Claim Lines File Data Elements

 The Extract Identifier code for this file is CD.

 

See Claim Data-Map Process document in the Claim Header File Data Elements section for more details on how the process affects both claim header and claim line records.

 

Field #

Field Name

Req.

Len

Type

Notes

1

VersionNumber

K

10

AN

Spec Version Number:  3.04

2

ClaimNumber

K

64

AN

Corresponding Claim Number from Header

3

ClaimLineNumber

R

4

NU

Claim Line Number

4

GroupNumber

K

20

AN

Corresponding Group Number from header

5

TOS

R

16

AN

Type of Service Code

6

ServiceTypeDesc

R

255

AN

Type of Service Description

7

POS

R

8

AN

Place of Service Code

8

CPT/SVC

R

10

AN

CPT/SVC Code

9

CPTDESC

R

50

AN

CPT Description

10

MOD1

R

2

AN

CPT Modifier 1

11

MOD2

R

2

AN

CPT Modifier 2

12

REV

R

8

AN

Revenue Code

13

RevDesc

R

50

AN

Revenue Code Description

14

DX

R

5

AN

Diagnosis Code

15

DOSStart

R

8

DT

Date of Service Start

16

DOSEnd

R

8

DT

Date of Service End

17

Charge

R

12

DE

Total Charge Amt Submitted to Payor

18

Ineligible

R

12

DE

Amt Not Covered by Plan (Over Usual & Reasonable)

19

Discount

R

12

DE

Discount or Penalty Amount

20

Eligible

R

12

DE

Eligible Charge (i.e. Total Charge – (excluded amt + discount/penalty amt))

21

Deductible

R

12

DE

Amt of Calendar Year Deductible applied for this charge

22

Units

R

12

NU

Units/Quantity

23

PaidAtPercent

R

8

DE

Percentage the Balance is paid at

24

Paid

R

12

DE

Total Paid Amount

25

Adjustment

O

12

DE

Adjustment Amount

26

RemarkCode1

R

8

AN

Remark Code 1

27

RemarkCodeDesc1

R

1000

AN

Remark Code Description 1

28

RemarkCode2

R

8

AN

Remark Code 2

29

RemarkCodeDesc2

R

1000

AN

Remark Code Description 2

30

RemarkCode3

R

8

AN

Remark Code 3

31

RemarkCodeDesc3

R

1000

AN

Remark Code Description 3

32

RemarkCode4

R

8

AN

Remark Code 4

33

RemarkCodeDesc4

R

1000

AN

Remark Code Description 4

34

BenefitCode

R

10

AN

Benefit Code

35

BenefitCodeDesc

R

255

AN

Benefit Code Description

36

Copay

R

12

DE

Co-Pay Amount

 

Field #

Field Name

Req.

Len

Type

Notes

37

BenefitDeductible

R

12

DE

Benefit Deductible Amount

38

UserDefinedText1

O

255

AN

User Defined Text Field 1

39

UserDefinedText2

O

255

AN

User Defined Text Field 2

40

UserDefinedText3

O

255

AN

User Defined Text Field 3

41

UserDefinedText4

O

255

AN

User Defined Text Field 4

42

UserDefinedNumeric1

O

12

DE

User Defined Numeric Field 1

43

UserDefinedNumeric2

O

12

DE

User Defined Numeric Field 2

44

UserDefinedNumeric3

O

12

DE

User Defined Numeric Field 3

45

UserDefinedNumeric4

O

12

DE

User Defined Numeric Field 4

46

ProvRemarkCode1

R

8

AN

Provider EOP Remark Code 1

47

ProvRemarkCodeDesc1

R

1000

AN

Provider EOP Remark Code Description 1

48

ProvRemarkCode2

R

8

AN

Provider EOP Remark Code 2

49

ProvRemarkCodeDesc2

R

1000

AN

Provider EOP Remark Code Description 2

50

ProvRemarkCode3

R

8

AN

Provider EOP Remark Code 3

51

ProvRemarkCodeDesc3

R

1000

AN

Provider EOP Remark Code Description 3

52

ProvRemarkCode4

R

8

AN

Provider EOP Remark Code 4

53

ProvRemarkCodeDesc4

R

1000

AN

Provider EOP Remark Code Description 4

54

PhysicianReserve

O

12

DE

Physician Reserve Amount

55

CoInsurance

R

12

DE

Co-Insurance Amount

56

Payment

O

12

DE

Provider Payment after Reserve

57

DXDesc

R

100

AN

Diagnosis Description

58

COB

R

12

DE

Coordination of Benefits Paid Amount

59

MemResponsibility

R

12

DE

Member’s Payment Responsibility

60

ContractNumber

O

64

AN

PPO Contract Number

61

CovAnalysisCode

O

2

AN

Coverage Analysis Code

62

NDCNumber

O

15

AN

National Drug Classification Number

63

AuthNumber

O

64

AN

The authorization number for this line

64

CheckNumber

O

20

AN

The check number for this line

65

PayorPDDT

O

8

DT

Date of Disbursement for this line

66

SystemClaimStatus

O

10

AN

Claim Status Code

67

SystemClaimStatusDesc

O

50

AN

Claim Status Description

68

CheckPayee

O

50

AN

Check Paid To Name

69

CheckAddress1

O

55

AN

Check Address

70

CheckAddress2

O

55

AN

Check Address 2

71

CheckCity

O

30

AN

Check Address City

72

CheckState

O

2

AN

Check Address State Abbreviation

73

CheckZip

O

10

AN

Check Address Zip Code

74

CheckAmount

O

12

DE

Amount of Check

75

PayeeTIN

O

12

AN

Provider of Service’s Tax ID Number

 

Note:  All claim lines must be placed in continuous order within the extract.

 

 

 

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