Claims Header File Data Elements

The Extract Identifier code for this file is CH.

 

Refer to Appendix B, “Claim Data-Map Process,” for details on how claim records are added or updated in the Healthx database.

 

Field #

Field Name

Req.

Len

Type

Notes

1

VersionNumber

K

10

AN

Spec Version Number:  3.04

2

ClaimNumber

K

64

AN

Claim Number (must be an unique number)

3

PayorName

R

100

AN

Payor Name

4

GroupNumber

K

20

AN

Group Number

5

GroupName

R

100

AN

Group Name

6

MemberID

K

64

AN

ID # of the Member (from their ID card)

7

SSN

R

9

AN

Member’s SSN

8

FullName

R

50

AN

Member’s Last Name, First Name &/or Middle Name or Initial

9

Address1

R

100

AN

Member’s Address Line One

10

Address2

O

100

AN

Member’s Address Line Two

11

City

R

50

AN

Member’s City

12

State

R

2

AN

Member’s State

13

Zip

R

10

AN

Member’s Zip Code

14

ProcessedDate

R

8

DT

Date the EOB/Claim was processed

15

I/P

R

1

AN

Institutional/Professional Provider = I/P

16

PatientID

R

64

AN

ID # of the Patient (from their ID card)

17

PTName

R

100

AN

Patient Name

18

PTNumber

O

30

AN

Patient’s Account Number with Provider

19

PTDOB

R

8

DT

Patient’s Date of Birth

20

PTGender

R

1

AN

M = Male

F = Female

21

PCPName

O

100

AN

Primary Care Physician Name

22

AuthNumber

O

12

AN

Referral Authorization Number

23

DOSStart

R

8

DT

Date of Service – Start

24

DOSEnd

R

8

DT

Date of Service – End

25

OrgProviderID

R

100

AN

This is a value that uniquely identifies the provider and is used in the Provider Data Service to tie all provider data together. It can be an NPI, UPIN, or any other value that uniquely identifies the provider for your organization.  It should be a value the provider knows.

26

ProviderName

R

100

AN

Provider of Service’s Name

27

ProviderAddress1

R

100

AN

Provider of Service’s Address Line One

28

ProviderAddress2

O

100

AN

Provider of Service’s Address Line Two

29

ProviderCity

R

50

AN

Provider of Service’s City

30

ProviderState

R

2

AN

Provider of Service’s State

31

ProviderZip

R

10

AN

Provider of Service’s Zip Code

32

ProviderTIN

R

12

AN

Provider of Service’s Tax ID Number

 

Field #

Field Name

Req.

Len

Type

Notes

33

ProviderTINSuffix

R

10

AN

Provider of Service’s TIN Suffix

34

ProviderSpecCode

O

2

AN

Provider of Service’s Specialty Code

35

ProviderSpecDesc

O

100

AN

Provider of Service’s Specialty Description

36

ProviderGroupName

O

100

AN

Provider of Service’s Group Practice Name

37

AttendingProviderID

O

12

AN

Tax Identification Number or National Provider ID of the attending physician.

38

PPONumber

O

45

AN

Preferred Provider Organization Number

39

PPOName

O

50

AN

Preferred Provider Organization Name

40

WorkComp

O

1

AN

Worker’s Compensation – Y/N

41

TotalCOB

R

12

DE

Coordination of Benefits - $$$

42

SUBRO

O

1

AN

Subrogation – Y/N

43

Other_Insurance

O

1

AN

Other Insurance Coverage – Y/N

44

DX1

R

5

AN

Diagnosis Code

45

DX2

R

5

AN

Diagnosis Code – Addtl

46

DX3

R

5

AN

Diagnosis Code – Addtl

47

DX4

R

5

AN

Diagnosis Code – Addtl

48

DX5

R

5

AN

Diagnosis Code – Addtl

49

DX6

R

5

AN

Diagnosis Code – Addtl

50

DX7

R

5

AN

Diagnosis Code – Addtl

51

DX8

R

5

AN

Diagnosis Code – Addtl

52

DX9

R

5

AN

Diagnosis Code – Addtl

53

IOFlag

R

1

AN

Inpatient/Outpatient Designation – I/O

54

ProcMethod

R

10

AN

Procedure Code Type

55

PrincProc

R

8

AN

Principal Procedure Code

56

ProcDate

O

8

DT

Procedure Date

57

Proc2

R

8

AN

Procedure Code – Addtl

58

Proc2Date

O

8

DT

Procedure Date

59

Proc3

R

8

AN

Procedure Code – Addtl

60

Proc3Date

O

8

DT

Procedure Date

61

Proc4

R

8

AN

Procedure Code – Addtl

62

Proc4Date

O

8

DT

Procedure Date

63

Proc5

R

8

AN

Procedure Code – Addtl

64

Proc5Date

O

8

DT

Procedure Date

65

Proc6

R

8

AN

Procedure Code – Addtl

66

Proc6Date

O

8

DT

Procedure Date

67

DRG

R

5

AN

DRG Code

68

AdmitDX

R

5

AN

Admitting Diagnosis Code

69

AdmSource

O

12

AN

Admission Source

70

AdmType

O

12

AN

Admission Type

71

DischargeStatus

O

2

AN

Discharge Status

72

UB_BillType

O

8

AN

The Uniform Billing Bill Type

73

DedRem

O

12

DE

Calendar Year Deductible Remaining

74

DedRemDesc

O

30

AN

Deductible Description

75

DedRemNetwork

O

12

DE

Calendar Year PPO Deductible Remaining

76

DedRemNetorkDesc

O

30

AN

PPO Deductible Description

77

OOP

O

12

DE

Calendar Year Out-of-Pocket Remaining

78

OOPDesc

O

30

AN

Out-of-Pocket Description

79

OOPNetwork

O

12

DE

Calendar Year PPO Out-of-Pocket Remaining

 

Field #

Field Name

Req.

Len

Type

Notes

80

OOPNetworkDesc

O

30

AN

PPO Out-of-Pocket Description

81

TotalCharge

R

12

DE

Total Amount Submitted to Payor

82

TotalIneligible

R

12

DE

Total Amount Excluded by Plan (over U&C)

83

TotalEligible

R

12

DE

Total Eligible Amount

84

TotalPaidByOtherIns

O

12

DE

Total Paid by other Insurance other than COB

85

TotalDiscount

R

12

DE

Total Discount Amount

86

DiscountReason

R

100

AN

Discount Description

87

TotalDeductible

R

12

DE

Total Applied to Calendar year Deductible for this Claim

88

TotalCoPay

R

12

DE

Co-Pay Amount

89

AllowableCharge

R

12

DE

Usual/Reasonable & Customary

90

TotalMemResponsibility

R

12

DE

Member’s Payment Responsibility

91

TotalCheck1

R

12

DE

Amount Paid to Provider or Employee

92

TotalCheck2

R

12

DE

2nd Amount Paid to Provider or Employee

93

PayorPDDT

R

8

DT

Date of Disbursement

94

ProcessorID

O

12

AN

Claim Processor’s ID

95

LastChange

O

8

DT

Last Date Changes/Revision Made to Claim

96

OON_Flag

R

1

AN

Out-of-Network Indicator – Y/N

97

POS_Flag

R

6

AN

Point-of-Service Indicator

98

RelCode

R

15

AN

Relationship Code – Refer to Appendix B for HIPAA Relationship Codes

99

TotalAdjustment

O

12

DE

Adjustment Amount

100

AdjustDate

O

8

DT

Adjustment Date

101

AdjustMemo

O

255

AN

Adjustment Comments/Details

102

PLNYTDMED

O

12

DE

Plan YTD Medical Deductible Accumulated

103

PLNYTDFAM

O

12

DE

Plan YTD Family Deductible Accumulated

104

CheckNumber1

R

20

AN

Check Number 1

105

CheckPaidTo1

R

50

AN

Check Paid To1

106

CheckNumber2

R

20

AN

Check Number 2

107

CheckPaidTo2

R

50

AN

2nd Check Paid To

108

Comment

O

1000

AN

EOB Comments

109

ErrMsg

O

255

AN

Error Message

110

TotalCoInsurance

R

12

DE

Total Patient Coinsurance Amount

111

TotalBenefitDeductible

R

12

DE

Total Benefit Deductible Amount

112

TotalPaid

R

12

DE

Total Amount Payable

113

ClaimType

R

2

AN

M = Medical

D = Dental

V = Vision

9 = RX

W = Disability

To control the Display on Claim Results Screen, send:

ME  to display 'MED'

DE to display 'DEN'

VI to display 'VIS'

DR to display 'DRU'

HO to display 'HOS'

114

Location

R

12

AN

Location Code

115

ClaimReceivedDate

R

8

DT

Date Claim Received

116

SystemClaimStatus

R

10

AN

Claim Status Code

117

SystemClaimStatusDesc

R

50

AN

Claim Status Description

118

UserDefinedText1

O

255

AN

User Defined Text Field 1

119

UserDefinedText2

O

255

AN

User Defined Text Field 2

 

Field #

Field Name

Req.

Len

Type

Notes

120

UserDefinedText3

O

255

AN

User Defined Text Field 3

121

UserDefinedNumeric1

O

12

DE

User Defined Numeric Field 1

122

UserDefinedNumeric2

O

12

DE

User Defined Numeric Field 2

123

UserDefinedNumeric3

O

12

DE

User Defined Numeric Field 3

124

ProviderComments

O

1000

AN

EOP Comments

125

MasterTIN

O

12

AN

Master Provider TIN

126

ProdID

K

50

AN

Production Directory ID

127

NPIN

R

10

AN

National Provider ID

128

IntSystemID

O

64

AN

Claim System Internal ID for the Member

129

ProviderIntSystemID

O

64

AN

Claim System Internal ID for the Provider

130

BnftPlan

O

10

AN

Benefit Plan for the Claim

131

ActionFlag

R

1

AN

D = Delete

R = Restrict

Blank = Load/Update

 

Note:  The Claims extract should include the current detail of all headers and line information of each Claim, not the entire History of a claim’s header and lines. Claim Header amounts are the sum of all Lines.

 

 

 

 


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