GLOBAL MAP DATA DICTIONARY #392 -- BENEFICIARY TRAVEL CLAIM FILE 3/24/25 PAGE 1
STORED IN ^DGBT(392, *** NO DATA STORED YET *** SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 1.0)
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This file contains the completed travel claim entries for patients showing departure/destination data, as well as specific claim
data.
CROSS
REFERENCED BY: ACCOUNT(AC), ACCOUNT(ACTP), DEDUCTIBLE AMOUNT(AD), CLAIM DENIED(ADENIED), ELIGIBILITY(AE), COREFLS CARRIER(AFLS),
NAME(AI), CARRIER(AS), Claim DATE/TIME(B), NAME(C), DATE ENTERED INTO THE FILE(D)
INDEXED BY: Claim DATE/TIME & NAME & Claim DATE/TIME (AF)
^DGBT(392,D0,0)= (#.01) Claim DATE/TIME [1D] ^ (#2) NAME [2P:2] ^ (#3) ELIGIBILITY [3P:8] ^ (#4) SC PERCENTAGE [4N] ^ (#5)
==>CERTIFICATION DATE [5P:392.2] ^ (#6) ACCOUNT [6P:392.3] ^ (#7) CARRIER [7P:440] ^ (#8) MOST ECON. COST [8N] ^
==>(#9) DEDUCTIBLE AMOUNT [9N] ^ (#10) AMOUNT PAYABLE [10N] ^ (#11) DIVISION [11P:40.8] ^ (#12) WHO ENTERED INTO
==>FILE [12P:200] ^ (#13) DATE ENTERED INTO THE FILE [13D] ^ (#14) COREFLS CARRIER [14P:392.31] ^ (#56) TYPE OF
==>CLAIM [15S] ^
^DGBT(392,D0,1)= (#43.2) BT CLAIM ELIGIBILITY ADDITION [1F] ^ (#43.1) BT CLAIM ELIGIBILITY CODE [2P:392.41] ^
^DGBT(392,D0,A)= (#41) AUTHORIZING PERSON [1P:200] ^ (#42) ATTENDANT/PAYEE [2F] ^ (#43) C&P REVIEW VISIT [3S] ^ (#44) MODE OF
==>TRANSPORTATION [4P:392.43] ^ ^ (#45) DENIAL LETTER ISSUED [6S] ^ (#45.1) DENIAL LETTER ISSUED DATE [7D] ^
==>(#45.2) CLAIM DENIED [8S] ^ (#45.3) DATE CLAIM DENIED [9D] ^ (#45.4) CLAIM DENIED REASON [10P:392.8] ^ (#43.5)
==>QUALIFIED APPOINTMENT [11S] ^ (#43.4) SC APPOINTMENT [12S] ^
^DGBT(392,D0,B)= (#52) BUS PASS OR TICKET [1S] ^ (#53) BUS PASS EXPIRATION DATE [2D] ^
^DGBT(392,D0,C)= (#54) COMMON CARRIER DATE REIMBURSED [1D] ^ (#55) COMMON CARRIER FEE [2N] ^ (#55.1) COMMON CARRIER REQUIRED [3S]
==>^
^DGBT(392,D0,D)= (#21) PLACE OF DEPARTURE [LINE 1] [1F] ^ (#22) PLACE OF DEPARTURE [LINE 2] [2F] ^ (#23) PLACE OF DEPARTURE [LINE
==>3] [3F] ^ (#24) CITY OF DEPARTURE [4F] ^ (#24.1) STATE OF DEPARTURE [5P:5] ^ (#24.2) ZIP CODE/DEPARTURE [6F] ^
^DGBT(392,D0,M)= (#31) ONE WAY/ROUND TRIP [1S] ^ (#32) MILEAGE/ONE WAY [2N] ^ (#33) TOTAL MILEAGE AMOUNT [3N] ^ (#34) MEALS &
==>LODGING [4N] ^ (#35) FERRY, BRIDGES, ETC. [5N] ^
^DGBT(392,D0,R)= (#51) REMARKS [1F] ^
^DGBT(392,D0,SP)= (#57) SPECIAL MODE OF TRANSPORTATION [1P:392.42] ^ (#58) INVOICE NUMBER [2F] ^ (#59) DATE INVOICE RECEIVED [3D]
==>^ (#60) TOTAL INVOICE AMOUNT [4N] ^ (#61) BASE RATE FEE [5N] ^ (#62) MILEAGE FEE [6N] ^ (#63) NO SHOW/NO LOAD
==>FEE [7N] ^ (#64) WAIT TIME FEE [8N] ^ (#65) EXTRA CREW FEE [9N] ^ (#66) SPECIAL EQUIPMENT FEE [10N] ^ (#67)
==>SPECIAL MODE RT/ONE-WAY [11S] ^ (#68) SPECIAL MODE TOTAL MILES [12N] ^ (#70) PRE-AUTHORIZED [13S] ^ (#71)
==>SPECIAL MODE VENDOR [14P:440] ^ (#85) SPECIAL MODE CLAIM AUTHORIZED [15S] ^ (#84) PRE-AUTHORIZED BY [16P:200] ^
==>(#86) DATE/TIME AUTHORIZED [17D] ^ ^ ^ ^ ^ ^ ^ ^ (#69) OTHER SM TRANSPORTATION [25F] ^ (#72) SPECIAL
==>MODE OTHER REMARKS [26F] ^
^DGBT(392,D0,SPAD)= (#73) SP MODE DEPARTURE ADDRESS1 [1F] ^ (#74) SP MODE DEPARTURE ADDRESS2 [2F] ^ (#75) SP MODE DEPARTURE CITY
==>[3F] ^ (#76) SP MODE DEPARTURE STATE [4P:5] ^ (#77) SP MODE DEPARTURE ZIP CODE [5F] ^ (#78) SP MODE
==>DESTINATION 1 [6F] ^ (#79) SP MODE DESTINATION 2 [7F] ^ (#80) SP MODE DESTINATION 3 [8F] ^ (#81) SP MODE
==>DESTINATION CITY [9F] ^ (#82) SP MODE DESTINATION STATE [10P:5] ^ (#83) SP MODE DESTINATION ZIP CODE [11F] ^
^DGBT(392,D0,T)= (#25) DESTINATION [LINE 1] [1F] ^ (#26) DESTINATION [LINE 2] [2F] ^ (#27) DESTINATION [LINE 3] [3F] ^ (#28) CITY
==>OF DESTINATION [4F] ^ (#28.1) STATE OF DESTINATION [5P:5] ^ (#28.2) ZIP CODE/DESTINATION [6F] ^
INPUT TEMPLATE(S):
PRINT TEMPLATE(S):
^DIPT(227)= DGBT CLAIM STATS
SORT TEMPLATE(S):
FORM(S)/BLOCK(S):