Member's gender. Member Date of Birth. Member City Name. The city location of the member. Member State or Province. As defined by the US Postal Service. Member ZIP Code. Admission Date. Admission Hour. HHMM: If only the hour is known, code the minutes as Admission Type. Type of Admission. Admission Source. Source of Admission. Discharge Hour. Discharge Status. Status of Discharge. Service Provider Number.
Payer assigned number for provider of service. Federal tax id for provider of service. National Service Provider ID. If available NPI for provider of service. Service Provider Entity Type Qualifier. Person or non-person qualifier of provider of service. Service Provider First Name. First name of provider of service. Service Provider Middle Name. Middle name of provider of service. Last name of provider of service. Service Provider Suffix. Any sufficx of provider of service.
Service Provider Specialty. Specialty code of provider of service as defined by payer. Service Provider City Name. The city location of the provider of service. Service Provider State or Province. As defined by the US Postal Service state or province of provider of service. Type of Bill - on Facility Claims. Institutional claim type of bill.
Site of service on professional claim. Status of claim. Admitting Diagnosis. Describes an injury, poisoning or adverse effect. Principal Diagnosis. Other Diagnosis - 1. Other Diagnosis - 2. Other Diagnosis - 3. Other Diagnosis 1 Present on Admission Indicator. Other Diagnosis 2. This payer-supplied field contains the ICD-9 diagnosis code for the second secondary diagnosis. Other Diagnosis 2 Present on Admission Indicator.
Other Diagnosis 3. This payer-supplied field contains the ICD-9 diagnosis code for the third secondary diagnosis. Other Diagnosis 3 Present on Admission Indicator. Other Diagnosis 4. This payer-supplied field contains the ICD-9 diagnosis code for the fourth secondary diagnosis. Other Diagnosis 4 Present on Admission Indicator.
Other Diagnosis 5. This payer-supplied field contains the ICD-9 diagnosis code for the fifth secondary diagnosis. Other Diagnosis 5 Present on Admission Indicator.
Other Diagnosis 6. This payer-supplied field contains the ICD-9 diagnosis code for the sixth secondary diagnosis. Other Diagnosis 6 Present on Admission Indicator. Other Diagnosis 7. This payer-supplied field contains the ICD-9 diagnosis code for the seventh secondary diagnosis.
Other Diagnosis 8. This payer-supplied field contains the ICD-9 diagnosis code for the eigth secondary diagnosis. This payer-supplied field describes an injury, poisoning, or adverse effect using an ICD-9 E-Code diagnosis.
Date of Service - From. This payer-supplied field contains the first date of service for this service line. This field contains an ICD-9 procedure code, which is generally available on inpatient claims. Inpatient Category Code. Inpatient Discharge Identifier. This field is a value-added element that associates all claim lines for a given inpatient stay under one coded value.
Date of Service - Thru. This payer-supplied field contains the last date of service for this service line. This field contains the line number for this service as reported by the payer. Member ID Number. This field generally represents a unique combination of member fields unique to the payer. National Drug Code. This field contains the National Drug Code for this claim as reported by the payer. Original Claim ID number. This field is used with adjustments.
Paid Amount Medical Paid Amount. This payer-supplied field contains the total dollar amount paid to the provider, including all health plan payments and excluding withhold amounts and all member payments.
This field contains the data reporter code for the payer or data reporter submitting payments. This field contains the Payer ID Number. Provider ID Medical Claims. This field contains the payer-assigned provider number. National Plan ID. This payer-supplied field contains the National Plan ID for the data reporter. Prepaid Amount. This payer-supplied field contains the fee for service equivalent that would have been paid by the health care claims processor for a specific service if the service had not been capitated.
Standardized Product Code. This field contains the code identifying the member's type of insurance or insurance product. This field contains a count of services performed as reported by the payer. This payer-supplied field contains the revenue code for hospital claims as reported per the National Uniform Billing Committee's official UB specifications manual.
Service Provider Number. This field contains the service provider ID number. Service Site Professional. This payer-supplied field, which is required for professional claims and is not be used for institutional claims, records the site where the service was performed.
Type of Service. This field contains the type of service for this claim. FL Occurrence Codes and Dates — 2 alphanumeric characters that identify a significant event related to this claim.
FL Occurrence Span Codes and Dates — 2 alphanumeric characters that identify an event that relates to payment of the claim. These codes identify occurrences that happened over a span of time. FL Value Codes and Amounts — 2 alphanumeric characters that identify data elements that are necessary to process the claim and related dollar amounts or values. Enter revenue code as the last line with the sum of the charges billed.
FL Revenue Description - A description or standard abbreviation for each revenue code reported. FL Service Date — The date on which the indicated service was provided.
FL Service Units - A quantitative measure of services rendered including items such as the number of accommodation days, visits, miles, pints of blood, units of treatments.
FL Payer Name — Name of each health plan for which the provider might expect some payment for the bill. FL Rel. FL Asg. FL Est. Amount Due — represents an estimate by the hospital of the amount due from the indicated payer in FL50 on lines A, B, and C.
FL P. Rel — two alpha-numeric character code that indicates the relationship to the insured individual identified in FL 58 on lines A, B, and C. This field allows 20 alphanumeric characters in three lines.
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