Filetype Excel XLSX | Posted on 08 Aug 2022 | 3 years ago
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280x Filetype XLSX File size 0.05 MB Source: www.tdi.texas.gov
Sheet 1: SV1 Header
| Column Number | Column Label | Column Type | DN# | Encrypted | Description |
| 1 | Bill Selection Date | Date | Bill Selection Date is a date field common to bill and bill line item records. It is usually the earliest date of service on a bill. | ||
| 2 | Bill ID | Number | Bill ID uniquely identifies a bill and links line items to the bill. | ||
| 3 | Billing Provider Unique Bill Identification Number | Text | 523 | A unique number assigned by the billing provider to a specific bill within a batch of bills. | |
| 4 | Unique Bill ID Number | Text | 500 | Assigned by and unique to the Insurer. This number should never be reused except when sending bill submission type "01" for cancellations or "05" for replacing a bill. Acknowledgements will refer to this number when a bill is accepted or rejected. | |
| 5 | Bill Type | Text | SV1 = Professional Service | ||
| 6 | Reporting Period Start Date | Date | 615 | The start date during which the information sent was processed. | |
| 7 | Reporting Period End Date | Date | 615 | The end date during which the information sent was processed. | |
| 8 | Insurer FEIN | Text | 6 | Yes | The federal identification number of the carrier or self-insured assuming responsibility for workers' compensation claims. |
| 9 | Insurer Postal Code | Text | 616 | The zip code of the carrier or self-insured's specific business site. | |
| 10 | Claim Administrator FEIN | Text | 187 | Yes | The federal identification number of the entity licensed or allowed to adjust a bill. |
| 11 | Claim Administrator Name | Text | 188 | The name of the entity licensed or allowed to adjust a bill. | |
| 12 | Claim Administrator Postal Code | Text | 14 | The mailing zip code of the claim administrator's processing facility. | |
| 13 | Transaction Set Purpose Code | Text | 353 | Identifies the purpose of the transaction set. | |
| 14 | Employer FEIN | Text | 16 | Yes | The federal identification number of the employer where the employee was employed at the time of the injury. |
| 15 | Employer Physical City | Text | 21 | The city name of the facility where the injured worker was employed at the time of the injury. | |
| 16 | Employer Physical State Code | Text | 22 | The two-character state code of the facility where the injured worker was employed at the time of the injury. | |
| 17 | Employer Physical Postal Code | Text | 23 | The zip code of the facility where the injured worker was employed at the time of the injury. | |
| 18 | Employer Physical Country Code | Text | 164 | A three-character code indicating the country where the injured worker was employed at the time of the injury. | |
| 19 | Employee Mailing City | Text | 48 | The city name of the injured worker's mailing address. | |
| 20 | Employee Mailing State Code | Text | 49 | The two-character state code of the injured worker's mailing address. | |
| 21 | Employee Mailing Postal Code | Text | 50 | The zip code of the injured worker's mailing address. | |
| 22 | Employee Mailing Country Code | Text | 155 | A three-character code indicating the country of the injured worker's mailing address. | |
| 23 | Employee Date of Birth | Date | 52 | The month and year the injured worker was born. Day redacted. | |
| 24 | Employee Gender Code | Text | 53 | Indicates the sex of the injured worker: M=Male F=Female U=Unknown |
|
| 25 | Employee Marital Status Code | Text | 54 | Indicates the marital status of the injured worker: I=Single K=Unknown M=Married S=Separated U=Widowed |
|
| 26 | Claim Administrator Claim Number | Text | 15 | Yes | A number assigned by the insurance carrier or TPA to identify a specific claim. |
| 27 | Employee Date of Injury | Date | 31 | The month and year the accident occurred. Day redacted. | |
| 28 | Total Charge Per Bill | Number | 501 | The cumulative dollar amount of all line items on the bill. | |
| 29 | Billing Type Code | Text | 502 | Identifies the kind of billing: DM=Durable Medical MO=Mail Order Drug RX=Pharmacy or Drug |
|
| 30 | Place of Service Bill Code | Text | 555 | Identifies the place of service at the bill level. | |
| 31 | Billing Format Code | Text | 503 | Indicates the data is from a CMS1500. B=Professional (CMS 1500) Note: If the bill is not a CMS 1500, uses 'B' as the default. |
|
| 32 | Provider Signature On File Indicator | Text | 506 | Indicates if the signature of the provider is on file. Y=Yes N=No |
|
| 33 | Release of Information Code | Text | 526 | Identifies whether the release of information related to a claim is authorized or not. A = Appropriate release of information on file at health care service provider or at a URA. I = Informed consent to release medical information for conditions or diagnosis regulated by Federal Statues. M = The provider has a limited or restricted ability to release data related to a claim. N = No, provider is not allowed to release data. O = On file at payor or at plan sponsor. Y = Yes, provider has signed statement permitting release of medical billing data related to the claim. |
|
| 34 | Provider Agreement Code | Text | 507 | Identifies the kind of provider agreement applicable to a bill: H=Network N=No Agreement P=Participant Agreement Y=PPO Agreement |
|
| 35 | Bill Submission Reason Code | Text | 508 | Identifies the bill submission/re-submission type: 00 = Original 01 = Cancellation (removed during bill sequencing) 05 = Replacement |
|
| 36 | Date Insurer Received Bill | Date | 511 | The calendar date the insurer received the bill from the provider. | |
| 37 | Service Bill From Date | Date | 509 | The starting date in which services were performed. | |
| 38 | Service Bill To Date | Date | 509 | The ending date in which services were performed. | |
| 39 | Date of Bill | Date | 510 | The provider's bill date. | |
| 40 | Date Insurer Paid Bill | Date | 512 | The calendar date the insurer or financially responsible party paid the bill or received credit from the provider. | |
| 41 | Contract Type Code | Text | 515 | Identifies the kind of contractual agreement for provider reimbursement: 01 = Diagnosis Related Group 02 = Per Diem 03 = Variable per diem 04 = Flat fee per service 05 = Capitate 06 = Percent 09 = Other |
|
| 42 | Total Amount Paid Per Bill | Number | 516 | The dollar amount paid or credited for a submitted bill by payor after adjustments. | |
| 43 | Patient Account Number | Text | 517 | Yes | A unique number assigned by the provider to identify the patient/claimant. |
| 44 | Transaction Tracking Number | Text | 266 | Yes | A number assigned by the sender (the organization that actually sent the data). |
| 45 | First ICD-9CM or ICD-10CM Diagnosis Code | Text | 522 | Identifies the diagnosis of the work related injury or illness. | |
| 46 | Second ICD-9CM or ICD-10CM Diagnosis Code | Text | 522 | Identifies the diagnosis of the work related injury or illness. | |
| 47 | Third ICD-9CM or ICD-10CM Diagnosis Code | Text | 522 | Identifies the diagnosis of the work related injury or illness. | |
| 48 | Fourth ICD-9CM or ICD-10CM Diagnosis Code | Text | 522 | Identifies the diagnosis of the work related injury or illness. | |
| 49 | Fifth ICD-9CM or ICD-10CM Diagnosis Code | Text | 522 | Identifies the diagnosis of the work related injury or illness. | |
| 50 | Facility Name | Text | 678 | The name of the facility where the medical services were rendered. Mandatory for SV1 bills. | |
| 51 | Facility FEIN | Text | 679 | Yes | The federal identification number of the facility where the medical services were rendered. |
| 52 | Facility Primary Address | Text | 684 | The first line in the facility's address. | |
| 53 | Facility Secondary Address | Text | 685 | The second line in the facility's address. | |
| 54 | Facility City | Text | 686 | The city name of the facility's address. | |
| 55 | Facility State Code | Text | 687 | The two-character state code of the facility's address. | |
| 56 | Facility Postal Code | Text | 688 | The zip code of the facility's address. | |
| 57 | Facility Country Code | Text | 689 | A three-character code indicating the country of the facility's mailing address. | |
| 58 | Facility State License Number | Text | 680 | A unique number assigned to identify the facility. | |
| 59 | Facility Medicare Number | Text | 681 | A unique number assigned to the facility by the Medicare program. | |
| 60 | Facility National Provider ID | Text | 682 | The unique National Provider ID of the facility. | |
| 61 | Managed Care Organization Identification | Text | 208 | Yes | The jurisdiction assigned number that corresponds to and uniquely identifies the managed care organization involved in the claim. |
| 62 | Billing Provider Last Name or Group | Text | 528 | The surname of the person or full name of an organization receiving payment. It is assumed to be the rendering provider for all services unless a specific rendering provider is identified at the bill or service line levels. If the billing provider is a non-person, a specific individual rendering bill provider may be required by a jurisdiction. | |
| 63 | Billing Provider First Name | Text | 529 | The given name of the billing provider. | |
| 64 | Billing Provider Middle Name Initial | Text | 530 | The middle name or initial of the billing provider. | |
| 65 | Billing Provider Suffix | Text | 531 | The legally recognized last name suffix of the billing provider which is used on legal documents. Examples: Jr., Sr., II, III | |
| 66 | Billing Provider FEIN | Text | 629 | Yes | The federal tax identification number of the billing provider. |
| 67 | Billing Provider Gate Keeper Indicator | Text | 534 | Indicates that the billing provider is the treating doctor. If present, must = 'GP' (Gateway Provider). | |
| 68 | Billing Provider Primary Specialty Code | Text | 537 | Indicates the primary specialty of the billing provider. | |
| 69 | Billing Provider Primary Address | Text | 538 | The first line in the billing provider's address. | |
| 70 | Billing Provider Secondary Address | Text | 539 | The second line of the billing provider's address. | |
| 71 | Billing Provider City | Text | 540 | The city name of the billing provider's address. | |
| 72 | Billing Provider State Code | Text | 541 | The two-character state code of the billing provider's address. | |
| 73 | Billing Provider Postal Code | Text | 542 | The zip code of the billing provider's address. | |
| 74 | Billing Provider Country Code | Text | 569 | A three-character code indicating the country of the billing provider's mailing address. | |
| 75 | Billing Provider State License Number | Text | 630 | The billing provider's license type, license number and jurisdiction code. | |
| 76 | Billing Provider Medicare Number | Text | 632 | The specific number issued to the billing provider by the Medicare program. | |
| 77 | Treatment Authorization Number | Text | 581 | A number assigned by the carrier to identify pre-authorized or pre-certified treatment plans. Y = reported, N = not reported. | |
| 78 | Billing Provider National Provider ID | Text | 634 | The unique National Provider ID of the billing provider. | |
| 79 | Rendering Bill Provider Last Name or Group | Text | 638 | The surname of the individual provider actually rendering care. If not present, the billing provider is assumed to be the rendering provider for all services on this bill. If the billing provider was not an individual, a jurisdiction may require a rendering bill provider to be specified. | |
| 80 | Rendering Bill Provider First Name | Text | 639 | The given name of the rendering bill provider. | |
| 81 | Rendering Bill Provider Middle Name Initial | Text | 640 | The middle name or initial of the rendering bill provider. | |
| 82 | Rendering Bill Provider Suffix | Text | 641 | The legally recognized last name suffix of the rendering bill provider which is used on legal documents. Examples: Jr., Sr., II, III | |
| 83 | Rendering Bill Provider FEIN | Text | 642 | Yes | The federal tax identification number of the rendering bill provider. |
| 84 | Rendering Bill Provider Gate Keeper Indicator | Text | 534 | Indicates that the rendering bill provider is the treating doctor. If present, must = 'GP' (Gateway Provider). | |
| 85 | Rendering Bill Provider Primary Specialty Code | Text | 651 | Indicates the primary medical specialty of the rendering bill provider. | |
| 86 | Rendering Bill Provider Primary Address | Text | 652 | The first line of the rendering bill provider's address. | |
| 87 | Rendering Bill Provider Secondary Address | Text | 653 | The second line of the rendering bill provider's address. | |
| 88 | Rendering Bill Provider City | Text | 654 | The city name of the rendering bill provider's address. | |
| 89 | Rendering Bill Provider State Code | Text | 655 | The two-character state code of the rendering bill provider's address. | |
| 90 | Rendering Bill Provider Postal Code | Text | 656 | The zip code in the rendering bill provider's address. | |
| 91 | Rendering Bill Provider Country Code | Text | 657 | A three-character code indicating the country of the rendering bill provider's mailing address. | |
| 92 | Rendering Bill Provider State License Number | Text | 643 | The rendering bill provider's license type, license number and jurisdiction code. | |
| 93 | Rendering Bill Provider National Provider ID | Text | 647 | The unique National Provider ID of the rendering bill provider. | |
| 94 | Referring Provider Last Name or Group | Text | 690 | The surname of the provider referring claimant for care. Only used when needed to document that a bill results from care provided based on a referral from another provider. | |
| 95 | Referring Provider First Name | Text | 691 | The given name of the referring provider. | |
| 96 | Referring Provider Middle Name Initial | Text | 692 | The middle name or initial of the referring provider. | |
| 97 | Referring Provider Suffix | Text | 693 | The legally recognized last name suffix of the referring provider which is used on legal documents. Examples: Jr., Sr., II, III | |
| 98 | Referring Provider FEIN | Text | 694 | Yes | The federal tax identification number of the referring provider. |
| 99 | Referring Provider Gate Keeper Indicator | Text | 534 | Indicates that the referring provider is the treating doctor. If present, must = 'GP' (Gateway Provider). | |
| 100 | Referring Provider State License Number | Text | 695 | The referring provider's license type, license number and jurisdiction code. | |
| 101 | Referring Provider Specialty License Number | Text | 701 | The specific license number issued by a state to the referring provider that denotes specialty of the referring provider. | |
| 102 | Referring Provider Medicare Number | Text | 697 | The specific number issued to the referring provider by the Medicare Program. | |
| 103 | Referring Provider National Provider ID | Text | 699 | The unique National Provider ID of the referring provider. |
| Column Number | Column Label | Column Type | DN# | Details |
| 1 | Bill Selection Date | Date | Bill Selection Date is a date field common to bill and bill line item records. It is usually the earliest date of service on a bill. | |
| 2 | Bill ID | Number | Bill ID uniquely identifies a bill and links line items to the bill. | |
| 3 | Bill Detail ID | Number | Bill Detail ID uniquely identifies a bill line item. | |
| 4 | Line Number | Number | The number of the line item on the bill. | |
| 5 | HCPCS Line Procedure Billed Code | Text | 714 | Identifies the treatment that was rendered and billed. HCPCS is the abbreviation for Health Care Financing Administration's Common Procedure Coding System. HCPCS codes include Level 1 CPT procedure codes. |
| 6 | First HCPCS Modifier Billed Code | Text | 717 | The first two-character code identifying special circumstances related to the procedure billed. |
| 7 | Second HCPCS Modifier Billed Code | Text | 717 | The second two-character code identifying special circumstances related to the procedure billed. |
| 8 | Third HCPCS Modifier Billed Code | Text | 717 | The third two-character code identifying special circumstances related to the procedure billed. |
| 9 | Fourth HCPCS Modifier Billed Code | Text | 717 | The fourth two-character code identifying special circumstances related to the procedure billed. |
| 10 | Procedure Description | Text | 551 | Free form text describing the treatment rendered. |
| 11 | Total Charge Per Line | Number | 552 | The service charge amount for the line item. |
| 12 | Days/Units Code | Text | 553 | Indicates the time or units billed or paid. DA = Days MJ = Minutes UN = Unit |
| 13 | Days/Units Billed | Number | 554 | The number of services billed for the line item in days or units. |
| 14 | Place of Service Line Code | Text | 600 | Identifies the place where the medical service was rendered. Examples: 21 = Inpatient Hospital 56 = Psychiatric Residential Treatment Center 72 = Rural Health Clinic |
| 15 | First Diagnosis Pointer | Text | 557 | References the diagnosis code (ICD-9 CM or ICD-10 CM) for which the medical services were rendered. |
| 16 | Second Diagnosis Pointer | Text | 557 | References the diagnosis code (ICD-9 CM or ICD-10 CM) for which the medical services were rendered. |
| 17 | Third Diagnosis Pointer | Text | 557 | References the diagnosis code (ICD-9 CM or ICD-10 CM) for which the medical services were rendered. |
| 18 | Fourth Diagnosis Pointer | Text | 557 | References the diagnosis code (ICD-9 CM or ICD-10 CM) for which the medical services were rendered. |
| 19 | CRNA Supervision Indicator | Text | 568 | Flags that a Certified Registered Nurse Anesthetist (CRNA) was supervised. Y = Yes, N = No |
| 20 | Provider Agreement Line Code | Text | 42 | Indicates the type of provider agreement applicable to the line item. H = Network N = No Agreement P = Participation Agreement Y = PPO Agreement |
| 21 | Service Line From Date | Date | 605 | The starting date that services were performed for the line item. |
| 22 | Service Line To Date | Date | 605 | The ending date that services were performed for the line item. |
| 23 | Contract Line Type Code | Text | 741 | A two-character code indicating the line item contractual arrangement for provider reimbursement. 01 = Diagnosis Related Group 02 = Per Diem 03 = Variable Per Diem 04 = Flat 05 = Capitate 06 = Percent 09 = Other |
| 24 | Treatment Line Authorization Number | Text | 738 | Defaults to the Treatment Authorization Number (DN581 at the bill level) unless a data element is transmitted in this field. Y = reported, N = not reported. |
| 25 | Total Amount Paid Per Line | Number | 574 | The total dollar amount paid or credited to the line item. |
| 26 | HCPCS Line Procedure Paid Code | Text | 726 | Identifies the treatment that was rendered and paid. |
| 27 | First HCPCS Modifier Paid Code | Text | 727 | The first two-character code identifying special circumstances related to the procedure paid. |
| 28 | Second HCPCS Modifier Paid Code | Text | 727 | The second two-character code identifying special circumstances related to the procedure paid. |
| 29 | Third HCPCS Modifier Paid Code | Text | 727 | The third two-character code identifying special circumstances related to the procedure paid. |
| 30 | Fourth HCPCS Modifier Paid Code | Text | 727 | The fourth two-character code identifying special circumstances related to the procedure paid. |
| 31 | Days/Units Paid | Number | 580 | The number of services paid for the line item in days or units. |
| 32 | Rendering Line Provider National Provider ID | Text | 592 | The unique National Provider ID of the rendering line provider. |
| 33 | Number of Service Adjustments | Number | The number of service adjustments for the line item. | |
| 34 | Service Adjustment Group Code 1 | Text | 731 | A code indicating the general category of the first adjustment made to the dollar amount paid or credited to the line item. CO = Contractual Obligations OA = Other Adjustments PI = Payer initiated reductions PR = Patient Responsibility |
| 35 | Service Adjustment Reason Code 1 | Text | 732 | A code indicating the detailed reason of the first adjustment made to the dollar amount paid or credited to the line item. |
| 36 | Service Adjustment Amount 1 | Number | 733 | The dollar amount of the first adjustment paid or credited to the line item. |
| 37 | Service Adjustment Units 1 | Number | 734 | The number of units applicable to the first adjustment to the line item. |
| 38 | Service Adjustment Group Code 2 | Text | 731 | A code indicating the general category of the second adjustment made to the dollar amount paid or credited to the line item. |
| 39 | Service Adjustment Reason Code 2 | Text | 732 | A code indicating the detailed reason of the second adjustment made to the dollar amount paid or credited to the line item. |
| 40 | Service Adjustment Amount 2 | Number | 733 | The dollar amount of the second adjustment paid or credited to the line item. |
| 41 | Service Adjustment Units 2 | Number | 734 | The number of units applicable to the second adjustment to the line item. |
| 42 | Service Adjustment Group Code 3 | Text | 731 | A code indicating the general category of the third adjustment made to the dollar amount paid or credited to the line item. |
| 43 | Service Adjustment Reason Code 3 | Text | 732 | A code indicating the detailed reason of the third adjustment made to the dollar amount paid or credited to the line item. |
| 44 | Service Adjustment Amount 3 | Number | 733 | The dollar amount of the third adjustment paid or credited to the line item. |
| 45 | Service Adjustment Units 3 | Number | 734 | The number of units applicable to the third adjustment to the line item. |
| 46 | Service Adjustment Group Code 4 | Text | 731 | A code indicating the general category of the fourth adjustment made to the dollar amount paid or credited to the line item. |
| 47 | Service Adjustment Reason Code 4 | Text | 732 | A code indicating the detailed reason of the fourth adjustment made to the dollar amount paid or credited to the line item. |
| 48 | Service Adjustment Amount 4 | Number | 733 | The dollar amount of the fourth adjustment paid or credited to the line item. |
| 49 | Service Adjustment Units 4 | Number | 734 | The number of units applicable to the fourth adjustment to the line item. |
| 50 | Service Adjustment Group Code 5 | Text | 731 | A code indicating the general category of the fifth adjustment made to the dollar amount paid or credited to the line item. |
| 51 | Service Adjustment Reason Code 5 | Text | 732 | A code indicating the detailed reason of the fifth adjustment made to the dollar amount paid or credited to the line item. |
| 52 | Service Adjustment Amount 5 | Number | 733 | The dollar amount of the fifth adjustment paid or credited to the line item. |
| 53 | Service Adjustment Units 5 | Number | 734 | The number of units applicable to the fifth adjustment to the line item. |
| Column Number | Column Label | Column Type | DN# | Encrypted | Description |
| 1 | Bill Selection Date | Date | Bill Selection Date is a date field common to bill and bill line item records. It is usually the earliest date of service on a bill. | ||
| 2 | Bill ID | Number | Bill ID uniquely identifies a bill and links line items to the bill. | ||
| 3 | Billing Provider Unique Bill Identification Number | Text | 523 | A unique number assigned by the billing provider to a specific bill within a batch of bills. | |
| 4 | Unique Bill ID Number | Text | 500 | Assigned by and unique to the Insurer. This number should never be reused except when sending bill submission type "01" for cancellations or "05" for replacing a bill. Acknowledgements will refer to this number when a bill is accepted or rejected. | |
| 5 | Bill Type | Text | SV2 = Institutional (Hospital) Service | ||
| 6 | Reporting Period Start Date | Date | 615 | The start date during which the information sent was processed. | |
| 7 | Reporting Period End Date | Date | 615 | The end date during which the information sent was processed. | |
| 8 | Insurer FEIN | Text | 6 | Yes | The federal identification number of the carrier or self-insured assuming responsibility for workers' compensation claims. |
| 9 | Insurer Postal Code | Text | 616 | The zip code of the carrier or self-insured's specific business site. | |
| 10 | Claim Administrator FEIN | Text | 187 | Yes | The federal identification number of the entity licensed or allowed to adjust a bill. |
| 11 | Claim Administrator Name | Text | 188 | The name of the entity licensed or allowed to adjust a bill. | |
| 12 | Claim Administrator Postal Code | Text | 14 | The mailing zip code of the claim administrator's processing facility. | |
| 13 | Transaction Set Purpose Code | Text | 353 | Identifies the purpose of the transaction set. | |
| 14 | Employer FEIN | Text | 16 | Yes | The federal identification number of the employer where the employee was employed at the time of the injury. |
| 15 | Employer Physical City | Text | 21 | The city name of the facility where the injured worker was employed at the time of the injury. | |
| 16 | Employer Physical State Code | Text | 22 | The two-character state code of the facility where the injured worker was employed at the time of the injury. | |
| 17 | Employer Physical Postal Code | Text | 23 | The zip code of the facility where the injured worker was employed at the time of the injury. | |
| 18 | Employer Physical Country Code | Text | 164 | A three-character code indicating the country where the injured worker was employed at the time of the injury. | |
| 19 | Employee Mailing City | Text | 48 | The city name of the injured worker's mailing address. | |
| 20 | Employee Mailing State Code | Text | 49 | The two-character state code of the injured worker's mailing address. | |
| 21 | Employee Mailing Postal Code | Text | 50 | The zip code of the injured worker's mailing address. | |
| 22 | Employee Mailing Country Code | Text | 155 | A three-character code indicating the country of the injured worker's mailing address. | |
| 23 | Employee Date of Birth | Date | 52 | The month and year the injured worker was born. Day redacted. | |
| 24 | Employee Gender Code | Text | 53 | Indicates the sex of the injured worker: M=Male F=Female U=Unknown |
|
| 25 | Employee Marital Status Code | Text | 54 | Indicates the marital status of the injured worker: I=Single K=Unknown M=Married S=Separated U=Widowed |
|
| 26 | Claim Administrator Claim Number | Text | 15 | Yes | A number assigned by the insurance carrier or TPA to identify a specific claim. |
| 27 | Employee Date of Injury | Date | 31 | The month and year the accident occurred. Day redacted. | |
| 28 | Total Charge Per Bill | Number | 501 | The cumulative dollar amount of all line items on the bill. | |
| 29 | Billing Type Code | Text | 502 | Identifies the kind of billing: DM = Durable Medical MO = Mail Order Drug RX = Pharmacy or Drug |
|
| 30 | Place of Service Bill Code | Text | 555 | Identifies the place of service at the bill level. | |
| 31 | Billing Format Code | Text | 503 | Indicates the data is from a UB92. A = Institutional (UB 92) Note: If the bill is not a UB92, use 'A' as the default. |
|
| 32 | Provider Signature On File Indicator | Text | 506 | Indicates if the signature of the provider is on file. Y=Yes N=No |
|
| 33 | Release of Information Code | Text | 526 | Identifies whether the release of information related to a claim is authorized or not. A = Appropriate release of information on file at health care service provider or at a URA. I = Informed consent to release medical information for conditions or diagnosis regulated by Federal Statues. M = The provider has a limited or restricted ability to release data related to a claim. N = No, provider is not allowed to release data. O = On file at payor or at plan sponsor. Y = Yes, provider has signed statement permitting release of medical billing data related to the claim. |
|
| 34 | Provider Agreement Code | Text | 507 | Identifies the kind of provider agreement applicable to a bill: H=Network N=No Agreement P=Participant Agreement Y=PPO Agreement |
|
| 35 | Facility Code | Text | 504 | Identifies the kind of facility where treatment was rendered. | |
| 36 | Bill Frequency Type Code | Text | 505 | Indicates the claim billing status: 0 = Non Payment/Zero Payment 1 = Admit through Discharge Claim 2 = Interim - First Claim 3 = Interim - Continuing Claim 4 = Interim - Last Claim 5 = Late Charges(s) Only Claim 6 = Adjustment of Prior Claim 7 = Replacement of Prior Claim 8 = Void/Cancel of Prior Claim |
|
| 37 | Admission Date | Date | 513 | The calendar date the claimant was admitted to the facility. | |
| 38 | Admission Hour | Time | 622 | The hour the claimant was admitted to the facility. Format: HH:MM:SS | |
| 39 | Discharge Date | Date | 514 | The calendar date the claimant was discharged from the facility. | |
| 40 | Discharge Hour | Time | 623 | The hour the claimant was discharged from the facility. Format: HH:MM:SS | |
| 41 | Admission Type Code | Text | 577 | Identifies the kind of admission: 1 = Emergency 2 = Urgent 3 = Elective 9 = Information not available |
|
| 42 | Diagnosis Related Group Code | Text | 518 | Classification of a hospital stay in terms of what was wrong and what was done for the patient. The DRG frequently determines the amount of money that will be reimbursed, independently of the charges that the hospital may have incurred. | |
| 43 | Bill Submission Reason Code | Text | 508 | Identifies the bill submission/re-submission type: 00 = Original 01 = Cancellation (removed during bill sequencing) 05 = Replacement |
|
| 44 | Date Insurer Received Bill | Date | 511 | The calendar date the insurer received the bill from the provider. | |
| 45 | Service Bill From Date | Date | 509 | The starting date in which services were performed. | |
| 46 | Service Bill To Date | Date | 509 | The ending date in which services were performed. | |
| 47 | Date of Bill | Date | 510 | The provider's bill date. | |
| 48 | Date Insurer Paid Bill | Date | 512 | The calendar date the insurer or financially responsible party paid the bill or received credit from the provider. | |
| 49 | Contract Type Code | Text | 515 | Identifies the kind of contractual agreement for provider reimbursement: 01 = Diagnosis Related Group 02 = Per Diem 03 = Variable per diem 04 = Flat fee per service 05 = Capitate 06 = Percent 09 = Other |
|
| 50 | Total Amount Paid Per Bill | Number | 516 | The dollar amount paid or credited for a submitted bill by payor after adjustments. | |
| 51 | Patient Account Number | Text | 517 | Yes | A unique number assigned by the provider to identify the patient/claimant. |
| 52 | Transaction Tracking Number | Text | 266 | Yes | A number assigned by the sender (the organization that actually sent the data). |
| 53 | First ICD-9CM or ICD-10CM Diagnosis Code | Text | 522 | Identifies the diagnosis of the work related injury or illness. | |
| 54 | Second ICD-9CM or ICD-10CM Diagnosis Code | Text | 522 | Identifies the diagnosis of the work related injury or illness. | |
| 55 | Third ICD-9CM or ICD-10CM Diagnosis Code | Text | 522 | Identifies the diagnosis of the work related injury or illness. | |
| 56 | Fourth ICD-9CM or ICD-10CM Diagnosis Code | Text | 522 | Identifies the diagnosis of the work related injury or illness. | |
| 57 | Fifth ICD-9CM or ICD-10CM Diagnosis Code | Text | 522 | Identifies the diagnosis of the work related injury or illness. | |
| 58 | Principal Diagnosis Code | Text | 521 | Identifies the primary ICD-9 CM or ICD-10 CM code of the bill. | |
| 59 | Admitting Diagnosis Code | Text | 535 | Identifies the admitting ICD-9 CM or ICD-10 CM code of the bill. | |
| 60 | ICD-9CM or ICD-10CM Principal Procedure Code | Text | 525 | Identifies the principal procedure rendered. | |
| 61 | Principal Procedure Date | Date | 550 | The calendar date the primary procedure was performed. | |
| 62 | First ICD-9CM or ICD-10CM Procedure Code | Text | 736 | Identifies a procedure rendered other than the principal procedure. | |
| 63 | Second ICD-9CM or ICD-10CM Procedure Code | Text | 736 | Identifies a procedure rendered other than the principal procedure. | |
| 64 | Third ICD-9CM or ICD-10CM Procedure Code | Text | 736 | Identifies a procedure rendered other than the principal procedure. | |
| 65 | Fourth ICD-9CM or ICD-10CM Procedure Code | Text | 736 | Identifies a procedure rendered other than the principal procedure. | |
| 66 | First Procedure Date | Date | 524 | The calendar date the first procedure was performed. | |
| 67 | Second Procedure Date | Date | 524 | The calendar date the second procedure was performed. | |
| 68 | Third Procedure Date | Date | 524 | The calendar date the third procedure was performed. | |
| 69 | Fourth Procedure Date | Date | 524 | The calendar date the fourth procedure was performed. | |
| 70 | Facility Name | Text | 678 | The name of the facility where the medical services were rendered. Mandatory for SV1 bills. | |
| 71 | Facility FEIN | Text | 679 | Yes | The federal identification number of the facility where the medical services were rendered. |
| 72 | Facility Primary Address | Text | 684 | The first line in the facility's address. | |
| 73 | Facility Secondary Address | Text | 685 | The second line in the facility's address. | |
| 74 | Facility City | Text | 686 | The city name of the facility's address. | |
| 75 | Facility State Code | Text | 687 | The two-character state code of the facility's address. | |
| 76 | Facility Postal Code | Text | 688 | The zip code of the facility's address. | |
| 77 | Facility Country Code | Text | 689 | A three-character code indicating the country of the facility's mailing address. | |
| 78 | Facility State License Number | Text | 680 | A unique number assigned to identify the facility. | |
| 79 | Facility Medicare Number | Text | 681 | A unique number assigned to the facility by the Medicare program. | |
| 80 | Facility National Provider ID | Text | 682 | The unique National Provider ID of the facility. | |
| 81 | Managed Care Organization Identification | Text | 208 | Yes | The jurisdiction assigned number that corresponds to and uniquely identifies the managed care organization involved in the claim. |
| 82 | Billing Provider Last Name or Group | Text | 528 | The surname of the person or full name of an organization receiving payment. It is assumed to be the rendering provider for all services unless a specific rendering provider is identified at the bill or service line levels. If the billing provider is a non-person, a specific individual rendering bill provider may be required by a jurisdiction. | |
| 83 | Billing Provider First Name | Text | 529 | The given name of the billing provider. | |
| 84 | Billing Provider Middle Name Initial | Text | 530 | The middle name or initial of the billing provider. | |
| 85 | Billing Provider Suffix | Text | 531 | The legally recognized last name suffix of the billing provider which is used on legal documents. Examples: Jr., Sr., II, III | |
| 86 | Billing Provider FEIN | Text | 629 | Yes | The federal tax identification number of the billing provider. |
| 87 | Billing Provider Gate Keeper Indicator | Text | 534 | Indicates that the billing provider is the treating doctor. If present, must = 'GP' (Gateway Provider). | |
| 88 | Billing Provider Primary Specialty Code | Text | 537 | Indicates the primary specialty of the billing provider. | |
| 89 | Billing Provider Primary Address | Text | 538 | The first line in the billing provider's address. | |
| 90 | Billing Provider Secondary Address | Text | 539 | The second line of the billing provider's address. | |
| 91 | Billing Provider City | Text | 540 | The city name of the billing provider's address. | |
| 92 | Billing Provider State Code | Text | 541 | The two-character state code of the billing provider's address. | |
| 93 | Billing Provider Postal Code | Text | 542 | The zip code of the billing provider's address. | |
| 94 | Billing Provider Country Code | Text | 569 | A three-character code indicating the country of the billing provider's mailing address. | |
| 95 | Billing Provider State License Number | Text | 630 | The billing provider's license type, license number and jurisdiction code. | |
| 96 | Billing Provider Medicare Number | Text | 632 | The specific number issued to the billing provider by the Medicare program. | |
| 97 | Treatment Authorization Number | Text | 581 | A number assigned by the carrier to identify pre-authorized or pre-certified treatment plans. Y = reported, N = not reported. |
|
| 98 | Billing Provider National Provider ID | Text | 634 | The unique National Provider ID of the billing provider. | |
| 99 | Rendering Bill Provider Last Name or Group | Text | 638 | The surname of the individual provider actually rendering care. If not present, the billing provider is assumed to be the rendering provider for all services on this bill. If the billing provider was not an individual, a jurisdiction may require a rendering bill provider to be specified. | |
| 100 | Rendering Bill Provider First Name | Text | 639 | The given name of the rendering bill provider. | |
| 101 | Rendering Bill Provider Middle Name Initial | Text | 640 | The middle name or initial of the rendering bill provider. | |
| 102 | Rendering Bill Provider Suffix | Text | 641 | The legally recognized last name suffix of the rendering bill provider which is used on legal documents. Examples: Jr., Sr., II, III | |
| 103 | Rendering Bill Provider FEIN | Text | 642 | Yes | The federal tax identification number of the rendering bill provider. |
| 104 | Rendering Bill Provider Gate Keeper Indicator | Text | 534 | Indicates that the rendering bill provider is the treating doctor. If present, must = 'GP' (Gateway Provider). | |
| 105 | Rendering Bill Provider Primary Specialty Code | Text | 651 | Indicates the primary medical specialty of the rendering bill provider. | |
| 106 | Rendering Bill Provider Primary Address | Text | 652 | The first line of the rendering bill provider's address. | |
| 107 | Rendering Bill Provider Secondary Address | Text | 653 | The second line of the rendering bill provider's address. | |
| 108 | Rendering Bill Provider City | Text | 654 | The city name of the rendering bill provider's address. | |
| 109 | Rendering Bill Provider State Code | Text | 655 | The two-character state code of the rendering bill provider's address. | |
| 110 | Rendering Bill Provider Postal Code | Text | 656 | The zip code in the rendering bill provider's address. | |
| 111 | Rendering Bill Provider Country Code | Text | 657 | A three-character code indicating the country of the rendering bill provider's mailing address. | |
| 112 | Rendering Bill Provider State License Number | Text | 643 | The rendering bill provider's license type, license number and jurisdiction code. | |
| 113 | Rendering Bill Provider National Provider ID | Text | 647 | The unique National Provider ID of the rendering bill provider. | |
| 114 | Referring Provider Last Name or Group | Text | 690 | The surname of the provider referring claimant for care. Only used when needed to document that a bill results from care provided based on a referral from another provider. | |
| 115 | Referring Provider First Name | Text | 691 | The given name of the referring provider. | |
| 116 | Referring Provider Middle Name Initial | Text | 692 | The middle name or initial of the referring provider. | |
| 117 | Referring Provider Suffix | Text | 693 | The legally recognized last name suffix of the referring provider which is used on legal documents. Examples: Jr., Sr., II, III | |
| 118 | Referring Provider FEIN | Text | 694 | Yes | The federal tax identification number of the referring provider. |
| 119 | Referring Provider Gate Keeper Indicator | Text | 534 | Indicates that the referring provider is the treating doctor. If present, must = 'GP' (Gateway Provider). | |
| 120 | Referring Provider State License Number | Text | 695 | The referring provider's license type, license number and jurisdiction code. | |
| 121 | Referring Provider Specialty License Number | Text | 701 | The specific license number issued by a state to the referring provider that denotes specialty of the referring provider. | |
| 122 | Referring Provider Medicare Number | Text | 697 | The specific number issued to the referring provider by the Medicare Program. | |
| 123 | Referring Provider National Provider ID | Text | 699 | The unique National Provider ID of the referring provider. |
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