GLOBAL MAP DATA DICTIONARY #361.1 -- EXPLANATION OF BENEFITS FILE 3/24/25 PAGE 1
STORED IN ^IBM(361.1, *** NO DATA STORED YET *** SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 2.0)
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This file contains the explanation of benefits results (EOB) for bills as well as MEDICARE remittance advice data. The data in
this file may be appended to any subsequent claims in the COB process.
CROSS
REFERENCED BY: BILL(ABB), RETURN MESSAGE ID(AC), ENTRY DATE/TIME(AD), DATE/TIME EEOB MOVED(AEOB), TRANSMIT BILL(AERR),
REVIEW STATUS(AREV), BILL(B), BILL #(C), BILL REFERENCE(C), PAYER ID(D), EOB PAID DATE(E)
INDEXED BY: BILL & EOB PAID DATE (ABD), BILL & INSURANCE SEQUENCE (ABS), EOB TYPE & ENTRY DATE/TIME (AEDT), BILL & ENTRY
DATE/TIME & EEOB REMOVED (AMCCF), EOB TYPE & REVIEW STATUS (AMRA), ENTRY DATE/TIME & TRANSFERRED IN (ATIN), TRACE
NUMBER & PAYER ID & EOB TYPE (ATRID)
^IBM(361.1,D0,0)= (#.01) BILL [1P:399] ^ (#.02) PAYER NAME [2P:36] ^ (#.03) PAYER ID [3F] ^ (#.04) EOB TYPE [4S] ^ (#.05) ENTRY
==>DATE/TIME [5D] ^ (#.06) EOB PAID DATE [6D] ^ (#.07) TRACE NUMBER [7F] ^ ^ (#.09) CROSSED OVER ID [9F] ^ (#.1)
==>DRG CODE USED [10F] ^ (#.11) DRG WEIGHT USED [11N] ^ (#.12) DISCHARGE FRACTION [12N] ^ (#.13) CLAIM STATUS
==>[13S] ^ (#.14) ICN [14F] ^ (#.15) INSURANCE SEQUENCE [15S] ^ (#.16) REVIEW STATUS [16S] ^ (#.17) MANUAL ENTRY?
==>[17S] ^ (#.18) MANUALLY ENTERED BY [18P:200] ^ (#.19) TRANSMIT BILL [19P:364] ^ (#.2) FINAL REVIEW ACTION [20S]
==>^ (#.21) CLAIM STATUS CODE [21F] ^ (#.22) PARTIAL EOB [22S] ^
^IBM(361.1,D0,1)= (#1.01) PAYER PAID AMT [1N] ^ (#1.02) PATIENT RESPONSIBILITY AMT [2N] ^ (#1.03) COVERED AMT [3N] ^ (#1.04)
==>DISCOUNT AMT [4N] ^ (#1.05) PER DAY LIMIT AMT [5N] ^ ^ (#1.07) INTEREST AMT [7N] ^ (#1.08) TAX AMT [8N] ^
==>(#1.09) TOTAL BEFORE TAXES AMT [9N] ^ (#1.1) STATEMENT START DATE [10D] ^ (#1.11) STATEMENT END DATE [11D] ^
^IBM(361.1,D0,2)= ^ ^ (#2.03) TOTAL ALLOWED AMT [3N] ^ (#2.04) TOTAL SUBMITTED CHARGES [4N] ^ (#2.05) NEGATIVE REIMBURSEMENT
==>AMT [5N] ^ (#2.06) HPID/OEID [6F] ^
^IBM(361.1,D0,3)= (#3.01) M-CARE OUTP REIMBURS. RATE [1N] ^ (#3.02) M-CARE OUTP HCPCS PAYMNT AMT [2N] ^ (#3.03) M-CARE OUTP
==>REMARKS CODE-1 [3F] ^ (#3.04) M-CARE OUTP REMARKS CODE-2 [4F] ^ (#3.05) M-CARE OUTP REMARKS CODE-3 [5F] ^
==>(#3.06) M-CARE OUTP REMARKS CODE-4 [6F] ^ (#3.07) M-CARE OUTP REMARKS CODE-5 [7F] ^ (#3.08) M-CARE ESRD PAID
==>AMT [8N] ^ (#3.09) M-CARE NON-PAYABLE PROF COMP [9N] ^
^IBM(361.1,D0,4)= (#4.01) M-CARE INP COV. DAYS/VISIT CT [1N] ^ (#4.02) M-CARE INP LIFETM PSYCH DY CT [2N] ^ (#4.03) M-CARE INP
==>CLAIM DRG AMT [3N] ^ (#4.04) M-CARE INP CAP EXCEPTION AMT [4N] ^ (#4.05) M-CARE INP DISPROP. SHARE AMT [5N] ^
==>(#4.06) M-CARE INP MSP PASS THRU AMT [6N] ^ (#4.07) M-CARE INP PPS CAPITAL AMT [7N] ^ (#4.08) M-CARE INP PPS
==>CAP FSP-DRG AMT [8N] ^ (#4.09) M-CARE INP PPS CAP HSP-DRG AMT [9N] ^ (#4.1) M-CARE INP PPS CAP DSH-DRG AMT
==>[10N] ^ (#4.11) M-CARE INP OLD CAPITAL AMT [11N] ^ (#4.12) M-CARE INP PPS CAPITAL IME AMT [12N] ^ (#4.13)
==>M-CARE INP PPS OP HOS DRG AMT [13N] ^ (#4.14) M-CARE INP COST REPORT DAY CT [14N] ^ (#4.15) M-CARE INP PPS OP
==>FED DRG AMT [15N] ^ (#4.16) M-CARE INP PPS CAP OUTLIER AMT [16N] ^ (#4.17) M-CARE INP INDIRECT TEACH AMT [17N]
==>^ (#4.18) M-CARE INP NON-PAY PROF COMP [18N] ^ (#4.19) MEDICARE NON-COVERED DAYS [19N] ^
^IBM(361.1,D0,5)= (#5.01) M-CARE INP PYMNT REMARK CODE-1 [1F] ^ (#5.02) M-CARE INP PYMNT REMARK CODE-2 [2F] ^ (#5.03) M-CARE INP
==>PYMNT REMARK CODE-3 [3F] ^ (#5.04) M-CARE INP PYMNT REMARK CODE-4 [4F] ^ (#5.05) M-CARE INP PYMNT REMARK CODE-5
==>[5F] ^
^IBM(361.1,D0,6)= (#6.01) NEW PATIENT NAME [1F] ^ (#6.02) NEW PATIENT ID [2F] ^ (#6.03) CORRECTED DATA MESSAGE [3F] ^
^IBM(361.1,D0,6.1)= (#61.01) ORIGINAL 06 RECORD DATA [E1,200F] ^
^IBM(361.1,D0,6.2)= (#62.01) MAILMAN HEADER INFORMATION [E1,200F] ^
^IBM(361.1,D0,7)= (#7.01) TRANSFERRED IN [1F] ^
^IBM(361.1,D0,8,0)=^361.18A^^ (#8) AR AMOUNTS DISTRIBUTION
^IBM(361.1,D0,8,D1,0)= (#.01) BILL # [1F] ^ (#.02) AMOUNT [2N] ^ (#.03) BILL REFERENCE [3P:399] ^
^IBM(361.1,D0,10,0)=^361.11S^^ (#10) 835 CLAIM LEVEL ADJUSTMENTS
^IBM(361.1,D0,10,D1,0)= (#.01) ADJUSTMENT CATEGORY (GRP CODE) [1S] ^
^IBM(361.1,D0,10,D1,1,0)=^361.111^^ (#1) REASONS
^IBM(361.1,D0,10,D1,1,D2,0)= (#.01) REASON CODE [1F] ^ (#.02) AMOUNT [2N] ^ (#.03) QUANTITY [3N] ^ (#.04) REASON TEXT [4F] ^
^IBM(361.1,D0,15,0)=^361.115A^^ (#15) 835 LINE LEVEL ADJUSTMENTS
^IBM(361.1,D0,15,D1,0)= (#.01) ADJUSTMENT SEQUENCE # [1N] ^ (#.02) PAYER ID CODE [2F] ^ (#.03) AMOUNT PAID [3N] ^ (#.04)
==>PROCEDURE [4F] ^ ^ ^ ^ ^ (#.09) DESCRIPTION [9F] ^ (#.1) REVENUE CODE [10P:399.2] ^ (#.11) PAID UNITS
==>OF SERVICE [11N] ^ (#.12) REFERENCED LINE # [12N] ^ (#.13) ALLOWED AMOUNT [13N] ^ (#.14) PER DIEM AMOUNT
==>[14N] ^ (#.15) ORIGINAL PROCEDURE [15F] ^ (#.16) SERVICE DATE FROM [16D] ^ (#.17) SERVICE DATE TO [17D] ^
==>(#.18) PROCEDURE TYPE [18F] ^
^IBM(361.1,D0,15,D1,1,0)=^361.1151SA^^ (#1) ADJUSTMENTS
^IBM(361.1,D0,15,D1,1,D2,0)= (#.01) GROUP CODE [1S] ^
^IBM(361.1,D0,15,D1,1,D2,1,0)=^361.11511A^^ (#1) REASONS
^IBM(361.1,D0,15,D1,1,D2,1,D3,0)= (#.01) REASON CODE [1F] ^ (#.02) AMOUNT [2N] ^ (#.03) QUANTITY [3N] ^ (#.04) REASON TEXT [4F] ^
^IBM(361.1,D0,15,D1,1,D2,2,0)=^361.11512A^^ (#2) PAYER POLICY REFERENCE
^IBM(361.1,D0,15,D1,1,D2,2,D3,0)= (#.01) PAYER POLICY REFERENCE [1F] ^
^IBM(361.1,D0,15,D1,2,0)=^361.1152A^^ (#2) PAID MODIFIERS
^IBM(361.1,D0,15,D1,2,D2,0)= (#.01) PAID MODIFIERS [1F] ^
^IBM(361.1,D0,15,D1,4,0)=^361.1154A^^ (#4) LINE ITEM REMARK
^IBM(361.1,D0,15,D1,4,D2,0)= (#.01) LINE ITEM REMARK [1N] ^ (#.02) LINE ITEM REMARK CODE [2F] ^ (#.03) LINE ITEM REMARK CODE TEXT
==>[3F] ^
^IBM(361.1,D0,15,D1,6,0)=^361.1156^^ (#6) SERVICE SUPPLEMENTAL QUANTITY
^IBM(361.1,D0,15,D1,6,D2,0)= (#.01) SEQUENCE NUMBER [1N] ^ (#.02) SERVICE SUPPLEMENTAL QUANTITY [2N] ^
^IBM(361.1,D0,15,D1,7,0)=^361.1157^^ (#7) SERVICE PAYMENT QUALIFIER
^IBM(361.1,D0,15,D1,7,D2,0)= (#.01) SERVICE PAYMENT QUALIFIER [1F] ^ (#.02) REFERENCE IDENTIFICATION [2F] ^
^IBM(361.1,D0,21,0)=^361.121DA^^ (#21) REVIEW DATE/TIME
^IBM(361.1,D0,21,D1,0)= (#.01) REVIEW DATE/TIME [1D] ^ (#.02) REVIEWED BY [2P:200] ^
^IBM(361.1,D0,21,D1,1,0)=^361.1211^^ (#1) COMMENTS
^IBM(361.1,D0,21,D1,1,D2,0)= (#.01) COMMENTS [1W] ^
^IBM(361.1,D0,25)= (#25.01) PAYER CONTACT NAME [1F] ^ (#25.02) CONTACT NUMBER 1 [2F] ^ (#25.03) CONTACT TYPE 1 [3S] ^ (#25.04)
==>CONTACT NUMBER 2 [4F] ^ (#25.05) CONTACT TYPE 2 [5S] ^ (#25.06) CONTACT NUMBER 3 [6F] ^ (#25.07) CONTACT TYPE
==>3 [7S] ^
^IBM(361.1,D0,30)= (#30.01) AUTO BILL MESSAGE [1F] ^ (#30.02) AUTO BILL MESSAGE DATE/TIME [2D] ^
^IBM(361.1,D0,50)= (#1.12) CLAIM RECEIVED DATE [1D] ^ (#1.13) COVERAGE EXPIRATION DATE [2D] ^ (#1.14) CORRECTED PRIORITY PAYER
==>NAME [3F] ^ (#1.15) CORRECTED PRIORITY PAYER TYPE [4S] ^ (#1.16) CORRECTED PRIORITY PAYER ID [5F] ^
^IBM(361.1,D0,51)= (#1.17) OTHER SUBSCRIBER NAME [1F] ^ (#.08) CROSSED OVER NAME [2F] ^
^IBM(361.1,D0,100)= (#100.01) BATCH NUMBER [1P:364.1] ^ (#100.02) RETURN MESSAGE ID [2F] ^ (#100.03) LAST EDITED BY [3P:200] ^
==>(#100.04) LAST EDITED DATE [4D] ^ (#100.05) MESSAGE CHECKSUM [5F] ^
^IBM(361.1,D0,101,0)=^361.1101DA^^ (#101) MOVE/COPY/REMOVE HISTORY
^IBM(361.1,D0,101,D1,0)= (#.01) DATE/TIME EEOB MOVED [1D] ^ (#.02) EEOB MOVE/COPY/REMOVE BY [2P:200] ^ (#.03) MOVE/COPY/REMOVE
==>REASON [3F] ^ (#.04) ORIGINAL BILL NUMBER [4P:399] ^ (#.05) MOVE/COPY/REMOVE EVENT [5S] ^
^IBM(361.1,D0,101,D1,1,0)=^361.11016PA^^ (#.06) OTHER CLAIM NUMBERS
^IBM(361.1,D0,101,D1,1,D2,0)= (#.01) OTHER CLAIM NUMBERS [1P:399] ^
^IBM(361.1,D0,102)= (#102) EEOB REMOVED [1S] ^ (#103) PLB DUPLICATE [2S] ^ (#104) ERA DETAIL [3F] ^
^IBM(361.1,D0,ERR,0)=^361.12^^ (#20) MESSAGE STORAGE ERRORS
^IBM(361.1,D0,ERR,D1,0)= (#.01) MESSAGE STORAGE ERRORS [1W] ^
^IBM(361.1,D0,RM1)= (#5.011) REMARK CODE-1 SHORT TEXT [1F] ^
^IBM(361.1,D0,RM2)= (#5.021) REMARK CODE-2 SHORT TEXT [1F] ^
^IBM(361.1,D0,RM3)= (#5.031) REMARK CODE-3 SHORT TEXT [1F] ^
^IBM(361.1,D0,RM4)= (#5.041) REMARK CODE-4 SHORT TEXT [1F] ^
^IBM(361.1,D0,RM5)= (#5.051) REMARK CODE-5 SHORT TEXT [1F] ^
INPUT TEMPLATE(S):
PRINT TEMPLATE(S):
SORT TEMPLATE(S):
FORM(S)/BLOCK(S):