GLOBAL MAP DATA DICTIONARY #368 -- HEALTH CARE CLAIM RFAI (277) FILE 3/24/25 PAGE 1
STORED IN ^IBA(368, *** NO DATA STORED YET *** SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 2.0)
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This file contains all records received from the FSC ASC X12N health Care Claim Request For Additional Information (277) HL7
message.
CROSS
REFERENCED BY: MESSAGE CONTROL ID(B), TRANSACTION DATE/TIME(C), PATIENT CONTROL NUMBER [D](D), DELETED FLAG(E)
^IBA(368,D0,0)= (#.01) MESSAGE CONTROL ID [1F] ^ (#.02) REQUEST DATE/TIME [2F] ^ (#.03) TRANSACTION DATE/TIME [3F] ^
^IBA(368,D0,1)= (#1.01) PAYER NAME [1F] ^ (#1.02) PAYER IDENTIFIER [2F] ^ (#1.03) PAYER CONTACT NAME [3F] ^
^IBA(368,D0,2)= (#2.01) PAYER CONTACT COMM TYPE 1 [1F] ^ (#2.02) PAYER CONTACT COMM TYPE 2 [2F] ^ (#2.03) PAYER CONTACT COMM TYPE
==>3 [3F] ^
^IBA(368,D0,3)= (#3.01) PAYER CONTACT COMMUNICATION 1 [1F] ^
^IBA(368,D0,4)= (#4.01) PAYER CONTACT COMMUNICATION 2 [1F] ^
^IBA(368,D0,5)= (#5.01) PAYER CONTACT COMMUNICATION 3 [1F] ^
^IBA(368,D0,6)= (#6.01) INFORMATION RECEIVER NAME [1F] ^ (#6.02) INFORMATION RECEIVER ID [2F] ^
^IBA(368,D0,7)= (#7.01) SERVICE PROVIDER NAME [1F] ^ (#7.02) SERVICE PROV FED TAXPAYER CODE [2F] ^
^IBA(368,D0,8)= (#8.01) SERVICE PROVIDER ID [1F] ^
^IBA(368,D0,9)= (#9.01) PATIENT NAME [1F] ^
^IBA(368,D0,10)= (#10.01) PATIENT PRIMARY IDENTIFIER [1F] ^
^IBA(368,D0,11)= (#11.01) PATIENT CONTROL NUMBER [1F] ^ (#11.02) PAYER CLAIM CONTROL NUMBER [2F] ^ (#11.03) MEDICAL RECORD NUMBER
==>[3F] ^ (#11.04) CLEARINGHOUSE TRACE NUMBER [4F] ^
^IBA(368,D0,12)= (#12.01) RESPONSE DUE DATE [1F] ^ (#12.02) REPORT TRANSMISSION CODE [2F] ^
^IBA(368,D0,13,0)=^368.013^^ (#13) STC SEQ
^IBA(368,D0,13,D1,0)= (#.01) STC SEQ [1N] ^ (#.02) STATUS INFO EFFECTIVE DATE [2F] ^
^IBA(368,D0,13,D1,1)= (#1.01) HEALTH CARE CLAIM STATUS CAT [1F] ^ (#1.02) ADDTL INFO REQUEST MOD [2F] ^ ^ (#1.04) CODE LIST
==>QUALIFIER CODE [4F] ^
^IBA(368,D0,13,D1,10)= (#10.01) HEALTH CARE CLAIM STATUS CAT [1F] ^ (#10.02) ADDTL INFO REQUEST MOD [2F] ^ ^ (#10.04) CODE LIST
==>QUALIFIER CODE [4F] ^
^IBA(368,D0,13,D1,11)= (#11.01) HEALTH CARE CLAIM STATUS CAT [1F] ^ (#11.02) ADDTL INFO REQUEST MOD [2F] ^ ^ (#11.04) CODE LIST
==>QUALIFIER CODE [4F] ^
^IBA(368,D0,14)= ^ ^ (#14.03) CLAIM SERVICE START DATE [3F] ^ (#14.04) CLAIM SERVICE END DATE [4F] ^ (#14.05) CLAIM SERVICE
==>PERIOD [5F] ^
^IBA(368,D0,15)= (#15.01) PAYER RESPONSE CONTACT NAME [1F] ^
^IBA(368,D0,16)= (#16.01) PAYER RESP CONTACT COMM TYPE 1 [1F] ^ (#16.02) PAYER RESP CONTACT COMM TYPE 2 [2F] ^ (#16.03) PAYER
==>RESP CONTACT COMM TYPE 3 [3F] ^
^IBA(368,D0,17)= (#17.01) PAYER RESPONSE CONTACT COMM 1 [1F] ^
^IBA(368,D0,18)= (#18.01) PAYER RESPONSE CONTACT COMM 2 [1F] ^
^IBA(368,D0,19)= (#19.01) PAYER RESPONSE CONTACT COMM 3 [1F] ^
^IBA(368,D0,20)= (#20.01) PAYER RESP CONTACT ADDR LINE 1 [1F] ^ (#20.02) PAYER RESP CONTACT ADDR LINE 2 [2F] ^ (#20.03) PAYER
==>RESP CONTACT CITY [3F] ^ (#20.04) PAYER RESP CONTACT STATE [4F] ^ (#20.05) PAYER RESP CONTACT ZIP CODE [5F] ^
==>(#20.06) PAYER RESP CONTACT COUNTRY [6F] ^ (#20.07) PAYER RESP CONT CNTRY SUBDIV [7F] ^
^IBA(368,D0,21,0)=^368.021^^ (#21) STC-SVC LINE STAT INFO SEQ
^IBA(368,D0,21,D1,0)= (#.01) STC-SVC LINE STAT INFO SEQ [1N] ^ (#.02) PRODUCT/SERVICE ID QUALIFIER [2F] ^ (#.03) SERVICE
==>IDENTIFICATION CODE [3F] ^ (#.04) PROCEDURE MODIFIER 1 [4F] ^ (#.05) PROCEDURE MODIFIER 2 [5F] ^ (#.06)
==>PROCEDURE MODIFIER 3 [6F] ^ (#.07) PROCEDURE MODIFIER 4 [7F] ^ (#.08) LINE ITEM CHARGE AMOUNT [8F] ^ (#.09)
==>REVENUE CODE [9F] ^ (#.1) LINE ITEM CONTROL NUMBER [10F] ^ (#.11) SERVICE LINE DATE [11F] ^
^IBA(368,D0,21,D1,1)= (#1.01) SERVICE LINE REF ID QUALIFIER [1F] ^
^IBA(368,D0,21,D1,99,0)=^368.2199^^ (#99) STC SEQ-SERVICE LINE
^IBA(368,D0,21,D1,99,D2,0)= (#.01) STC SEQ-SERVICE LINE [1N] ^ (#.02) STATUS INFO EFFECTIVE DATE [2F] ^
^IBA(368,D0,21,D1,99,D2,1)= (#1.01) HEALTH CARE CLAIM STATUS CAT [1F] ^ (#1.02) ADDTL INFO REQUEST MOD [2F] ^ ^ (#1.04) CODE
==>LIST QUALIFIER CODE [4F] ^
^IBA(368,D0,21,D1,99,D2,10)= (#10.01) HEALTH CARE CLAIM STATUS CAT [1F] ^ (#10.02) ADDTL INFO REQUEST MOD [2F] ^ ^ (#10.04) CODE
==>LIST QUALIFIER CODE [4F] ^
^IBA(368,D0,21,D1,99,D2,11)= (#11.01) HEALTH CARE CLAIM STATUS CAT [1F] ^ (#11.02) ADDTL INFO REQUEST MOD [2F] ^ ^ (#11.04) CODE
==>LIST QUALIFIER CODE [4F] ^
^IBA(368,D0,22)= ^ ^ (#22.03) PRIMARY LOINC [3F] ^
^IBA(368,D0,25)= (#25.01) REFERENCE ID-INST TYPE OF BILL [1F] ^
^IBA(368,D0,26)= (#26.01) PAYER CONTACT COMM 1 EXTENSION [1F] ^
^IBA(368,D0,27)= (#27.01) PAYER CONTACT COMM 2 EXTENSION [1F] ^
^IBA(368,D0,28)= (#28.01) PAYER CONTACT COMM 3 EXTENSION [1F] ^
^IBA(368,D0,29)= (#29.01) PAYER RESP CONTACT COMM 1 EXT [1F] ^
^IBA(368,D0,30)= (#30.01) PAYER RESP CONTACT COMM 2 EXT [1F] ^
^IBA(368,D0,31)= (#31.01) PAYER RESP CONTACT COMM 3 EXT [1F] ^
^IBA(368,D0,80)= (#80.01) PAYER ENTITY IDENTIFIER CODE [1F] ^ (#80.02) PAYER ENTITY TYPE QUALIFIER [2F] ^ (#80.03) PAYER ID CODE
==>QUALIFIER [3F] ^ (#80.04) PAYER CONTACT FUNCTION CODE [4F] ^ (#80.05) INFORMATION RECEIVER ENTITY ID [5F] ^
==>(#80.06) INFO RECEIVER ENTITY TYPE [6F] ^ (#80.07) INFO RECEIVER ID QUALIFIER [7F] ^ (#80.08) SERVICE PROV
==>ENTITY ID CODE [8F] ^ (#80.09) SERVICE PROV ENTITY TYPE QUAL [9F] ^ (#80.1) SERVICE PROVIDER ID QUALIFIER [10F]
==>^ (#80.11) PATIENT ENTITY IDENTIFIER CODE [11F] ^ (#80.12) PATIENT ENTITY TYPE QUALIFIER [12F] ^ (#80.13)
==>PATIENT ID CODE QUALIFIER [13F] ^ (#80.14) PAYER CLAIM TRACE TYPE CODE [14F] ^ ^ ^ ^ (#80.18) REFERENCE ID
==>QUALIFIER-PT CRTL [18F] ^ (#80.19) REFERENCE ID QUALIFIER-INST [19F] ^ (#80.2) REFERENCE ID QUALIFIER-MRN [20F]
==>^ (#80.21) REFERENCE ID QUALIFIER-CTN [21F] ^ (#80.22) CLAIM SERVICE DT/TM QUALIFIER [22F] ^ (#80.23) CLAIM SERV
==>DT/TM PERIOD QUAL [23F] ^ (#80.24) RESPONSE DUE DT/TM QUALIFIER [24F] ^ (#80.25) RESPONSE DUE DT/TM PERIOD QUAL
==>[25F] ^ (#80.26) CLAIM SUPP INFO REPORT TYPE [26F] ^ (#80.27) PAYER RESP CONTACT FUNC CODE [27F] ^ ^ (#80.29)
==>SERVICE LINE DT/TM QUALIFIER [29F] ^ (#80.3) SERVICE LINE DT/TM PERIOD QUAL [30F] ^
^IBA(368,D0,100)= ^ (#100.02) REQUEST DATE/TIME [D] [2D] ^ (#100.03) MESSAGE DATE/TIME [D] [3D] ^
^IBA(368,D0,101)= (#101.01) PAYER NAME [D] [1P:36] ^
^IBA(368,D0,102)= (#102.01) PAYER CONTACT COMM TYPE 1 [D] [1P:365.021] ^ (#102.02) PAYER CONTACT COMM TYPE 2 [D] [2P:365.021] ^
==>(#102.03) PAYER CONTACT COMM TYPE 3 [D] [3P:365.021] ^
^IBA(368,D0,109)= (#109.01) PATIENT NAME [D] [1P:2] ^
^IBA(368,D0,111)= (#111.01) PATIENT CONTROL NUMBER [D] [1P:399] ^
^IBA(368,D0,112)= (#112.01) RESPONSE DUE DATE [D] [1D] ^
^IBA(368,D0,113,0)=^368.0113A^^ (#113) STC SEQ [D]
^IBA(368,D0,113,D1,0)= (#.01) STC SEQ [D] [1N] ^ (#.02) STATUS INFO EFFECTIVE DATE [D] [2D] ^
^IBA(368,D0,113,D1,1)= (#1.01) HEALTH CARE CLAIM STAT CAT-1 [1P:368.001] ^
^IBA(368,D0,113,D1,10)= (#10.01) HEALTH CARE CLAIM STAT CAT-10 [1P:368.001] ^
^IBA(368,D0,113,D1,11)= (#11.01) HEALTH CARE CLAIM STAT CAT-11 [1P:368.001] ^
^IBA(368,D0,114)= ^ ^ (#114.03) CLAIM SERVICE START DATE [D] [3D] ^ (#114.04) CLAIM SERVICE END DATE [D] [4D] ^
^IBA(368,D0,116)= (#116.01) PAYER RESP CONT COM TYPE 1 [D] [1P:365.021] ^ (#116.02) PAYER RESP CONT COM TYPE 2 [D] [2P:365.021] ^
==>(#116.03) PAYER RESP CONT COM TYPE 3 [D] [3P:365.021] ^
^IBA(368,D0,120)= ^ ^ ^ (#120.04) PAYER RESP CONTACT ADDR ST [D] [4P:5] ^ (#120.05) PAYER RESP CONT POSTAL/ZIP [D] [5P:5.11] ^
==>(#120.06) PAYER RESP CONTACT COUNTRY [D] [6P:779.004] ^
^IBA(368,D0,121,0)=^368.0121A^^ (#121) STC-SVC LINE STAT INFO SEQ [D]
^IBA(368,D0,121,D1,0)= (#.01) STC-SVC LINE STAT INFO SEQ [D] [1N] ^ (#.02) PRODUCT/SERVICE ID QUAL [D] [2P:368.002] ^ (#.03)
==>SERVICE IDENTIFICATION CODE [3V] ^ (#.04) PROCEDURE MODIFIER 1 [D] [4P:81.3] ^ (#.05) PROCEDURE MODIFIER 2
==>[D] [5P:81.3] ^ (#.06) PROCEDURE MODIFIER 3 [D] [6P:81.3] ^ (#.07) PROCEDURE MODIFIER 4 [D] [7P:81.3] ^
==>(#.08) LINE ITEM CHARGE AMOUNT [D] [8N] ^ (#.09) REVENUE CODE [9P:399.2] ^ ^ (#.11) SERVICE LINE DATE
==>[11D] ^
^IBA(368,D0,121,D1,99,0)=^368.12199A^^ (#99) STC SEQ-SERVICE LINE [D]
^IBA(368,D0,121,D1,99,D2,0)= (#.01) STC SEQ-SERVICE LINE [D] [1N] ^ (#.02) STATUS INFO EFFECTIVE DATE [D] [2D] ^
^IBA(368,D0,121,D1,99,D2,1)= (#1.01) HEALTH CARE CLAIM STAT CAT-1 [1P:368.001] ^
^IBA(368,D0,121,D1,99,D2,10)= (#10.01) HEALTH CARE CLAIM STAT CAT-10 [1P:368.001] ^
^IBA(368,D0,121,D1,99,D2,11)= (#11.01) HEALTH CARE CLAIM STAT CAT-11 [1P:368.001] ^
^IBA(368,D0,200)= (#200.01) DELETED FLAG [1S] ^ (#200.02) DELETED DATE/TIME [2D] ^ (#200.03) DELETED BY [3P:200] ^ (#200.04)
==>REVIEW STATUS [4S] ^ (#200.05) REVIEW STATUS DATE/TIME [5D] ^ (#200.06) REVIEW STATUS BY [6P:200] ^
^IBA(368,D0,201,0)=^368.0201D^^ (#201) RFAI WORKLIST COMMENTS
^IBA(368,D0,201,D1,0)= (#.01) COMMENT ENTERED DATE [1D] ^ (#.02) COMMENT ENTERED BY [2P:200] ^
^IBA(368,D0,201,D1,1,0)=^368.0301^^ (#.03) COMMENTS
^IBA(368,D0,201,D1,1,D2,0)= (#.01) COMMENTS [1W] ^
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