STANDARD DATA DICTIONARY #162 -- FEE BASIS PAYMENT FILE 3/24/25 PAGE 1
STORED IN ^FBAAC( *** NO DATA STORED YET *** SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 3.5)
DATA NAME GLOBAL DATA
ELEMENT TITLE LOCATION TYPE
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Contains all Fee Outpatient medical payment data. Include's payment ancillary data for Contract Hospital as of version 2. Does NOT
include Pharmacy payment data.
Per VHA Directive 10-93-142, this file definition should not be modified.
DD ACCESS: @
RD ACCESS: #
WR ACCESS: #
DEL ACCESS: #
LAYGO ACCESS: #
CROSS
REFERENCED BY: VENDOR(AB), BATCH NUMBER(AC), CHECK NUMBER(ACK), CHECK NUMBER(ACKT), CONTRACT(ACN), TRAVEL BATCH NUMBER(AD),
CPT MODIFIER(AE), *AUTHORIZATION POINTER(AF), AUTHORIZATION POINTER(AFN), OLD BATCH NUMBER(AG),
OLD BATCH NUMBER(AH), SUSPEND CODE(AI), DATE FINALIZED(AK), DATE FINALIZED(AL), ASSOCIATED 7078/583(AM),
FEE PROGRAM(AN), ADJUSTMENT REASON(AO), DATE FINALIZED(AP), INITIAL TREATMENT DATE(AX), PATIENT(B),
INVOICE NUMBER(C), DoD INVOICE NUMBER(DODI), IPAC AGREEMENT(IPAC)
INDEXED BY: FPPS CLAIM ID (AFC), BATCH NUMBER & INVOICE NUMBER (AJ)
LAST MODIFIED: JUN 4,2019@18:09:54
162,.01 PATIENT 0;1 POINTER TO PATIENT FILE (#2) (Required)
INPUT TRANSFORM: S:$D(X) DINUM=X
DESCRIPTION:
The veteran for which service was provided.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 162^B
1)= S ^FBAAC("B",$E(X,1,30),DA)=""
2)= K ^FBAAC("B",$E(X,1,30),DA)
162,6 VENDOR 1;0 POINTER Multiple #162.01
DESCRIPTION:
This mutiple keeps track of all the vendors used by the Fee Basis patient.
162.01,.01 VENDOR 0;1 POINTER TO FEE BASIS VENDOR FILE (#161.2) (Required)
INPUT TRANSFORM: S:$D(X) DINUM=X
LAST EDITED: JAN 16, 1986
DESCRIPTION:
The vendor/provider who's bill is being entered for payment.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 162.01^AC
1)= S ^FBAAC(DA(1),1,"AC",$E(X,1,30),DA)=""
2)= K ^FBAAC(DA(1),1,"AC",$E(X,1,30),DA)
CROSS-REFERENCE: 162^AB
1)= S ^FBAAC("AB",$E(X,1,30),DA(1),DA)=""
2)= K ^FBAAC("AB",$E(X,1,30),DA(1),DA)
162.01,1 INITIAL TREATMENT DATE 1;0 DATE Multiple #162.02 (Add New Entry without Asking)
DESCRIPTION:
The date that the treatment or service was provided.
162.02,.01 INITIAL TREATMENT DATE 0;1 DATE (Required)
INPUT TRANSFORM: S %DT="ETXP" D ^%DT S X=Y D DATCK^FBAAUTL
LAST EDITED: MAY 12, 1993
DESCRIPTION:
The date that the treatment/service took place.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 162.01^AB^MUMPS
1)= S ^FBAAC(DA(2),"AB",(9999999.9999-X),DA(1),DA)=""
2)= K ^FBAAC(DA(2),"AB",(9999999.9999-X),DA(1),DA)
CROSS-REFERENCE: 162.01^AD^MUMPS
1)= S ^FBAAC(DA(2),DA(1),"AD",(9999999.9999-X),DA)=""
2)= K ^FBAAC(DA(2),DA(1),"AD",(9999999.9999-X),DA)
CROSS-REFERENCE: 162^AX^MUMPS
1)= S ^FBAAC("AX",DA(1),(9999999.9999-X),DA(2),DA)=""
2)= K ^FBAAC("AX",DA(1),(9999999.9999-X),DA(2),DA)
162.02,1.5 *FEE PROGRAM 0;3 POINTER TO FEE BASIS PROGRAM FILE (#161.8) (Required)
LAST EDITED: FEB 18, 1986
DESCRIPTION: The Fee Basis program which this payment is related to. For example, is this a payment related
to the Outpatient Medical program or a payment related to the Contract Hospital program.
162.02,2 SERVICE PROVIDED 1;0 POINTER Multiple #162.03 (Add New Entry without Asking)
DESCRIPTION: This multiple contains all the outpatient and ancillary services provided the Fee Basis
patient.
WRITE AUTHORITY: #
READ AUTHORITY: #
162.03,.01 SERVICE PROVIDED 0;1 POINTER TO CPT FILE (#81) (Required) (Multiply asked)
LAST EDITED: JUL 05, 2017
DESCRIPTION: The Current Procedural Terminology Code (CPT Code) as specified on the vendors invoice
identifying the service the vendor provided to the veteran.
CROSS-REFERENCE: 162.03^AE^MUMPS
1)= D SCPT^FBAAUTL7
2)= D KCPT^FBAAUTL7
Cross-reference built to concatenate CPT with Modifier(s) for duplicate payment checks. The
cross-reference is set by both the Service Provided field, as well as the CPT Modifier field.
The cross-reference format is
^FBAAC("AE",pat IEN,ven IEN,date,cpt-mod list,serv prov IEN)="" where
pat IEN is the PATIENT internal entry number in file 162. (dinum)
ven IEN is the VENDOR multiple internal entry number. (dinum)
date is the value of the INITIAL TREATMENT DATE (fileman format)
cpt-mod list is the value of the SERVICE PROVIDED (internal)
followed by a dash ("-") and a sorted list of values (internal) from
the CPT MODIFER multiple. Examples:
12345 for a service provided without any modifiers
12345-11,12 for a service provided with two modifiers
serv prov IEN is the SERVICE PROVIDED multiple internal entry number.
***If the need arises to re-index the entire cross-reference, it should be done by
re-indexing the Service Provided field and not the CPT Modifier field. As a Service Provided
(CPT code) is mandatory for each payment entry, but a CPT Modifier is not, to assure a
complete cross-reference, the re-indexing should be done on the Service Provided field.
CROSS-REFERENCE: 162.03^B
1)= S ^FBAAC(DA(3),1,DA(2),1,DA(1),1,"B",$E(X,1,30),DA)=""
2)= K ^FBAAC(DA(3),1,DA(2),1,DA(1),1,"B",$E(X,1,30),DA)
162.03,.05 IPAC AGREEMENT 3;6 POINTER TO IPAC VENDOR AGREEMENT FILE FILE (#161.95)
LAST EDITED: JAN 30, 2014
HELP-PROMPT: Enter the IPAC agreement associated with this invoice.
DESCRIPTION:
This is the pointer to the IPAC Agreement file that is associated with the invoice.
CROSS-REFERENCE: 162^IPAC
1)= S ^FBAAC("IPAC",$E(X,1,30),DA(3),DA(2),DA(1),DA)=""
2)= K ^FBAAC("IPAC",$E(X,1,30),DA(3),DA(2),DA(1),DA)
This cross reference is used to identify any invoices that are associated with IPAC.
162.03,.055 DoD INVOICE NUMBER 3;7 FREE TEXT
INPUT TRANSFORM: K:$L(X)>22!($L(X)<3) X
LAST EDITED: JAN 30, 2014
HELP-PROMPT: Answer must be 3-22 characters in length.
DESCRIPTION: The DoD invoice number that is associated with this VistA invoice. Note that one DoD invoice
number may have more than one VistA invoice.
CROSS-REFERENCE: 162^DODI
1)= S ^FBAAC("DODI",$E(X,1,30),DA(3),DA(2),DA(1),DA)=""
2)= K ^FBAAC("DODI",$E(X,1,30),DA(3),DA(2),DA(1),DA)
DoD invoice number cross reference
162.03,1 AMOUNT CLAIMED 0;2 NUMBER (Required)
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>999999)!(X<.01) X
LAST EDITED: MAR 01, 1988
HELP-PROMPT: Type a Dollar Amount between .01 and 999999, 2 Decimal Digits
DESCRIPTION:
The amount the vendor is billing us for this service provided.
162.03,2 AMOUNT PAID 0;3 NUMBER (Required)
INPUT TRANSFORM: S X=$TR(X,"$") K:+X'=X&(X'?.N.1".".2N)!(X>999999)!(X<0) X
LAST EDITED: SEP 21, 2014
HELP-PROMPT: Enter the amount to pay in dollars and cents between 0 and 999999.
DESCRIPTION:
The amount that the VA is going to pay for this service provided.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
162.03,3 AMOUNT SUSPENDED 0;4 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999)!(X<.01) X
LAST EDITED: MAR 01, 1988
HELP-PROMPT: Type a Dollar Amount between .01 and 9999999, 2 Decimal Digits
DESCRIPTION: The portion of the vendor's claimed amount that the VA will not pay for various reasons. This
amount is usually the difference between the vendor's amount claimed and the amount paid.
162.03,3.5 DATE SUSPENDED 0;11 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: MAY 14, 1993
DESCRIPTION:
The date that this payment is suspended.
CROSS-REFERENCE: 162.03^AI1^MUMPS
1)= S:$P(^FBAAC(DA(3),1,DA(2),1,DA(1),1,DA,0),U,5) ^FBAAC("AI",DA(2),$E(X,1,30),DA(3),$P(^(0),U,5),
DA(1),DA)=""
2)= K:$P(^FBAAC(DA(3),1,DA(2),1,DA(1),1,DA,0),U,5) ^FBAAC("AI",DA(2),$E(X,1,30),DA(3),$P(^(0),U,5),
DA(1),DA)
This will update the cross-reference on the suspense code field if the Date suspended has been
changed.
162.03,4 SUSPEND CODE 0;5 POINTER TO FEE BASIS SUSPENSION FILE (#161.27)
LAST EDITED: MAY 14, 1993
DESCRIPTION:The code that identifies why the amount paid was less than the amount claimed. The valid list of
codes are contained in the Fee Basis Suspension file.
CROSS-REFERENCE:162^AI^MUMPS
1)= S:$P(^FBAAC(DA(3),1,DA(2),1,DA(1),1,DA,0),U,11) ^FBAAC("AI",DA(2),$P(^(0),U,11),DA(3),$E(X,1,30
),DA(1),DA)=""
2)= K:$P(^FBAAC(DA(3),1,DA(2),1,DA(1),1,DA,0),U,11) ^FBAAC("AI",DA(2),$P(^(0),U,11),DA(3),$E(X,1,30
),DA(1),DA)
This cross-reference is used to sort suspense letters.
162.03,5 DATE FINALIZED 0;6 DATE
INPUT TRANSFORM:S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JUN 11, 1990
DESCRIPTION:
The date that this payment line item was finalized (Certified) by the Fee Supervisor.
CROSS-REFERENCE:162^AP^MUMPS
1)= S ^FBAAC("AP",DA(2),$E(X,1,30),DA(3),DA(1),DA)=""
2)= K ^FBAAC("AP",DA(2),$E(X,1,30),DA(3),DA(1),DA)
CROSS-REFERENCE:162^AK
1)= S ^FBAAC("AK",$E(X,1,30),DA(3),DA(2),DA(1),DA)=""
2)= K ^FBAAC("AK",$E(X,1,30),DA(3),DA(2),DA(1),DA)
CROSS-REFERENCE:162.03^AQ^MUMPS
1)= I $P(^FBAAC(DA(3),1,DA(2),1,DA(1),1,DA,0),U,12)]"" S ^FBAAC("AQ",$P(^FBAAC(DA(3),1,DA(2),1,DA(1
),1,DA,0),U,12),9999999-$E(X,1,30),DA(3),DA(2),DA(1),DA)=""
2)= I $P(^FBAAC(DA(3),1,DA(2),1,DA(1),1,DA,0),U,12)]"" K ^FBAAC("AQ",$P(^FBAAC(DA(3),1,DA(2),1,DA(1
),1,DA,0),U,12),9999999-$E(X,1,30),DA(3),DA(2),DA(1),DA)
162.03,6 CLERK 0;7 POINTER TO NEW PERSON FILE (#200) (Required)
LAST EDITED: APR 05, 1990
DESCRIPTION:
The Fee clerk who entered in the payment data.
162.03,7 BATCH NUMBER 0;8 POINTER TO FEE BASIS BATCH FILE (#161.7)
INPUT TRANSFORM:S DIC("S")="I $P(^(""ST""),U,1)=""O""" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: DEC 13, 2011
DESCRIPTION:The batch number with which this payment was associated. If the batch file has been purged this may
be blank.
SCREEN: S DIC("S")="I $P(^(""ST""),U,1)=""O"""
EXPLANATION:ALLOWS SELECTION OF ONLY BATCHES THAT ARE OPEN
CROSS-REFERENCE:162^AC
1)= S ^FBAAC("AC",$E(X,1,30),DA(3),DA(2),DA(1),DA)=""
2)= K ^FBAAC("AC",$E(X,1,30),DA(3),DA(2),DA(1),DA)
RECORD INDEXES: AJ (#1097) (WHOLE FILE #162)
162.03,8 OBLIGATION NUMBER 0;10 FREE TEXT (Required)
INPUT TRANSFORM:K:$L(X)>6!($L(X)<6) X D:$D(X) CKOB^FBAAUTL1
LAST EDITED: APR 12, 1990
HELP-PROMPT:ANSWER MUST BE 6 CHARACTERS IN LENGTH
DESCRIPTION:
The obligation number identifying which funds this payment will be paid with.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
162.03,12 DATE PAID 0;14 DATE
INPUT TRANSFORM:S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 02, 1986
HELP-PROMPT:This is the date of the check, as issued by the treasury.
DESCRIPTION:This is the date of the check, as issued by the treasury. This information will be passed back to
DHCP from the Financial Management System (FMS) when the check is issued to the vendor. This field
will use the check date beginning with version 3.5 of Fee Basis. Entries prior to version 3.5 are
the date the system automatically entered when the payment line item was queued to be transmitted
to the Austin Automation Center for payment.
162.03,13 DATE CORRECT INVOICE RECEIVED 0;15 DATE (Required)
INPUT TRANSFORM:S %DT="EX" D ^%DT K %DT(0) S X=Y K:Y<1 X
LAST EDITED: MAR 08, 1993
DESCRIPTION:Date that the VA receives what it feels to be a complete/correct invoice. This date is very
important since it is the date used by the Central Fee system in determining if interest should be
paid because of untimely processing by VA. Requirements for the prompt payment act apply.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
162.03,14 INVOICE NUMBER 0;16 NUMBER
INPUT TRANSFORM:K:+X'=X!(X>999999999)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: DEC 13, 2011
HELP-PROMPT:TYPE A WHOLE NUMBER BETWEEN 1 AND 999999999
DESCRIPTION:
An automatically generated number associated with a vendor's bill.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE:162^C
1)= S ^FBAAC("C",$E(X,1,30),DA(3),DA(2),DA(1),DA)=""
2)= K ^FBAAC("C",$E(X,1,30),DA(3),DA(2),DA(1),DA)
RECORD INDEXES: AJ (#1097) (WHOLE FILE #162)
162.03,15 PATIENT TYPE CODE 0;17 SET (Required)
'00' FOR SURGICAL;
'10' FOR MEDICAL;
'60' FOR HOME NURSING SERVICE;
'85' FOR PSYCHIATRIC-CONTRACT;
'86' FOR PSYCHIATRIC;
'95' FOR NEUROLOGICAL-CONTACT;
'96' FOR NEUROLOGICAL;
LAST EDITED: JAN 11, 1991
DESCRIPTION:The patient's type code (ie medical, surgical) related to this payment line item. This is based on
the authorization that is selected during the payment process.
162.03,15.5 AUTHORIZATION POINTER 3;9 NUMBER
INPUT TRANSFORM:K:+X'=X!(X>9999999)!(X<1)!(X?.E1"."1.N) X
LAST EDITED: MAR 04, 2014
HELP-PROMPT:Enter the internal entry number of the authorization in the FEE BASIS PATIENT file.
DESCRIPTION:Type a number between 1 and 9999999, 0 decimal digits. This field is automatically populated with
the internal entry number of the patient's authorization in the Fee Basis Patient file.
TECHNICAL DESCR:
This field was added by patch FB*3.5*154 to replace the AUTHORIZATION POINTER field in the INITIAL
TREATMENT DATE multiple.
CROSS-REFERENCE:162^AFN
1)= S ^FBAAC("AFN",$E(X,1,30),DA(3),DA(2),DA(1),DA)=""
2)= K ^FBAAC("AFN",$E(X,1,30),DA(3),DA(2),DA(1),DA)
This cross-reference is used to locate payments that are associated with an authorization in the
FEE BASIS PATIENT file.
162.03,16 PURPOSE OF VISIT 0;18 POINTER TO FEE BASIS PURPOSE OF VISIT FILE (#161.82) (Required)
INPUT TRANSFORM:N FBZ S FBZ=$P($G(^FBAAC(DA(3),1,DA(2),1,DA(1),1,DA,0)),U,9),DIC("S")="I $S($G(FBZ):$P(^(0),U,2
)=FBZ,1:1)&($S('$G(^(""I"")):1,DT'>^(""I""):1,1:0))" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: JAN 13, 1995
DESCRIPTION:This identifies the purpose that the veteran received the service provided. This data is obtained
from the authorization data for the patient, at the time of payment entry.
SCREEN: S DIC("S")="I $S($G(FBZ):$P(^(0),U,2)=FBZ,1:1)&($S('$G(^(""I"")):1,DT'>^(""I""):1,1:0))"
EXPLANATION:A Purpose of Visit that matches the Fee Program selected and the POV must not have an inactive date
.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
162.03,17 TREATMENT TYPE CODE 0;19 SET (Required)
'1' FOR SHORT TERM FEE STATUS;
'2' FOR HOME NURSING SERVICE;
'3' FOR I.D. CARD STATUS;
LAST EDITED: JAN 29, 1993
DESCRIPTION:The treatment type code this payment is related to. It is obtained from the authorization data for
the patient which was selected at the time of payment entry.
162.03,18 PAYMENT TYPE CODE 0;20 SET (Required)
'R' FOR REIMBURSEMENT;
'S' FOR STATISTICAL;
'V' FOR VENDOR;
'SR' FOR STAT-REIMBURSEMENT;
LAST EDITED: APR 24, 1986
DESCRIPTION:Identifies whether this is a payment to a vendor, a reimbursement to the veteran, a statistical
payment which only updates veteran year-to-date amounts and results in NO payment and a statistical
reimbursement which allows the user to update payment record with a reimbursement paid out of
system.
162.03,19 REJECT STATUS FBREJ;1 SET
'P' FOR REJECTED, PENDING;
'C' FOR REJECTED, COMPLETED;
LAST EDITED: OCT 26, 1994
DESCRIPTION:
Identifies whether this line item has been rejected and is pending assignment to another batch.
162.03,20 REJECT REASON FBREJ;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>40!($L(X)<2) X
LAST EDITED: AUG 11, 1986
HELP-PROMPT:ANSWER MUST BE 2-40 CHARACTERS IN LENGTH
DESCRIPTION:
The reason this line item was rejected for payment. Normally, the Austin reject code is entered.
162.03,21 OLD BATCH NUMBER FBREJ;3 POINTER TO FEE BASIS BATCH FILE (#161.7)
LAST EDITED: AUG 11, 1986
DESCRIPTION:
The batch number this line item was associated with before the line item was rejected.
CROSS-REFERENCE:162^AH
1)= S ^FBAAC("AH",$E(X,1,30),DA(3),DA(2),DA(1),DA)=""
2)= K ^FBAAC("AH",$E(X,1,30),DA(3),DA(2),DA(1),DA)
162.03,21.3 INTERFACE REJECT FBREJ;4 SET
'1' FOR YES;
LAST EDITED: DEC 13, 2011
HELP-PROMPT:Enter YES if the line item was rejected by Central Fee.
DESCRIPTION:This field is populated by the FBAA BATCH SERVER and FBAA REJECT SERVER server options when a
payment line item is rejected via the interface with Central Fee. This field is used to
distinguish line items that were locally rejected from those that were rejected by a downstream
system. This field is not populated for a local reject.
162.03,21.6 REJECT CODE FBREJC;0 Multiple #162.031
DESCRIPTION:The REJECT CODE multiple is populated with one to four reject codes by the FBAA BATCH SERVER and
FBAA REJECT SERVER server options when a line item is rejected via the interface with Central Fee.
The REJECT CODE multiple is not used for local rejects. The reason for a local reject is entered
into the REJECT REASON (#20) field.
162.031,.01 REJECT CODE 0;1 FREE TEXT (Multiply asked)
INPUT TRANSFORM:K:$L(X)>4!($L(X)<1) X
LAST EDITED: FEB 01, 2012
HELP-PROMPT:Answer must be 1-4 characters in length.
DESCRIPTION:The REJECT CODE field is populated by the FBAA BATCH SERVER and FBAA REJECT SERVER server options
when a line item is rejected via the interface with Central Fee. The REJECT CODE field is not
used for local rejects. The reason for a local reject is entered into the REJECT REASON (#20)
field.
TECHNICAL DESCR:
Values stored in the REJECT CODE field are normally expected to have a matching entry in the FEE
BASIS PAYMENT REJECT CODE (#161.99) file. The FEE BASIS PAYMENT REJECT CODE file contains a list
of reject codes and their descriptions.
However it is possible that a new reject code will be transmitted to VistA by Central Fee and
stored in the REJECT CODE field before the FEE BASIS PAYMENT REJECT CODE file is updated with
that new code. In this case outputs that display the description of a code will display text
similar to "Reject reason code not currently defined in list."
CROSS-REFERENCE:162.031^B
1)= S ^FBAAC(DA(4),1,DA(3),1,DA(2),1,DA(1),"FBREJC","B",$E(X,1,30),DA)=""
2)= K ^FBAAC(DA(4),1,DA(3),1,DA(2),1,DA(1),"FBREJC","B",$E(X,1,30),DA)
162.03,22 DESCRIPTION OF SUSPENSION 1;0 WORD-PROCESSING #162.05
DESCRIPTION:This field is used only when the suspend code entered is '4' meaning 'Other'. This allows the
entering of the reason that the payment amount was not in full. This will be printed on the
suspense letter.
LAST EDITED: OCT 10, 1986
162.03,23 FEE PROGRAM 0;9 POINTER TO FEE BASIS PROGRAM FILE (#161.8)
LAST EDITED: SEP 08, 1992
DESCRIPTION:The Fee program that this line item is associated with (ie Outpatient Medical, Contract
Hospital).
CROSS-REFERENCE:162^AN^MUMPS
1)= S:X'=2 ^FBAAC("AN",X,DA(3),DA(2),DA(1),DA)=""
2)= K ^FBAAC("AN",X,DA(3),DA(2),DA(1),DA)
Cross-reference is used to easily identify those fee services which belong to fee programs
other than outpatient medical.
162.03,24 VOID PAYMENT 0;21 SET
'VP' FOR VOID;
LAST EDITED: MAR 25, 1988
DESCRIPTION:This field is set when a payment was made in error and the site has initiated a bill of
collection to retrieve the dollars expended. The ability to void a payment is restricted to
the holder of the FBAASUPERVISOR security key.
162.03,24.5 REASON FOR VOIDED PAYMENT R;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>75!($L(X)<3) X
LAST EDITED: AUG 31, 1992
HELP-PROMPT:Answer must be 3-75 characters in length.
DESCRIPTION:
This field will allow the Fee Supervisor to store the reason why they had to void a payment.
162.03,25 SUPERVISOR 0;22 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: APR 05, 1990
DESCRIPTION:
This is the Fee Supervisor who cancelled(voided) the payment.
162.03,26 PRIMARY SERVICE FACILITY 0;12 POINTER TO INSTITUTION FILE (#4)
LAST EDITED: APR 19, 1990
DESCRIPTION:
The VA Hospital responsible for the veterans care.
162.03,27 ASSOCIATED 7078/583 0;13 VARIABLE POINTER
FILE ORDER PREFIX LAYGO MESSAGE
162.4 1 FB7078 n Select associated 7078
162.7 2 FB583 n Select associated 583
LAST EDITED: SEP 18, 1990
DESCRIPTION:
Contains the related 7078 or 583 if an unauthorized claim.
CROSS-REFERENCE:162^AM
1)= S ^FBAAC("AM",$E(X,1,30),DA(3),DA(2),DA(1),DA)=""
2)= K ^FBAAC("AM",$E(X,1,30),DA(3),DA(2),DA(1),DA)
162.03,28 PRIMARY DIAGNOSIS 0;23 POINTER TO ICD DIAGNOSIS FILE (#80)
LAST EDITED: MAY 26, 1993
DESCRIPTION:
This field contains the primary diagnosis of the patient for the service provided.
TECHNICAL DESCR:
This field is a pointer to the ICD DIAGNOSIS (#80) file. It is used to attach a diagnosis to a
CPT code.
162.03,29 VA TYPE OF SERVICE 0;24 POINTER TO FEE BASIS VA TYPE OF SERVICE FILE (#163.85)
LAST EDITED: JUN 30, 1992
DESCRIPTION:The information recorded in this field will be sent with the payment record to the Austin DPC.
It will allow the program office to do some comparisons between VA supplied services and those
supplied by Fee Basis.
TECHNICAL DESCR:
This filed is a pointer to Fee Basis VA Type of Service (#163.85) file. It is a static table
file populated by the program office.
162.03,30 PLACE OF SERVICE 0;25 POINTER TO PLACE OF SERVICE FILE (#353.1)
OUTPUT TRANSFORM:N FBX S FBX=$G(^IBE(353.1,+Y,0)) Q:FBX']"" S Y=$P(FBX,U,2)_" ("_$P(FBX,U)_")"
LAST EDITED: JUN 10, 1996
DESCRIPTION:
This field determines where the service was administered to the veteran.
TECHNICAL DESCR:
This field is a pointer to the Place of Service (#353.1) file. It contains data supplied by
the Health Care Finance Administration and is recorded on HCFA form 1500.
162.03,31 HCFA TYPE OF SERVICE 0;26 POINTER TO TYPE OF SERVICE FILE (#353.2)
OUTPUT TRANSFORM:N FBX S FBX=$G(^IBE(353.2,+Y,0)) Q:FBX']"" S Y=$P(FBX,U,2)_" ("_$P(FBX,U)_")"
LAST EDITED: JUN 10, 1996
DESCRIPTION:This information will be used to determine payment amounts in the future. It is currently
asked on the HCFA 1500 form.
TECHNICAL DESCR:
This field is a pointer to the Type of Service (#353.2) file. It is a table file with data
supplied by the Health Care finance Administration.
162.03,32 SERVICE CONNECTED CONDITION? 0;27 FREE TEXT
INPUT TRANSFORM:I $D(X) D YN^FBAAUTL3
OUTPUT TRANSFORM:D OUTYN^FBAAUTL3
LAST EDITED: MAR 18, 1994
HELP-PROMPT:Answer 'Yes' or '1' for YES and 'No' or '0' for NO.
DESCRIPTION:Indicates whether the service provided was for a Service Connected condition. Answer 'Yes' if
service provided was for a Service Connected condition, 'No' if eligible under NSC such as Aid
and Attendance.
TECHNICAL DESCR:
EXECUTABLE HELP:I $G(DFN) W !?1,*7,"Patient: ",$$NAME^FBCHREQ2(DFN) D DIS^DGRPDB W !!
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
162.03,33 VENDOR INVOICE DATE 2;1 DATE (Required)
INPUT TRANSFORM:S %DT="E" D ^%DT S X=Y K:Y<1 X I X>$P(^FBAAC(DA(3),1,DA(2),1,DA(1),1,DA,0),"^",15) W !,*7,"
Vendor Invoice Date cannot be later than the Date Correct Invoice Received" K X
LAST EDITED: APR 14, 1994
HELP-PROMPT:Enter the date the vendor issued the invoice.
DESCRIPTION:
This is the date that the vendor issued the invoice.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
162.03,34 PROMPT PAY TYPE 2;2 SET
'1' FOR MONEY MANAGED;
LAST EDITED: MAR 18, 1994
HELP-PROMPT:Set equal to 1 if payment is subject to interest payments.
DESCRIPTION:
Field is set to 1 if the payment is subject to interest payments (prompt pay). Otherwise it
remains blank.
162.03,35 CHECK NUMBER 2;3 FREE TEXT
INPUT TRANSFORM:K:X[""""!($A(X)=45) X I $D(X) K:$L(X)>8!($L(X)<1)!'(X?.NA) X
LAST EDITED: APR 25, 1994
HELP-PROMPT:Answer must be 1-8 characters in length.
DESCRIPTION:
Contains the check number as issued by the treasury. This field is updated after the check is
issued, through a server option that records actual payment information for each Fee payment made.
CROSS-REFERENCE:162^ACK^MUMPS
1)= S ^FBAAC("ACK",X,DA(3),DA(2),DA(1),DA)=""
2)= K ^FBAAC("ACK",X,DA(3),DA(2),DA(1),DA)
This cross-reference is used for finding payment items for specific check numbers.
162.03,36 CANCELLATION DATE 2;4 DATE
INPUT TRANSFORM:S %DT="E" D ^%DT S X=Y K:Y<1 X
LAST EDITED: MAR 15, 1994
HELP-PROMPT:The date the check was cancelled by the treasury.
DESCRIPTION:
This is the date the treasury cancelled the check. This field is updated through a server option
that records cancellations of previously recorded payment data.
162.03,37 REASON CODE 2;5 POINTER TO FEE BASIS CHECK CANCELLATION REASON FILE (#162.95)
LAST EDITED: MAR 15, 1994
HELP-PROMPT:Enter the reason the check was cancelled.
DESCRIPTION:
This field contains a pointer to the Fee Basis Check Cancellation Reason file. It is populated
through a server option that updates the payment record when the treasury cancels a check that was
previously payed.
162.03,38 CANCELLATION ACTIVITY 2;6 SET
'R' FOR WILL BE REPLACED;
'C' FOR WILL BE REISSUED;
'X' FOR WILL NOT BE REISSUED;
LAST EDITED: APR 26, 1994
HELP-PROMPT:Field will contain the cancellation code if there has been cancellation activity on this
payment.
DESCRIPTION:
This field is populated when a cancellation is recorded for the payment referenced. This field
will always remain populated, to indicate that there was cancellation activity on this payment at
one time. New payments will replace the cancellation date and reason code fields, but the
cancellation activity flag will not be overwritten. This flag will allow the user to know that
previous cancellation activity existed, and to review the cancellation history output for further
information.
162.03,40 DISBURSED AMOUNT 2;8 NUMBER
INPUT TRANSFORM:S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>999999)!(X<0) X
LAST EDITED: APR 21, 1994
HELP-PROMPT:Type a Dollar Amount between 0 and 999999, 2 Decimal Digits
DESCRIPTION:
This is the dollar amount paid by the treasury, less any interest paid.
162.03,41 INTEREST AMOUNT 2;9 NUMBER
INPUT TRANSFORM:S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>999999)!(X<0) X
LAST EDITED: APR 21, 1994
HELP-PROMPT:Type a Dollar Amount between 0 and 999999, 2 Decimal Digits
DESCRIPTION:
The interest amount paid on this line item by the treasury.
162.03,42 SITE OF SERVICE ZIP CODE 2;10 FREE TEXT (Required)
INPUT TRANSFORM:K:$L(X)>5!($L(X)<5)!'(X?5N&(X'?5"0")) X
LAST EDITED: MAY 05, 1999
HELP-PROMPT:Answer must be 5 characters in length.
DESCRIPTION:
Zip Code of the location where the service was actually performed.
162.03,43 ANESTHESIA TIME (MINUTES) 2;11 NUMBER
INPUT TRANSFORM:K:+X'=X!(X>9999)!(X<15)!(X?.E1"."1N.N) X
LAST EDITED: FEB 12, 2016
HELP-PROMPT:Type a Number between 15 and 9999, 0 Decimal Digits
DESCRIPTION:
Enter time billed for an anesthesia service in minutes. The bill may specify anesthesia units
which will need to be converted to minutes.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
162.03,44 FEE SCHEDULE AMOUNT 2;12 NUMBER
INPUT TRANSFORM:S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>999999.99)!(X<0) X
LAST EDITED: MAY 05, 1999
HELP-PROMPT:Type a Dollar Amount between 0 and 999999.99, 2 Decimal Digits
DESCRIPTION:
This is the dollar amount obtained from a fee schedule for the service provided.
162.03,45 FEE SCHEDULE 2;13 SET
'F' FOR VA FEE SCHEDULE;
'R' FOR RBRVS FEE SCHEDULE;
LAST EDITED: MAY 05, 1999
HELP-PROMPT:Enter the fee schedule used to obtain the fee schedule amount.
DESCRIPTION:
Specifies which fee schedule was used to obtain the fee schedule amount for this service provided.
162.03,46 CPT MODIFIER M;0 POINTER Multiple #162.06
162.06,.01 CPT MODIFIER 0;1 POINTER TO CPT MODIFIER FILE (#81.3) (Multiply asked)
LAST EDITED: JUN 01, 1999
DESCRIPTION:
This field is used to better describe the service (CPT) rendered. The modifiers (if any) will be
combined with the CPT code to determine fee schedule amounts and to check for duplicate payments.
CROSS-REFERENCE:162.06^B
1)= S ^FBAAC(DA(4),1,DA(3),1,DA(2),1,DA(1),"M","B",$E(X,1,30),DA)=""
2)= K ^FBAAC(DA(4),1,DA(3),1,DA(2),1,DA(1),"M","B",$E(X,1,30),DA)
CROSS-REFERENCE:162^AE^MUMPS
1)= D SMOD^FBAAUTL7
2)= D KMOD^FBAAUTL7
Cross-reference built to concatenate CPT with Modifier(s) for duplicate payment checks. The
cross-reference is set by both the Service Provided field, as well as the CPT Modifier field.
The cross-reference format is
^FBAAC("AE",pat IEN,ven IEN,date,cpt-mod list,serv prov IEN)="" where
pat IEN is the PATIENT internal entry number in file 162. (dinum)
ven IEN is the VENDOR multiple internal entry number. (dinum)
date is the value of the INITIAL TREATMENT DATE (fileman format)
cpt-mod list is the value of the SERVICE PROVIDED (internal)
followed by a dash ("-") and a sorted list of values (internal) from
the CPT MODIFIER multiple. Examples:
12345 for a service provided without any modifiers
12345-11,12 for a service provided with two modifiers
serv prov IEN is the SERVICE PROVIDED multiple internal entry number.
***If the need arises to re-index the entire cross-reference, it should be done by re-indexing
the Service Provided field and not the CPT Modifier the CPT Modifier field. As a Service
Provided (CPT code) is mandatory for each payment entry, but a CPT Modifier is not, to assure a
complete cross-reference, the re-indexing should be done on the Service Provided field.
162.03,47 UNITS PAID 2;14 NUMBER (Required)
INPUT TRANSFORM:K:+X'=X!(X>99999)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: JUN 26, 2003
HELP-PROMPT:Type a Number between 1 and 99999, 0 Decimal Digits
DESCRIPTION:
Units of service being paid for this line item if any payment is being made for the line item.
If payment disapproved for the line item then enter the units of service that were billed.
162.03,48 REVENUE CODE 2;15 POINTER TO REVENUE CODE FILE (#399.2)
LAST EDITED: JUN 17, 2003
HELP-PROMPT:Answer with the revenue code associated with this charge.
DESCRIPTION:
Revenue code is a 3-digit code associated with itemized charges on a UB92 billing invoice. A
revenue code should be entered if a CPT/HCPCS code was not specified for the line item. If both
revenue code and a CPT/HCPCS code have been entered for a line item, the revenue code will be
considered the more accurate description of the service.
TECHNICAL DESCR:
IA #4128 allows Fee Basis to point to the REVENUE CODE (#399.2) file.
162.03,49 PATIENT ACCOUNT NUMBER 2;16 FREE TEXT
INPUT TRANSFORM:K:$L(X)>20!($L(X)<1) X
LAST EDITED: JUN 17, 2003
HELP-PROMPT:Answer must be 1-20 characters in length.
DESCRIPTION:
Please enter the Patient control number. This could be either the Patient Identification Number
or Patient Account Number from the vendor's invoice.
162.03,50 FPPS CLAIM ID 3;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>32!($L(X)<1)!'(X?1.32N) X
LAST EDITED: JUN 18, 2003
HELP-PROMPT:Enter a non-zero number from 1 to 32 digits long, 0 decimal digits.
DESCRIPTION:
Enter the entire FPPS Claim ID as shown on the invoice document. (1-32 character text ID created
by FPPS system).
FIELD INDEX: AFC (#299) REGULAR IR SORTING ONLY WHOLE FILE (#162)
Short Descr: Whole file cross-reference on FPPS CLAIM ID.
Description: Regular, whole-file cross-reference on the FPPS CLAIM ID field.
Set Logic: S ^FBAAC("AFC",$E(X,1,32),DA(3),DA(2),DA(1),DA)=""
Kill Logic: K ^FBAAC("AFC",$E(X,1,32),DA(3),DA(2),DA(1),DA)
Whole Kill: K ^FBAAC("AFC")
X(1): FPPS CLAIM ID (162.03,50) (Subscr 1) (Len 32) (forwards)
162.03,51 FPPS LINE ITEM 3;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>40!($L(X)<1) X
LAST EDITED: JUN 17, 2003
HELP-PROMPT:This response must be a number or a list or range, e.g., 1,3,5 or 2-4,8.
DESCRIPTION:
Enter the line item sequence number associated with this charge. Each charge on the FPPS invoice
document will have a line item sequence number associated with it. A line item can be entered
individually or a group of charges from multiple lines can be entered. If all line items in a
group are in numerical sequence, you may enter the first line item sequence number followed by a
hyphen and the last line item sequence number. If the grouped charges are not in sequential
order, each line item must be entered individually, followed by a comma.
162.03,52 ADJUSTMENT 7;0 POINTER Multiple #162.07 (Add New Entry without Asking)
162.07,.01 ADJUSTMENT REASON 0;1 POINTER TO ADJUSTMENT REASON FILE (#161.91) (Multiply asked)
INPUT TRANSFORM:S DIC("S")="I $P($$AR^FBUTL1(Y),U,4)=1" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: JUN 18, 2003
HELP-PROMPT:Select a HIPAA Adjustment (suspense) Reason Code.
DESCRIPTION:
Adjustment reason codes explain why the amount paid differs from the amount claimed.
SCREEN: S DIC("S")="I $P($$AR^FBUTL1(Y),U,4)=1"
EXPLANATION:Only adjustment reasons that are applicable for Fee use can be selected.
CROSS-REFERENCE:162.07^B
1)= S ^FBAAC(DA(4),1,DA(3),1,DA(2),1,DA(1),7,"B",$E(X,1,30),DA)=""
2)= K ^FBAAC(DA(4),1,DA(3),1,DA(2),1,DA(1),7,"B",$E(X,1,30),DA)
CROSS-REFERENCE:162^AO^MUMPS
1)= Q
2)= D KILLRR^FBAAFR(X,.DA)
Deletes remittance remarks associated with adjustment reasons when the reason is deleted.
162.07,1 ADJUSTMENT GROUP 0;2 POINTER TO ADJUSTMENT GROUP FILE (#161.92)
INPUT TRANSFORM:S DIC("S")="I $P($$AG^FBUTL1(Y),U,4)=1" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: JUN 18, 2003
HELP-PROMPT:Select a HIPAA Adjustment Group Code.
DESCRIPTION:
The Adjustment Group Code pertains to the previously entered adjustment reason code.
SCREEN: S DIC("S")="I $P($$AG^FBUTL1(Y),U,4)=1"
EXPLANATION:Only adjustment groups that are applicable for Fee use can be selected.
162.07,2 ADJUSTMENT AMOUNT 0;3 NUMBER
INPUT TRANSFORM:S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>999999)!(X<.01) X
LAST EDITED: JUN 17, 2003
HELP-PROMPT:Type a Dollar Amount between .01 and 999999, 2 Decimal Digits
DESCRIPTION:
Enter the dollar amount that is not being paid for this charge per the adjustment reason.
162.03,53 REMITTANCE REMARK 8;0 POINTER Multiple #162.08
162.08,.01 REMITTANCE REMARK 0;1 POINTER TO REMITTANCE REMARK FILE (#161.93) (Multiply asked)
INPUT TRANSFORM:S DIC("S")="I $P($$RR^FBUTL1(Y),U,4)=1" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: JUN 18, 2003
HELP-PROMPT:Select a HIPAA Remittance Remark Code.
DESCRIPTION:
Select a remittance remark code to provide non-financial information critical to
understanding the adjudication of the claim.
SCREEN: S DIC("S")="I $P($$RR^FBUTL1(Y),U,4)=1"
EXPLANATION:Only remittance remarks that are applicable for Fee use can be selected.
CROSS-REFERENCE:162.08^B
1)= S ^FBAAC(DA(4),1,DA(3),1,DA(2),1,DA(1),8,"B",$E(X,1,30),DA)=""
2)= K ^FBAAC(DA(4),1,DA(3),1,DA(2),1,DA(1),8,"B",$E(X,1,30),DA)
162.08,1 ADJUSTMENT 0;2 NUMBER
INPUT TRANSFORM:K:+X'=X!(X>999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: MAR 19, 2015
HELP-PROMPT:Type a number between 0 and 999, 0 decimal digits.
DESCRIPTION:
For Internal use only. Used to associate a remittance remark entry with an adjustment reason.
The value entered into the ADJUSTMENT field is the DA of the adjustment reason entry.
162.03,54 CONTRACT 3;8 POINTER TO FEE BASIS CONTRACT FILE (#161.43)
LAST EDITED: JUL 09, 2009
HELP-PROMPT:If applicable, enter the contract.
DESCRIPTION:
If the payment is for contracted services, the contract number can be specified in this
field. The selected contract must be active and applicable to the vendor being paid.
TECHNICAL DESCR:
In some cases this field will be automatically populated by the software based on the
associated authorization. In other cases, the user will be prompted for a value.
CROSS-REFERENCE:162^ACN
1)= S ^FBAAC("ACN",$E(X,1,30),DA(3),DA(2),DA(1),DA)=""
2)= K ^FBAAC("ACN",$E(X,1,30),DA(3),DA(2),DA(1),DA)
This is an index of contracts entered for outpatient and ancillary payments. The index will
be used to prevent deletion of entries from the FEE BASIS CONTRACT file that are referenced
(pointed to) by a payment.
162.03,55 ROUTING NUMBER 2;17 FREE TEXT
INPUT TRANSFORM:K:$L(X)>9!($L(X)<9) X
LAST EDITED: MAY 13, 2011
HELP-PROMPT:Answer must be 9 characters in length.
DESCRIPTION:
Enter the financial routing number information that was returned with the payment from
Central Fee for Electronic Fund Transfer (EFT) entries. This information will be forwarded to
FPPS so that the vendor can be notified of the payment. This field must be 9 characters,
including any leading zeros. Note: The Central Fee nightly update will automatically set this
field if the data is included in their message.
162.03,56 ACCOUNT NUMBER 2;18 FREE TEXT
INPUT TRANSFORM:K:$L(X)>17!($L(X)<1) X
LAST EDITED: MAY 13, 2011
HELP-PROMPT:Answer must be 1-17 characters in length.
DESCRIPTION:
Enter the financial account number information that was returned with the payment from
Central Fee for Electronic Fund Transfer (EFT) entries. This information will be forwarded to
FPPS so that the vendor can be notified of the payment. This field must be 1-17 characters,
including any leading zeros. Note: The Central Fee nightly update will automatically set
this field if the data is included in their message.
162.03,57 FINANCIAL INSTITUTION 2;19 FREE TEXT
INPUT TRANSFORM:K:$L(X)>30!($L(X)<1) X
LAST EDITED: MAY 13, 2011
HELP-PROMPT:Answer must be 1-30 characters in length.
DESCRIPTION:
Enter the financial institution name that was returned with the payment from Central Fee for
Electronic Fund Transfer (EFT) entries. This information will be forwarded to FPPS so that
the vendor can be notified of the payment. Note: The Central Fee nightly update will
automatically set this field if the data is included in their message.
162.03,58 ATTENDING PROV NAME 4;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>30!($L(X)<1) X
LAST EDITED: OCT 13, 2011
HELP-PROMPT:Answer must be 1-30 characters in length.
DESCRIPTION:
Enter the Attending Provider's name found in the claim information.
162.03,59 ATTENDING PROV NPI 4;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>10!($L(X)<10) X
LAST EDITED: OCT 13, 2011
HELP-PROMPT:Answer must be 10 characters in length.
DESCRIPTION:
Enter the Attending Provider's National Provider Identifier (NPI) found in the claim
information. This value must be 10 characters, including any leading zeros.
162.03,60 ATTENDING PROV TAXONOMY CODE 4;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>10!($L(X)<10) X
LAST EDITED: OCT 13, 2011
HELP-PROMPT:Answer must be 10 characters in length.
DESCRIPTION:
Enter the Attending Provider's Taxonomy code found in the claim information. This value must
be 10 characters, including any leading zeros.
162.03,61 OPERATING PROV NAME 4;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>30!($L(X)<1) X
LAST EDITED: OCT 13, 2011
HELP-PROMPT:Answer must be 1-30 characters in length.
DESCRIPTION:
Enter the Operating Provider's name found in the claim information.
162.03,62 OPERATING PROV NPI 4;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>10!($L(X)<10) X
LAST EDITED: OCT 13, 2011
HELP-PROMPT:Answer must be 10 characters in length.
DESCRIPTION:
Enter the Operating Provider's National Provider Identifier (NPI) found in the claim
information. This value must be 10 characters, including any leading zeros.
162.03,63 RENDERING PROV NAME 4;6 FREE TEXT
INPUT TRANSFORM:K:$L(X)>30!($L(X)<1) X
LAST EDITED: OCT 13, 2011
HELP-PROMPT:Answer must be 1-30 characters in length.
DESCRIPTION:
Enter the Rendering Provider's name found in the claim information.
162.03,64 RENDERING PROV NPI 4;7 FREE TEXT
INPUT TRANSFORM:K:$L(X)>10!($L(X)<10) X
LAST EDITED: OCT 13, 2011
HELP-PROMPT:Answer must be 10 characters in length.
DESCRIPTION:
Enter the Rendering Provider's National Provider Identifier (NPI) found in the claim
information. This value must be 10 characters, including any leading zeros.
162.03,65 RENDERING PROV TAXONOMY CODE 4;8 FREE TEXT
INPUT TRANSFORM:K:$L(X)>10!($L(X)<10) X
LAST EDITED: OCT 13, 2011
HELP-PROMPT:Answer must be 10 characters in length.
DESCRIPTION:
Enter the Rendering Provider's Taxonomy code found in the claim information. This value must
be 10 characters, including any leading zeros.
162.03,66 SERVICING PROV NAME 4;9 FREE TEXT
INPUT TRANSFORM:K:$L(X)>30!($L(X)<1) X
LAST EDITED: OCT 13, 2011
HELP-PROMPT:Answer must be 1-30 characters in length.
DESCRIPTION:
Enter the Servicing Provider's name found in the claim information.
162.03,67 SERVICING PROV NPI 4;10 FREE TEXT
INPUT TRANSFORM:K:$L(X)>10!($L(X)<10) X
LAST EDITED: OCT 13, 2011
HELP-PROMPT:Answer must be 10 characters in length.
DESCRIPTION:
Enter the Servicing Provider's National Provider Identifier (NPI) found in the claim
information. This value must be 10 characters, including any leading zeros.
162.03,68 REFERRING PROV NAME 4;11 FREE TEXT
INPUT TRANSFORM:K:$L(X)>30!($L(X)<1) X
LAST EDITED: OCT 13, 2011
HELP-PROMPT:Answer must be 1-30 characters in length.
DESCRIPTION:
Enter the Referring Provider's name found in the claim information.
162.03,69 REFERRING PROV NPI 4;12 FREE TEXT
INPUT TRANSFORM:K:$L(X)>10!($L(X)<10) X
LAST EDITED: OCT 13, 2011
HELP-PROMPT:Answer must be 10 characters in length.
DESCRIPTION:
Enter the Referring Provider's National Provider Identifier (NPI) found in the claim
information. This value must be 10 characters, including ay leading zeros.
162.03,70 OHI OTHER SUBSCRIBER INFO 6;0 Multiple #162.09 (Add New Entry without Asking)
LAST EDITED: APR 18, 2017
DESCRIPTION:
This multiple contains information that pertains to payers that are known to be involved in
the paying on this claim.
TECHNICAL DESCR:
OHI data stored in X12, #2320 Other Subscriber Information. (Up to 10 entries).
162.09,.01 PAYER RESP SEQUENCE CODE 0;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>1!($L(X)<1) X
MAXIMUM LENGTH: 1
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1 character in length.
DESCRIPTION:
Payer Responsibility Sequence Number Code.
TECHNICAL DESCR:
Payer Responsibility Sequence Number Code (X12 #2320, SBR01).
CROSS-REFERENCE:162.09^B
1)= S ^FBAAC(DA(4),1,DA(3),1,DA(2),1,DA(1),6,"B",$E(X,1,30),DA)=""
2)= K ^FBAAC(DA(4),1,DA(3),1,DA(2),1,DA(1),6,"B",$E(X,1,30),DA)
162.09,.02 INDIVIDUAL RELATIONSHIP CODE 0;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>2!($L(X)<2) X
MAXIMUM LENGTH: 2
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 2 characters in length.
DESCRIPTION:
Individual Relationship Code.
TECHNICAL DESCR:
Individual Relationship Code (X12 #2320, SBR02).
162.09,.03 INSURED GROUP OR POL NUMBER 0;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-50 characters in length.
DESCRIPTION:
Insured Group or Policy Number.
TECHNICAL DESCR:
Insured Group or Policy Number (X12 #2320, SBR03).
162.09,.04 OTHER INSUR GROUP NAME 0;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>60!($L(X)<1) X
MAXIMUM LENGTH: 60
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-60 characters in length.
DESCRIPTION:
Other Insured Group Name.
TECHNICAL DESCR:
Other Insured Group Name (X12 #2320, SBR04).
162.09,.05 INSURANCE TYPE CODE 0;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<1) X
MAXIMUM LENGTH: 3
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-3 characters in length.
DESCRIPTION:
Insurance Type Code.
TECHNICAL DESCR:
Insurance Type Code (X12 #2320, SBR05).
162.09,.06 CLAIM FILING INDICATOR CODE 0;6 FREE TEXT
INPUT TRANSFORM:K:$L(X)>2!($L(X)<1) X
MAXIMUM LENGTH: 2
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-2 characters in length.
DESCRIPTION:
Claim Filing Indicator Code.
TECHNICAL DESCR:
Claim Filing Indicator Code (X12 #2320, SBR09).
162.09,1 CLAIM LEVEL ADJUSTMENTS 1;0 Multiple #162.13 (Add New Entry without Asking)
DESCRIPTION:
X12, #2320 CAS section - contains the Claim Adjustment Group Code and related to it
adjustment codes, amounts and quantities.
TECHNICAL DESCR:
X12, #2320 CAS section (multiple - up to 5 entries).
162.13,.01 CLAIM ADJUSTMENT GROUP CODE 0;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>2!($L(X)<1) X
MAXIMUM LENGTH: 2
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-2 characters in length.
DESCRIPTION:
Claim Adjustment Group Code.
TECHNICAL DESCR:
Claim Adjustment Group Code (X12, #2320, CAS01).
CROSS-REFERENCE:162.13^B
1)= S ^FBAAC(DA(5),1,DA(4),1,DA(3),1,DA(2),6,DA(1),1,"B",$E(X,1,30),DA)=""
2)= K ^FBAAC(DA(5),1,DA(4),1,DA(3),1,DA(2),6,DA(1),1,"B",$E(X,1,30),DA)
162.13,1.01 ADJ REASON CODE 1 1;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>5!($L(X)<1) X
MAXIMUM LENGTH: 5
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-5 characters in length.
DESCRIPTION:
Adjustment Reason Code 1 (required).
TECHNICAL DESCR:
Adjustment Reason Code 1 (X12, #2320, CAS02 - required).
162.13,1.02 ADJ REASON CODE 2 1;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>5!($L(X)<1) X
MAXIMUM LENGTH: 5
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-5 characters in length.
DESCRIPTION:
Adjustment Reason Code 2.
TECHNICAL DESCR:
Adjustment Reason Code 2 (X12, #2320, CAS05).
162.13,1.03 ADJ REASON CODE 3 1;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>5!($L(X)<1) X
MAXIMUM LENGTH: 5
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-5 characters in length.
DESCRIPTION:
Adjustment Reason Code 3.
TECHNICAL DESCR:
Adjustment Reason Code 3 (X12, #2320, CAS08).
162.13,1.04 ADJ REASON CODE 4 1;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>5!($L(X)<1) X
MAXIMUM LENGTH: 5
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-5 characters in length.
DESCRIPTION:
Adjustment Reason Code 4.
TECHNICAL DESCR:
Adjustment Reason Code 4 (X12, #2320, CAS11).
162.13,1.05 ADJ REASON CODE 5 1;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>5!($L(X)<1) X
MAXIMUM LENGTH: 5
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-5 characters in length.
DESCRIPTION:
Adjustment Reason Code 5.
TECHNICAL DESCR:
Adjustment Reason Code 5 (X12, #2320, CAS14).
162.13,1.06 ADJ REASON CODE 6 1;6 FREE TEXT
INPUT TRANSFORM:K:$L(X)>5!($L(X)<1) X
MAXIMUM LENGTH: 5
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-5 characters in length.
DESCRIPTION:
Adjustment Reason Code 6.
TECHNICAL DESCR:
Adjustment Reason Code 6 (X12, #2320, CAS17).
162.13,2.01 ADJ AMOUNT 1 2;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Adjustment Amount 1 - required.
TECHNICAL DESCR:
Adjustment Amount (X12, #2320, CAS03 - required).
162.13,2.02 ADJ AMOUNT 2 2;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Adjustment Amount 2.
TECHNICAL DESCR:
Adjustment Amount 2 (X12, #2320, CAS06).
162.13,2.03 ADJ AMOUNT 3 2;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Adjustment Amount 3.
TECHNICAL DESCR:
Adjustment Amount 3 (X12, #2320, CAS09).
162.13,2.04 ADJ AMOUNT 4 2;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Adjustment Amount 4.
TECHNICAL DESCR:
Adjustment Amount 4 (X12, #2320, CAS12).
162.13,2.05 ADJ AMOUNT 5 2;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Adjustment Amount 5.
TECHNICAL DESCR:
Adjustment Amount 5 (X12, #2320, CAS15).
162.13,2.06 ADJ AMOUNT 6 2;6 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Adjustment Amount 6.
TECHNICAL DESCR:
Adjustment Amount 6 (X12, #2320, CAS18).
162.13,3.01 ADJ QUANTITY 1 3;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>15!($L(X)<1) X
MAXIMUM LENGTH: 15
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-15 characters in length.
DESCRIPTION:
Adjustment Quantity 1 (required).
TECHNICAL DESCR:
Adjustment Quantity 1 (X12, #2320, CAS04).
162.13,3.02 ADJ QUANTITY 2 3;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>15!($L(X)<1) X
MAXIMUM LENGTH: 15
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-15 characters in length.
DESCRIPTION:
Adjustment Quantity 2.
TECHNICAL DESCR:
Adjustment Quantity 2 (X12, #2320, CAS07).
162.13,3.03 ADJ QUANTITY 3 3;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>15!($L(X)<1) X
MAXIMUM LENGTH: 15
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-15 characters in length.
DESCRIPTION:
Adjustment Quantity 3.
TECHNICAL DESCR:
Adjustment Quantity 3 (X12, #2320, CAS10).
162.13,3.04 ADJ QUANTITY 4 3;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>15!($L(X)<1) X
MAXIMUM LENGTH: 15
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-15 characters in length.
DESCRIPTION:
Adjustment Quantity 4.
TECHNICAL DESCR:
Adjustment Quantity 4 (X12, #2320, CAS13).
162.13,3.05 ADJ QUANTITY 5 3;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>15!($L(X)<1) X
MAXIMUM LENGTH: 15
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-15 characters in length.
DESCRIPTION:
Adjustment Quantity 5.
TECHNICAL DESCR:
Adjustment Quantity 5 (X12, #2320, CAS16).
162.13,3.06 ADJ QUANTITY 6 3;6 FREE TEXT
INPUT TRANSFORM:K:$L(X)>15!($L(X)<1) X
MAXIMUM LENGTH: 15
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-15 characters in length.
DESCRIPTION:
Adjustment Quantity 6.
TECHNICAL DESCR:
Adjustment Quantity 6 (X12, #2320, CAS19).
162.09,2.01 COB PAYER PAID AMT QUAL CODE 2;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<1) X
MAXIMUM LENGTH: 3
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-3 characters in length.
DESCRIPTION:
COB Payer Paid Amount Qualifier Code.
TECHNICAL DESCR:
COB Payer Paid Amount- Required when the claim has been adjudicated by the payer
identified in loop 2330B or when loop 2010AC is present. AMT01 - Amount Qualifier Code
= D (X12, #2320, AMT).
162.09,2.02 COB PAYER PAID AMOUNT 2;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
COB Payer Paid Amount.
TECHNICAL DESCR:
COB Payer Paid Amount- Required when the claim has been adjudicated by the payer
identified in loop 2330B or when loop 2010AC is present. AMT02 - Payer Paid Amount
(X12, #2320, AMT).
162.09,3.01 REMAIN PAT LIAB AMT QUAL CODE 3;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<1) X
MAXIMUM LENGTH: 3
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-3 characters in length.
DESCRIPTION:
Remaining Patient Liability Amount Qualifier Code.
TECHNICAL DESCR:
Remaining Patient Liability, required when the Other Payer Identified in loop 2330B has
adjudicated this claim and provided claim level info only or when the Other Payer
Identified in loop 2330B does not have the ability to report line item information.
AMT01 Amount Qualifier Code = EAF (X12, #2320, AMT).
162.09,3.02 REMAIN PAT LIAB AMOUNT 3;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Remaining Patient Liability Amount.
TECHNICAL DESCR:
Remaining Patient Liability, required when the Other Payer Identified in loop 2330B has
adjudicated this claim and provided claim level info only or when the Other Payer
Identified in loop 2330B does not have the ability to report line item information.
AMT02 Remaining Patient Liability Amount (X12, #2320, AMT).
162.09,4.01 COB TOT NON-COV AMT QUAL CODE 4;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<1) X
MAXIMUM LENGTH: 3
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-3 characters in length.
DESCRIPTION:
COB Total Non-Covered Amount Qualifier Code.
TECHNICAL DESCR:
COB Total Non-Covered Amount - Required when the destination payer's cost avoidance
policy allows providers to bypass claims submission. AMT01 Amount Qualifier Code = A8
(X12, #2320, AMT).
162.09,4.02 COB TOT NON-COV AMOUNT 4;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
COB Total Non-Covered Amount.
TECHNICAL DESCR:
COB Total Non-Covered Amount, required when the destination payer's cost avoidance
policy allows providers to bypass claims submission. AMT02 Non-Covered Amount (X12,
#2320, AMT).
162.09,5.01 OTH INS BENEF ASSIGN CERT INFO 5;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>1!($L(X)<1) X
MAXIMUM LENGTH: 1
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1 character in length.
DESCRIPTION:
Other Insurance Coverage Info - Benefit Assignment Certification Indicator.
TECHNICAL DESCR:
Other Insurance Coverage Info. OI03 Benefit Assignment Certification Indicator (X12,
#2320, OI).
162.09,5.02 OTH INS PAT SIGNAT SOURCE CODE 5;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>1!($L(X)<1) X
MAXIMUM LENGTH: 1
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1 character in length.
DESCRIPTION:
Other Insurance Coverage Info - Patient Signature Source Code.
TECHNICAL DESCR:
Other Insurance Coverage Info. OI04 Patient Signature Source Code (X12, #2320, OI).
162.09,5.03 OTH INS ROI CODE 5;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>1!($L(X)<1) X
MAXIMUM LENGTH: 1
LAST EDITED: APR 17, 2017
HELP-PROMPT:Answer must be 1 character in length.
DESCRIPTION:
Other Insurance Coverage Info Release of Information Code.
TECHNICAL DESCR:
Other Insurance Coverage Info. OI06 Release of Information Code, this is a crosswalk
from CLM09 when doing COB (X12, #2320, OI).
162.09,6.01 INP ADJ QUANT COV DAYS VIS CNT 6;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>15!($L(X)<1) X
MAXIMUM LENGTH: 15
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-15 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - Covered Days or Visit Count.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA01 Covered Days or Visit Count (X12, #2320,
MIA).
162.09,6.02 INP ADJ LIFETIME PSYCH CNT 6;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>15!($L(X)<1) X
MAXIMUM LENGTH: 15
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-15 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - Lifetime Psychiatric Days Count.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA03 Lifetime Psychiatric Days Count (X12, #2320,
MIA).
162.09,6.03 INP ADJ REM PAT LIAB AMOUNT 6;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - Remaining Patient Liability Amount.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA04 Remaining Patient Liability Amount (X12,
#2320, MIA).
162.09,6.04 INP ADJ REF ID-REM CODE MIA05 6;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-50 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - Claim Payment Remark Code.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA05 Claim Payment Remark Code (X12, #2320, MIA).
162.09,6.05 INP ADJ AMT-CLM DISPR SHARE 6;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - Claim Disproportionate Share Amount.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA06 Claim Disproportionate Share Amount (X12,
#2320, MIA).
162.09,6.06 INP ADJ AMT-CLM MSP PASS 6;6 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - Claim MSP Pass-through Amount.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA07 Claim MSP Pass-through Amount (X12, #2320,
MIA).
162.09,6.07 INP ADJ AMT-CLM PPS CAPITAL 6;7 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - Claims PPS Capital Amount.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA08 Claims PPS Capital Amount (X12, #2320, MIA).
162.09,6.08 INP ADJ AMT-PPS CAP FSP DRG 6;8 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - PPS-Capital FSP DRG Amount.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA09 PPS-Capital FSP DRG Amount (X12, #2320, MIA).
162.09,7.01 INP ADJ AMT-PPS CAP HSP DRG 7;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - PPS-Capital HSP DRG Amount.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA10 PPS-Capital HSP DRG Amount (X12, #2320, MIA).
162.09,7.02 INP ADJ AMT-PPS CAP DSH DRG 7;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - PPS-Capital DSH DRG Amount.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA11 PPS-Capital DSH DRG Amount (X12, #2320, MIA).
162.09,7.03 INP ADJ AMT-OLD CAPITAL AMN 7;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - Old Capital Amount.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA12 Old Capital Amount (X12, #2320, MIA).
162.09,7.04 INP ADJ AMT-PPS CAPIT IME AMT 7;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - PPS-Capital ImE Amount (X12, #2320, MIA).
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA13 PPS-Capital ImE Amount (X12, #2320, MIA).
162.09,7.05 INP ADJ AMT-PPS OPER HOSP DRG 7;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - PPS-Operating Hospital Specific DRG Amount.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA14 PPS-Operating Hospital Specific DRG Amount
(X12, #2320, MIA).
162.09,7.06 INP ADJ COST REPORT DAY COUNT 7;6 FREE TEXT
INPUT TRANSFORM:K:$L(X)>15!($L(X)<1) X
MAXIMUM LENGTH: 15
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-15 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - Cost Report Day Count.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA15 Cost Report Day Count (X12, #2320, MIA).
162.09,7.07 INP ADJ AMT-PPS OP FED SPE DRG 7;7 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - PPS-Operating Federal Specific DRG Amount.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA16 PPS-Operating Federal Specific DRG Amount
(X12, #2320, MIA).
162.09,7.08 INP ADJ AMT-CLM PPS CAPIT OUTL 7;8 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - Claims PPS Capital Outlier Amount.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA17 Claims PPS Capital Outlier Amount (X12,
#2320, MIA).
162.09,7.09 INP ADJ AMT-CLM INDIR TEACHING 7;9 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - Claim Indirect Teaching Amount.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA18 Claim Indirect Teaching Amount (X12, #2320,
MIA).
162.09,7.1 INP ADJ AMT-NON-PAY PROF BILLD 7;10 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - Non-Payable Professional Component Billed Amount.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA19 Non-Payable Professional Component Billed
Amount (X12, #2320, MIA).
162.09,8.01 INP ADJ REF ID-REM CODE MIA20 8;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-50 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - Claim Payment Remark Code.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA20 Claim Payment Remark Code (X12, #2320, MIA).
162.09,8.02 INP ADJ REF ID-REM CODE MIA21 8;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-50 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - Claim Payment Remark Code.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA21 Reference ID - Claim Payment Remark Code (X12,
#2320, MIA).
162.09,8.03 INP ADJ REF ID-REM CODE MIA22 8;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-50 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - Claim Payment Remark Code (MIA22).
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA22 Reference ID - Claim Payment Remark Code (X12,
#2320, MIA).
162.09,8.04 INP ADJ REF ID-REM CODE MIA23 8;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-50 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - Claim Payment Remark Code (MIA23).
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA23 Reference ID - Claim Payment Remark Code (X12,
#2320, MIA).
162.09,8.05 INP ADJ AMT-PPS CAPITAL EXCEPT 8;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Inpatient Adjudication Info - PPS-Capital Exception Amount.
TECHNICAL DESCR:
Inpatient Adjudication Info - required when inpatient adjudication information is
reported in the remittance advice. MIA24 Monetary Amount - PPS Capital Exception (X12,
#2320, MIA).
162.09,9.01 OUTP ADJ REIMBURSE RATE 9;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>10!($L(X)<1) X
MAXIMUM LENGTH: 10
LAST EDITED: JUL 13, 2017
HELP-PROMPT:Answer must be 1-10 characters in length.
DESCRIPTION:
MOA Outpatient Adjudication Info - Reimbursement Rate.
TECHNICAL DESCR:
MOA Outpatient Adjudication Info. MOA01 Reimbursement Rate. (X12, #2320, MOA).
162.09,9.02 OUTP ADJ HCPCS PAYABLE AMT 9;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
MOA Outpatient Adjudication Info - HCPCS Payable Amount.
TECHNICAL DESCR:
MOA Outpatient Adjudication Info. MOA02 Monetary Amt - HCPCS Payable Amount (X12,
#2320, MOA).
162.09,9.03 OUTP ADJ REF ID-REM COD MOA03 9;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-50 characters in length.
DESCRIPTION:
Outpatient Adjudication Info - Remark Code MOA03.
TECHNICAL DESCR:
MOA Outpatient Adjudication Info. MOA03 Reference ID - Claim Payment Remark Code (X12,
#2320, MOA).
162.09,9.04 OUTP ADJ REF ID-REM COD MOA04 9;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-50 characters in length.
DESCRIPTION:
Outpatient Adjudication Info - Remark Code MOA04.
TECHNICAL DESCR:
MOA Outpatient Adjudication Info. MOA04 Reference ID - Claim Payment Remark Code (X12,
#2320, MOA).
162.09,10.01 OUTP ADJ REF ID-REM COD MOA05 10;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-50 characters in length.
DESCRIPTION:
Outpatient Adjudication Info - Remark Code MOA05.
TECHNICAL DESCR:
MOA Outpatient Adjudication Info. MOA05 Reference ID - Claim Payment Remark Code (X12,
#2320, MOA).
162.09,10.02 OUTP ADJ REF ID-REM COD MOA06 10;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-50 characters in length.
DESCRIPTION:
Outpatient Adjudication Info - Remark Code MOA06.
TECHNICAL DESCR:
MOA Outpatient Adjudication Info. MOA06 Reference ID - Claim Payment Remark Code (X12,
#2320, MOA).
162.09,10.03 OUTP ADJ REF ID-REM COD MOA07 10;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-50 characters in length.
DESCRIPTION:
Outpatient Adjudication Info - Remark Code MOA07.
TECHNICAL DESCR:
MOA Outpatient Adjudication Info. MOA07 Reference ID - Claim Payment Remark Code (X12,
#2320, MOA).
162.09,10.04 OUTP ADJ ESRD PAYM AMT 10;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Outpatient Adjudication Info - End Stage Renal Disease Payment Amount.
TECHNICAL DESCR:
Outpatient Adjudication Info - End Stage Renal Disease Payment Amount. MOA08 End Stage
Renal Disease Payment Amount (X12, #2320, MOA).
162.09,10.05 OUTP ADJ NON PAY PROF BILLED 10;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Outpatient Adjudication Info - Non-Payable Professional Component Billed Amount.
TECHNICAL DESCR:
MOA Outpatient Adjudication Info. MOA09 Monetary Amt - Non-Payable Professional
Component Billed Amount (X12, #2320, MOA).
162.09,11.01 OTH SUB ENTITY ID CODE 11;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<2) X
MAXIMUM LENGTH: 3
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 2-3 characters in length.
DESCRIPTION:
Entity Identifier Code.
TECHNICAL DESCR:
X12, #2330A, Other Subscriber Name, NM1 Other Subscriber Name, NM101 Entity
Identifier Code.
162.09,11.02 OTH SUB ENTITY TYPE QUAL 11;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>1!($L(X)<1) X
MAXIMUM LENGTH: 1
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1 character in length.
DESCRIPTION:
Entity Type Qualifier.
TECHNICAL DESCR:
X12, #2330A, Other Subscriber Name, NM1 Other Subscriber Name, NM102 Entity Type
Qualifier.
162.09,11.03 OTH SUB LAST NAME 11;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>60!($L(X)<1) X
MAXIMUM LENGTH: 60
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-60 characters in length.
DESCRIPTION:
Other Insured Last Name.
TECHNICAL DESCR:
X12, #2330A, Other Subscriber Name, NM1 Other Subscriber Name, NM103 Other Insured
Last Name.
162.09,11.04 OTH SUB FIRST NAME 11;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>35!($L(X)<1) X
MAXIMUM LENGTH: 35
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-35 characters in length.
DESCRIPTION:
Other Insured First Name.
TECHNICAL DESCR:
X12, #2330A, Other Subscriber Name, NM1 Other Subscriber Name, NM104 Other Insured
First Name.
162.09,11.05 OTH SUB MIDDLE NAME 11;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>25!($L(X)<1) X
MAXIMUM LENGTH: 25
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-25 characters in length.
DESCRIPTION:
Other Insured Middle Name.
TECHNICAL DESCR:
X12, #2330A, Other Subscriber Name, NM1 Other Subscriber Name, NM105 Other Insured
Middle Name.
162.09,11.06 OTH SUB NAME SUFFIX 11;6 FREE TEXT
INPUT TRANSFORM:K:$L(X)>10!($L(X)<1) X
MAXIMUM LENGTH: 10
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-10 characters in length.
DESCRIPTION:
Other Insured Name Suffix.
TECHNICAL DESCR:
X12, #2330A, Other Subscriber Name, NM1 Other Subscriber Name, NM107 Other Insured
Name Suffix.
162.09,11.07 OTH SUB ID CODE QUAL 11;7 FREE TEXT
INPUT TRANSFORM:K:$L(X)>2!($L(X)<1) X
MAXIMUM LENGTH: 2
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-2 characters in length.
DESCRIPTION:
Identification Code Qualifier.
TECHNICAL DESCR:
X12, #2330A, Other Subscriber Name, NM1 Other Subscriber Name, NM108 Identification
Code Qualifier.
162.09,11.08 OTH SUB INSURED ID 11;8 FREE TEXT
INPUT TRANSFORM:K:$L(X)>80!($L(X)<2) X
MAXIMUM LENGTH: 80
LAST EDITED: JUL 13, 2017
HELP-PROMPT:Answer must be 2-80 characters in length.
DESCRIPTION:
Other Insured Identifier.
TECHNICAL DESCR:
X12, #2330A, Other Subscriber Name, NM1 Other Subscriber Name, NM109 Other Insured
Identifier.
162.09,12.01 OTH SUB ADDR LINE 1 12;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>55!($L(X)<1) X
MAXIMUM LENGTH: 55
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-55 characters in length.
DESCRIPTION:
Other Insured's Address line 1.
TECHNICAL DESCR:
X12, #2330A, Other Subscriber Name, N3 Other Subscriber Address, N301 Other
Insured's Address line 1.
162.09,12.02 OTH SUB ADDR LINE 2 12;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>55!($L(X)<1) X
MAXIMUM LENGTH: 55
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-55 characters in length.
DESCRIPTION:
Other Insured's Address line 2.
TECHNICAL DESCR:
X12, #2330A, Other Subscriber Name, N3 Other Subscriber Address, N302 Other
Insured's Address line 2.
162.09,12.03 OTH SUB CITY NAME 12;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>30!($L(X)<2) X
MAXIMUM LENGTH: 30
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 2-30 characters in length.
DESCRIPTION:
Other Insured City Name.
TECHNICAL DESCR:
X12, #2330A, Other Subscriber Name, N4 Other Subscriber City, State, Zip, N401
Other Insured City Name.
162.09,12.04 OTH SUB STATE CODE 12;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>2!($L(X)<2) X
MAXIMUM LENGTH: 2
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 2 characters in length.
DESCRIPTION:
Other Insured State Code.
TECHNICAL DESCR:
X12, #2330A, Other Subscriber Name, N4 Other Subscriber City, State, Zip, N402
Other Insured State Code.
162.09,12.05 OTH SUB POSTAL ZIP 12;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>15!($L(X)<3) X
MAXIMUM LENGTH: 15
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 3-15 characters in length.
DESCRIPTION:
Other Insured Postal Zone or ZIP Code.
TECHNICAL DESCR:
X12, #2330A, Other Subscriber Name, N4 Other Subscriber City, State, Zip, N403
Other Insured Postal Zone or ZIP Code.
162.09,12.06 OTH SUB COUNTRY CODE 12;6 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<2) X
MAXIMUM LENGTH: 3
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 2-3 characters in length.
DESCRIPTION:
Other Insured Country Code.
TECHNICAL DESCR:
X12, #2330A, Other Subscriber Name, N4 Other Subscriber City, State, Zip, N404
Other Insured Country Code.
162.09,12.07 OTH SUB COUNTRY SUBDIV CODE 12;7 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<1) X
MAXIMUM LENGTH: 3
LAST EDITED: JUL 13, 2017
HELP-PROMPT:Answer must be 1-3 characters in length.
DESCRIPTION:
Other Insured Country subdivision code.
TECHNICAL DESCR:
X12, #2330A, Other Subscriber Name, N4 Other Subscriber City, State, Zip, N407
Other Insured Country subdivision code.
162.09,13.01 OTH SUB 2ND ID REF QUAL 1 13;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<2) X
MAXIMUM LENGTH: 3
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 2-3 characters in length.
DESCRIPTION:
Reference Identification Qualifier 1.
TECHNICAL DESCR:
X12, #2330A, Other Subscriber Name, REF Other Subscriber secondary ID, REF01
Reference Identification Qualifier 1.
162.09,13.02 OTH SUB 2ND ID-ADDTNL ID 1 13;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-50 characters in length.
DESCRIPTION:
Other Insured Additional Identifier 1.
TECHNICAL DESCR:
X12, #2330A, Other Subscriber Name, REF Other Subscriber secondary ID, REF02 Other
Insured Additional Identifier 1.
162.09,13.03 OTH SUB 2ND ID REF QUAL 2 13;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<2) X
MAXIMUM LENGTH: 3
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 2-3 characters in length.
DESCRIPTION:
Reference Identification Qualifier 2.
TECHNICAL DESCR:
X12, #2330A, Other Subscriber Name, REF Other Subscriber secondary ID, REF01
Reference Identification Qualifier 2.
162.09,13.04 OTH SUB 2ND ID-ADDTNL ID 2 13;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-50 characters in length.
DESCRIPTION:
Other Insured Additional Identifier 2.
TECHNICAL DESCR:
X12, #2330A, Other Subscriber Name, REF Other Subscriber secondary ID, REF02 Other
Insured Additional Identifier 2.
162.09,14.01 OTH PAYER ENTITY ID CODE 14;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<2) X
MAXIMUM LENGTH: 3
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 2-3 characters in length.
DESCRIPTION:
Entity Identifier Code.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, NM1 Other Payer Name, NM101 Entity Identifier Code.
162.09,14.02 OTH PAYER ENTITY TYPE QUAL 14;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>1!($L(X)<1) X
MAXIMUM LENGTH: 1
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1 character in length.
DESCRIPTION:
Entity Type Qualifier.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, NM1 Other Payer Name, NM102 Entity Type Qualifier.
162.09,14.03 OTH PAYER LAST OR ORG NAME 14;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>60!($L(X)<1) X
MAXIMUM LENGTH: 60
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-60 characters in length.
DESCRIPTION:
Other Payer Last or Organization Name.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, NM1 Other Payer Name, NM103 Other Payer Last or
Organization Name.
162.09,14.04 OTH PAYER ID CODE QUALIFIER 14;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>2!($L(X)<1) X
MAXIMUM LENGTH: 2
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-2 characters in length.
DESCRIPTION:
Identification Code Qualifier.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, NM1 Other Payer Name, NM108 Identification Code
Qualifier.
162.09,14.05 OTH PAYER PRIMARY IDENTIFIER 14;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>80!($L(X)<2) X
MAXIMUM LENGTH: 80
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 2-80 characters in length.
DESCRIPTION:
Other Payer Primary Identifier.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, NM1 Other Payer Name, NM109 Other Payer Primary
Identifier.
162.09,15.01 OTH PAYER ADDR LINE 1 15;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>55!($L(X)<1) X
MAXIMUM LENGTH: 55
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-55 characters in length.
DESCRIPTION:
Other Payer Address Line 1.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, N3 Other Payer Address, N301 Other Payer Address
Line 1.
162.09,15.02 OTH PAYER ADDR LINE 2 15;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>55!($L(X)<1) X
MAXIMUM LENGTH: 55
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-55 characters in length.
DESCRIPTION:
Other Payer Address Line 2.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, N3 Other Payer Address, N302 Other Payer Address
Line 2.
162.09,15.03 OTH PAYER CITY NAME 15;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>30!($L(X)<2) X
MAXIMUM LENGTH: 30
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 2-30 characters in length.
DESCRIPTION:
Other Payer City Name.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, N4 Other Payer City, State, Zip, N401 Other Payer
City Name.
162.09,15.04 OTH PAYER STATE CODE 15;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>2!($L(X)<2) X
MAXIMUM LENGTH: 2
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 2 characters in length.
DESCRIPTION:
Other Payer State Code.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, N4 Other Payer City, State, Zip, N402 Other Payer
State Code.
162.09,15.05 OTH PAYER POSTAL ZIP 15;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>15!($L(X)<3) X
MAXIMUM LENGTH: 15
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 3-15 characters in length.
DESCRIPTION:
Other Payer Postal Zone or ZIP Code.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, N4 Other Payer City, State, Zip, N403 Other Payer
Postal Zone or ZIP Code.
162.09,15.06 OTH PAYER COUNTRY CODE 15;6 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<2) X
MAXIMUM LENGTH: 3
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 2-3 characters in length.
DESCRIPTION:
Other Payer Country Code.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, N4 Other Payer City, State, Zip, N404 Other Payer
Country Code.
162.09,15.07 OTH PAYER COUNTRY SUBDIV CODE 15;7 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<1) X
MAXIMUM LENGTH: 3
LAST EDITED: JUL 13, 2017
HELP-PROMPT:Answer must be 1-3 characters in length.
DESCRIPTION:
Other Payer Country Subdivision Code.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, N4 Other Payer City, State, Zip, N407 Other Payer
Country Subdivision Code.
162.09,16.01 OTH PAYER DATE TIME QUAL 16;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<3) X
MAXIMUM LENGTH: 3
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 3 characters in length.
DESCRIPTION:
Date Time Qualifier.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, DTP Claim Check or Remittance Date, DTP01 Date Time
Qualifier.
162.09,16.02 OTH PAYER DTIME PER FORM QUAL 16;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<2) X
MAXIMUM LENGTH: 3
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 2-3 characters in length.
DESCRIPTION:
Date Time Period Format Qualifier.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, DTP Claim Check or Remittance Date, DTP02 Date Time
Period Format Qualifier.
162.09,16.03 OTH PAYER ADJ OR PAYMENT DATE 16;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>35!($L(X)<1) X
MAXIMUM LENGTH: 35
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-35 characters in length.
DESCRIPTION:
Adjudication or Payment Date.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, DTP Claim Check or Remittance Date, DTP03
Adjudication or Payment Date.
162.09,17.01 OTH PAYER 2ND REF ID QUAL 1 17;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<2) X
MAXIMUM LENGTH: 3
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 2-3 characters in length.
DESCRIPTION:
Reference Identification Qualifier 1.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, REF Other Payer Secondary ID, REF01 Reference
Identification Qualifier 1.
162.09,17.02 OTH PAYER 2NDARY ID 1 17;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-50 characters in length.
DESCRIPTION:
Other Payer Secondary Identifier 1.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, REF Other Payer Secondary ID, REF02 Other Payer
Secondary Identifier 1.
162.09,17.03 OTH PAYER 2ND REF ID QUAL 2 17;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<2) X
MAXIMUM LENGTH: 3
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 2-3 characters in length.
DESCRIPTION:
Reference Identification Qualifier 2.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, REF Other Payer Secondary ID, REF01 Reference
Identification Qualifier 2.
162.09,17.04 OTH PAYER 2NDARY ID 2 17;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-50 characters in length.
DESCRIPTION:
Other Payer Secondary Identifier 2.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, REF Other Payer Secondary ID, REF02 Other Payer
Secondary Identifier 2.
162.09,17.05 OTH PAYER PR AUTH REF ID QUAL 17;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<2) X
MAXIMUM LENGTH: 3
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 2-3 characters in length.
DESCRIPTION:
Reference Identification Qualifier.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, REF Other Payer Prior Authorization Number, REF01
Reference Identification Qualifier.
162.09,17.06 OTH PAYER PRIOR AUTH NUM 17;6 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-50 characters in length.
DESCRIPTION:
Other Payer Prior Authorization Number.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, REF Other Payer Prior Authorization Number, REF02
Other Payer Prior Authorization Number.
162.09,17.07 OTH PAYER REFFERL REF ID QUAL 17;7 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<2) X
MAXIMUM LENGTH: 3
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 2-3 characters in length.
DESCRIPTION:
Reference Identification Qualifier.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, REF Other Payer Referral Number, REF01 Reference
Identification Qualifier.
162.09,17.08 OTH PAYER REFFERAL NUMBER 17;8 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-50 characters in length.
DESCRIPTION:
Reference Identification Qualifier.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, REF Other Payer Referral Number, REF01 Reference
Identification Qualifier.
162.09,18.01 OTH PAYER CLM ADJ REF ID QUAL 18;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<2) X
MAXIMUM LENGTH: 3
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 2-3 characters in length.
DESCRIPTION:
Reference Identification Qualifier.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, REF Other Payer Claim Adjustment Indicator, REF01
Reference Identification Qualifier.
162.09,18.02 OTH PAYER CLAIM ADJ INDICATOR 18;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-50 characters in length.
DESCRIPTION:
Other Payer Claim Adjustment Indicator.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, REF Other Payer Claim Adjustment Indicator, REF02
Other Payer Claim Adjustment Indicator.
162.09,18.03 OTH PAYER CLM CTRL REF ID QUAL 18;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<2) X
MAXIMUM LENGTH: 3
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 2-3 characters in length.
DESCRIPTION:
Reference Identification Qualifier.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, REF Other Payer Claim Control Number, REF01
Reference Identification Qualifier.
162.09,18.04 OTH PAYER CLAIM CTRL NUMBER 18;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: APR 18, 2017
HELP-PROMPT:Answer must be 1-50 characters in length.
DESCRIPTION:
Other Payer Claim Control Number.
TECHNICAL DESCR:
X12, #2330B, Other Payer Name, REF Other Payer Claim Control Number, REF02 Other
Payer Claim Control Number.
162.03,71 OHI SERVICE LINE INFO 11;0 Multiple #162.371 (Add New Entry without Asking)
DESCRIPTION:
This multiple contains payment and payer information for each specific service provided
to the patient.
TECHNICAL DESCR:
OHI Service Line number information, X12, #2400.
162.371,.01 SERVICE LINE NUMBER 0;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>20!($L(X)<1) X
MAXIMUM LENGTH: 20
LAST EDITED: JUL 05, 2017
HELP-PROMPT:Answer must be 1-20 characters in length.
DESCRIPTION:
LX Service Line Number.
TECHNICAL DESCR:
X12, #2400, Service Line Number, Service Line number information, LX Service Line
Number.
CROSS-REFERENCE:162.371^B
1)= S ^FBAAC(DA(4),1,DA(3),1,DA(2),1,DA(1),11,"B",$E(X,1,30),DA)=""
2)= K ^FBAAC(DA(4),1,DA(3),1,DA(2),1,DA(1),11,"B",$E(X,1,30),DA)
162.371,1 LINE ADJUDICATION INFORMATION 1;0 Multiple #162.3711 (Add New Entry without Asking)
DESCRIPTION:
This multiple contains payment and payer information for each payment line for the
specific service provided to the patient.
TECHNICAL DESCR:
X12, #2400, Service Line Number, Line Adjudication Information.
162.3711,.01 OTHER PRIMARY PAYER ID 0;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>80!($L(X)<2) X
MAXIMUM LENGTH: 80
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 2-80 characters in length.
DESCRIPTION:
Other Primary Payer Identifier.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line
Adjudication Info, SVD01 Other Primary Payer Identifier.
CROSS-REFERENCE:162.3711^B
1)= S ^FBAAC(DA(5),1,DA(4),1,DA(3),1,DA(2),11,DA(1),1,"B",$E(X,1,30),DA)=""
2)= K ^FBAAC(DA(5),1,DA(4),1,DA(3),1,DA(2),11,DA(1),1,"B",$E(X,1,30),DA)
162.3711,.02 SERVICE LINE PAID AMT 0;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Service Line Paid Amount.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line
Adjudication Info, SVD02 Service Line Paid Amount.
162.3711,1.01 PROD OR SERV ID QUAL 1;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>2!($L(X)<2) X
MAXIMUM LENGTH: 2
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 2 characters in length.
DESCRIPTION:
Product or Service ID Qualifier.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line
Adjudication Info, SVD03-1 Product or Service ID Qualifier.
162.3711,1.02 PROCEDURE CODE 1;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>48!($L(X)<1) X
MAXIMUM LENGTH: 48
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-48 characters in length.
DESCRIPTION:
Procedure Code.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line
Adjudication Info, SVD03-2 Procedure Code.
162.3711,1.03 PROC MODIF SVD03-3 1;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>2!($L(X)<2) X
MAXIMUM LENGTH: 2
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 2 characters in length.
DESCRIPTION:
Procedure Modifier.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line
Adjudication Info, SVD03-3 Procedure Modifier.
162.3711,1.04 PROC MODIF SVD03-4 1;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>2!($L(X)<2) X
MAXIMUM LENGTH: 2
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 2 characters in length.
DESCRIPTION:
Procedure Modifier.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line
Adjudication Info, SVD03-4 Procedure Modifier.
162.3711,1.05 PROC MODIF SVD03-5 1;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>2!($L(X)<2) X
MAXIMUM LENGTH: 2
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 2 characters in length.
DESCRIPTION:
Procedure Modifier.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line
Adjudication Info, SVD03-5 Procedure Modifier.
162.3711,1.06 PROC MODIF SVD03-6 1;6 FREE TEXT
INPUT TRANSFORM:K:$L(X)>2!($L(X)<2) X
MAXIMUM LENGTH: 2
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 2 characters in length.
DESCRIPTION:
Procedure Modifier.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line
Adjudication Info, SVD03-6 Procedure Modifier.
162.3711,1.07 PROC CODE DESCRIPTION 1;7 FREE TEXT
INPUT TRANSFORM:K:$L(X)>80!($L(X)<1) X
MAXIMUM LENGTH: 80
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-80 characters in length.
DESCRIPTION:
Procedure Code Description.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line
Adjudication Info, SVD03-7 Procedure Code Description.
162.3711,1.08 PRODUCT OR SERV ID 1;8 FREE TEXT
INPUT TRANSFORM:K:$L(X)>48!($L(X)<1) X
MAXIMUM LENGTH: 48
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-48 characters in length.
DESCRIPTION:
Product or Service ID.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line
Adjudication Info, SVD04 Product or Service ID.
162.3711,1.09 PAID SERV UNIT CNT 1;9 FREE TEXT
INPUT TRANSFORM:K:$L(X)>15!($L(X)<1) X
MAXIMUM LENGTH: 15
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-15 characters in length.
DESCRIPTION:
Paid Service Unit Count.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line
Adjudication Info, SVD05 Paid Service Unit Count.
162.3711,1.1 BUNDL OR UNBUNDL LINE NUM 1;10 FREE TEXT
INPUT TRANSFORM:K:$L(X)>6!($L(X)<1) X
MAXIMUM LENGTH: 6
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-6 characters in length.
DESCRIPTION:
Bundled or Unbundled Line Number.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line
Adjudication Info, SVD06 Bundled or Unbundled Line Number.
162.3711,2 LINE ADJUSTMENT 2;0 Multiple #162.37112 (Add New Entry without Asking)
DESCRIPTION:
This multiple contains the Claim Adjustment Group Code and adjustment codes, amounts
and quantities related to it.
TECHNICAL DESCR:
CAS Line Adjustment multiple.
162.37112,.01 CLAIM ADJUSTMENT GROUP CODE 0;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>2!($L(X)<1) X
MAXIMUM LENGTH: 2
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-2 characters in length.
DESCRIPTION:
Claim Adjustment Group Code.
CROSS-REFERENCE:162.37112^B
1)= S ^FBAAC(DA(6),1,DA(5),1,DA(4),1,DA(3),11,DA(2),1,DA(1),2,"B",$E(X,1,30),DA)=""
2)= K ^FBAAC(DA(6),1,DA(5),1,DA(4),1,DA(3),11,DA(2),1,DA(1),2,"B",$E(X,1,30),DA)
162.37112,1.01 ADJ REASON CODE 1 1;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>5!($L(X)<1) X
MAXIMUM LENGTH: 5
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-5 characters in length.
DESCRIPTION:
Adjustment Reason Code.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, CAS
Line Adjustment, CAS02 Adjustment Reason Code.
162.37112,1.02 ADJ REASON CODE 2 1;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>5!($L(X)<1) X
MAXIMUM LENGTH: 5
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-5 characters in length.
DESCRIPTION:
Adjustment Reason Code.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, CAS
Line Adjustment, CAS05 Adjustment Reason Code.
162.37112,1.03 ADJ REASON CODE 3 1;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>5!($L(X)<1) X
MAXIMUM LENGTH: 5
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-5 characters in length.
DESCRIPTION:
Adjustment Reason Code.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, CAS
Line Adjustment, CAS08 Adjustment Reason Code.
162.37112,1.04 ADJ REASON CODE 4 1;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>5!($L(X)<1) X
MAXIMUM LENGTH: 5
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-5 characters in length.
DESCRIPTION:
Adjustment Reason Code.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, CAS
Line Adjustment, CAS11 Adjustment Reason Code.
162.37112,1.05 ADJ REASON CODE 5 1;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>5!($L(X)<1) X
MAXIMUM LENGTH: 5
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-5 characters in length.
DESCRIPTION:
Adjustment Reason Code.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, CAS
Line Adjustment, CAS14 Adjustment Reason Code.
162.37112,1.06 ADJ REASON CODE 6 1;6 FREE TEXT
INPUT TRANSFORM:K:$L(X)>5!($L(X)<1) X
MAXIMUM LENGTH: 5
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-5 characters in length.
DESCRIPTION:
Adjustment Reason Code.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, CAS
Line Adjustment, CAS17 Adjustment Reason Code.
162.37112,2.01 ADJ AMOUNT 1 2;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Adjustment Amount.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, CAS
Line Adjustment, CAS03 Adjustment Amount.
162.37112,2.02 ADJ AMOUNT 2 2;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Adjustment Amount.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, CAS
Line Adjustment, CAS06 Adjustment Amount.
162.37112,2.03 ADJ AMOUNT 3 2;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Adjustment Amount.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, CAS
Line Adjustment, CAS09 Adjustment Amount.
162.37112,2.04 ADJ AMOUNT 4 2;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Adjustment Amount.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, CAS
Line Adjustment, CAS12 Adjustment Amount.
162.37112,2.05 ADJ AMOUNT 5 2;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Adjustment Amount.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, CAS
Line Adjustment, CAS15 Adjustment Amount.
162.37112,2.06 ADJ AMOUNT 6 2;6 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Adjustment Amount.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, CAS
Line Adjustment, CAS18 Adjustment Amount.
162.37112,3.01 ADJ QUANTITY 1 3;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>15!($L(X)<1) X
MAXIMUM LENGTH: 15
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-15 characters in length.
DESCRIPTION:
Adjustment Quantity.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, CAS Line
Adjustment, CAS04 Adjustment Quantity.
162.37112,3.02 ADJ QUANTITY 2 3;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>15!($L(X)<1) X
MAXIMUM LENGTH: 15
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-15 characters in length.
DESCRIPTION:
Adjustment Quantity.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, CAS
Line Adjustment, CAS07 Adjustment Quantity.
162.37112,3.03 ADJ QUANTITY 3 3;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>15!($L(X)<1) X
MAXIMUM LENGTH: 15
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-15 characters in length.
DESCRIPTION:
Adjustment Quantity.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, CAS
Line Adjustment, CAS10 Adjustment Quantity.
162.37112,3.04 ADJ QUANTITY 4 3;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>15!($L(X)<1) X
MAXIMUM LENGTH: 15
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-15 characters in length.
DESCRIPTION:
Adjustment Quantity.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, CAS
Line Adjustment, CAS13 Adjustment Quantity.
162.37112,3.05 ADJ QUANTITY 5 3;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>15!($L(X)<1) X
MAXIMUM LENGTH: 15
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-15 characters in length.
DESCRIPTION:
Adjustment Quantity.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, CAS
Line Adjustment, CAS16 Adjustment Quantity.
162.37112,3.06 ADJ QUANTITY 6 3;6 FREE TEXT
INPUT TRANSFORM:K:$L(X)>15!($L(X)<1) X
MAXIMUM LENGTH: 15
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-15 characters in length.
DESCRIPTION:
Adjustment Quantity.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, CAS
Line Adjustment, CAS19 Adjustment Quantity.
162.3711,3.01 LN CHK DATE TIME QUALIFIER 3;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<3) X
MAXIMUM LENGTH: 3
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 3 characters in length.
DESCRIPTION:
Date Time Qualifier.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, DTP
Line Check or Remittance Advice, DTP01 Date Time Qualifier.
162.3711,3.02 LN CHK DATE TIME PER FORM QUAL 3;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<2) X
MAXIMUM LENGTH: 3
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 2-3 characters in length.
DESCRIPTION:
Date Time Period Format Qualifier.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, DTP
Line Check or Remittance Advice, DTP02 Date Time Period Format Qualifier.
162.3711,3.03 LN CHK ADJ OR PAYMENT DATE 3;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>35!($L(X)<1) X
MAXIMUM LENGTH: 35
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-35 characters in length.
DESCRIPTION:
Adjudication or Payment Date.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, DTP
Line Check or Remittance Advice, DTP03 Adjudication or Payment Date.
162.3711,4.01 REMAIN PAT LIAB AMT QUAL CODE 4;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>3!($L(X)<1) X
MAXIMUM LENGTH: 3
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-3 characters in length.
DESCRIPTION:
Amount Qualifier Code.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, AMT
Remaining Patient Liability, AMT01 Amount Qualifier Code.
162.3711,4.02 REMAIN PAT LIABILITY AMOUNT 4;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>18!($L(X)<1) X
MAXIMUM LENGTH: 18
LAST EDITED: JUL 06, 2017
HELP-PROMPT:Answer must be 1-18 characters in length.
DESCRIPTION:
Remaining Patient Liability Amount.
TECHNICAL DESCR:
X12, #2400, Service Line Number, 2430 Line Adjudication Information, AMT
Remaining Patient Liability, AMT02 Remaining Patient Liability Amount.
162.03,73 LI RENDERING PROV NAME 3;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>30!($L(X)<1) X
LAST EDITED: MAY 17, 2011
HELP-PROMPT:Answer must be 1-30 characters in length.
DESCRIPTION:
Enter the associated line item Rendering Provider's name found in the line item
level claim information. Note: This field is only necessary if the line item
Rendering Provider is different than the claim Rendering Provider.
162.03,74 LI RENDERING PROV NPI 3;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>10!($L(X)<10) X
LAST EDITED: APR 25, 2011
HELP-PROMPT:Answer must be 10 characters in length.
DESCRIPTION:
Enter the associated line item Rendering Provider's name found in the line item
level claim information. This value must be 10 characters, including any leading
zeros.
Note: This field is only necessary if the line item Rendering Provider is different
than the claim Rendering Provider.
162.03,75 LI RENDERING PROV TAXONOMY 3;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>10!($L(X)<10) X
LAST EDITED: APR 25, 2011
HELP-PROMPT:Answer must be 10 characters in length.
DESCRIPTION:
Enter the associated line item Rendering Provider's Taxonomy code found in the line
item level of the claim information. This value must be 10 characters, including
any leading zeros.
Note: This field is only necessary if the line item Rendering Provider is different
than the claim Rendering Provider.
162.03,76 SERVICING FACILITY ADDRESS 5;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>60!($L(X)<1) X
LAST EDITED: OCT 13, 2011
HELP-PROMPT:Answer must be 1-60 characters in length.
DESCRIPTION:
Enter the Servicing Facility street address found in the claim information.
162.03,77 SERVICING FACILITY CITY 5;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>20!($L(X)<1) X
LAST EDITED: OCT 13, 2011
HELP-PROMPT:Answer must be 1-20 characters in length.
DESCRIPTION:
Enter the Servicing Facility city found in the claim information.
162.03,78 SERVICING FACILITY STATE 5;3 POINTER TO STATE FILE (#5)
LAST EDITED: OCT 13, 2011
DESCRIPTION:
Enter the Servicing Facility state found in the claim information.
162.03,79 SERVICING FACILITY ZIP 5;4 FREE TEXT
INPUT TRANSFORM:K:X[""""!($A(X)=45) X I $D(X) K:$L(X)>20!($L(X)<5) X I $D(X) D ZIPIN^VAFADD
R
OUTPUT TRANSFORM:D ZIPOUT^VAFADDR
LAST EDITED: OCT 13, 2011
HELP-PROMPT:Answer with either 5 digit or 9 digit zip code.
DESCRIPTION:
Enter the Servicing Facility zip code, in either the 5 digit format (e.g. 12345) or
9 digit format (e.g. 12345.6789 or 123456789).
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
162.03,81 UNIQUE CLAIM IDENTIFIER 5;5 FREE TEXT
INPUT TRANSFORM:K:$L(X)>28!($L(X)<1) X
LAST EDITED: MAR 22, 2012
HELP-PROMPT:Answer must be 1-28 characters in length.
DESCRIPTION:
This field contains a unique identifier for tracking claims. Fee5010 Project.
162.03,82 PAYMENT METHODOLOGY 2;7 POINTER TO FEE BASIS PAYMENT METHODOLOGY FILE (#163.98)
LAST EDITED: APR 17, 2015
HELP-PROMPT:Enter a valid Fee Basis Payment Methodology
DESCRIPTION:
The values in this field come from FBCS and represents the actual payment
methodology used in FBCS to adjudicate the claim.
162.03,83 AUTHORIZATION NUMBER 9;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>30!($L(X)<3) X
LAST EDITED: MAY 27, 2015
HELP-PROMPT:Answer must be 3-30 characters in length.
DESCRIPTION:
This field holds the authorization numbers transmitted from FBCS.
162.03,84 ATTACHMENT ID 10;0 Multiple #162.0384 (Add New Entry without Asking)
DESCRIPTION:
This multiple holds Attachment IDs and Attachment Report Types supporting this
payment in the Attachment Retrieval System (ARS).
162.0384,.01 ATTACHMENT ID 0;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>30!($L(X)<1) X
LAST EDITED: JUN 17, 2016
HELP-PROMPT:Answer must be 1-30 characters in length.
DESCRIPTION:
This field contains the ID of an attachment supporting this payment in the
Attachment Retrieval System (ARS). This data is populated automatically and
should not be edited by users.
CROSS-REFERENCE:162.0384^B
1)= S ^FBAAC(DA(4),1,DA(3),1,DA(2),1,DA(1),10,"B",$E(X,1,30),DA)=""
2)= K ^FBAAC(DA(4),1,DA(3),1,DA(2),1,DA(1),10,"B",$E(X,1,30),DA)
162.0384,.02 ATTACHMENT REPORT TYPE 0;2 POINTER TO IB ATTACHMENT REPORT TYPE FILE (#353.3)
LAST EDITED: JUN 17, 2016
HELP-PROMPT:Enter an Attachment Report Type Code.
DESCRIPTION:
The Report Type Code describes the type of documentation that will provide
additional information for this payment.
162.02,3 *AUTHORIZATION POINTER 0;4 NUMBER
INPUT TRANSFORM:K:+X'=X!(X>9999999)!(X<1)!(X?.E1"."1.N) X
LAST EDITED: MAR 04, 2014
HELP-PROMPT:OBSOLETE. Type a number between 1 and 9999999, 0 decimal digits.
DESCRIPTION:
This field is obsolete with patch FB*3.5*154. Data will no longer be saved to
this field and the field may be deleted by a future patch. The AUTHORIZATION
POINTER in the SERVICE PROVIDED multiple should be referenced instead of this
field.
This field is set to the internal entry number of the appropriate authorization
in file 161. It is used to retrieve the appropriate purpose of visit code when
payments are sent to Austin.
CROSS-REFERENCE:162^AF
1)= S ^FBAAC("AF",$E(X,1,30),DA(2),DA(1),DA)=""
2)= K ^FBAAC("AF",$E(X,1,30),DA(2),DA(1),DA)
the cross-reference is used for active/ending authorization reports
162,7 TRAVEL PAYMENT DATE 3;0 DATE Multiple #162.04 (Add New Entry without Asking)
DESCRIPTION: This multiple keeps track of any travel paid to a Fee Basis patient, in conjunction with an
outpatient service.
162.04,.01 TRAVEL PAYMENT DATE 0;1 DATE (Multiply asked)
INPUT TRANSFORM: S %DT="EX",%DT(0)=-DT D ^%DT K %DT(0) S X=Y K:Y<1 X
LAST EDITED: MAR 20, 1987
DESCRIPTION:
The date the travel being paid was performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 162.04^AB
1)= S ^FBAAC(DA(1),3,"AB",$E(X,1,30),DA)=""
2)= K ^FBAAC(DA(1),3,"AB",$E(X,1,30),DA)
162.04,1 TRAVEL BATCH NUMBER 0;2 POINTER TO FEE BASIS BATCH FILE (#161.7) (Required)
INPUT TRANSFORM:S DIC("S")="I $P(^(0),U,3)=""B2""&($P(^(0),U,5)=DUZ)&($P($G(^(""ST"")),U)=""O"")" D ^DIC K DIC S DI
C=DIE,X=+Y K:Y<0 X
LAST EDITED: DEC 04, 2012
HELP-PROMPT: Select the batch number associated with this travel payment.
DESCRIPTION:
The batch number that this travel payment will be associated with.
SCREEN: S DIC("S")="I $P(^(0),U,3)=""B2""&($P(^(0),U,5)=DUZ)&($P($G(^(""ST"")),U)=""O"")"
EXPLANATION: Allows selection of travel batches in open status, which were opened by this specific user.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE:162^AD
1)= S ^FBAAC("AD",$E(X,1,30),DA(1),DA)=""
2)= K ^FBAAC("AD",$E(X,1,30),DA(1),DA)
162.04,2 TRAVEL AMOUNT 0;3 NUMBER (Required)
INPUT TRANSFORM:S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>999)!(X<.01) X
LAST EDITED: MAR 01, 1988
HELP-PROMPT: Type a Dollar Amount between .01 and 999, 2 Decimal Digits
DESCRIPTION:
The amount to be paid for the travel.
CROSS-REFERENCE:^^TRIGGER^161.7^8
1)= K DIV S DIV=X,D0=DA(1),DIV(0)=D0,D1=DA X ^DD(162.04,2,1,1,1.2) S X=DIV S X=DIU+DIV X ^DD(162.04
,2,1,1,1.4)
1.2)= X ^DD(162.04,2,1,1,89.2) K DIC S DIC="^FBAA(161.7,",DIC(0)="NMF" D ^DIC S (D,D0,DIV(0))=+Y S
Y(101)=$S($D(^FBAA(161.7,D0,0)):^(0),1:"") S X=$P(Y(101),U,9) S D0=I(0,0) S D1=I(1,0) S DIU=X K Y
1.4)= S DIH=$S($D(^FBAA(161.7,DIV(0),0)):^(0),1:""),DIV=X I $D(^(0)) X "F %=0:0 Q:$L($P(DIH,U,8,99)
) S DIH=DIH_U" S %=$P(DIH,U,10,999),DIU=$P(DIH,U,9),^(0)=$P(DIH,U,1,8)_U_DIV_$S(%]"":U_%,1:""),DIH
=161.7,DIG=8 D ^DICR:$N(^DD(DIH,DIG,1,0))>0
2)= K DIV S DIV=X,D0=DA(1),DIV(0)=D0,D1=DA X ^DD(162.04,2,1,1,2.2) S X=DIV S X=DIU-X X ^DD(162.04,2
,1,1,2.4)
2.2)= X ^DD(162.04,2,1,1,89.2) K DIC S DIC="^FBAA(161.7,",DIC(0)="NMF" D ^DIC S (D,D0,DIV(0))=+Y S
Y(101)=$S($D(^FBAA(161.7,D0,0)):^(0),1:"") S X=$P(Y(101),U,9) S D0=I(0,0) S D1=I(1,0) S DIU=X K Y
2.4)= S DIH=$S($D(^FBAA(161.7,DIV(0),0)):^(0),1:""),DIV=X I $D(^(0)) X "F %=0:0 Q:$L($P(DIH,U,8,99)
) S DIH=DIH_U" S %=$P(DIH,U,10,999),DIU=$P(DIH,U,9),^(0)=$P(DIH,U,1,8)_U_DIV_$S(%]"":U_%,1:""),DIH
=161.7,DIG=8 D ^DICR:$N(^DD(DIH,DIG,1,0))>0
89.2)= S I(1,0)=$S($D(D1):D1,1:""),I(0,0)=$S($D(D0):D0,1:""),Y(1)=$S($D(^FBAAC(D0,3,D1,0)):^(0),1:"
") S X=$P(Y(1),U,2),X=X S X=X
CREATE VALUE)= TOTAL DOLLARS+TRAVEL AMOUNT
DELETE VALUE)= TOTAL DOLLARS-OLD TRAVEL AMOUNT
DIC)= LOOKUP
FIELD)= TRAVEL BATCH NUMBER:FEE BASIS BATCH:TOTAL DOLLARS
CROSS-REFERENCE:^^TRIGGER^161.7^10
1)= K DIV S DIV=X,D0=DA(1),DIV(0)=D0,D1=DA X ^DD(162.04,2,1,2,1.2) S X=DIV S X=DIU+1 X ^DD(162.04,2
,1,2,1.4)
1.2)= X ^DD(162.04,2,1,2,89.2) K DIC S DIC="^FBAA(161.7,",DIC(0)="NMF" D ^DIC S (D,D0,DIV(0))=+Y S
Y(101)=$S($D(^FBAA(161.7,D0,0)):^(0),1:"") S X=$P(Y(101),U,11) S D0=I(0,0) S D1=I(1,0) S DIU=X K Y
1.4)= S DIH=$S($D(^FBAA(161.7,DIV(0),0)):^(0),1:""),DIV=X I $D(^(0)) X "F %=0:0 Q:$L($P(DIH,U,10,99
)) S DIH=DIH_U" S %=$P(DIH,U,12,999),DIU=$P(DIH,U,11),^(0)=$P(DIH,U,1,10)_U_DIV_$S(%]"":U_%,1:""),
DIH=161.7,DIG=10 D ^DICR:$N(^DD(DIH,DIG,1,0))>0
2)= K DIV S DIV=X,D0=DA(1),DIV(0)=D0,D1=DA X ^DD(162.04,2,1,2,2.2) S X=DIV S X=DIU-1 X ^DD(162.04,2
,1,2,2.4)
2.2)= X ^DD(162.04,2,1,2,89.2) K DIC S DIC="^FBAA(161.7,",DIC(0)="NMF" D ^DIC S (D,D0,DIV(0))=+Y S
Y(101)=$S($D(^FBAA(161.7,D0,0)):^(0),1:"") S X=$P(Y(101),U,11) S D0=I(0,0) S D1=I(1,0) S DIU=X K Y
2.4)= S DIH=$S($D(^FBAA(161.7,DIV(0),0)):^(0),1:""),DIV=X I $D(^(0)) X "F %=0:0 Q:$L($P(DIH,U,10,99
)) S DIH=DIH_U" S %=$P(DIH,U,12,999),DIU=$P(DIH,U,11),^(0)=$P(DIH,U,1,10)_U_DIV_$S(%]"":U_%,1:""),
DIH=161.7,DIG=10 D ^DICR:$N(^DD(DIH,DIG,1,0))>0
89.2)= S I(1,0)=$S($D(D1):D1,1:""),I(0,0)=$S($D(D0):D0,1:""),Y(1)=$S($D(^FBAAC(D0,3,D1,0)):^(0),1:"
") S X=$P(Y(1),U,2),X=X S X=X S:X]"" X="`"_X
CREATE VALUE)= PAYMENT LINE COUNT+1
DELETE VALUE)= PAYMENT LINE COUNT-1
DIC)= LOOKUP
FIELD)= TRAVEL BATCH NUMBER:FEE BASIS BATCH:PAYMENT LINE COUNT
CROSS-REFERENCE:^^TRIGGER^161.7^10
1)= K DIV S DIV=X,D0=DA(1),DIV(0)=D0,D1=DA X ^DD(162.04,2,1,3,1.2) S X=DIV S X=DIU+1 X ^DD(162.04,2
,1,3,1.4)
1.2)= X ^DD(162.04,2,1,3,89.2) K DIC S DIC="^FBAA(161.7,",DIC(0)="NMF" D ^DIC S (D,D0,DIV(0))=+Y S
Y(101)=$S($D(^FBAA(161.7,D0,0)):^(0),1:"") S X=$P(Y(101),U,11) S D0=I(0,0) S D1=I(1,0) S DIU=X K Y
1.4)= S DIH=$S($D(^FBAA(161.7,DIV(0),0)):^(0),1:""),DIV=X I $D(^(0)) X "F %=0:0 Q:$L($P(DIH,U,10,99
)) S DIH=DIH_U" S %=$P(DIH,U,12,999),DIU=$P(DIH,U,11),^(0)=$P(DIH,U,1,10)_U_DIV_$S(%]"":U_%,1:""),
DIH=161.7,DIG=10 D ^DICR:$N(^DD(DIH,DIG,1,0))>0
2)= K DIV S DIV=X,D0=DA(1),DIV(0)=D0,D1=DA X ^DD(162.04,2,1,3,2.2) S X=DIV S X=DIU-1 X ^DD(162.04,2
,1,3,2.4)
2.2)= X ^DD(162.04,2,1,3,89.2) K DIC S DIC="^FBAA(161.7,",DIC(0)="NMF" D ^DIC S (D,D0,DIV(0))=+Y S
Y(101)=$S($D(^FBAA(161.7,D0,0)):^(0),1:"") S X=$P(Y(101),U,11) S D0=I(0,0) S D1=I(1,0) S DIU=X K Y
2.4)= S DIH=$S($D(^FBAA(161.7,DIV(0),0)):^(0),1:""),DIV=X I $D(^(0)) X "F %=0:0 Q:$L($P(DIH,U,10,99
)) S DIH=DIH_U" S %=$P(DIH,U,12,999),DIU=$P(DIH,U,11),^(0)=$P(DIH,U,1,10)_U_DIV_$S(%]"":U_%,1:""),
DIH=161.7,DIG=10 D ^DICR:$N(^DD(DIH,DIG,1,0))>0
89.2)= S I(1,0)=$S($D(D1):D1,1:""),I(0,0)=$S($D(D0):D0,1:""),Y(1)=$S($D(^FBAAC(D0,3,D1,0)):^(0),1:"
") S X=$P(Y(1),U,2),X=X S X=X
CREATE VALUE)= PAYMENT LINE COUNT+1
DELETE VALUE)= PAYMENT LINE COUNT-1
DIC)= LOOKUP
FIELD)= TRAVEL BATCH NUMBER:FEE BASIS BATCH:PAYMENT LINE COUNT
162.04,3 TRAVEL OBLIGATION NUMBER 0;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>6!($L(X)<6) X
LAST EDITED: AUG 05, 1986
HELP-PROMPT: ANSWER MUST BE 6 CHARACTERS IN LENGTH
DESCRIPTION:
The obligation number identifying the funds from which this travel payment will be paid.
162.04,3.5 PAYMENT TYPE CODE 0;13 SET
'R' FOR REIMBURSEMENT;
'S' FOR STATISTICAL;
'SR' FOR STAT-REIMBURSEMENT;
'V' FOR VENDOR;
LAST EDITED: SEP 26, 1994
DESCRIPTION: An entry of 'R' will indicate the travel is for a reimbursement to the veteran. An entry of 'S'
will indicate the travel was paid "out of system" to a vendor and allows the update of the payment
history files. An entry of 'SR' will indicate a statistical reimbursement to a party other than
the vendor. An entry of 'V' or 'S' is not used currently. Travel is only paid to a veteran.
162.04,4 REJECT STATUS FBREJ;1 SET
'P' FOR REJECTED, PENDING;
'C' FOR REJECTED, COMPLETED;
LAST EDITED: AUG 11, 1986
DESCRIPTION:
Identifies whether this line item is in a reject status pending assignment to another batch.
162.04,5 REJECT REASON FBREJ;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>40!($L(X)<2) X
LAST EDITED: AUG 11, 1986
HELP-PROMPT: ANSWER MUST BE 2-40 CHARACTERS IN LENGTH
DESCRIPTION: The reason this line item was rejected for payment. Usually, the error code identified by the
Austin Central Fee system is entered.
162.04,6 OLD BATCH NUMBER FBREJ;3 POINTER TO FEE BASIS BATCH FILE (#161.7)
LAST EDITED: AUG 11, 1986
DESCRIPTION:
The batch number this line item was associated with prior to being rejected.
CROSS-REFERENCE:162^AG
1)= S ^FBAAC("AG",$E(X,1,30),DA(1),DA)=""
2)= K ^FBAAC("AG",$E(X,1,30),DA(1),DA)
162.04,6.3 INTERFACE REJECT FBREJ;4 SET
'1' FOR YES;
LAST EDITED: DEC 13, 2011
HELP-PROMPT: Enter YES if the line item was rejected by Central Fee.
DESCRIPTION: This field is populated by the FBAA BATCH SERVER and FBAA REJECT SERVER server options when a
payment line item is rejected via the interface with Central Fee. This field is used to
distinguish line items that were locally rejected from those that were rejected by a downstream
system. This field is not populated for a local reject.
162.04,6.6 REJECT CODE FBREJC;0 Multiple #162.041
DESCRIPTION: The REJECT CODE multiple is populated with one to four reject codes by the FBAA BATCH SERVER and
FBAA REJECT SERVER server options when a line item is rejected via the interface with Central Fee.
The REJECT CODE multiple is not used for local rejects. The reason for a local reject is entered
into the REJECT REASON (#5) field.
162.041,.01 REJECT CODE 0;1 FREE TEXT (Multiply asked)
INPUT TRANSFORM:K:$L(X)>4!($L(X)<1) X
LAST EDITED: FEB 01, 2012
HELP-PROMPT: Answer must be 1-4 characters in length.
DESCRIPTION: The REJECT CODE field is populated by the FBAA BATCH SERVER and FBAA REJECT SERVER server options
when a line item is rejected via the interface with Central Fee. The REJECT CODE field is not
used for local rejects. The reason for a local reject is entered into the REJECT REASON (#5)
field.
TECHNICAL DESCR:Values stored in the REJECT CODE field are normally expected to have a matching entry in the FEE
BASIS PAYMENT REJECT CODE (#161.99) file. The FEE BASIS PAYMENT REJECT CODE file contains a list
of reject codes and their descriptions.
However it is possible that a new reject code will be transmitted to VistA by Central Fee and
stored in the REJECT CODE field before the FEE BASIS PAYMENT REJECT CODE file is updated with
that new code. In this case outputs that display the description of a code will display text
similar to "Reject reason code not currently defined in list."
CROSS-REFERENCE:162.041^B
1)= S ^FBAAC(DA(2),3,DA(1),"FBREJC","B",$E(X,1,30),DA)=""
2)= K ^FBAAC(DA(2),3,DA(1),"FBREJC","B",$E(X,1,30),DA)
162.04,7 DATE FINALIZED 0;5 DATE
INPUT TRANSFORM:S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: MAR 21, 1988
DESCRIPTION:
Indicates the date and time the travel payment was vouchered by Fiscal.
CROSS-REFERENCE:162^AL
1)= S ^FBAAC("AL",$E(X,1,30),DA(1),DA)=""
2)= K ^FBAAC("AL",$E(X,1,30),DA(1),DA)
162.04,8 DATE PAID 0;6 DATE
INPUT TRANSFORM:S %DT="E" D ^%DT S X=Y K:Y<1 X
LAST EDITED: MAR 24, 1994
HELP-PROMPT: This is the date of the check, as issued by the treasury.
DESCRIPTION: This is the date of the check, as issued by the treasury. This information will be passed back
to DHCP from the Financial Management System (FMS) when the check is issued to the vendor. This
field will be populated beginning in version 3.5 of Fee Basis.
162.04,9 CHECK NUMBER 0;7 FREE TEXT
INPUT TRANSFORM:K:X[""""!($A(X)=45) X I $D(X) K:$L(X)>8!($L(X)<1)!'(X?.NA) X
LAST EDITED: APR 25, 1994
HELP-PROMPT: Answer must be 1-8 characters in length.
DESCRIPTION: Contains the check number as issued by the treasury. This field is updated after the check is
issued, through a server option that records actual payment information for each Fee payment
made.
CROSS-REFERENCE:162^ACKT^MUMPS
1)= S ^FBAAC("ACKT",X,DA(1),DA)=""
2)= K ^FBAAC("ACKT",X,DA(1),DA)
This cross-reference is used to located payment items for a specific check number.
162.04,10 CANCELLATION DATE 0;8 DATE
INPUT TRANSFORM:S %DT="E" D ^%DT S X=Y K:Y<1 X
LAST EDITED: MAR 24, 1994
HELP-PROMPT: The date the check was cancelled by the treasury.
DESCRIPTION: This is the date the treasury cancelled the check. This field is updated through a server option
that records cancellations of previously recorded payment data.
162.04,11 REASON CODE 0;9 POINTER TO FEE BASIS CHECK CANCELLATION REASON FILE (#162.95)
LAST EDITED: MAR 24, 1994
HELP-PROMPT: Enter the reason the check was cancelled.
DESCRIPTION: This field contains a pointer to the Fee Basis Check Cancellation Reason file. It is populated
through a server option that updates the payment record when the treasury cancels a check that
was previously payed.
162.04,12 CANCELLATION ACTIVITY 0;10 SET
'R' FOR WILL BE REPLACED;
'C' FOR WIL BE REISSUED;
'X' FOR WILL NOT BE REISSUED;
LAST EDITED: APR 26, 1994
HELP-PROMPT: Field will contain the cancellation code if there has been cancellation activity on this payment.
DESCRIPTION: This field is populated when a cancellation is recorded for the payment referenced. This field
will always remain populated, to indicate that there was cancellation activity on this payment at
one time. New payments will replace the cancellation date and reason code fields, but the
cancellation activity flag will not be overwritten. This flag will allow the user to know that
previous cancellation activity existed, and to review the cancellation history output for further
information.
162.04,13 DISBURSED AMOUNT 0;11 NUMBER
INPUT TRANSFORM:S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>999999)!(X<0) X
LAST EDITED: APR 21, 1994
HELP-PROMPT: Type a Dollar Amount between 0 and 999999, 2 Decimal Digits
DESCRIPTION:
This is the dollar amount paid by the treasury, less any interest paid.
162.04,14 INTEREST AMOUNT 0;12 NUMBER
INPUT TRANSFORM:S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>999999)!(X<0) X
LAST EDITED: APR 21, 1994
HELP-PROMPT: Type a Dollar Amount between 0 and 999999, 2 Decimal Digits
DESCRIPTION:
The interest amount paid on this line item by the treasury.
162.04,15 AUTHORIZATION POINTER 1;1 NUMBER
INPUT TRANSFORM:K:+X'=X!(X>9999999)!(X<1)!(X?.E1"."1.N) X
LAST EDITED: MAR 04, 2014
HELP-PROMPT: Enter the internal entry number of the authorization in the FEE BASIS PATIENT file.
DESCRIPTION: Type a number between 1 and 9999999, 0 decimal digits. This field is automatically populated with
the internal entry number of the patient's authorization in the Fee Basis Patient file.
TECHNICAL DESCR:This field was added by patch FB*3.5*154. It will not be populated for travel payments created
prior to the installation of the patch.
162,99 DATE OF PURGE PURGE;0 DATE Multiple #162.099 (Add New Entry without Asking)
DESCRIPTION: Date that the purge routine was run which resulted in the purging of payment data for this patient.
This data will exist ONLY IF data was purged for the patient for the specific purge run.
162.099,.01 PURGE DATE 0;1 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X I $D(X) S DINUM=X
LAST EDITED: JUL 15, 1992
DESCRIPTION: Date that the purge routine was run which resulted in the purging of payment data for this
patient. This data will exist ONLY IF data was purged for the patient for the specific purge run.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
162.099,1 OPT MEDICAL DATA PURGED 0;2 SET
'Y' FOR YES;
LAST EDITED: MAR 21, 1988
DESCRIPTION: This field will be populated ONLY if the purge has been run for Outpatient Medical data for this
patient.
162.099,2 PHARMACY DATA PURGED 0;3 SET
'Y' FOR YES;
LAST EDITED: MAR 21, 1988
DESCRIPTION:
This field will be populated ONLY if the purge has been run for Pharmacy data for this patient.
162.099,3 TRAVEL DATA PURGED 0;4 SET
'Y' FOR YES;
LAST EDITED: MAR 21, 1988
DESCRIPTION:
This field will be populated ONLY if the purge has been run for Travel data for this patient.
FILES POINTED TO FIELDS
ADJUSTMENT GROUP (#161.92) ADJUSTMENT:ADJUSTMENT GROUP (#1)
ADJUSTMENT REASON (#161.91) ADJUSTMENT:ADJUSTMENT REASON (#.01)
CPT (#81) FIELD^NL^84^86:SERVICE PROVIDED (#.01)
CPT MODIFIER (#81.3) CPT MODIFIER:CPT MODIFIER (#.01)
FEE BASIS BATCH (#161.7) FIELD^NL^84^86:BATCH NUMBER (#7)
OLD BATCH NUMBER (#21)
TRAVEL PAYMENT DATE:TRAVEL BATCH NUMBER (#1)
TRAVEL AMOUNT (#2)
OLD BATCH NUMBER (#6)
FEE BASIS CHECK CANCELLATION R
(#162.95) FIELD^NL^84^86:REASON CODE (#37)
TRAVEL PAYMENT DATE:REASON CODE (#11)
FEE BASIS CONTRACT (#161.43) FIELD^NL^84^86:CONTRACT (#54)
FEE BASIS PAYMENT METHODOLOGY
(#163.98) FIELD^NL^84^86:PAYMENT METHODOLOGY (#82)
FEE BASIS PROGRAM (#161.8) INITIAL TREATMENT DATE:*FEE PROGRAM (#1.5)
FIELD^NL^84^86:FEE PROGRAM (#23)
FEE BASIS PURPOSE OF VISIT
(#161.82) FIELD^NL^84^86:PURPOSE OF VISIT (#16)
FEE BASIS SUSPENSION (#161.27) FIELD^NL^84^86:SUSPEND CODE (#4)
FEE BASIS VA TYPE OF SERVICE
(#163.85) FIELD^NL^84^86:VA TYPE OF SERVICE (#29)
FEE BASIS VENDOR (#161.2) VENDOR:VENDOR (#.01)
IB ATTACHMENT REPORT TYPE
(#353.3) ATTACHMENT ID:ATTACHMENT REPORT TYPE (#.02)
ICD DIAGNOSIS (#80) FIELD^NL^84^86:PRIMARY DIAGNOSIS (#28)
INSTITUTION (#4) FIELD^NL^84^86:PRIMARY SERVICE FACILITY (#26)
IPAC VENDOR AGREEMENT FILE
(#161.95) FIELD^NL^84^86:IPAC AGREEMENT (#.05)
NEW PERSON (#200) FIELD^NL^84^86:CLERK (#6)
SUPERVISOR (#25)
PATIENT (#2) PATIENT (#.01)
PLACE OF SERVICE (#353.1) FIELD^NL^84^86:PLACE OF SERVICE (#30)
REMITTANCE REMARK (#161.93) REMITTANCE REMARK:REMITTANCE REMARK (#.01)
REVENUE CODE (#399.2) FIELD^NL^84^86:REVENUE CODE (#48)
STATE (#5) FIELD^NL^84^86:SERVICING FACILITY STATE (#78)
TYPE OF SERVICE (#353.2) FIELD^NL^84^86:HCFA TYPE OF SERVICE (#31)
Subfile #162.03
Record Indexes:
AJ (#1097) RECORD REGULAR IR SORTING ONLY WHOLE FILE (#162)
Short Descr: Index on batch number and invoice number.
Description: This is a whole file index on the BATCH NUMBER and INVOICE NUMBER fields that are located in the SERVICE
PROVIDED multiple.
Set Logic: S ^FBAAC("AJ",X(1),X(2),DA(3),DA(2),DA(1),DA)=""
Kill Logic: K ^FBAAC("AJ",X(1),X(2),DA(3),DA(2),DA(1),DA)
Whole Kill: K ^FBAAC("AJ")
X(1): BATCH NUMBER (162.03,7) (Subscr 1) (forwards)
X(2): INVOICE NUMBER (162.03,14) (Subscr 2) (forwards)
INPUT TEMPLATE(S):
PRINT TEMPLATE(S):
FB UCID PAYMENT SEP 13, 2012@11:21 USER #0 FB UCID PAYMENT SEARCH
SORT TEMPLATE(S):
FORM(S)/BLOCK(S):