10) |
1150 |
1159 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 191 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP191 |
REFERRING-PROV-TAXONOMY |
X(12) |
1160 |
1171 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP191 |
REFERRING-PROV-TAXONOMY |
X(12) |
1160 |
1171 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 192 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP192 |
REFERRING-PROV-TYPE |
X(2) |
1172 |
1173 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP192 |
REFERRING-PROV-TYPE |
X(2) |
1172 |
1173 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 193 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP193 |
REFERRING-PROV-SPECIALTY |
X(2) |
1174 |
1175 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP193 |
REFERRING-PROV-SPECIALTY |
X(2) |
1174 |
1175 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 194 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP194 |
DRG-OUTLIER-AMT |
S9(11)V99 |
1176 |
1188 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP194 |
DRG-OUTLIER-AMT |
S9(11)V99 |
1176 |
1188 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 195 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP195 |
DRG-REL-WEIGHT |
X(8) |
1189 |
1196 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP195 |
DRG-REL-WEIGHT |
X(8) |
1189 |
1196 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 196 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP196 |
MEDICARE-HIC-NUM |
X(12) |
1197 |
1208 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP196 |
MEDICARE-HIC-NUM |
X(12) |
1197 |
1208 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 197 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP197 |
OUTLIER-CODE |
X(2) |
1209 |
1210 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP197 |
OUTLIER-CODE |
X(2) |
1209 |
1210 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 198 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP198 |
OUTLIER-DAYS |
S9(5) |
1211 |
1215 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP198 |
OUTLIER-DAYS |
S9(5) |
1211 |
1215 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 199 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP199 |
PATIENT-STATUS |
X(2) |
1216 |
1217 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP199 |
PATIENT-STATUS |
X(2) |
1216 |
1217 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 200 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP201 |
BMI |
S9(5)V9 |
1218 |
1223 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP201 |
BMI |
S9(5)V9 |
1218 |
1223 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 201 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP202 |
REMITTANCE-NUM |
X(30) |
1224 |
1253 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP202 |
REMITTANCE-NUM |
X(30) |
1224 |
1253 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 202 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP203 |
SPLIT-CLAIM-IND |
X(1) |
1254 |
1254 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP203 |
SPLIT-CLAIM-IND |
X(1) |
1254 |
1254 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 203 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP204 |
BORDER-STATE-IND |
X(1) |
1255 |
1255 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP204 |
BORDER-STATE-IND |
X(1) |
1255 |
1255 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 204 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP206 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
1256 |
1268 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP206 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
1256 |
1268 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 205 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP207 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
1269 |
1276 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP207 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
1269 |
1276 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 206 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP208 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
1277 |
1289 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP208 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
1277 |
1289 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 207 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP209 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
1290 |
1297 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP209 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
1290 |
1297 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 208 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP210 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
1298 |
1310 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP210 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
1298 |
1310 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 209 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP211 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
1311 |
1318 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP211 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
1311 |
1318 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 210 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP212 |
CLAIM-DENIED-INDICATOR |
X(1) |
1319 |
1319 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP212 |
CLAIM-DENIED-INDICATOR |
X(1) |
1319 |
1319 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 211 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP213 |
COPAY-WAIVED-IND |
X(1) |
1320 |
1320 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP213 |
COPAY-WAIVED-IND |
X(1) |
1320 |
1320 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 212 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP214 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
1321 |
1370 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP214 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
1321 |
1370 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 213 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP216 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
1371 |
1383 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP216 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
1371 |
1383 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 214 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP217 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
1384 |
1391 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP217 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
1384 |
1391 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 215 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP218 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
1392 |
1404 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP218 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
1392 |
1404 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 216 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP219 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
1405 |
1412 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP219 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
1405 |
1412 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 217 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP220 |
MEDICAID-AMOUNT-PAID-DSH |
S9(11)V99 |
1413 |
1425 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP220 |
MEDICAID-AMOUNT-PAID-DSH |
S9(11)V99 |
1413 |
1425 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 218 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP221 |
HEALTH-HOME-PROVIDER-NPI |
X(10) |
1426 |
1435 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP221 |
HEALTH-HOME-PROVIDER-NPI |
X(10) |
1426 |
1435 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 219 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP222 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
1436 |
1447 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP222 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
1436 |
1447 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 220 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP223 |
OPERATING-PROV-TAXONOMY |
X(12) |
1448 |
1459 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP223 |
OPERATING-PROV-TAXONOMY |
X(12) |
1448 |
1459 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 221 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP224 |
UNDER-DIRECTION-OF-PROV-NPI |
X(10) |
1460 |
1469 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP224 |
UNDER-DIRECTION-OF-PROV-NPI |
X(10) |
1460 |
1469 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 222 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP225 |
UNDER-DIRECTION-OF-PROV-TAXONOMY |
X(12) |
1470 |
1481 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP225 |
UNDER-DIRECTION-OF-PROV-TAXONOMY |
X(12) |
1470 |
1481 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 223 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP226 |
UNDER-SUPERVISION-OF-PROV-NPI |
X(10) |
1482 |
1491 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP226 |
UNDER-SUPERVISION-OF-PROV-NPI |
X(10) |
1482 |
1491 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 224 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP227 |
UNDER-SUPERVISION-OF-PROV-TAXONOMY |
X(12) |
1492 |
1503 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP227 |
UNDER-SUPERVISION-OF-PROV-TAXONOMY |
X(12) |
1492 |
1503 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 225 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP228 |
MEDICARE-PAID-AMT |
S9(11)V99 |
1504 |
1516 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP228 |
MEDICARE-PAID-AMT |
S9(11)V99 |
1504 |
1516 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 226 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP229 |
STATE-NOTATION |
X(500) |
1517 |
2016 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP229 |
STATE-NOTATION |
X(500) |
1517 |
2016 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 227 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP289 |
PROV-LOCATION-ID |
X(5) |
2017 |
2021 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP289 |
PROV-LOCATION-ID |
X(5) |
2017 |
2021 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 228 |
1 |
1 |
0 |
1 |
1 |
1 |
1 |
CIP230 |
FILLER |
X(79) |
2022 |
2100 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP230 |
FILLER |
X(78) |
2022 |
2100 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 229 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP231 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP231 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 230 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP232 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP232 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 231 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP233 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP233 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 232 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP234 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP234 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 233 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP235 |
ICN-ORIG |
X(50) |
42 |
91 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP235 |
ICN-ORIG |
X(50) |
42 |
91 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 234 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP236 |
ICN-ADJ |
X(50) |
92 |
141 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP236 |
ICN-ADJ |
X(50) |
92 |
141 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 235 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP237 |
LINE-NUM-ORIG |
X(3) |
142 |
144 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP237 |
LINE-NUM-ORIG |
X(3) |
142 |
144 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 236 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP238 |
LINE-NUM-ADJ |
X(3) |
145 |
147 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP238 |
LINE-NUM-ADJ |
X(3) |
145 |
147 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 237 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP239 |
LINE-ADJUSTMENT-IND |
X(1) |
148 |
148 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP239 |
LINE-ADJUSTMENT-IND |
X(1) |
148 |
148 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 238 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP240 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
149 |
151 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP240 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
149 |
151 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 239 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP241 |
SUBMITTER-ID |
X(12) |
152 |
163 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP241 |
SUBMITTER-ID |
X(12) |
152 |
163 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 240 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP242 |
CLAIM-LINE-STATUS |
X(3) |
164 |
166 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP242 |
CLAIM-LINE-STATUS |
X(3) |
164 |
166 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 241 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP243 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
167 |
174 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP243 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
167 |
174 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 242 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP244 |
ENDING-DATE-OF-SERVICE |
9(8) |
175 |
182 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP244 |
ENDING-DATE-OF-SERVICE |
9(8) |
175 |
182 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 243 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP245 |
REVENUE-CODE |
X(4) |
183 |
186 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP245 |
REVENUE-CODE |
X(4) |
183 |
186 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 244 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP248 |
IMMUNIZATION-TYPE |
X(2) |
187 |
188 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP248 |
IMMUNIZATION-TYPE |
X(2) |
187 |
188 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 245 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP249 |
IP-LT-QUANTITY-OF-SERVICE-ACTUAL |
S9(6)V999 |
189 |
197 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP249 |
IP-LT-QUANTITY-OF-SERVICE-ACTUAL |
S9(6)V999 |
189 |
197 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 246 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP250 |
IP-LT-QUANTITY-OF-SERVICE-ALLOWED |
S9(6)V999 |
198 |
206 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP250 |
IP-LT-QUANTITY-OF-SERVICE-ALLOWED |
S9(6)V999 |
198 |
206 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 247 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP251 |
REVENUE-CHARGE |
S9(11)V99 |
207 |
219 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP251 |
REVENUE-CHARGE |
S9(11)V99 |
207 |
219 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 248 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP252 |
ALLOWED-AMT |
S9(11)V99 |
220 |
232 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP252 |
ALLOWED-AMT |
S9(11)V99 |
220 |
232 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 249 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP253 |
TPL-AMT |
S9(11)V99 |
233 |
245 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP253 |
TPL-AMT |
S9(11)V99 |
233 |
245 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 250 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP254 |
MEDICAID-PAID-AMT |
S9(11)V99 |
246 |
258 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP254 |
MEDICAID-PAID-AMT |
S9(11)V99 |
246 |
258 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 251 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP255 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
259 |
271 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP255 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
259 |
271 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 252 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP256 |
BILLING-UNIT |
X(2) |
272 |
273 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP256 |
BILLING-UNIT |
X(2) |
272 |
273 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 253 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP257 |
TYPE-OF-SERVICE |
X(3) |
274 |
276 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP257 |
TYPE-OF-SERVICE |
X(3) |
274 |
276 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 254 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP260 |
SERVICING-PROV-NUM |
X(30) |
277 |
306 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP260 |
SERVICING-PROV-NUM |
X(30) |
277 |
306 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 255 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP261 |
SERVICING-PROV-NPI-NUM |
X(10) |
307 |
316 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP261 |
SERVICING-PROV-NPI-NUM |
X(10) |
307 |
316 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 256 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP262 |
SERVICING-PROV-TAXONOMY |
X(12) |
317 |
328 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP262 |
SERVICING-PROV-TAXONOMY |
X(12) |
317 |
328 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 257 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP263 |
SERVICING-PROV-TYPE |
X(2) |
329 |
330 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP263 |
SERVICING-PROV-TYPE |
X(2) |
329 |
330 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 258 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP264 |
SERVICING-PROV-SPECIALTY |
X(2) |
331 |
332 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP264 |
SERVICING-PROV-SPECIALTY |
X(2) |
331 |
332 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 259 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP265 |
OPERATING-PROV-NPI-NUM |
X(10) |
333 |
342 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP265 |
OPERATING-PROV-NPI-NUM |
X(10) |
333 |
342 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 260 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP266 |
OTHER-TPL-COLLECTION |
X(3) |
343 |
345 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP266 |
OTHER-TPL-COLLECTION |
X(3) |
343 |
345 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 261 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP267 |
PROV-FACILITY-TYPE |
X(9) |
346 |
354 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP267 |
PROV-FACILITY-TYPE |
X(9) |
346 |
354 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 262 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP268 |
BENEFIT-TYPE |
X(3) |
355 |
357 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP268 |
BENEFIT-TYPE |
X(3) |
355 |
357 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 263 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP269 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
358 |
359 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP269 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
358 |
359 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 264 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP270 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
360 |
363 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP270 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
360 |
363 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 265 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP271 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
364 |
366 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP271 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
364 |
366 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 266 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP272 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
367 |
379 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP272 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
367 |
379 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 267 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP273 |
STATE-NOTATION |
X(500) |
380 |
879 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP273 |
STATE-NOTATION |
X(500) |
380 |
879 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 268 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CIP279 |
HCPCS-RATE |
X(14) |
880 |
893 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP279 |
HCPCS-RATE |
X(14) |
880 |
893 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 269 |
1 |
1 |
1 |
1 |
0 |
1 |
1 |
CIP284 |
NATIONAL-DRUG-CODE |
X(12) |
894 |
905 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP284 |
NATIONAL-DRUG-CODE |
X(12) |
894 |
904 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 270 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CIP285 |
NDC-UNIT-OF-MEASURE |
X(2) |
906 |
907 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP285 |
NDC-UNIT-OF-MEASURE |
X(2) |
905 |
906 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 271 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CIP278 |
NDC-QUANTITY |
S9(6)V999 |
908 |
916 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP278 |
NDC-QUANTITY |
S9(6)V999 |
907 |
915 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 272 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CIP286 |
ADJUDICATION-DATE |
9(8) |
917 |
924 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP286 |
ADJUDICATION-DATE |
9(8) |
916 |
923 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 273 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CIP287 |
SELF-DIRECTION-TYPE |
X(3) |
925 |
927 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP287 |
SELF-DIRECTION-TYPE |
X(3) |
924 |
926 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 274 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CIP288 |
PRE-AUTHORIZATION-NUM |
X(18) |
928 |
945 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP288 |
PRE-AUTHORIZATION-NUM |
X(18) |
927 |
944 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 275 |
1 |
1 |
1 |
0 |
1 |
1 |
1 |
CIP274 |
FILLER |
X(1155) |
946 |
2100 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP274 |
FILLER |
X(1155) |
945 |
2100 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 276 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT001 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT001 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 277 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 278 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 279 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 280 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 281 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT006 |
FILE-NAME |
X(8) |
32 |
39 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT006 |
FILE-NAME |
X(8) |
32 |
39 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 282 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 283 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 284 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 285 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 286 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 287 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT012 |
SSN-INDICATOR |
X(1) |
67 |
67 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT012 |
SSN-INDICATOR |
X(1) |
67 |
67 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 288 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT013 |
TOT-REC-CNT |
9(11) |
68 |
78 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT013 |
TOT-REC-CNT |
9(11) |
68 |
78 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 289 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT227 |
SEQUENCE-NUMBER |
X(4) |
79 |
82 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT227 |
SEQUENCE-NUMBER |
X(4) |
79 |
82 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 290 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT014 |
STATE-NOTATION |
X(500) |
83 |
582 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT014 |
STATE-NOTATION |
X(500) |
83 |
582 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 291 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT015 |
FILLER |
X(1318) |
583 |
1900 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT015 |
FILLER |
X(1318) |
583 |
1900 |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 292 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT016 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT016 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 293 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 294 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 295 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT019 |
ICN-ORIG |
X(50) |
22 |
71 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT019 |
ICN-ORIG |
X(50) |
22 |
71 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 296 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT020 |
ICN-ADJ |
X(50) |
72 |
121 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT020 |
ICN-ADJ |
X(50) |
72 |
121 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 297 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT021 |
SUBMITTER-ID |
X(12) |
122 |
133 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT021 |
SUBMITTER-ID |
X(12) |
122 |
133 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 298 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
134 |
153 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
134 |
153 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 299 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT023 |
CROSSOVER-INDICATOR |
X(1) |
154 |
154 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT023 |
CROSSOVER-INDICATOR |
X(1) |
154 |
154 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 300 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT024 |
1115A-DEMONSTRATION-IND |
X(1) |
155 |
155 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT024 |
1115A-DEMONSTRATION-IND |
X(1) |
155 |
155 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 301 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT025 |
ADJUSTMENT-IND |
X(1) |
156 |
156 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT025 |
ADJUSTMENT-IND |
X(1) |
156 |
156 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 302 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT026 |
ADJUSTMENT-REASON-CODE |
X(3) |
157 |
159 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT026 |
ADJUSTMENT-REASON-CODE |
X(3) |
157 |
159 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 303 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT027 |
ADMITTING-DIAGNOSIS-CODE |
X(7) |
160 |
166 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT027 |
ADMITTING-DIAGNOSIS-CODE |
X(7) |
160 |
166 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 304 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT028 |
ADMITTING-DIAGNOSIS-CODE-FLAG |
X(1) |
167 |
167 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT028 |
ADMITTING-DIAGNOSIS-CODE-FLAG |
X(1) |
167 |
167 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 305 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT029 |
DIAGNOSIS-CODE-1 |
X(7) |
168 |
174 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT029 |
DIAGNOSIS-CODE-1 |
X(7) |
168 |
174 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 306 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT030 |
DIAGNOSIS-CODE-FLAG-1 |
X(1) |
175 |
175 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT030 |
DIAGNOSIS-CODE-FLAG-1 |
X(1) |
175 |
175 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 307 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT031 |
DIAGNOSIS-POA-FLAG-1 |
X(1) |
176 |
176 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT031 |
DIAGNOSIS-POA-FLAG-1 |
X(1) |
176 |
176 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 308 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT032 |
DIAGNOSIS-CODE-2 |
X(7) |
177 |
183 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT032 |
DIAGNOSIS-CODE-2 |
X(7) |
177 |
183 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 309 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT033 |
DIAGNOSIS-CODE-FLAG-2 |
X(1) |
184 |
184 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT033 |
DIAGNOSIS-CODE-FLAG-2 |
X(1) |
184 |
184 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 310 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT034 |
DIAGNOSIS-POA-FLAG-2 |
X(1) |
185 |
185 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT034 |
DIAGNOSIS-POA-FLAG-2 |
X(1) |
185 |
185 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 311 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT035 |
DIAGNOSIS-CODE-3 |
X(7) |
186 |
192 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT035 |
DIAGNOSIS-CODE-3 |
X(7) |
186 |
192 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 312 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT036 |
DIAGNOSIS-CODE-FLAG-3 |
X(1) |
193 |
193 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT036 |
DIAGNOSIS-CODE-FLAG-3 |
X(1) |
193 |
193 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 313 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT037 |
DIAGNOSIS-POA-FLAG-3 |
X(1) |
194 |
194 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT037 |
DIAGNOSIS-POA-FLAG-3 |
X(1) |
194 |
194 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 314 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT038 |
DIAGNOSIS-CODE-4 |
X(7) |
195 |
201 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT038 |
DIAGNOSIS-CODE-4 |
X(7) |
195 |
201 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 315 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT039 |
DIAGNOSIS-CODE-FLAG-4 |
X(1) |
202 |
202 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT039 |
DIAGNOSIS-CODE-FLAG-4 |
X(1) |
202 |
202 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 316 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT040 |
DIAGNOSIS-POA-FLAG-4 |
X(1) |
203 |
203 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT040 |
DIAGNOSIS-POA-FLAG-4 |
X(1) |
203 |
203 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 317 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT041 |
DIAGNOSIS-CODE-5 |
X(7) |
204 |
210 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT041 |
DIAGNOSIS-CODE-5 |
X(7) |
204 |
210 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 318 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT042 |
DIAGNOSIS-CODE-FLAG-5 |
X(1) |
211 |
211 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT042 |
DIAGNOSIS-CODE-FLAG-5 |
X(1) |
211 |
211 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 319 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT043 |
DIAGNOSIS-POA-FLAG-5 |
X(1) |
212 |
212 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT043 |
DIAGNOSIS-POA-FLAG-5 |
X(1) |
212 |
212 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 320 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT044 |
ADMISSION-DATE |
9(8) |
213 |
220 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT044 |
ADMISSION-DATE |
9(8) |
213 |
220 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 321 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT045 |
ADMISSION-HOUR |
X(2) |
221 |
222 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT045 |
ADMISSION-HOUR |
X(2) |
221 |
222 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 322 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT046 |
DISCHARGE-DATE |
9(8) |
223 |
230 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT046 |
DISCHARGE-DATE |
9(8) |
223 |
230 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 323 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT047 |
DISCHARGE-HOUR |
X(2) |
231 |
232 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT047 |
DISCHARGE-HOUR |
X(2) |
231 |
232 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 324 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT048 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
233 |
240 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT048 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
233 |
240 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 325 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT049 |
ENDING-DATE-OF-SERVICE |
9(8) |
241 |
248 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT049 |
ENDING-DATE-OF-SERVICE |
9(8) |
241 |
248 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 326 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT050 |
ADJUDICATION-DATE |
9(8) |
249 |
256 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT050 |
ADJUDICATION-DATE |
9(8) |
249 |
256 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 327 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT051 |
MEDICAID-PAID-DATE |
9(8) |
257 |
264 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT051 |
MEDICAID-PAID-DATE |
9(8) |
257 |
264 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 328 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT052 |
TYPE-OF-CLAIM |
X(1) |
265 |
265 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT052 |
TYPE-OF-CLAIM |
X(1) |
265 |
265 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 329 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT053 |
TYPE-OF-BILL |
X(4) |
266 |
269 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT053 |
TYPE-OF-BILL |
X(4) |
266 |
269 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 330 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT054 |
CLAIM-STATUS |
X(3) |
270 |
272 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT054 |
CLAIM-STATUS |
X(3) |
270 |
272 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 331 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT055 |
CLAIM-STATUS-CATEGORY |
X(3) |
273 |
275 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT055 |
CLAIM-STATUS-CATEGORY |
X(3) |
273 |
275 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 332 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT056 |
SOURCE-LOCATION |
X(2) |
276 |
277 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT056 |
SOURCE-LOCATION |
X(2) |
276 |
277 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 333 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT057 |
CHECK-NUM |
X(15) |
278 |
292 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT057 |
CHECK-NUM |
X(15) |
278 |
292 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 334 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT058 |
CHECK-EFF-DATE |
9(8) |
293 |
300 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT058 |
CHECK-EFF-DATE |
9(8) |
293 |
300 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 335 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT059 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
301 |
305 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT059 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
301 |
305 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 336 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT060 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
306 |
310 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT060 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
306 |
310 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 337 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT061 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
311 |
315 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT061 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
311 |
315 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 338 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT062 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
316 |
320 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT062 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
316 |
320 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 339 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT063 |
TOT-BILLED-AMT |
S9(11)V99 |
321 |
333 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT063 |
TOT-BILLED-AMT |
S9(11)V99 |
321 |
333 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 340 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT064 |
TOT-ALLOWED-AMT |
S9(11)V99 |
334 |
346 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT064 |
TOT-ALLOWED-AMT |
S9(11)V99 |
334 |
346 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 341 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT065 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
347 |
359 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT065 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
347 |
359 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 342 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT066 |
TOT-COPAY-AMT |
S9(11)V99 |
360 |
372 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT066 |
TOT-COPAY-AMT |
S9(11)V99 |
360 |
372 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 343 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT067 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
373 |
385 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT067 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
373 |
385 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 344 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT068 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
386 |
398 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT068 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
386 |
398 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 345 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT069 |
TOT-TPL-AMT |
S9(11)V99 |
399 |
411 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT069 |
TOT-TPL-AMT |
S9(11)V99 |
399 |
411 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 346 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT070 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
412 |
424 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT070 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
412 |
424 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 347 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT071 |
OTHER-INSURANCE-IND |
X(1) |
425 |
425 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT071 |
OTHER-INSURANCE-IND |
X(1) |
425 |
425 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 348 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT072 |
OTHER-TPL-COLLECTION |
X(3) |
426 |
428 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT072 |
OTHER-TPL-COLLECTION |
X(3) |
426 |
428 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 349 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT073 |
SERVICE-TRACKING-TYPE |
X(2) |
429 |
430 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT073 |
SERVICE-TRACKING-TYPE |
X(2) |
429 |
430 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 350 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT074 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
431 |
443 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT074 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
431 |
443 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 351 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT075 |
FIXED-PAYMENT-IND |
X(1) |
444 |
444 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT075 |
FIXED-PAYMENT-IND |
X(1) |
444 |
444 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 352 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT076 |
FUNDING-CODE |
X(2) |
445 |
446 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT076 |
FUNDING-CODE |
X(2) |
445 |
446 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 353 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT077 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
447 |
448 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT077 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
447 |
448 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 354 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT078 |
MEDICARE-COMB-DED-IND |
X(1) |
449 |
449 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT078 |
MEDICARE-COMB-DED-IND |
X(1) |
449 |
449 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 355 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT079 |
PROGRAM-TYPE |
X(2) |
450 |
451 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT079 |
PROGRAM-TYPE |
X(2) |
450 |
451 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 356 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT080 |
PLAN-ID-NUMBER |
X(12) |
452 |
463 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT080 |
PLAN-ID-NUMBER |
X(12) |
452 |
463 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 357 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT081 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
464 |
473 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT081 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
464 |
473 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 358 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT082 |
PAYMENT-LEVEL-IND |
X(1) |
474 |
474 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT082 |
PAYMENT-LEVEL-IND |
X(1) |
474 |
474 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 359 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT083 |
MEDICARE-REIM-TYPE |
X(2) |
475 |
476 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT083 |
MEDICARE-REIM-TYPE |
X(2) |
475 |
476 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 360 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT084 |
NON-COV-DAYS |
S9(5) |
477 |
481 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT084 |
NON-COV-DAYS |
S9(5) |
477 |
481 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 361 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT085 |
NON-COV-CHARGES |
S9(11)V99 |
482 |
494 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT085 |
NON-COV-CHARGES |
S9(11)V99 |
482 |
494 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 362 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT086 |
MEDICAID-COV-INPATIENT-DAYS |
S9(5) |
495 |
499 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT086 |
MEDICAID-COV-INPATIENT-DAYS |
S9(5) |
495 |
499 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 363 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT087 |
CLAIM-LINE-COUNT |
9(4) |
500 |
503 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT087 |
CLAIM-LINE-COUNT |
9(4) |
500 |
503 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 364 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT090 |
FORCED-CLAIM-IND |
X(1) |
504 |
504 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT090 |
FORCED-CLAIM-IND |
X(1) |
504 |
504 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 365 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT091 |
HEALTH-CARE-ACQUIRED-CONDITION-IND |
X(1) |
505 |
505 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT091 |
HEALTH-CARE-ACQUIRED-CONDITION-IND |
X(1) |
505 |
505 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 366 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT092 |
OCCURRENCE-CODE-01 |
X(2) |
506 |
507 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT092 |
OCCURRENCE-CODE-01 |
X(2) |
506 |
507 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 367 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT093 |
OCCURRENCE-CODE-02 |
X(2) |
508 |
509 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT093 |
OCCURRENCE-CODE-02 |
X(2) |
508 |
509 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 368 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT094 |
OCCURRENCE-CODE-03 |
X(2) |
510 |
511 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT094 |
OCCURRENCE-CODE-03 |
X(2) |
510 |
511 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 369 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT095 |
OCCURRENCE-CODE-04 |
X(2) |
512 |
513 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT095 |
OCCURRENCE-CODE-04 |
X(2) |
512 |
513 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 370 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT096 |
OCCURRENCE-CODE-05 |
X(2) |
514 |
515 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT096 |
OCCURRENCE-CODE-05 |
X(2) |
514 |
515 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 371 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT097 |
OCCURRENCE-CODE-06 |
X(2) |
516 |
517 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT097 |
OCCURRENCE-CODE-06 |
X(2) |
516 |
517 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 372 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT098 |
OCCURRENCE-CODE-07 |
X(2) |
518 |
519 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT098 |
OCCURRENCE-CODE-07 |
X(2) |
518 |
519 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 373 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT099 |
OCCURRENCE-CODE-08 |
X(2) |
520 |
521 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT099 |
OCCURRENCE-CODE-08 |
X(2) |
520 |
521 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 374 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT100 |
OCCURRENCE-CODE-09 |
X(2) |
522 |
523 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT100 |
OCCURRENCE-CODE-09 |
X(2) |
522 |
523 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 375 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT101 |
OCCURRENCE-CODE-10 |
X(2) |
524 |
525 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT101 |
OCCURRENCE-CODE-10 |
X(2) |
524 |
525 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 376 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT102 |
OCCURRENCE-CODE-EFF-DATE-01 |
9(8) |
526 |
533 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT102 |
OCCURRENCE-CODE-EFF-DATE-01 |
9(8) |
526 |
533 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 377 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT103 |
OCCURRENCE-CODE-EFF-DATE-02 |
9(8) |
534 |
541 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT103 |
OCCURRENCE-CODE-EFF-DATE-02 |
9(8) |
534 |
541 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 378 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT104 |
OCCURRENCE-CODE-EFF-DATE-03 |
9(8) |
542 |
549 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT104 |
OCCURRENCE-CODE-EFF-DATE-03 |
9(8) |
542 |
549 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 379 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT105 |
OCCURRENCE-CODE-EFF-DATE-04 |
9(8) |
550 |
557 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT105 |
OCCURRENCE-CODE-EFF-DATE-04 |
9(8) |
550 |
557 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 380 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT106 |
OCCURRENCE-CODE-EFF-DATE-05 |
9(8) |
558 |
565 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT106 |
OCCURRENCE-CODE-EFF-DATE-05 |
9(8) |
558 |
565 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 381 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT107 |
OCCURRENCE-CODE-EFF-DATE-06 |
9(8) |
566 |
573 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT107 |
OCCURRENCE-CODE-EFF-DATE-06 |
9(8) |
566 |
573 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 382 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT108 |
OCCURRENCE-CODE-EFF-DATE-07 |
9(8) |
574 |
581 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT108 |
OCCURRENCE-CODE-EFF-DATE-07 |
9(8) |
574 |
581 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 383 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT109 |
OCCURRENCE-CODE-EFF-DATE-08 |
9(8) |
582 |
589 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT109 |
OCCURRENCE-CODE-EFF-DATE-08 |
9(8) |
582 |
589 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 384 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT110 |
OCCURRENCE-CODE-EFF-DATE-09 |
9(8) |
590 |
597 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT110 |
OCCURRENCE-CODE-EFF-DATE-09 |
9(8) |
590 |
597 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 385 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT111 |
OCCURRENCE-CODE-EFF-DATE-10 |
9(8) |
598 |
605 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT111 |
OCCURRENCE-CODE-EFF-DATE-10 |
9(8) |
598 |
605 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 386 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT112 |
OCCURRENCE-CODE-END-DATE-01 |
9(8) |
606 |
613 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT112 |
OCCURRENCE-CODE-END-DATE-01 |
9(8) |
606 |
613 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 387 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT113 |
OCCURRENCE-CODE-END-DATE-02 |
9(8) |
614 |
621 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT113 |
OCCURRENCE-CODE-END-DATE-02 |
9(8) |
614 |
621 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 388 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT114 |
OCCURRENCE-CODE-END-DATE-03 |
9(8) |
622 |
629 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT114 |
OCCURRENCE-CODE-END-DATE-03 |
9(8) |
622 |
629 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 389 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT115 |
OCCURRENCE-CODE-END-DATE-04 |
9(8) |
630 |
637 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT115 |
OCCURRENCE-CODE-END-DATE-04 |
9(8) |
630 |
637 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 390 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT116 |
OCCURRENCE-CODE-END-DATE-05 |
9(8) |
638 |
645 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT116 |
OCCURRENCE-CODE-END-DATE-05 |
9(8) |
638 |
645 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 391 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT117 |
OCCURRENCE-CODE-END-DATE-06 |
9(8) |
646 |
653 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT117 |
OCCURRENCE-CODE-END-DATE-06 |
9(8) |
646 |
653 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 392 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT118 |
OCCURRENCE-CODE-END-DATE-07 |
9(8) |
654 |
661 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT118 |
OCCURRENCE-CODE-END-DATE-07 |
9(8) |
654 |
661 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 393 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT119 |
OCCURRENCE-CODE-END-DATE-08 |
9(8) |
662 |
669 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT119 |
OCCURRENCE-CODE-END-DATE-08 |
9(8) |
662 |
669 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 394 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT120 |
OCCURRENCE-CODE-END-DATE-09 |
9(8) |
670 |
677 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT120 |
OCCURRENCE-CODE-END-DATE-09 |
9(8) |
670 |
677 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 395 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT121 |
OCCURRENCE-CODE-END-DATE-10 |
9(8) |
678 |
685 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT121 |
OCCURRENCE-CODE-END-DATE-10 |
9(8) |
678 |
685 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 396 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT122 |
PATIENT-CONTROL-NUM |
X(20) |
686 |
705 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT122 |
PATIENT-CONTROL-NUM |
X(20) |
686 |
705 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 397 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT123 |
ELIGIBLE-LAST-NAME |
X(30) |
706 |
735 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT123 |
ELIGIBLE-LAST-NAME |
X(30) |
706 |
735 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 398 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT124 |
ELIGIBLE-FIRST-NAME |
X(30) |
736 |
765 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT124 |
ELIGIBLE-FIRST-NAME |
X(30) |
736 |
765 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 399 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT125 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
766 |
766 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT125 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
766 |
766 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 400 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT126 |
DATE-OF-BIRTH |
9(8) |
767 |
774 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT126 |
DATE-OF-BIRTH |
9(8) |
767 |
774 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 401 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT127 |
HEALTH-HOME-PROV-IND |
X(1) |
775 |
775 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT127 |
HEALTH-HOME-PROV-IND |
X(1) |
775 |
775 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 402 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT128 |
WAIVER-TYPE |
X(2) |
776 |
777 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT128 |
WAIVER-TYPE |
X(2) |
776 |
777 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 403 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT129 |
WAIVER-ID |
X(20) |
778 |
797 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT129 |
WAIVER-ID |
X(20) |
778 |
797 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 404 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT130 |
BILLING-PROV-NUM |
X(30) |
798 |
827 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT130 |
BILLING-PROV-NUM |
X(30) |
798 |
827 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 405 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT131 |
BILLING-PROV-NPI-NUM |
X(10) |
828 |
837 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT131 |
BILLING-PROV-NPI-NUM |
X(10) |
828 |
837 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 406 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT132 |
BILLING-PROV-TAXONOMY |
X(12) |
838 |
849 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT132 |
BILLING-PROV-TAXONOMY |
X(12) |
838 |
849 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 407 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT133 |
BILLING-PROV-TYPE |
X(2) |
850 |
851 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT133 |
BILLING-PROV-TYPE |
X(2) |
850 |
851 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 408 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT134 |
BILLING-PROV-SPECIALTY |
X(2) |
852 |
853 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT134 |
BILLING-PROV-SPECIALTY |
X(2) |
852 |
853 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 409 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT135 |
REFERRING-PROV-NUM |
X(30) |
854 |
883 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT135 |
REFERRING-PROV-NUM |
X(30) |
854 |
883 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 410 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT136 |
REFERRING-PROV-NPI-NUM |
X(10) |
884 |
893 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT136 |
REFERRING-PROV-NPI-NUM |
X(10) |
884 |
893 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 411 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT137 |
REFERRING-PROV-TAXONOMY |
X(12) |
894 |
905 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT137 |
REFERRING-PROV-TAXONOMY |
X(12) |
894 |
905 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 412 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT138 |
REFERRING-PROV-TYPE |
X(2) |
906 |
907 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT138 |
REFERRING-PROV-TYPE |
X(2) |
906 |
907 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 413 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT139 |
REFERRING-PROV-SPECIALTY |
X(2) |
908 |
909 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT139 |
REFERRING-PROV-SPECIALTY |
X(2) |
908 |
909 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 414 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT140 |
MEDICARE-HIC-NUM |
X(12) |
910 |
921 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT140 |
MEDICARE-HIC-NUM |
X(12) |
910 |
921 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 415 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT141 |
PATIENT-STATUS |
X(2) |
922 |
923 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT141 |
PATIENT-STATUS |
X(2) |
922 |
923 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 416 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT143 |
BMI |
S9(5)V9 |
924 |
929 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT143 |
BMI |
S9(5)V9 |
924 |
929 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 417 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT144 |
REMITTANCE-NUM |
X(30) |
930 |
959 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT144 |
REMITTANCE-NUM |
X(30) |
930 |
959 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 418 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT145 |
LTC-RCP-LIAB-AMT |
S9(11)V99 |
960 |
972 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT145 |
LTC-RCP-LIAB-AMT |
S9(11)V99 |
960 |
972 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 419 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT146 |
DAILY-RATE |
S9(5)V99 |
973 |
979 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT146 |
DAILY-RATE |
S9(5)V99 |
973 |
979 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 420 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT147 |
ICF-IID-DAYS |
S9(5) |
980 |
984 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT147 |
ICF-IID-DAYS |
S9(5) |
980 |
984 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 421 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT148 |
LEAVE-DAYS |
S9(5) |
985 |
989 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT148 |
LEAVE-DAYS |
S9(5) |
985 |
989 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 422 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT149 |
NURSING-FACILITY-DAYS |
S9(5) |
990 |
994 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT149 |
NURSING-FACILITY-DAYS |
S9(5) |
990 |
994 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 423 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT150 |
SPLIT-CLAIM-IND |
X(1) |
995 |
995 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT150 |
SPLIT-CLAIM-IND |
X(1) |
995 |
995 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 424 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT151 |
BORDER-STATE-IND |
X(1) |
996 |
996 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT151 |
BORDER-STATE-IND |
X(1) |
996 |
996 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 425 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT153 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
997 |
1009 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT153 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
997 |
1009 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 426 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT154 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
1010 |
1017 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT154 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
1010 |
1017 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 427 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT155 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
1018 |
1030 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT155 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
1018 |
1030 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 428 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT156 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
1031 |
1038 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT156 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
1031 |
1038 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 429 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT157 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
1039 |
1051 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT157 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
1039 |
1051 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 430 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT158 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
1052 |
1059 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT158 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
1052 |
1059 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 431 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT159 |
CLAIM-DENIED-INDICATOR |
X(1) |
1060 |
1060 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT159 |
CLAIM-DENIED-INDICATOR |
X(1) |
1060 |
1060 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 432 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT160 |
COPAY-WAIVED-IND |
X(1) |
1061 |
1061 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT160 |
COPAY-WAIVED-IND |
X(1) |
1061 |
1061 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 433 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT161 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
1062 |
1111 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT161 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
1062 |
1111 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 434 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT163 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
1112 |
1124 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT163 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
1112 |
1124 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 435 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT164 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
1125 |
1132 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT164 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
1125 |
1132 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 436 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT165 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
1133 |
1145 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT165 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
1133 |
1145 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 437 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT166 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
1146 |
1153 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT166 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
1146 |
1153 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 438 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT167 |
HEALTH-HOME-PROVIDER-NPI |
X(12) |
1154 |
1165 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT167 |
HEALTH-HOME-PROVIDER-NPI |
X(12) |
1154 |
1165 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 439 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT168 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
1166 |
1177 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT168 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
1166 |
1177 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 440 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT169 |
UNDER-DIRECTION-OF-PROV-NPI |
X(12) |
1178 |
1189 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT169 |
UNDER-DIRECTION-OF-PROV-NPI |
X(12) |
1178 |
1189 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 441 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT170 |
UNDER-DIRECTION-OF-PROV-TAXONOMY |
X(12) |
1190 |
1201 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT170 |
UNDER-DIRECTION-OF-PROV-TAXONOMY |
X(12) |
1190 |
1201 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 442 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT171 |
UNDER-SUPERVISION-OF-PROV-NPI |
X(12) |
1202 |
1213 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT171 |
UNDER-SUPERVISION-OF-PROV-NPI |
X(12) |
1202 |
1213 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 443 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT172 |
UNDER-SUPERVISION-OF-PROV-TAXONOMY |
X(12) |
1214 |
1225 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT172 |
UNDER-SUPERVISION-OF-PROV-TAXONOMY |
X(12) |
1214 |
1225 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 444 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT174 |
ADMITTING-PROV-NPI-NUM |
X(10) |
1226 |
1235 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT174 |
ADMITTING-PROV-NPI-NUM |
X(10) |
1226 |
1235 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 445 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT175 |
ADMITTING-PROV-NUM |
X(30) |
1236 |
1265 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT175 |
ADMITTING-PROV-NUM |
X(30) |
1236 |
1265 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 446 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT176 |
ADMITTING-PROV-SPECIALTY |
X(2) |
1266 |
1267 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT176 |
ADMITTING-PROV-SPECIALTY |
X(2) |
1266 |
1267 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 447 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT177 |
ADMITTING-PROV-TAXONOMY |
X(12) |
1268 |
1279 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT177 |
ADMITTING-PROV-TAXONOMY |
X(12) |
1268 |
1279 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 448 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT178 |
ADMITTING-PROV-TYPE |
X(2) |
1280 |
1281 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT178 |
ADMITTING-PROV-TYPE |
X(2) |
1280 |
1281 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 449 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT179 |
MEDICARE-PAID-AMT |
S9(11)V99 |
1282 |
1294 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT179 |
MEDICARE-PAID-AMT |
S9(11)V99 |
1282 |
1294 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 450 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT173 |
STATE-NOTATION |
X(500) |
1295 |
1794 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT173 |
STATE-NOTATION |
X(500) |
1295 |
1794 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 451 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT237 |
PROV-LOCATION-ID |
X(5) |
1795 |
1799 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT237 |
PROV-LOCATION-ID |
X(5) |
1795 |
1799 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 452 |
1 |
1 |
0 |
1 |
1 |
1 |
1 |
CLT183 |
FILLER |
X(101) |
1800 |
1900 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT183 |
FILLER |
X(100) |
1800 |
1900 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 453 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT184 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT184 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 454 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT185 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT185 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 455 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT186 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT186 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 456 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT187 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT187 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 457 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT188 |
ICN-ORIG |
X(50) |
42 |
91 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT188 |
ICN-ORIG |
X(50) |
42 |
91 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 458 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT189 |
ICN-ADJ |
X(50) |
92 |
141 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT189 |
ICN-ADJ |
X(50) |
92 |
141 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 459 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT190 |
LINE-NUM-ORIG |
X(3) |
142 |
144 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT190 |
LINE-NUM-ORIG |
X(3) |
142 |
144 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 460 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT191 |
LINE-NUM-ADJ |
X(3) |
145 |
147 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT191 |
LINE-NUM-ADJ |
X(3) |
145 |
147 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 461 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT192 |
LINE-ADJUSTMENT-IND |
X(1) |
148 |
148 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT192 |
LINE-ADJUSTMENT-IND |
X(1) |
148 |
148 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 462 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT193 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
149 |
151 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT193 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
149 |
151 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 463 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT194 |
SUBMITTER-ID |
X(12) |
152 |
163 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT194 |
SUBMITTER-ID |
X(12) |
152 |
163 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 464 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT195 |
CLAIM-LINE-STATUS |
X(3) |
164 |
166 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT195 |
CLAIM-LINE-STATUS |
X(3) |
164 |
166 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 465 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT196 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
167 |
174 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT196 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
167 |
174 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 466 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT197 |
ENDING-DATE-OF-SERVICE |
9(8) |
175 |
182 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT197 |
ENDING-DATE-OF-SERVICE |
9(8) |
175 |
182 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 467 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT198 |
REVENUE-CODE |
X(4) |
183 |
186 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT198 |
REVENUE-CODE |
X(4) |
183 |
186 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 468 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT201 |
IMMUNIZATION-TYPE |
X(2) |
187 |
188 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT201 |
IMMUNIZATION-TYPE |
X(2) |
187 |
188 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 469 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT202 |
IP-LT-QUANTITY-OF-SERVICE-ACTUAL |
S9(6)V999 |
189 |
197 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT202 |
IP-LT-QUANTITY-OF-SERVICE-ACTUAL |
S9(6)V999 |
189 |
197 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 470 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT203 |
IP-LT-QUANTITY-OF-SERVICE-ALLOWED |
S9(6)V999 |
198 |
206 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT203 |
IP-LT-QUANTITY-OF-SERVICE-ALLOWED |
S9(6)V999 |
198 |
206 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 471 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT204 |
REVENUE-CHARGE |
S9(11)V99 |
207 |
219 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT204 |
REVENUE-CHARGE |
S9(11)V99 |
207 |
219 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 472 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT205 |
ALLOWED-AMT |
S9(11)V99 |
220 |
232 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT205 |
ALLOWED-AMT |
S9(11)V99 |
220 |
232 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 473 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT206 |
TPL-AMT |
S9(11)V99 |
233 |
245 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT206 |
TPL-AMT |
S9(11)V99 |
233 |
245 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 474 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT207 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
246 |
258 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT207 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
246 |
258 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 475 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT208 |
MEDICAID-PAID-AMT |
S9(11)V99 |
259 |
271 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT208 |
MEDICAID-PAID-AMT |
S9(11)V99 |
259 |
271 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 476 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT209 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
272 |
284 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT209 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
272 |
284 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 477 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT210 |
BILLING-UNIT |
X(2) |
285 |
286 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT210 |
BILLING-UNIT |
X(2) |
285 |
286 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 478 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT211 |
TYPE-OF-SERVICE |
X(3) |
287 |
289 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT211 |
TYPE-OF-SERVICE |
X(3) |
287 |
289 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 479 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT212 |
SERVICING-PROV-NUM |
X(30) |
290 |
319 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT212 |
SERVICING-PROV-NUM |
X(30) |
290 |
319 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 480 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT213 |
SERVICING-PROV-NPI-NUM |
X(10) |
320 |
329 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT213 |
SERVICING-PROV-NPI-NUM |
X(10) |
320 |
329 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 481 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT214 |
SERVICING-PROV-TAXONOMY |
X(12) |
330 |
341 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT214 |
SERVICING-PROV-TAXONOMY |
X(12) |
330 |
341 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 482 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT215 |
SERVICING-PROV-TYPE |
X(2) |
342 |
343 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT215 |
SERVICING-PROV-TYPE |
X(2) |
342 |
343 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 483 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT216 |
SERVICING-PROV-SPECIALTY |
X(2) |
344 |
345 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT216 |
SERVICING-PROV-SPECIALTY |
X(2) |
344 |
345 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 484 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT217 |
OTHER-TPL-COLLECTION |
X(3) |
346 |
348 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT217 |
OTHER-TPL-COLLECTION |
X(3) |
346 |
348 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 485 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT218 |
BENEFIT-TYPE |
X(3) |
349 |
351 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT218 |
BENEFIT-TYPE |
X(3) |
349 |
351 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 486 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT219 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
352 |
353 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT219 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
352 |
353 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 487 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT221 |
PROV-FACILITY-TYPE |
X(9) |
354 |
362 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT221 |
PROV-FACILITY-TYPE |
X(9) |
354 |
362 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 488 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT224 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
363 |
366 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT224 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
363 |
366 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 489 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT225 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
367 |
369 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT225 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
367 |
369 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 490 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CLT226 |
STATE-NOTATION |
X(500) |
370 |
869 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT226 |
STATE-NOTATION |
X(500) |
370 |
869 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 491 |
1 |
1 |
1 |
1 |
0 |
1 |
1 |
CLT228 |
NATIONAL-DRUG-CODE |
X(12) |
870 |
881 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT228 |
NATIONAL-DRUG-CODE |
X(12) |
870 |
880 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 492 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CLT229 |
NDC-UNIT-OF-MEASURE |
X(2) |
882 |
883 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT229 |
NDC-UNIT-OF-MEASURE |
X(2) |
881 |
882 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 493 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CLT230 |
NDC-QUANTITY |
S9(6)V999 |
884 |
892 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT230 |
NDC-QUANTITY |
S9(6)V999 |
883 |
891 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 494 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CLT231 |
HCPCS-RATE |
X(14) |
893 |
906 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT231 |
HCPCS-RATE |
X(14) |
892 |
905 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 495 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CLT233 |
ADJUDICATION-DATE |
9(8) |
907 |
914 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT233 |
ADJUDICATION-DATE |
9(8) |
906 |
913 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 496 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CLT234 |
SELF-DIRECTION-TYPE |
X(3) |
915 |
917 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT234 |
SELF-DIRECTION-TYPE |
X(3) |
914 |
916 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 497 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CLT235 |
PRE-AUTHORIZATION-NUM |
X(18) |
918 |
935 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT235 |
PRE-AUTHORIZATION-NUM |
X(18) |
917 |
934 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 498 |
1 |
1 |
1 |
0 |
1 |
1 |
1 |
CLT238 |
FILLER |
X(965) |
936 |
1900 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT238 |
FILLER |
X(965) |
935 |
1900 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 499 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT001 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT001 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 500 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 501 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 502 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 503 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 504 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT006 |
FILE-NAME |
X(8) |
32 |
39 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT006 |
FILE-NAME |
X(8) |
32 |
39 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 505 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 506 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 507 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 508 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 509 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 510 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT012 |
SSN-INDICATOR |
X(1) |
67 |
67 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT012 |
SSN-INDICATOR |
X(1) |
67 |
67 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 511 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT013 |
TOT-REC-CNT |
9(11) |
68 |
78 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT013 |
TOT-REC-CNT |
9(11) |
68 |
78 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 512 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT216 |
SEQUENCE-NUMBER |
X(4) |
79 |
82 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT216 |
SEQUENCE-NUMBER |
X(4) |
79 |
82 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 513 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT014 |
STATE-NOTATION |
X(500) |
83 |
582 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT014 |
STATE-NOTATION |
X(500) |
83 |
582 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 514 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT015 |
FILLER |
X(1168) |
583 |
1750 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT015 |
FILLER |
X(1168) |
583 |
1750 |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 515 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT016 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT016 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 516 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 517 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 518 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT019 |
ICN-ORIG |
X(50) |
22 |
71 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT019 |
ICN-ORIG |
X(50) |
22 |
71 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 519 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT020 |
ICN-ADJ |
X(50) |
72 |
121 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT020 |
ICN-ADJ |
X(50) |
72 |
121 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 520 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT021 |
SUBMITTER-ID |
X(12) |
122 |
133 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT021 |
SUBMITTER-ID |
X(12) |
122 |
133 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 521 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
134 |
153 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
134 |
153 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 522 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT023 |
CROSSOVER-INDICATOR |
X(1) |
154 |
154 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT023 |
CROSSOVER-INDICATOR |
X(1) |
154 |
154 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 523 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT024 |
1115A-DEMONSTRATION-IND |
X(1) |
155 |
155 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT024 |
1115A-DEMONSTRATION-IND |
X(1) |
155 |
155 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 524 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT025 |
ADJUSTMENT-IND |
X(1) |
156 |
156 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT025 |
ADJUSTMENT-IND |
X(1) |
156 |
156 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 525 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT026 |
ADJUSTMENT-REASON-CODE |
X(3) |
157 |
159 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT026 |
ADJUSTMENT-REASON-CODE |
X(3) |
157 |
159 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 526 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT027 |
DIAGNOSIS-CODE-1 |
X(7) |
160 |
166 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT027 |
DIAGNOSIS-CODE-1 |
X(7) |
160 |
166 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 527 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT028 |
DIAGNOSIS-CODE-FLAG-1 |
X(1) |
167 |
167 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT028 |
DIAGNOSIS-CODE-FLAG-1 |
X(1) |
167 |
167 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 528 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT029 |
DIAGNOSIS-POA-FLAG-1 |
X(1) |
168 |
168 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT029 |
DIAGNOSIS-POA-FLAG-1 |
X(1) |
168 |
168 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 529 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT030 |
DIAGNOSIS-CODE-2 |
X(7) |
169 |
175 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT030 |
DIAGNOSIS-CODE-2 |
X(7) |
169 |
175 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 530 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT031 |
DIAGNOSIS-CODE-FLAG-2 |
X(1) |
176 |
176 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT031 |
DIAGNOSIS-CODE-FLAG-2 |
X(1) |
176 |
176 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 531 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT032 |
DIAGNOSIS-POA-FLAG-2 |
X(1) |
177 |
177 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT032 |
DIAGNOSIS-POA-FLAG-2 |
X(1) |
177 |
177 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 532 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT033 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
178 |
185 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT033 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
178 |
185 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 533 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT034 |
ENDING-DATE-OF-SERVICE |
9(8) |
186 |
193 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT034 |
ENDING-DATE-OF-SERVICE |
9(8) |
186 |
193 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 534 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT035 |
ADJUDICATION-DATE |
9(8) |
194 |
201 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT035 |
ADJUDICATION-DATE |
9(8) |
194 |
201 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 535 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT036 |
MEDICAID-PAID-DATE |
9(8) |
202 |
209 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT036 |
MEDICAID-PAID-DATE |
9(8) |
202 |
209 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 536 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT037 |
TYPE-OF-CLAIM |
X(1) |
210 |
210 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT037 |
TYPE-OF-CLAIM |
X(1) |
210 |
210 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 537 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT038 |
TYPE-OF-BILL |
X(4) |
211 |
214 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT038 |
TYPE-OF-BILL |
X(4) |
211 |
214 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 538 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT039 |
CLAIM-STATUS |
X(3) |
215 |
217 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT039 |
CLAIM-STATUS |
X(3) |
215 |
217 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 539 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT040 |
CLAIM-STATUS-CATEGORY |
X(3) |
218 |
220 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT040 |
CLAIM-STATUS-CATEGORY |
X(3) |
218 |
220 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 540 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT041 |
SOURCE-LOCATION |
X(2) |
221 |
222 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT041 |
SOURCE-LOCATION |
X(2) |
221 |
222 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 541 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT042 |
CHECK-NUM |
X(15) |
223 |
237 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT042 |
CHECK-NUM |
X(15) |
223 |
237 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 542 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT043 |
CHECK-EFF-DATE |
9(8) |
238 |
245 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT043 |
CHECK-EFF-DATE |
9(8) |
238 |
245 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 543 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT044 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
246 |
250 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT044 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
246 |
250 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 544 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT045 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
251 |
255 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT045 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
251 |
255 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 545 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT046 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
256 |
260 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT046 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
256 |
260 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 546 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT047 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
261 |
265 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT047 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
261 |
265 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 547 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT048 |
TOT-BILLED-AMT |
S9(11)V99 |
266 |
278 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT048 |
TOT-BILLED-AMT |
S9(11)V99 |
266 |
278 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 548 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT049 |
TOT-ALLOWED-AMT |
S9(11)V99 |
279 |
291 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT049 |
TOT-ALLOWED-AMT |
S9(11)V99 |
279 |
291 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 549 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT050 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
292 |
304 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT050 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
292 |
304 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 550 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT051 |
TOT-COPAY-AMT |
S9(11)V99 |
305 |
317 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT051 |
TOT-COPAY-AMT |
S9(11)V99 |
305 |
317 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 551 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT052 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
318 |
330 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT052 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
318 |
330 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 552 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT053 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
331 |
343 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT053 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
331 |
343 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 553 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT054 |
TOT-TPL-AMT |
S9(11)V99 |
344 |
356 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT054 |
TOT-TPL-AMT |
S9(11)V99 |
344 |
356 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 554 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT056 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
357 |
369 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT056 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
357 |
369 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 555 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT057 |
OTHER-INSURANCE-IND |
X(1) |
370 |
370 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT057 |
OTHER-INSURANCE-IND |
X(1) |
370 |
370 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 556 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT058 |
OTHER-TPL-COLLECTION |
X(3) |
371 |
373 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT058 |
OTHER-TPL-COLLECTION |
X(3) |
371 |
373 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 557 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT059 |
SERVICE-TRACKING-TYPE |
X(2) |
374 |
375 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT059 |
SERVICE-TRACKING-TYPE |
X(2) |
374 |
375 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 558 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT060 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
376 |
388 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT060 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
376 |
388 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 559 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT061 |
FIXED-PAYMENT-IND |
X(1) |
389 |
389 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT061 |
FIXED-PAYMENT-IND |
X(1) |
389 |
389 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 560 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT062 |
FUNDING-CODE |
X(2) |
390 |
391 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT062 |
FUNDING-CODE |
X(2) |
390 |
391 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 561 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT063 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
392 |
393 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT063 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
392 |
393 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 562 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT064 |
MEDICARE-COMB-DED-IND |
X(1) |
394 |
394 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT064 |
MEDICARE-COMB-DED-IND |
X(1) |
394 |
394 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 563 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT065 |
PROGRAM-TYPE |
X(2) |
395 |
396 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT065 |
PROGRAM-TYPE |
X(2) |
395 |
396 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 564 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT066 |
PLAN-ID-NUMBER |
X(12) |
397 |
408 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT066 |
PLAN-ID-NUMBER |
X(12) |
397 |
408 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 565 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT067 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
409 |
418 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT067 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
409 |
418 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 566 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT068 |
PAYMENT-LEVEL-IND |
X(1) |
419 |
419 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT068 |
PAYMENT-LEVEL-IND |
X(1) |
419 |
419 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 567 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT069 |
MEDICARE-REIM-TYPE |
X(2) |
420 |
421 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT069 |
MEDICARE-REIM-TYPE |
X(2) |
420 |
421 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 568 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT070 |
CLAIM-LINE-COUNT |
9(4) |
422 |
425 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT070 |
CLAIM-LINE-COUNT |
9(4) |
422 |
425 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 569 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT072 |
FORCED-CLAIM-IND |
X(1) |
426 |
426 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT072 |
FORCED-CLAIM-IND |
X(1) |
426 |
426 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 570 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT073 |
HEALTH-CARE-ACQUIRED-CONDITION-IND |
X(1) |
427 |
427 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT073 |
HEALTH-CARE-ACQUIRED-CONDITION-IND |
X(1) |
427 |
427 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 571 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT074 |
OCCURRENCE-CODE-01 |
X(2) |
428 |
429 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT074 |
OCCURRENCE-CODE-01 |
X(2) |
428 |
429 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 572 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT075 |
OCCURRENCE-CODE-02 |
X(2) |
430 |
431 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT075 |
OCCURRENCE-CODE-02 |
X(2) |
430 |
431 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 573 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT076 |
OCCURRENCE-CODE-03 |
X(2) |
432 |
433 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT076 |
OCCURRENCE-CODE-03 |
X(2) |
432 |
433 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 574 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT077 |
OCCURRENCE-CODE-04 |
X(2) |
434 |
435 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT077 |
OCCURRENCE-CODE-04 |
X(2) |
434 |
435 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 575 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT078 |
OCCURRENCE-CODE-05 |
X(2) |
436 |
437 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT078 |
OCCURRENCE-CODE-05 |
X(2) |
436 |
437 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 576 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT079 |
OCCURRENCE-CODE-06 |
X(2) |
438 |
439 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT079 |
OCCURRENCE-CODE-06 |
X(2) |
438 |
439 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 577 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT080 |
OCCURRENCE-CODE-07 |
X(2) |
440 |
441 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT080 |
OCCURRENCE-CODE-07 |
X(2) |
440 |
441 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 578 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT081 |
OCCURRENCE-CODE-08 |
X(2) |
442 |
443 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT081 |
OCCURRENCE-CODE-08 |
X(2) |
442 |
443 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 579 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT082 |
OCCURRENCE-CODE-09 |
X(2) |
444 |
445 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT082 |
OCCURRENCE-CODE-09 |
X(2) |
444 |
445 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 580 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT083 |
OCCURRENCE-CODE-10 |
X(2) |
446 |
447 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT083 |
OCCURRENCE-CODE-10 |
X(2) |
446 |
447 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 581 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT084 |
OCCURRENCE-CODE-EFF-DATE-01 |
9(8) |
448 |
455 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT084 |
OCCURRENCE-CODE-EFF-DATE-01 |
9(8) |
448 |
455 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 582 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT085 |
OCCURRENCE-CODE-EFF-DATE-02 |
9(8) |
456 |
463 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT085 |
OCCURRENCE-CODE-EFF-DATE-02 |
9(8) |
456 |
463 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 583 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT086 |
OCCURRENCE-CODE-EFF-DATE-03 |
9(8) |
464 |
471 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT086 |
OCCURRENCE-CODE-EFF-DATE-03 |
9(8) |
464 |
471 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 584 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT087 |
OCCURRENCE-CODE-EFF-DATE-04 |
9(8) |
472 |
479 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT087 |
OCCURRENCE-CODE-EFF-DATE-04 |
9(8) |
472 |
479 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 585 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT088 |
OCCURRENCE-CODE-EFF-DATE-05 |
9(8) |
480 |
487 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT088 |
OCCURRENCE-CODE-EFF-DATE-05 |
9(8) |
480 |
487 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 586 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT089 |
OCCURRENCE-CODE-EFF-DATE-06 |
9(8) |
488 |
495 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT089 |
OCCURRENCE-CODE-EFF-DATE-06 |
9(8) |
488 |
495 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 587 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT090 |
OCCURRENCE-CODE-EFF-DATE-07 |
9(8) |
496 |
503 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT090 |
OCCURRENCE-CODE-EFF-DATE-07 |
9(8) |
496 |
503 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 588 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT091 |
OCCURRENCE-CODE-EFF-DATE-08 |
9(8) |
504 |
511 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT091 |
OCCURRENCE-CODE-EFF-DATE-08 |
9(8) |
504 |
511 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 589 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT092 |
OCCURRENCE-CODE-EFF-DATE-09 |
9(8) |
512 |
519 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT092 |
OCCURRENCE-CODE-EFF-DATE-09 |
9(8) |
512 |
519 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 590 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT093 |
OCCURRENCE-CODE-EFF-DATE-10 |
9(8) |
520 |
527 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT093 |
OCCURRENCE-CODE-EFF-DATE-10 |
9(8) |
520 |
527 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 591 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT094 |
OCCURRENCE-CODE-END-DATE-01 |
9(8) |
528 |
535 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT094 |
OCCURRENCE-CODE-END-DATE-01 |
9(8) |
528 |
535 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 592 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT095 |
OCCURRENCE-CODE-END-DATE-02 |
9(8) |
536 |
543 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT095 |
OCCURRENCE-CODE-END-DATE-02 |
9(8) |
536 |
543 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 593 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT096 |
OCCURRENCE-CODE-END-DATE-03 |
9(8) |
544 |
551 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT096 |
OCCURRENCE-CODE-END-DATE-03 |
9(8) |
544 |
551 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 594 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT097 |
OCCURRENCE-CODE-END-DATE-04 |
9(8) |
552 |
559 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT097 |
OCCURRENCE-CODE-END-DATE-04 |
9(8) |
552 |
559 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 595 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT098 |
OCCURRENCE-CODE-END-DATE-05 |
9(8) |
560 |
567 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT098 |
OCCURRENCE-CODE-END-DATE-05 |
9(8) |
560 |
567 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 596 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT099 |
OCCURRENCE-CODE-END-DATE-06 |
9(8) |
568 |
575 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT099 |
OCCURRENCE-CODE-END-DATE-06 |
9(8) |
568 |
575 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 597 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT100 |
OCCURRENCE-CODE-END-DATE-07 |
9(8) |
576 |
583 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT100 |
OCCURRENCE-CODE-END-DATE-07 |
9(8) |
576 |
583 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 598 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT101 |
OCCURRENCE-CODE-END-DATE-08 |
9(8) |
584 |
591 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT101 |
OCCURRENCE-CODE-END-DATE-08 |
9(8) |
584 |
591 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 599 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT102 |
OCCURRENCE-CODE-END-DATE-09 |
9(8) |
592 |
599 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT102 |
OCCURRENCE-CODE-END-DATE-09 |
9(8) |
592 |
599 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 600 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT103 |
OCCURRENCE-CODE-END-DATE-10 |
9(8) |
600 |
607 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT103 |
OCCURRENCE-CODE-END-DATE-10 |
9(8) |
600 |
607 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 601 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT104 |
PATIENT-CONTROL-NUM |
X(20) |
608 |
627 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT104 |
PATIENT-CONTROL-NUM |
X(20) |
608 |
627 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 602 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT105 |
ELIGIBLE-LAST-NAME |
X(30) |
628 |
657 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT105 |
ELIGIBLE-LAST-NAME |
X(30) |
628 |
657 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 603 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT106 |
ELIGIBLE-FIRST-NAME |
X(30) |
658 |
687 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT106 |
ELIGIBLE-FIRST-NAME |
X(30) |
658 |
687 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 604 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT107 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
688 |
688 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT107 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
688 |
688 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 605 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT108 |
DATE-OF-BIRTH |
9(8) |
689 |
696 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT108 |
DATE-OF-BIRTH |
9(8) |
689 |
696 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 606 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT109 |
HEALTH-HOME-PROV-IND |
X(1) |
697 |
697 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT109 |
HEALTH-HOME-PROV-IND |
X(1) |
697 |
697 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 607 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT110 |
WAIVER-TYPE |
X(2) |
698 |
699 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT110 |
WAIVER-TYPE |
X(2) |
698 |
699 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 608 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT111 |
WAIVER-ID |
X(20) |
700 |
719 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT111 |
WAIVER-ID |
X(20) |
700 |
719 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 609 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT112 |
BILLING-PROV-NUM |
X(30) |
720 |
749 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT112 |
BILLING-PROV-NUM |
X(30) |
720 |
749 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 610 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT113 |
BILLING-PROV-NPI-NUM |
X(10) |
750 |
759 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT113 |
BILLING-PROV-NPI-NUM |
X(10) |
750 |
759 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 611 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT114 |
BILLING-PROV-TAXONOMY |
X(12) |
760 |
771 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT114 |
BILLING-PROV-TAXONOMY |
X(12) |
760 |
771 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 612 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT115 |
BILLING-PROV-TYPE |
X(2) |
772 |
773 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT115 |
BILLING-PROV-TYPE |
X(2) |
772 |
773 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 613 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT116 |
BILLING-PROV-SPECIALTY |
X(2) |
774 |
775 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT116 |
BILLING-PROV-SPECIALTY |
X(2) |
774 |
775 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 614 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT117 |
REFERRING-PROV-NUM |
X(30) |
776 |
805 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT117 |
REFERRING-PROV-NUM |
X(30) |
776 |
805 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 615 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT118 |
REFERRING-PROV-NPI-NUM |
X(10) |
806 |
815 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT118 |
REFERRING-PROV-NPI-NUM |
X(10) |
806 |
815 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 616 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT119 |
REFERRING-PROV-TAXONOMY |
X(12) |
816 |
827 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT119 |
REFERRING-PROV-TAXONOMY |
X(12) |
816 |
827 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 617 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT120 |
REFERRING-PROV-TYPE |
X(2) |
828 |
829 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT120 |
REFERRING-PROV-TYPE |
X(2) |
828 |
829 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 618 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT121 |
REFERRING-PROV-SPECIALTY |
X(2) |
830 |
831 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT121 |
REFERRING-PROV-SPECIALTY |
X(2) |
830 |
831 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 619 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT122 |
MEDICARE-HIC-NUM |
X(12) |
832 |
843 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT122 |
MEDICARE-HIC-NUM |
X(12) |
832 |
843 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 620 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT123 |
PLACE-OF-SERVICE |
X(2) |
844 |
845 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT123 |
PLACE-OF-SERVICE |
X(2) |
844 |
845 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 621 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT125 |
BMI |
S9(5)V9 |
846 |
851 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT125 |
BMI |
S9(5)V9 |
846 |
851 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 622 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT126 |
REMITTANCE-NUM |
X(30) |
852 |
881 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT126 |
REMITTANCE-NUM |
X(30) |
852 |
881 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 623 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT127 |
DAILY-RATE |
S9(5)V99 |
882 |
888 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT127 |
DAILY-RATE |
S9(5)V99 |
882 |
888 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 624 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT128 |
BORDER-STATE-IND |
X(1) |
889 |
889 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT128 |
BORDER-STATE-IND |
X(1) |
889 |
889 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 625 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT130 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
890 |
902 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT130 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
890 |
902 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 626 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT131 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
903 |
910 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT131 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
903 |
910 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 627 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT132 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
911 |
923 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT132 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
911 |
923 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 628 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT133 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
924 |
931 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT133 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
924 |
931 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 629 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT134 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
932 |
944 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT134 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
932 |
944 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 630 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT135 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
945 |
952 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT135 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
945 |
952 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 631 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT136 |
CLAIM-DENIED-INDICATOR |
X(1) |
953 |
953 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT136 |
CLAIM-DENIED-INDICATOR |
X(1) |
953 |
953 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 632 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT137 |
COPAY-WAIVED-IND |
X(1) |
954 |
954 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT137 |
COPAY-WAIVED-IND |
X(1) |
954 |
954 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 633 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT138 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
955 |
1004 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT138 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
955 |
1004 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 634 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT140 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
1005 |
1017 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT140 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
1005 |
1017 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 635 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT141 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
1018 |
1025 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT141 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
1018 |
1025 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 636 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT142 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
1026 |
1038 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT142 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
1026 |
1038 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 637 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT143 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
1039 |
1046 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT143 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
1039 |
1046 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 638 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT144 |
DATE-CAPITATED-AMOUNT-REQUESTED |
9(8) |
1047 |
1054 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT144 |
DATE-CAPITATED-AMOUNT-REQUESTED |
9(8) |
1047 |
1054 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 639 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT145 |
CAPITATED-PAYMENT-AMT-REQUESTED |
S9(11)V99 |
1055 |
1067 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT145 |
CAPITATED-PAYMENT-AMT-REQUESTED |
S9(11)V99 |
1055 |
1067 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 640 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT146 |
HEALTH-HOME-PROVIDER-NPI |
X(10) |
1068 |
1077 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT146 |
HEALTH-HOME-PROVIDER-NPI |
X(10) |
1068 |
1077 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 641 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT147 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
1078 |
1089 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT147 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
1078 |
1089 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 642 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT148 |
UNDER-DIRECTION-OF-PROV-NPI |
X(10) |
1090 |
1099 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT148 |
UNDER-DIRECTION-OF-PROV-NPI |
X(10) |
1090 |
1099 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 643 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT149 |
UNDER-DIRECTION-OF-PROV-TAXONOMY |
X(12) |
1100 |
1111 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT149 |
UNDER-DIRECTION-OF-PROV-TAXONOMY |
X(12) |
1100 |
1111 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 644 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT150 |
UNDER-SUPERVISION-OF-PROV-NPI |
X(10) |
1112 |
1121 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT150 |
UNDER-SUPERVISION-OF-PROV-NPI |
X(10) |
1112 |
1121 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 645 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT151 |
UNDER-SUPERVISION-OF-PROV-TAXONOMY |
X(12) |
1122 |
1133 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT151 |
UNDER-SUPERVISION-OF-PROV-TAXONOMY |
X(12) |
1122 |
1133 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 646 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT152 |
STATE-NOTATION |
X(500) |
1134 |
1633 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT152 |
STATE-NOTATION |
X(500) |
1134 |
1633 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 647 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT226 |
PROV-LOCATION-ID |
X(5) |
1634 |
1638 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT226 |
PROV-LOCATION-ID |
X(5) |
1634 |
1638 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 648 |
1 |
1 |
0 |
1 |
1 |
1 |
1 |
COT153 |
FILLER |
X(112) |
1639 |
1750 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT153 |
FILLER |
X(111) |
1639 |
1750 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 649 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT154 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT154 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 650 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT155 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT155 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 651 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT156 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT156 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 652 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT157 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT157 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 653 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT158 |
ICN-ORIG |
X(50) |
42 |
91 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT158 |
ICN-ORIG |
X(50) |
42 |
91 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 654 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT159 |
ICN-ADJ |
X(50) |
92 |
141 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT159 |
ICN-ADJ |
X(50) |
92 |
141 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 655 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT160 |
LINE-NUM-ORIG |
X(3) |
142 |
144 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT160 |
LINE-NUM-ORIG |
X(3) |
142 |
144 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 656 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT161 |
LINE-NUM-ADJ |
X(3) |
145 |
147 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT161 |
LINE-NUM-ADJ |
X(3) |
145 |
147 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 657 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT162 |
LINE-ADJUSTMENT-IND |
X(1) |
148 |
148 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT162 |
LINE-ADJUSTMENT-IND |
X(1) |
148 |
148 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 658 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT163 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
149 |
151 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT163 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
149 |
151 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 659 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT164 |
SUBMITTER-ID |
X(12) |
152 |
163 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT164 |
SUBMITTER-ID |
X(12) |
152 |
163 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 660 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT165 |
CLAIM-LINE-STATUS |
X(3) |
164 |
166 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT165 |
CLAIM-LINE-STATUS |
X(3) |
164 |
166 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 661 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT166 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
167 |
174 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT166 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
167 |
174 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 662 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT167 |
ENDING-DATE-OF-SERVICE |
9(8) |
175 |
182 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT167 |
ENDING-DATE-OF-SERVICE |
9(8) |
175 |
182 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 663 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT168 |
REVENUE-CODE |
X(4) |
183 |
186 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT168 |
REVENUE-CODE |
X(4) |
183 |
186 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 664 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT169 |
PROCEDURE-CODE |
X(8) |
187 |
194 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT169 |
PROCEDURE-CODE |
X(8) |
187 |
194 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 665 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT170 |
PROCEDURE-CODE-DATE |
9(8) |
195 |
202 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT170 |
PROCEDURE-CODE-DATE |
9(8) |
195 |
202 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 666 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT171 |
PROCEDURE-CODE-FLAG |
X(2) |
203 |
204 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT171 |
PROCEDURE-CODE-FLAG |
X(2) |
203 |
204 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 667 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT172 |
PROCEDURE-CODE-MOD-1 |
X(2) |
205 |
206 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT172 |
PROCEDURE-CODE-MOD-1 |
X(2) |
205 |
206 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 668 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT173 |
IMMUNIZATION-TYPE |
X(2) |
207 |
208 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT173 |
IMMUNIZATION-TYPE |
X(2) |
207 |
208 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 669 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT174 |
BILLED-AMT |
S9(11)V99 |
209 |
221 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT174 |
BILLED-AMT |
S9(11)V99 |
209 |
221 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 670 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT175 |
ALLOWED-AMT |
S9(11)V99 |
222 |
234 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT175 |
ALLOWED-AMT |
S9(11)V99 |
222 |
234 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 671 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT176 |
COPAY-AMT |
S9(11)V99 |
235 |
247 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT176 |
COPAY-AMT |
S9(11)V99 |
235 |
247 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 672 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT177 |
TPL-AMT |
S9(11)V99 |
248 |
260 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT177 |
TPL-AMT |
S9(11)V99 |
248 |
260 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 673 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT178 |
MEDICAID-PAID-AMT |
S9(11)V99 |
261 |
273 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT178 |
MEDICAID-PAID-AMT |
S9(11)V99 |
261 |
273 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 674 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT179 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
274 |
286 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT179 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
274 |
286 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 675 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
COT182 |
MEDICARE-PAID-AMT |
S9(11)V99 |
287 |
299 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT182 |
MEDICARE-PAID-AMT |
S9(11)V99 |
287 |
299 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 676 |
1 |
1 |
1 |
1 |
0 |
1 |
1 |
COT183 |
OT-RX-CLAIM-QUANTITY-ACTUAL |
S9(6)V999 |
300 |
308 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT183 |
OT-RX-CLAIM-QUANTITY-ACTUAL |
S9(6)V999 |
300 |
312 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 677 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT184 |
OT-RX-CLAIM-QUANTITY-ALLOWED |
S9(6)V999 |
309 |
317 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT184 |
OT-RX-CLAIM-QUANTITY-ALLOWED |
S9(6)V999 |
313 |
325 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 678 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT186 |
TYPE-OF-SERVICE |
X(3) |
318 |
320 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT186 |
TYPE-OF-SERVICE |
X(3) |
326 |
328 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 679 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT187 |
HCBS-SERVICE-CODE |
X(1) |
321 |
321 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT187 |
HCBS-SERVICE-CODE |
X(1) |
329 |
329 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 680 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT188 |
HCBS-TAXONOMY |
X(5) |
322 |
326 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT188 |
HCBS-TAXONOMY |
X(5) |
330 |
334 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 681 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT189 |
SERVICING-PROV-NUM |
X(30) |
327 |
356 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT189 |
SERVICING-PROV-NUM |
X(30) |
335 |
364 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 682 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT190 |
SERVICING-PROV-NPI-NUM |
X(10) |
357 |
366 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT190 |
SERVICING-PROV-NPI-NUM |
X(10) |
365 |
374 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 683 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT191 |
SERVICING-PROV-TAXONOMY |
X(12) |
367 |
378 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT191 |
SERVICING-PROV-TAXONOMY |
X(12) |
375 |
386 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 684 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT192 |
SERVICING-PROV-TYPE |
X(2) |
379 |
380 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT192 |
SERVICING-PROV-TYPE |
X(2) |
387 |
388 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 685 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT193 |
SERVICING-PROV-SPECIALTY |
X(2) |
381 |
382 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT193 |
SERVICING-PROV-SPECIALTY |
X(2) |
389 |
390 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 686 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT194 |
OTHER-TPL-COLLECTION |
X(3) |
383 |
385 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT194 |
OTHER-TPL-COLLECTION |
X(3) |
391 |
393 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 687 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT195 |
TOOTH-DESIGNATION-SYSTEM |
X(2) |
386 |
387 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT195 |
TOOTH-DESIGNATION-SYSTEM |
X(2) |
394 |
395 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 688 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT196 |
TOOTH-NUM |
X(2) |
388 |
389 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT196 |
TOOTH-NUM |
X(2) |
396 |
397 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 689 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT197 |
TOOTH-QUAD-CODE |
X(2) |
390 |
391 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT197 |
TOOTH-QUAD-CODE |
X(2) |
398 |
399 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 690 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT198 |
TOOTH-SURFACE-CODE |
X(1) |
392 |
392 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT198 |
TOOTH-SURFACE-CODE |
X(1) |
400 |
400 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 691 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT199 |
ORIGINATION-ADDR-LN1 |
X(60) |
393 |
452 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT199 |
ORIGINATION-ADDR-LN1 |
X(60) |
401 |
460 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 692 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT200 |
ORIGINATION-ADDR-LN2 |
X(60) |
453 |
512 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT200 |
ORIGINATION-ADDR-LN2 |
X(60) |
461 |
520 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 693 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT201 |
ORIGINATION-CITY |
X(28) |
513 |
540 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT201 |
ORIGINATION-CITY |
X(28) |
521 |
548 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 694 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT202 |
ORIGINATION-STATE |
X(2) |
541 |
542 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT202 |
ORIGINATION-STATE |
X(2) |
549 |
550 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 695 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT203 |
ORIGINATION-ZIP-CODE |
X(9) |
543 |
551 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT203 |
ORIGINATION-ZIP-CODE |
X(9) |
551 |
559 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 696 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT204 |
DESTINATION-ADDR-LN1 |
X(60) |
552 |
611 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT204 |
DESTINATION-ADDR-LN1 |
X(60) |
560 |
619 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 697 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT205 |
DESTINATION-ADDR-LN2 |
X(60) |
612 |
671 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT205 |
DESTINATION-ADDR-LN2 |
X(60) |
620 |
679 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 698 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT206 |
DESTINATION-CITY |
X(28) |
672 |
699 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT206 |
DESTINATION-CITY |
X(28) |
680 |
707 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 699 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT207 |
DESTINATION-STATE |
X(2) |
700 |
701 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT207 |
DESTINATION-STATE |
X(2) |
708 |
709 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 700 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT208 |
DESTINATION-ZIP-CODE |
X(9) |
702 |
710 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT208 |
DESTINATION-ZIP-CODE |
X(9) |
710 |
718 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 701 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT209 |
BENEFIT-TYPE |
X(3) |
711 |
713 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT209 |
BENEFIT-TYPE |
X(3) |
719 |
721 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 702 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT210 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
714 |
715 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT210 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
722 |
723 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 703 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT211 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
716 |
719 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT211 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
724 |
727 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 704 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT212 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
720 |
722 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT212 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
728 |
730 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 706 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT213 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
723 |
735 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT213 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
731 |
743 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 707 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT214 |
STATE-NOTATION |
X(500) |
736 |
1235 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT214 |
STATE-NOTATION |
X(500) |
744 |
1243 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 708 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT217 |
NATIONAL-DRUG-CODE |
X(12) |
1236 |
1247 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT217 |
NATIONAL-DRUG-CODE |
X(12) |
1244 |
1254 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 709 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT227 |
PROCEDURE-CODE-MOD-2 |
X(2) |
1248 |
1249 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT227 |
PROCEDURE-CODE-MOD-2 |
X(2) |
1255 |
1256 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 710 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT218 |
PROCEDURE-CODE-MOD-3 |
X(2) |
1250 |
1251 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT218 |
PROCEDURE-CODE-MOD-3 |
X(2) |
1257 |
1258 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 711 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT219 |
PROCEDURE-CODE-MOD-4 |
X(2) |
1252 |
1253 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT219 |
PROCEDURE-CODE-MOD-4 |
X(2) |
1259 |
1260 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 712 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT220 |
HCPCS-RATE |
X(14) |
1254 |
1267 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT220 |
HCPCS-RATE |
X(14) |
1261 |
1274 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 713 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT221 |
ADJUDICATION-DATE |
9(8) |
1268 |
1275 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT221 |
ADJUDICATION-DATE |
9(8) |
1275 |
1282 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 714 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT222 |
SELF-DIRECTION-TYPE |
X(3) |
1276 |
1278 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT222 |
SELF-DIRECTION-TYPE |
X(3) |
1283 |
1285 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 715 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT223 |
PRE-AUTHORIZATION-NUM |
X(18) |
1279 |
1296 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT223 |
PRE-AUTHORIZATION-NUM |
X(18) |
1286 |
1303 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 716 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT224 |
NDC-UNIT-OF-MEASURE |
X(2) |
1297 |
1298 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT224 |
NDC-UNIT-OF-MEASURE |
X(2) |
1304 |
1305 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 717 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
COT225 |
NDC-QUANTITY |
S9(6)V999 |
1299 |
1307 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT225 |
NDC-QUANTITY |
S9(6)V999 |
1306 |
1314 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 718 |
1 |
1 |
0 |
0 |
1 |
1 |
1 |
COT215 |
FILLER |
X(443) |
1308 |
1750 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT215 |
FILLER |
X(435) |
1315 |
1750 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 719 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX001 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX001 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 720 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 721 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 722 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 723 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 724 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX006 |
FILE-NAME |
X(8) |
32 |
39 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX006 |
FILE-NAME |
X(8) |
32 |
39 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 725 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 726 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 727 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 728 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 729 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 730 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX012 |
SSN-INDICATOR |
X(1) |
67 |
67 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX012 |
SSN-INDICATOR |
X(1) |
67 |
67 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 731 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX013 |
TOT-REC-CNT |
9(11) |
68 |
78 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX013 |
TOT-REC-CNT |
9(11) |
68 |
78 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 732 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX155 |
SEQUENCE-NUMBER |
X(4) |
79 |
82 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX155 |
SEQUENCE-NUMBER |
X(4) |
79 |
82 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 733 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX014 |
STATE-NOTATION |
X(500) |
83 |
582 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX014 |
STATE-NOTATION |
X(500) |
83 |
582 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 734 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX015 |
FILLER |
X(868) |
583 |
1450 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX015 |
FILLER |
X(868) |
583 |
1450 |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 735 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX016 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX016 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 736 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 737 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 738 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX019 |
ICN-ORIG |
X(50) |
22 |
71 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX019 |
ICN-ORIG |
X(50) |
22 |
71 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 739 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX020 |
ICN-ADJ |
X(50) |
72 |
121 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX020 |
ICN-ADJ |
X(50) |
72 |
121 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 740 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX021 |
SUBMITTER-ID |
X(12) |
122 |
133 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX021 |
SUBMITTER-ID |
X(12) |
122 |
133 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 741 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
134 |
153 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
134 |
153 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 743 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX023 |
CROSSOVER-INDICATOR |
X(1) |
154 |
154 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX023 |
CROSSOVER-INDICATOR |
X(1) |
154 |
154 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 744 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX024 |
1115A-DEMONSTRATION-IND |
X(1) |
155 |
155 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX024 |
1115A-DEMONSTRATION-IND |
X(1) |
155 |
155 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 745 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX025 |
ADJUSTMENT-IND |
X(1) |
156 |
156 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX025 |
ADJUSTMENT-IND |
X(1) |
156 |
156 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 746 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX026 |
ADJUSTMENT-REASON-CODE |
X(3) |
157 |
159 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX026 |
ADJUSTMENT-REASON-CODE |
X(3) |
157 |
159 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 747 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX027 |
ADJUDICATION-DATE |
9(8) |
160 |
167 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX027 |
ADJUDICATION-DATE |
9(8) |
160 |
167 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 748 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX028 |
MEDICAID-PAID-DATE |
9(8) |
168 |
175 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX028 |
MEDICAID-PAID-DATE |
9(8) |
168 |
175 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 749 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX029 |
TYPE-OF-CLAIM |
X(1) |
176 |
176 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX029 |
TYPE-OF-CLAIM |
X(1) |
176 |
176 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 750 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX030 |
CLAIM-STATUS |
X(3) |
177 |
179 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX030 |
CLAIM-STATUS |
X(3) |
177 |
179 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 751 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX031 |
CLAIM-STATUS-CATEGORY |
X(3) |
180 |
182 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX031 |
CLAIM-STATUS-CATEGORY |
X(3) |
180 |
182 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 752 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX032 |
SOURCE-LOCATION |
X(2) |
183 |
184 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX032 |
SOURCE-LOCATION |
X(2) |
183 |
184 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 753 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX033 |
CHECK-NUM |
X(15) |
185 |
199 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX033 |
CHECK-NUM |
X(15) |
185 |
199 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 754 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX034 |
CHECK-EFF-DATE |
9(8) |
200 |
207 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX034 |
CHECK-EFF-DATE |
9(8) |
200 |
207 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 755 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX035 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
208 |
212 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX035 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
208 |
212 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 756 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX036 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
213 |
217 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX036 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
213 |
217 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 757 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX037 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
218 |
222 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX037 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
218 |
222 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 758 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX038 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
223 |
227 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX038 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
223 |
227 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 759 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX039 |
TOT-BILLED-AMT |
S9(11)V99 |
228 |
240 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX039 |
TOT-BILLED-AMT |
S9(11)V99 |
228 |
240 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 760 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX040 |
TOT-ALLOWED-AMT |
S9(11)V99 |
241 |
253 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX040 |
TOT-ALLOWED-AMT |
S9(11)V99 |
241 |
253 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 761 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX041 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
254 |
266 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX041 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
254 |
266 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 762 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX042 |
TOT-COPAY-AMT |
S9(11)V99 |
267 |
279 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX042 |
TOT-COPAY-AMT |
S9(11)V99 |
267 |
279 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 763 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX043 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
280 |
292 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX043 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
280 |
292 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 764 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX044 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
293 |
305 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX044 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
293 |
305 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 765 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX045 |
TOT-TPL-AMT |
S9(11)V99 |
306 |
318 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX045 |
TOT-TPL-AMT |
S9(11)V99 |
306 |
318 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 766 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX047 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
319 |
331 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX047 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
319 |
331 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 767 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX048 |
OTHER-INSURANCE-IND |
X(1) |
332 |
332 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX048 |
OTHER-INSURANCE-IND |
X(1) |
332 |
332 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 768 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX049 |
OTHER-TPL-COLLECTION |
X(3) |
333 |
335 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX049 |
OTHER-TPL-COLLECTION |
X(3) |
333 |
335 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 769 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX050 |
SERVICE-TRACKING-TYPE |
X(2) |
336 |
337 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX050 |
SERVICE-TRACKING-TYPE |
X(2) |
336 |
337 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 770 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX051 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
338 |
350 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX051 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
338 |
350 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 771 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX052 |
FIXED-PAYMENT-IND |
X(1) |
351 |
351 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX052 |
FIXED-PAYMENT-IND |
X(1) |
351 |
351 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 772 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX053 |
FUNDING-CODE |
X(2) |
352 |
353 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX053 |
FUNDING-CODE |
X(2) |
352 |
353 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 773 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX054 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
354 |
355 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX054 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
354 |
355 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 774 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX055 |
PROGRAM-TYPE |
X(2) |
356 |
357 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX055 |
PROGRAM-TYPE |
X(2) |
356 |
357 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 775 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX056 |
PLAN-ID-NUMBER |
X(12) |
358 |
369 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX056 |
PLAN-ID-NUMBER |
X(12) |
358 |
369 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 776 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX057 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
370 |
379 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX057 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
370 |
379 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 777 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX058 |
PAYMENT-LEVEL-IND |
X(1) |
380 |
380 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX058 |
PAYMENT-LEVEL-IND |
X(1) |
380 |
380 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 778 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX059 |
MEDICARE-REIM-TYPE |
X(2) |
381 |
382 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX059 |
MEDICARE-REIM-TYPE |
X(2) |
381 |
382 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 779 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX060 |
CLAIM-LINE-COUNT |
9(4) |
383 |
386 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX060 |
CLAIM-LINE-COUNT |
9(4) |
383 |
386 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 780 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX061 |
FORCED-CLAIM-IND |
X(1) |
387 |
387 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX061 |
FORCED-CLAIM-IND |
X(1) |
387 |
387 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 781 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX062 |
PATIENT-CONTROL-NUM |
X(20) |
388 |
407 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX062 |
PATIENT-CONTROL-NUM |
X(20) |
388 |
407 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 782 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX063 |
ELIGIBLE-LAST-NAME |
X(30) |
408 |
437 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX063 |
ELIGIBLE-LAST-NAME |
X(30) |
408 |
437 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 783 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX064 |
ELIGIBLE-FIRST-NAME |
X(30) |
438 |
467 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX064 |
ELIGIBLE-FIRST-NAME |
X(30) |
438 |
467 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 784 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX065 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
468 |
468 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX065 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
468 |
468 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 785 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX066 |
DATE-OF-BIRTH |
9(8) |
469 |
476 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX066 |
DATE-OF-BIRTH |
9(8) |
469 |
476 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 786 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX067 |
HEALTH-HOME-PROV-IND |
X(1) |
477 |
477 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX067 |
HEALTH-HOME-PROV-IND |
X(1) |
477 |
477 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 787 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX068 |
WAIVER-TYPE |
X(2) |
478 |
479 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX068 |
WAIVER-TYPE |
X(2) |
478 |
479 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 788 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX069 |
WAIVER-ID |
X(20) |
480 |
499 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX069 |
WAIVER-ID |
X(20) |
480 |
499 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 789 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX070 |
BILLING-PROV-NUM |
X(30) |
500 |
529 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX070 |
BILLING-PROV-NUM |
X(30) |
500 |
529 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 790 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX071 |
BILLING-PROV-NPI-NUM |
X(10) |
530 |
539 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX071 |
BILLING-PROV-NPI-NUM |
X(10) |
530 |
539 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 791 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX072 |
BILLING-PROV-TAXONOMY |
X(12) |
540 |
551 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX072 |
BILLING-PROV-TAXONOMY |
X(12) |
540 |
551 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 792 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX073 |
BILLING-PROV-SPECIALTY |
X(2) |
552 |
553 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX073 |
BILLING-PROV-SPECIALTY |
X(2) |
552 |
553 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 793 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX074 |
PRESCRIBING-PROV-NUM |
X(30) |
554 |
583 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX074 |
PRESCRIBING-PROV-NUM |
X(30) |
554 |
583 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 794 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX075 |
PRESCRIBING-PROV-NPI-NUM |
X(10) |
584 |
593 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX075 |
PRESCRIBING-PROV-NPI-NUM |
X(10) |
584 |
593 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 795 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX076 |
PRESCRIBING-PROV-TAXONOMY |
X(12) |
594 |
605 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX076 |
PRESCRIBING-PROV-TAXONOMY |
X(12) |
594 |
605 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 796 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX077 |
PRESCRIBING-PROV-TYPE |
X(2) |
606 |
607 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX077 |
PRESCRIBING-PROV-TYPE |
X(2) |
606 |
607 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 797 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX078 |
PRESCRIBING-PROV-SPECIALTY |
X(2) |
608 |
609 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX078 |
PRESCRIBING-PROV-SPECIALTY |
X(2) |
608 |
609 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 798 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX079 |
MEDICARE-HIC-NUM |
X(12) |
610 |
621 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX079 |
MEDICARE-HIC-NUM |
X(12) |
610 |
621 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 799 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX081 |
REMITTANCE-NUM |
X(30) |
622 |
651 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX081 |
REMITTANCE-NUM |
X(30) |
622 |
651 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 800 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX082 |
BORDER-STATE-IND |
X(1) |
652 |
652 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX082 |
BORDER-STATE-IND |
X(1) |
652 |
652 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 801 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX084 |
DATE-PRESCRIBED |
9(8) |
653 |
660 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX084 |
DATE-PRESCRIBED |
9(8) |
653 |
660 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 802 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX085 |
PRESCRIPTION-FILL-DATE |
9(8) |
661 |
668 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX085 |
PRESCRIPTION-FILL-DATE |
9(8) |
661 |
668 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 803 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX086 |
COMPOUND-DRUG-IND |
X(1) |
669 |
669 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX086 |
COMPOUND-DRUG-IND |
X(1) |
669 |
669 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 804 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX087 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
670 |
682 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX087 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
670 |
682 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 805 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX089 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
683 |
695 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX089 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
683 |
695 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 806 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX090 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
696 |
703 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX090 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
696 |
703 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 807 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX088 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
704 |
711 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX088 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
704 |
711 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 808 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX092 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
712 |
724 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX092 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
712 |
724 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 809 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX093 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
725 |
732 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX093 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
725 |
732 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 810 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX094 |
CLAIM-DENIED-INDICATOR |
X(1) |
733 |
733 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX094 |
CLAIM-DENIED-INDICATOR |
X(1) |
733 |
733 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 811 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX095 |
COPAY-WAIVED-IND |
X(1) |
734 |
734 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX095 |
COPAY-WAIVED-IND |
X(1) |
734 |
734 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 812 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX096 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
735 |
784 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX096 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
735 |
784 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 813 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX098 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
785 |
797 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX098 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
785 |
797 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 814 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX099 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
798 |
805 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX099 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
798 |
805 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 815 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX100 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
806 |
818 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX100 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
806 |
818 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 816 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX101 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
819 |
826 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX101 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
819 |
826 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 817 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX102 |
DISPENSING-PRESCRIPTION-DRUG-PROV-NPI |
X(10) |
827 |
836 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX102 |
DISPENSING-PRESCRIPTION-DRUG-PROV-NPI |
X(10) |
827 |
836 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 818 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX103 |
DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY |
X(12) |
837 |
848 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX103 |
DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY |
X(12) |
837 |
848 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 819 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX104 |
HEALTH-HOME-PROVIDER-NPI |
X(10) |
849 |
858 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX104 |
HEALTH-HOME-PROVIDER-NPI |
X(10) |
849 |
858 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 820 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX105 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
859 |
870 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX105 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
859 |
870 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 821 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX106 |
STATE-NOTATION |
X(500) |
871 |
1370 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX106 |
STATE-NOTATION |
X(500) |
871 |
1370 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 822 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX156 |
DISPENSING-PRESCRIPTION-DRUG-PROV-NUM |
X(30) |
1371 |
1400 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX156 |
DISPENSING-PRESCRIPTION-DRUG-PROV-NUM |
X(30) |
1371 |
1400 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 823 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX160 |
MEDICARE-COMB-DED-IND |
X(1) |
1401 |
1401 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX160 |
MEDICARE-COMB-DED-IND |
X(1) |
1401 |
1401 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 824 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX161 |
PROV-LOCATION-ID |
X(5) |
1402 |
1406 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX161 |
PROV-LOCATION-ID |
X(5) |
1402 |
1406 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 825 |
1 |
1 |
0 |
1 |
1 |
1 |
1 |
CRX107 |
FILLER |
X(44) |
1407 |
1450 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX107 |
FILLER |
X(43) |
1407 |
1450 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 826 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX108 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX108 |
RECORD-ID |
X(8) |
1 |
8 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 827 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX109 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX109 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 828 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX110 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX110 |
RECORD-NUMBER |
9(11) |
11 |
21 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 829 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX111 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX111 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 831 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX112 |
ICN-ORIG |
X(50) |
42 |
91 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX112 |
ICN-ORIG |
X(50) |
42 |
91 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 832 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX113 |
ICN-ADJ |
X(50) |
92 |
141 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX113 |
ICN-ADJ |
X(50) |
92 |
141 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 833 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX114 |
LINE-NUM-ORIG |
X(3) |
142 |
144 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX114 |
LINE-NUM-ORIG |
X(3) |
142 |
144 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 834 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX115 |
LINE-NUM-ADJ |
X(3) |
145 |
147 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX115 |
LINE-NUM-ADJ |
X(3) |
145 |
147 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 835 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX116 |
LINE-ADJUSTMENT-IND |
X(1) |
148 |
148 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX116 |
LINE-ADJUSTMENT-IND |
X(1) |
148 |
148 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 836 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX117 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
149 |
151 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX117 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
149 |
151 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 837 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX118 |
SUBMITTER-ID |
X(12) |
152 |
163 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX118 |
SUBMITTER-ID |
X(12) |
152 |
163 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 838 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
CRX119 |
CLAIM-LINE-STATUS |
X(3) |
164 |
166 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX119 |
CLAIM-LINE-STATUS |
X(3) |
164 |
166 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 839 |
1 |
1 |
1 |
1 |
0 |
1 |
1 |
CRX120 |
NATIONAL-DRUG-CODE |
X(12) |
167 |
178 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX120 |
NATIONAL-DRUG-CODE |
X(12) |
167 |
177 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 840 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX121 |
BILLED-AMT |
S9(11)V99 |
179 |
191 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX121 |
BILLED-AMT |
S9(11)V99 |
178 |
190 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 841 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX122 |
ALLOWED-AMT |
S9(11)V99 |
192 |
204 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX122 |
ALLOWED-AMT |
S9(11)V99 |
191 |
203 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 842 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX123 |
COPAY-AMT |
S9(5)V99 |
205 |
211 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX123 |
COPAY-AMT |
S9(5)V99 |
204 |
210 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 843 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX124 |
TPL-AMT |
S9(11)V99 |
212 |
224 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX124 |
TPL-AMT |
S9(11)V99 |
211 |
223 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 844 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX125 |
MEDICAID-PAID-AMT |
S9(11)V99 |
225 |
237 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX125 |
MEDICAID-PAID-AMT |
S9(11)V99 |
224 |
236 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 845 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX126 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
238 |
250 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX126 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
237 |
249 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 846 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX127 |
MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
251 |
263 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX127 |
MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
250 |
262 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 847 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX128 |
MEDICARE-COINS-AMT |
S9(11)V99 |
264 |
276 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX128 |
MEDICARE-COINS-AMT |
S9(11)V99 |
263 |
275 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 848 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX129 |
MEDICARE-PAID-AMT |
S9(11)V99 |
277 |
289 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX129 |
MEDICARE-PAID-AMT |
S9(11)V99 |
276 |
288 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 849 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX131 |
OT-RX-CLAIM-QUANTITY-ALLOWED |
S9(6)V999 |
290 |
298 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX131 |
OT-RX-CLAIM-QUANTITY-ALLOWED |
S9(6)V999 |
289 |
297 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 850 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX132 |
OT-RX-CLAIM-QUANTITY-ACTUAL |
S9(6)V999 |
299 |
307 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX132 |
OT-RX-CLAIM-QUANTITY-ACTUAL |
S9(6)V999 |
298 |
306 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 851 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX133 |
UNIT-OF-MEASURE |
X(2) |
308 |
309 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX133 |
UNIT-OF-MEASURE |
X(2) |
307 |
308 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 852 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX134 |
TYPE-OF-SERVICE |
X(3) |
310 |
312 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX134 |
TYPE-OF-SERVICE |
X(3) |
309 |
311 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 853 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX135 |
HCBS-SERVICE-CODE |
X(1) |
313 |
313 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX135 |
HCBS-SERVICE-CODE |
X(1) |
312 |
312 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 854 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX136 |
HCBS-TAXONOMY |
X(5) |
314 |
318 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX136 |
HCBS-TAXONOMY |
X(5) |
313 |
317 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 855 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX137 |
OTHER-TPL-COLLECTION |
X(3) |
319 |
321 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX137 |
OTHER-TPL-COLLECTION |
X(3) |
318 |
320 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 856 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX138 |
DAYS-SUPPLY |
S9(5) |
322 |
326 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX138 |
DAYS-SUPPLY |
S9(5) |
321 |
325 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 857 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX139 |
NEW-REFILL-IND |
X(2) |
327 |
328 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX139 |
NEW-REFILL-IND |
X(2) |
326 |
327 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 858 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX140 |
BRAND-GENERIC-IND |
X(1) |
329 |
329 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX140 |
BRAND-GENERIC-IND |
X(1) |
328 |
328 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 859 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX141 |
DISPENSE-FEE |
S9(6)V99 |
330 |
337 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX141 |
DISPENSE-FEE |
S9(6)V99 |
329 |
336 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 860 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX142 |
PRESCRIPTION-NUM |
X(12) |
338 |
349 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX142 |
PRESCRIPTION-NUM |
X(12) |
337 |
348 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 861 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX143 |
DRUG-UTILIZATION-CODE |
X(6) |
350 |
355 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX143 |
DRUG-UTILIZATION-CODE |
X(6) |
349 |
354 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 862 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX144 |
DTL-METRIC-DEC-QTY |
S9(7)V999 |
356 |
365 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX144 |
DTL-METRIC-DEC-QTY |
S9(7)V999 |
355 |
364 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 863 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX145 |
COMPOUND-DOSAGE-FORM |
X(2) |
366 |
367 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX145 |
COMPOUND-DOSAGE-FORM |
X(2) |
365 |
366 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 864 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX146 |
REBATE-ELIGIBLE-INDICATOR |
X(1) |
368 |
368 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX146 |
REBATE-ELIGIBLE-INDICATOR |
X(1) |
367 |
367 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 865 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX147 |
IMMUNIZATION-TYPE |
X(2) |
369 |
370 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX147 |
IMMUNIZATION-TYPE |
X(2) |
368 |
369 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 866 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX148 |
BENEFIT-TYPE |
X(3) |
371 |
373 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX148 |
BENEFIT-TYPE |
X(3) |
370 |
372 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 867 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX149 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
374 |
375 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX149 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
373 |
374 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 868 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX150 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
376 |
379 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX150 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
375 |
378 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 869 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX151 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
380 |
382 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX151 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
379 |
381 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 870 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX152 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
383 |
395 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX152 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
382 |
394 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 871 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX153 |
STATE-NOTATION |
X(500) |
396 |
895 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX153 |
STATE-NOTATION |
X(500) |
395 |
894 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 872 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX157 |
ADJUDICATION-DATE |
9(8) |
896 |
903 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX157 |
ADJUDICATION-DATE |
9(8) |
895 |
902 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 873 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX158 |
SELF-DIRECTION-TYPE |
X(3) |
904 |
906 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX158 |
SELF-DIRECTION-TYPE |
X(3) |
903 |
905 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 874 |
1 |
1 |
1 |
0 |
0 |
1 |
1 |
CRX159 |
PRE-AUTHORIZATION-NUM |
X(18) |
907 |
924 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX159 |
PRE-AUTHORIZATION-NUM |
X(18) |
906 |
923 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 875 |
1 |
1 |
1 |
0 |
1 |
1 |
1 |
CRX154 |
FILLER |
X(526) |
925 |
1450 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX154 |
FILLER |
X(526) |
924 |
1450 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 876 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG001 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG001 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 877 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 878 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 879 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 880 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 881 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG006 |
FILE-NAME |
X(8) |
32 |
39 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG006 |
FILE-NAME |
X(8) |
32 |
39 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 882 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 883 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 884 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 885 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 886 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 887 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG012 |
SSN-INDICATOR |
X(1) |
67 |
67 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG012 |
SSN-INDICATOR |
X(1) |
67 |
67 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 888 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG013 |
TOT-REC-CNT |
9(11) |
68 |
78 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG013 |
TOT-REC-CNT |
9(11) |
68 |
78 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 889 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG247 |
SEQUENCE-NUMBER |
X(4) |
79 |
82 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG247 |
SEQUENCE-NUMBER |
X(4) |
79 |
82 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 890 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG014 |
STATE-NOTATION |
X(500) |
83 |
582 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG014 |
STATE-NOTATION |
X(500) |
83 |
582 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 891 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG015 |
FILLER |
X(418) |
583 |
1000 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG015 |
FILLER |
X(418) |
583 |
1000 |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 892 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG016 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG016 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 893 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 894 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 895 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG019 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG019 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 896 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG020 |
ELIGIBLE-FIRST-NAME |
X(30) |
42 |
71 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG020 |
ELIGIBLE-FIRST-NAME |
X(30) |
42 |
71 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 897 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG021 |
ELIGIBLE-LAST-NAME |
X(30) |
72 |
101 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG021 |
ELIGIBLE-LAST-NAME |
X(30) |
72 |
101 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 898 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG022 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
102 |
102 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG022 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
102 |
102 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 899 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG023 |
SEX |
X(1) |
103 |
103 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG023 |
SEX |
X(1) |
103 |
103 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 900 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG024 |
DATE-OF-BIRTH |
9(8) |
104 |
111 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG024 |
DATE-OF-BIRTH |
9(8) |
104 |
111 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 901 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG025 |
DATE-OF-DEATH |
9(8) |
112 |
119 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG025 |
DATE-OF-DEATH |
9(8) |
112 |
119 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 902 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG026 |
PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE |
9(8) |
120 |
127 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG026 |
PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE |
9(8) |
120 |
127 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 903 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG027 |
PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE |
9(8) |
128 |
135 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG027 |
PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE |
9(8) |
128 |
135 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 904 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG028 |
STATE-NOTATION |
X(500) |
136 |
635 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG028 |
STATE-NOTATION |
X(500) |
136 |
635 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 905 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG029 |
FILLER |
X(365) |
636 |
1000 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG029 |
FILLER |
X(365) |
636 |
1000 |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 906 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG030 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG030 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 907 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG031 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG031 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 908 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG032 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG032 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 909 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG033 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG033 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 910 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG034 |
MARITAL-STATUS |
X(2) |
42 |
43 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG034 |
MARITAL-STATUS |
X(2) |
42 |
43 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 911 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG035 |
MARITAL-STATUS-OTHER-EXPLANATION |
X(50) |
44 |
93 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG035 |
MARITAL-STATUS-OTHER-EXPLANATION |
X(50) |
44 |
93 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 912 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG036 |
SSN |
9(9) |
94 |
102 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG036 |
SSN |
9(9) |
94 |
102 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 913 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG037 |
SSN-VERIFICATION-FLAG |
X(1) |
103 |
103 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG037 |
SSN-VERIFICATION-FLAG |
X(1) |
103 |
103 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 914 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG038 |
INCOME-CODE |
X(2) |
104 |
105 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG038 |
INCOME-CODE |
X(2) |
104 |
105 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 915 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG039 |
VETERAN-IND |
X(1) |
106 |
106 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG039 |
VETERAN-IND |
X(1) |
106 |
106 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 916 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG040 |
CITIZENSHIP-IND |
X(1) |
107 |
107 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG040 |
CITIZENSHIP-IND |
X(1) |
107 |
107 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 917 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG041 |
CITIZENSHIP-VERIFICATION-FLAG |
X(1) |
108 |
108 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG041 |
CITIZENSHIP-VERIFICATION-FLAG |
X(1) |
108 |
108 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 918 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG042 |
IMMIGRATION-STATUS |
X(1) |
109 |
109 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG042 |
IMMIGRATION-STATUS |
X(1) |
109 |
109 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 919 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG043 |
IMMIGRATION-VERIFICATION-FLAG |
X(1) |
110 |
110 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG043 |
IMMIGRATION-VERIFICATION-FLAG |
X(1) |
110 |
110 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 920 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG044 |
IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE |
9(8) |
111 |
118 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG044 |
IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE |
9(8) |
111 |
118 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 921 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG045 |
PRIMARY-LANGUAGE-ENGL-PROF-CODE |
X(1) |
119 |
119 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG045 |
PRIMARY-LANGUAGE-ENGL-PROF-CODE |
X(1) |
119 |
119 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 922 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG046 |
PRIMARY-LANGUAGE-CODE |
X(3) |
120 |
122 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG046 |
PRIMARY-LANGUAGE-CODE |
X(3) |
120 |
122 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 923 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG047 |
HOUSEHOLD-SIZE |
X(2) |
123 |
124 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG047 |
HOUSEHOLD-SIZE |
X(2) |
123 |
124 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 924 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG049 |
PREGNANCY-IND |
X(1) |
125 |
125 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG049 |
PREGNANCY-IND |
X(1) |
125 |
125 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 925 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG050 |
MEDICARE-HIC-NUM |
X(12) |
126 |
137 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG050 |
MEDICARE-HIC-NUM |
X(12) |
126 |
137 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 926 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG051 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
138 |
149 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG051 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
138 |
149 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 927 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG054 |
CHIP-CODE |
X(1) |
150 |
150 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG054 |
CHIP-CODE |
X(1) |
150 |
150 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 928 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG057 |
VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE |
9(8) |
151 |
158 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG057 |
VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE |
9(8) |
151 |
158 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 929 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG058 |
VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE |
9(8) |
159 |
166 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG058 |
VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE |
9(8) |
159 |
166 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 930 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG059 |
STATE-NOTATION |
X(500) |
167 |
666 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG059 |
STATE-NOTATION |
X(500) |
167 |
666 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 931 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG060 |
FILLER |
X(334) |
667 |
1000 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG060 |
FILLER |
X(334) |
667 |
1000 |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 932 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
ELG061 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG061 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 933 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
ELG062 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG062 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 934 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
ELG063 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG063 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 935 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
ELG064 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG064 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 936 |
1 |
0 |
1 |
1 |
1 |
1 |
0 |
ELG065 |
ELIGIBLE-ADDR-TYPE |
X(2) |
42 |
43 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG065 |
ADDR-TYPE |
X(2) |
42 |
43 |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 937 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
ELG066 |
ELIGIBLE-ADDR-LN1 |
X(60) |
44 |
103 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG066 |
ELIGIBLE-ADDR-LN1 |
X(60) |
44 |
103 |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 938 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
ELG067 |
ELIGIBLE-ADDR-LN2 |
X(60) |
104 |
163 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG067 |
ELIGIBLE-ADDR-LN2 |
X(60) |
104 |
163 |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 939 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
ELG068 |
ELIGIBLE-ADDR-LN3 |
X(60) |
164 |
223 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG068 |
ELIGIBLE-ADDR-LN3 |
X(60) |
164 |
223 |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 940 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
ELG069 |
ELIGIBLE-CITY |
X(28) |
224 |
251 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG069 |
ELIGIBLE-CITY |
X(28) |
224 |
251 |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 941 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
ELG070 |
ELIGIBLE-STATE |
X(2) |
252 |
253 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG070 |
ELIGIBLE-STATE |
X(2) |
252 |
253 |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 942 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
ELG071 |
ELIGIBLE-ZIP-CODE |
X(9) |
254 |
262 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG071 |
ELIGIBLE-ZIP-CODE |
X(9) |
254 |
262 |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 943 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
ELG072 |
ELIGIBLE-COUNTY-CODE |
X(3) |
263 |
265 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG072 |
ELIGIBLE-COUNTY-CODE |
X(3) |
263 |
265 |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 944 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
ELG073 |
ELIGIBLE-PHONE-NUM |
X(10) |
266 |
275 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG073 |
ELIGIBLE-PHONE-NUM |
X(10) |
266 |
275 |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 945 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
ELG074 |
TYPE-OF-LIVING-ARRANGEMENT |
X(100) |
276 |
375 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG074 |
TYPE-OF-LIVING-ARRANGEMENT |
X(100) |
276 |
375 |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 946 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
ELG075 |
ELIGIBLE-ADDR-EFF-DATE |
9(8) |
376 |
383 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG075 |
ELIGIBLE-ADDR-EFF-DATE |
9(8) |
376 |
383 |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 947 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
ELG076 |
ELIGIBLE-ADDR-END-DATE |
9(8) |
384 |
391 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG076 |
ELIGIBLE-ADDR-END-DATE |
9(8) |
384 |
391 |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 948 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
ELG077 |
STATE-NOTATION |
X(500) |
392 |
891 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG077 |
STATE-NOTATION |
X(500) |
392 |
891 |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 949 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
ELG078 |
FILLER |
X(109) |
892 |
1000 |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG078 |
FILLER |
X(109) |
892 |
1000 |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 950 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG079 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG079 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 951 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG080 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG080 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 952 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG081 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG081 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 953 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG082 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG082 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 954 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG083 |
MSIS-CASE-NUM |
X(12) |
42 |
53 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG083 |
MSIS-CASE-NUM |
X(12) |
42 |
53 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 955 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG084 |
MEDICAID-BASIS-OF-ELIGIBILITY |
X(2) |
54 |
55 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG084 |
MEDICAID-BASIS-OF-ELIGIBILITY |
X(2) |
54 |
55 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 956 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG085 |
DUAL-ELIGIBLE-CODE |
X(2) |
56 |
57 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG085 |
DUAL-ELIGIBLE-CODE |
X(2) |
56 |
57 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 957 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG086 |
PRIMARY-ELIGIBILITY-GROUP-IND |
X(1) |
58 |
58 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG086 |
PRIMARY-ELIGIBILITY-GROUP-IND |
X(1) |
58 |
58 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 958 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG087 |
ELIGIBILITY-GROUP |
X(2) |
59 |
60 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG087 |
ELIGIBILITY-GROUP |
X(2) |
59 |
60 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 959 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG088 |
LEVEL-OF-CARE-STATUS |
X(3) |
61 |
63 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG088 |
LEVEL-OF-CARE-STATUS |
X(3) |
61 |
63 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 960 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG089 |
SSDI-IND |
X(1) |
64 |
64 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG089 |
SSDI-IND |
X(1) |
64 |
64 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 961 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG090 |
SSI-IND |
X(1) |
65 |
65 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG090 |
SSI-IND |
X(1) |
65 |
65 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 962 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG091 |
SSI-STATE-SUPPLEMENT-STATUS-CODE |
X(3) |
66 |
68 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG091 |
SSI-STATE-SUPPLEMENT-STATUS-CODE |
X(3) |
66 |
68 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 963 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG092 |
SSI-STATUS |
X(3) |
69 |
71 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG092 |
SSI-STATUS |
X(3) |
69 |
71 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 964 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG093 |
STATE-SPEC-ELIG-GROUP |
X(6) |
72 |
77 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG093 |
STATE-SPEC-ELIG-GROUP |
X(6) |
72 |
77 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 965 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG094 |
CONCEPTION-TO-BIRTH-IND |
X(1) |
78 |
78 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG094 |
CONCEPTION-TO-BIRTH-IND |
X(1) |
78 |
78 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 966 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG095 |
ELIGIBILITY-CHANGE-REASON |
X(2) |
79 |
80 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG095 |
ELIGIBILITY-CHANGE-REASON |
X(2) |
79 |
80 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 967 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG096 |
MAINTENANCE-ASSISTANCE-STATUS |
X(1) |
81 |
81 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG096 |
MAINTENANCE-ASSISTANCE-STATUS |
X(1) |
81 |
81 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 968 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG097 |
RESTRICTED-BENEFITS-CODE |
X(1) |
82 |
82 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG097 |
RESTRICTED-BENEFITS-CODE |
X(1) |
82 |
82 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 969 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG098 |
TANF-CASH-CODE |
X(1) |
83 |
83 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG098 |
TANF-CASH-CODE |
X(1) |
83 |
83 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 970 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG099 |
ELIGIBILITY-DETERMINANT-EFF-DATE |
9(8) |
84 |
91 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG099 |
ELIGIBILITY-DETERMINANT-EFF-DATE |
9(8) |
84 |
91 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 971 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG100 |
ELIGIBILITY-DETERMINANT-END-DATE |
9(8) |
92 |
99 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG100 |
ELIGIBILITY-DETERMINANT-END-DATE |
9(8) |
92 |
99 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 972 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG101 |
STATE-NOTATION |
X(500) |
100 |
599 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG101 |
STATE-NOTATION |
X(500) |
100 |
599 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 973 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG102 |
FILLER |
X(401) |
600 |
1000 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG102 |
FILLER |
X(401) |
600 |
1000 |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 974 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG103 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG103 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 975 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG104 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG104 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 976 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG105 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG105 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 977 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG106 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG106 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 978 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG107 |
HEALTH-HOME-SPA-NAME |
X(100) |
42 |
141 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG107 |
HEALTH-HOME-SPA-NAME |
X(100) |
42 |
141 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 979 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG108 |
HEALTH-HOME-ENTITY-NAME |
X(100) |
142 |
241 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG108 |
HEALTH-HOME-ENTITY-NAME |
X(100) |
142 |
241 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 980 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG109 |
HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE |
9(8) |
242 |
249 |
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 |
| 981 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG110 |
HEALTH-HOME-SPA-PARTICIPATION-END-DATE |
9(8) |
250 |
257 |
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 |
| 982 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG111 |
HEALTH-HOME-ENTITY-EFF-DATE |
9(8) |
258 |
265 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG111 |
HEALTH-HOME-ENTITY-EFF-DATE |
9(8) |
258 |
265 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 983 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG112 |
STATE-NOTATION |
X(500) |
266 |
765 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG112 |
STATE-NOTATION |
X(500) |
266 |
765 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 984 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG113 |
FILLER |
X(235) |
766 |
1000 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG113 |
FILLER |
X(235) |
766 |
1000 |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 985 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG114 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG114 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 986 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG115 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG115 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 987 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG116 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG116 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 988 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG117 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG117 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 989 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG118 |
HEALTH-HOME-SPA-NAME |
X(100) |
42 |
141 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG118 |
HEALTH-HOME-SPA-NAME |
X(100) |
42 |
141 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 990 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG119 |
HEALTH-HOME-ENTITY-NAME |
X(100) |
142 |
241 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG119 |
HEALTH-HOME-ENTITY-NAME |
X(100) |
142 |
241 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 991 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG120 |
HEALTH-HOME-PROV-NUM |
X(30) |
242 |
271 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG120 |
HEALTH-HOME-PROV-NUM |
X(30) |
242 |
271 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 992 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG121 |
HEALTH-HOME-SPA-PROVIDER-EFF-DATE |
9(8) |
272 |
279 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG121 |
HEALTH-HOME-SPA-PROVIDER-EFF-DATE |
9(8) |
272 |
279 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 993 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG122 |
HEALTH-HOME-SPA-PROVIDER-END-DATE |
9(8) |
280 |
287 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG122 |
HEALTH-HOME-SPA-PROVIDER-END-DATE |
9(8) |
280 |
287 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 994 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG123 |
HEALTH-HOME-ENTITY-EFF-DATE |
9(8) |
288 |
295 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG123 |
HEALTH-HOME-ENTITY-EFF-DATE |
9(8) |
288 |
295 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 995 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG124 |
STATE-NOTATION |
X(500) |
296 |
795 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG124 |
STATE-NOTATION |
X(500) |
296 |
795 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 996 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG125 |
FILLER |
X(205) |
796 |
1000 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG125 |
FILLER |
X(205) |
796 |
1000 |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 997 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG126 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG126 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 998 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG127 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG127 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 999 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG128 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG128 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 1,000 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG129 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG129 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 1,001 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG130 |
HEALTH-HOME-CHRONIC-CONDITION |
X(1) |
42 |
42 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG130 |
HEALTH-HOME-CHRONIC-CONDITION |
X(1) |
42 |
42 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 1,002 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG131 |
HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION |
X(50) |
43 |
92 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG131 |
HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION |
X(50) |
43 |
92 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 1,003 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG132 |
HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE |
9(8) |
93 |
100 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG132 |
HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE |
9(8) |
93 |
100 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 1,004 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG133 |
HEALTH-HOME-CHRONIC-CONDITION-END-DATE |
9(8) |
101 |
108 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG133 |
HEALTH-HOME-CHRONIC-CONDITION-END-DATE |
9(8) |
101 |
108 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 1,005 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG134 |
STATE-NOTATION |
X(500) |
109 |
608 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG134 |
STATE-NOTATION |
X(500) |
109 |
608 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 1,006 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG135 |
FILLER |
X(392) |
609 |
1000 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG135 |
FILLER |
X(392) |
609 |
1000 |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 1,007 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG136 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG136 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,008 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG137 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG137 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,009 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG138 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG138 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,010 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG139 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG139 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,011 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG140 |
LOCKIN-PROV-NUM |
X(30) |
42 |
71 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG140 |
LOCKIN-PROV-NUM |
X(30) |
42 |
71 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,012 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG141 |
LOCKIN-PROV-TYPE |
X(2) |
72 |
73 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG141 |
LOCKIN-PROV-TYPE |
X(2) |
72 |
73 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,013 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG142 |
LOCKIN-EFF-DATE |
9(8) |
74 |
81 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG142 |
LOCKIN-EFF-DATE |
9(8) |
74 |
81 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,014 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG143 |
LOCKIN-END-DATE |
9(8) |
82 |
89 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG143 |
LOCKIN-END-DATE |
9(8) |
82 |
89 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,015 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG144 |
STATE-NOTATION |
X(500) |
90 |
589 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG144 |
STATE-NOTATION |
X(500) |
90 |
589 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,016 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG145 |
FILLER |
X(411) |
590 |
1000 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG145 |
FILLER |
X(411) |
590 |
1000 |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,017 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG146 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG146 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,018 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG147 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG147 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,019 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG148 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG148 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,020 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG149 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG149 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,021 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG150 |
MFP-LIVES-WITH-FAMILY |
X(1) |
42 |
42 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG150 |
MFP-LIVES-WITH-FAMILY |
X(1) |
42 |
42 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,022 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG151 |
MFP-QUALIFIED-INSTITUTION |
X(2) |
43 |
44 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG151 |
MFP-QUALIFIED-INSTITUTION |
X(2) |
43 |
44 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,023 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG152 |
MFP-QUALIFIED-RESIDENCE |
X(2) |
45 |
46 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG152 |
MFP-QUALIFIED-RESIDENCE |
X(2) |
45 |
46 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,024 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG153 |
MFP-REASON-PARTICIPATION-ENDED |
X(2) |
47 |
48 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG153 |
MFP-REASON-PARTICIPATION-ENDED |
X(2) |
47 |
48 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,025 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG154 |
MFP-REINSTITUTIONALIZED-REASON |
X(2) |
49 |
50 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG154 |
MFP-REINSTITUTIONALIZED-REASON |
X(2) |
49 |
50 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,026 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG155 |
MFP-ENROLLMENT-EFF-DATE |
9(8) |
51 |
58 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG155 |
MFP-ENROLLMENT-EFF-DATE |
9(8) |
51 |
58 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,027 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG156 |
MFP-ENROLLMENT-END-DATE |
9(8) |
59 |
66 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG156 |
MFP-ENROLLMENT-END-DATE |
9(8) |
59 |
66 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,028 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG157 |
STATE-NOTATION |
X(500) |
67 |
566 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG157 |
STATE-NOTATION |
X(500) |
67 |
566 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,029 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG158 |
FILLER |
X(434) |
567 |
1000 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG158 |
FILLER |
X(434) |
567 |
1000 |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,030 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG159 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
ELG159 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| 1,031 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG160 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
ELG160 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| 1,032 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG161 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
ELG161 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| 1,033 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG162 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
ELG162 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| 1,034 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG163 |
STATE-PLAN-OPTION-TYPE |
X(2) |
42 |
43 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
ELG163 |
STATE-PLAN-OPTION-TYPE |
X(2) |
42 |
43 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| 1,035 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG164 |
STATE-PLAN-OPTION-EFF-DATE |
9(8) |
44 |
51 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
ELG164 |
STATE-PLAN-OPTION-EFF-DATE |
9(8) |
44 |
51 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| 1,036 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG165 |
STATE-PLAN-OPTION-END-DATE |
9(8) |
52 |
59 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
ELG165 |
STATE-PLAN-OPTION-END-DATE |
9(8) |
52 |
59 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| 1,037 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG166 |
STATE-NOTATION |
X(500) |
60 |
559 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
ELG166 |
STATE-NOTATION |
X(500) |
60 |
559 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| 1,038 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG167 |
FILLER |
X(441) |
560 |
1000 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
ELG167 |
FILLER |
X(441) |
560 |
1000 |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| 1,039 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG168 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG168 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,040 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG169 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG169 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,041 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG170 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG170 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,042 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG171 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG171 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,043 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG172 |
WAIVER-ID |
X(20) |
42 |
61 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG172 |
WAIVER-ID |
X(20) |
42 |
61 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,044 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG173 |
WAIVER-TYPE |
X(2) |
62 |
63 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG173 |
WAIVER-TYPE |
X(2) |
62 |
63 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,045 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG174 |
WAIVER-ENROLLMENT-EFF-DATE |
9(8) |
64 |
71 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG174 |
WAIVER-ENROLLMENT-EFF-DATE |
9(8) |
64 |
71 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,046 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG175 |
WAIVER-ENROLLMENT-END-DATE |
9(8) |
72 |
79 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG175 |
WAIVER-ENROLLMENT-END-DATE |
9(8) |
72 |
79 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,047 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG176 |
STATE-NOTATION |
X(500) |
80 |
579 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG176 |
STATE-NOTATION |
X(500) |
80 |
579 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,048 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG177 |
FILLER |
X(421) |
580 |
1000 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG177 |
FILLER |
X(421) |
580 |
1000 |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,049 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG178 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG178 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,050 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG179 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG179 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,051 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG180 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG180 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,052 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG181 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG181 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,053 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG182 |
LTSS-LEVEL-CARE |
X(1) |
42 |
42 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG182 |
LTSS-LEVEL-CARE |
X(1) |
42 |
42 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,054 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG183 |
LTSS-PROV-NUM |
X(30) |
43 |
72 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG183 |
LTSS-PROV-NUM |
X(30) |
43 |
72 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,055 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG184 |
LTSS-ELIGIBILITY-EFF-DATE |
9(8) |
73 |
80 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG184 |
LTSS-ELIGIBILITY-EFF-DATE |
9(8) |
73 |
80 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,056 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG185 |
LTSS-ELIGIBILITY-END-DATE |
9(8) |
81 |
88 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG185 |
LTSS-ELIGIBILITY-END-DATE |
9(8) |
81 |
88 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,057 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG186 |
STATE-NOTATION |
X(500) |
89 |
588 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG186 |
STATE-NOTATION |
X(500) |
89 |
588 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,058 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG187 |
FILLER |
X(412) |
589 |
1000 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG187 |
FILLER |
X(412) |
589 |
1000 |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,059 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG188 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG188 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,060 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG189 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG189 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,061 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG190 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG190 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,062 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG191 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG191 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,063 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG192 |
MANAGED-CARE-PLAN-ID |
X(12) |
42 |
53 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG192 |
MANAGED-CARE-PLAN-ID |
X(12) |
42 |
53 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,064 |
1 |
0 |
1 |
1 |
1 |
1 |
1 |
ELG193 |
ENROLLED-MANAGED-CARE-PLAN-TYPE |
X(2) |
54 |
55 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG193 |
MANAGED-CARE-PLAN-TYPE |
X(2) |
54 |
55 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,065 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG194 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
56 |
65 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG194 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
56 |
65 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,066 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG195 |
NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE |
X(1) |
66 |
66 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG195 |
NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE |
X(1) |
66 |
66 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,067 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG196 |
MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE |
9(8) |
67 |
74 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG196 |
MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE |
9(8) |
67 |
74 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,068 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG197 |
MANAGED-CARE-PLAN-ENROLLMENT-END-DATE |
9(8) |
75 |
82 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG197 |
MANAGED-CARE-PLAN-ENROLLMENT-END-DATE |
9(8) |
75 |
82 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,069 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG198 |
STATE-NOTATION |
X(500) |
83 |
582 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG198 |
STATE-NOTATION |
X(500) |
83 |
582 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,070 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG199 |
FILLER |
X(418) |
583 |
1000 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG199 |
FILLER |
X(418) |
583 |
1000 |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,071 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG200 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
ELG200 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| 1,072 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG201 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
ELG201 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| 1,073 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG202 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
ELG202 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| 1,074 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG203 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
ELG203 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| 1,075 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG204 |
ETHNICITY-CODE |
X(1) |
42 |
42 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
ELG204 |
ETHNICITY-CODE |
X(1) |
42 |
42 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| 1,076 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG205 |
ETHNICITY-DECLARATION-EFF-DATE |
9(8) |
43 |
50 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
ELG205 |
ETHNICITY-DECLARATION-EFF-DATE |
9(8) |
43 |
50 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| 1,077 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG206 |
ETHNICITY-DECLARATION-END-DATE |
9(8) |
51 |
58 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
ELG206 |
ETHNICITY-DECLARATION-END-DATE |
9(8) |
51 |
58 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| 1,078 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG207 |
STATE-NOTATION |
X(500) |
59 |
558 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
ELG207 |
STATE-NOTATION |
X(500) |
59 |
558 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| 1,079 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG208 |
FILLER |
X(442) |
559 |
1000 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
ELG208 |
FILLER |
X(442) |
559 |
1000 |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| 1,080 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG209 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG209 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,081 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG210 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG210 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,082 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG211 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG211 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,083 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG212 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG212 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,084 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG213 |
RACE |
X(3) |
42 |
44 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG213 |
RACE |
X(3) |
42 |
44 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,085 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG214 |
RACE-OTHER |
X(25) |
45 |
69 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG214 |
RACE-OTHER |
X(25) |
45 |
69 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,086 |
1 |
0 |
1 |
1 |
1 |
1 |
1 |
ELG215 |
CERTIFIED-AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR |
X(1) |
70 |
70 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG215 |
CERTIFIED-AMERICAN-INDIAN/ALASKAN-NATIVE-INDICATOR |
X(1) |
70 |
70 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,087 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG216 |
RACE-DECLARATION-EFF-DATE |
9(8) |
71 |
78 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG216 |
RACE-DECLARATION-EFF-DATE |
9(8) |
71 |
78 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,088 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG217 |
RACE-DECLARATION-END-DATE |
9(8) |
79 |
86 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG217 |
RACE-DECLARATION-END-DATE |
9(8) |
79 |
86 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,089 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG218 |
STATE-NOTATION |
X(500) |
87 |
586 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG218 |
STATE-NOTATION |
X(500) |
87 |
586 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,090 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG219 |
FILLER |
X(414) |
587 |
1000 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG219 |
FILLER |
X(414) |
587 |
1000 |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,091 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG220 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
ELG220 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| 1,092 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG221 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
ELG221 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| 1,093 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG222 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
ELG222 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| 1,094 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG223 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
ELG223 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| 1,095 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG224 |
DISABILITY-TYPE-CODE |
X(2) |
42 |
43 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
ELG224 |
DISABILITY-TYPE-CODE |
X(2) |
42 |
43 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| 1,096 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG225 |
DISABILITY-TYPE-EFF-DATE |
9(8) |
44 |
51 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
ELG225 |
DISABILITY-TYPE-EFF-DATE |
9(8) |
44 |
51 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| 1,097 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG226 |
DISABILITY-TYPE-END-DATE |
9(8) |
52 |
59 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
ELG226 |
DISABILITY-TYPE-END-DATE |
9(8) |
52 |
59 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| 1,098 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG227 |
STATE-NOTATION |
X(500) |
60 |
559 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
ELG227 |
STATE-NOTATION |
X(500) |
60 |
559 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| 1,099 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG228 |
FILLER |
X(441) |
560 |
1000 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
ELG228 |
FILLER |
X(441) |
560 |
1000 |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| 1,100 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG229 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
ELG229 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| 1,101 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG230 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
ELG230 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| 1,102 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG231 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
ELG231 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| 1,103 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG232 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
ELG232 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| 1,104 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG233 |
1115A-DEMONSTRATION-IND |
X(1) |
42 |
42 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
ELG233 |
1115A-DEMONSTRATION-IND |
X(1) |
42 |
42 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| 1,105 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG234 |
1115A-EFF-DATE |
9(8) |
43 |
50 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
ELG234 |
1115A-EFF-DATE |
9(8) |
43 |
50 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| 1,106 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG235 |
1115A-END-DATE |
9(8) |
51 |
58 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
ELG235 |
1115A-END-DATE |
9(8) |
51 |
58 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| 1,107 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG236 |
STATE-NOTATION |
X(500) |
59 |
558 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
ELG236 |
STATE-NOTATION |
X(500) |
59 |
558 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| 1,108 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG237 |
FILLER |
X(442) |
559 |
1000 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
ELG237 |
FILLER |
X(442) |
559 |
1000 |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| 1,109 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG238 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
ELG238 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| 1,110 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG239 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
ELG239 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| 1,111 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG240 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
ELG240 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| 1,112 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG241 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
ELG241 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| 1,113 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG242 |
HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE |
X(3) |
42 |
44 |
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 |
| 1,114 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG243 |
HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE |
9(8) |
45 |
52 |
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 |
| 1,115 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG244 |
HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE |
9(8) |
53 |
60 |
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 |
| 1,116 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG245 |
STATE-NOTATION |
X(500) |
61 |
560 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
ELG245 |
STATE-NOTATION |
X(500) |
61 |
560 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| 1,117 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG246 |
FILLER |
X(440) |
561 |
1000 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
ELG246 |
FILLER |
X(440) |
561 |
1000 |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| 1,118 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG248 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
ELG248 |
RECORD-ID |
X(8) |
1 |
8 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
| 1,119 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG249 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
ELG249 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
| 1,120 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG250 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
ELG250 |
RECORD-NUMBER |
9(11) |
11 |
21 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
| 1,121 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG251 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
ELG251 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
| 1,122 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG252 |
ENROLLMENT-TYPE |
X(1) |
42 |
42 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
ELG252 |
ENROLLMENT-TYPE |
X(1) |
42 |
42 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
| 1,123 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG253 |
ENROLLMENT-EFF-DATE |
9(8) |
43 |
50 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
ELG253 |
ENROLLMENT-EFF-DATE |
9(8) |
43 |
50 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
| 1,124 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG254 |
ENROLLMENT-END-DATE |
9(8) |
51 |
58 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
ELG254 |
ENROLLMENT-END-DATE |
9(8) |
51 |
58 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
| 1,125 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG255 |
STATE-NOTATION |
X(500) |
59 |
558 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
ELG255 |
STATE-NOTATION |
X(500) |
59 |
558 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
| 1,126 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
ELG256 |
FILLER |
X(442) |
559 |
1000 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
ELG256 |
FILLER |
X(442) |
559 |
1000 |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
| 1,127 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR001 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR001 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,128 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,129 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,130 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,131 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,132 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR006 |
FILE-NAME |
X(8) |
32 |
39 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR006 |
FILE-NAME |
X(8) |
32 |
39 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,133 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,134 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,135 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,136 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,137 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,138 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR013 |
TOT-REC-CNT |
9(11) |
67 |
77 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR013 |
TOT-REC-CNT |
9(11) |
67 |
77 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,139 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR112 |
SEQUENCE-NUMBER |
X(4) |
78 |
81 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR112 |
SEQUENCE-NUMBER |
X(4) |
78 |
81 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,140 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR014 |
STATE-NOTATION |
X(500) |
82 |
581 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR014 |
STATE-NOTATION |
X(500) |
82 |
581 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,141 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR012 |
FILLER |
X(419) |
582 |
1000 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR012 |
FILLER |
X(419) |
582 |
1000 |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,142 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR016 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR016 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,143 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,144 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,145 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR019 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR019 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,146 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR020 |
MANAGED-CARE-CONTRACT-EFF-DATE |
9(8) |
34 |
41 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR020 |
MANAGED-CARE-CONTRACT-EFF-DATE |
9(8) |
34 |
41 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,147 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR021 |
MANAGED-CARE-CONTRACT-END-DATE |
9(8) |
42 |
49 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR021 |
MANAGED-CARE-CONTRACT-END-DATE |
9(8) |
42 |
49 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,148 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR022 |
MANAGED-CARE-NAME |
X(55) |
50 |
104 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR022 |
MANAGED-CARE-NAME |
X(55) |
50 |
104 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,149 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR023 |
MANAGED-CARE-PROGRAM |
X(1) |
105 |
105 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR023 |
MANAGED-CARE-PROGRAM |
X(1) |
105 |
105 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,150 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR024 |
MANAGED-CARE-PLAN-TYPE |
X(2) |
106 |
107 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR024 |
MANAGED-CARE-PLAN-TYPE |
X(2) |
106 |
107 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,151 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR025 |
REIMBURSEMENT-ARRANGEMENT |
X(2) |
108 |
109 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR025 |
REIMBURSEMENT-ARRANGEMENT |
X(2) |
108 |
109 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,152 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR026 |
MANAGED-CARE-PROFIT-STATUS |
X(2) |
110 |
111 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR026 |
MANAGED-CARE-PROFIT-STATUS |
X(2) |
110 |
111 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,153 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR027 |
CORE-BASED-STATISTICAL-AREA-CODE |
X(1) |
112 |
112 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR027 |
CORE-BASED-STATISTICAL-AREA-CODE |
X(1) |
112 |
112 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,154 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR028 |
PERCENT-BUSINESS |
9(3) |
113 |
115 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR028 |
PERCENT-BUSINESS |
9(3) |
113 |
115 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,155 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR029 |
MANAGED-CARE-SERVICE-AREA |
X(1) |
116 |
116 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR029 |
MANAGED-CARE-SERVICE-AREA |
X(1) |
116 |
116 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,156 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR030 |
MANAGED-CARE-MAIN-REC-EFF-DATE |
9(8) |
117 |
124 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR030 |
MANAGED-CARE-MAIN-REC-EFF-DATE |
9(8) |
117 |
124 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,157 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR031 |
MANAGED-CARE-MAIN-REC-END-DATE |
9(8) |
125 |
132 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR031 |
MANAGED-CARE-MAIN-REC-END-DATE |
9(8) |
125 |
132 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,158 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR032 |
STATE-NOTATION |
X(500) |
133 |
632 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR032 |
STATE-NOTATION |
X(500) |
133 |
632 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,159 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR033 |
FILLER |
X(368) |
633 |
1000 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR033 |
FILLER |
X(368) |
633 |
1000 |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,160 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR034 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR034 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,161 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR035 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR035 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,162 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR036 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR036 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,163 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR037 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
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 |
| 1,164 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR038 |
MANAGED-CARE-LOCATION-ID |
X(15) |
34 |
48 |
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 |
| 1,165 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR039 |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE |
9(8) |
49 |
56 |
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 |
| 1,166 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR040 |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE |
9(8) |
57 |
64 |
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 |
| 1,167 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR041 |
MANAGED-CARE-ADDR-TYPE |
X(1) |
65 |
65 |
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 |
| 1,168 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR042 |
MANAGED-CARE-ADDR-LN1 |
X(60) |
66 |
125 |
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 |
| 1,169 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR043 |
MANAGED-CARE-ADDR-LN2 |
X(60) |
126 |
185 |
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 |
| 1,170 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR044 |
MANAGED-CARE-ADDR-LN3 |
X(60) |
186 |
245 |
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 |
| 1,171 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR045 |
MANAGED-CARE-CITY |
X(28) |
246 |
273 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR045 |
MANAGED-CARE-CITY |
X(28) |
246 |
273 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,172 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR046 |
MANAGED-CARE-STATE |
X(2) |
274 |
275 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR046 |
MANAGED-CARE-STATE |
X(2) |
274 |
275 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,173 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR047 |
MANAGED-CARE-ZIP-CODE |
X(9) |
276 |
284 |
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 |
| 1,174 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR048 |
MANAGED-CARE-COUNTY |
X(3) |
285 |
287 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR048 |
MANAGED-CARE-COUNTY |
X(3) |
285 |
287 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,175 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR049 |
MANAGED-CARE-TELEPHONE |
X(10) |
288 |
297 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR049 |
MANAGED-CARE-TELEPHONE |
X(10) |
288 |
297 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,176 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR050 |
MANAGED-CARE-EMAIL |
X(60) |
298 |
357 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR050 |
MANAGED-CARE-EMAIL |
X(60) |
298 |
357 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,177 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR051 |
MANAGED-CARE-FAX-NUMBER |
X(10) |
358 |
367 |
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 |
| 1,178 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR052 |
STATE-NOTATION |
X(500) |
368 |
867 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR052 |
STATE-NOTATION |
X(500) |
368 |
867 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,179 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR053 |
FILLER |
X(133) |
868 |
1000 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR053 |
FILLER |
X(133) |
868 |
1000 |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,180 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR054 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
MCR054 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| 1,181 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR055 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
MCR055 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| 1,182 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR056 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
MCR056 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| 1,183 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR057 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
MCR057 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| 1,184 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR058 |
MANAGED-CARE-SERVICE-AREA-NAME |
X(30) |
34 |
63 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
MCR058 |
MANAGED-CARE-SERVICE-AREA-NAME |
X(30) |
34 |
63 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| 1,185 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR059 |
MANAGED-CARE-SERVICE-AREA-EFF-DATE |
9(8) |
64 |
71 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
MCR059 |
MANAGED-CARE-SERVICE-AREA-EFF-DATE |
9(8) |
64 |
71 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| 1,186 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR060 |
MANAGED-CARE-SERVICE-AREA-END-DATE |
9(8) |
72 |
79 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
MCR060 |
MANAGED-CARE-SERVICE-AREA-END-DATE |
9(8) |
72 |
79 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| 1,187 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR061 |
STATE-NOTATION |
X(500) |
80 |
579 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
MCR061 |
STATE-NOTATION |
X(500) |
80 |
579 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| 1,188 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR062 |
FILLER |
X(421) |
580 |
1000 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
MCR062 |
FILLER |
X(421) |
580 |
1000 |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| 1,189 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR063 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR063 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,190 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR064 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR064 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,191 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR065 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR065 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,192 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR066 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR066 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,193 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR067 |
OPERATING-AUTHORITY |
X(2) |
34 |
35 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR067 |
OPERATING-AUTHORITY |
X(2) |
34 |
35 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,194 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR068 |
WAIVER-ID |
X(20) |
36 |
55 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR068 |
WAIVER-ID |
X(20) |
36 |
55 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,195 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR069 |
MANAGED-CARE-OP-AUTHORITY-EFF-DATE |
9(8) |
56 |
63 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR069 |
MANAGED-CARE-OP-AUTHORITY-EFF-DATE |
9(8) |
56 |
63 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,196 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR070 |
MANAGED-CARE-OP-AUTHORITY-END-DATE |
9(8) |
64 |
71 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR070 |
MANAGED-CARE-OP-AUTHORITY-END-DATE |
9(8) |
64 |
71 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,197 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR071 |
STATE-NOTATION |
X(500) |
72 |
571 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR071 |
STATE-NOTATION |
X(500) |
72 |
571 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,198 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR072 |
FILLER |
X(429) |
572 |
1000 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR072 |
FILLER |
X(429) |
572 |
1000 |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,199 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR073 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
MCR073 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| 1,200 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR074 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
MCR074 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| 1,201 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR075 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
MCR075 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| 1,202 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR076 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
MCR076 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| 1,203 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR077 |
MANAGED-CARE-PLAN-POP |
9(2) |
34 |
35 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
MCR077 |
MANAGED-CARE-PLAN-POP |
9(2) |
34 |
35 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| 1,204 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR078 |
MANAGED-CARE-PLAN-POP-EFF-DATE |
9(8) |
36 |
43 |
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 |
| 1,205 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR079 |
MANAGED-CARE-PLAN-POP-END-DATE |
9(8) |
44 |
51 |
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 |
| 1,206 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR080 |
STATE-NOTATION |
X(500) |
52 |
551 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
MCR080 |
STATE-NOTATION |
X(500) |
52 |
551 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| 1,207 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR081 |
FILLER |
X(449) |
552 |
1000 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
MCR081 |
FILLER |
X(449) |
552 |
1000 |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| 1,208 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
MCR082 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
MCR082 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| 1,209 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
MCR083 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
MCR083 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| 1,210 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
MCR084 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
MCR084 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| 1,211 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
MCR085 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
MCR085 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| 1,212 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
MCR086 |
ACCREDITATION-ORGANIZATION |
X(2) |
34 |
35 |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
MCR086 |
ACCREDITATION-ORGANIZATION |
X(2) |
34 |
35 |
MNGDCARE |
MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| 1,213 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
MCR087 |
DATE-ACCREDITATION-ACHIEVED |
9(8) |
36 |
43 |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
MCR087 |
DATE-ACCREDITATION-ACHIEVED |
9(8) |
36 |
43 |
MNGDCARE |
MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| 1,214 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
MCR088 |
DATE-ACCREDITATION-END |
9(8) |
44 |
51 |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
MCR088 |
DATE-ACCREDITATION-END |
9(8) |
44 |
51 |
MNGDCARE |
MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| 1,215 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
MCR089 |
STATE-NOTATION |
X(500) |
52 |
551 |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
MCR089 |
STATE-NOTATION |
X(500) |
52 |
551 |
MNGDCARE |
MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| 1,216 |
1 |
1 |
1 |
1 |
1 |
1 |
0 |
MCR090 |
FILLER |
X(449) |
552 |
1000 |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
MCR090 |
FILLER |
X(449) |
552 |
1000 |
MNGDCARE |
MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| 1,217 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR091 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
MCR091 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| 1,218 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR092 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
MCR092 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| 1,219 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR093 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
MCR093 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| 1,220 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR094 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
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 |
| 1,221 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR095 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
34 |
43 |
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 |
| 1,222 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR096 |
NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE |
X(1) |
44 |
44 |
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 |
| 1,223 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR097 |
NATIONAL-HEALTH-CARE-ENTITY-NAME |
X(50) |
45 |
94 |
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 |
| 1,224 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR098 |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE |
9(8) |
95 |
102 |
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 |
| 1,225 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR099 |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE |
9(8) |
103 |
110 |
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 |
| 1,226 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR100 |
STATE-NOTATION |
X(500) |
111 |
610 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
MCR100 |
STATE-NOTATION |
X(500) |
111 |
610 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| 1,227 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR101 |
FILLER |
X(390) |
611 |
1000 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
MCR101 |
FILLER |
X(390) |
611 |
1000 |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| 1,228 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR102 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR102 |
RECORD-ID |
X(8) |
1 |
8 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,229 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR103 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR103 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,230 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR104 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR104 |
RECORD-NUMBER |
9(11) |
11 |
21 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,231 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR105 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR105 |
STATE-PLAN-ID-NUM |
X(12) |
22 |
33 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,232 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR106 |
CHPID |
X(10) |
34 |
43 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR106 |
CHPID |
X(10) |
34 |
43 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,233 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR107 |
SHPID |
X(10) |
44 |
53 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR107 |
SHPID |
X(10) |
44 |
53 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,234 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR108 |
CHPID-SHPID-RELATIONSHIP-EFF-DATE |
9(8) |
54 |
61 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR108 |
CHPID-SHPID-RELATIONSHIP-EFF-DATE |
9(8) |
54 |
61 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,235 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR109 |
CHPID-SHPID-RELATIONSHIP-END-DATE |
9(8) |
62 |
69 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR109 |
CHPID-SHPID-RELATIONSHIP-END-DATE |
9(8) |
62 |
69 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,236 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR110 |
STATE-NOTATION |
X(500) |
70 |
569 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR110 |
STATE-NOTATION |
X(500) |
70 |
569 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,237 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
MCR111 |
FILLER |
X(431) |
570 |
1000 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR111 |
FILLER |
X(431) |
570 |
1000 |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,238 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV001 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV001 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,239 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,240 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,241 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,242 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,243 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV006 |
FILE-NAME |
X(8) |
32 |
39 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV006 |
FILE-NAME |
X(8) |
32 |
39 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,244 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,245 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,246 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,247 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,248 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,249 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV013 |
TOT-REC-CNT |
9(11) |
67 |
77 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV013 |
TOT-REC-CNT |
9(11) |
67 |
77 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,250 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV138 |
SEQUENCE-NUMBER |
X(4) |
78 |
81 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV138 |
SEQUENCE-NUMBER |
X(4) |
78 |
81 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,251 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV014 |
STATE-NOTATION |
X(500) |
82 |
581 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV014 |
STATE-NOTATION |
X(500) |
82 |
581 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,252 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV012 |
FILLER |
X(519) |
582 |
1100 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV012 |
FILLER |
X(519) |
582 |
1100 |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,253 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV016 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV016 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,254 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,255 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,256 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV019 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV019 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,257 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV020 |
PROV-ATTRIBUTES-EFF-DATE |
9(8) |
52 |
59 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV020 |
PROV-ATTRIBUTES-EFF-DATE |
9(8) |
52 |
59 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,258 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV021 |
PROV-ATTRIBUTES-END-DATE |
9(8) |
60 |
67 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV021 |
PROV-ATTRIBUTES-END-DATE |
9(8) |
60 |
67 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,259 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV022 |
PROV-DOING-BUSINESS-AS-NAME |
X(100) |
68 |
167 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV022 |
PROV-DOING-BUSINESS-AS-NAME |
X(100) |
68 |
167 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,260 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV023 |
PROV-LEGAL-NAME |
X(100) |
168 |
267 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV023 |
PROV-LEGAL-NAME |
X(100) |
168 |
267 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,261 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV024 |
PROV-ORGANIZATION-NAME |
X(60) |
268 |
327 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV024 |
PROV-ORGANIZATION-NAME |
X(60) |
268 |
327 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,262 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV025 |
PROV-TAX-NAME |
X(100) |
328 |
427 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV025 |
PROV-TAX-NAME |
X(100) |
328 |
427 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,263 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV026 |
FACILITY-GROUP-INDIVIDUAL-CODE |
X(2) |
428 |
429 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV026 |
FACILITY-GROUP-INDIVIDUAL-CODE |
X(2) |
428 |
429 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,264 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV027 |
TEACHING-IND |
X(1) |
430 |
430 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV027 |
TEACHING-IND |
X(1) |
430 |
430 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,265 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV028 |
PROV-FIRST-NAME |
X(30) |
431 |
460 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV028 |
PROV-FIRST-NAME |
X(30) |
431 |
460 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,266 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV029 |
PROV-MIDDLE-INITIAL |
X(1) |
461 |
461 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV029 |
PROV-MIDDLE-INITIAL |
X(1) |
461 |
461 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,267 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV030 |
PROV-LAST-NAME |
X(30) |
462 |
491 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV030 |
PROV-LAST-NAME |
X(30) |
462 |
491 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,268 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV031 |
SEX |
X(1) |
492 |
492 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV031 |
SEX |
X(1) |
492 |
492 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,269 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV032 |
OWNERSHIP-CODE |
X(2) |
493 |
494 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV032 |
OWNERSHIP-CODE |
X(2) |
493 |
494 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,270 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV033 |
PROV-PROFIT-STATUS |
X(2) |
495 |
496 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV033 |
PROV-PROFIT-STATUS |
X(2) |
495 |
496 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,271 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV034 |
DATE-OF-BIRTH |
9(8) |
497 |
504 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV034 |
DATE-OF-BIRTH |
9(8) |
497 |
504 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,272 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV035 |
DATE-OF-DEATH |
9(8) |
505 |
512 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV035 |
DATE-OF-DEATH |
9(8) |
505 |
512 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,273 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV036 |
ACCEPTING-NEW-PATIENTS-IND |
X(1) |
513 |
513 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV036 |
ACCEPTING-NEW-PATIENTS-IND |
X(1) |
513 |
513 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,274 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV037 |
STATE-NOTATION |
X(500) |
514 |
1013 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV037 |
STATE-NOTATION |
X(500) |
514 |
1013 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,275 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV038 |
FILLER |
X(87) |
1014 |
1100 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV038 |
FILLER |
X(87) |
1014 |
1100 |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,276 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV039 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV039 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,277 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV040 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV040 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,278 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV041 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV041 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,279 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV042 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV042 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,280 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV043 |
PROV-LOCATION-ID |
X(5) |
52 |
56 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV043 |
PROV-LOCATION-ID |
X(5) |
52 |
56 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,281 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV044 |
PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE |
9(8) |
57 |
64 |
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 |
| 1,282 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV045 |
PROV-LOCATION-AND-CONTACT-INFO-END-DATE |
9(8) |
65 |
72 |
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 |
| 1,283 |
1 |
0 |
1 |
1 |
1 |
1 |
1 |
PRV046 |
PROV-ADDR-TYPE |
X(1) |
73 |
73 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV046 |
ADDR-TYPE |
X(1) |
73 |
73 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,284 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV047 |
ADDR-LN1 |
X(60) |
74 |
133 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV047 |
ADDR-LN1 |
X(60) |
74 |
133 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,285 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV048 |
ADDR-LN2 |
X(60) |
134 |
193 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV048 |
ADDR-LN2 |
X(60) |
134 |
193 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,286 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV049 |
ADDR-LN3 |
X(60) |
194 |
253 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV049 |
ADDR-LN3 |
X(60) |
194 |
253 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,287 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV050 |
ADDR-CITY |
X(28) |
254 |
281 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV050 |
ADDR-CITY |
X(28) |
254 |
281 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,288 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV051 |
ADDR-STATE |
X(2) |
282 |
283 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV051 |
ADDR-STATE |
X(2) |
282 |
283 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,289 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV052 |
ADDR-ZIP-CODE |
X(9) |
284 |
292 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV052 |
ADDR-ZIP-CODE |
X(9) |
284 |
292 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,290 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV053 |
ADDR-TELEPHONE |
X(10) |
293 |
302 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV053 |
ADDR-TELEPHONE |
X(10) |
293 |
302 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,291 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV054 |
ADDR-EMAIL |
X(60) |
303 |
362 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV054 |
ADDR-EMAIL |
X(60) |
303 |
362 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,292 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV055 |
ADDR-FAX-NUM |
X(10) |
363 |
372 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV055 |
ADDR-FAX-NUM |
X(10) |
363 |
372 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,293 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV056 |
ADDR-BORDER-STATE-IND |
X(1) |
373 |
373 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV056 |
ADDR-BORDER-STATE-IND |
X(1) |
373 |
373 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,294 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV057 |
ADDR-COUNTY |
X(3) |
374 |
376 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV057 |
ADDR-COUNTY |
X(3) |
374 |
376 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,295 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV058 |
STATE-NOTATION |
X(500) |
377 |
876 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV058 |
STATE-NOTATION |
X(500) |
377 |
876 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,296 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV059 |
FILLER |
X(224) |
877 |
1100 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV059 |
FILLER |
X(224) |
877 |
1100 |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,297 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV060 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV060 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,298 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV061 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV061 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,299 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV062 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV062 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,300 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV063 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV063 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,301 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV064 |
PROV-LOCATION-ID |
X(5) |
52 |
56 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV064 |
PROV-LOCATION-ID |
X(5) |
52 |
56 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,302 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV065 |
PROV-LICENSE-EFF-DATE |
9(8) |
57 |
64 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV065 |
PROV-LICENSE-EFF-DATE |
9(8) |
57 |
64 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,303 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV066 |
PROV-LICENSE-END-DATE |
9(8) |
65 |
72 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV066 |
PROV-LICENSE-END-DATE |
9(8) |
65 |
72 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,304 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV067 |
LICENSE-TYPE |
X(1) |
73 |
73 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV067 |
LICENSE-TYPE |
X(1) |
73 |
73 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,305 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV068 |
LICENSE-ISSUING-ENTITY-ID |
X(60) |
74 |
133 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV068 |
LICENSE-ISSUING-ENTITY-ID |
X(60) |
74 |
133 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,306 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV069 |
LICENSE-OR-ACCREDITATION-NUMBER |
X(20) |
134 |
153 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV069 |
LICENSE-OR-ACCREDITATION-NUMBER |
X(20) |
134 |
153 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,307 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV070 |
STATE-NOTATION |
X(500) |
154 |
653 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV070 |
STATE-NOTATION |
X(500) |
154 |
653 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,308 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV071 |
FILLER |
X(447) |
654 |
1100 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV071 |
FILLER |
X(447) |
654 |
1100 |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,309 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV072 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV072 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,310 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV073 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV073 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,311 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV074 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV074 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,312 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV075 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV075 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,313 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV076 |
PROV-LOCATION-ID |
X(5) |
52 |
56 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV076 |
PROV-LOCATION-ID |
X(5) |
52 |
56 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,314 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV077 |
PROV-IDENTIFIER-TYPE |
X(1) |
57 |
57 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV077 |
PROV-IDENTIFIER-TYPE |
X(1) |
57 |
57 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,315 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV078 |
PROV-IDENTIFIER-ISSUING-ENTITY-ID |
X(18) |
58 |
75 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV078 |
PROV-IDENTIFIER-ISSUING-ENTITY-ID |
X(18) |
58 |
75 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,316 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV079 |
PROV-IDENTIFIER-EFF-DATE |
9(8) |
76 |
83 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV079 |
PROV-IDENTIFIER-EFF-DATE |
9(8) |
76 |
83 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,317 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV080 |
PROV-IDENTIFIER-END-DATE |
9(8) |
84 |
91 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV080 |
PROV-IDENTIFIER-END-DATE |
9(8) |
84 |
91 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,318 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV081 |
PROV-IDENTIFIER |
X(12) |
92 |
103 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV081 |
PROV-IDENTIFIER |
X(12) |
92 |
103 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,319 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV082 |
STATE-NOTATION |
X(500) |
104 |
603 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV082 |
STATE-NOTATION |
X(500) |
104 |
603 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,320 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV083 |
FILLER |
X(497) |
604 |
1100 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV083 |
FILLER |
X(497) |
604 |
1100 |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,321 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV084 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV084 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,322 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV085 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV085 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,323 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV086 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV086 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,324 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV087 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV087 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,325 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV088 |
PROV-CLASSIFICATION-TYPE |
X(1) |
52 |
52 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV088 |
PROV-CLASSIFICATION-TYPE |
X(1) |
52 |
52 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,326 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV089 |
PROV-CLASSIFICATION-CODE |
X(20) |
53 |
72 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV089 |
PROV-CLASSIFICATION-CODE |
X(20) |
53 |
72 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,327 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV090 |
PROV-TAXONOMY-CLASSIFICATION-EFF-DATE |
9(8) |
73 |
80 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV090 |
PROV-TAXONOMY-CLASSIFICATION-EFF-DATE |
9(8) |
73 |
80 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,328 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV091 |
PROV-TAXONOMY-CLASSIFICATION-END-DATE |
9(8) |
81 |
88 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV091 |
PROV-TAXONOMY-CLASSIFICATION-END-DATE |
9(8) |
81 |
88 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,329 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV092 |
STATE-NOTATION |
X(500) |
89 |
588 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV092 |
STATE-NOTATION |
X(500) |
89 |
588 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,330 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV093 |
FILLER |
X(512) |
589 |
1100 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV093 |
FILLER |
X(512) |
589 |
1100 |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,331 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV094 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV094 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,332 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV095 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV095 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,333 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV096 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV096 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,334 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV097 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV097 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,335 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV098 |
PROV-MEDICAID-EFF-DATE |
9(8) |
52 |
59 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV098 |
PROV-MEDICAID-EFF-DATE |
9(8) |
52 |
59 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,336 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV099 |
PROV-MEDICAID-END-DATE |
9(8) |
60 |
67 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV099 |
PROV-MEDICAID-END-DATE |
9(8) |
60 |
67 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,337 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV100 |
PROV-MEDICAID-ENROLLMENT-STATUS-CODE |
X(2) |
68 |
69 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV100 |
PROV-MEDICAID-ENROLLMENT-STATUS-CODE |
X(2) |
68 |
69 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,338 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV101 |
STATE-PLAN-ENROLLMENT |
X(1) |
70 |
70 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV101 |
STATE-PLAN-ENROLLMENT |
X(1) |
70 |
70 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,339 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV102 |
PROV-ENROLLMENT-METHOD |
X(1) |
71 |
71 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV102 |
PROV-ENROLLMENT-METHOD |
X(1) |
71 |
71 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,340 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV103 |
APPL-DATE |
9(8) |
72 |
79 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV103 |
APPL-DATE |
9(8) |
72 |
79 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,341 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV104 |
STATE-NOTATION |
X(500) |
80 |
579 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV104 |
STATE-NOTATION |
X(500) |
80 |
579 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,342 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV105 |
FILLER |
X(521) |
580 |
1100 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV105 |
FILLER |
X(521) |
580 |
1100 |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,343 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV106 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
PRV106 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| 1,344 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV107 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
PRV107 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| 1,345 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV108 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
PRV108 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| 1,346 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV109 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
PRV109 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| 1,347 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV110 |
SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY |
X(12) |
52 |
63 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
PRV110 |
SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY |
X(12) |
52 |
63 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| 1,348 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV111 |
PROV-AFFILIATED-GROUP-EFF-DATE |
9(8) |
64 |
71 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
PRV111 |
PROV-AFFILIATED-GROUP-EFF-DATE |
9(8) |
64 |
71 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| 1,349 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV112 |
PROV-AFFILIATED-GROUP-END-DATE |
9(8) |
72 |
79 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
PRV112 |
PROV-AFFILIATED-GROUP-END-DATE |
9(8) |
72 |
79 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
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1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV113 |
STATE-NOTATION |
X(500) |
80 |
579 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
PRV113 |
STATE-NOTATION |
X(500) |
80 |
579 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| 1,351 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV114 |
FILLER |
X(521) |
580 |
1100 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
PRV114 |
FILLER |
X(521) |
580 |
1100 |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| 1,352 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV115 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV115 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| 1,353 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV116 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV116 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
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1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV117 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV117 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| 1,355 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV118 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV118 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| 1,356 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV119 |
AFFILIATED-PROGRAM-TYPE |
X(1) |
52 |
52 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV119 |
AFFILIATED-PROGRAM-TYPE |
X(1) |
52 |
52 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| 1,357 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV120 |
AFFILIATED-PROGRAM-ID |
X(50) |
53 |
102 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV120 |
AFFILIATED-PROGRAM-ID |
X(50) |
53 |
102 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| 1,358 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV121 |
PROV-AFFILIATED-PROGRAM-EFF-DATE |
9(8) |
103 |
110 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV121 |
PROV-AFFILIATED-PROGRAM-EFF-DATE |
9(8) |
103 |
110 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| 1,359 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV122 |
PROV-AFFILIATED-PROGRAM-END-DATE |
9(8) |
111 |
118 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV122 |
PROV-AFFILIATED-PROGRAM-END-DATE |
9(8) |
111 |
118 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| 1,360 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV123 |
STATE-NOTATION |
X(500) |
119 |
618 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV123 |
STATE-NOTATION |
X(500) |
119 |
618 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| 1,361 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV124 |
FILLER |
X(482) |
619 |
1100 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV124 |
FILLER |
X(482) |
619 |
1100 |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| 1,362 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV125 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV125 |
RECORD-ID |
X(8) |
1 |
8 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,363 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV126 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV126 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,364 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV127 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV127 |
RECORD-NUMBER |
9(11) |
11 |
21 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,365 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV128 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV128 |
SUBMITTING-STATE-PROV-ID |
X(30) |
22 |
51 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,366 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV129 |
PROV-LOCATION-ID |
X(5) |
52 |
56 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV129 |
PROV-LOCATION-ID |
X(5) |
52 |
56 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,367 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV130 |
BED-TYPE-EFF-DATE |
9(8) |
57 |
64 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV130 |
BED-TYPE-EFF-DATE |
9(8) |
57 |
64 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,368 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV131 |
BED-TYPE-END-DATE |
9(8) |
65 |
72 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV131 |
BED-TYPE-END-DATE |
9(8) |
65 |
72 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,369 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV134 |
BED-TYPE-CODE |
X(1) |
73 |
73 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV134 |
BED-TYPE-CODE |
X(1) |
73 |
73 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,370 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV135 |
BED-COUNT |
9(5) |
74 |
78 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV135 |
BED-COUNT |
9(5) |
74 |
78 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,371 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV136 |
STATE-NOTATION |
X(500) |
79 |
578 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV136 |
STATE-NOTATION |
X(500) |
79 |
578 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,372 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
PRV137 |
FILLER |
X(522) |
579 |
1100 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV137 |
FILLER |
X(522) |
579 |
1100 |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,373 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL001 |
RECORD-ID |
X(8) |
1 |
8 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL001 |
RECORD-ID |
X(8) |
1 |
8 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,374 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL002 |
DATA-DICTIONARY-VERSION |
X(10) |
9 |
18 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,375 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
19 |
19 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,376 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
20 |
22 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,377 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
23 |
31 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,378 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL006 |
FILE-NAME |
X(8) |
32 |
39 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL006 |
FILE-NAME |
X(8) |
32 |
39 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,379 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL007 |
SUBMITTING-STATE |
X(2) |
40 |
41 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,380 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL008 |
DATE-FILE-CREATED |
9(8) |
42 |
49 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,381 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL009 |
START-OF-TIME-PERIOD |
9(8) |
50 |
57 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,382 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL010 |
END-OF-TIME-PERIOD |
9(8) |
58 |
65 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,383 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL011 |
FILE-STATUS-INDICATOR |
X(1) |
66 |
66 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,384 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL012 |
SSN-INDICATOR |
X(1) |
67 |
67 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL012 |
SSN-INDICATOR |
X(1) |
67 |
67 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,385 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL013 |
TOT-REC-CNT |
9(11) |
68 |
78 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL013 |
TOT-REC-CNT |
9(11) |
68 |
78 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,386 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL088 |
SEQUENCE-NUMBER |
X(4) |
79 |
82 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL088 |
SEQUENCE-NUMBER |
X(4) |
79 |
82 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,387 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL014 |
STATE-NOTATION |
X(500) |
83 |
582 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL014 |
STATE-NOTATION |
X(500) |
83 |
582 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,388 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL015 |
FILLER |
X(318) |
583 |
900 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL015 |
FILLER |
X(318) |
583 |
900 |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,389 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL016 |
RECORD-ID |
X(8) |
1 |
8 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL016 |
RECORD-ID |
X(8) |
1 |
8 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,390 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL017 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,391 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL018 |
RECORD-NUMBER |
9(11) |
11 |
21 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,392 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL019 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL019 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,393 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL020 |
TPL-HEALTH-INSURANCE-COVERAGE-IND |
X(1) |
42 |
42 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL020 |
TPL-HEALTH-INSURANCE-COVERAGE-IND |
X(1) |
42 |
42 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,394 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL021 |
TPL-OTHER-COVERAGE-IND |
X(1) |
43 |
43 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL021 |
TPL-OTHER-COVERAGE-IND |
X(1) |
43 |
43 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,395 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL022 |
ELIGIBLE-FIRST-NAME |
X(30) |
44 |
73 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL022 |
ELIGIBLE-FIRST-NAME |
X(30) |
44 |
73 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,396 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL023 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
74 |
74 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL023 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
74 |
74 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,397 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL024 |
ELIGIBLE-LAST-NAME |
X(30) |
75 |
104 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL024 |
ELIGIBLE-LAST-NAME |
X(30) |
75 |
104 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,398 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL025 |
ELIG-PRSN-MAIN-EFF-DATE |
9(8) |
105 |
112 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL025 |
ELIG-PRSN-MAIN-EFF-DATE |
9(8) |
105 |
112 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,399 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL026 |
ELIG-PRSN-MAIN-END-DATE |
9(8) |
113 |
120 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL026 |
ELIG-PRSN-MAIN-END-DATE |
9(8) |
113 |
120 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,400 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL027 |
STATE-NOTATION |
X(500) |
121 |
620 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL027 |
STATE-NOTATION |
X(500) |
121 |
620 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,401 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL028 |
FILLER |
X(280) |
621 |
900 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL028 |
FILLER |
X(280) |
621 |
900 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,402 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL029 |
RECORD-ID |
X(8) |
1 |
8 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL029 |
RECORD-ID |
X(8) |
1 |
8 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,403 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL030 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
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 |
| 1,404 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL031 |
RECORD-NUMBER |
9(11) |
11 |
21 |
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 |
| 1,405 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL032 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
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 |
| 1,406 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL033 |
INSURANCE-CARRIER-ID-NUM |
X(12) |
42 |
53 |
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 |
| 1,407 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL034 |
INSURANCE-PLAN-ID |
X(20) |
54 |
73 |
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 |
| 1,408 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL035 |
GROUP-NUM |
X(16) |
74 |
89 |
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 |
| 1,409 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL036 |
MEMBER-ID |
X(20) |
90 |
109 |
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 |
| 1,410 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL037 |
INSURANCE-PLAN-TYPE |
X(2) |
110 |
111 |
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 |
| 1,411 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL089 |
COVERAGE-TYPE |
X(2) |
112 |
113 |
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 |
| 1,412 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL038 |
ANNUAL-DEDUCTIBLE-AMT |
S9(11)V99 |
114 |
126 |
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 |
| 1,413 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL044 |
POLICY-OWNER-FIRST-NAME |
X(30) |
127 |
156 |
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 |
| 1,414 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL045 |
POLICY-OWNER-LAST-NAME |
X(30) |
157 |
186 |
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 |
| 1,415 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL046 |
POLICY-OWNER-SSN |
X(9) |
187 |
195 |
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 |
| 1,416 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL047 |
POLICY-OWNER-CODE |
X(2) |
196 |
197 |
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 |
| 1,417 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL048 |
INSURANCE-COVERAGE-EFF-DATE |
9(8) |
198 |
205 |
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 |
| 1,418 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL049 |
INSURANCE-COVERAGE-END-DATE |
9(8) |
206 |
213 |
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 |
| 1,419 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL050 |
STATE-NOTATION |
X(500) |
214 |
713 |
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 |
| 1,420 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL051 |
FILLER |
X(187) |
714 |
900 |
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 |
| 1,421 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL052 |
RECORD-ID |
X(8) |
1 |
8 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
TPL052 |
RECORD-ID |
X(8) |
1 |
8 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| 1,422 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL053 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
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 |
| 1,423 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL054 |
RECORD-NUMBER |
9(11) |
11 |
21 |
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 |
| 1,424 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL055 |
INSURANCE-CARRIER-ID-NUM |
X(12) |
22 |
33 |
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 |
| 1,425 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL056 |
INSURANCE-PLAN-ID |
X(20) |
34 |
53 |
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 |
| 1,426 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL057 |
INSURANCE-PLAN-TYPE |
X(2) |
54 |
55 |
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 |
| 1,427 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL058 |
COVERAGE-TYPE |
X(2) |
56 |
57 |
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 |
| 1,428 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL059 |
INSURANCE-CATEGORIES-EFF-DATE |
9(8) |
58 |
65 |
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 |
| 1,429 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL060 |
INSURANCE-CATEGORIES-END-DATE |
9(8) |
66 |
73 |
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 |
| 1,430 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL061 |
STATE-NOTATION |
X(500) |
74 |
573 |
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 |
| 1,431 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL062 |
FILLER |
X(327) |
574 |
900 |
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 |
| 1,432 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL063 |
RECORD-ID |
X(8) |
1 |
8 |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
TPL063 |
RECORD-ID |
X(8) |
1 |
8 |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| 1,433 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL064 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
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 |
| 1,434 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL065 |
RECORD-NUMBER |
9(11) |
11 |
21 |
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 |
| 1,435 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL066 |
MSIS-IDENTIFICATION-NUM |
X(20) |
22 |
41 |
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 |
| 1,436 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL067 |
TYPE-OF-OTHER-THIRD-PARTY-LIABILITY |
X(1) |
42 |
42 |
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 |
| 1,437 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL068 |
OTHER-TPL-EFF-DATE |
9(8) |
43 |
50 |
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 |
| 1,438 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL069 |
OTHER-TPL-END-DATE |
9(8) |
51 |
58 |
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 |
| 1,439 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL070 |
STATE-NOTATION |
X(500) |
59 |
558 |
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 |
| 1,440 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL071 |
FILLER |
X(342) |
559 |
900 |
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 |
| 1,441 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL072 |
RECORD-ID |
X(8) |
1 |
8 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL072 |
RECORD-ID |
X(8) |
1 |
8 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,442 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL073 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL073 |
SUBMITTING-STATE |
X(2) |
9 |
10 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,443 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL074 |
RECORD-NUMBER |
9(11) |
11 |
21 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL074 |
RECORD-NUMBER |
9(11) |
11 |
21 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,444 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL075 |
INSURANCE-CARRIER-ID-NUM |
X(12) |
22 |
33 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL075 |
INSURANCE-CARRIER-ID-NUM |
X(12) |
22 |
33 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,445 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL076 |
TPL-ENTITY-ADDR-TYPE |
X(2) |
34 |
35 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL076 |
TPL-ENTITY-ADDR-TYPE |
X(2) |
34 |
35 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,446 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL077 |
INSURANCE-CARRIER-ADDR-LN1 |
X(60) |
36 |
95 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL077 |
INSURANCE-CARRIER-ADDR-LN1 |
X(60) |
36 |
95 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,447 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL078 |
INSURANCE-CARRIER-ADDR-LN2 |
X(60) |
96 |
155 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL078 |
INSURANCE-CARRIER-ADDR-LN2 |
X(60) |
96 |
155 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,448 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL079 |
INSURANCE-CARRIER-ADDR-LN3 |
X(60) |
156 |
215 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL079 |
INSURANCE-CARRIER-ADDR-LN3 |
X(60) |
156 |
215 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,449 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL080 |
INSURANCE-CARRIER-CITY |
X(28) |
216 |
243 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL080 |
INSURANCE-CARRIER-CITY |
X(28) |
216 |
243 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,450 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL081 |
INSURANCE-CARRIER-STATE |
X(2) |
244 |
245 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL081 |
INSURANCE-CARRIER-STATE |
X(2) |
244 |
245 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,451 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL082 |
INSURANCE-CARRIER-ZIP-CODE |
X(9) |
246 |
254 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL082 |
INSURANCE-CARRIER-ZIP-CODE |
X(9) |
246 |
254 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,452 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL083 |
INSURANCE-CARRIER-PHONE-NUM |
X(10) |
255 |
264 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL083 |
INSURANCE-CARRIER-PHONE-NUM |
X(10) |
255 |
264 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,453 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL084 |
TPL-ENTITY-CONTACT-INFO-EFF-DATE |
9(8) |
265 |
272 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL084 |
TPL-ENTITY-CONTACT-INFO-EFF-DATE |
9(8) |
265 |
272 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,454 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL085 |
TPL-ENTITY-CONTACT-INFO-END-DATE |
9(8) |
273 |
280 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL085 |
TPL-ENTITY-CONTACT-INFO-END-DATE |
9(8) |
273 |
280 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,455 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL086 |
STATE-NOTATION |
X(500) |
281 |
780 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL086 |
STATE-NOTATION |
X(500) |
281 |
780 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,456 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL090 |
INSURANCE-CARRIER-NAIC-CODE |
X(10) |
781 |
790 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL090 |
INSURANCE-CARRIER-NAIC-CODE |
X(10) |
781 |
790 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,457 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL091 |
INSURANCE-CARRIER-NAME |
X(30) |
791 |
820 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL091 |
INSURANCE-CARRIER-NAME |
X(30) |
791 |
820 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,458 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL092 |
NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE |
X(1) |
821 |
821 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL092 |
NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE |
X(1) |
821 |
821 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,459 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL093 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
822 |
831 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL093 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
822 |
831 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,460 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
TPL094 |
NATIONAL-HEALTH-CARE-ENTITY-NAME |
X(50) |
832 |
881 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL094 |
NATIONAL-HEALTH-CARE-ENTITY-NAME |
X(50) |
832 |
881 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,461 |
1 |
1 |
0 |
1 |
1 |
1 |
1 |
TPL087 |
FILLER |
X (19) |
882 |
900 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL087 |
FILLER |
X (18) |
882 |
900 |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| Comparison of Data Element Size on v1.1 Main Presentation Tab versus Size in v2.0 |
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= Change between v1.1 DD and v2.0 DD |
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= duplicate row on v1.1 DD Main Presentation tab |
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The "NbrFalse" line shows how many spreadsheet rows have a V1.1 to V2.0 change.
NbrFalse |
0 |
4 |
13 |
0 |
28 |
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Filter on one of the "Comparison" columns to see those spreadsheet rows with V1.0 to V2.0 changes to the specified data element.
Comparison |
v2.0 DD |
v1.1 DD Main Presentation Tab |
|
Filter by color (red) to see all spreadsheet rows with changes in any of the data elements.
Filter by color (purple) to see the rows that were duplicated on the V1.1 Main Presentation Tab.
RowNo |
DE NO |
DATA ELEMENT NAME |
SIZE |
FILE NAME |
FILE SEGMENT (with RECORD-ID) |
DE_NO |
DATA_ELEMENT_NAME |
SIZE |
FILE NAME |
FILE SEGMENT (with RECORD-ID) |
DE NO |
DATA ELEMENT NAME |
SIZE |
FILE NAME |
FILE SEGMENT (with RECORD-ID) |
| 1 |
1 |
1 |
1 |
1 |
1 |
CIP001 |
RECORD-ID |
X(8) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP001 |
RECORD-ID |
X(8) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 2 |
1 |
1 |
1 |
1 |
1 |
CIP002 |
DATA-DICTIONARY-VERSION |
X(10) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP002 |
DATA-DICTIONARY-VERSION |
X(10) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 3 |
1 |
1 |
1 |
1 |
1 |
CIP003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 4 |
1 |
1 |
1 |
1 |
1 |
CIP004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 5 |
1 |
1 |
1 |
1 |
1 |
CIP005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 6 |
1 |
1 |
1 |
1 |
1 |
CIP006 |
FILE-NAME |
X(8) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP006 |
FILE-NAME |
X(8) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 7 |
1 |
1 |
1 |
1 |
1 |
CIP007 |
SUBMITTING-STATE |
X(2) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP007 |
SUBMITTING-STATE |
X(2) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 8 |
1 |
1 |
1 |
1 |
1 |
CIP008 |
DATE-FILE-CREATED |
9(8) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP008 |
DATE-FILE-CREATED |
9(8) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 9 |
1 |
1 |
1 |
1 |
1 |
CIP009 |
START-OF-TIME-PERIOD |
9(8) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP009 |
START-OF-TIME-PERIOD |
9(8) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 10 |
1 |
1 |
1 |
1 |
1 |
CIP010 |
END-OF-TIME-PERIOD |
9(8) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP010 |
END-OF-TIME-PERIOD |
9(8) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 11 |
1 |
1 |
1 |
1 |
1 |
CIP011 |
FILE-STATUS-INDICATOR |
X(1) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP011 |
FILE-STATUS-INDICATOR |
X(1) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 12 |
1 |
1 |
1 |
1 |
1 |
CIP012 |
SSN-INDICATOR |
X(1) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP012 |
SSN-INDICATOR |
X(1) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 13 |
1 |
1 |
1 |
1 |
1 |
CIP013 |
TOT-REC-CNT |
9(11) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP013 |
TOT-REC-CNT |
9(11) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 14 |
1 |
1 |
1 |
1 |
1 |
CIP275 |
SEQUENCE-NUMBER |
X(4) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP275 |
SEQUENCE-NUMBER |
X(4) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 15 |
1 |
1 |
1 |
1 |
1 |
CIP014 |
STATE-NOTATION |
X(500) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP014 |
STATE-NOTATION |
X(500) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 16 |
1 |
1 |
1 |
1 |
1 |
CIP015 |
FILLER |
X(1518) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
CIP015 |
FILLER |
X(1518) |
CLAIMIP |
FILE-HEADER-RECORD-IP-CIP00001 |
| 17 |
1 |
1 |
1 |
1 |
1 |
CIP016 |
RECORD-ID |
X(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP016 |
RECORD-ID |
X(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 18 |
1 |
1 |
1 |
1 |
1 |
CIP017 |
SUBMITTING-STATE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP017 |
SUBMITTING-STATE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 19 |
1 |
1 |
1 |
1 |
1 |
CIP018 |
RECORD-NUMBER |
9(11) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP018 |
RECORD-NUMBER |
9(11) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 20 |
1 |
1 |
1 |
1 |
1 |
CIP019 |
ICN-ORIG |
X(50) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP019 |
ICN-ORIG |
X(50) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 21 |
1 |
1 |
1 |
1 |
1 |
CIP020 |
ICN-ADJ |
X(50) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP020 |
ICN-ADJ |
X(50) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 22 |
1 |
1 |
1 |
1 |
1 |
CIP021 |
SUBMITTER-ID |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP021 |
SUBMITTER-ID |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 23 |
1 |
1 |
1 |
1 |
1 |
CIP022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 24 |
1 |
1 |
1 |
1 |
1 |
CIP023 |
CROSSOVER-INDICATOR |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP023 |
CROSSOVER-INDICATOR |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 25 |
1 |
1 |
1 |
1 |
1 |
CIP024 |
TYPE-OF-HOSPITAL |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP024 |
TYPE-OF-HOSPITAL |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 26 |
1 |
1 |
1 |
1 |
1 |
CIP025 |
1115A-DEMONSTRATION-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP025 |
1115A-DEMONSTRATION-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 27 |
1 |
1 |
1 |
1 |
1 |
CIP026 |
ADJUSTMENT-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP026 |
ADJUSTMENT-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 28 |
1 |
1 |
1 |
1 |
1 |
CIP027 |
ADJUSTMENT-REASON-CODE |
X(3) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP027 |
ADJUSTMENT-REASON-CODE |
X(3) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 29 |
1 |
1 |
1 |
1 |
1 |
CIP028 |
ADMISSION-TYPE |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP028 |
ADMISSION-TYPE |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 30 |
1 |
1 |
1 |
1 |
1 |
CIP029 |
DRG-DESCRIPTION |
X(20) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP029 |
DRG-DESCRIPTION |
X(20) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 31 |
1 |
1 |
1 |
1 |
1 |
CIP030 |
ADMITTING-DIAGNOSIS-CODE |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP030 |
ADMITTING-DIAGNOSIS-CODE |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 32 |
1 |
1 |
1 |
1 |
1 |
CIP031 |
ADMITTING-DIAGNOSIS-CODE-FLAG |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP031 |
ADMITTING-DIAGNOSIS-CODE-FLAG |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 33 |
1 |
1 |
1 |
1 |
1 |
CIP032 |
DIAGNOSIS-CODE-1 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP032 |
DIAGNOSIS-CODE-1 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 34 |
1 |
1 |
1 |
1 |
1 |
CIP033 |
DIAGNOSIS-CODE-FLAG-1 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP033 |
DIAGNOSIS-CODE-FLAG-1 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 35 |
1 |
1 |
1 |
1 |
1 |
CIP034 |
DIAGNOSIS-POA-FLAG-1 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP034 |
DIAGNOSIS-POA-FLAG-1 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 36 |
1 |
1 |
1 |
1 |
1 |
CIP035 |
DIAGNOSIS-CODE-2 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP035 |
DIAGNOSIS-CODE-2 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 37 |
1 |
1 |
1 |
1 |
1 |
CIP036 |
DIAGNOSIS-CODE-FLAG-2 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP036 |
DIAGNOSIS-CODE-FLAG-2 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 38 |
1 |
1 |
1 |
1 |
1 |
CIP037 |
DIAGNOSIS-POA-FLAG-2 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP037 |
DIAGNOSIS-POA-FLAG-2 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 39 |
1 |
1 |
1 |
1 |
1 |
CIP038 |
DIAGNOSIS-CODE-3 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP038 |
DIAGNOSIS-CODE-3 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 40 |
1 |
1 |
1 |
1 |
1 |
CIP039 |
DIAGNOSIS-CODE-FLAG-3 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP039 |
DIAGNOSIS-CODE-FLAG-3 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 41 |
1 |
1 |
1 |
1 |
1 |
CIP040 |
DIAGNOSIS-POA-FLAG-3 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP040 |
DIAGNOSIS-POA-FLAG-3 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 42 |
1 |
1 |
1 |
1 |
1 |
CIP041 |
DIAGNOSIS-CODE-4 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP041 |
DIAGNOSIS-CODE-4 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 43 |
1 |
1 |
1 |
1 |
1 |
CIP042 |
DIAGNOSIS-CODE-FLAG-4 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP042 |
DIAGNOSIS-CODE-FLAG-4 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 44 |
1 |
1 |
1 |
1 |
1 |
CIP043 |
DIAGNOSIS-POA-FLAG-4 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP043 |
DIAGNOSIS-POA-FLAG-4 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 45 |
1 |
1 |
1 |
1 |
1 |
CIP044 |
DIAGNOSIS-CODE-5 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP044 |
DIAGNOSIS-CODE-5 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 46 |
1 |
1 |
1 |
1 |
1 |
CIP045 |
DIAGNOSIS-CODE-FLAG-5 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP045 |
DIAGNOSIS-CODE-FLAG-5 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 47 |
1 |
1 |
1 |
1 |
1 |
CIP046 |
DIAGNOSIS-POA-FLAG-5 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP046 |
DIAGNOSIS-POA-FLAG-5 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 48 |
1 |
1 |
1 |
1 |
1 |
CIP047 |
DIAGNOSIS-CODE-6 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP047 |
DIAGNOSIS-CODE-6 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 49 |
1 |
1 |
1 |
1 |
1 |
CIP048 |
DIAGNOSIS-CODE-FLAG-6 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP048 |
DIAGNOSIS-CODE-FLAG-6 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 50 |
1 |
1 |
1 |
1 |
1 |
CIP049 |
DIAGNOSIS-POA-FLAG-6 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP049 |
DIAGNOSIS-POA-FLAG-6 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 51 |
1 |
1 |
1 |
1 |
1 |
CIP050 |
DIAGNOSIS-CODE-7 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP050 |
DIAGNOSIS-CODE-7 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 52 |
1 |
1 |
1 |
1 |
1 |
CIP051 |
DIAGNOSIS-CODE-FLAG-7 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP051 |
DIAGNOSIS-CODE-FLAG-7 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 53 |
1 |
1 |
1 |
1 |
1 |
CIP052 |
DIAGNOSIS-POA-FLAG-7 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP052 |
DIAGNOSIS-POA-FLAG-7 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 54 |
1 |
1 |
1 |
1 |
1 |
CIP053 |
DIAGNOSIS-CODE-8 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP053 |
DIAGNOSIS-CODE-8 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 55 |
1 |
1 |
1 |
1 |
1 |
CIP054 |
DIAGNOSIS-CODE-FLAG-8 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP054 |
DIAGNOSIS-CODE-FLAG-8 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 56 |
1 |
1 |
1 |
1 |
1 |
CIP055 |
DIAGNOSIS-POA-FLAG-8 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP055 |
DIAGNOSIS-POA-FLAG-8 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 57 |
1 |
1 |
1 |
1 |
1 |
CIP056 |
DIAGNOSIS-CODE-9 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP056 |
DIAGNOSIS-CODE-9 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 58 |
1 |
1 |
1 |
1 |
1 |
CIP057 |
DIAGNOSIS-CODE-FLAG-9 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP057 |
DIAGNOSIS-CODE-FLAG-9 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 59 |
1 |
1 |
1 |
1 |
1 |
CIP058 |
DIAGNOSIS-POA-FLAG-9 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP058 |
DIAGNOSIS-POA-FLAG-9 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 60 |
1 |
1 |
1 |
1 |
1 |
CIP059 |
DIAGNOSIS-CODE-10 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP059 |
DIAGNOSIS-CODE-10 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 61 |
1 |
1 |
1 |
1 |
1 |
CIP060 |
DIAGNOSIS-CODE-FLAG-10 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP060 |
DIAGNOSIS-CODE-FLAG-10 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 62 |
1 |
1 |
1 |
1 |
1 |
CIP061 |
DIAGNOSIS-POA-FLAG-10 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP061 |
DIAGNOSIS-POA-FLAG-10 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 63 |
1 |
1 |
1 |
1 |
1 |
CIP062 |
DIAGNOSIS-CODE-11 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP062 |
DIAGNOSIS-CODE-11 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 64 |
1 |
1 |
1 |
1 |
1 |
CIP063 |
DIAGNOSIS-CODE-FLAG-11 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP063 |
DIAGNOSIS-CODE-FLAG-11 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 65 |
1 |
1 |
1 |
1 |
1 |
CIP064 |
DIAGNOSIS-POA-FLAG-11 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP064 |
DIAGNOSIS-POA-FLAG-11 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 66 |
1 |
1 |
1 |
1 |
1 |
CIP065 |
DIAGNOSIS-CODE-12 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP065 |
DIAGNOSIS-CODE-12 |
X(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 67 |
1 |
1 |
1 |
1 |
1 |
CIP066 |
DIAGNOSIS-CODE-FLAG-12 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP066 |
DIAGNOSIS-CODE-FLAG-12 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 68 |
1 |
1 |
1 |
1 |
1 |
CIP067 |
DIAGNOSIS-POA-FLAG-12 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP067 |
DIAGNOSIS-POA-FLAG-12 |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 69 |
1 |
1 |
1 |
1 |
1 |
CIP068 |
DIAGNOSIS-RELATED-GROUP |
X(4) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP068 |
DIAGNOSIS-RELATED-GROUP |
X(4) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 70 |
1 |
1 |
1 |
1 |
1 |
CIP069 |
DIAGNOSIS-RELATED-GROUP-IND |
X(4) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP069 |
DIAGNOSIS-RELATED-GROUP-IND |
X(4) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 71 |
1 |
1 |
1 |
1 |
1 |
CIP070 |
PROCEDURE-CODE-1 |
X(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP070 |
PROCEDURE-CODE-1 |
X(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 72 |
1 |
1 |
1 |
1 |
1 |
CIP071 |
PROCEDURE-CODE-MOD-1 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP071 |
PROCEDURE-CODE-MOD-1 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 73 |
1 |
1 |
1 |
1 |
1 |
CIP072 |
PROCEDURE-CODE-FLAG-1 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP072 |
PROCEDURE-CODE-FLAG-1 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 74 |
1 |
1 |
1 |
1 |
1 |
CIP073 |
PROCEDURE-CODE-DATE-1 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP073 |
PROCEDURE-CODE-DATE-1 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 75 |
1 |
1 |
1 |
1 |
1 |
CIP074 |
PROCEDURE-CODE-2 |
X(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP074 |
PROCEDURE-CODE-2 |
X(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 76 |
1 |
1 |
1 |
1 |
1 |
CIP075 |
PROCEDURE-CODE-MOD-2 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP075 |
PROCEDURE-CODE-MOD-2 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 77 |
1 |
1 |
1 |
1 |
1 |
CIP076 |
PROCEDURE-CODE-FLAG-2 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP076 |
PROCEDURE-CODE-FLAG-2 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 78 |
1 |
1 |
1 |
1 |
1 |
CIP077 |
PROCEDURE-CODE-DATE-2 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP077 |
PROCEDURE-CODE-DATE-2 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 79 |
1 |
1 |
1 |
1 |
1 |
CIP078 |
PROCEDURE-CODE-3 |
X(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP078 |
PROCEDURE-CODE-3 |
X(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 80 |
1 |
1 |
1 |
1 |
1 |
CIP079 |
PROCEDURE-CODE-MOD-3 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP079 |
PROCEDURE-CODE-MOD-3 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 81 |
1 |
1 |
1 |
1 |
1 |
CIP080 |
PROCEDURE-CODE-FLAG-3 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP080 |
PROCEDURE-CODE-FLAG-3 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 82 |
1 |
1 |
1 |
1 |
1 |
CIP081 |
PROCEDURE-CODE-DATE-3 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP081 |
PROCEDURE-CODE-DATE-3 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 83 |
1 |
1 |
1 |
1 |
1 |
CIP082 |
PROCEDURE-CODE-4 |
X(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP082 |
PROCEDURE-CODE-4 |
X(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 84 |
1 |
1 |
1 |
1 |
1 |
CIP083 |
PROCEDURE-CODE-MOD-4 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP083 |
PROCEDURE-CODE-MOD-4 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 85 |
1 |
1 |
1 |
1 |
1 |
CIP084 |
PROCEDURE-CODE-FLAG-4 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP084 |
PROCEDURE-CODE-FLAG-4 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 86 |
1 |
1 |
1 |
1 |
1 |
CIP085 |
PROCEDURE-CODE-DATE-4 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP085 |
PROCEDURE-CODE-DATE-4 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 87 |
1 |
1 |
1 |
1 |
1 |
CIP086 |
PROCEDURE-CODE-5 |
X(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP086 |
PROCEDURE-CODE-5 |
X(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 88 |
1 |
1 |
1 |
1 |
1 |
CIP087 |
PROCEDURE-CODE-MOD-5 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP087 |
PROCEDURE-CODE-MOD-5 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 89 |
1 |
1 |
1 |
1 |
1 |
CIP088 |
PROCEDURE-CODE-FLAG-5 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP088 |
PROCEDURE-CODE-FLAG-5 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 90 |
1 |
1 |
1 |
1 |
1 |
CIP089 |
PROCEDURE-CODE-DATE-5 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP089 |
PROCEDURE-CODE-DATE-5 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 91 |
1 |
1 |
1 |
1 |
1 |
CIP090 |
PROCEDURE-CODE-6 |
X(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP090 |
PROCEDURE-CODE-6 |
X(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 92 |
1 |
1 |
1 |
1 |
1 |
CIP091 |
PROCEDURE-CODE-MOD-6 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP091 |
PROCEDURE-CODE-MOD-6 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 93 |
1 |
1 |
1 |
1 |
1 |
CIP092 |
PROCEDURE-CODE-FLAG-6 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP092 |
PROCEDURE-CODE-FLAG-6 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 94 |
1 |
1 |
1 |
1 |
1 |
CIP093 |
PROCEDURE-CODE-DATE-6 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP093 |
PROCEDURE-CODE-DATE-6 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 95 |
1 |
1 |
1 |
1 |
1 |
CIP094 |
ADMISSION-DATE |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP094 |
ADMISSION-DATE |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 96 |
1 |
1 |
1 |
1 |
1 |
CIP095 |
ADMISSION-HOUR |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP095 |
ADMISSION-HOUR |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 97 |
1 |
1 |
1 |
1 |
1 |
CIP096 |
DISCHARGE-DATE |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP096 |
DISCHARGE-DATE |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 98 |
1 |
1 |
1 |
1 |
1 |
CIP097 |
DISCHARGE-HOUR |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP097 |
DISCHARGE-HOUR |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 99 |
1 |
1 |
1 |
1 |
1 |
CIP098 |
ADJUDICATION-DATE |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP098 |
ADJUDICATION-DATE |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 100 |
1 |
1 |
1 |
1 |
1 |
CIP099 |
MEDICAID-PAID-DATE |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP099 |
MEDICAID-PAID-DATE |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 101 |
1 |
1 |
1 |
1 |
1 |
CIP100 |
TYPE-OF-CLAIM |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP100 |
TYPE-OF-CLAIM |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 102 |
1 |
1 |
1 |
1 |
1 |
CIP101 |
TYPE-OF-BILL |
X(4) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP101 |
TYPE-OF-BILL |
X(4) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 103 |
1 |
1 |
1 |
1 |
1 |
CIP102 |
CLAIM-STATUS |
X(3) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP102 |
CLAIM-STATUS |
X(3) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 104 |
1 |
1 |
1 |
1 |
1 |
CIP103 |
CLAIM-STATUS-CATEGORY |
X(3) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP103 |
CLAIM-STATUS-CATEGORY |
X(3) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 105 |
1 |
1 |
1 |
1 |
1 |
CIP104 |
SOURCE-LOCATION |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP104 |
SOURCE-LOCATION |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 106 |
1 |
1 |
1 |
1 |
1 |
CIP105 |
CHECK-NUM |
X(15) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP105 |
CHECK-NUM |
X(15) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 107 |
1 |
1 |
1 |
1 |
1 |
CIP106 |
CHECK-EFF-DATE |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP106 |
CHECK-EFF-DATE |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 108 |
1 |
1 |
1 |
1 |
1 |
CIP107 |
ALLOWED-CHARGE-SRC |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP107 |
ALLOWED-CHARGE-SRC |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 109 |
1 |
1 |
1 |
1 |
1 |
CIP108 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP108 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 110 |
1 |
1 |
1 |
1 |
1 |
CIP109 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP109 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 111 |
1 |
1 |
1 |
1 |
1 |
CIP110 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP110 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 112 |
1 |
1 |
1 |
1 |
1 |
CIP111 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP111 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 113 |
1 |
1 |
1 |
1 |
1 |
CIP112 |
TOT-BILLED-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP112 |
TOT-BILLED-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 114 |
1 |
1 |
1 |
1 |
1 |
CIP113 |
TOT-ALLOWED-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP113 |
TOT-ALLOWED-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 115 |
1 |
1 |
1 |
1 |
1 |
CIP114 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP114 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 116 |
1 |
1 |
1 |
1 |
1 |
CIP115 |
TOT-COPAY-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP115 |
TOT-COPAY-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 117 |
1 |
1 |
1 |
1 |
1 |
CIP116 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP116 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 118 |
1 |
1 |
1 |
1 |
1 |
CIP117 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP117 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 119 |
1 |
1 |
1 |
1 |
1 |
CIP118 |
TOT-TPL-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP118 |
TOT-TPL-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 120 |
1 |
1 |
1 |
1 |
1 |
CIP119 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP119 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 121 |
1 |
1 |
1 |
1 |
1 |
CIP121 |
OTHER-INSURANCE-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP121 |
OTHER-INSURANCE-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 122 |
1 |
1 |
1 |
1 |
1 |
CIP122 |
OTHER-TPL-COLLECTION |
X(3) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP122 |
OTHER-TPL-COLLECTION |
X(3) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 123 |
1 |
1 |
1 |
1 |
1 |
CIP123 |
SERVICE-TRACKING-TYPE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP123 |
SERVICE-TRACKING-TYPE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 124 |
1 |
1 |
1 |
1 |
1 |
CIP124 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP124 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 125 |
1 |
1 |
1 |
1 |
1 |
CIP125 |
FIXED-PAYMENT-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP125 |
FIXED-PAYMENT-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 126 |
1 |
1 |
1 |
1 |
1 |
CIP126 |
FUNDING-CODE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP126 |
FUNDING-CODE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 127 |
1 |
1 |
1 |
1 |
1 |
CIP127 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP127 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 128 |
1 |
1 |
1 |
1 |
1 |
CIP128 |
MEDICARE-COMB-DED-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP128 |
MEDICARE-COMB-DED-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 129 |
1 |
1 |
1 |
1 |
1 |
CIP129 |
PROGRAM-TYPE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP129 |
PROGRAM-TYPE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 130 |
1 |
1 |
1 |
1 |
1 |
CIP130 |
PLAN-ID-NUMBER |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP130 |
PLAN-ID-NUMBER |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 131 |
1 |
1 |
1 |
1 |
1 |
CIP131 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP131 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 132 |
1 |
1 |
1 |
1 |
1 |
CIP132 |
PAYMENT-LEVEL-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP132 |
PAYMENT-LEVEL-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 133 |
1 |
1 |
1 |
1 |
1 |
CIP133 |
MEDICARE-REIM-TYPE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP133 |
MEDICARE-REIM-TYPE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 134 |
1 |
1 |
1 |
1 |
1 |
CIP134 |
NON-COV-DAYS |
S9(5) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP134 |
NON-COV-DAYS |
S9(5) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 135 |
1 |
1 |
1 |
1 |
1 |
CIP135 |
NON-COV-CHARGES |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP135 |
NON-COV-CHARGES |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 136 |
1 |
1 |
1 |
1 |
1 |
CIP136 |
MEDICAID-COV-INPATIENT-DAYS |
S9(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP136 |
MEDICAID-COV-INPATIENT-DAYS |
S9(7) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 137 |
1 |
1 |
1 |
1 |
1 |
CIP137 |
CLAIM-LINE-COUNT |
9(4) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP137 |
CLAIM-LINE-COUNT |
9(4) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 138 |
1 |
1 |
1 |
1 |
1 |
CIP138 |
FORCED-CLAIM-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP138 |
FORCED-CLAIM-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 139 |
1 |
1 |
1 |
1 |
1 |
CIP139 |
HEALTH-CARE-ACQUIRED-CONDITION-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP139 |
HEALTH-CARE-ACQUIRED-CONDITION-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 140 |
1 |
1 |
1 |
1 |
1 |
CIP140 |
OCCURRENCE-CODE-01 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP140 |
OCCURRENCE-CODE-01 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 141 |
1 |
1 |
1 |
1 |
1 |
CIP141 |
OCCURRENCE-CODE-02 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP141 |
OCCURRENCE-CODE-02 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 142 |
1 |
1 |
1 |
1 |
1 |
CIP142 |
OCCURRENCE-CODE-03 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP142 |
OCCURRENCE-CODE-03 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 143 |
1 |
1 |
1 |
1 |
1 |
CIP143 |
OCCURRENCE-CODE-04 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP143 |
OCCURRENCE-CODE-04 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 144 |
1 |
1 |
1 |
1 |
1 |
CIP144 |
OCCURRENCE-CODE-05 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP144 |
OCCURRENCE-CODE-05 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 145 |
1 |
1 |
1 |
1 |
1 |
CIP145 |
OCCURRENCE-CODE-06 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP145 |
OCCURRENCE-CODE-06 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 146 |
1 |
1 |
1 |
1 |
1 |
CIP146 |
OCCURRENCE-CODE-07 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP146 |
OCCURRENCE-CODE-07 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 147 |
1 |
1 |
1 |
1 |
1 |
CIP147 |
OCCURRENCE-CODE-08 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP147 |
OCCURRENCE-CODE-08 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 148 |
1 |
1 |
1 |
1 |
1 |
CIP148 |
OCCURRENCE-CODE-09 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP148 |
OCCURRENCE-CODE-09 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 149 |
1 |
1 |
1 |
1 |
1 |
CIP149 |
OCCURRENCE-CODE-10 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP149 |
OCCURRENCE-CODE-10 |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 150 |
1 |
1 |
1 |
1 |
1 |
CIP150 |
OCCURRENCE-CODE-EFF-DATE-01 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP150 |
OCCURRENCE-CODE-EFF-DATE-01 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 151 |
1 |
1 |
1 |
1 |
1 |
CIP151 |
OCCURRENCE-CODE-EFF-DATE-02 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP151 |
OCCURRENCE-CODE-EFF-DATE-02 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 152 |
1 |
1 |
1 |
1 |
1 |
CIP152 |
OCCURRENCE-CODE-EFF-DATE-03 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP152 |
OCCURRENCE-CODE-EFF-DATE-03 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 153 |
1 |
1 |
1 |
1 |
1 |
CIP153 |
OCCURRENCE-CODE-EFF-DATE-04 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP153 |
OCCURRENCE-CODE-EFF-DATE-04 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 154 |
1 |
1 |
1 |
1 |
1 |
CIP154 |
OCCURRENCE-CODE-EFF-DATE-05 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP154 |
OCCURRENCE-CODE-EFF-DATE-05 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 155 |
1 |
1 |
1 |
1 |
1 |
CIP155 |
OCCURRENCE-CODE-EFF-DATE-06 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP155 |
OCCURRENCE-CODE-EFF-DATE-06 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 156 |
1 |
1 |
1 |
1 |
1 |
CIP156 |
OCCURRENCE-CODE-EFF-DATE-07 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP156 |
OCCURRENCE-CODE-EFF-DATE-07 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 157 |
1 |
1 |
1 |
1 |
1 |
CIP157 |
OCCURRENCE-CODE-EFF-DATE-08 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP157 |
OCCURRENCE-CODE-EFF-DATE-08 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 158 |
1 |
1 |
1 |
1 |
1 |
CIP158 |
OCCURRENCE-CODE-EFF-DATE-09 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP158 |
OCCURRENCE-CODE-EFF-DATE-09 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 159 |
1 |
1 |
1 |
1 |
1 |
CIP159 |
OCCURRENCE-CODE-EFF-DATE-10 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP159 |
OCCURRENCE-CODE-EFF-DATE-10 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 160 |
1 |
1 |
1 |
1 |
1 |
CIP160 |
OCCURRENCE-CODE-END-DATE-01 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP160 |
OCCURRENCE-CODE-END-DATE-01 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 161 |
1 |
1 |
1 |
1 |
1 |
CIP161 |
OCCURRENCE-CODE-END-DATE-02 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP161 |
OCCURRENCE-CODE-END-DATE-02 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 162 |
1 |
1 |
1 |
1 |
1 |
CIP162 |
OCCURRENCE-CODE-END-DATE-03 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP162 |
OCCURRENCE-CODE-END-DATE-03 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 163 |
1 |
1 |
1 |
1 |
1 |
CIP163 |
OCCURRENCE-CODE-END-DATE-04 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP163 |
OCCURRENCE-CODE-END-DATE-04 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 164 |
1 |
1 |
1 |
1 |
1 |
CIP164 |
OCCURRENCE-CODE-END-DATE-05 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP164 |
OCCURRENCE-CODE-END-DATE-05 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 165 |
1 |
1 |
1 |
1 |
1 |
CIP165 |
OCCURRENCE-CODE-END-DATE-06 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP165 |
OCCURRENCE-CODE-END-DATE-06 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 166 |
1 |
1 |
1 |
1 |
1 |
CIP166 |
OCCURRENCE-CODE-END-DATE-07 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP166 |
OCCURRENCE-CODE-END-DATE-07 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 167 |
1 |
1 |
1 |
1 |
1 |
CIP167 |
OCCURRENCE-CODE-END-DATE-08 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP167 |
OCCURRENCE-CODE-END-DATE-08 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 168 |
1 |
1 |
1 |
1 |
1 |
CIP168 |
OCCURRENCE-CODE-END-DATE-09 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP168 |
OCCURRENCE-CODE-END-DATE-09 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 169 |
1 |
1 |
1 |
1 |
1 |
CIP169 |
OCCURRENCE-CODE-END-DATE-10 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP169 |
OCCURRENCE-CODE-END-DATE-10 |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 170 |
1 |
1 |
1 |
1 |
1 |
CIP170 |
BIRTH-WEIGHT-GRAMS |
S9(6)V999 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP170 |
BIRTH-WEIGHT-GRAMS |
S9(6)V999 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 171 |
1 |
1 |
1 |
1 |
1 |
CIP171 |
PATIENT-CONTROL-NUM |
X(20) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP171 |
PATIENT-CONTROL-NUM |
X(20) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 172 |
1 |
1 |
1 |
1 |
1 |
CIP172 |
ELIGIBLE-LAST-NAME |
X(30) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP172 |
ELIGIBLE-LAST-NAME |
X(30) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 173 |
1 |
1 |
1 |
1 |
1 |
CIP173 |
ELIGIBLE-FIRST-NAME |
X(30) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP173 |
ELIGIBLE-FIRST-NAME |
X(30) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 174 |
1 |
1 |
1 |
1 |
1 |
CIP174 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP174 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 175 |
1 |
1 |
1 |
1 |
1 |
CIP175 |
DATE-OF-BIRTH |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP175 |
DATE-OF-BIRTH |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 176 |
1 |
1 |
1 |
1 |
1 |
CIP176 |
HEALTH-HOME-PROV-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP176 |
HEALTH-HOME-PROV-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 177 |
1 |
1 |
1 |
1 |
1 |
CIP177 |
WAIVER-TYPE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP177 |
WAIVER-TYPE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 178 |
1 |
1 |
1 |
1 |
1 |
CIP178 |
WAIVER-ID |
X(20) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP178 |
WAIVER-ID |
X(20) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 179 |
1 |
1 |
1 |
1 |
1 |
CIP179 |
BILLING-PROV-NUM |
X(30) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP179 |
BILLING-PROV-NUM |
X(30) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 180 |
1 |
1 |
1 |
1 |
1 |
CIP180 |
BILLING-PROV-NPI-NUM |
X(10) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP180 |
BILLING-PROV-NPI-NUM |
X(10) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 181 |
1 |
1 |
1 |
1 |
1 |
CIP181 |
BILLING-PROV-TAXONOMY |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP181 |
BILLING-PROV-TAXONOMY |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 182 |
1 |
1 |
1 |
1 |
1 |
CIP182 |
BILLING-PROV-TYPE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP182 |
BILLING-PROV-TYPE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 183 |
1 |
1 |
1 |
1 |
1 |
CIP183 |
BILLING-PROV-SPECIALTY |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP183 |
BILLING-PROV-SPECIALTY |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 184 |
1 |
1 |
1 |
1 |
1 |
CIP184 |
ADMITTING-PROV-NPI-NUM |
X(10) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP184 |
ADMITTING-PROV-NPI-NUM |
X(10) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 185 |
1 |
1 |
1 |
1 |
1 |
CIP185 |
ADMITTING-PROV-NUM |
X(30) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP185 |
ADMITTING-PROV-NUM |
X(30) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 186 |
1 |
1 |
1 |
1 |
1 |
CIP186 |
ADMITTING-PROV-SPECIALTY |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP186 |
ADMITTING-PROV-SPECIALTY |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 187 |
1 |
1 |
1 |
1 |
1 |
CIP187 |
ADMITTING-PROV-TAXONOMY |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP187 |
ADMITTING-PROV-TAXONOMY |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 188 |
1 |
1 |
1 |
1 |
1 |
CIP188 |
ADMITTING-PROV-TYPE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP188 |
ADMITTING-PROV-TYPE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 189 |
1 |
1 |
1 |
1 |
1 |
CIP189 |
REFERRING-PROV-NUM |
X(30) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP189 |
REFERRING-PROV-NUM |
X(30) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 190 |
1 |
1 |
1 |
1 |
1 |
CIP190 |
REFERRING-PROV-NPI-NUM |
X(10) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP190 |
REFERRING-PROV-NPI-NUM |
X(10) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 191 |
1 |
1 |
1 |
1 |
1 |
CIP191 |
REFERRING-PROV-TAXONOMY |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP191 |
REFERRING-PROV-TAXONOMY |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 192 |
1 |
1 |
1 |
1 |
1 |
CIP192 |
REFERRING-PROV-TYPE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP192 |
REFERRING-PROV-TYPE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 193 |
1 |
1 |
1 |
1 |
1 |
CIP193 |
REFERRING-PROV-SPECIALTY |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP193 |
REFERRING-PROV-SPECIALTY |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 194 |
1 |
1 |
1 |
1 |
1 |
CIP194 |
DRG-OUTLIER-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP194 |
DRG-OUTLIER-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 195 |
1 |
1 |
1 |
1 |
1 |
CIP195 |
DRG-REL-WEIGHT |
X(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP195 |
DRG-REL-WEIGHT |
X(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 196 |
1 |
1 |
1 |
1 |
1 |
CIP196 |
MEDICARE-HIC-NUM |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP196 |
MEDICARE-HIC-NUM |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 197 |
1 |
1 |
1 |
1 |
1 |
CIP197 |
OUTLIER-CODE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP197 |
OUTLIER-CODE |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 198 |
1 |
1 |
1 |
1 |
1 |
CIP198 |
OUTLIER-DAYS |
S9(5) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP198 |
OUTLIER-DAYS |
S9(5) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 199 |
1 |
1 |
1 |
1 |
1 |
CIP199 |
PATIENT-STATUS |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP199 |
PATIENT-STATUS |
X(2) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 200 |
1 |
1 |
1 |
1 |
1 |
CIP201 |
BMI |
S9(5)V9 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP201 |
BMI |
S9(5)V9 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 201 |
1 |
1 |
1 |
1 |
1 |
CIP202 |
REMITTANCE-NUM |
X(30) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP202 |
REMITTANCE-NUM |
X(30) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 202 |
1 |
1 |
1 |
1 |
1 |
CIP203 |
SPLIT-CLAIM-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP203 |
SPLIT-CLAIM-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 203 |
1 |
1 |
1 |
1 |
1 |
CIP204 |
BORDER-STATE-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP204 |
BORDER-STATE-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 204 |
1 |
1 |
1 |
1 |
1 |
CIP206 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP206 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 205 |
1 |
1 |
1 |
1 |
1 |
CIP207 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP207 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 206 |
1 |
1 |
1 |
1 |
1 |
CIP208 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP208 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 207 |
1 |
1 |
1 |
1 |
1 |
CIP209 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP209 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 208 |
1 |
1 |
1 |
1 |
1 |
CIP210 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP210 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 209 |
1 |
1 |
1 |
1 |
1 |
CIP211 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP211 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 210 |
1 |
1 |
1 |
1 |
1 |
CIP212 |
CLAIM-DENIED-INDICATOR |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP212 |
CLAIM-DENIED-INDICATOR |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 211 |
1 |
1 |
1 |
1 |
1 |
CIP213 |
COPAY-WAIVED-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP213 |
COPAY-WAIVED-IND |
X(1) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 212 |
1 |
1 |
1 |
1 |
1 |
CIP214 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP214 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 213 |
1 |
1 |
1 |
1 |
1 |
CIP216 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP216 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 214 |
1 |
1 |
1 |
1 |
1 |
CIP217 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP217 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 215 |
1 |
1 |
1 |
1 |
1 |
CIP218 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP218 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 216 |
1 |
1 |
1 |
1 |
1 |
CIP219 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP219 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 217 |
1 |
1 |
1 |
1 |
1 |
CIP220 |
MEDICAID-AMOUNT-PAID-DSH |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP220 |
MEDICAID-AMOUNT-PAID-DSH |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 218 |
1 |
1 |
1 |
1 |
1 |
CIP221 |
HEALTH-HOME-PROVIDER-NPI |
X(10) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP221 |
HEALTH-HOME-PROVIDER-NPI |
X(10) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 219 |
1 |
1 |
1 |
1 |
1 |
CIP222 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP222 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 220 |
1 |
1 |
1 |
1 |
1 |
CIP223 |
OPERATING-PROV-TAXONOMY |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP223 |
OPERATING-PROV-TAXONOMY |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 221 |
1 |
1 |
1 |
1 |
1 |
CIP224 |
UNDER-DIRECTION-OF-PROV-NPI |
X(10) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP224 |
UNDER-DIRECTION-OF-PROV-NPI |
X(10) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 222 |
1 |
1 |
1 |
1 |
1 |
CIP225 |
UNDER-DIRECTION-OF-PROV-TAXONOMY |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP225 |
UNDER-DIRECTION-OF-PROV-TAXONOMY |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 223 |
1 |
1 |
1 |
1 |
1 |
CIP226 |
UNDER-SUPERVISION-OF-PROV-NPI |
X(10) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP226 |
UNDER-SUPERVISION-OF-PROV-NPI |
X(10) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 224 |
1 |
1 |
1 |
1 |
1 |
CIP227 |
UNDER-SUPERVISION-OF-PROV-TAXONOMY |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP227 |
UNDER-SUPERVISION-OF-PROV-TAXONOMY |
X(12) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 225 |
1 |
1 |
1 |
1 |
1 |
CIP228 |
MEDICARE-PAID-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP228 |
MEDICARE-PAID-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 226 |
1 |
1 |
1 |
1 |
1 |
CIP229 |
STATE-NOTATION |
X(500) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP229 |
STATE-NOTATION |
X(500) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 227 |
1 |
1 |
1 |
1 |
1 |
CIP289 |
PROV-LOCATION-ID |
X(5) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP289 |
PROV-LOCATION-ID |
X(5) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 228 |
1 |
1 |
0 |
1 |
1 |
CIP230 |
FILLER |
X(79) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
CIP230 |
FILLER |
X(78) |
CLAIMIP |
CLAIM-HEADER-RECORD-IP-CIP00002 |
| 229 |
1 |
1 |
1 |
1 |
1 |
CIP231 |
RECORD-ID |
X(8) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP231 |
RECORD-ID |
X(8) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 230 |
1 |
1 |
1 |
1 |
1 |
CIP232 |
SUBMITTING-STATE |
X(2) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP232 |
SUBMITTING-STATE |
X(2) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 231 |
1 |
1 |
1 |
1 |
1 |
CIP233 |
RECORD-NUMBER |
9(11) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP233 |
RECORD-NUMBER |
9(11) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 232 |
1 |
1 |
1 |
1 |
1 |
CIP234 |
MSIS-IDENTIFICATION-NUM |
X(20) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP234 |
MSIS-IDENTIFICATION-NUM |
X(20) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 233 |
1 |
1 |
1 |
1 |
1 |
CIP235 |
ICN-ORIG |
X(50) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP235 |
ICN-ORIG |
X(50) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 234 |
1 |
1 |
1 |
1 |
1 |
CIP236 |
ICN-ADJ |
X(50) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP236 |
ICN-ADJ |
X(50) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 235 |
1 |
1 |
1 |
1 |
1 |
CIP237 |
LINE-NUM-ORIG |
X(3) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP237 |
LINE-NUM-ORIG |
X(3) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 236 |
1 |
1 |
1 |
1 |
1 |
CIP238 |
LINE-NUM-ADJ |
X(3) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP238 |
LINE-NUM-ADJ |
X(3) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 237 |
1 |
1 |
1 |
1 |
1 |
CIP239 |
LINE-ADJUSTMENT-IND |
X(1) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP239 |
LINE-ADJUSTMENT-IND |
X(1) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 238 |
1 |
1 |
1 |
1 |
1 |
CIP240 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP240 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 239 |
1 |
1 |
1 |
1 |
1 |
CIP241 |
SUBMITTER-ID |
X(12) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP241 |
SUBMITTER-ID |
X(12) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 240 |
1 |
1 |
1 |
1 |
1 |
CIP242 |
CLAIM-LINE-STATUS |
X(3) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP242 |
CLAIM-LINE-STATUS |
X(3) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 241 |
1 |
1 |
1 |
1 |
1 |
CIP243 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP243 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 242 |
1 |
1 |
1 |
1 |
1 |
CIP244 |
ENDING-DATE-OF-SERVICE |
9(8) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP244 |
ENDING-DATE-OF-SERVICE |
9(8) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 243 |
1 |
1 |
1 |
1 |
1 |
CIP245 |
REVENUE-CODE |
X(4) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP245 |
REVENUE-CODE |
X(4) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 244 |
1 |
1 |
1 |
1 |
1 |
CIP248 |
IMMUNIZATION-TYPE |
X(2) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP248 |
IMMUNIZATION-TYPE |
X(2) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 245 |
1 |
1 |
1 |
1 |
1 |
CIP249 |
IP-LT-QUANTITY-OF-SERVICE-ACTUAL |
S9(6)V999 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP249 |
IP-LT-QUANTITY-OF-SERVICE-ACTUAL |
S9(6)V999 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 246 |
1 |
1 |
1 |
1 |
1 |
CIP250 |
IP-LT-QUANTITY-OF-SERVICE-ALLOWED |
S9(6)V999 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP250 |
IP-LT-QUANTITY-OF-SERVICE-ALLOWED |
S9(6)V999 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 247 |
1 |
1 |
1 |
1 |
1 |
CIP251 |
REVENUE-CHARGE |
S9(11)V99 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP251 |
REVENUE-CHARGE |
S9(11)V99 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 248 |
1 |
1 |
1 |
1 |
1 |
CIP252 |
ALLOWED-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP252 |
ALLOWED-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 249 |
1 |
1 |
1 |
1 |
1 |
CIP253 |
TPL-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP253 |
TPL-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 250 |
1 |
1 |
1 |
1 |
1 |
CIP254 |
MEDICAID-PAID-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP254 |
MEDICAID-PAID-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 251 |
1 |
1 |
1 |
1 |
1 |
CIP255 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP255 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 252 |
1 |
1 |
1 |
1 |
1 |
CIP256 |
BILLING-UNIT |
X(2) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP256 |
BILLING-UNIT |
X(2) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 253 |
1 |
1 |
1 |
1 |
1 |
CIP257 |
TYPE-OF-SERVICE |
X(3) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP257 |
TYPE-OF-SERVICE |
X(3) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 254 |
1 |
1 |
1 |
1 |
1 |
CIP260 |
SERVICING-PROV-NUM |
X(30) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP260 |
SERVICING-PROV-NUM |
X(30) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 255 |
1 |
1 |
1 |
1 |
1 |
CIP261 |
SERVICING-PROV-NPI-NUM |
X(10) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP261 |
SERVICING-PROV-NPI-NUM |
X(10) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 256 |
1 |
1 |
1 |
1 |
1 |
CIP262 |
SERVICING-PROV-TAXONOMY |
X(12) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP262 |
SERVICING-PROV-TAXONOMY |
X(12) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 257 |
1 |
1 |
1 |
1 |
1 |
CIP263 |
SERVICING-PROV-TYPE |
X(2) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP263 |
SERVICING-PROV-TYPE |
X(2) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 258 |
1 |
1 |
1 |
1 |
1 |
CIP264 |
SERVICING-PROV-SPECIALTY |
X(2) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP264 |
SERVICING-PROV-SPECIALTY |
X(2) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 259 |
1 |
1 |
1 |
1 |
1 |
CIP265 |
OPERATING-PROV-NPI-NUM |
X(10) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP265 |
OPERATING-PROV-NPI-NUM |
X(10) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 260 |
1 |
1 |
1 |
1 |
1 |
CIP266 |
OTHER-TPL-COLLECTION |
X(3) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP266 |
OTHER-TPL-COLLECTION |
X(3) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 261 |
1 |
1 |
1 |
1 |
1 |
CIP267 |
PROV-FACILITY-TYPE |
X(9) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP267 |
PROV-FACILITY-TYPE |
X(9) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 262 |
1 |
1 |
1 |
1 |
1 |
CIP268 |
BENEFIT-TYPE |
X(3) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP268 |
BENEFIT-TYPE |
X(3) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 263 |
1 |
1 |
1 |
1 |
1 |
CIP269 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP269 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 264 |
1 |
1 |
1 |
1 |
1 |
CIP270 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP270 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 265 |
1 |
1 |
1 |
1 |
1 |
CIP271 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP271 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 266 |
1 |
1 |
1 |
1 |
1 |
CIP272 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP272 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 267 |
1 |
1 |
1 |
1 |
1 |
CIP273 |
STATE-NOTATION |
X(500) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP273 |
STATE-NOTATION |
X(500) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 268 |
1 |
1 |
1 |
1 |
1 |
CIP279 |
HCPCS-RATE |
X(14) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP279 |
HCPCS-RATE |
X(14) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 269 |
1 |
1 |
0 |
1 |
1 |
CIP284 |
NATIONAL-DRUG-CODE |
X(12) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP284 |
NATIONAL-DRUG-CODE |
X(11) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 270 |
1 |
1 |
1 |
1 |
1 |
CIP285 |
NDC-UNIT-OF-MEASURE |
X(2) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP285 |
NDC-UNIT-OF-MEASURE |
X(2) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 271 |
1 |
1 |
1 |
1 |
1 |
CIP278 |
NDC-QUANTITY |
S9(6)V999 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP278 |
NDC-QUANTITY |
S9(6)V999 |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 272 |
1 |
1 |
1 |
1 |
1 |
CIP286 |
ADJUDICATION-DATE |
9(8) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP286 |
ADJUDICATION-DATE |
9(8) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 273 |
1 |
1 |
1 |
1 |
1 |
CIP287 |
SELF-DIRECTION-TYPE |
X(3) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP287 |
SELF-DIRECTION-TYPE |
X(3) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 274 |
1 |
1 |
1 |
1 |
1 |
CIP288 |
PRE-AUTHORIZATION-NUM |
X(18) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP288 |
PRE-AUTHORIZATION-NUM |
X(18) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 275 |
1 |
1 |
1 |
1 |
1 |
CIP274 |
FILLER |
X(1155) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
CIP274 |
FILLER |
X(1155) |
CLAIMIP |
CLAIM-LINE-RECORD-IP-CIP00003 |
| 276 |
1 |
1 |
1 |
1 |
1 |
CLT001 |
RECORD-ID |
X(8) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT001 |
RECORD-ID |
X(8) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 277 |
1 |
1 |
1 |
1 |
1 |
CLT002 |
DATA-DICTIONARY-VERSION |
X(10) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT002 |
DATA-DICTIONARY-VERSION |
X(10) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 278 |
1 |
1 |
1 |
1 |
1 |
CLT003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 279 |
1 |
1 |
1 |
1 |
1 |
CLT004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 280 |
1 |
1 |
1 |
1 |
1 |
CLT005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 281 |
1 |
1 |
1 |
1 |
1 |
CLT006 |
FILE-NAME |
X(8) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT006 |
FILE-NAME |
X(8) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 282 |
1 |
1 |
1 |
1 |
1 |
CLT007 |
SUBMITTING-STATE |
X(2) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT007 |
SUBMITTING-STATE |
X(2) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 283 |
1 |
1 |
1 |
1 |
1 |
CLT008 |
DATE-FILE-CREATED |
9(8) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT008 |
DATE-FILE-CREATED |
9(8) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 284 |
1 |
1 |
1 |
1 |
1 |
CLT009 |
START-OF-TIME-PERIOD |
9(8) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT009 |
START-OF-TIME-PERIOD |
9(8) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 285 |
1 |
1 |
1 |
1 |
1 |
CLT010 |
END-OF-TIME-PERIOD |
9(8) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT010 |
END-OF-TIME-PERIOD |
9(8) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 286 |
1 |
1 |
1 |
1 |
1 |
CLT011 |
FILE-STATUS-INDICATOR |
X(1) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT011 |
FILE-STATUS-INDICATOR |
X(1) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 287 |
1 |
1 |
1 |
1 |
1 |
CLT012 |
SSN-INDICATOR |
X(1) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT012 |
SSN-INDICATOR |
X(1) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 288 |
1 |
1 |
1 |
1 |
1 |
CLT013 |
TOT-REC-CNT |
9(11) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT013 |
TOT-REC-CNT |
9(11) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 289 |
1 |
1 |
1 |
1 |
1 |
CLT227 |
SEQUENCE-NUMBER |
X(4) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT227 |
SEQUENCE-NUMBER |
X(4) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 290 |
1 |
1 |
1 |
1 |
1 |
CLT014 |
STATE-NOTATION |
X(500) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT014 |
STATE-NOTATION |
X(500) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 291 |
1 |
1 |
1 |
1 |
1 |
CLT015 |
FILLER |
X(1318) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
CLT015 |
FILLER |
X(1318) |
CLAIMLT |
FILE-HEADER-RECORD-LT-CLT00001 |
| 292 |
1 |
1 |
1 |
1 |
1 |
CLT016 |
RECORD-ID |
X(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT016 |
RECORD-ID |
X(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 293 |
1 |
1 |
1 |
1 |
1 |
CLT017 |
SUBMITTING-STATE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT017 |
SUBMITTING-STATE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 294 |
1 |
1 |
1 |
1 |
1 |
CLT018 |
RECORD-NUMBER |
9(11) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT018 |
RECORD-NUMBER |
9(11) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 295 |
1 |
1 |
1 |
1 |
1 |
CLT019 |
ICN-ORIG |
X(50) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT019 |
ICN-ORIG |
X(50) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 296 |
1 |
1 |
1 |
1 |
1 |
CLT020 |
ICN-ADJ |
X(50) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT020 |
ICN-ADJ |
X(50) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 297 |
1 |
1 |
1 |
1 |
1 |
CLT021 |
SUBMITTER-ID |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT021 |
SUBMITTER-ID |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 298 |
1 |
1 |
1 |
1 |
1 |
CLT022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 299 |
1 |
1 |
1 |
1 |
1 |
CLT023 |
CROSSOVER-INDICATOR |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT023 |
CROSSOVER-INDICATOR |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 300 |
1 |
1 |
1 |
1 |
1 |
CLT024 |
1115A-DEMONSTRATION-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT024 |
1115A-DEMONSTRATION-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 301 |
1 |
1 |
1 |
1 |
1 |
CLT025 |
ADJUSTMENT-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT025 |
ADJUSTMENT-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 302 |
1 |
1 |
1 |
1 |
1 |
CLT026 |
ADJUSTMENT-REASON-CODE |
X(3) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT026 |
ADJUSTMENT-REASON-CODE |
X(3) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 303 |
1 |
1 |
1 |
1 |
1 |
CLT027 |
ADMITTING-DIAGNOSIS-CODE |
X(7) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT027 |
ADMITTING-DIAGNOSIS-CODE |
X(7) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 304 |
1 |
1 |
1 |
1 |
1 |
CLT028 |
ADMITTING-DIAGNOSIS-CODE-FLAG |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT028 |
ADMITTING-DIAGNOSIS-CODE-FLAG |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 305 |
1 |
1 |
1 |
1 |
1 |
CLT029 |
DIAGNOSIS-CODE-1 |
X(7) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT029 |
DIAGNOSIS-CODE-1 |
X(7) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 306 |
1 |
1 |
1 |
1 |
1 |
CLT030 |
DIAGNOSIS-CODE-FLAG-1 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT030 |
DIAGNOSIS-CODE-FLAG-1 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 307 |
1 |
1 |
1 |
1 |
1 |
CLT031 |
DIAGNOSIS-POA-FLAG-1 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT031 |
DIAGNOSIS-POA-FLAG-1 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 308 |
1 |
1 |
1 |
1 |
1 |
CLT032 |
DIAGNOSIS-CODE-2 |
X(7) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT032 |
DIAGNOSIS-CODE-2 |
X(7) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 309 |
1 |
1 |
1 |
1 |
1 |
CLT033 |
DIAGNOSIS-CODE-FLAG-2 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT033 |
DIAGNOSIS-CODE-FLAG-2 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 310 |
1 |
1 |
1 |
1 |
1 |
CLT034 |
DIAGNOSIS-POA-FLAG-2 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT034 |
DIAGNOSIS-POA-FLAG-2 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 311 |
1 |
1 |
1 |
1 |
1 |
CLT035 |
DIAGNOSIS-CODE-3 |
X(7) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT035 |
DIAGNOSIS-CODE-3 |
X(7) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 312 |
1 |
1 |
1 |
1 |
1 |
CLT036 |
DIAGNOSIS-CODE-FLAG-3 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT036 |
DIAGNOSIS-CODE-FLAG-3 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 313 |
1 |
1 |
1 |
1 |
1 |
CLT037 |
DIAGNOSIS-POA-FLAG-3 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT037 |
DIAGNOSIS-POA-FLAG-3 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 314 |
1 |
1 |
1 |
1 |
1 |
CLT038 |
DIAGNOSIS-CODE-4 |
X(7) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT038 |
DIAGNOSIS-CODE-4 |
X(7) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 315 |
1 |
1 |
1 |
1 |
1 |
CLT039 |
DIAGNOSIS-CODE-FLAG-4 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT039 |
DIAGNOSIS-CODE-FLAG-4 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 316 |
1 |
1 |
1 |
1 |
1 |
CLT040 |
DIAGNOSIS-POA-FLAG-4 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT040 |
DIAGNOSIS-POA-FLAG-4 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 317 |
1 |
1 |
1 |
1 |
1 |
CLT041 |
DIAGNOSIS-CODE-5 |
X(7) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT041 |
DIAGNOSIS-CODE-5 |
X(7) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 318 |
1 |
1 |
1 |
1 |
1 |
CLT042 |
DIAGNOSIS-CODE-FLAG-5 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT042 |
DIAGNOSIS-CODE-FLAG-5 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 319 |
1 |
1 |
1 |
1 |
1 |
CLT043 |
DIAGNOSIS-POA-FLAG-5 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT043 |
DIAGNOSIS-POA-FLAG-5 |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 320 |
1 |
1 |
1 |
1 |
1 |
CLT044 |
ADMISSION-DATE |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT044 |
ADMISSION-DATE |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 321 |
1 |
1 |
1 |
1 |
1 |
CLT045 |
ADMISSION-HOUR |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT045 |
ADMISSION-HOUR |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 322 |
1 |
1 |
1 |
1 |
1 |
CLT046 |
DISCHARGE-DATE |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT046 |
DISCHARGE-DATE |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 323 |
1 |
1 |
1 |
1 |
1 |
CLT047 |
DISCHARGE-HOUR |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT047 |
DISCHARGE-HOUR |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 324 |
1 |
1 |
1 |
1 |
1 |
CLT048 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT048 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 325 |
1 |
1 |
1 |
1 |
1 |
CLT049 |
ENDING-DATE-OF-SERVICE |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT049 |
ENDING-DATE-OF-SERVICE |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 326 |
1 |
1 |
1 |
1 |
1 |
CLT050 |
ADJUDICATION-DATE |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT050 |
ADJUDICATION-DATE |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 327 |
1 |
1 |
1 |
1 |
1 |
CLT051 |
MEDICAID-PAID-DATE |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT051 |
MEDICAID-PAID-DATE |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 328 |
1 |
1 |
1 |
1 |
1 |
CLT052 |
TYPE-OF-CLAIM |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT052 |
TYPE-OF-CLAIM |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 329 |
1 |
1 |
1 |
1 |
1 |
CLT053 |
TYPE-OF-BILL |
X(4) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT053 |
TYPE-OF-BILL |
X(4) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 330 |
1 |
1 |
1 |
1 |
1 |
CLT054 |
CLAIM-STATUS |
X(3) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT054 |
CLAIM-STATUS |
X(3) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 331 |
1 |
1 |
1 |
1 |
1 |
CLT055 |
CLAIM-STATUS-CATEGORY |
X(3) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT055 |
CLAIM-STATUS-CATEGORY |
X(3) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 332 |
1 |
1 |
1 |
1 |
1 |
CLT056 |
SOURCE-LOCATION |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT056 |
SOURCE-LOCATION |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 333 |
1 |
1 |
1 |
1 |
1 |
CLT057 |
CHECK-NUM |
X(15) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT057 |
CHECK-NUM |
X(15) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 334 |
1 |
1 |
1 |
1 |
1 |
CLT058 |
CHECK-EFF-DATE |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT058 |
CHECK-EFF-DATE |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 335 |
1 |
1 |
1 |
1 |
1 |
CLT059 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT059 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 336 |
1 |
1 |
1 |
1 |
1 |
CLT060 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT060 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 337 |
1 |
1 |
1 |
1 |
1 |
CLT061 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT061 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 338 |
1 |
1 |
1 |
1 |
1 |
CLT062 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT062 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 339 |
1 |
1 |
1 |
1 |
1 |
CLT063 |
TOT-BILLED-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT063 |
TOT-BILLED-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 340 |
1 |
1 |
1 |
1 |
1 |
CLT064 |
TOT-ALLOWED-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT064 |
TOT-ALLOWED-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 341 |
1 |
1 |
1 |
1 |
1 |
CLT065 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT065 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 342 |
1 |
1 |
1 |
1 |
1 |
CLT066 |
TOT-COPAY-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT066 |
TOT-COPAY-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 343 |
1 |
1 |
1 |
1 |
1 |
CLT067 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT067 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 344 |
1 |
1 |
1 |
1 |
1 |
CLT068 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT068 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 345 |
1 |
1 |
1 |
1 |
1 |
CLT069 |
TOT-TPL-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT069 |
TOT-TPL-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 346 |
1 |
1 |
1 |
1 |
1 |
CLT070 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT070 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 347 |
1 |
1 |
1 |
1 |
1 |
CLT071 |
OTHER-INSURANCE-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT071 |
OTHER-INSURANCE-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 348 |
1 |
1 |
1 |
1 |
1 |
CLT072 |
OTHER-TPL-COLLECTION |
X(3) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT072 |
OTHER-TPL-COLLECTION |
X(3) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 349 |
1 |
1 |
1 |
1 |
1 |
CLT073 |
SERVICE-TRACKING-TYPE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT073 |
SERVICE-TRACKING-TYPE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 350 |
1 |
1 |
1 |
1 |
1 |
CLT074 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT074 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 351 |
1 |
1 |
1 |
1 |
1 |
CLT075 |
FIXED-PAYMENT-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT075 |
FIXED-PAYMENT-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 352 |
1 |
1 |
1 |
1 |
1 |
CLT076 |
FUNDING-CODE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT076 |
FUNDING-CODE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 353 |
1 |
1 |
1 |
1 |
1 |
CLT077 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT077 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 354 |
1 |
1 |
1 |
1 |
1 |
CLT078 |
MEDICARE-COMB-DED-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT078 |
MEDICARE-COMB-DED-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 355 |
1 |
1 |
1 |
1 |
1 |
CLT079 |
PROGRAM-TYPE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT079 |
PROGRAM-TYPE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 356 |
1 |
1 |
1 |
1 |
1 |
CLT080 |
PLAN-ID-NUMBER |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT080 |
PLAN-ID-NUMBER |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 357 |
1 |
1 |
1 |
1 |
1 |
CLT081 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT081 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 358 |
1 |
1 |
1 |
1 |
1 |
CLT082 |
PAYMENT-LEVEL-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT082 |
PAYMENT-LEVEL-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 359 |
1 |
1 |
1 |
1 |
1 |
CLT083 |
MEDICARE-REIM-TYPE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT083 |
MEDICARE-REIM-TYPE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 360 |
1 |
1 |
1 |
1 |
1 |
CLT084 |
NON-COV-DAYS |
S9(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT084 |
NON-COV-DAYS |
S9(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 361 |
1 |
1 |
1 |
1 |
1 |
CLT085 |
NON-COV-CHARGES |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT085 |
NON-COV-CHARGES |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 362 |
1 |
1 |
1 |
1 |
1 |
CLT086 |
MEDICAID-COV-INPATIENT-DAYS |
S9(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT086 |
MEDICAID-COV-INPATIENT-DAYS |
S9(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 363 |
1 |
1 |
1 |
1 |
1 |
CLT087 |
CLAIM-LINE-COUNT |
9(4) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT087 |
CLAIM-LINE-COUNT |
9(4) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 364 |
1 |
1 |
1 |
1 |
1 |
CLT090 |
FORCED-CLAIM-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT090 |
FORCED-CLAIM-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 365 |
1 |
1 |
1 |
1 |
1 |
CLT091 |
HEALTH-CARE-ACQUIRED-CONDITION-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT091 |
HEALTH-CARE-ACQUIRED-CONDITION-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 366 |
1 |
1 |
1 |
1 |
1 |
CLT092 |
OCCURRENCE-CODE-01 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT092 |
OCCURRENCE-CODE-01 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 367 |
1 |
1 |
1 |
1 |
1 |
CLT093 |
OCCURRENCE-CODE-02 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT093 |
OCCURRENCE-CODE-02 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 368 |
1 |
1 |
1 |
1 |
1 |
CLT094 |
OCCURRENCE-CODE-03 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT094 |
OCCURRENCE-CODE-03 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 369 |
1 |
1 |
1 |
1 |
1 |
CLT095 |
OCCURRENCE-CODE-04 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT095 |
OCCURRENCE-CODE-04 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 370 |
1 |
1 |
1 |
1 |
1 |
CLT096 |
OCCURRENCE-CODE-05 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT096 |
OCCURRENCE-CODE-05 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 371 |
1 |
1 |
1 |
1 |
1 |
CLT097 |
OCCURRENCE-CODE-06 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT097 |
OCCURRENCE-CODE-06 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 372 |
1 |
1 |
1 |
1 |
1 |
CLT098 |
OCCURRENCE-CODE-07 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT098 |
OCCURRENCE-CODE-07 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 373 |
1 |
1 |
1 |
1 |
1 |
CLT099 |
OCCURRENCE-CODE-08 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT099 |
OCCURRENCE-CODE-08 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 374 |
1 |
1 |
1 |
1 |
1 |
CLT100 |
OCCURRENCE-CODE-09 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT100 |
OCCURRENCE-CODE-09 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 375 |
1 |
1 |
1 |
1 |
1 |
CLT101 |
OCCURRENCE-CODE-10 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT101 |
OCCURRENCE-CODE-10 |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 376 |
1 |
1 |
1 |
1 |
1 |
CLT102 |
OCCURRENCE-CODE-EFF-DATE-01 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT102 |
OCCURRENCE-CODE-EFF-DATE-01 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 377 |
1 |
1 |
1 |
1 |
1 |
CLT103 |
OCCURRENCE-CODE-EFF-DATE-02 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT103 |
OCCURRENCE-CODE-EFF-DATE-02 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 378 |
1 |
1 |
1 |
1 |
1 |
CLT104 |
OCCURRENCE-CODE-EFF-DATE-03 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT104 |
OCCURRENCE-CODE-EFF-DATE-03 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 379 |
1 |
1 |
1 |
1 |
1 |
CLT105 |
OCCURRENCE-CODE-EFF-DATE-04 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT105 |
OCCURRENCE-CODE-EFF-DATE-04 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 380 |
1 |
1 |
1 |
1 |
1 |
CLT106 |
OCCURRENCE-CODE-EFF-DATE-05 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT106 |
OCCURRENCE-CODE-EFF-DATE-05 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 381 |
1 |
1 |
1 |
1 |
1 |
CLT107 |
OCCURRENCE-CODE-EFF-DATE-06 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT107 |
OCCURRENCE-CODE-EFF-DATE-06 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 382 |
1 |
1 |
1 |
1 |
1 |
CLT108 |
OCCURRENCE-CODE-EFF-DATE-07 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT108 |
OCCURRENCE-CODE-EFF-DATE-07 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 383 |
1 |
1 |
1 |
1 |
1 |
CLT109 |
OCCURRENCE-CODE-EFF-DATE-08 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT109 |
OCCURRENCE-CODE-EFF-DATE-08 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 384 |
1 |
1 |
1 |
1 |
1 |
CLT110 |
OCCURRENCE-CODE-EFF-DATE-09 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT110 |
OCCURRENCE-CODE-EFF-DATE-09 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 385 |
1 |
1 |
1 |
1 |
1 |
CLT111 |
OCCURRENCE-CODE-EFF-DATE-10 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT111 |
OCCURRENCE-CODE-EFF-DATE-10 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 386 |
1 |
1 |
1 |
1 |
1 |
CLT112 |
OCCURRENCE-CODE-END-DATE-01 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT112 |
OCCURRENCE-CODE-END-DATE-01 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 387 |
1 |
1 |
1 |
1 |
1 |
CLT113 |
OCCURRENCE-CODE-END-DATE-02 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT113 |
OCCURRENCE-CODE-END-DATE-02 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 388 |
1 |
1 |
1 |
1 |
1 |
CLT114 |
OCCURRENCE-CODE-END-DATE-03 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT114 |
OCCURRENCE-CODE-END-DATE-03 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 389 |
1 |
1 |
1 |
1 |
1 |
CLT115 |
OCCURRENCE-CODE-END-DATE-04 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT115 |
OCCURRENCE-CODE-END-DATE-04 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 390 |
1 |
1 |
1 |
1 |
1 |
CLT116 |
OCCURRENCE-CODE-END-DATE-05 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT116 |
OCCURRENCE-CODE-END-DATE-05 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 391 |
1 |
1 |
1 |
1 |
1 |
CLT117 |
OCCURRENCE-CODE-END-DATE-06 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT117 |
OCCURRENCE-CODE-END-DATE-06 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 392 |
1 |
1 |
1 |
1 |
1 |
CLT118 |
OCCURRENCE-CODE-END-DATE-07 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT118 |
OCCURRENCE-CODE-END-DATE-07 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 393 |
1 |
1 |
1 |
1 |
1 |
CLT119 |
OCCURRENCE-CODE-END-DATE-08 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT119 |
OCCURRENCE-CODE-END-DATE-08 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 394 |
1 |
1 |
1 |
1 |
1 |
CLT120 |
OCCURRENCE-CODE-END-DATE-09 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT120 |
OCCURRENCE-CODE-END-DATE-09 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 395 |
1 |
1 |
1 |
1 |
1 |
CLT121 |
OCCURRENCE-CODE-END-DATE-10 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT121 |
OCCURRENCE-CODE-END-DATE-10 |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 396 |
1 |
1 |
1 |
1 |
1 |
CLT122 |
PATIENT-CONTROL-NUM |
X(20) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT122 |
PATIENT-CONTROL-NUM |
X(20) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 397 |
1 |
1 |
1 |
1 |
1 |
CLT123 |
ELIGIBLE-LAST-NAME |
X(30) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT123 |
ELIGIBLE-LAST-NAME |
X(30) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 398 |
1 |
1 |
1 |
1 |
1 |
CLT124 |
ELIGIBLE-FIRST-NAME |
X(30) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT124 |
ELIGIBLE-FIRST-NAME |
X(30) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 399 |
1 |
1 |
1 |
1 |
1 |
CLT125 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT125 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 400 |
1 |
1 |
1 |
1 |
1 |
CLT126 |
DATE-OF-BIRTH |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT126 |
DATE-OF-BIRTH |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 401 |
1 |
1 |
1 |
1 |
1 |
CLT127 |
HEALTH-HOME-PROV-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT127 |
HEALTH-HOME-PROV-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 402 |
1 |
1 |
1 |
1 |
1 |
CLT128 |
WAIVER-TYPE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT128 |
WAIVER-TYPE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 403 |
1 |
1 |
1 |
1 |
1 |
CLT129 |
WAIVER-ID |
X(20) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT129 |
WAIVER-ID |
X(20) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 404 |
1 |
1 |
1 |
1 |
1 |
CLT130 |
BILLING-PROV-NUM |
X(30) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT130 |
BILLING-PROV-NUM |
X(30) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 405 |
1 |
1 |
1 |
1 |
1 |
CLT131 |
BILLING-PROV-NPI-NUM |
X(10) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT131 |
BILLING-PROV-NPI-NUM |
X(10) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 406 |
1 |
1 |
1 |
1 |
1 |
CLT132 |
BILLING-PROV-TAXONOMY |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT132 |
BILLING-PROV-TAXONOMY |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 407 |
1 |
1 |
1 |
1 |
1 |
CLT133 |
BILLING-PROV-TYPE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT133 |
BILLING-PROV-TYPE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 408 |
1 |
1 |
1 |
1 |
1 |
CLT134 |
BILLING-PROV-SPECIALTY |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT134 |
BILLING-PROV-SPECIALTY |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 409 |
1 |
1 |
1 |
1 |
1 |
CLT135 |
REFERRING-PROV-NUM |
X(30) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT135 |
REFERRING-PROV-NUM |
X(30) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 410 |
1 |
1 |
1 |
1 |
1 |
CLT136 |
REFERRING-PROV-NPI-NUM |
X(10) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT136 |
REFERRING-PROV-NPI-NUM |
X(10) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 411 |
1 |
1 |
1 |
1 |
1 |
CLT137 |
REFERRING-PROV-TAXONOMY |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT137 |
REFERRING-PROV-TAXONOMY |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 412 |
1 |
1 |
1 |
1 |
1 |
CLT138 |
REFERRING-PROV-TYPE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT138 |
REFERRING-PROV-TYPE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 413 |
1 |
1 |
1 |
1 |
1 |
CLT139 |
REFERRING-PROV-SPECIALTY |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT139 |
REFERRING-PROV-SPECIALTY |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 414 |
1 |
1 |
1 |
1 |
1 |
CLT140 |
MEDICARE-HIC-NUM |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT140 |
MEDICARE-HIC-NUM |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 415 |
1 |
1 |
1 |
1 |
1 |
CLT141 |
PATIENT-STATUS |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT141 |
PATIENT-STATUS |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 416 |
1 |
1 |
1 |
1 |
1 |
CLT143 |
BMI |
S9(5)V9 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT143 |
BMI |
S9(5)V9 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 417 |
1 |
1 |
1 |
1 |
1 |
CLT144 |
REMITTANCE-NUM |
X(30) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT144 |
REMITTANCE-NUM |
X(30) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 418 |
1 |
1 |
1 |
1 |
1 |
CLT145 |
LTC-RCP-LIAB-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT145 |
LTC-RCP-LIAB-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 419 |
1 |
1 |
1 |
1 |
1 |
CLT146 |
DAILY-RATE |
S9(5)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT146 |
DAILY-RATE |
S9(5)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 420 |
1 |
1 |
1 |
1 |
1 |
CLT147 |
ICF-IID-DAYS |
S9(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT147 |
ICF-IID-DAYS |
S9(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 421 |
1 |
1 |
1 |
1 |
1 |
CLT148 |
LEAVE-DAYS |
S9(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT148 |
LEAVE-DAYS |
S9(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 422 |
1 |
1 |
1 |
1 |
1 |
CLT149 |
NURSING-FACILITY-DAYS |
S9(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT149 |
NURSING-FACILITY-DAYS |
S9(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 423 |
1 |
1 |
1 |
1 |
1 |
CLT150 |
SPLIT-CLAIM-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT150 |
SPLIT-CLAIM-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 424 |
1 |
1 |
1 |
1 |
1 |
CLT151 |
BORDER-STATE-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT151 |
BORDER-STATE-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 425 |
1 |
1 |
1 |
1 |
1 |
CLT153 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT153 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 426 |
1 |
1 |
1 |
1 |
1 |
CLT154 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT154 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 427 |
1 |
1 |
1 |
1 |
1 |
CLT155 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT155 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 428 |
1 |
1 |
1 |
1 |
1 |
CLT156 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT156 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 429 |
1 |
1 |
1 |
1 |
1 |
CLT157 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT157 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 430 |
1 |
1 |
1 |
1 |
1 |
CLT158 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT158 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 431 |
1 |
1 |
1 |
1 |
1 |
CLT159 |
CLAIM-DENIED-INDICATOR |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT159 |
CLAIM-DENIED-INDICATOR |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 432 |
1 |
1 |
1 |
1 |
1 |
CLT160 |
COPAY-WAIVED-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT160 |
COPAY-WAIVED-IND |
X(1) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 433 |
1 |
1 |
1 |
1 |
1 |
CLT161 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT161 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 434 |
1 |
1 |
1 |
1 |
1 |
CLT163 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT163 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 435 |
1 |
1 |
1 |
1 |
1 |
CLT164 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT164 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 436 |
1 |
1 |
1 |
1 |
1 |
CLT165 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT165 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 437 |
1 |
1 |
1 |
1 |
1 |
CLT166 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT166 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 438 |
1 |
1 |
1 |
1 |
1 |
CLT167 |
HEALTH-HOME-PROVIDER-NPI |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT167 |
HEALTH-HOME-PROVIDER-NPI |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 439 |
1 |
1 |
1 |
1 |
1 |
CLT168 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT168 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 440 |
1 |
1 |
1 |
1 |
1 |
CLT169 |
UNDER-DIRECTION-OF-PROV-NPI |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT169 |
UNDER-DIRECTION-OF-PROV-NPI |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 441 |
1 |
1 |
1 |
1 |
1 |
CLT170 |
UNDER-DIRECTION-OF-PROV-TAXONOMY |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT170 |
UNDER-DIRECTION-OF-PROV-TAXONOMY |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 442 |
1 |
1 |
1 |
1 |
1 |
CLT171 |
UNDER-SUPERVISION-OF-PROV-NPI |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT171 |
UNDER-SUPERVISION-OF-PROV-NPI |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 443 |
1 |
1 |
1 |
1 |
1 |
CLT172 |
UNDER-SUPERVISION-OF-PROV-TAXONOMY |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT172 |
UNDER-SUPERVISION-OF-PROV-TAXONOMY |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 444 |
1 |
1 |
1 |
1 |
1 |
CLT174 |
ADMITTING-PROV-NPI-NUM |
X(10) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT174 |
ADMITTING-PROV-NPI-NUM |
X(10) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 445 |
1 |
1 |
1 |
1 |
1 |
CLT175 |
ADMITTING-PROV-NUM |
X(30) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT175 |
ADMITTING-PROV-NUM |
X(30) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 446 |
1 |
1 |
1 |
1 |
1 |
CLT176 |
ADMITTING-PROV-SPECIALTY |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT176 |
ADMITTING-PROV-SPECIALTY |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 447 |
1 |
1 |
1 |
1 |
1 |
CLT177 |
ADMITTING-PROV-TAXONOMY |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT177 |
ADMITTING-PROV-TAXONOMY |
X(12) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 448 |
1 |
1 |
1 |
1 |
1 |
CLT178 |
ADMITTING-PROV-TYPE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT178 |
ADMITTING-PROV-TYPE |
X(2) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 449 |
1 |
1 |
1 |
1 |
1 |
CLT179 |
MEDICARE-PAID-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT179 |
MEDICARE-PAID-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 450 |
1 |
1 |
1 |
1 |
1 |
CLT173 |
STATE-NOTATION |
X(500) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT173 |
STATE-NOTATION |
X(500) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 451 |
1 |
1 |
1 |
1 |
1 |
CLT237 |
PROV-LOCATION-ID |
X(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT237 |
PROV-LOCATION-ID |
X(5) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 452 |
1 |
1 |
0 |
1 |
1 |
CLT183 |
FILLER |
X(101) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
CLT183 |
FILLER |
X(100) |
CLAIMLT |
CLAIM-HEADER-RECORD-LT-CLT00002 |
| 453 |
1 |
1 |
1 |
1 |
1 |
CLT184 |
RECORD-ID |
X(8) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT184 |
RECORD-ID |
X(8) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 454 |
1 |
1 |
1 |
1 |
1 |
CLT185 |
SUBMITTING-STATE |
X(2) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT185 |
SUBMITTING-STATE |
X(2) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 455 |
1 |
1 |
1 |
1 |
1 |
CLT186 |
RECORD-NUMBER |
9(11) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT186 |
RECORD-NUMBER |
9(11) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 456 |
1 |
1 |
1 |
1 |
1 |
CLT187 |
MSIS-IDENTIFICATION-NUM |
X(20) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT187 |
MSIS-IDENTIFICATION-NUM |
X(20) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 457 |
1 |
1 |
1 |
1 |
1 |
CLT188 |
ICN-ORIG |
X(50) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT188 |
ICN-ORIG |
X(50) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 458 |
1 |
1 |
1 |
1 |
1 |
CLT189 |
ICN-ADJ |
X(50) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT189 |
ICN-ADJ |
X(50) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 459 |
1 |
1 |
1 |
1 |
1 |
CLT190 |
LINE-NUM-ORIG |
X(3) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT190 |
LINE-NUM-ORIG |
X(3) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 460 |
1 |
1 |
1 |
1 |
1 |
CLT191 |
LINE-NUM-ADJ |
X(3) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT191 |
LINE-NUM-ADJ |
X(3) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 461 |
1 |
1 |
1 |
1 |
1 |
CLT192 |
LINE-ADJUSTMENT-IND |
X(1) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT192 |
LINE-ADJUSTMENT-IND |
X(1) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 462 |
1 |
1 |
1 |
1 |
1 |
CLT193 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT193 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 463 |
1 |
1 |
1 |
1 |
1 |
CLT194 |
SUBMITTER-ID |
X(12) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT194 |
SUBMITTER-ID |
X(12) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 464 |
1 |
1 |
1 |
1 |
1 |
CLT195 |
CLAIM-LINE-STATUS |
X(3) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT195 |
CLAIM-LINE-STATUS |
X(3) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 465 |
1 |
1 |
1 |
1 |
1 |
CLT196 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT196 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 466 |
1 |
1 |
1 |
1 |
1 |
CLT197 |
ENDING-DATE-OF-SERVICE |
9(8) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT197 |
ENDING-DATE-OF-SERVICE |
9(8) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 467 |
1 |
1 |
1 |
1 |
1 |
CLT198 |
REVENUE-CODE |
X(4) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT198 |
REVENUE-CODE |
X(4) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 468 |
1 |
1 |
1 |
1 |
1 |
CLT201 |
IMMUNIZATION-TYPE |
X(2) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT201 |
IMMUNIZATION-TYPE |
X(2) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 469 |
1 |
1 |
1 |
1 |
1 |
CLT202 |
IP-LT-QUANTITY-OF-SERVICE-ACTUAL |
S9(6)V999 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT202 |
IP-LT-QUANTITY-OF-SERVICE-ACTUAL |
S9(6)V999 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 470 |
1 |
1 |
1 |
1 |
1 |
CLT203 |
IP-LT-QUANTITY-OF-SERVICE-ALLOWED |
S9(6)V999 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT203 |
IP-LT-QUANTITY-OF-SERVICE-ALLOWED |
S9(6)V999 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 471 |
1 |
1 |
1 |
1 |
1 |
CLT204 |
REVENUE-CHARGE |
S9(11)V99 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT204 |
REVENUE-CHARGE |
S9(11)V99 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 472 |
1 |
1 |
1 |
1 |
1 |
CLT205 |
ALLOWED-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT205 |
ALLOWED-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 473 |
1 |
1 |
1 |
1 |
1 |
CLT206 |
TPL-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT206 |
TPL-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 474 |
1 |
1 |
1 |
1 |
1 |
CLT207 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT207 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 475 |
1 |
1 |
1 |
1 |
1 |
CLT208 |
MEDICAID-PAID-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT208 |
MEDICAID-PAID-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 476 |
1 |
1 |
1 |
1 |
1 |
CLT209 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT209 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 477 |
1 |
1 |
1 |
1 |
1 |
CLT210 |
BILLING-UNIT |
X(2) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT210 |
BILLING-UNIT |
X(2) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 478 |
1 |
1 |
1 |
1 |
1 |
CLT211 |
TYPE-OF-SERVICE |
X(3) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT211 |
TYPE-OF-SERVICE |
X(3) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 479 |
1 |
1 |
1 |
1 |
1 |
CLT212 |
SERVICING-PROV-NUM |
X(30) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT212 |
SERVICING-PROV-NUM |
X(30) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 480 |
1 |
1 |
1 |
1 |
1 |
CLT213 |
SERVICING-PROV-NPI-NUM |
X(10) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT213 |
SERVICING-PROV-NPI-NUM |
X(10) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 481 |
1 |
1 |
1 |
1 |
1 |
CLT214 |
SERVICING-PROV-TAXONOMY |
X(12) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT214 |
SERVICING-PROV-TAXONOMY |
X(12) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 482 |
1 |
1 |
1 |
1 |
1 |
CLT215 |
SERVICING-PROV-TYPE |
X(2) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT215 |
SERVICING-PROV-TYPE |
X(2) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 483 |
1 |
1 |
1 |
1 |
1 |
CLT216 |
SERVICING-PROV-SPECIALTY |
X(2) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT216 |
SERVICING-PROV-SPECIALTY |
X(2) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 484 |
1 |
1 |
1 |
1 |
1 |
CLT217 |
OTHER-TPL-COLLECTION |
X(3) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT217 |
OTHER-TPL-COLLECTION |
X(3) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 485 |
1 |
1 |
1 |
1 |
1 |
CLT218 |
BENEFIT-TYPE |
X(3) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT218 |
BENEFIT-TYPE |
X(3) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 486 |
1 |
1 |
1 |
1 |
1 |
CLT219 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT219 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 487 |
1 |
1 |
1 |
1 |
1 |
CLT221 |
PROV-FACILITY-TYPE |
X(9) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT221 |
PROV-FACILITY-TYPE |
X(9) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 488 |
1 |
1 |
1 |
1 |
1 |
CLT224 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT224 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 489 |
1 |
1 |
1 |
1 |
1 |
CLT225 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT225 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 490 |
1 |
1 |
1 |
1 |
1 |
CLT226 |
STATE-NOTATION |
X(500) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT226 |
STATE-NOTATION |
X(500) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 491 |
1 |
1 |
0 |
1 |
1 |
CLT228 |
NATIONAL-DRUG-CODE |
X(12) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT228 |
NATIONAL-DRUG-CODE |
X(11) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 492 |
1 |
1 |
1 |
1 |
1 |
CLT229 |
NDC-UNIT-OF-MEASURE |
X(2) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT229 |
NDC-UNIT-OF-MEASURE |
X(2) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 493 |
1 |
1 |
1 |
1 |
1 |
CLT230 |
NDC-QUANTITY |
S9(6)V999 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT230 |
NDC-QUANTITY |
S9(6)V999 |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 494 |
1 |
1 |
1 |
1 |
1 |
CLT231 |
HCPCS-RATE |
X(14) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT231 |
HCPCS-RATE |
X(14) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 495 |
1 |
1 |
1 |
1 |
1 |
CLT233 |
ADJUDICATION-DATE |
9(8) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT233 |
ADJUDICATION-DATE |
9(8) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 496 |
1 |
1 |
1 |
1 |
1 |
CLT234 |
SELF-DIRECTION-TYPE |
X(3) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT234 |
SELF-DIRECTION-TYPE |
X(3) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 497 |
1 |
1 |
1 |
1 |
1 |
CLT235 |
PRE-AUTHORIZATION-NUM |
X(18) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT235 |
PRE-AUTHORIZATION-NUM |
X(18) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 498 |
1 |
1 |
0 |
1 |
1 |
CLT238 |
FILLER |
X(965) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
CLT238 |
FILLER |
X(968) |
CLAIMLT |
CLAIM-LINE-RECORD-LT-CLT00003 |
| 499 |
1 |
1 |
1 |
1 |
1 |
COT001 |
RECORD-ID |
X(8) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT001 |
RECORD-ID |
X(8) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 500 |
1 |
1 |
1 |
1 |
1 |
COT002 |
DATA-DICTIONARY-VERSION |
X(10) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT002 |
DATA-DICTIONARY-VERSION |
X(10) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 501 |
1 |
1 |
1 |
1 |
1 |
COT003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 502 |
1 |
1 |
1 |
1 |
1 |
COT004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 503 |
1 |
1 |
1 |
1 |
1 |
COT005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 504 |
1 |
1 |
1 |
1 |
1 |
COT006 |
FILE-NAME |
X(8) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT006 |
FILE-NAME |
X(8) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 505 |
1 |
1 |
1 |
1 |
1 |
COT007 |
SUBMITTING-STATE |
X(2) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT007 |
SUBMITTING-STATE |
X(2) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 506 |
1 |
1 |
1 |
1 |
1 |
COT008 |
DATE-FILE-CREATED |
9(8) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT008 |
DATE-FILE-CREATED |
9(8) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 507 |
1 |
1 |
1 |
1 |
1 |
COT009 |
START-OF-TIME-PERIOD |
9(8) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT009 |
START-OF-TIME-PERIOD |
9(8) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 508 |
1 |
1 |
1 |
1 |
1 |
COT010 |
END-OF-TIME-PERIOD |
9(8) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT010 |
END-OF-TIME-PERIOD |
9(8) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 509 |
1 |
1 |
1 |
1 |
1 |
COT011 |
FILE-STATUS-INDICATOR |
X(1) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT011 |
FILE-STATUS-INDICATOR |
X(1) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 510 |
1 |
1 |
1 |
1 |
1 |
COT012 |
SSN-INDICATOR |
X(1) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT012 |
SSN-INDICATOR |
X(1) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 511 |
1 |
1 |
1 |
1 |
1 |
COT013 |
TOT-REC-CNT |
9(11) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT013 |
TOT-REC-CNT |
9(11) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 512 |
1 |
1 |
1 |
1 |
1 |
COT216 |
SEQUENCE-NUMBER |
X(4) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT216 |
SEQUENCE-NUMBER |
X(4) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 513 |
1 |
1 |
1 |
1 |
1 |
COT014 |
STATE-NOTATION |
X(500) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT014 |
STATE-NOTATION |
X(500) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 514 |
1 |
1 |
1 |
1 |
1 |
COT015 |
FILLER |
X(1168) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
COT015 |
FILLER |
X(1168) |
CLAIMOT |
FILE-HEADER-RECORD-OT-COT00001 |
| 515 |
1 |
1 |
1 |
1 |
1 |
COT016 |
RECORD-ID |
X(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT016 |
RECORD-ID |
X(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 516 |
1 |
1 |
1 |
1 |
1 |
COT017 |
SUBMITTING-STATE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT017 |
SUBMITTING-STATE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 517 |
1 |
1 |
1 |
1 |
1 |
COT018 |
RECORD-NUMBER |
9(11) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT018 |
RECORD-NUMBER |
9(11) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 518 |
1 |
1 |
1 |
1 |
1 |
COT019 |
ICN-ORIG |
X(50) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT019 |
ICN-ORIG |
X(50) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 519 |
1 |
1 |
1 |
1 |
1 |
COT020 |
ICN-ADJ |
X(50) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT020 |
ICN-ADJ |
X(50) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 520 |
1 |
1 |
1 |
1 |
1 |
COT021 |
SUBMITTER-ID |
X(12) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT021 |
SUBMITTER-ID |
X(12) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 521 |
1 |
1 |
1 |
1 |
1 |
COT022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 522 |
1 |
1 |
1 |
1 |
1 |
COT023 |
CROSSOVER-INDICATOR |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT023 |
CROSSOVER-INDICATOR |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 523 |
1 |
1 |
1 |
1 |
1 |
COT024 |
1115A-DEMONSTRATION-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT024 |
1115A-DEMONSTRATION-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 524 |
1 |
1 |
1 |
1 |
1 |
COT025 |
ADJUSTMENT-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT025 |
ADJUSTMENT-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 525 |
1 |
1 |
1 |
1 |
1 |
COT026 |
ADJUSTMENT-REASON-CODE |
X(3) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT026 |
ADJUSTMENT-REASON-CODE |
X(3) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 526 |
1 |
1 |
1 |
1 |
1 |
COT027 |
DIAGNOSIS-CODE-1 |
X(7) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT027 |
DIAGNOSIS-CODE-1 |
X(7) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 527 |
1 |
1 |
1 |
1 |
1 |
COT028 |
DIAGNOSIS-CODE-FLAG-1 |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT028 |
DIAGNOSIS-CODE-FLAG-1 |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 528 |
1 |
1 |
1 |
1 |
1 |
COT029 |
DIAGNOSIS-POA-FLAG-1 |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT029 |
DIAGNOSIS-POA-FLAG-1 |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 529 |
1 |
1 |
1 |
1 |
1 |
COT030 |
DIAGNOSIS-CODE-2 |
X(7) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT030 |
DIAGNOSIS-CODE-2 |
X(7) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 530 |
1 |
1 |
1 |
1 |
1 |
COT031 |
DIAGNOSIS-CODE-FLAG-2 |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT031 |
DIAGNOSIS-CODE-FLAG-2 |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 531 |
1 |
1 |
1 |
1 |
1 |
COT032 |
DIAGNOSIS-POA-FLAG-2 |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT032 |
DIAGNOSIS-POA-FLAG-2 |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 532 |
1 |
1 |
1 |
1 |
1 |
COT033 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT033 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 533 |
1 |
1 |
1 |
1 |
1 |
COT034 |
ENDING-DATE-OF-SERVICE |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT034 |
ENDING-DATE-OF-SERVICE |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 534 |
1 |
1 |
1 |
1 |
1 |
COT035 |
ADJUDICATION-DATE |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT035 |
ADJUDICATION-DATE |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 535 |
1 |
1 |
1 |
1 |
1 |
COT036 |
MEDICAID-PAID-DATE |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT036 |
MEDICAID-PAID-DATE |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 536 |
1 |
1 |
1 |
1 |
1 |
COT037 |
TYPE-OF-CLAIM |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT037 |
TYPE-OF-CLAIM |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 537 |
1 |
1 |
1 |
1 |
1 |
COT038 |
TYPE-OF-BILL |
X(4) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT038 |
TYPE-OF-BILL |
X(4) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 538 |
1 |
1 |
1 |
1 |
1 |
COT039 |
CLAIM-STATUS |
X(3) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT039 |
CLAIM-STATUS |
X(3) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 539 |
1 |
1 |
1 |
1 |
1 |
COT040 |
CLAIM-STATUS-CATEGORY |
X(3) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT040 |
CLAIM-STATUS-CATEGORY |
X(3) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 540 |
1 |
1 |
1 |
1 |
1 |
COT041 |
SOURCE-LOCATION |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT041 |
SOURCE-LOCATION |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 541 |
1 |
1 |
1 |
1 |
1 |
COT042 |
CHECK-NUM |
X(15) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT042 |
CHECK-NUM |
X(15) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 542 |
1 |
1 |
1 |
1 |
1 |
COT043 |
CHECK-EFF-DATE |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT043 |
CHECK-EFF-DATE |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 543 |
1 |
1 |
1 |
1 |
1 |
COT044 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT044 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 544 |
1 |
1 |
1 |
1 |
1 |
COT045 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT045 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 545 |
1 |
1 |
1 |
1 |
1 |
COT046 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT046 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 546 |
1 |
1 |
1 |
1 |
1 |
COT047 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT047 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 547 |
1 |
1 |
1 |
1 |
1 |
COT048 |
TOT-BILLED-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT048 |
TOT-BILLED-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 548 |
1 |
1 |
1 |
1 |
1 |
COT049 |
TOT-ALLOWED-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT049 |
TOT-ALLOWED-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 549 |
1 |
1 |
1 |
1 |
1 |
COT050 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT050 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 550 |
1 |
1 |
1 |
1 |
1 |
COT051 |
TOT-COPAY-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT051 |
TOT-COPAY-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 551 |
1 |
1 |
1 |
1 |
1 |
COT052 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT052 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 552 |
1 |
1 |
1 |
1 |
1 |
COT053 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT053 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 553 |
1 |
1 |
1 |
1 |
1 |
COT054 |
TOT-TPL-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT054 |
TOT-TPL-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 554 |
1 |
1 |
1 |
1 |
1 |
COT056 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT056 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 555 |
1 |
1 |
1 |
1 |
1 |
COT057 |
OTHER-INSURANCE-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT057 |
OTHER-INSURANCE-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 556 |
1 |
1 |
1 |
1 |
1 |
COT058 |
OTHER-TPL-COLLECTION |
X(3) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT058 |
OTHER-TPL-COLLECTION |
X(3) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 557 |
1 |
1 |
1 |
1 |
1 |
COT059 |
SERVICE-TRACKING-TYPE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT059 |
SERVICE-TRACKING-TYPE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 558 |
1 |
1 |
1 |
1 |
1 |
COT060 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT060 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 559 |
1 |
1 |
1 |
1 |
1 |
COT061 |
FIXED-PAYMENT-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT061 |
FIXED-PAYMENT-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 560 |
1 |
1 |
1 |
1 |
1 |
COT062 |
FUNDING-CODE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT062 |
FUNDING-CODE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 561 |
1 |
1 |
1 |
1 |
1 |
COT063 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT063 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 562 |
1 |
1 |
1 |
1 |
1 |
COT064 |
MEDICARE-COMB-DED-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT064 |
MEDICARE-COMB-DED-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 563 |
1 |
1 |
1 |
1 |
1 |
COT065 |
PROGRAM-TYPE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT065 |
PROGRAM-TYPE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 564 |
1 |
1 |
1 |
1 |
1 |
COT066 |
PLAN-ID-NUMBER |
X(12) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT066 |
PLAN-ID-NUMBER |
X(12) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 565 |
1 |
1 |
1 |
1 |
1 |
COT067 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT067 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 566 |
1 |
1 |
1 |
1 |
1 |
COT068 |
PAYMENT-LEVEL-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT068 |
PAYMENT-LEVEL-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 567 |
1 |
1 |
1 |
1 |
1 |
COT069 |
MEDICARE-REIM-TYPE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT069 |
MEDICARE-REIM-TYPE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 568 |
1 |
1 |
1 |
1 |
1 |
COT070 |
CLAIM-LINE-COUNT |
9(4) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT070 |
CLAIM-LINE-COUNT |
9(4) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 569 |
1 |
1 |
1 |
1 |
1 |
COT072 |
FORCED-CLAIM-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT072 |
FORCED-CLAIM-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 570 |
1 |
1 |
1 |
1 |
1 |
COT073 |
HEALTH-CARE-ACQUIRED-CONDITION-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT073 |
HEALTH-CARE-ACQUIRED-CONDITION-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 571 |
1 |
1 |
1 |
1 |
1 |
COT074 |
OCCURRENCE-CODE-01 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT074 |
OCCURRENCE-CODE-01 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 572 |
1 |
1 |
1 |
1 |
1 |
COT075 |
OCCURRENCE-CODE-02 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT075 |
OCCURRENCE-CODE-02 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 573 |
1 |
1 |
1 |
1 |
1 |
COT076 |
OCCURRENCE-CODE-03 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT076 |
OCCURRENCE-CODE-03 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 574 |
1 |
1 |
1 |
1 |
1 |
COT077 |
OCCURRENCE-CODE-04 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT077 |
OCCURRENCE-CODE-04 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 575 |
1 |
1 |
1 |
1 |
1 |
COT078 |
OCCURRENCE-CODE-05 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT078 |
OCCURRENCE-CODE-05 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 576 |
1 |
1 |
1 |
1 |
1 |
COT079 |
OCCURRENCE-CODE-06 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT079 |
OCCURRENCE-CODE-06 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 577 |
1 |
1 |
1 |
1 |
1 |
COT080 |
OCCURRENCE-CODE-07 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT080 |
OCCURRENCE-CODE-07 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 578 |
1 |
1 |
1 |
1 |
1 |
COT081 |
OCCURRENCE-CODE-08 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT081 |
OCCURRENCE-CODE-08 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 579 |
1 |
1 |
1 |
1 |
1 |
COT082 |
OCCURRENCE-CODE-09 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT082 |
OCCURRENCE-CODE-09 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 580 |
1 |
1 |
1 |
1 |
1 |
COT083 |
OCCURRENCE-CODE-10 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT083 |
OCCURRENCE-CODE-10 |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 581 |
1 |
1 |
1 |
1 |
1 |
COT084 |
OCCURRENCE-CODE-EFF-DATE-01 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT084 |
OCCURRENCE-CODE-EFF-DATE-01 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 582 |
1 |
1 |
1 |
1 |
1 |
COT085 |
OCCURRENCE-CODE-EFF-DATE-02 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT085 |
OCCURRENCE-CODE-EFF-DATE-02 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 583 |
1 |
1 |
1 |
1 |
1 |
COT086 |
OCCURRENCE-CODE-EFF-DATE-03 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT086 |
OCCURRENCE-CODE-EFF-DATE-03 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 584 |
1 |
1 |
1 |
1 |
1 |
COT087 |
OCCURRENCE-CODE-EFF-DATE-04 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT087 |
OCCURRENCE-CODE-EFF-DATE-04 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 585 |
1 |
1 |
1 |
1 |
1 |
COT088 |
OCCURRENCE-CODE-EFF-DATE-05 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT088 |
OCCURRENCE-CODE-EFF-DATE-05 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 586 |
1 |
1 |
1 |
1 |
1 |
COT089 |
OCCURRENCE-CODE-EFF-DATE-06 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT089 |
OCCURRENCE-CODE-EFF-DATE-06 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 587 |
1 |
1 |
1 |
1 |
1 |
COT090 |
OCCURRENCE-CODE-EFF-DATE-07 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT090 |
OCCURRENCE-CODE-EFF-DATE-07 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 588 |
1 |
1 |
1 |
1 |
1 |
COT091 |
OCCURRENCE-CODE-EFF-DATE-08 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT091 |
OCCURRENCE-CODE-EFF-DATE-08 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 589 |
1 |
1 |
1 |
1 |
1 |
COT092 |
OCCURRENCE-CODE-EFF-DATE-09 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT092 |
OCCURRENCE-CODE-EFF-DATE-09 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 590 |
1 |
1 |
1 |
1 |
1 |
COT093 |
OCCURRENCE-CODE-EFF-DATE-10 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT093 |
OCCURRENCE-CODE-EFF-DATE-10 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 591 |
1 |
1 |
1 |
1 |
1 |
COT094 |
OCCURRENCE-CODE-END-DATE-01 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT094 |
OCCURRENCE-CODE-END-DATE-01 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 592 |
1 |
1 |
1 |
1 |
1 |
COT095 |
OCCURRENCE-CODE-END-DATE-02 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT095 |
OCCURRENCE-CODE-END-DATE-02 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 593 |
1 |
1 |
1 |
1 |
1 |
COT096 |
OCCURRENCE-CODE-END-DATE-03 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT096 |
OCCURRENCE-CODE-END-DATE-03 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 594 |
1 |
1 |
1 |
1 |
1 |
COT097 |
OCCURRENCE-CODE-END-DATE-04 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT097 |
OCCURRENCE-CODE-END-DATE-04 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 595 |
1 |
1 |
1 |
1 |
1 |
COT098 |
OCCURRENCE-CODE-END-DATE-05 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT098 |
OCCURRENCE-CODE-END-DATE-05 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 596 |
1 |
1 |
1 |
1 |
1 |
COT099 |
OCCURRENCE-CODE-END-DATE-06 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT099 |
OCCURRENCE-CODE-END-DATE-06 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 597 |
1 |
1 |
1 |
1 |
1 |
COT100 |
OCCURRENCE-CODE-END-DATE-07 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT100 |
OCCURRENCE-CODE-END-DATE-07 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 598 |
1 |
1 |
1 |
1 |
1 |
COT101 |
OCCURRENCE-CODE-END-DATE-08 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT101 |
OCCURRENCE-CODE-END-DATE-08 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 599 |
1 |
1 |
1 |
1 |
1 |
COT102 |
OCCURRENCE-CODE-END-DATE-09 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT102 |
OCCURRENCE-CODE-END-DATE-09 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 600 |
1 |
1 |
1 |
1 |
1 |
COT103 |
OCCURRENCE-CODE-END-DATE-10 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT103 |
OCCURRENCE-CODE-END-DATE-10 |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 601 |
1 |
1 |
1 |
1 |
1 |
COT104 |
PATIENT-CONTROL-NUM |
X(20) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT104 |
PATIENT-CONTROL-NUM |
X(20) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 602 |
1 |
1 |
1 |
1 |
1 |
COT105 |
ELIGIBLE-LAST-NAME |
X(30) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT105 |
ELIGIBLE-LAST-NAME |
X(30) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 603 |
1 |
1 |
1 |
1 |
1 |
COT106 |
ELIGIBLE-FIRST-NAME |
X(30) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT106 |
ELIGIBLE-FIRST-NAME |
X(30) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 604 |
1 |
1 |
1 |
1 |
1 |
COT107 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT107 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 605 |
1 |
1 |
1 |
1 |
1 |
COT108 |
DATE-OF-BIRTH |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT108 |
DATE-OF-BIRTH |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 606 |
1 |
1 |
1 |
1 |
1 |
COT109 |
HEALTH-HOME-PROV-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT109 |
HEALTH-HOME-PROV-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 607 |
1 |
1 |
1 |
1 |
1 |
COT110 |
WAIVER-TYPE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT110 |
WAIVER-TYPE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 608 |
1 |
1 |
1 |
1 |
1 |
COT111 |
WAIVER-ID |
X(20) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT111 |
WAIVER-ID |
X(20) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 609 |
1 |
1 |
1 |
1 |
1 |
COT112 |
BILLING-PROV-NUM |
X(30) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT112 |
BILLING-PROV-NUM |
X(30) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 610 |
1 |
1 |
1 |
1 |
1 |
COT113 |
BILLING-PROV-NPI-NUM |
X(10) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT113 |
BILLING-PROV-NPI-NUM |
X(10) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 611 |
1 |
1 |
1 |
1 |
1 |
COT114 |
BILLING-PROV-TAXONOMY |
X(12) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT114 |
BILLING-PROV-TAXONOMY |
X(12) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 612 |
1 |
1 |
1 |
1 |
1 |
COT115 |
BILLING-PROV-TYPE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT115 |
BILLING-PROV-TYPE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 613 |
1 |
1 |
1 |
1 |
1 |
COT116 |
BILLING-PROV-SPECIALTY |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT116 |
BILLING-PROV-SPECIALTY |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 614 |
1 |
1 |
1 |
1 |
1 |
COT117 |
REFERRING-PROV-NUM |
X(30) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT117 |
REFERRING-PROV-NUM |
X(30) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 615 |
1 |
1 |
1 |
1 |
1 |
COT118 |
REFERRING-PROV-NPI-NUM |
X(10) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT118 |
REFERRING-PROV-NPI-NUM |
X(10) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 616 |
1 |
1 |
1 |
1 |
1 |
COT119 |
REFERRING-PROV-TAXONOMY |
X(12) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT119 |
REFERRING-PROV-TAXONOMY |
X(12) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 617 |
1 |
1 |
1 |
1 |
1 |
COT120 |
REFERRING-PROV-TYPE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT120 |
REFERRING-PROV-TYPE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 618 |
1 |
1 |
1 |
1 |
1 |
COT121 |
REFERRING-PROV-SPECIALTY |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT121 |
REFERRING-PROV-SPECIALTY |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 619 |
1 |
1 |
1 |
1 |
1 |
COT122 |
MEDICARE-HIC-NUM |
X(12) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT122 |
MEDICARE-HIC-NUM |
X(12) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 620 |
1 |
1 |
1 |
1 |
1 |
COT123 |
PLACE-OF-SERVICE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT123 |
PLACE-OF-SERVICE |
X(2) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 621 |
1 |
1 |
1 |
1 |
1 |
COT125 |
BMI |
S9(5)V9 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT125 |
BMI |
S9(5)V9 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 622 |
1 |
1 |
1 |
1 |
1 |
COT126 |
REMITTANCE-NUM |
X(30) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT126 |
REMITTANCE-NUM |
X(30) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 623 |
1 |
1 |
1 |
1 |
1 |
COT127 |
DAILY-RATE |
S9(5)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT127 |
DAILY-RATE |
S9(5)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 624 |
1 |
1 |
1 |
1 |
1 |
COT128 |
BORDER-STATE-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT128 |
BORDER-STATE-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 625 |
1 |
1 |
1 |
1 |
1 |
COT130 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT130 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 626 |
1 |
1 |
1 |
1 |
1 |
COT131 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT131 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 627 |
1 |
1 |
1 |
1 |
1 |
COT132 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT132 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 628 |
1 |
1 |
1 |
1 |
1 |
COT133 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT133 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 629 |
1 |
1 |
1 |
1 |
1 |
COT134 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT134 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 630 |
1 |
1 |
1 |
1 |
1 |
COT135 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT135 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 631 |
1 |
1 |
1 |
1 |
1 |
COT136 |
CLAIM-DENIED-INDICATOR |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT136 |
CLAIM-DENIED-INDICATOR |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 632 |
1 |
1 |
1 |
1 |
1 |
COT137 |
COPAY-WAIVED-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT137 |
COPAY-WAIVED-IND |
X(1) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 633 |
1 |
1 |
1 |
1 |
1 |
COT138 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT138 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 634 |
1 |
1 |
1 |
1 |
1 |
COT140 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT140 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 635 |
1 |
1 |
1 |
1 |
1 |
COT141 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT141 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 636 |
1 |
1 |
1 |
1 |
1 |
COT142 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT142 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 637 |
1 |
1 |
1 |
1 |
1 |
COT143 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT143 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 638 |
1 |
1 |
1 |
1 |
1 |
COT144 |
DATE-CAPITATED-AMOUNT-REQUESTED |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT144 |
DATE-CAPITATED-AMOUNT-REQUESTED |
9(8) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 639 |
1 |
1 |
1 |
1 |
1 |
COT145 |
CAPITATED-PAYMENT-AMT-REQUESTED |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT145 |
CAPITATED-PAYMENT-AMT-REQUESTED |
S9(11)V99 |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 640 |
1 |
1 |
1 |
1 |
1 |
COT146 |
HEALTH-HOME-PROVIDER-NPI |
X(10) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT146 |
HEALTH-HOME-PROVIDER-NPI |
X(10) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 641 |
1 |
1 |
1 |
1 |
1 |
COT147 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT147 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 642 |
1 |
1 |
1 |
1 |
1 |
COT148 |
UNDER-DIRECTION-OF-PROV-NPI |
X(10) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT148 |
UNDER-DIRECTION-OF-PROV-NPI |
X(10) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 643 |
1 |
1 |
1 |
1 |
1 |
COT149 |
UNDER-DIRECTION-OF-PROV-TAXONOMY |
X(12) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT149 |
UNDER-DIRECTION-OF-PROV-TAXONOMY |
X(12) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 644 |
1 |
1 |
1 |
1 |
1 |
COT150 |
UNDER-SUPERVISION-OF-PROV-NPI |
X(10) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT150 |
UNDER-SUPERVISION-OF-PROV-NPI |
X(10) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 645 |
1 |
1 |
1 |
1 |
1 |
COT151 |
UNDER-SUPERVISION-OF-PROV-TAXONOMY |
X(12) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT151 |
UNDER-SUPERVISION-OF-PROV-TAXONOMY |
X(12) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 646 |
1 |
1 |
1 |
1 |
1 |
COT152 |
STATE-NOTATION |
X(500) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT152 |
STATE-NOTATION |
X(500) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 647 |
1 |
1 |
1 |
1 |
1 |
COT226 |
PROV-LOCATION-ID |
X(5) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT226 |
PROV-LOCATION-ID |
X(5) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 648 |
1 |
1 |
0 |
1 |
1 |
COT153 |
FILLER |
X(112) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
COT153 |
FILLER |
X(111) |
CLAIMOT |
CLAIM-HEADER-RECORD-OT-COT00002 |
| 649 |
1 |
1 |
1 |
1 |
1 |
COT154 |
RECORD-ID |
X(8) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT154 |
RECORD-ID |
X(8) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 650 |
1 |
1 |
1 |
1 |
1 |
COT155 |
SUBMITTING-STATE |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT155 |
SUBMITTING-STATE |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 651 |
1 |
1 |
1 |
1 |
1 |
COT156 |
RECORD-NUMBER |
9(11) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT156 |
RECORD-NUMBER |
9(11) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 652 |
1 |
1 |
1 |
1 |
1 |
COT157 |
MSIS-IDENTIFICATION-NUM |
X(20) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT157 |
MSIS-IDENTIFICATION-NUM |
X(20) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 653 |
1 |
1 |
1 |
1 |
1 |
COT158 |
ICN-ORIG |
X(50) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT158 |
ICN-ORIG |
X(50) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 654 |
1 |
1 |
1 |
1 |
1 |
COT159 |
ICN-ADJ |
X(50) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT159 |
ICN-ADJ |
X(50) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 655 |
1 |
1 |
1 |
1 |
1 |
COT160 |
LINE-NUM-ORIG |
X(3) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT160 |
LINE-NUM-ORIG |
X(3) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 656 |
1 |
1 |
1 |
1 |
1 |
COT161 |
LINE-NUM-ADJ |
X(3) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT161 |
LINE-NUM-ADJ |
X(3) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 657 |
1 |
1 |
1 |
1 |
1 |
COT162 |
LINE-ADJUSTMENT-IND |
X(1) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT162 |
LINE-ADJUSTMENT-IND |
X(1) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 658 |
1 |
1 |
1 |
1 |
1 |
COT163 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT163 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 659 |
1 |
1 |
1 |
1 |
1 |
COT164 |
SUBMITTER-ID |
X(12) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT164 |
SUBMITTER-ID |
X(12) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 660 |
1 |
1 |
1 |
1 |
1 |
COT165 |
CLAIM-LINE-STATUS |
X(3) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT165 |
CLAIM-LINE-STATUS |
X(3) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 661 |
1 |
1 |
1 |
1 |
1 |
COT166 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT166 |
BEGINNING-DATE-OF-SERVICE |
9(8) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 662 |
1 |
1 |
1 |
1 |
1 |
COT167 |
ENDING-DATE-OF-SERVICE |
9(8) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT167 |
ENDING-DATE-OF-SERVICE |
9(8) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 663 |
1 |
1 |
1 |
1 |
1 |
COT168 |
REVENUE-CODE |
X(4) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT168 |
REVENUE-CODE |
X(4) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 664 |
1 |
1 |
1 |
1 |
1 |
COT169 |
PROCEDURE-CODE |
X(8) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT169 |
PROCEDURE-CODE |
X(8) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 665 |
1 |
1 |
1 |
1 |
1 |
COT170 |
PROCEDURE-CODE-DATE |
9(8) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT170 |
PROCEDURE-CODE-DATE |
9(8) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 666 |
1 |
1 |
1 |
1 |
1 |
COT171 |
PROCEDURE-CODE-FLAG |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT171 |
PROCEDURE-CODE-FLAG |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 667 |
1 |
1 |
1 |
1 |
1 |
COT172 |
PROCEDURE-CODE-MOD-1 |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT172 |
PROCEDURE-CODE-MOD-1 |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 668 |
1 |
1 |
1 |
1 |
1 |
COT173 |
IMMUNIZATION-TYPE |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT173 |
IMMUNIZATION-TYPE |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 669 |
1 |
1 |
1 |
1 |
1 |
COT174 |
BILLED-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT174 |
BILLED-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 670 |
1 |
1 |
1 |
1 |
1 |
COT175 |
ALLOWED-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT175 |
ALLOWED-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 671 |
1 |
1 |
1 |
1 |
1 |
COT176 |
COPAY-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT176 |
COPAY-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 672 |
1 |
1 |
1 |
1 |
1 |
COT177 |
TPL-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT177 |
TPL-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 673 |
1 |
1 |
1 |
1 |
1 |
COT178 |
MEDICAID-PAID-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT178 |
MEDICAID-PAID-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 674 |
1 |
1 |
1 |
1 |
1 |
COT179 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT179 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 675 |
1 |
1 |
1 |
1 |
1 |
COT182 |
MEDICARE-PAID-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT182 |
MEDICARE-PAID-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 676 |
1 |
1 |
0 |
1 |
1 |
COT183 |
OT-RX-CLAIM-QUANTITY-ACTUAL |
S9(6)V999 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT183 |
OT-RX-CLAIM-QUANTITY-ACTUAL |
9(6)V999 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 677 |
1 |
1 |
0 |
1 |
1 |
COT184 |
OT-RX-CLAIM-QUANTITY-ALLOWED |
S9(6)V999 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT184 |
OT-RX-CLAIM-QUANTITY-ALLOWED |
S9(11)V99 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 678 |
1 |
1 |
1 |
1 |
1 |
COT186 |
TYPE-OF-SERVICE |
X(3) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT186 |
TYPE-OF-SERVICE |
X(3) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 679 |
1 |
1 |
1 |
1 |
1 |
COT187 |
HCBS-SERVICE-CODE |
X(1) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT187 |
HCBS-SERVICE-CODE |
X(1) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 680 |
1 |
1 |
1 |
1 |
1 |
COT188 |
HCBS-TAXONOMY |
X(5) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT188 |
HCBS-TAXONOMY |
X(5) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 681 |
1 |
1 |
1 |
1 |
1 |
COT189 |
SERVICING-PROV-NUM |
X(30) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT189 |
SERVICING-PROV-NUM |
X(30) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 682 |
1 |
1 |
1 |
1 |
1 |
COT190 |
SERVICING-PROV-NPI-NUM |
X(10) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT190 |
SERVICING-PROV-NPI-NUM |
X(10) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 683 |
1 |
1 |
1 |
1 |
1 |
COT191 |
SERVICING-PROV-TAXONOMY |
X(12) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT191 |
SERVICING-PROV-TAXONOMY |
X(12) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 684 |
1 |
1 |
1 |
1 |
1 |
COT192 |
SERVICING-PROV-TYPE |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT192 |
SERVICING-PROV-TYPE |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 685 |
1 |
1 |
1 |
1 |
1 |
COT193 |
SERVICING-PROV-SPECIALTY |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT193 |
SERVICING-PROV-SPECIALTY |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 686 |
1 |
1 |
1 |
1 |
1 |
COT194 |
OTHER-TPL-COLLECTION |
X(3) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT194 |
OTHER-TPL-COLLECTION |
X(3) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 687 |
1 |
1 |
1 |
1 |
1 |
COT195 |
TOOTH-DESIGNATION-SYSTEM |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT195 |
TOOTH-DESIGNATION-SYSTEM |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 688 |
1 |
1 |
1 |
1 |
1 |
COT196 |
TOOTH-NUM |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT196 |
TOOTH-NUM |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 689 |
1 |
1 |
1 |
1 |
1 |
COT197 |
TOOTH-QUAD-CODE |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT197 |
TOOTH-QUAD-CODE |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 690 |
1 |
1 |
1 |
1 |
1 |
COT198 |
TOOTH-SURFACE-CODE |
X(1) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT198 |
TOOTH-SURFACE-CODE |
X(1) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 691 |
1 |
1 |
1 |
1 |
1 |
COT199 |
ORIGINATION-ADDR-LN1 |
X(60) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT199 |
ORIGINATION-ADDR-LN1 |
X(60) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 692 |
1 |
1 |
1 |
1 |
1 |
COT200 |
ORIGINATION-ADDR-LN2 |
X(60) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT200 |
ORIGINATION-ADDR-LN2 |
X(60) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 693 |
1 |
1 |
1 |
1 |
1 |
COT201 |
ORIGINATION-CITY |
X(28) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT201 |
ORIGINATION-CITY |
X(28) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 694 |
1 |
1 |
1 |
1 |
1 |
COT202 |
ORIGINATION-STATE |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT202 |
ORIGINATION-STATE |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 695 |
1 |
1 |
1 |
1 |
1 |
COT203 |
ORIGINATION-ZIP-CODE |
X(9) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT203 |
ORIGINATION-ZIP-CODE |
X(9) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 696 |
1 |
1 |
1 |
1 |
1 |
COT204 |
DESTINATION-ADDR-LN1 |
X(60) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT204 |
DESTINATION-ADDR-LN1 |
X(60) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 697 |
1 |
1 |
1 |
1 |
1 |
COT205 |
DESTINATION-ADDR-LN2 |
X(60) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT205 |
DESTINATION-ADDR-LN2 |
X(60) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 698 |
1 |
1 |
1 |
1 |
1 |
COT206 |
DESTINATION-CITY |
X(28) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT206 |
DESTINATION-CITY |
X(28) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 699 |
1 |
1 |
1 |
1 |
1 |
COT207 |
DESTINATION-STATE |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT207 |
DESTINATION-STATE |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 700 |
1 |
1 |
1 |
1 |
1 |
COT208 |
DESTINATION-ZIP-CODE |
X(9) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT208 |
DESTINATION-ZIP-CODE |
X(9) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 701 |
1 |
1 |
1 |
1 |
1 |
COT209 |
BENEFIT-TYPE |
X(3) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT209 |
BENEFIT-TYPE |
X(3) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 702 |
1 |
1 |
1 |
1 |
1 |
COT210 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT210 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 703 |
1 |
1 |
1 |
1 |
1 |
COT211 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT211 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 704 |
1 |
1 |
1 |
1 |
1 |
COT212 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT212 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 705 |
NA |
NA |
NA |
NA |
NA |
|
|
|
|
|
COT212 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 706 |
1 |
1 |
1 |
1 |
1 |
COT213 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT213 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 707 |
1 |
1 |
1 |
1 |
1 |
COT214 |
STATE-NOTATION |
X(500) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT214 |
STATE-NOTATION |
X(500) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 708 |
1 |
1 |
0 |
1 |
1 |
COT217 |
NATIONAL-DRUG-CODE |
X(12) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT217 |
NATIONAL-DRUG-CODE |
X(11) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 709 |
1 |
1 |
1 |
1 |
1 |
COT227 |
PROCEDURE-CODE-MOD-2 |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT227 |
PROCEDURE-CODE-MOD-2 |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 710 |
1 |
1 |
1 |
1 |
1 |
COT218 |
PROCEDURE-CODE-MOD-3 |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT218 |
PROCEDURE-CODE-MOD-3 |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 711 |
1 |
1 |
1 |
1 |
1 |
COT219 |
PROCEDURE-CODE-MOD-4 |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT219 |
PROCEDURE-CODE-MOD-4 |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 712 |
1 |
1 |
1 |
1 |
1 |
COT220 |
HCPCS-RATE |
X(14) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT220 |
HCPCS-RATE |
X(14) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 713 |
1 |
1 |
1 |
1 |
1 |
COT221 |
ADJUDICATION-DATE |
9(8) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT221 |
ADJUDICATION-DATE |
9(8) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 714 |
1 |
1 |
1 |
1 |
1 |
COT222 |
SELF-DIRECTION-TYPE |
X(3) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT222 |
SELF-DIRECTION-TYPE |
X(3) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 715 |
1 |
1 |
1 |
1 |
1 |
COT223 |
PRE-AUTHORIZATION-NUM |
X(18) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT223 |
PRE-AUTHORIZATION-NUM |
X(18) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 716 |
1 |
1 |
1 |
1 |
1 |
COT224 |
NDC-UNIT-OF-MEASURE |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT224 |
NDC-UNIT-OF-MEASURE |
X(2) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 717 |
1 |
1 |
1 |
1 |
1 |
COT225 |
NDC-QUANTITY |
S9(6)V999 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT225 |
NDC-QUANTITY |
S9(6)V999 |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 718 |
1 |
1 |
0 |
1 |
1 |
COT215 |
FILLER |
X(443) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
COT215 |
FILLER |
X(435) |
CLAIMOT |
CLAIM-LINE-RECORD-OT-COT00003 |
| 719 |
1 |
1 |
1 |
1 |
1 |
CRX001 |
RECORD-ID |
X(8) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX001 |
RECORD-ID |
X(8) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 720 |
1 |
1 |
1 |
1 |
1 |
CRX002 |
DATA-DICTIONARY-VERSION |
X(10) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX002 |
DATA-DICTIONARY-VERSION |
X(10) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 721 |
1 |
1 |
1 |
1 |
1 |
CRX003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 722 |
1 |
1 |
1 |
1 |
1 |
CRX004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 723 |
1 |
1 |
1 |
1 |
1 |
CRX005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 724 |
1 |
1 |
1 |
1 |
1 |
CRX006 |
FILE-NAME |
X(8) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX006 |
FILE-NAME |
X(8) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 725 |
1 |
1 |
1 |
1 |
1 |
CRX007 |
SUBMITTING-STATE |
X(2) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX007 |
SUBMITTING-STATE |
X(2) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 726 |
1 |
1 |
1 |
1 |
1 |
CRX008 |
DATE-FILE-CREATED |
9(8) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX008 |
DATE-FILE-CREATED |
9(8) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 727 |
1 |
1 |
1 |
1 |
1 |
CRX009 |
START-OF-TIME-PERIOD |
9(8) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX009 |
START-OF-TIME-PERIOD |
9(8) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 728 |
1 |
1 |
1 |
1 |
1 |
CRX010 |
END-OF-TIME-PERIOD |
9(8) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX010 |
END-OF-TIME-PERIOD |
9(8) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 729 |
1 |
1 |
1 |
1 |
1 |
CRX011 |
FILE-STATUS-INDICATOR |
X(1) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX011 |
FILE-STATUS-INDICATOR |
X(1) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 730 |
1 |
1 |
1 |
1 |
1 |
CRX012 |
SSN-INDICATOR |
X(1) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX012 |
SSN-INDICATOR |
X(1) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 731 |
1 |
1 |
1 |
1 |
1 |
CRX013 |
TOT-REC-CNT |
9(11) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX013 |
TOT-REC-CNT |
9(11) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 732 |
1 |
1 |
1 |
1 |
1 |
CRX155 |
SEQUENCE-NUMBER |
X(4) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX155 |
SEQUENCE-NUMBER |
X(4) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 733 |
1 |
1 |
1 |
1 |
1 |
CRX014 |
STATE-NOTATION |
X(500) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX014 |
STATE-NOTATION |
X(500) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 734 |
1 |
1 |
1 |
1 |
1 |
CRX015 |
FILLER |
X(868) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
CRX015 |
FILLER |
X(868) |
CLAIMRX |
FILE-HEADER-RECORD-RX-CRX00001 |
| 735 |
1 |
1 |
1 |
1 |
1 |
CRX016 |
RECORD-ID |
X(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX016 |
RECORD-ID |
X(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 736 |
1 |
1 |
1 |
1 |
1 |
CRX017 |
SUBMITTING-STATE |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX017 |
SUBMITTING-STATE |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 737 |
1 |
1 |
1 |
1 |
1 |
CRX018 |
RECORD-NUMBER |
9(11) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX018 |
RECORD-NUMBER |
9(11) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 738 |
1 |
1 |
1 |
1 |
1 |
CRX019 |
ICN-ORIG |
X(50) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX019 |
ICN-ORIG |
X(50) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 739 |
1 |
1 |
1 |
1 |
1 |
CRX020 |
ICN-ADJ |
X(50) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX020 |
ICN-ADJ |
X(50) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 740 |
1 |
1 |
1 |
1 |
1 |
CRX021 |
SUBMITTER-ID |
X(12) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX021 |
SUBMITTER-ID |
X(12) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 741 |
1 |
1 |
1 |
1 |
1 |
CRX022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 742 |
NA |
NA |
NA |
NA |
NA |
|
|
|
|
|
CRX022 |
MSIS-IDENTIFICATION-NUM |
X(20) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 743 |
1 |
1 |
1 |
1 |
1 |
CRX023 |
CROSSOVER-INDICATOR |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX023 |
CROSSOVER-INDICATOR |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 744 |
1 |
1 |
1 |
1 |
1 |
CRX024 |
1115A-DEMONSTRATION-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX024 |
1115A-DEMONSTRATION-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 745 |
1 |
1 |
1 |
1 |
1 |
CRX025 |
ADJUSTMENT-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX025 |
ADJUSTMENT-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 746 |
1 |
1 |
1 |
1 |
1 |
CRX026 |
ADJUSTMENT-REASON-CODE |
X(3) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX026 |
ADJUSTMENT-REASON-CODE |
X(3) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 747 |
1 |
1 |
1 |
1 |
1 |
CRX027 |
ADJUDICATION-DATE |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX027 |
ADJUDICATION-DATE |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 748 |
1 |
1 |
1 |
1 |
1 |
CRX028 |
MEDICAID-PAID-DATE |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX028 |
MEDICAID-PAID-DATE |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 749 |
1 |
1 |
1 |
1 |
1 |
CRX029 |
TYPE-OF-CLAIM |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX029 |
TYPE-OF-CLAIM |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 750 |
1 |
1 |
1 |
1 |
1 |
CRX030 |
CLAIM-STATUS |
X(3) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX030 |
CLAIM-STATUS |
X(3) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 751 |
1 |
1 |
1 |
1 |
1 |
CRX031 |
CLAIM-STATUS-CATEGORY |
X(3) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX031 |
CLAIM-STATUS-CATEGORY |
X(3) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 752 |
1 |
1 |
1 |
1 |
1 |
CRX032 |
SOURCE-LOCATION |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX032 |
SOURCE-LOCATION |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 753 |
1 |
1 |
1 |
1 |
1 |
CRX033 |
CHECK-NUM |
X(15) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX033 |
CHECK-NUM |
X(15) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 754 |
1 |
1 |
1 |
1 |
1 |
CRX034 |
CHECK-EFF-DATE |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX034 |
CHECK-EFF-DATE |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 755 |
1 |
1 |
1 |
1 |
1 |
CRX035 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX035 |
CLAIM-PYMT-REM-CODE-1 |
X(5) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 756 |
1 |
1 |
1 |
1 |
1 |
CRX036 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX036 |
CLAIM-PYMT-REM-CODE-2 |
X(5) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 757 |
1 |
1 |
1 |
1 |
1 |
CRX037 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX037 |
CLAIM-PYMT-REM-CODE-3 |
X(5) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 758 |
1 |
1 |
1 |
1 |
1 |
CRX038 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX038 |
CLAIM-PYMT-REM-CODE-4 |
X(5) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 759 |
1 |
1 |
1 |
1 |
1 |
CRX039 |
TOT-BILLED-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX039 |
TOT-BILLED-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 760 |
1 |
1 |
1 |
1 |
1 |
CRX040 |
TOT-ALLOWED-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX040 |
TOT-ALLOWED-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 761 |
1 |
1 |
1 |
1 |
1 |
CRX041 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX041 |
TOT-MEDICAID-PAID-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 762 |
1 |
1 |
1 |
1 |
1 |
CRX042 |
TOT-COPAY-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX042 |
TOT-COPAY-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 763 |
1 |
1 |
1 |
1 |
1 |
CRX043 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX043 |
TOT-MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 764 |
1 |
1 |
1 |
1 |
1 |
CRX044 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX044 |
TOT-MEDICARE-COINS-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 765 |
1 |
1 |
1 |
1 |
1 |
CRX045 |
TOT-TPL-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX045 |
TOT-TPL-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 766 |
1 |
1 |
1 |
1 |
1 |
CRX047 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX047 |
TOT-OTHER-INSURANCE-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 767 |
1 |
1 |
1 |
1 |
1 |
CRX048 |
OTHER-INSURANCE-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX048 |
OTHER-INSURANCE-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 768 |
1 |
1 |
1 |
1 |
1 |
CRX049 |
OTHER-TPL-COLLECTION |
X(3) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX049 |
OTHER-TPL-COLLECTION |
X(3) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 769 |
1 |
1 |
1 |
1 |
1 |
CRX050 |
SERVICE-TRACKING-TYPE |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX050 |
SERVICE-TRACKING-TYPE |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 770 |
1 |
1 |
1 |
1 |
1 |
CRX051 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX051 |
SERVICE-TRACKING-PAYMENT-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 771 |
1 |
1 |
1 |
1 |
1 |
CRX052 |
FIXED-PAYMENT-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX052 |
FIXED-PAYMENT-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 772 |
1 |
1 |
1 |
1 |
1 |
CRX053 |
FUNDING-CODE |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX053 |
FUNDING-CODE |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 773 |
1 |
1 |
1 |
1 |
1 |
CRX054 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX054 |
FUNDING-SOURCE-NONFEDERAL-SHARE |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 774 |
1 |
1 |
1 |
1 |
1 |
CRX055 |
PROGRAM-TYPE |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX055 |
PROGRAM-TYPE |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 775 |
1 |
1 |
1 |
1 |
1 |
CRX056 |
PLAN-ID-NUMBER |
X(12) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX056 |
PLAN-ID-NUMBER |
X(12) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 776 |
1 |
1 |
1 |
1 |
1 |
CRX057 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX057 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 777 |
1 |
1 |
1 |
1 |
1 |
CRX058 |
PAYMENT-LEVEL-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX058 |
PAYMENT-LEVEL-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 778 |
1 |
1 |
1 |
1 |
1 |
CRX059 |
MEDICARE-REIM-TYPE |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX059 |
MEDICARE-REIM-TYPE |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 779 |
1 |
1 |
1 |
1 |
1 |
CRX060 |
CLAIM-LINE-COUNT |
9(4) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX060 |
CLAIM-LINE-COUNT |
9(4) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 780 |
1 |
1 |
1 |
1 |
1 |
CRX061 |
FORCED-CLAIM-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX061 |
FORCED-CLAIM-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 781 |
1 |
1 |
1 |
1 |
1 |
CRX062 |
PATIENT-CONTROL-NUM |
X(20) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX062 |
PATIENT-CONTROL-NUM |
X(20) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 782 |
1 |
1 |
1 |
1 |
1 |
CRX063 |
ELIGIBLE-LAST-NAME |
X(30) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX063 |
ELIGIBLE-LAST-NAME |
X(30) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 783 |
1 |
1 |
1 |
1 |
1 |
CRX064 |
ELIGIBLE-FIRST-NAME |
X(30) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX064 |
ELIGIBLE-FIRST-NAME |
X(30) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 784 |
1 |
1 |
1 |
1 |
1 |
CRX065 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX065 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 785 |
1 |
1 |
1 |
1 |
1 |
CRX066 |
DATE-OF-BIRTH |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX066 |
DATE-OF-BIRTH |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 786 |
1 |
1 |
1 |
1 |
1 |
CRX067 |
HEALTH-HOME-PROV-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX067 |
HEALTH-HOME-PROV-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 787 |
1 |
1 |
1 |
1 |
1 |
CRX068 |
WAIVER-TYPE |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX068 |
WAIVER-TYPE |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 788 |
1 |
1 |
1 |
1 |
1 |
CRX069 |
WAIVER-ID |
X(20) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX069 |
WAIVER-ID |
X(20) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 789 |
1 |
1 |
1 |
1 |
1 |
CRX070 |
BILLING-PROV-NUM |
X(30) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX070 |
BILLING-PROV-NUM |
X(30) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 790 |
1 |
1 |
1 |
1 |
1 |
CRX071 |
BILLING-PROV-NPI-NUM |
X(10) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX071 |
BILLING-PROV-NPI-NUM |
X(10) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 791 |
1 |
1 |
1 |
1 |
1 |
CRX072 |
BILLING-PROV-TAXONOMY |
X(12) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX072 |
BILLING-PROV-TAXONOMY |
X(12) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 792 |
1 |
1 |
1 |
1 |
1 |
CRX073 |
BILLING-PROV-SPECIALTY |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX073 |
BILLING-PROV-SPECIALTY |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 793 |
1 |
1 |
1 |
1 |
1 |
CRX074 |
PRESCRIBING-PROV-NUM |
X(30) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX074 |
PRESCRIBING-PROV-NUM |
X(30) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 794 |
1 |
1 |
1 |
1 |
1 |
CRX075 |
PRESCRIBING-PROV-NPI-NUM |
X(10) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX075 |
PRESCRIBING-PROV-NPI-NUM |
X(10) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 795 |
1 |
1 |
1 |
1 |
1 |
CRX076 |
PRESCRIBING-PROV-TAXONOMY |
X(12) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX076 |
PRESCRIBING-PROV-TAXONOMY |
X(12) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 796 |
1 |
1 |
1 |
1 |
1 |
CRX077 |
PRESCRIBING-PROV-TYPE |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX077 |
PRESCRIBING-PROV-TYPE |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 797 |
1 |
1 |
1 |
1 |
1 |
CRX078 |
PRESCRIBING-PROV-SPECIALTY |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX078 |
PRESCRIBING-PROV-SPECIALTY |
X(2) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 798 |
1 |
1 |
1 |
1 |
1 |
CRX079 |
MEDICARE-HIC-NUM |
X(12) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX079 |
MEDICARE-HIC-NUM |
X(12) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 799 |
1 |
1 |
1 |
1 |
1 |
CRX081 |
REMITTANCE-NUM |
X(30) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX081 |
REMITTANCE-NUM |
X(30) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 800 |
1 |
1 |
1 |
1 |
1 |
CRX082 |
BORDER-STATE-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX082 |
BORDER-STATE-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 801 |
1 |
1 |
1 |
1 |
1 |
CRX084 |
DATE-PRESCRIBED |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX084 |
DATE-PRESCRIBED |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 802 |
1 |
1 |
1 |
1 |
1 |
CRX085 |
PRESCRIPTION-FILL-DATE |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX085 |
PRESCRIPTION-FILL-DATE |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 803 |
1 |
1 |
1 |
1 |
1 |
CRX086 |
COMPOUND-DRUG-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX086 |
COMPOUND-DRUG-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 804 |
1 |
1 |
1 |
1 |
1 |
CRX087 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX087 |
BENEFICIARY-COINSURANCE-AMOUNT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 805 |
1 |
1 |
1 |
1 |
1 |
CRX089 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX089 |
BENEFICIARY-COPAYMENT-AMOUNT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 806 |
1 |
1 |
1 |
1 |
1 |
CRX090 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX090 |
BENEFICIARY-COPAYMENT-DATE-PAID |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 807 |
1 |
1 |
1 |
1 |
1 |
CRX088 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX088 |
BENEFICIARY-COINSURANCE-DATE-PAID |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 808 |
1 |
1 |
1 |
1 |
1 |
CRX092 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX092 |
BENEFICIARY-DEDUCTIBLE-AMOUNT |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 809 |
1 |
1 |
1 |
1 |
1 |
CRX093 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX093 |
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 810 |
1 |
1 |
1 |
1 |
1 |
CRX094 |
CLAIM-DENIED-INDICATOR |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX094 |
CLAIM-DENIED-INDICATOR |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 811 |
1 |
1 |
1 |
1 |
1 |
CRX095 |
COPAY-WAIVED-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX095 |
COPAY-WAIVED-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 812 |
1 |
1 |
1 |
1 |
1 |
CRX096 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX096 |
HEALTH-HOME-ENTITY-NAME |
X(50) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 813 |
1 |
1 |
1 |
1 |
1 |
CRX098 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX098 |
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 814 |
1 |
1 |
1 |
1 |
1 |
CRX099 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX099 |
THIRD-PARTY-COINSURANCE-DATE-PAID |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 815 |
1 |
1 |
1 |
1 |
1 |
CRX100 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX100 |
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
S9(11)V99 |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 816 |
1 |
1 |
1 |
1 |
1 |
CRX101 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX101 |
THIRD-PARTY-COPAYMENT-DATE-PAID |
9(8) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 817 |
1 |
1 |
1 |
1 |
1 |
CRX102 |
DISPENSING-PRESCRIPTION-DRUG-PROV-NPI |
X(10) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX102 |
DISPENSING-PRESCRIPTION-DRUG-PROV-NPI |
X(10) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 818 |
1 |
1 |
1 |
1 |
1 |
CRX103 |
DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY |
X(12) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX103 |
DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY |
X(12) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 819 |
1 |
1 |
1 |
1 |
1 |
CRX104 |
HEALTH-HOME-PROVIDER-NPI |
X(10) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX104 |
HEALTH-HOME-PROVIDER-NPI |
X(10) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 820 |
1 |
1 |
1 |
1 |
1 |
CRX105 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX105 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 821 |
1 |
1 |
1 |
1 |
1 |
CRX106 |
STATE-NOTATION |
X(500) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX106 |
STATE-NOTATION |
X(500) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 822 |
1 |
1 |
1 |
1 |
1 |
CRX156 |
DISPENSING-PRESCRIPTION-DRUG-PROV-NUM |
X(30) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX156 |
DISPENSING-PRESCRIPTION-DRUG-PROV-NUM |
X(30) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 823 |
1 |
1 |
1 |
1 |
1 |
CRX160 |
MEDICARE-COMB-DED-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX160 |
MEDICARE-COMB-DED-IND |
X(1) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 824 |
1 |
1 |
1 |
1 |
1 |
CRX161 |
PROV-LOCATION-ID |
X(5) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX161 |
PROV-LOCATION-ID |
X(5) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 825 |
1 |
1 |
0 |
1 |
1 |
CRX107 |
FILLER |
X(44) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
CRX107 |
FILLER |
X(43) |
CLAIMRX |
CLAIM-HEADER-RECORD-RX-CRX00002 |
| 826 |
1 |
1 |
1 |
1 |
1 |
CRX108 |
RECORD-ID |
X(8) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX108 |
RECORD-ID |
X(8) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 827 |
1 |
1 |
1 |
1 |
1 |
CRX109 |
SUBMITTING-STATE |
X(2) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX109 |
SUBMITTING-STATE |
X(2) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 828 |
1 |
1 |
1 |
1 |
1 |
CRX110 |
RECORD-NUMBER |
9(11) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX110 |
RECORD-NUMBER |
9(11) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 829 |
1 |
1 |
1 |
1 |
1 |
CRX111 |
MSIS-IDENTIFICATION-NUM |
X(20) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX111 |
MSIS-IDENTIFICATION-NUM |
X(20) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 830 |
NA |
NA |
NA |
NA |
NA |
|
|
|
|
|
CRX111 |
MSIS-IDENTIFICATION-NUM |
X(20) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 831 |
1 |
1 |
1 |
1 |
1 |
CRX112 |
ICN-ORIG |
X(50) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX112 |
ICN-ORIG |
X(50) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 832 |
1 |
1 |
1 |
1 |
1 |
CRX113 |
ICN-ADJ |
X(50) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX113 |
ICN-ADJ |
X(50) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 833 |
1 |
1 |
1 |
1 |
1 |
CRX114 |
LINE-NUM-ORIG |
X(3) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX114 |
LINE-NUM-ORIG |
X(3) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 834 |
1 |
1 |
1 |
1 |
1 |
CRX115 |
LINE-NUM-ADJ |
X(3) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX115 |
LINE-NUM-ADJ |
X(3) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 835 |
1 |
1 |
1 |
1 |
1 |
CRX116 |
LINE-ADJUSTMENT-IND |
X(1) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX116 |
LINE-ADJUSTMENT-IND |
X(1) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 836 |
1 |
1 |
1 |
1 |
1 |
CRX117 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX117 |
LINE-ADJUSTMENT-REASON-CODE |
X(3) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 837 |
1 |
1 |
1 |
1 |
1 |
CRX118 |
SUBMITTER-ID |
X(12) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX118 |
SUBMITTER-ID |
X(12) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 838 |
1 |
1 |
1 |
1 |
1 |
CRX119 |
CLAIM-LINE-STATUS |
X(3) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX119 |
CLAIM-LINE-STATUS |
X(3) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 839 |
1 |
1 |
0 |
1 |
1 |
CRX120 |
NATIONAL-DRUG-CODE |
X(12) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX120 |
NATIONAL-DRUG-CODE |
X(11) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 840 |
1 |
1 |
1 |
1 |
1 |
CRX121 |
BILLED-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX121 |
BILLED-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 841 |
1 |
1 |
1 |
1 |
1 |
CRX122 |
ALLOWED-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX122 |
ALLOWED-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 842 |
1 |
1 |
1 |
1 |
1 |
CRX123 |
COPAY-AMT |
S9(5)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX123 |
COPAY-AMT |
S9(5)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 843 |
1 |
1 |
1 |
1 |
1 |
CRX124 |
TPL-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX124 |
TPL-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 844 |
1 |
1 |
1 |
1 |
1 |
CRX125 |
MEDICAID-PAID-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX125 |
MEDICAID-PAID-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 845 |
1 |
1 |
1 |
1 |
1 |
CRX126 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX126 |
MEDICAID-FFS-EQUIVALENT-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 846 |
1 |
1 |
1 |
1 |
1 |
CRX127 |
MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX127 |
MEDICARE-DEDUCTIBLE-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 847 |
1 |
1 |
1 |
1 |
1 |
CRX128 |
MEDICARE-COINS-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX128 |
MEDICARE-COINS-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 848 |
1 |
1 |
1 |
1 |
1 |
CRX129 |
MEDICARE-PAID-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX129 |
MEDICARE-PAID-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 849 |
1 |
1 |
1 |
1 |
1 |
CRX131 |
OT-RX-CLAIM-QUANTITY-ALLOWED |
S9(6)V999 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX131 |
OT-RX-CLAIM-QUANTITY-ALLOWED |
S9(6)V999 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 850 |
1 |
1 |
1 |
1 |
1 |
CRX132 |
OT-RX-CLAIM-QUANTITY-ACTUAL |
S9(6)V999 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX132 |
OT-RX-CLAIM-QUANTITY-ACTUAL |
S9(6)V999 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 851 |
1 |
1 |
1 |
1 |
1 |
CRX133 |
UNIT-OF-MEASURE |
X(2) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX133 |
UNIT-OF-MEASURE |
X(2) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 852 |
1 |
1 |
1 |
1 |
1 |
CRX134 |
TYPE-OF-SERVICE |
X(3) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX134 |
TYPE-OF-SERVICE |
X(3) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 853 |
1 |
1 |
1 |
1 |
1 |
CRX135 |
HCBS-SERVICE-CODE |
X(1) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX135 |
HCBS-SERVICE-CODE |
X(1) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 854 |
1 |
1 |
1 |
1 |
1 |
CRX136 |
HCBS-TAXONOMY |
X(5) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX136 |
HCBS-TAXONOMY |
X(5) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 855 |
1 |
1 |
1 |
1 |
1 |
CRX137 |
OTHER-TPL-COLLECTION |
X(3) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX137 |
OTHER-TPL-COLLECTION |
X(3) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 856 |
1 |
1 |
1 |
1 |
1 |
CRX138 |
DAYS-SUPPLY |
S9(5) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX138 |
DAYS-SUPPLY |
S9(5) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 857 |
1 |
1 |
1 |
1 |
1 |
CRX139 |
NEW-REFILL-IND |
X(2) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX139 |
NEW-REFILL-IND |
X(2) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 858 |
1 |
1 |
1 |
1 |
1 |
CRX140 |
BRAND-GENERIC-IND |
X(1) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX140 |
BRAND-GENERIC-IND |
X(1) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 859 |
1 |
1 |
1 |
1 |
1 |
CRX141 |
DISPENSE-FEE |
S9(6)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX141 |
DISPENSE-FEE |
S9(6)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 860 |
1 |
1 |
1 |
1 |
1 |
CRX142 |
PRESCRIPTION-NUM |
X(12) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX142 |
PRESCRIPTION-NUM |
X(12) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 861 |
1 |
1 |
1 |
1 |
1 |
CRX143 |
DRUG-UTILIZATION-CODE |
X(6) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX143 |
DRUG-UTILIZATION-CODE |
X(6) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 862 |
1 |
1 |
1 |
1 |
1 |
CRX144 |
DTL-METRIC-DEC-QTY |
S9(7)V999 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX144 |
DTL-METRIC-DEC-QTY |
S9(7)V999 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 863 |
1 |
1 |
1 |
1 |
1 |
CRX145 |
COMPOUND-DOSAGE-FORM |
X(2) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX145 |
COMPOUND-DOSAGE-FORM |
X(2) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 864 |
1 |
1 |
1 |
1 |
1 |
CRX146 |
REBATE-ELIGIBLE-INDICATOR |
X(1) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX146 |
REBATE-ELIGIBLE-INDICATOR |
X(1) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 865 |
1 |
1 |
1 |
1 |
1 |
CRX147 |
IMMUNIZATION-TYPE |
X(2) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX147 |
IMMUNIZATION-TYPE |
X(2) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 866 |
1 |
1 |
1 |
1 |
1 |
CRX148 |
BENEFIT-TYPE |
X(3) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX148 |
BENEFIT-TYPE |
X(3) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 867 |
1 |
1 |
1 |
1 |
1 |
CRX149 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX149 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
X(2) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 868 |
1 |
1 |
1 |
1 |
1 |
CRX150 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX150 |
XIX-MBESCBES-CATEGORY-OF-SERVICE |
X(4) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 869 |
1 |
1 |
1 |
1 |
1 |
CRX151 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX151 |
XXI-MBESCBES-CATEGORY-OF-SERVICE |
X(3) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 870 |
1 |
1 |
1 |
1 |
1 |
CRX152 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX152 |
OTHER-INSURANCE-AMT |
S9(11)V99 |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 871 |
1 |
1 |
1 |
1 |
1 |
CRX153 |
STATE-NOTATION |
X(500) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX153 |
STATE-NOTATION |
X(500) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 872 |
1 |
1 |
1 |
1 |
1 |
CRX157 |
ADJUDICATION-DATE |
9(8) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX157 |
ADJUDICATION-DATE |
9(8) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 873 |
1 |
1 |
1 |
1 |
1 |
CRX158 |
SELF-DIRECTION-TYPE |
X(3) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX158 |
SELF-DIRECTION-TYPE |
X(3) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 874 |
1 |
1 |
1 |
1 |
1 |
CRX159 |
PRE-AUTHORIZATION-NUM |
X(18) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX159 |
PRE-AUTHORIZATION-NUM |
X(18) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 875 |
1 |
1 |
1 |
1 |
1 |
CRX154 |
FILLER |
X(526) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
CRX154 |
FILLER |
X(526) |
CLAIMRX |
CLAIM-LINE-RECORD-RX-CRX00003 |
| 876 |
1 |
1 |
1 |
1 |
1 |
ELG001 |
RECORD-ID |
X(8) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG001 |
RECORD-ID |
X(8) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 877 |
1 |
1 |
1 |
1 |
1 |
ELG002 |
DATA-DICTIONARY-VERSION |
X(10) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG002 |
DATA-DICTIONARY-VERSION |
X(10) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 878 |
1 |
1 |
1 |
1 |
1 |
ELG003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 879 |
1 |
1 |
1 |
1 |
1 |
ELG004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 880 |
1 |
1 |
1 |
1 |
1 |
ELG005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 881 |
1 |
1 |
1 |
1 |
1 |
ELG006 |
FILE-NAME |
X(8) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG006 |
FILE-NAME |
X(8) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 882 |
1 |
1 |
1 |
1 |
1 |
ELG007 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG007 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 883 |
1 |
1 |
1 |
1 |
1 |
ELG008 |
DATE-FILE-CREATED |
9(8) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG008 |
DATE-FILE-CREATED |
9(8) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 884 |
1 |
1 |
1 |
1 |
1 |
ELG009 |
START-OF-TIME-PERIOD |
9(8) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG009 |
START-OF-TIME-PERIOD |
9(8) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 885 |
1 |
1 |
1 |
1 |
1 |
ELG010 |
END-OF-TIME-PERIOD |
9(8) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG010 |
END-OF-TIME-PERIOD |
9(8) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 886 |
1 |
1 |
1 |
1 |
1 |
ELG011 |
FILE-STATUS-INDICATOR |
X(1) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG011 |
FILE-STATUS-INDICATOR |
X(1) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 887 |
1 |
1 |
1 |
1 |
1 |
ELG012 |
SSN-INDICATOR |
X(1) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG012 |
SSN-INDICATOR |
X(1) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 888 |
1 |
1 |
1 |
1 |
1 |
ELG013 |
TOT-REC-CNT |
9(11) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG013 |
TOT-REC-CNT |
9(11) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 889 |
1 |
1 |
1 |
1 |
1 |
ELG247 |
SEQUENCE-NUMBER |
X(4) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG247 |
SEQUENCE-NUMBER |
X(4) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 890 |
1 |
1 |
1 |
1 |
1 |
ELG014 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG014 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 891 |
1 |
1 |
1 |
1 |
1 |
ELG015 |
FILLER |
X(418) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
ELG015 |
FILLER |
X(418) |
ELIGIBLE |
FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| 892 |
1 |
1 |
1 |
1 |
1 |
ELG016 |
RECORD-ID |
X(8) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG016 |
RECORD-ID |
X(8) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 893 |
1 |
1 |
1 |
1 |
1 |
ELG017 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG017 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 894 |
1 |
1 |
1 |
1 |
1 |
ELG018 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG018 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 895 |
1 |
1 |
1 |
1 |
1 |
ELG019 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG019 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 896 |
1 |
1 |
1 |
1 |
1 |
ELG020 |
ELIGIBLE-FIRST-NAME |
X(30) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG020 |
ELIGIBLE-FIRST-NAME |
X(30) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 897 |
1 |
1 |
1 |
1 |
1 |
ELG021 |
ELIGIBLE-LAST-NAME |
X(30) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG021 |
ELIGIBLE-LAST-NAME |
X(30) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 898 |
1 |
1 |
1 |
1 |
1 |
ELG022 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG022 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 899 |
1 |
1 |
1 |
1 |
1 |
ELG023 |
SEX |
X(1) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG023 |
SEX |
X(1) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 900 |
1 |
1 |
1 |
1 |
1 |
ELG024 |
DATE-OF-BIRTH |
9(8) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG024 |
DATE-OF-BIRTH |
9(8) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 901 |
1 |
1 |
1 |
1 |
1 |
ELG025 |
DATE-OF-DEATH |
9(8) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG025 |
DATE-OF-DEATH |
9(8) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 902 |
1 |
1 |
1 |
1 |
1 |
ELG026 |
PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE |
9(8) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG026 |
PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE |
9(8) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 903 |
1 |
1 |
1 |
1 |
1 |
ELG027 |
PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE |
9(8) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG027 |
PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE |
9(8) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 904 |
1 |
1 |
1 |
1 |
1 |
ELG028 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG028 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 905 |
1 |
1 |
1 |
1 |
1 |
ELG029 |
FILLER |
X(365) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
ELG029 |
FILLER |
X(365) |
ELIGIBLE |
PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| 906 |
1 |
1 |
1 |
1 |
1 |
ELG030 |
RECORD-ID |
X(8) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG030 |
RECORD-ID |
X(8) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 907 |
1 |
1 |
1 |
1 |
1 |
ELG031 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG031 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 908 |
1 |
1 |
1 |
1 |
1 |
ELG032 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG032 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 909 |
1 |
1 |
1 |
1 |
1 |
ELG033 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG033 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 910 |
1 |
1 |
1 |
1 |
1 |
ELG034 |
MARITAL-STATUS |
X(2) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG034 |
MARITAL-STATUS |
X(2) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 911 |
1 |
1 |
1 |
1 |
1 |
ELG035 |
MARITAL-STATUS-OTHER-EXPLANATION |
X(50) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG035 |
MARITAL-STATUS-OTHER-EXPLANATION |
X(50) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 912 |
1 |
1 |
1 |
1 |
1 |
ELG036 |
SSN |
9(9) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG036 |
SSN |
9(9) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 913 |
1 |
1 |
1 |
1 |
1 |
ELG037 |
SSN-VERIFICATION-FLAG |
X(1) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG037 |
SSN-VERIFICATION-FLAG |
X(1) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 914 |
1 |
1 |
1 |
1 |
1 |
ELG038 |
INCOME-CODE |
X(2) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG038 |
INCOME-CODE |
X(2) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 915 |
1 |
1 |
1 |
1 |
1 |
ELG039 |
VETERAN-IND |
X(1) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG039 |
VETERAN-IND |
X(1) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 916 |
1 |
1 |
1 |
1 |
1 |
ELG040 |
CITIZENSHIP-IND |
X(1) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG040 |
CITIZENSHIP-IND |
X(1) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 917 |
1 |
1 |
1 |
1 |
1 |
ELG041 |
CITIZENSHIP-VERIFICATION-FLAG |
X(1) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG041 |
CITIZENSHIP-VERIFICATION-FLAG |
X(1) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 918 |
1 |
1 |
1 |
1 |
1 |
ELG042 |
IMMIGRATION-STATUS |
X(1) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG042 |
IMMIGRATION-STATUS |
X(1) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 919 |
1 |
1 |
1 |
1 |
1 |
ELG043 |
IMMIGRATION-VERIFICATION-FLAG |
X(1) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG043 |
IMMIGRATION-VERIFICATION-FLAG |
X(1) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 920 |
1 |
1 |
1 |
1 |
1 |
ELG044 |
IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE |
9(8) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG044 |
IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE |
9(8) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 921 |
1 |
1 |
1 |
1 |
1 |
ELG045 |
PRIMARY-LANGUAGE-ENGL-PROF-CODE |
X(1) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG045 |
PRIMARY-LANGUAGE-ENGL-PROF-CODE |
X(1) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 922 |
1 |
1 |
1 |
1 |
1 |
ELG046 |
PRIMARY-LANGUAGE-CODE |
X(3) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG046 |
PRIMARY-LANGUAGE-CODE |
X(3) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 923 |
1 |
1 |
1 |
1 |
1 |
ELG047 |
HOUSEHOLD-SIZE |
X(2) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG047 |
HOUSEHOLD-SIZE |
X(2) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 924 |
1 |
1 |
1 |
1 |
1 |
ELG049 |
PREGNANCY-IND |
X(1) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG049 |
PREGNANCY-IND |
X(1) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 925 |
1 |
1 |
1 |
1 |
1 |
ELG050 |
MEDICARE-HIC-NUM |
X(12) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG050 |
MEDICARE-HIC-NUM |
X(12) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 926 |
1 |
1 |
1 |
1 |
1 |
ELG051 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG051 |
MEDICARE-BENEFICIARY-IDENTIFIER |
X(12) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 927 |
1 |
1 |
1 |
1 |
1 |
ELG054 |
CHIP-CODE |
X(1) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG054 |
CHIP-CODE |
X(1) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 928 |
1 |
1 |
1 |
1 |
1 |
ELG057 |
VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE |
9(8) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG057 |
VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE |
9(8) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 929 |
1 |
1 |
1 |
1 |
1 |
ELG058 |
VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE |
9(8) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG058 |
VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE |
9(8) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 930 |
1 |
1 |
1 |
1 |
1 |
ELG059 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG059 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 931 |
1 |
1 |
1 |
1 |
1 |
ELG060 |
FILLER |
X(334) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
ELG060 |
FILLER |
X(334) |
ELIGIBLE |
VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 932 |
1 |
1 |
1 |
1 |
0 |
ELG061 |
RECORD-ID |
X(8) |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG061 |
RECORD-ID |
X(8) |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 933 |
1 |
1 |
1 |
1 |
0 |
ELG062 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG062 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 934 |
1 |
1 |
1 |
1 |
0 |
ELG063 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG063 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 935 |
1 |
1 |
1 |
1 |
0 |
ELG064 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG064 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 936 |
1 |
0 |
1 |
1 |
0 |
ELG065 |
ELIGIBLE-ADDR-TYPE |
X(2) |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG065 |
ADDR-TYPE |
X(2) |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 937 |
1 |
1 |
1 |
1 |
0 |
ELG066 |
ELIGIBLE-ADDR-LN1 |
X(60) |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG066 |
ELIGIBLE-ADDR-LN1 |
X(60) |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 938 |
1 |
1 |
1 |
1 |
0 |
ELG067 |
ELIGIBLE-ADDR-LN2 |
X(60) |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG067 |
ELIGIBLE-ADDR-LN2 |
X(60) |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 939 |
1 |
1 |
1 |
1 |
0 |
ELG068 |
ELIGIBLE-ADDR-LN3 |
X(60) |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG068 |
ELIGIBLE-ADDR-LN3 |
X(60) |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 940 |
1 |
1 |
1 |
1 |
0 |
ELG069 |
ELIGIBLE-CITY |
X(28) |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG069 |
ELIGIBLE-CITY |
X(28) |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 941 |
1 |
1 |
1 |
1 |
0 |
ELG070 |
ELIGIBLE-STATE |
X(2) |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG070 |
ELIGIBLE-STATE |
X(2) |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 942 |
1 |
1 |
1 |
1 |
0 |
ELG071 |
ELIGIBLE-ZIP-CODE |
X(9) |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG071 |
ELIGIBLE-ZIP-CODE |
X(9) |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 943 |
1 |
1 |
1 |
1 |
0 |
ELG072 |
ELIGIBLE-COUNTY-CODE |
X(3) |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG072 |
ELIGIBLE-COUNTY-CODE |
X(3) |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 944 |
1 |
1 |
1 |
1 |
0 |
ELG073 |
ELIGIBLE-PHONE-NUM |
X(10) |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG073 |
ELIGIBLE-PHONE-NUM |
X(10) |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 945 |
1 |
1 |
1 |
1 |
0 |
ELG074 |
TYPE-OF-LIVING-ARRANGEMENT |
X(100) |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG074 |
TYPE-OF-LIVING-ARRANGEMENT |
X(100) |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 946 |
1 |
1 |
1 |
1 |
0 |
ELG075 |
ELIGIBLE-ADDR-EFF-DATE |
9(8) |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG075 |
ELIGIBLE-ADDR-EFF-DATE |
9(8) |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 947 |
1 |
1 |
1 |
1 |
0 |
ELG076 |
ELIGIBLE-ADDR-END-DATE |
9(8) |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG076 |
ELIGIBLE-ADDR-END-DATE |
9(8) |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 948 |
1 |
1 |
1 |
1 |
0 |
ELG077 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG077 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 949 |
1 |
1 |
1 |
1 |
0 |
ELG078 |
FILLER |
X(109) |
ELIGIBLE |
ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
ELG078 |
FILLER |
X(109) |
ELIGIBLE |
ELIGIBILE-CONTACT-INFORMATION-ELG00004 |
| 950 |
1 |
1 |
1 |
1 |
1 |
ELG079 |
RECORD-ID |
X(8) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG079 |
RECORD-ID |
X(8) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 951 |
1 |
1 |
1 |
1 |
1 |
ELG080 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG080 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 952 |
1 |
1 |
1 |
1 |
1 |
ELG081 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG081 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 953 |
1 |
1 |
1 |
1 |
1 |
ELG082 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG082 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 954 |
1 |
1 |
1 |
1 |
1 |
ELG083 |
MSIS-CASE-NUM |
X(12) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG083 |
MSIS-CASE-NUM |
X(12) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 955 |
1 |
1 |
1 |
1 |
1 |
ELG084 |
MEDICAID-BASIS-OF-ELIGIBILITY |
X(2) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG084 |
MEDICAID-BASIS-OF-ELIGIBILITY |
X(2) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 956 |
1 |
1 |
1 |
1 |
1 |
ELG085 |
DUAL-ELIGIBLE-CODE |
X(2) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG085 |
DUAL-ELIGIBLE-CODE |
X(2) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 957 |
1 |
1 |
1 |
1 |
1 |
ELG086 |
PRIMARY-ELIGIBILITY-GROUP-IND |
X(1) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG086 |
PRIMARY-ELIGIBILITY-GROUP-IND |
X(1) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 958 |
1 |
1 |
1 |
1 |
1 |
ELG087 |
ELIGIBILITY-GROUP |
X(2) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG087 |
ELIGIBILITY-GROUP |
X(2) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 959 |
1 |
1 |
1 |
1 |
1 |
ELG088 |
LEVEL-OF-CARE-STATUS |
X(3) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG088 |
LEVEL-OF-CARE-STATUS |
X(3) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 960 |
1 |
1 |
1 |
1 |
1 |
ELG089 |
SSDI-IND |
X(1) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG089 |
SSDI-IND |
X(1) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 961 |
1 |
1 |
1 |
1 |
1 |
ELG090 |
SSI-IND |
X(1) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG090 |
SSI-IND |
X(1) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 962 |
1 |
1 |
1 |
1 |
1 |
ELG091 |
SSI-STATE-SUPPLEMENT-STATUS-CODE |
X(3) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG091 |
SSI-STATE-SUPPLEMENT-STATUS-CODE |
X(3) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 963 |
1 |
1 |
1 |
1 |
1 |
ELG092 |
SSI-STATUS |
X(3) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG092 |
SSI-STATUS |
X(3) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 964 |
1 |
1 |
1 |
1 |
1 |
ELG093 |
STATE-SPEC-ELIG-GROUP |
X(6) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG093 |
STATE-SPEC-ELIG-GROUP |
X(6) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 965 |
1 |
1 |
1 |
1 |
1 |
ELG094 |
CONCEPTION-TO-BIRTH-IND |
X(1) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG094 |
CONCEPTION-TO-BIRTH-IND |
X(1) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 966 |
1 |
1 |
1 |
1 |
1 |
ELG095 |
ELIGIBILITY-CHANGE-REASON |
X(2) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG095 |
ELIGIBILITY-CHANGE-REASON |
X(2) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 967 |
1 |
1 |
1 |
1 |
1 |
ELG096 |
MAINTENANCE-ASSISTANCE-STATUS |
X(1) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG096 |
MAINTENANCE-ASSISTANCE-STATUS |
X(1) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 968 |
1 |
1 |
1 |
1 |
1 |
ELG097 |
RESTRICTED-BENEFITS-CODE |
X(1) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG097 |
RESTRICTED-BENEFITS-CODE |
X(1) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 969 |
1 |
1 |
1 |
1 |
1 |
ELG098 |
TANF-CASH-CODE |
X(1) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG098 |
TANF-CASH-CODE |
X(1) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 970 |
1 |
1 |
1 |
1 |
1 |
ELG099 |
ELIGIBILITY-DETERMINANT-EFF-DATE |
9(8) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG099 |
ELIGIBILITY-DETERMINANT-EFF-DATE |
9(8) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 971 |
1 |
1 |
1 |
1 |
1 |
ELG100 |
ELIGIBILITY-DETERMINANT-END-DATE |
9(8) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG100 |
ELIGIBILITY-DETERMINANT-END-DATE |
9(8) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 972 |
1 |
1 |
1 |
1 |
1 |
ELG101 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG101 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 973 |
1 |
1 |
1 |
1 |
1 |
ELG102 |
FILLER |
X(401) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
ELG102 |
FILLER |
X(401) |
ELIGIBLE |
ELIGIBILITY-DETERMINANTS-ELG00005 |
| 974 |
1 |
1 |
1 |
1 |
1 |
ELG103 |
RECORD-ID |
X(8) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG103 |
RECORD-ID |
X(8) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 975 |
1 |
1 |
1 |
1 |
1 |
ELG104 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG104 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 976 |
1 |
1 |
1 |
1 |
1 |
ELG105 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG105 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 977 |
1 |
1 |
1 |
1 |
1 |
ELG106 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG106 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 978 |
1 |
1 |
1 |
1 |
1 |
ELG107 |
HEALTH-HOME-SPA-NAME |
X(100) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG107 |
HEALTH-HOME-SPA-NAME |
X(100) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 979 |
1 |
1 |
1 |
1 |
1 |
ELG108 |
HEALTH-HOME-ENTITY-NAME |
X(100) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG108 |
HEALTH-HOME-ENTITY-NAME |
X(100) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 980 |
1 |
1 |
1 |
1 |
1 |
ELG109 |
HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE |
9(8) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG109 |
HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE |
9(8) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 981 |
1 |
1 |
1 |
1 |
1 |
ELG110 |
HEALTH-HOME-SPA-PARTICIPATION-END-DATE |
9(8) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG110 |
HEALTH-HOME-SPA-PARTICIPATION-END-DATE |
9(8) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 982 |
1 |
1 |
1 |
1 |
1 |
ELG111 |
HEALTH-HOME-ENTITY-EFF-DATE |
9(8) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG111 |
HEALTH-HOME-ENTITY-EFF-DATE |
9(8) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 983 |
1 |
1 |
1 |
1 |
1 |
ELG112 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG112 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 984 |
1 |
1 |
1 |
1 |
1 |
ELG113 |
FILLER |
X(235) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
ELG113 |
FILLER |
X(235) |
ELIGIBLE |
HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| 985 |
1 |
1 |
1 |
1 |
1 |
ELG114 |
RECORD-ID |
X(8) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG114 |
RECORD-ID |
X(8) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 986 |
1 |
1 |
1 |
1 |
1 |
ELG115 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG115 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 987 |
1 |
1 |
1 |
1 |
1 |
ELG116 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG116 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 988 |
1 |
1 |
1 |
1 |
1 |
ELG117 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG117 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 989 |
1 |
1 |
1 |
1 |
1 |
ELG118 |
HEALTH-HOME-SPA-NAME |
X(100) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG118 |
HEALTH-HOME-SPA-NAME |
X(100) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 990 |
1 |
1 |
1 |
1 |
1 |
ELG119 |
HEALTH-HOME-ENTITY-NAME |
X(100) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG119 |
HEALTH-HOME-ENTITY-NAME |
X(100) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 991 |
1 |
1 |
1 |
1 |
1 |
ELG120 |
HEALTH-HOME-PROV-NUM |
X(30) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG120 |
HEALTH-HOME-PROV-NUM |
X(30) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 992 |
1 |
1 |
1 |
1 |
1 |
ELG121 |
HEALTH-HOME-SPA-PROVIDER-EFF-DATE |
9(8) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG121 |
HEALTH-HOME-SPA-PROVIDER-EFF-DATE |
9(8) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 993 |
1 |
1 |
1 |
1 |
1 |
ELG122 |
HEALTH-HOME-SPA-PROVIDER-END-DATE |
9(8) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG122 |
HEALTH-HOME-SPA-PROVIDER-END-DATE |
9(8) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 994 |
1 |
1 |
1 |
1 |
1 |
ELG123 |
HEALTH-HOME-ENTITY-EFF-DATE |
9(8) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG123 |
HEALTH-HOME-ENTITY-EFF-DATE |
9(8) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 995 |
1 |
1 |
1 |
1 |
1 |
ELG124 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG124 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 996 |
1 |
1 |
1 |
1 |
1 |
ELG125 |
FILLER |
X(205) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
ELG125 |
FILLER |
X(205) |
ELIGIBLE |
HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| 997 |
1 |
1 |
1 |
1 |
1 |
ELG126 |
RECORD-ID |
X(8) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG126 |
RECORD-ID |
X(8) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 998 |
1 |
1 |
1 |
1 |
1 |
ELG127 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG127 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 999 |
1 |
1 |
1 |
1 |
1 |
ELG128 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG128 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 1,000 |
1 |
1 |
1 |
1 |
1 |
ELG129 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG129 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 1,001 |
1 |
1 |
1 |
1 |
1 |
ELG130 |
HEALTH-HOME-CHRONIC-CONDITION |
X(1) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG130 |
HEALTH-HOME-CHRONIC-CONDITION |
X(1) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 1,002 |
1 |
1 |
1 |
1 |
1 |
ELG131 |
HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION |
X(50) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG131 |
HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION |
X(50) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 1,003 |
1 |
1 |
1 |
1 |
1 |
ELG132 |
HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE |
9(8) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG132 |
HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE |
9(8) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 1,004 |
1 |
1 |
1 |
1 |
1 |
ELG133 |
HEALTH-HOME-CHRONIC-CONDITION-END-DATE |
9(8) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG133 |
HEALTH-HOME-CHRONIC-CONDITION-END-DATE |
9(8) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 1,005 |
1 |
1 |
1 |
1 |
1 |
ELG134 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG134 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 1,006 |
1 |
1 |
1 |
1 |
1 |
ELG135 |
FILLER |
X(392) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
ELG135 |
FILLER |
X(392) |
ELIGIBLE |
HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| 1,007 |
1 |
1 |
1 |
1 |
1 |
ELG136 |
RECORD-ID |
X(8) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG136 |
RECORD-ID |
X(8) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,008 |
1 |
1 |
1 |
1 |
1 |
ELG137 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG137 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,009 |
1 |
1 |
1 |
1 |
1 |
ELG138 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG138 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,010 |
1 |
1 |
1 |
1 |
1 |
ELG139 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG139 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,011 |
1 |
1 |
1 |
1 |
1 |
ELG140 |
LOCKIN-PROV-NUM |
X(30) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG140 |
LOCKIN-PROV-NUM |
X(30) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,012 |
1 |
1 |
1 |
1 |
1 |
ELG141 |
LOCKIN-PROV-TYPE |
X(2) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG141 |
LOCKIN-PROV-TYPE |
X(2) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,013 |
1 |
1 |
1 |
1 |
1 |
ELG142 |
LOCKIN-EFF-DATE |
9(8) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG142 |
LOCKIN-EFF-DATE |
9(8) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,014 |
1 |
1 |
1 |
1 |
1 |
ELG143 |
LOCKIN-END-DATE |
9(8) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG143 |
LOCKIN-END-DATE |
9(8) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,015 |
1 |
1 |
1 |
1 |
1 |
ELG144 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG144 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,016 |
1 |
1 |
1 |
1 |
1 |
ELG145 |
FILLER |
X(411) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
ELG145 |
FILLER |
X(411) |
ELIGIBLE |
LOCK-IN-INFORMATION-ELG00009 |
| 1,017 |
1 |
1 |
1 |
1 |
1 |
ELG146 |
RECORD-ID |
X(8) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG146 |
RECORD-ID |
X(8) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,018 |
1 |
1 |
1 |
1 |
1 |
ELG147 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG147 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,019 |
1 |
1 |
1 |
1 |
1 |
ELG148 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG148 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,020 |
1 |
1 |
1 |
1 |
1 |
ELG149 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG149 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,021 |
1 |
1 |
1 |
1 |
1 |
ELG150 |
MFP-LIVES-WITH-FAMILY |
X(1) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG150 |
MFP-LIVES-WITH-FAMILY |
X(1) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,022 |
1 |
1 |
1 |
1 |
1 |
ELG151 |
MFP-QUALIFIED-INSTITUTION |
X(2) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG151 |
MFP-QUALIFIED-INSTITUTION |
X(2) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,023 |
1 |
1 |
1 |
1 |
1 |
ELG152 |
MFP-QUALIFIED-RESIDENCE |
X(2) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG152 |
MFP-QUALIFIED-RESIDENCE |
X(2) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,024 |
1 |
1 |
1 |
1 |
1 |
ELG153 |
MFP-REASON-PARTICIPATION-ENDED |
X(2) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG153 |
MFP-REASON-PARTICIPATION-ENDED |
X(2) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,025 |
1 |
1 |
1 |
1 |
1 |
ELG154 |
MFP-REINSTITUTIONALIZED-REASON |
X(2) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG154 |
MFP-REINSTITUTIONALIZED-REASON |
X(2) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,026 |
1 |
1 |
1 |
1 |
1 |
ELG155 |
MFP-ENROLLMENT-EFF-DATE |
9(8) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG155 |
MFP-ENROLLMENT-EFF-DATE |
9(8) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,027 |
1 |
1 |
1 |
1 |
1 |
ELG156 |
MFP-ENROLLMENT-END-DATE |
9(8) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG156 |
MFP-ENROLLMENT-END-DATE |
9(8) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,028 |
1 |
1 |
1 |
1 |
1 |
ELG157 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG157 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,029 |
1 |
1 |
1 |
1 |
1 |
ELG158 |
FILLER |
X(434) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
ELG158 |
FILLER |
X(434) |
ELIGIBLE |
MFP-INFORMATION-ELG00010 |
| 1,030 |
1 |
1 |
1 |
1 |
1 |
ELG159 |
RECORD-ID |
X(8) |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
ELG159 |
RECORD-ID |
X(8) |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| 1,031 |
1 |
1 |
1 |
1 |
1 |
ELG160 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
ELG160 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| 1,032 |
1 |
1 |
1 |
1 |
1 |
ELG161 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
ELG161 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| 1,033 |
1 |
1 |
1 |
1 |
1 |
ELG162 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
ELG162 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| 1,034 |
1 |
1 |
1 |
1 |
1 |
ELG163 |
STATE-PLAN-OPTION-TYPE |
X(2) |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
ELG163 |
STATE-PLAN-OPTION-TYPE |
X(2) |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| 1,035 |
1 |
1 |
1 |
1 |
1 |
ELG164 |
STATE-PLAN-OPTION-EFF-DATE |
9(8) |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
ELG164 |
STATE-PLAN-OPTION-EFF-DATE |
9(8) |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| 1,036 |
1 |
1 |
1 |
1 |
1 |
ELG165 |
STATE-PLAN-OPTION-END-DATE |
9(8) |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
ELG165 |
STATE-PLAN-OPTION-END-DATE |
9(8) |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| 1,037 |
1 |
1 |
1 |
1 |
1 |
ELG166 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
ELG166 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| 1,038 |
1 |
1 |
1 |
1 |
1 |
ELG167 |
FILLER |
X(441) |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
ELG167 |
FILLER |
X(441) |
ELIGIBLE |
STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| 1,039 |
1 |
1 |
1 |
1 |
1 |
ELG168 |
RECORD-ID |
X(8) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG168 |
RECORD-ID |
X(8) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,040 |
1 |
1 |
1 |
1 |
1 |
ELG169 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG169 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,041 |
1 |
1 |
1 |
1 |
1 |
ELG170 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG170 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,042 |
1 |
1 |
1 |
1 |
1 |
ELG171 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG171 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,043 |
1 |
1 |
1 |
1 |
1 |
ELG172 |
WAIVER-ID |
X(20) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG172 |
WAIVER-ID |
X(20) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,044 |
1 |
1 |
1 |
1 |
1 |
ELG173 |
WAIVER-TYPE |
X(2) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG173 |
WAIVER-TYPE |
X(2) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,045 |
1 |
1 |
1 |
1 |
1 |
ELG174 |
WAIVER-ENROLLMENT-EFF-DATE |
9(8) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG174 |
WAIVER-ENROLLMENT-EFF-DATE |
9(8) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,046 |
1 |
1 |
1 |
1 |
1 |
ELG175 |
WAIVER-ENROLLMENT-END-DATE |
9(8) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG175 |
WAIVER-ENROLLMENT-END-DATE |
9(8) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,047 |
1 |
1 |
1 |
1 |
1 |
ELG176 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG176 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,048 |
1 |
1 |
1 |
1 |
1 |
ELG177 |
FILLER |
X(421) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
ELG177 |
FILLER |
X(421) |
ELIGIBLE |
WAIVER-PARTICIPATION-ELG00012 |
| 1,049 |
1 |
1 |
1 |
1 |
1 |
ELG178 |
RECORD-ID |
X(8) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG178 |
RECORD-ID |
X(8) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,050 |
1 |
1 |
1 |
1 |
1 |
ELG179 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG179 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,051 |
1 |
1 |
1 |
1 |
1 |
ELG180 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG180 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,052 |
1 |
1 |
1 |
1 |
1 |
ELG181 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG181 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,053 |
1 |
1 |
1 |
1 |
1 |
ELG182 |
LTSS-LEVEL-CARE |
X(1) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG182 |
LTSS-LEVEL-CARE |
X(1) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,054 |
1 |
1 |
1 |
1 |
1 |
ELG183 |
LTSS-PROV-NUM |
X(30) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG183 |
LTSS-PROV-NUM |
X(30) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,055 |
1 |
1 |
1 |
1 |
1 |
ELG184 |
LTSS-ELIGIBILITY-EFF-DATE |
9(8) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG184 |
LTSS-ELIGIBILITY-EFF-DATE |
9(8) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,056 |
1 |
1 |
1 |
1 |
1 |
ELG185 |
LTSS-ELIGIBILITY-END-DATE |
9(8) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG185 |
LTSS-ELIGIBILITY-END-DATE |
9(8) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,057 |
1 |
1 |
1 |
1 |
1 |
ELG186 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG186 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,058 |
1 |
1 |
1 |
1 |
1 |
ELG187 |
FILLER |
X(412) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
ELG187 |
FILLER |
X(412) |
ELIGIBLE |
LTSS-PARTICIPATION-ELG00013 |
| 1,059 |
1 |
1 |
1 |
1 |
1 |
ELG188 |
RECORD-ID |
X(8) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG188 |
RECORD-ID |
X(8) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,060 |
1 |
1 |
1 |
1 |
1 |
ELG189 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG189 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,061 |
1 |
1 |
1 |
1 |
1 |
ELG190 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG190 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,062 |
1 |
1 |
1 |
1 |
1 |
ELG191 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG191 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,063 |
1 |
1 |
1 |
1 |
1 |
ELG192 |
MANAGED-CARE-PLAN-ID |
X(12) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG192 |
MANAGED-CARE-PLAN-ID |
X(12) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,064 |
1 |
0 |
1 |
1 |
1 |
ELG193 |
ENROLLED-MANAGED-CARE-PLAN-TYPE |
X(2) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG193 |
MANAGED-CARE-PLAN-TYPE |
X(2) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,065 |
1 |
1 |
1 |
1 |
1 |
ELG194 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG194 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,066 |
1 |
1 |
1 |
1 |
1 |
ELG195 |
NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE |
X(1) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG195 |
NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE |
X(1) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,067 |
1 |
1 |
1 |
1 |
1 |
ELG196 |
MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE |
9(8) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG196 |
MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE |
9(8) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,068 |
1 |
1 |
1 |
1 |
1 |
ELG197 |
MANAGED-CARE-PLAN-ENROLLMENT-END-DATE |
9(8) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG197 |
MANAGED-CARE-PLAN-ENROLLMENT-END-DATE |
9(8) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,069 |
1 |
1 |
1 |
1 |
1 |
ELG198 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG198 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,070 |
1 |
1 |
1 |
1 |
1 |
ELG199 |
FILLER |
X(418) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
ELG199 |
FILLER |
X(418) |
ELIGIBLE |
MANAGED-CARE-PARTICIPATION-ELG00014 |
| 1,071 |
1 |
1 |
1 |
1 |
1 |
ELG200 |
RECORD-ID |
X(8) |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
ELG200 |
RECORD-ID |
X(8) |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| 1,072 |
1 |
1 |
1 |
1 |
1 |
ELG201 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
ELG201 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| 1,073 |
1 |
1 |
1 |
1 |
1 |
ELG202 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
ELG202 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| 1,074 |
1 |
1 |
1 |
1 |
1 |
ELG203 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
ELG203 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| 1,075 |
1 |
1 |
1 |
1 |
1 |
ELG204 |
ETHNICITY-CODE |
X(1) |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
ELG204 |
ETHNICITY-CODE |
X(1) |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| 1,076 |
1 |
1 |
1 |
1 |
1 |
ELG205 |
ETHNICITY-DECLARATION-EFF-DATE |
9(8) |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
ELG205 |
ETHNICITY-DECLARATION-EFF-DATE |
9(8) |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| 1,077 |
1 |
1 |
1 |
1 |
1 |
ELG206 |
ETHNICITY-DECLARATION-END-DATE |
9(8) |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
ELG206 |
ETHNICITY-DECLARATION-END-DATE |
9(8) |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| 1,078 |
1 |
1 |
1 |
1 |
1 |
ELG207 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
ELG207 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| 1,079 |
1 |
1 |
1 |
1 |
1 |
ELG208 |
FILLER |
X(442) |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
ELG208 |
FILLER |
X(442) |
ELIGIBLE |
ETHNICITY-INFORMATION-ELG00015 |
| 1,080 |
1 |
1 |
1 |
1 |
1 |
ELG209 |
RECORD-ID |
X(8) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG209 |
RECORD-ID |
X(8) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,081 |
1 |
1 |
1 |
1 |
1 |
ELG210 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG210 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,082 |
1 |
1 |
1 |
1 |
1 |
ELG211 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG211 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,083 |
1 |
1 |
1 |
1 |
1 |
ELG212 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG212 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,084 |
1 |
1 |
1 |
1 |
1 |
ELG213 |
RACE |
X(3) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG213 |
RACE |
X(3) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,085 |
1 |
1 |
1 |
1 |
1 |
ELG214 |
RACE-OTHER |
X(25) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG214 |
RACE-OTHER |
X(25) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,086 |
1 |
0 |
1 |
1 |
1 |
ELG215 |
CERTIFIED-AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR |
X(1) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG215 |
CERTIFIED-AMERICAN-INDIAN/ALASKAN-NATIVE-INDICATOR |
X(1) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,087 |
1 |
1 |
1 |
1 |
1 |
ELG216 |
RACE-DECLARATION-EFF-DATE |
9(8) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG216 |
RACE-DECLARATION-EFF-DATE |
9(8) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,088 |
1 |
1 |
1 |
1 |
1 |
ELG217 |
RACE-DECLARATION-END-DATE |
9(8) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG217 |
RACE-DECLARATION-END-DATE |
9(8) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,089 |
1 |
1 |
1 |
1 |
1 |
ELG218 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG218 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,090 |
1 |
1 |
1 |
1 |
1 |
ELG219 |
FILLER |
X(414) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
ELG219 |
FILLER |
X(414) |
ELIGIBLE |
RACE-INFORMATION-ELG00016 |
| 1,091 |
1 |
1 |
1 |
1 |
1 |
ELG220 |
RECORD-ID |
X(8) |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
ELG220 |
RECORD-ID |
X(8) |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| 1,092 |
1 |
1 |
1 |
1 |
1 |
ELG221 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
ELG221 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| 1,093 |
1 |
1 |
1 |
1 |
1 |
ELG222 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
ELG222 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| 1,094 |
1 |
1 |
1 |
1 |
1 |
ELG223 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
ELG223 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| 1,095 |
1 |
1 |
1 |
1 |
1 |
ELG224 |
DISABILITY-TYPE-CODE |
X(2) |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
ELG224 |
DISABILITY-TYPE-CODE |
X(2) |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| 1,096 |
1 |
1 |
1 |
1 |
1 |
ELG225 |
DISABILITY-TYPE-EFF-DATE |
9(8) |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
ELG225 |
DISABILITY-TYPE-EFF-DATE |
9(8) |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| 1,097 |
1 |
1 |
1 |
1 |
1 |
ELG226 |
DISABILITY-TYPE-END-DATE |
9(8) |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
ELG226 |
DISABILITY-TYPE-END-DATE |
9(8) |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| 1,098 |
1 |
1 |
1 |
1 |
1 |
ELG227 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
ELG227 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| 1,099 |
1 |
1 |
1 |
1 |
1 |
ELG228 |
FILLER |
X(441) |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
ELG228 |
FILLER |
X(441) |
ELIGIBLE |
DISABILITY-INFORMATION-ELG00017 |
| 1,100 |
1 |
1 |
1 |
1 |
1 |
ELG229 |
RECORD-ID |
X(8) |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
ELG229 |
RECORD-ID |
X(8) |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| 1,101 |
1 |
1 |
1 |
1 |
1 |
ELG230 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
ELG230 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| 1,102 |
1 |
1 |
1 |
1 |
1 |
ELG231 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
ELG231 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| 1,103 |
1 |
1 |
1 |
1 |
1 |
ELG232 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
ELG232 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| 1,104 |
1 |
1 |
1 |
1 |
1 |
ELG233 |
1115A-DEMONSTRATION-IND |
X(1) |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
ELG233 |
1115A-DEMONSTRATION-IND |
X(1) |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| 1,105 |
1 |
1 |
1 |
1 |
1 |
ELG234 |
1115A-EFF-DATE |
9(8) |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
ELG234 |
1115A-EFF-DATE |
9(8) |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| 1,106 |
1 |
1 |
1 |
1 |
1 |
ELG235 |
1115A-END-DATE |
9(8) |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
ELG235 |
1115A-END-DATE |
9(8) |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| 1,107 |
1 |
1 |
1 |
1 |
1 |
ELG236 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
ELG236 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| 1,108 |
1 |
1 |
1 |
1 |
1 |
ELG237 |
FILLER |
X(442) |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
ELG237 |
FILLER |
X(442) |
ELIGIBLE |
1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| 1,109 |
1 |
1 |
1 |
1 |
1 |
ELG238 |
RECORD-ID |
X(8) |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
ELG238 |
RECORD-ID |
X(8) |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| 1,110 |
1 |
1 |
1 |
1 |
1 |
ELG239 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
ELG239 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| 1,111 |
1 |
1 |
1 |
1 |
1 |
ELG240 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
ELG240 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| 1,112 |
1 |
1 |
1 |
1 |
1 |
ELG241 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
ELG241 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| 1,113 |
1 |
1 |
1 |
1 |
1 |
ELG242 |
HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE |
X(3) |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
ELG242 |
HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE |
X(3) |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| 1,114 |
1 |
1 |
1 |
1 |
1 |
ELG243 |
HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE |
9(8) |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
ELG243 |
HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE |
9(8) |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| 1,115 |
1 |
1 |
1 |
1 |
1 |
ELG244 |
HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE |
9(8) |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
ELG244 |
HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE |
9(8) |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| 1,116 |
1 |
1 |
1 |
1 |
1 |
ELG245 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
ELG245 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| 1,117 |
1 |
1 |
1 |
1 |
1 |
ELG246 |
FILLER |
X(440) |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
ELG246 |
FILLER |
X(440) |
ELIGIBLE |
HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| 1,118 |
1 |
1 |
1 |
1 |
1 |
ELG248 |
RECORD-ID |
X(8) |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
ELG248 |
RECORD-ID |
X(8) |
ELIGIBLE |
ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 |
| 1,119 |
1 |
1 |
1 |
1 |
1 |
ELG249 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
ELG249 |
SUBMITTING-STATE |
X(2) |
ELIGIBLE |
ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 |
| 1,120 |
1 |
1 |
1 |
1 |
1 |
ELG250 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
ELG250 |
RECORD-NUMBER |
9(11) |
ELIGIBLE |
ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 |
| 1,121 |
1 |
1 |
1 |
1 |
1 |
ELG251 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
ELG251 |
MSIS-IDENTIFICATION-NUM |
X(20) |
ELIGIBLE |
ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 |
| 1,122 |
1 |
1 |
1 |
1 |
1 |
ELG252 |
ENROLLMENT-TYPE |
X(1) |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
ELG252 |
ENROLLMENT-TYPE |
X(1) |
ELIGIBLE |
ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 |
| 1,123 |
1 |
1 |
1 |
1 |
1 |
ELG253 |
ENROLLMENT-EFF-DATE |
9(8) |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
ELG253 |
ENROLLMENT-EFF-DATE |
9(8) |
ELIGIBLE |
ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 |
| 1,124 |
1 |
1 |
1 |
1 |
1 |
ELG254 |
ENROLLMENT-END-DATE |
9(8) |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
ELG254 |
ENROLLMENT-END-DATE |
9(8) |
ELIGIBLE |
ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 |
| 1,125 |
1 |
1 |
1 |
1 |
1 |
ELG255 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
ELG255 |
STATE-NOTATION |
X(500) |
ELIGIBLE |
ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 |
| 1,126 |
1 |
1 |
1 |
1 |
1 |
ELG256 |
FILLER |
X(442) |
ELIGIBLE |
Enrollment-Time-Span-Segment-ELG00021 |
ELG256 |
FILLER |
X(442) |
ELIGIBLE |
ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 |
| 1,127 |
1 |
1 |
1 |
1 |
1 |
MCR001 |
RECORD-ID |
X(8) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR001 |
RECORD-ID |
X(8) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,128 |
1 |
1 |
1 |
1 |
1 |
MCR002 |
DATA-DICTIONARY-VERSION |
X(10) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR002 |
DATA-DICTIONARY-VERSION |
X(10) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,129 |
1 |
1 |
1 |
1 |
1 |
MCR003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,130 |
1 |
1 |
1 |
1 |
1 |
MCR004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,131 |
1 |
1 |
1 |
1 |
1 |
MCR005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,132 |
1 |
1 |
1 |
1 |
1 |
MCR006 |
FILE-NAME |
X(8) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR006 |
FILE-NAME |
X(8) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,133 |
1 |
1 |
1 |
1 |
1 |
MCR007 |
SUBMITTING-STATE |
X(2) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR007 |
SUBMITTING-STATE |
X(2) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,134 |
1 |
1 |
1 |
1 |
1 |
MCR008 |
DATE-FILE-CREATED |
9(8) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR008 |
DATE-FILE-CREATED |
9(8) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,135 |
1 |
1 |
1 |
1 |
1 |
MCR009 |
START-OF-TIME-PERIOD |
9(8) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR009 |
START-OF-TIME-PERIOD |
9(8) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,136 |
1 |
1 |
1 |
1 |
1 |
MCR010 |
END-OF-TIME-PERIOD |
9(8) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR010 |
END-OF-TIME-PERIOD |
9(8) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,137 |
1 |
1 |
1 |
1 |
1 |
MCR011 |
FILE-STATUS-INDICATOR |
X(1) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR011 |
FILE-STATUS-INDICATOR |
X(1) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,138 |
1 |
1 |
1 |
1 |
1 |
MCR013 |
TOT-REC-CNT |
9(11) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR013 |
TOT-REC-CNT |
9(11) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,139 |
1 |
1 |
1 |
1 |
1 |
MCR112 |
SEQUENCE-NUMBER |
X(4) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR112 |
SEQUENCE-NUMBER |
X(4) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,140 |
1 |
1 |
1 |
1 |
1 |
MCR014 |
STATE-NOTATION |
X(500) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR014 |
STATE-NOTATION |
X(500) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,141 |
1 |
1 |
1 |
1 |
1 |
MCR012 |
FILLER |
X(419) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
MCR012 |
FILLER |
X(419) |
MNGDCARE |
FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| 1,142 |
1 |
1 |
1 |
1 |
1 |
MCR016 |
RECORD-ID |
X(8) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR016 |
RECORD-ID |
X(8) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,143 |
1 |
1 |
1 |
1 |
1 |
MCR017 |
SUBMITTING-STATE |
X(2) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR017 |
SUBMITTING-STATE |
X(2) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,144 |
1 |
1 |
1 |
1 |
1 |
MCR018 |
RECORD-NUMBER |
9(11) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR018 |
RECORD-NUMBER |
9(11) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,145 |
1 |
1 |
1 |
1 |
1 |
MCR019 |
STATE-PLAN-ID-NUM |
X(12) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR019 |
STATE-PLAN-ID-NUM |
X(12) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,146 |
1 |
1 |
1 |
1 |
1 |
MCR020 |
MANAGED-CARE-CONTRACT-EFF-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR020 |
MANAGED-CARE-CONTRACT-EFF-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,147 |
1 |
1 |
1 |
1 |
1 |
MCR021 |
MANAGED-CARE-CONTRACT-END-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR021 |
MANAGED-CARE-CONTRACT-END-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,148 |
1 |
1 |
1 |
1 |
1 |
MCR022 |
MANAGED-CARE-NAME |
X(55) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR022 |
MANAGED-CARE-NAME |
X(55) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,149 |
1 |
1 |
1 |
1 |
1 |
MCR023 |
MANAGED-CARE-PROGRAM |
X(1) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR023 |
MANAGED-CARE-PROGRAM |
X(1) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,150 |
1 |
1 |
1 |
1 |
1 |
MCR024 |
MANAGED-CARE-PLAN-TYPE |
X(2) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR024 |
MANAGED-CARE-PLAN-TYPE |
X(2) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,151 |
1 |
1 |
1 |
1 |
1 |
MCR025 |
REIMBURSEMENT-ARRANGEMENT |
X(2) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR025 |
REIMBURSEMENT-ARRANGEMENT |
X(2) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,152 |
1 |
1 |
1 |
1 |
1 |
MCR026 |
MANAGED-CARE-PROFIT-STATUS |
X(2) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR026 |
MANAGED-CARE-PROFIT-STATUS |
X(2) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,153 |
1 |
1 |
1 |
1 |
1 |
MCR027 |
CORE-BASED-STATISTICAL-AREA-CODE |
X(1) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR027 |
CORE-BASED-STATISTICAL-AREA-CODE |
X(1) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,154 |
1 |
1 |
1 |
1 |
1 |
MCR028 |
PERCENT-BUSINESS |
9(3) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR028 |
PERCENT-BUSINESS |
9(3) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,155 |
1 |
1 |
1 |
1 |
1 |
MCR029 |
MANAGED-CARE-SERVICE-AREA |
X(1) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR029 |
MANAGED-CARE-SERVICE-AREA |
X(1) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,156 |
1 |
1 |
1 |
1 |
1 |
MCR030 |
MANAGED-CARE-MAIN-REC-EFF-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR030 |
MANAGED-CARE-MAIN-REC-EFF-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,157 |
1 |
1 |
1 |
1 |
1 |
MCR031 |
MANAGED-CARE-MAIN-REC-END-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR031 |
MANAGED-CARE-MAIN-REC-END-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,158 |
1 |
1 |
1 |
1 |
1 |
MCR032 |
STATE-NOTATION |
X(500) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR032 |
STATE-NOTATION |
X(500) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,159 |
1 |
1 |
1 |
1 |
1 |
MCR033 |
FILLER |
X(368) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
MCR033 |
FILLER |
X(368) |
MNGDCARE |
MANAGED-CARE-MAIN-MCR00002 |
| 1,160 |
1 |
1 |
1 |
1 |
1 |
MCR034 |
RECORD-ID |
X(8) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR034 |
RECORD-ID |
X(8) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,161 |
1 |
1 |
1 |
1 |
1 |
MCR035 |
SUBMITTING-STATE |
X(2) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR035 |
SUBMITTING-STATE |
X(2) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,162 |
1 |
1 |
1 |
1 |
1 |
MCR036 |
RECORD-NUMBER |
9(11) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR036 |
RECORD-NUMBER |
9(11) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,163 |
1 |
1 |
1 |
1 |
1 |
MCR037 |
STATE-PLAN-ID-NUM |
X(12) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR037 |
STATE-PLAN-ID-NUM |
X(12) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,164 |
1 |
1 |
1 |
1 |
1 |
MCR038 |
MANAGED-CARE-LOCATION-ID |
X(15) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR038 |
MANAGED-CARE-LOCATION-ID |
X(15) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,165 |
1 |
1 |
1 |
1 |
1 |
MCR039 |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR039 |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,166 |
1 |
1 |
1 |
1 |
1 |
MCR040 |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR040 |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,167 |
1 |
1 |
1 |
1 |
1 |
MCR041 |
MANAGED-CARE-ADDR-TYPE |
X(1) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR041 |
MANAGED-CARE-ADDR-TYPE |
X(1) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,168 |
1 |
1 |
1 |
1 |
1 |
MCR042 |
MANAGED-CARE-ADDR-LN1 |
X(60) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR042 |
MANAGED-CARE-ADDR-LN1 |
X(60) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,169 |
1 |
1 |
1 |
1 |
1 |
MCR043 |
MANAGED-CARE-ADDR-LN2 |
X(60) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR043 |
MANAGED-CARE-ADDR-LN2 |
X(60) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,170 |
1 |
1 |
1 |
1 |
1 |
MCR044 |
MANAGED-CARE-ADDR-LN3 |
X(60) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR044 |
MANAGED-CARE-ADDR-LN3 |
X(60) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,171 |
1 |
1 |
1 |
1 |
1 |
MCR045 |
MANAGED-CARE-CITY |
X(28) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR045 |
MANAGED-CARE-CITY |
X(28) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,172 |
1 |
1 |
1 |
1 |
1 |
MCR046 |
MANAGED-CARE-STATE |
X(2) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR046 |
MANAGED-CARE-STATE |
X(2) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,173 |
1 |
1 |
1 |
1 |
1 |
MCR047 |
MANAGED-CARE-ZIP-CODE |
X(9) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR047 |
MANAGED-CARE-ZIP-CODE |
X(9) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,174 |
1 |
1 |
1 |
1 |
1 |
MCR048 |
MANAGED-CARE-COUNTY |
X(3) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR048 |
MANAGED-CARE-COUNTY |
X(3) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,175 |
1 |
1 |
1 |
1 |
1 |
MCR049 |
MANAGED-CARE-TELEPHONE |
X(10) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR049 |
MANAGED-CARE-TELEPHONE |
X(10) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,176 |
1 |
1 |
1 |
1 |
1 |
MCR050 |
MANAGED-CARE-EMAIL |
X(60) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR050 |
MANAGED-CARE-EMAIL |
X(60) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,177 |
1 |
1 |
1 |
1 |
1 |
MCR051 |
MANAGED-CARE-FAX-NUMBER |
X(10) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR051 |
MANAGED-CARE-FAX-NUMBER |
X(10) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,178 |
1 |
1 |
1 |
1 |
1 |
MCR052 |
STATE-NOTATION |
X(500) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR052 |
STATE-NOTATION |
X(500) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,179 |
1 |
1 |
1 |
1 |
1 |
MCR053 |
FILLER |
X(133) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
MCR053 |
FILLER |
X(133) |
MNGDCARE |
MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| 1,180 |
1 |
1 |
1 |
1 |
1 |
MCR054 |
RECORD-ID |
X(8) |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
MCR054 |
RECORD-ID |
X(8) |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| 1,181 |
1 |
1 |
1 |
1 |
1 |
MCR055 |
SUBMITTING-STATE |
X(2) |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
MCR055 |
SUBMITTING-STATE |
X(2) |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| 1,182 |
1 |
1 |
1 |
1 |
1 |
MCR056 |
RECORD-NUMBER |
9(11) |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
MCR056 |
RECORD-NUMBER |
9(11) |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| 1,183 |
1 |
1 |
1 |
1 |
1 |
MCR057 |
STATE-PLAN-ID-NUM |
X(12) |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
MCR057 |
STATE-PLAN-ID-NUM |
X(12) |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| 1,184 |
1 |
1 |
1 |
1 |
1 |
MCR058 |
MANAGED-CARE-SERVICE-AREA-NAME |
X(30) |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
MCR058 |
MANAGED-CARE-SERVICE-AREA-NAME |
X(30) |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| 1,185 |
1 |
1 |
1 |
1 |
1 |
MCR059 |
MANAGED-CARE-SERVICE-AREA-EFF-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
MCR059 |
MANAGED-CARE-SERVICE-AREA-EFF-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| 1,186 |
1 |
1 |
1 |
1 |
1 |
MCR060 |
MANAGED-CARE-SERVICE-AREA-END-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
MCR060 |
MANAGED-CARE-SERVICE-AREA-END-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| 1,187 |
1 |
1 |
1 |
1 |
1 |
MCR061 |
STATE-NOTATION |
X(500) |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
MCR061 |
STATE-NOTATION |
X(500) |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| 1,188 |
1 |
1 |
1 |
1 |
1 |
MCR062 |
FILLER |
X(421) |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
MCR062 |
FILLER |
X(421) |
MNGDCARE |
MANAGED-CARE-SERVICE-AREA-MCR00004 |
| 1,189 |
1 |
1 |
1 |
1 |
1 |
MCR063 |
RECORD-ID |
X(8) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR063 |
RECORD-ID |
X(8) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,190 |
1 |
1 |
1 |
1 |
1 |
MCR064 |
SUBMITTING-STATE |
X(2) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR064 |
SUBMITTING-STATE |
X(2) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,191 |
1 |
1 |
1 |
1 |
1 |
MCR065 |
RECORD-NUMBER |
9(11) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR065 |
RECORD-NUMBER |
9(11) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,192 |
1 |
1 |
1 |
1 |
1 |
MCR066 |
STATE-PLAN-ID-NUM |
X(12) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR066 |
STATE-PLAN-ID-NUM |
X(12) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,193 |
1 |
1 |
1 |
1 |
1 |
MCR067 |
OPERATING-AUTHORITY |
X(2) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR067 |
OPERATING-AUTHORITY |
X(2) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,194 |
1 |
1 |
1 |
1 |
1 |
MCR068 |
WAIVER-ID |
X(20) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR068 |
WAIVER-ID |
X(20) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,195 |
1 |
1 |
1 |
1 |
1 |
MCR069 |
MANAGED-CARE-OP-AUTHORITY-EFF-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR069 |
MANAGED-CARE-OP-AUTHORITY-EFF-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,196 |
1 |
1 |
1 |
1 |
1 |
MCR070 |
MANAGED-CARE-OP-AUTHORITY-END-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR070 |
MANAGED-CARE-OP-AUTHORITY-END-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,197 |
1 |
1 |
1 |
1 |
1 |
MCR071 |
STATE-NOTATION |
X(500) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR071 |
STATE-NOTATION |
X(500) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,198 |
1 |
1 |
1 |
1 |
1 |
MCR072 |
FILLER |
X(429) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
MCR072 |
FILLER |
X(429) |
MNGDCARE |
MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| 1,199 |
1 |
1 |
1 |
1 |
1 |
MCR073 |
RECORD-ID |
X(8) |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
MCR073 |
RECORD-ID |
X(8) |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| 1,200 |
1 |
1 |
1 |
1 |
1 |
MCR074 |
SUBMITTING-STATE |
X(2) |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
MCR074 |
SUBMITTING-STATE |
X(2) |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| 1,201 |
1 |
1 |
1 |
1 |
1 |
MCR075 |
RECORD-NUMBER |
9(11) |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
MCR075 |
RECORD-NUMBER |
9(11) |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| 1,202 |
1 |
1 |
1 |
1 |
1 |
MCR076 |
STATE-PLAN-ID-NUM |
X(12) |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
MCR076 |
STATE-PLAN-ID-NUM |
X(12) |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| 1,203 |
1 |
1 |
1 |
1 |
1 |
MCR077 |
MANAGED-CARE-PLAN-POP |
9(2) |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
MCR077 |
MANAGED-CARE-PLAN-POP |
9(2) |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| 1,204 |
1 |
1 |
1 |
1 |
1 |
MCR078 |
MANAGED-CARE-PLAN-POP-EFF-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
MCR078 |
MANAGED-CARE-PLAN-POP-EFF-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| 1,205 |
1 |
1 |
1 |
1 |
1 |
MCR079 |
MANAGED-CARE-PLAN-POP-END-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
MCR079 |
MANAGED-CARE-PLAN-POP-END-DATE |
9(8) |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| 1,206 |
1 |
1 |
1 |
1 |
1 |
MCR080 |
STATE-NOTATION |
X(500) |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
MCR080 |
STATE-NOTATION |
X(500) |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| 1,207 |
1 |
1 |
1 |
1 |
1 |
MCR081 |
FILLER |
X(449) |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
MCR081 |
FILLER |
X(449) |
MNGDCARE |
MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| 1,208 |
1 |
1 |
1 |
1 |
0 |
MCR082 |
RECORD-ID |
X(8) |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
MCR082 |
RECORD-ID |
X(8) |
MNGDCARE |
MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| 1,209 |
1 |
1 |
1 |
1 |
0 |
MCR083 |
SUBMITTING-STATE |
X(2) |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
MCR083 |
SUBMITTING-STATE |
X(2) |
MNGDCARE |
MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| 1,210 |
1 |
1 |
1 |
1 |
0 |
MCR084 |
RECORD-NUMBER |
9(11) |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
MCR084 |
RECORD-NUMBER |
9(11) |
MNGDCARE |
MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| 1,211 |
1 |
1 |
1 |
1 |
0 |
MCR085 |
STATE-PLAN-ID-NUM |
X(12) |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
MCR085 |
STATE-PLAN-ID-NUM |
X(12) |
MNGDCARE |
MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| 1,212 |
1 |
1 |
1 |
1 |
0 |
MCR086 |
ACCREDITATION-ORGANIZATION |
X(2) |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
MCR086 |
ACCREDITATION-ORGANIZATION |
X(2) |
MNGDCARE |
MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| 1,213 |
1 |
1 |
1 |
1 |
0 |
MCR087 |
DATE-ACCREDITATION-ACHIEVED |
9(8) |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
MCR087 |
DATE-ACCREDITATION-ACHIEVED |
9(8) |
MNGDCARE |
MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| 1,214 |
1 |
1 |
1 |
1 |
0 |
MCR088 |
DATE-ACCREDITATION-END |
9(8) |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
MCR088 |
DATE-ACCREDITATION-END |
9(8) |
MNGDCARE |
MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| 1,215 |
1 |
1 |
1 |
1 |
0 |
MCR089 |
STATE-NOTATION |
X(500) |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
MCR089 |
STATE-NOTATION |
X(500) |
MNGDCARE |
MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| 1,216 |
1 |
1 |
1 |
1 |
0 |
MCR090 |
FILLER |
X(449) |
MNGDCARE |
MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
MCR090 |
FILLER |
X(449) |
MNGDCARE |
MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| 1,217 |
1 |
1 |
1 |
1 |
1 |
MCR091 |
RECORD-ID |
X(8) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
MCR091 |
RECORD-ID |
X(8) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| 1,218 |
1 |
1 |
1 |
1 |
1 |
MCR092 |
SUBMITTING-STATE |
X(2) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
MCR092 |
SUBMITTING-STATE |
X(2) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| 1,219 |
1 |
1 |
1 |
1 |
1 |
MCR093 |
RECORD-NUMBER |
9(11) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
MCR093 |
RECORD-NUMBER |
9(11) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| 1,220 |
1 |
1 |
1 |
1 |
1 |
MCR094 |
STATE-PLAN-ID-NUM |
X(12) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
MCR094 |
STATE-PLAN-ID-NUM |
X(12) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| 1,221 |
1 |
1 |
1 |
1 |
1 |
MCR095 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
MCR095 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| 1,222 |
1 |
1 |
1 |
1 |
1 |
MCR096 |
NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE |
X(1) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
MCR096 |
NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE |
X(1) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| 1,223 |
1 |
1 |
1 |
1 |
1 |
MCR097 |
NATIONAL-HEALTH-CARE-ENTITY-NAME |
X(50) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
MCR097 |
NATIONAL-HEALTH-CARE-ENTITY-NAME |
X(50) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| 1,224 |
1 |
1 |
1 |
1 |
1 |
MCR098 |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE |
9(8) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
MCR098 |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE |
9(8) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| 1,225 |
1 |
1 |
1 |
1 |
1 |
MCR099 |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE |
9(8) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
MCR099 |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE |
9(8) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| 1,226 |
1 |
1 |
1 |
1 |
1 |
MCR100 |
STATE-NOTATION |
X(500) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
MCR100 |
STATE-NOTATION |
X(500) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| 1,227 |
1 |
1 |
1 |
1 |
1 |
MCR101 |
FILLER |
X(390) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
MCR101 |
FILLER |
X(390) |
MNGDCARE |
NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| 1,228 |
1 |
1 |
1 |
1 |
1 |
MCR102 |
RECORD-ID |
X(8) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR102 |
RECORD-ID |
X(8) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,229 |
1 |
1 |
1 |
1 |
1 |
MCR103 |
SUBMITTING-STATE |
X(2) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR103 |
SUBMITTING-STATE |
X(2) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,230 |
1 |
1 |
1 |
1 |
1 |
MCR104 |
RECORD-NUMBER |
9(11) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR104 |
RECORD-NUMBER |
9(11) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,231 |
1 |
1 |
1 |
1 |
1 |
MCR105 |
STATE-PLAN-ID-NUM |
X(12) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR105 |
STATE-PLAN-ID-NUM |
X(12) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,232 |
1 |
1 |
1 |
1 |
1 |
MCR106 |
CHPID |
X(10) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR106 |
CHPID |
X(10) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,233 |
1 |
1 |
1 |
1 |
1 |
MCR107 |
SHPID |
X(10) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR107 |
SHPID |
X(10) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,234 |
1 |
1 |
1 |
1 |
1 |
MCR108 |
CHPID-SHPID-RELATIONSHIP-EFF-DATE |
9(8) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR108 |
CHPID-SHPID-RELATIONSHIP-EFF-DATE |
9(8) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,235 |
1 |
1 |
1 |
1 |
1 |
MCR109 |
CHPID-SHPID-RELATIONSHIP-END-DATE |
9(8) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR109 |
CHPID-SHPID-RELATIONSHIP-END-DATE |
9(8) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,236 |
1 |
1 |
1 |
1 |
1 |
MCR110 |
STATE-NOTATION |
X(500) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR110 |
STATE-NOTATION |
X(500) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,237 |
1 |
1 |
1 |
1 |
1 |
MCR111 |
FILLER |
X(431) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
MCR111 |
FILLER |
X(431) |
MNGDCARE |
CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| 1,238 |
1 |
1 |
1 |
1 |
1 |
PRV001 |
RECORD-ID |
X(8) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV001 |
RECORD-ID |
X(8) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,239 |
1 |
1 |
1 |
1 |
1 |
PRV002 |
DATA-DICTIONARY-VERSION |
X(10) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV002 |
DATA-DICTIONARY-VERSION |
X(10) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,240 |
1 |
1 |
1 |
1 |
1 |
PRV003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,241 |
1 |
1 |
1 |
1 |
1 |
PRV004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,242 |
1 |
1 |
1 |
1 |
1 |
PRV005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,243 |
1 |
1 |
1 |
1 |
1 |
PRV006 |
FILE-NAME |
X(8) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV006 |
FILE-NAME |
X(8) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,244 |
1 |
1 |
1 |
1 |
1 |
PRV007 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV007 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,245 |
1 |
1 |
1 |
1 |
1 |
PRV008 |
DATE-FILE-CREATED |
9(8) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV008 |
DATE-FILE-CREATED |
9(8) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,246 |
1 |
1 |
1 |
1 |
1 |
PRV009 |
START-OF-TIME-PERIOD |
9(8) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV009 |
START-OF-TIME-PERIOD |
9(8) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,247 |
1 |
1 |
1 |
1 |
1 |
PRV010 |
END-OF-TIME-PERIOD |
9(8) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV010 |
END-OF-TIME-PERIOD |
9(8) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,248 |
1 |
1 |
1 |
1 |
1 |
PRV011 |
FILE-STATUS-INDICATOR |
X(1) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV011 |
FILE-STATUS-INDICATOR |
X(1) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,249 |
1 |
1 |
1 |
1 |
1 |
PRV013 |
TOT-REC-CNT |
9(11) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV013 |
TOT-REC-CNT |
9(11) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,250 |
1 |
1 |
1 |
1 |
1 |
PRV138 |
SEQUENCE-NUMBER |
X(4) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV138 |
SEQUENCE-NUMBER |
X(4) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,251 |
1 |
1 |
1 |
1 |
1 |
PRV014 |
STATE-NOTATION |
X(500) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV014 |
STATE-NOTATION |
X(500) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,252 |
1 |
1 |
1 |
1 |
1 |
PRV012 |
FILLER |
X(519) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
PRV012 |
FILLER |
X(519) |
PROVIDER |
FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| 1,253 |
1 |
1 |
1 |
1 |
1 |
PRV016 |
RECORD-ID |
X(8) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV016 |
RECORD-ID |
X(8) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,254 |
1 |
1 |
1 |
1 |
1 |
PRV017 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV017 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,255 |
1 |
1 |
1 |
1 |
1 |
PRV018 |
RECORD-NUMBER |
9(11) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV018 |
RECORD-NUMBER |
9(11) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,256 |
1 |
1 |
1 |
1 |
1 |
PRV019 |
SUBMITTING-STATE-PROV-ID |
X(30) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV019 |
SUBMITTING-STATE-PROV-ID |
X(30) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,257 |
1 |
1 |
1 |
1 |
1 |
PRV020 |
PROV-ATTRIBUTES-EFF-DATE |
9(8) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV020 |
PROV-ATTRIBUTES-EFF-DATE |
9(8) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,258 |
1 |
1 |
1 |
1 |
1 |
PRV021 |
PROV-ATTRIBUTES-END-DATE |
9(8) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV021 |
PROV-ATTRIBUTES-END-DATE |
9(8) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,259 |
1 |
1 |
1 |
1 |
1 |
PRV022 |
PROV-DOING-BUSINESS-AS-NAME |
X(100) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV022 |
PROV-DOING-BUSINESS-AS-NAME |
X(100) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,260 |
1 |
1 |
1 |
1 |
1 |
PRV023 |
PROV-LEGAL-NAME |
X(100) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV023 |
PROV-LEGAL-NAME |
X(100) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,261 |
1 |
1 |
1 |
1 |
1 |
PRV024 |
PROV-ORGANIZATION-NAME |
X(60) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV024 |
PROV-ORGANIZATION-NAME |
X(60) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,262 |
1 |
1 |
1 |
1 |
1 |
PRV025 |
PROV-TAX-NAME |
X(100) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV025 |
PROV-TAX-NAME |
X(100) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,263 |
1 |
1 |
1 |
1 |
1 |
PRV026 |
FACILITY-GROUP-INDIVIDUAL-CODE |
X(2) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV026 |
FACILITY-GROUP-INDIVIDUAL-CODE |
X(2) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,264 |
1 |
1 |
1 |
1 |
1 |
PRV027 |
TEACHING-IND |
X(1) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV027 |
TEACHING-IND |
X(1) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,265 |
1 |
1 |
1 |
1 |
1 |
PRV028 |
PROV-FIRST-NAME |
X(30) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV028 |
PROV-FIRST-NAME |
X(30) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,266 |
1 |
1 |
1 |
1 |
1 |
PRV029 |
PROV-MIDDLE-INITIAL |
X(1) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV029 |
PROV-MIDDLE-INITIAL |
X(1) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,267 |
1 |
1 |
1 |
1 |
1 |
PRV030 |
PROV-LAST-NAME |
X(30) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV030 |
PROV-LAST-NAME |
X(30) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,268 |
1 |
1 |
1 |
1 |
1 |
PRV031 |
SEX |
X(1) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV031 |
SEX |
X(1) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,269 |
1 |
1 |
1 |
1 |
1 |
PRV032 |
OWNERSHIP-CODE |
X(2) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV032 |
OWNERSHIP-CODE |
X(2) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,270 |
1 |
1 |
1 |
1 |
1 |
PRV033 |
PROV-PROFIT-STATUS |
X(2) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV033 |
PROV-PROFIT-STATUS |
X(2) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,271 |
1 |
1 |
1 |
1 |
1 |
PRV034 |
DATE-OF-BIRTH |
9(8) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV034 |
DATE-OF-BIRTH |
9(8) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,272 |
1 |
1 |
1 |
1 |
1 |
PRV035 |
DATE-OF-DEATH |
9(8) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV035 |
DATE-OF-DEATH |
9(8) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,273 |
1 |
1 |
1 |
1 |
1 |
PRV036 |
ACCEPTING-NEW-PATIENTS-IND |
X(1) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV036 |
ACCEPTING-NEW-PATIENTS-IND |
X(1) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,274 |
1 |
1 |
1 |
1 |
1 |
PRV037 |
STATE-NOTATION |
X(500) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV037 |
STATE-NOTATION |
X(500) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,275 |
1 |
1 |
1 |
1 |
1 |
PRV038 |
FILLER |
X(87) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
PRV038 |
FILLER |
X(87) |
PROVIDER |
PROV-ATTRIBUTES-MAIN-PRV00002 |
| 1,276 |
1 |
1 |
1 |
1 |
1 |
PRV039 |
RECORD-ID |
X(8) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV039 |
RECORD-ID |
X(8) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,277 |
1 |
1 |
1 |
1 |
1 |
PRV040 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV040 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,278 |
1 |
1 |
1 |
1 |
1 |
PRV041 |
RECORD-NUMBER |
9(11) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV041 |
RECORD-NUMBER |
9(11) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,279 |
1 |
1 |
1 |
1 |
1 |
PRV042 |
SUBMITTING-STATE-PROV-ID |
X(30) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV042 |
SUBMITTING-STATE-PROV-ID |
X(30) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,280 |
1 |
1 |
1 |
1 |
1 |
PRV043 |
PROV-LOCATION-ID |
X(5) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV043 |
PROV-LOCATION-ID |
X(5) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,281 |
1 |
1 |
1 |
1 |
1 |
PRV044 |
PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE |
9(8) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV044 |
PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE |
9(8) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,282 |
1 |
1 |
1 |
1 |
1 |
PRV045 |
PROV-LOCATION-AND-CONTACT-INFO-END-DATE |
9(8) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV045 |
PROV-LOCATION-AND-CONTACT-INFO-END-DATE |
9(8) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,283 |
1 |
0 |
1 |
1 |
1 |
PRV046 |
PROV-ADDR-TYPE |
X(1) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV046 |
ADDR-TYPE |
X(1) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,284 |
1 |
1 |
1 |
1 |
1 |
PRV047 |
ADDR-LN1 |
X(60) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV047 |
ADDR-LN1 |
X(60) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,285 |
1 |
1 |
1 |
1 |
1 |
PRV048 |
ADDR-LN2 |
X(60) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV048 |
ADDR-LN2 |
X(60) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,286 |
1 |
1 |
1 |
1 |
1 |
PRV049 |
ADDR-LN3 |
X(60) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV049 |
ADDR-LN3 |
X(60) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,287 |
1 |
1 |
1 |
1 |
1 |
PRV050 |
ADDR-CITY |
X(28) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV050 |
ADDR-CITY |
X(28) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,288 |
1 |
1 |
1 |
1 |
1 |
PRV051 |
ADDR-STATE |
X(2) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV051 |
ADDR-STATE |
X(2) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,289 |
1 |
1 |
1 |
1 |
1 |
PRV052 |
ADDR-ZIP-CODE |
X(9) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV052 |
ADDR-ZIP-CODE |
X(9) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,290 |
1 |
1 |
1 |
1 |
1 |
PRV053 |
ADDR-TELEPHONE |
X(10) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV053 |
ADDR-TELEPHONE |
X(10) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,291 |
1 |
1 |
1 |
1 |
1 |
PRV054 |
ADDR-EMAIL |
X(60) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV054 |
ADDR-EMAIL |
X(60) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,292 |
1 |
1 |
1 |
1 |
1 |
PRV055 |
ADDR-FAX-NUM |
X(10) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV055 |
ADDR-FAX-NUM |
X(10) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,293 |
1 |
1 |
1 |
1 |
1 |
PRV056 |
ADDR-BORDER-STATE-IND |
X(1) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV056 |
ADDR-BORDER-STATE-IND |
X(1) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,294 |
1 |
1 |
1 |
1 |
1 |
PRV057 |
ADDR-COUNTY |
X(3) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV057 |
ADDR-COUNTY |
X(3) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,295 |
1 |
1 |
1 |
1 |
1 |
PRV058 |
STATE-NOTATION |
X(500) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV058 |
STATE-NOTATION |
X(500) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,296 |
1 |
1 |
1 |
1 |
1 |
PRV059 |
FILLER |
X(224) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
PRV059 |
FILLER |
X(224) |
PROVIDER |
PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| 1,297 |
1 |
1 |
1 |
1 |
1 |
PRV060 |
RECORD-ID |
X(8) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV060 |
RECORD-ID |
X(8) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,298 |
1 |
1 |
1 |
1 |
1 |
PRV061 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV061 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,299 |
1 |
1 |
1 |
1 |
1 |
PRV062 |
RECORD-NUMBER |
9(11) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV062 |
RECORD-NUMBER |
9(11) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,300 |
1 |
1 |
1 |
1 |
1 |
PRV063 |
SUBMITTING-STATE-PROV-ID |
X(30) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV063 |
SUBMITTING-STATE-PROV-ID |
X(30) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,301 |
1 |
1 |
1 |
1 |
1 |
PRV064 |
PROV-LOCATION-ID |
X(5) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV064 |
PROV-LOCATION-ID |
X(5) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,302 |
1 |
1 |
1 |
1 |
1 |
PRV065 |
PROV-LICENSE-EFF-DATE |
9(8) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV065 |
PROV-LICENSE-EFF-DATE |
9(8) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,303 |
1 |
1 |
1 |
1 |
1 |
PRV066 |
PROV-LICENSE-END-DATE |
9(8) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV066 |
PROV-LICENSE-END-DATE |
9(8) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,304 |
1 |
1 |
1 |
1 |
1 |
PRV067 |
LICENSE-TYPE |
X(1) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV067 |
LICENSE-TYPE |
X(1) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,305 |
1 |
1 |
1 |
1 |
1 |
PRV068 |
LICENSE-ISSUING-ENTITY-ID |
X(60) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV068 |
LICENSE-ISSUING-ENTITY-ID |
X(60) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,306 |
1 |
1 |
1 |
1 |
1 |
PRV069 |
LICENSE-OR-ACCREDITATION-NUMBER |
X(20) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV069 |
LICENSE-OR-ACCREDITATION-NUMBER |
X(20) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,307 |
1 |
1 |
1 |
1 |
1 |
PRV070 |
STATE-NOTATION |
X(500) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV070 |
STATE-NOTATION |
X(500) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,308 |
1 |
1 |
1 |
1 |
1 |
PRV071 |
FILLER |
X(447) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
PRV071 |
FILLER |
X(447) |
PROVIDER |
PROV-LICENSING-INFO-PRV00004 |
| 1,309 |
1 |
1 |
1 |
1 |
1 |
PRV072 |
RECORD-ID |
X(8) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV072 |
RECORD-ID |
X(8) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,310 |
1 |
1 |
1 |
1 |
1 |
PRV073 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV073 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,311 |
1 |
1 |
1 |
1 |
1 |
PRV074 |
RECORD-NUMBER |
9(11) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV074 |
RECORD-NUMBER |
9(11) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,312 |
1 |
1 |
1 |
1 |
1 |
PRV075 |
SUBMITTING-STATE-PROV-ID |
X(30) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV075 |
SUBMITTING-STATE-PROV-ID |
X(30) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,313 |
1 |
1 |
1 |
1 |
1 |
PRV076 |
PROV-LOCATION-ID |
X(5) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV076 |
PROV-LOCATION-ID |
X(5) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,314 |
1 |
1 |
1 |
1 |
1 |
PRV077 |
PROV-IDENTIFIER-TYPE |
X(1) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV077 |
PROV-IDENTIFIER-TYPE |
X(1) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,315 |
1 |
1 |
1 |
1 |
1 |
PRV078 |
PROV-IDENTIFIER-ISSUING-ENTITY-ID |
X(18) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV078 |
PROV-IDENTIFIER-ISSUING-ENTITY-ID |
X(18) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,316 |
1 |
1 |
1 |
1 |
1 |
PRV079 |
PROV-IDENTIFIER-EFF-DATE |
9(8) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV079 |
PROV-IDENTIFIER-EFF-DATE |
9(8) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,317 |
1 |
1 |
1 |
1 |
1 |
PRV080 |
PROV-IDENTIFIER-END-DATE |
9(8) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV080 |
PROV-IDENTIFIER-END-DATE |
9(8) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,318 |
1 |
1 |
1 |
1 |
1 |
PRV081 |
PROV-IDENTIFIER |
X(12) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV081 |
PROV-IDENTIFIER |
X(12) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,319 |
1 |
1 |
1 |
1 |
1 |
PRV082 |
STATE-NOTATION |
X(500) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV082 |
STATE-NOTATION |
X(500) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,320 |
1 |
1 |
1 |
1 |
1 |
PRV083 |
FILLER |
X(497) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
PRV083 |
FILLER |
X(497) |
PROVIDER |
PROV-IDENTIFIERS-PRV00005 |
| 1,321 |
1 |
1 |
1 |
1 |
1 |
PRV084 |
RECORD-ID |
X(8) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV084 |
RECORD-ID |
X(8) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,322 |
1 |
1 |
1 |
1 |
1 |
PRV085 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV085 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,323 |
1 |
1 |
1 |
1 |
1 |
PRV086 |
RECORD-NUMBER |
9(11) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV086 |
RECORD-NUMBER |
9(11) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,324 |
1 |
1 |
1 |
1 |
1 |
PRV087 |
SUBMITTING-STATE-PROV-ID |
X(30) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV087 |
SUBMITTING-STATE-PROV-ID |
X(30) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,325 |
1 |
1 |
1 |
1 |
1 |
PRV088 |
PROV-CLASSIFICATION-TYPE |
X(1) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV088 |
PROV-CLASSIFICATION-TYPE |
X(1) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,326 |
1 |
1 |
1 |
1 |
1 |
PRV089 |
PROV-CLASSIFICATION-CODE |
X(20) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV089 |
PROV-CLASSIFICATION-CODE |
X(20) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,327 |
1 |
1 |
1 |
1 |
1 |
PRV090 |
PROV-TAXONOMY-CLASSIFICATION-EFF-DATE |
9(8) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV090 |
PROV-TAXONOMY-CLASSIFICATION-EFF-DATE |
9(8) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,328 |
1 |
1 |
1 |
1 |
1 |
PRV091 |
PROV-TAXONOMY-CLASSIFICATION-END-DATE |
9(8) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV091 |
PROV-TAXONOMY-CLASSIFICATION-END-DATE |
9(8) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,329 |
1 |
1 |
1 |
1 |
1 |
PRV092 |
STATE-NOTATION |
X(500) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV092 |
STATE-NOTATION |
X(500) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,330 |
1 |
1 |
1 |
1 |
1 |
PRV093 |
FILLER |
X(512) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
PRV093 |
FILLER |
X(512) |
PROVIDER |
PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| 1,331 |
1 |
1 |
1 |
1 |
1 |
PRV094 |
RECORD-ID |
X(8) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV094 |
RECORD-ID |
X(8) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,332 |
1 |
1 |
1 |
1 |
1 |
PRV095 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV095 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,333 |
1 |
1 |
1 |
1 |
1 |
PRV096 |
RECORD-NUMBER |
9(11) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV096 |
RECORD-NUMBER |
9(11) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,334 |
1 |
1 |
1 |
1 |
1 |
PRV097 |
SUBMITTING-STATE-PROV-ID |
X(30) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV097 |
SUBMITTING-STATE-PROV-ID |
X(30) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,335 |
1 |
1 |
1 |
1 |
1 |
PRV098 |
PROV-MEDICAID-EFF-DATE |
9(8) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV098 |
PROV-MEDICAID-EFF-DATE |
9(8) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,336 |
1 |
1 |
1 |
1 |
1 |
PRV099 |
PROV-MEDICAID-END-DATE |
9(8) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV099 |
PROV-MEDICAID-END-DATE |
9(8) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,337 |
1 |
1 |
1 |
1 |
1 |
PRV100 |
PROV-MEDICAID-ENROLLMENT-STATUS-CODE |
X(2) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV100 |
PROV-MEDICAID-ENROLLMENT-STATUS-CODE |
X(2) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,338 |
1 |
1 |
1 |
1 |
1 |
PRV101 |
STATE-PLAN-ENROLLMENT |
X(1) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV101 |
STATE-PLAN-ENROLLMENT |
X(1) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,339 |
1 |
1 |
1 |
1 |
1 |
PRV102 |
PROV-ENROLLMENT-METHOD |
X(1) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV102 |
PROV-ENROLLMENT-METHOD |
X(1) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,340 |
1 |
1 |
1 |
1 |
1 |
PRV103 |
APPL-DATE |
9(8) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV103 |
APPL-DATE |
9(8) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,341 |
1 |
1 |
1 |
1 |
1 |
PRV104 |
STATE-NOTATION |
X(500) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV104 |
STATE-NOTATION |
X(500) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,342 |
1 |
1 |
1 |
1 |
1 |
PRV105 |
FILLER |
X(521) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
PRV105 |
FILLER |
X(521) |
PROVIDER |
PROV-MEDICAID-ENROLLMENT-PRV00007 |
| 1,343 |
1 |
1 |
1 |
1 |
1 |
PRV106 |
RECORD-ID |
X(8) |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
PRV106 |
RECORD-ID |
X(8) |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| 1,344 |
1 |
1 |
1 |
1 |
1 |
PRV107 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
PRV107 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| 1,345 |
1 |
1 |
1 |
1 |
1 |
PRV108 |
RECORD-NUMBER |
9(11) |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
PRV108 |
RECORD-NUMBER |
9(11) |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| 1,346 |
1 |
1 |
1 |
1 |
1 |
PRV109 |
SUBMITTING-STATE-PROV-ID |
X(30) |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
PRV109 |
SUBMITTING-STATE-PROV-ID |
X(30) |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| 1,347 |
1 |
1 |
1 |
1 |
1 |
PRV110 |
SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY |
X(12) |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
PRV110 |
SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY |
X(12) |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| 1,348 |
1 |
1 |
1 |
1 |
1 |
PRV111 |
PROV-AFFILIATED-GROUP-EFF-DATE |
9(8) |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
PRV111 |
PROV-AFFILIATED-GROUP-EFF-DATE |
9(8) |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| 1,349 |
1 |
1 |
1 |
1 |
1 |
PRV112 |
PROV-AFFILIATED-GROUP-END-DATE |
9(8) |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
PRV112 |
PROV-AFFILIATED-GROUP-END-DATE |
9(8) |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| 1,350 |
1 |
1 |
1 |
1 |
1 |
PRV113 |
STATE-NOTATION |
X(500) |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
PRV113 |
STATE-NOTATION |
X(500) |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| 1,351 |
1 |
1 |
1 |
1 |
1 |
PRV114 |
FILLER |
X(521) |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
PRV114 |
FILLER |
X(521) |
PROVIDER |
PROV-AFFILIATED-GROUPS-PRV00008 |
| 1,352 |
1 |
1 |
1 |
1 |
1 |
PRV115 |
RECORD-ID |
X(8) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV115 |
RECORD-ID |
X(8) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| 1,353 |
1 |
1 |
1 |
1 |
1 |
PRV116 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV116 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| 1,354 |
1 |
1 |
1 |
1 |
1 |
PRV117 |
RECORD-NUMBER |
9(11) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV117 |
RECORD-NUMBER |
9(11) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| 1,355 |
1 |
1 |
1 |
1 |
1 |
PRV118 |
SUBMITTING-STATE-PROV-ID |
X(30) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV118 |
SUBMITTING-STATE-PROV-ID |
X(30) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| 1,356 |
1 |
1 |
1 |
1 |
1 |
PRV119 |
AFFILIATED-PROGRAM-TYPE |
X(1) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV119 |
AFFILIATED-PROGRAM-TYPE |
X(1) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| 1,357 |
1 |
1 |
1 |
1 |
1 |
PRV120 |
AFFILIATED-PROGRAM-ID |
X(50) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV120 |
AFFILIATED-PROGRAM-ID |
X(50) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| 1,358 |
1 |
1 |
1 |
1 |
1 |
PRV121 |
PROV-AFFILIATED-PROGRAM-EFF-DATE |
9(8) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV121 |
PROV-AFFILIATED-PROGRAM-EFF-DATE |
9(8) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| 1,359 |
1 |
1 |
1 |
1 |
1 |
PRV122 |
PROV-AFFILIATED-PROGRAM-END-DATE |
9(8) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV122 |
PROV-AFFILIATED-PROGRAM-END-DATE |
9(8) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| 1,360 |
1 |
1 |
1 |
1 |
1 |
PRV123 |
STATE-NOTATION |
X(500) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV123 |
STATE-NOTATION |
X(500) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| 1,361 |
1 |
1 |
1 |
1 |
1 |
PRV124 |
FILLER |
X(482) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
PRV124 |
FILLER |
X(482) |
PROVIDER |
PROV-AFFILIATED-PROGRAMS-PRV00009 |
| 1,362 |
1 |
1 |
1 |
1 |
1 |
PRV125 |
RECORD-ID |
X(8) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV125 |
RECORD-ID |
X(8) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,363 |
1 |
1 |
1 |
1 |
1 |
PRV126 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV126 |
SUBMITTING-STATE |
X(2) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,364 |
1 |
1 |
1 |
1 |
1 |
PRV127 |
RECORD-NUMBER |
9(11) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV127 |
RECORD-NUMBER |
9(11) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,365 |
1 |
1 |
1 |
1 |
1 |
PRV128 |
SUBMITTING-STATE-PROV-ID |
X(30) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV128 |
SUBMITTING-STATE-PROV-ID |
X(30) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,366 |
1 |
1 |
1 |
1 |
1 |
PRV129 |
PROV-LOCATION-ID |
X(5) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV129 |
PROV-LOCATION-ID |
X(5) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,367 |
1 |
1 |
1 |
1 |
1 |
PRV130 |
BED-TYPE-EFF-DATE |
9(8) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV130 |
BED-TYPE-EFF-DATE |
9(8) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,368 |
1 |
1 |
1 |
1 |
1 |
PRV131 |
BED-TYPE-END-DATE |
9(8) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV131 |
BED-TYPE-END-DATE |
9(8) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,369 |
1 |
1 |
1 |
1 |
1 |
PRV134 |
BED-TYPE-CODE |
X(1) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV134 |
BED-TYPE-CODE |
X(1) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,370 |
1 |
1 |
1 |
1 |
1 |
PRV135 |
BED-COUNT |
9(5) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV135 |
BED-COUNT |
9(5) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,371 |
1 |
1 |
1 |
1 |
1 |
PRV136 |
STATE-NOTATION |
X(500) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV136 |
STATE-NOTATION |
X(500) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,372 |
1 |
1 |
1 |
1 |
1 |
PRV137 |
FILLER |
X(522) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
PRV137 |
FILLER |
X(522) |
PROVIDER |
PROV-BED-TYPE-INFO-PRV00010 |
| 1,373 |
1 |
1 |
1 |
1 |
1 |
TPL001 |
RECORD-ID |
X(8) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL001 |
RECORD-ID |
X(8) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,374 |
1 |
1 |
1 |
1 |
1 |
TPL002 |
DATA-DICTIONARY-VERSION |
X(10) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL002 |
DATA-DICTIONARY-VERSION |
X(10) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,375 |
1 |
1 |
1 |
1 |
1 |
TPL003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL003 |
SUBMISSION-TRANSACTION-TYPE |
X(1) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,376 |
1 |
1 |
1 |
1 |
1 |
TPL004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL004 |
FILE-ENCODING-SPECIFICATION |
X(3) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,377 |
1 |
1 |
1 |
1 |
1 |
TPL005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL005 |
DATA-MAPPING-DOCUMENT-VERSION |
X(9) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,378 |
1 |
1 |
1 |
1 |
1 |
TPL006 |
FILE-NAME |
X(8) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL006 |
FILE-NAME |
X(8) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,379 |
1 |
1 |
1 |
1 |
1 |
TPL007 |
SUBMITTING-STATE |
X(2) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL007 |
SUBMITTING-STATE |
X(2) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,380 |
1 |
1 |
1 |
1 |
1 |
TPL008 |
DATE-FILE-CREATED |
9(8) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL008 |
DATE-FILE-CREATED |
9(8) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,381 |
1 |
1 |
1 |
1 |
1 |
TPL009 |
START-OF-TIME-PERIOD |
9(8) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL009 |
START-OF-TIME-PERIOD |
9(8) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,382 |
1 |
1 |
1 |
1 |
1 |
TPL010 |
END-OF-TIME-PERIOD |
9(8) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL010 |
END-OF-TIME-PERIOD |
9(8) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,383 |
1 |
1 |
1 |
1 |
1 |
TPL011 |
FILE-STATUS-INDICATOR |
X(1) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL011 |
FILE-STATUS-INDICATOR |
X(1) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,384 |
1 |
1 |
1 |
1 |
1 |
TPL012 |
SSN-INDICATOR |
X(1) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL012 |
SSN-INDICATOR |
X(1) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,385 |
1 |
1 |
1 |
1 |
1 |
TPL013 |
TOT-REC-CNT |
9(11) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL013 |
TOT-REC-CNT |
9(11) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,386 |
1 |
1 |
1 |
1 |
1 |
TPL088 |
SEQUENCE-NUMBER |
X(4) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL088 |
SEQUENCE-NUMBER |
X(4) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,387 |
1 |
1 |
1 |
1 |
1 |
TPL014 |
STATE-NOTATION |
X(500) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL014 |
STATE-NOTATION |
X(500) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,388 |
1 |
1 |
1 |
1 |
1 |
TPL015 |
FILLER |
X(318) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
TPL015 |
FILLER |
X(318) |
TPL |
FILE-HEADER-RECORD-TPL-TPL00001 |
| 1,389 |
1 |
1 |
1 |
1 |
1 |
TPL016 |
RECORD-ID |
X(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL016 |
RECORD-ID |
X(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,390 |
1 |
1 |
1 |
1 |
1 |
TPL017 |
SUBMITTING-STATE |
X(2) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL017 |
SUBMITTING-STATE |
X(2) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,391 |
1 |
1 |
1 |
1 |
1 |
TPL018 |
RECORD-NUMBER |
9(11) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL018 |
RECORD-NUMBER |
9(11) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,392 |
1 |
1 |
1 |
1 |
1 |
TPL019 |
MSIS-IDENTIFICATION-NUM |
X(20) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL019 |
MSIS-IDENTIFICATION-NUM |
X(20) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,393 |
1 |
1 |
1 |
1 |
1 |
TPL020 |
TPL-HEALTH-INSURANCE-COVERAGE-IND |
X(1) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL020 |
TPL-HEALTH-INSURANCE-COVERAGE-IND |
X(1) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,394 |
1 |
1 |
1 |
1 |
1 |
TPL021 |
TPL-OTHER-COVERAGE-IND |
X(1) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL021 |
TPL-OTHER-COVERAGE-IND |
X(1) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,395 |
1 |
1 |
1 |
1 |
1 |
TPL022 |
ELIGIBLE-FIRST-NAME |
X(30) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL022 |
ELIGIBLE-FIRST-NAME |
X(30) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,396 |
1 |
1 |
1 |
1 |
1 |
TPL023 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL023 |
ELIGIBLE-MIDDLE-INIT |
X(1) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,397 |
1 |
1 |
1 |
1 |
1 |
TPL024 |
ELIGIBLE-LAST-NAME |
X(30) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL024 |
ELIGIBLE-LAST-NAME |
X(30) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,398 |
1 |
1 |
1 |
1 |
1 |
TPL025 |
ELIG-PRSN-MAIN-EFF-DATE |
9(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL025 |
ELIG-PRSN-MAIN-EFF-DATE |
9(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,399 |
1 |
1 |
1 |
1 |
1 |
TPL026 |
ELIG-PRSN-MAIN-END-DATE |
9(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL026 |
ELIG-PRSN-MAIN-END-DATE |
9(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,400 |
1 |
1 |
1 |
1 |
1 |
TPL027 |
STATE-NOTATION |
X(500) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL027 |
STATE-NOTATION |
X(500) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,401 |
1 |
1 |
1 |
1 |
1 |
TPL028 |
FILLER |
X(280) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
TPL028 |
FILLER |
X(280) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| 1,402 |
1 |
1 |
1 |
1 |
1 |
TPL029 |
RECORD-ID |
X(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL029 |
RECORD-ID |
X(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,403 |
1 |
1 |
1 |
1 |
1 |
TPL030 |
SUBMITTING-STATE |
X(2) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL030 |
SUBMITTING-STATE |
X(2) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,404 |
1 |
1 |
1 |
1 |
1 |
TPL031 |
RECORD-NUMBER |
9(11) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL031 |
RECORD-NUMBER |
9(11) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,405 |
1 |
1 |
1 |
1 |
1 |
TPL032 |
MSIS-IDENTIFICATION-NUM |
X(20) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL032 |
MSIS-IDENTIFICATION-NUM |
X(20) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,406 |
1 |
1 |
1 |
1 |
1 |
TPL033 |
INSURANCE-CARRIER-ID-NUM |
X(12) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL033 |
INSURANCE-CARRIER-ID-NUM |
X(12) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,407 |
1 |
1 |
1 |
1 |
1 |
TPL034 |
INSURANCE-PLAN-ID |
X(20) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL034 |
INSURANCE-PLAN-ID |
X(20) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,408 |
1 |
1 |
1 |
1 |
1 |
TPL035 |
GROUP-NUM |
X(16) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL035 |
GROUP-NUM |
X(16) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,409 |
1 |
1 |
1 |
1 |
1 |
TPL036 |
MEMBER-ID |
X(20) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL036 |
MEMBER-ID |
X(20) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,410 |
1 |
1 |
1 |
1 |
1 |
TPL037 |
INSURANCE-PLAN-TYPE |
X(2) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL037 |
INSURANCE-PLAN-TYPE |
X(2) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,411 |
1 |
1 |
1 |
1 |
1 |
TPL089 |
COVERAGE-TYPE |
X(2) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL089 |
COVERAGE-TYPE |
X(2) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,412 |
1 |
1 |
1 |
1 |
1 |
TPL038 |
ANNUAL-DEDUCTIBLE-AMT |
S9(11)V99 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL038 |
ANNUAL-DEDUCTIBLE-AMT |
S9(11)V99 |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,413 |
1 |
1 |
1 |
1 |
1 |
TPL044 |
POLICY-OWNER-FIRST-NAME |
X(30) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL044 |
POLICY-OWNER-FIRST-NAME |
X(30) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,414 |
1 |
1 |
1 |
1 |
1 |
TPL045 |
POLICY-OWNER-LAST-NAME |
X(30) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL045 |
POLICY-OWNER-LAST-NAME |
X(30) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,415 |
1 |
1 |
1 |
1 |
1 |
TPL046 |
POLICY-OWNER-SSN |
X(9) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL046 |
POLICY-OWNER-SSN |
X(9) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,416 |
1 |
1 |
1 |
1 |
1 |
TPL047 |
POLICY-OWNER-CODE |
X(2) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL047 |
POLICY-OWNER-CODE |
X(2) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,417 |
1 |
1 |
1 |
1 |
1 |
TPL048 |
INSURANCE-COVERAGE-EFF-DATE |
9(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL048 |
INSURANCE-COVERAGE-EFF-DATE |
9(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,418 |
1 |
1 |
1 |
1 |
1 |
TPL049 |
INSURANCE-COVERAGE-END-DATE |
9(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL049 |
INSURANCE-COVERAGE-END-DATE |
9(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,419 |
1 |
1 |
1 |
1 |
1 |
TPL050 |
STATE-NOTATION |
X(500) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL050 |
STATE-NOTATION |
X(500) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,420 |
1 |
1 |
1 |
1 |
1 |
TPL051 |
FILLER |
X(187) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
TPL051 |
FILLER |
X(187) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| 1,421 |
1 |
1 |
1 |
1 |
1 |
TPL052 |
RECORD-ID |
X(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
TPL052 |
RECORD-ID |
X(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| 1,422 |
1 |
1 |
1 |
1 |
1 |
TPL053 |
SUBMITTING-STATE |
X(2) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
TPL053 |
SUBMITTING-STATE |
X(2) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| 1,423 |
1 |
1 |
1 |
1 |
1 |
TPL054 |
RECORD-NUMBER |
9(11) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
TPL054 |
RECORD-NUMBER |
9(11) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| 1,424 |
1 |
1 |
1 |
1 |
1 |
TPL055 |
INSURANCE-CARRIER-ID-NUM |
X(12) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
TPL055 |
INSURANCE-CARRIER-ID-NUM |
X(12) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| 1,425 |
1 |
1 |
1 |
1 |
1 |
TPL056 |
INSURANCE-PLAN-ID |
X(20) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
TPL056 |
INSURANCE-PLAN-ID |
X(20) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| 1,426 |
1 |
1 |
1 |
1 |
1 |
TPL057 |
INSURANCE-PLAN-TYPE |
X(2) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
TPL057 |
INSURANCE-PLAN-TYPE |
X(2) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| 1,427 |
1 |
1 |
1 |
1 |
1 |
TPL058 |
COVERAGE-TYPE |
X(2) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
TPL058 |
COVERAGE-TYPE |
X(2) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| 1,428 |
1 |
1 |
1 |
1 |
1 |
TPL059 |
INSURANCE-CATEGORIES-EFF-DATE |
9(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
TPL059 |
INSURANCE-CATEGORIES-EFF-DATE |
9(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| 1,429 |
1 |
1 |
1 |
1 |
1 |
TPL060 |
INSURANCE-CATEGORIES-END-DATE |
9(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
TPL060 |
INSURANCE-CATEGORIES-END-DATE |
9(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| 1,430 |
1 |
1 |
1 |
1 |
1 |
TPL061 |
STATE-NOTATION |
X(500) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
TPL061 |
STATE-NOTATION |
X(500) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| 1,431 |
1 |
1 |
1 |
1 |
1 |
TPL062 |
FILLER |
X(327) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
TPL062 |
FILLER |
X(327) |
TPL |
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| 1,432 |
1 |
1 |
1 |
1 |
1 |
TPL063 |
RECORD-ID |
X(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
TPL063 |
RECORD-ID |
X(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| 1,433 |
1 |
1 |
1 |
1 |
1 |
TPL064 |
SUBMITTING-STATE |
X(2) |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
TPL064 |
SUBMITTING-STATE |
X(2) |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| 1,434 |
1 |
1 |
1 |
1 |
1 |
TPL065 |
RECORD-NUMBER |
9(11) |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
TPL065 |
RECORD-NUMBER |
9(11) |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| 1,435 |
1 |
1 |
1 |
1 |
1 |
TPL066 |
MSIS-IDENTIFICATION-NUM |
X(20) |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
TPL066 |
MSIS-IDENTIFICATION-NUM |
X(20) |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| 1,436 |
1 |
1 |
1 |
1 |
1 |
TPL067 |
TYPE-OF-OTHER-THIRD-PARTY-LIABILITY |
X(1) |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
TPL067 |
TYPE-OF-OTHER-THIRD-PARTY-LIABILITY |
X(1) |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| 1,437 |
1 |
1 |
1 |
1 |
1 |
TPL068 |
OTHER-TPL-EFF-DATE |
9(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
TPL068 |
OTHER-TPL-EFF-DATE |
9(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| 1,438 |
1 |
1 |
1 |
1 |
1 |
TPL069 |
OTHER-TPL-END-DATE |
9(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
TPL069 |
OTHER-TPL-END-DATE |
9(8) |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| 1,439 |
1 |
1 |
1 |
1 |
1 |
TPL070 |
STATE-NOTATION |
X(500) |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
TPL070 |
STATE-NOTATION |
X(500) |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| 1,440 |
1 |
1 |
1 |
1 |
1 |
TPL071 |
FILLER |
X(342) |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
TPL071 |
FILLER |
X(342) |
TPL |
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| 1,441 |
1 |
1 |
1 |
1 |
0 |
TPL072 |
RECORD-ID |
X(8) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL072 |
RECORD-ID |
X(8) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION- TPL00006 |
| 1,442 |
1 |
1 |
1 |
1 |
1 |
TPL073 |
SUBMITTING-STATE |
X(2) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL073 |
SUBMITTING-STATE |
X(2) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,443 |
1 |
1 |
1 |
1 |
1 |
TPL074 |
RECORD-NUMBER |
9(11) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL074 |
RECORD-NUMBER |
9(11) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,444 |
1 |
1 |
1 |
1 |
1 |
TPL075 |
INSURANCE-CARRIER-ID-NUM |
X(12) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL075 |
INSURANCE-CARRIER-ID-NUM |
X(12) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,445 |
1 |
1 |
1 |
1 |
1 |
TPL076 |
TPL-ENTITY-ADDR-TYPE |
X(2) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL076 |
TPL-ENTITY-ADDR-TYPE |
X(2) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,446 |
1 |
1 |
1 |
1 |
1 |
TPL077 |
INSURANCE-CARRIER-ADDR-LN1 |
X(60) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL077 |
INSURANCE-CARRIER-ADDR-LN1 |
X(60) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,447 |
1 |
1 |
1 |
1 |
1 |
TPL078 |
INSURANCE-CARRIER-ADDR-LN2 |
X(60) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL078 |
INSURANCE-CARRIER-ADDR-LN2 |
X(60) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,448 |
1 |
1 |
1 |
1 |
1 |
TPL079 |
INSURANCE-CARRIER-ADDR-LN3 |
X(60) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL079 |
INSURANCE-CARRIER-ADDR-LN3 |
X(60) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,449 |
1 |
1 |
1 |
1 |
1 |
TPL080 |
INSURANCE-CARRIER-CITY |
X(28) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL080 |
INSURANCE-CARRIER-CITY |
X(28) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,450 |
1 |
1 |
1 |
1 |
1 |
TPL081 |
INSURANCE-CARRIER-STATE |
X(2) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL081 |
INSURANCE-CARRIER-STATE |
X(2) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,451 |
1 |
1 |
1 |
1 |
1 |
TPL082 |
INSURANCE-CARRIER-ZIP-CODE |
X(9) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL082 |
INSURANCE-CARRIER-ZIP-CODE |
X(9) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,452 |
1 |
1 |
1 |
1 |
1 |
TPL083 |
INSURANCE-CARRIER-PHONE-NUM |
X(10) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL083 |
INSURANCE-CARRIER-PHONE-NUM |
X(10) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,453 |
1 |
1 |
1 |
1 |
1 |
TPL084 |
TPL-ENTITY-CONTACT-INFO-EFF-DATE |
9(8) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL084 |
TPL-ENTITY-CONTACT-INFO-EFF-DATE |
9(8) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,454 |
1 |
1 |
1 |
1 |
1 |
TPL085 |
TPL-ENTITY-CONTACT-INFO-END-DATE |
9(8) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL085 |
TPL-ENTITY-CONTACT-INFO-END-DATE |
9(8) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,455 |
1 |
1 |
1 |
1 |
1 |
TPL086 |
STATE-NOTATION |
X(500) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL086 |
STATE-NOTATION |
X(500) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,456 |
1 |
1 |
1 |
1 |
1 |
TPL090 |
INSURANCE-CARRIER-NAIC-CODE |
X(10) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL090 |
INSURANCE-CARRIER-NAIC-CODE |
X(10) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,457 |
1 |
1 |
1 |
1 |
1 |
TPL091 |
INSURANCE-CARRIER-NAME |
X(30) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL091 |
INSURANCE-CARRIER-NAME |
X(30) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,458 |
1 |
1 |
1 |
1 |
1 |
TPL092 |
NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE |
X(1) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL092 |
NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE |
X(1) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,459 |
1 |
1 |
1 |
1 |
1 |
TPL093 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL093 |
NATIONAL-HEALTH-CARE-ENTITY-ID |
X(10) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,460 |
1 |
1 |
1 |
1 |
1 |
TPL094 |
NATIONAL-HEALTH-CARE-ENTITY-NAME |
X(50) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL094 |
NATIONAL-HEALTH-CARE-ENTITY-NAME |
X(50) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| 1,461 |
1 |
1 |
0 |
1 |
1 |
TPL087 |
FILLER |
X (19) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
TPL087 |
FILLER |
X(18) |
TPL |
TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |