STANDARD DATA DICTIONARY #361.1 -- EXPLANATION OF BENEFITS FILE 6/27/25 PAGE 1
STORED IN ^IBM(361.1, *** NO DATA STORED YET *** SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 2.0)
DATA NAME GLOBAL DATA
ELEMENT TITLE LOCATION TYPE
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This file contains the explanation of benefits results (EOB) for bills as well as MEDICARE remittance advice data. The data in
this file may be appended to any subsequent claims in the COB process.
DD ACCESS: @
RD ACCESS: @
WR ACCESS: @
DEL ACCESS: @
LAYGO ACCESS: @
AUDIT ACCESS: @
IDENTIFIED BY:
"W": N %Y S %Y=$G(^(0)) D EN^DDIOL($$EXTERNAL^DILFD(361.1,.02,,$P(%Y,U,2))_" ("_$$EXTERNAL^DILFD(361.1,.15,,$P(%Y,U,15))_
")")
POINTED TO BY: EOB DETAIL field (#.02) of the ERA DETAIL sub-field (#344.41) of the ELECTRONIC REMITTANCE ADVICE File (#344.4)
CROSS
REFERENCED BY: BILL(ABB), RETURN MESSAGE ID(AC), ENTRY DATE/TIME(AD), DATE/TIME EEOB MOVED(AEOB), TRANSMIT BILL(AERR),
REVIEW STATUS(AREV), BILL(B), BILL #(C), BILL REFERENCE(C), PAYER ID(D), EOB PAID DATE(E)
INDEXED BY: BILL & EOB PAID DATE (ABD), BILL & INSURANCE SEQUENCE (ABS), EOB TYPE & ENTRY DATE/TIME (AEDT), BILL & ENTRY
DATE/TIME & EEOB REMOVED (AMCCF), EOB TYPE & REVIEW STATUS (AMRA), ENTRY DATE/TIME & TRANSFERRED IN (ATIN), TRACE
NUMBER & PAYER ID & EOB TYPE (ATRID)
LAST MODIFIED: DEC 18,2023@14:44:32
361.1,.01 BILL 0;1 POINTER TO BILL/CLAIMS FILE (#399) (Required)
LAST EDITED: APR 20, 2020
HELP-PROMPT: ENTER THE BILL # THAT THIS EOB IS FOR
DESCRIPTION:
This is the pointer to the bill # to which this EOB is associated.
CROSS-REFERENCE: 361.1^B
1)= S ^IBM(361.1,"B",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,"B",$E(X,1,30),DA)
CROSS-REFERENCE: 361.1^ABB^MUMPS
1)= N Z S Z=+$G(^IBM(361.1,DA,100)) I Z S ^IBM(361.1,"ABB",$E(X,1,30),Z,DA)=""
2)= S Z=+$G(^IBM(361.1,DA,100)) I Z K ^IBM(361.1,"ABB",$E(X,1,30),Z,DA)
3)= Do not delete
Compound cross reference by batch and bill #
RECORD INDEXES: ABD (#131), ABS (#132), AMCCF (#308)
361.1,.02 PAYER NAME 0;2 POINTER TO INSURANCE COMPANY FILE (#36)
LAST EDITED: MAY 28, 1999
HELP-PROMPT: Enter the name of the payer who returned this EOB.
DESCRIPTION:
This is the name of the insurance company that provided this EOB for the bill.
NOTES: TRIGGERED by the INSURANCE SEQUENCE field of the EXPLANATION OF BENEFITS File
361.1,.03 PAYER ID 0;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<1) X
LAST EDITED: JUL 10, 2015
HELP-PROMPT: Answer must be 1-20 characters in length.
DESCRIPTION:
This is the payer ID provided for the insurance co that returned this EOB.
CROSS-REFERENCE: 361.1^D
1)= S ^IBM(361.1,"D",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,"D",$E(X,1,30),DA)
3)= Do not delete
This search cross reference on PAYER ID field. Reports for EOB file use PAYER ID as a search
criteria and this index will speed up the ad-hoc reports.
RECORD INDEXES: ATRID (#297)
361.1,.04 EOB TYPE 0;4 SET
'0' FOR NORMAL EOB;
'1' FOR MEDICARE MRA;
OUTPUT TRANSFORM: S Y=$S(Y=0:"NORMAL EOB",1:"MRA") N Z S Z=$O(^(8,0)) I $O(^IBM(361.1,D0,8,Z),-1)'=Z S Y=Y_" (SPLIT T
O MORE CLAIMS)"
LAST EDITED: JUN 06, 2011
HELP-PROMPT: Enter 1 if an MRA from MEDICARE
DESCRIPTION: This field indicates whether this EOB contains actual payment data or is simply an MRA received
from MEDICARE.
RECORD INDEXES: AEDT (#988), AMRA (#307), ATRID (#297)
361.1,.05 ENTRY DATE/TIME 0;5 DATE (Required)
INPUT TRANSFORM: S %DT="ESTXR" D ^%DT S X=Y K:Y<1 X
LAST EDITED: AUG 10, 2015
HELP-PROMPT: Enter the date and time this entry is added to the file
DESCRIPTION: This is the date and time that this EOB entry was added to the Vista file. This is not mapped from
the 835 transmission.
CROSS-REFERENCE: 361.1^AD^MUMPS
1)= S ^IBM(361.1,"AD",+X,DA)=""
2)= K ^IBM(361.1,"AD",+X,DA)
3)= Please do not delete
This index will be used to lookup EEOB by date the EEOB was entered into VistA to speed up report
generation.
RECORD INDEXES: AEDT (#988), AMCCF (#308), ATIN (#184)
361.1,.06 EOB PAID DATE 0;6 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:X<1 X
LAST EDITED: FEB 09, 2015
HELP-PROMPT: Enter the date the payer paid the claim
DESCRIPTION: This is the effective date of money movement (paid date) from the payer, as indicated in the 835
transmission.
CROSS-REFERENCE: 361.1^E
1)= S ^IBM(361.1,"E",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,"E",$E(X,1,30),DA)
3)= Do not delete
This is a search index on EOB PAID DATE field. Reports for EOB file use date ranges and this index
will reduce the time necessary to generate ad-hoc reports.
RECORD INDEXES: ABD (#131)
361.1,.07 TRACE NUMBER 0;7 FREE TEXT
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: JUL 10, 2015
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION:
This is the TRACE NUMBER from the 835 transaction for this EOB
TECHNICAL DESCR:
This is the data from the 835 data field (TRN-02)
RECORD INDEXES: ATRID (#297)
361.1,.08 CROSSED OVER NAME 51;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>60!($L(X)<1) X
LAST EDITED: JUN 19, 2010
HELP-PROMPT: Answer must be 1-60 characters in length.
DESCRIPTION: This is the name of the insurance company to which this claim was sent for COB purposes
automatically.
TECHNICAL DESCR:
This is the data from the 835 data field (NM-103/Qualifier='DC')
361.1,.09 CROSSED OVER ID 0;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<1) X
LAST EDITED: OCT 07, 1998
HELP-PROMPT: Answer must be 1-20 characters in length.
DESCRIPTION:
This is the ID returned on the 835 for the CROSS-OVER payer.
TECHNICAL DESCR:
This is the data from the 835 data field (NM-109)
361.1,.1 DRG CODE USED 0;10 FREE TEXT
INPUT TRANSFORM: K:$L(X)>4!($L(X)<1) X
LAST EDITED: OCT 07, 1998
HELP-PROMPT: Answer must be 1-4 characters in length.
DESCRIPTION:
This is the DRG code used for pricing as reported from the payer for institutional claims only.
TECHNICAL DESCR:
This is the data from the 835 data field (CLP-11) or from manual entry of the amount
361.1,.11 DRG WEIGHT USED 0;11 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9999999999)!(X<0)!(X?.E1"."5N.N) X
LAST EDITED: MAR 03, 1999
HELP-PROMPT: Type a Number between 0 and 9999999999, 4 Decimal Digits
DESCRIPTION:
This is the DRG weight used for pricing as reported from the payer for institutional claims only.
TECHNICAL DESCR:
This is the data from the 835 data field (CLP-12) or from manual entry of the amount
361.1,.12 DISCHARGE FRACTION 0;12 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9999999999)!(X<0)!(X?.E1"."3N.N) X
LAST EDITED: OCT 07, 1998
HELP-PROMPT: Type a Number between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is the DISCHARGE FRACTION field as reported by the payer for institutional claims only.
TECHNICAL DESCR:
This is the data from the 835 data field (CLP-13) or from manual entry of the amount
361.1,.13 CLAIM STATUS 0;13 SET
'1' FOR PROCESSED;
'2' FOR DENIED;
'3' FOR PENDED;
'4' FOR REVERSAL;
'5' FOR OTHER;
LAST EDITED: OCT 07, 1998
HELP-PROMPT: Enter the status of this EOB.
DESCRIPTION: This is the status of this EOB. Only PROCESSED and DENIED claims will be sent to subsequent payers
for COB purposes.
TECHNICAL DESCR:
This is the data from the 835 data field (CLP-02) or from manual entry of the amount
361.1,.14 ICN 0;14 FREE TEXT
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: JUN 19, 2010
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION:
This is the ICN as reported on the EOB from the payer.
TECHNICAL DESCR:
This data is found on the 835 in the CLP-07 data element.
361.1,.15 INSURANCE SEQUENCE 0;15 SET (Required)
'1' FOR PRIMARY;
'2' FOR SECONDARY;
'3' FOR TERTIARY;
LAST EDITED: NOV 15, 1999
HELP-PROMPT: Enter the sequence for this insurance for this bill
DESCRIPTION:
This is the sequence for the insurance for this bill.
CROSS-REFERENCE: ^^TRIGGER^361.1^.02
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^IBM(361.1,D0,0)):^(0),1:"") S X=$P(Y(1),U,2),X=X S
DIU=X K Y X ^DD(361.1,.15,1,2,1.1) X ^DD(361.1,.15,1,2,1.4)
1.1)= S X=DIV S X=+$P(^DGCR(399,+$G(^IBM(361.1,DA,0)),"M"),U,X),X=$S(X:X,1:"")
1.4)= S DIH=$S($D(^IBM(361.1,DIV(0),0)):^(0),1:""),DIV=X S $P(^(0),U,2)=DIV,DIH=361.1,DIG=.02 D ^DI
CR:$O(^DD(DIH,DIG,1,0))>0
2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^IBM(361.1,D0,0)):^(0),1:"") S X=$P(Y(1),U,2),X=X S
DIU=X K Y S X="" X ^DD(361.1,.15,1,2,2.4)
2.4)= S DIH=$S($D(^IBM(361.1,DIV(0),0)):^(0),1:""),DIV=X S $P(^(0),U,2)=DIV,DIH=361.1,DIG=.02 D ^DI
CR:$O(^DD(DIH,DIG,1,0))>0
3)= Please do not delete
CREATE VALUE)= S X=+$P(^DGCR(399,+$G(^IBM(361.1,DA,0)),"M"),U,X),X=$S(X:X,1:"")
DELETE VALUE)= @
FIELD)= PAYER NAME
This trigger forces the insurance company pointer into the PAYER NAME field when the COB sequence
for the bill is entered.
RECORD INDEXES: ABS (#132)
361.1,.16 REVIEW STATUS 0;16 SET
'0' FOR NOT REVIEWED;
'1' FOR REVIEW IN PROCESS;
'1.5' FOR COB PROCESSED, NOT AUTHORIZED;
'2' FOR ACCEPTED-INTERIM EOB;
'3' FOR ACCEPTED-COMPLETE EOB;
'4' FOR REJECTED;
'9' FOR CLAIM CANCELLED;
LAST EDITED: SEP 15, 2004
DESCRIPTION:
This is the current processing status of the EOB/MRA. Only MRA claims can be in a REJECTED status.
CROSS-REFERENCE: 361.1^AREV
1)= S ^IBM(361.1,"AREV",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,"AREV",$E(X,1,30),DA)
3)= Do not delete
This xref is used to pull out EOB's that are in various stages of review.
CROSS-REFERENCE: ^^TRIGGER^361.1^100.03
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^IBM(361.1,D0,100)):^(100),1:"") S X=$P(Y(1),U,3),X=
X S DIU=X K Y S X=DIV S X=$G(DUZ) S DIH=$G(^IBM(361.1,DIV(0),100)),DIV=X S $P(^(100),U,3)=DIV,DIH=3
61.1,DIG=100.03 D ^DICR
2)= Q
CREATE VALUE)= S X=$G(DUZ)
DELETE VALUE)= NO EFFECT
FIELD)= LAST EDITED BY
CROSS-REFERENCE: ^^TRIGGER^361.1^100.04
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^IBM(361.1,D0,100)):^(100),1:"") S X=$P(Y(1),U,4),X=
X S DIU=X K Y S X=DIV S X=$$NOW^XLFDT() S DIH=$G(^IBM(361.1,DIV(0),100)),DIV=X S $P(^(100),U,4)=DIV
,DIH=361.1,DIG=100.04 D ^DICR
2)= Q
CREATE VALUE)= S X=$$NOW^XLFDT()
DELETE VALUE)= NO EFFECT
FIELD)= LAST EDITED DATE
RECORD INDEXES: AMRA (#307)
361.1,.17 MANUAL ENTRY? 0;17 SET
'0' FOR NO;
'1' FOR YES;
LAST EDITED: FEB 10, 1999
HELP-PROMPT: Enter a 1 if this EOB was manually entered or 0 if it was entered electronically
DESCRIPTION:
This field indicates whether the EOB was added electronically or manually.
361.1,.18 MANUALLY ENTERED BY 0;18 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: MAY 28, 1999
HELP-PROMPT: Enter the name of the person entering the EOB
DESCRIPTION:
This is the name of the person responsible for the entry of this EOB.
361.1,.19 TRANSMIT BILL 0;19 POINTER TO EDI TRANSMIT BILL FILE (#364)
INPUT TRANSFORM: S DIC("S")="N Z S Z=$G(^(0)) I +Z=+$G(^IBM(361.1,DA,0)),$TR($P(Z,U,8),""PST"",""123"")=$P(^(0),U,15
)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: NOV 10, 1999
HELP-PROMPT: Enter the transmit bill that generated this EOB.
DESCRIPTION:
This is the transmit bill entry that was responsible for this EOB.
SCREEN: S DIC("S")="N Z S Z=$G(^(0)) I +Z=+$G(^IBM(361.1,DA,0)),$TR($P(Z,U,8),""PST"",""123"")=$P(^(0),U,15
)"
EXPLANATION: Only for same bill entry and ins sequence
CROSS-REFERENCE: 361.1^AERR
1)= S ^IBM(361.1,"AERR",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,"AERR",$E(X,1,30),DA)
3)= Do not delete
361.1,.2 FINAL REVIEW ACTION 0;20 SET
'C' FOR BILL CANCELLED - NO FURTHER ACTION;
'F' FOR FILED - NO ACTION;
'R' FOR CORRECTED/RESUBMITTED;
'P' FOR COB PROCESSED;
'O' FOR OTHER ACTION;
LAST EDITED: JUL 03, 2003
HELP-PROMPT: Enter the final review action for this EOB
DESCRIPTION:
This is the action that was taken to complete the review of this EOB.
361.1,.21 CLAIM STATUS CODE 0;21 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: MAR 25, 2003
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION:
This is the actual X12 claim status code that was received for this EOB.
361.1,.22 PARTIAL EOB 0;22 SET (BOOLEAN Data Type)
LAST EDITED: MAR 04, 2022
HELP-PROMPT: Enter Yes if this MRA does not cover the entire claims.
DESCRIPTION: Does this MRA/EOB cover all lines submitted on claim? If not, it's a partial MRA and should be
flagged as such.
TECHNICAL DESCR: This field is calculated when an MRA is received. The code checks to see what lines were sent out
on the claim and which were returned and stores the result here when it is an incomplete MRA. It is
needed because one of the administrative contractors does not return an MA15 when a claim is split
so the software needs to figure it out. Otherwise, incomplete COB information is being send to
subsequent payers.
361.1,1.01 PAYER PAID AMT 1;1 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is the amount that was paid on this claim for this EOB
TECHNICAL DESCR:
This is the amount from the 835 data field (CLP-04) or from manual entry of the amount
361.1,1.02 PATIENT RESPONSIBILITY AMT 1;2 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999999.99)!(X<0) X
LAST EDITED: JAN 22, 1999
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999999.99, 2 Decimal Digits
DESCRIPTION: This is the amount the insurance company/MRA dictates is the responsibility of the patient for this
claim.
TECHNICAL DESCR:
This field is found from the data on the 835 in the CAS segment when the qualifier = 'PR'.
361.1,1.03 COVERED AMT 1;3 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is the amount as reported by the payer.
TECHNICAL DESCR: This is the amount from the 835 data field (AMT-02/Qualifier='AU') or from manual entry of the
amount
361.1,1.04 DISCOUNT AMT 1;4 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is the prompt pay discount amount as reported by the payer.
TECHNICAL DESCR: This is the amount from the 835 data field (AMT-02/Qualifier='D8') or from manual entry of the
amount
361.1,1.05 PER DAY LIMIT AMT 1;5 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is the amount as reported by the payer.
TECHNICAL DESCR: This is the amount from the 835 data field (AMT-02/Qualifier='DY') or from manual entry of the
amount
361.1,1.07 INTEREST AMT 1;7 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is the amount as reported by the payer.
TECHNICAL DESCR: This is the amount from the 835 data field (AMT-02/Qualifier='I') or from manual entry of the
amount
361.1,1.08 TAX AMT 1;8 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is the amount as reported by the payer.
TECHNICAL DESCR: This is the amount from the 835 data field (AMT-02/Qualifier='T') or from manual entry of the
amount
361.1,1.09 TOTAL BEFORE TAXES AMT 1;9 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is the amount as reported by the payer.
TECHNICAL DESCR: This is the amount from the 835 data field (AMT-02/Qualifier='T2') or from manual entry of the
amount
361.1,1.1 STATEMENT START DATE 1;10 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 28, 2004
HELP-PROMPT: Enter the date the payer reported as the starting date of service.
DESCRIPTION:
This is the date the payer reported as the starting date of service for the claim.
361.1,1.11 STATEMENT END DATE 1;11 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 28, 2004
HELP-PROMPT: Enter the date the payer reported as the ending date of service.
DESCRIPTION:
This is the date the payer reported as the ending date of service for the claim.
361.1,1.12 CLAIM RECEIVED DATE 50;1 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JUN 18, 2010
HELP-PROMPT: Enter the date the payer received the claim.
DESCRIPTION:
This is the date the payer received the claim.
TECHNICAL DESCR:
From 835 record: 2100 DTM02 where DTM01 = "050"
361.1,1.13 COVERAGE EXPIRATION DATE 50;2 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JUN 21, 2010
HELP-PROMPT: Enter the date the insurance coverage expires.
DESCRIPTION:
This is the date the insurance coverage expires.
TECHNICAL DESCR:
From 835 record: 2100 DTM02 where DTM01= "036"
361.1,1.14 CORRECTED PRIORITY PAYER NAME 50;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>60!($L(X)<1) X
LAST EDITED: JUN 21, 2010
HELP-PROMPT: Enter the corrected name (1-60 characters) of the priority payer.
DESCRIPTION:
This is the corrected name of the priority payer for this claim.
TECHNICAL DESCR:
From 835 record: 2100NM103 where NM101 = "PR"
361.1,1.15 CORRECTED PRIORITY PAYER TYPE 50;4 SET
'AD' FOR BLUE CROSS/BLUE SHIELD ASSOC;
'FI' FOR FEDERAL TAXPAYER;
'NI' FOR NAIC;
'PP' FOR PHARMACY PROCESSOR NUMBER;
'XV' FOR CENTERS FOR MEDICARE/MEDICAID;
'PI' FOR PAYER ID;
LAST EDITED: JAN 21, 2016
HELP-PROMPT: Enter code for type of corrected priority payer.
DESCRIPTION:
This is the type of the corrected priority payer.
TECHNICAL DESCR:
From 835 record: 2100 NM108 where NM101 = "PR"
361.1,1.16 CORRECTED PRIORITY PAYER ID 50;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>80!($L(X)<1) X
LAST EDITED: JUN 21, 2010
HELP-PROMPT: Enter the ID (1-80 characters) of the corrected priority payer.
DESCRIPTION:
This is the ID of the corrected priority payer.
TECHNICAL DESCR:
From 835 record: 2100 NM109 where NM101= "PR"
361.1,1.17 OTHER SUBSCRIBER NAME 51;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>122!($L(X)<1) X
LAST EDITED: JUN 14, 2010
HELP-PROMPT: Enter the name (1-122 characters) of the other subscriber for this claim.
DESCRIPTION:
This is the name of the other subscriber for this claim.
TECHNICAL DESCR:
From 835 record: 2100 NM104 where NM101 = "GB" or NM101 = "GN"
361.1,2.03 TOTAL ALLOWED AMT 2;3 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (AMT-02/Qualifier='B6')
361.1,2.04 TOTAL SUBMITTED CHARGES 2;4 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (AMT-02/Qualifier='T3')
361.1,2.05 NEGATIVE REIMBURSEMENT AMT 2;5 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?."-".N.1".".2N!(X>9999999999)!(X<-9999999999)!(X?.E1"."3.N) X
LAST EDITED: AUG 15, 2003
HELP-PROMPT: Type a Dollar amount between -9999999999 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is the amount of negative reimbursement on a claim as reported by MEDICARE.
TECHNICAL DESCR:
This data can be found on the electronic EOB (835) in the AMT-02 (qualifier 'NL') data element.
361.1,2.06 HPID/OEID 2;6 FREE TEXT
Health Plan/Other Entity Identifier
INPUT TRANSFORM: K:$L(X)>10 X
LAST EDITED: MAY 08, 2014
HELP-PROMPT: Answer must be 10 characters in length.
DESCRIPTION: The HPID/OEID is a 10-digit, all-numeric identifier following the ISO Standard 7812 format with a
Luhn check-digit as the tenth digit. The start digit of the HPID/OEID signals whether the
identifier has been provided to a health plan and not to an "other entity". If the start digit is
a seven (7) then it is an HPID and identifies a health plan, a six (6) indicates an "other entity"
(OEID). The OEID serves as the identifier for entities that are not health plans, healthcare
providers, or individuals (persons) who are not eligible for the HPID or National Provider
Identifier (NPI), yet they need to be identified in standard transactions and for other lawful
purposes.
UNEDITABLE
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
361.1,3.01 M-CARE OUTP REIMBURS. RATE 3;1 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>1)!(X<0)!(X?.E1"."5.N) X
LAST EDITED: JUN 25, 2003
HELP-PROMPT: Type a number between 0 and 1, 4 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MOA-01)
361.1,3.02 M-CARE OUTP HCPCS PAYMNT AMT 3;2 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MOA-02)
361.1,3.03 M-CARE OUTP REMARKS CODE-1 3;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>10!($L(X)<1) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Answer must be 1-10 characters in length.
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MOA-03)
361.1,3.04 M-CARE OUTP REMARKS CODE-2 3;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>10!($L(X)<1) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Answer must be 1-10 characters in length.
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MOA-04)
361.1,3.05 M-CARE OUTP REMARKS CODE-3 3;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>10!($L(X)<1) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Answer must be 1-10 characters in length.
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MOA-05)
361.1,3.06 M-CARE OUTP REMARKS CODE-4 3;6 FREE TEXT
INPUT TRANSFORM: K:$L(X)>10!($L(X)<1) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Answer must be 1-10 characters in length.
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MOA-06)
361.1,3.07 M-CARE OUTP REMARKS CODE-5 3;7 FREE TEXT
INPUT TRANSFORM: K:$L(X)>10!($L(X)<1) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Answer must be 1-10 characters in length.
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MOA-07)
361.1,3.08 M-CARE ESRD PAID AMT 3;8 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: JAN 12, 1999
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MOA-08)
361.1,3.09 M-CARE NON-PAYABLE PROF COMP 3;9 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: JAN 12, 1999
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MOA-09)
361.1,4.01 M-CARE INP COV. DAYS/VISIT CT 4;1 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Number between 0 and 9999, 0 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-01)
361.1,4.02 M-CARE INP LIFETM PSYCH DY CT 4;2 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Number between 0 and 9999, 0 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-03)
361.1,4.03 M-CARE INP CLAIM DRG AMT 4;3 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-04)
361.1,4.04 M-CARE INP CAP EXCEPTION AMT 4;4 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-24)
361.1,4.05 M-CARE INP DISPROP. SHARE AMT 4;5 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-06)
361.1,4.06 M-CARE INP MSP PASS THRU AMT 4;6 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
MIA-07
361.1,4.07 M-CARE INP PPS CAPITAL AMT 4;7 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-08)
361.1,4.08 M-CARE INP PPS CAP FSP-DRG AMT 4;8 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-09)
361.1,4.09 M-CARE INP PPS CAP HSP-DRG AMT 4;9 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-10)
361.1,4.1 M-CARE INP PPS CAP DSH-DRG AMT 4;10 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-11)
361.1,4.11 M-CARE INP OLD CAPITAL AMT 4;11 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-12)
361.1,4.12 M-CARE INP PPS CAPITAL IME AMT 4;12 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-13)
361.1,4.13 M-CARE INP PPS OP HOS DRG AMT 4;13 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-14)
361.1,4.14 M-CARE INP COST REPORT DAY CT 4;14 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Number between 0 and 999, 0 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-15)
361.1,4.15 M-CARE INP PPS OP FED DRG AMT 4;15 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-16)
361.1,4.16 M-CARE INP PPS CAP OUTLIER AMT 4;16 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-17)
361.1,4.17 M-CARE INP INDIRECT TEACH AMT 4;17 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-18)
361.1,4.18 M-CARE INP NON-PAY PROF COMP 4;18 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-19)
361.1,4.19 MEDICARE NON-COVERED DAYS 4;19 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: APR 12, 2001
HELP-PROMPT: Type a Number between 0 and 9999, 0 Decimal Digits
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice
TECHNICAL DESCR:
This is the amount from the 835 data field (QTY with qualifier 'NA')
361.1,5.01 M-CARE INP PYMNT REMARK CODE-1 5;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>10!($L(X)<1) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Answer must be 1-10 characters in length.
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-05)
361.1,5.011 REMARK CODE-1 SHORT TEXT RM1;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>190!($L(X)<1) X
LAST EDITED: FEB 05, 1999
HELP-PROMPT: Answer must be 1-190 characters in length.
DESCRIPTION: This is the abbreviated text for remark code # 1, if available This applies to EITHER inpatient or
outpatient remark codes from MEDICARE.
361.1,5.02 M-CARE INP PYMNT REMARK CODE-2 5;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>10!($L(X)<1) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Answer must be 1-10 characters in length.
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-20)
361.1,5.021 REMARK CODE-2 SHORT TEXT RM2;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>190!($L(X)<1) X
LAST EDITED: FEB 05, 1999
HELP-PROMPT: Answer must be 1-190 characters in length.
DESCRIPTION: This is the abbreviated text for remark code # 2, if available This applies to EITHER inpatient or
outpatient remark codes from MEDICARE.
361.1,5.03 M-CARE INP PYMNT REMARK CODE-3 5;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>10!($L(X)<1) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Answer must be 1-10 characters in length.
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-21)
361.1,5.031 REMARK CODE-3 SHORT TEXT RM3;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>190!($L(X)<1) X
LAST EDITED: FEB 05, 1999
HELP-PROMPT: Answer must be 1-190 characters in length.
DESCRIPTION: This is the abbreviated text for remark code # 3, if available This applies to EITHER inpatient or
outpatient remark codes from MEDICARE.
361.1,5.04 M-CARE INP PYMNT REMARK CODE-4 5;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>10!($L(X)<1) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Answer must be 1-10 characters in length.
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-22)
361.1,5.041 REMARK CODE-4 SHORT TEXT RM4;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>190!($L(X)<1) X
LAST EDITED: FEB 05, 1999
HELP-PROMPT: Answer must be 1-190 characters in length.
DESCRIPTION: This is the abbreviated text for remark code # 4, if available This applies to EITHER inpatient or
outpatient remark codes from MEDICARE.
361.1,5.05 M-CARE INP PYMNT REMARK CODE-5 5;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>10!($L(X)<1) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Answer must be 1-10 characters in length.
DESCRIPTION:
This is a data element from a MEDICARE electronic remittance advice.
TECHNICAL DESCR:
This is the amount from the 835 data field (MIA-23)
361.1,5.051 REMARK CODE-5 SHORT TEXT RM5;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>190!($L(X)<1) X
LAST EDITED: FEB 05, 1999
HELP-PROMPT: Answer must be 1-190 characters in length.
DESCRIPTION: This is the abbreviated text for remark code # 5, if available This applies to EITHER inpatient or
outpatient remark codes from MEDICARE.
361.1,6.01 NEW PATIENT NAME 6;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: FEB 08, 1999
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION:
This is the 'new' patient name as reported on the electronic EOB.
361.1,6.02 NEW PATIENT ID 6;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<1) X
LAST EDITED: FEB 08, 1999
HELP-PROMPT: Answer must be 1-20 characters in length.
DESCRIPTION:
This is the 'new' patient ID as reported on the electronic EOB.
361.1,6.03 CORRECTED DATA MESSAGE 6;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>190!($L(X)<1) X
LAST EDITED: JAN 16, 2008
HELP-PROMPT: Answer must be 1-190 characters in length
DESCRIPTION: This is a free text message describing the results of the processing of the "06" record type on the
incoming 835 transmission. The "06" record type is where the payer can send back the corrected
patient name and/or the corrected patient ID#. VistA will accept this information and attempt to
the update the patient insurance files with this data.
361.1,7.01 TRANSFERRED IN 7;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>64!($L(X)<1) X
LAST EDITED: JAN 13, 2003
HELP-PROMPT: Answer must be 1-64 characters in length.
DESCRIPTION:
This is the site that this EOB was transferred into this site from.
RECORD INDEXES: ATIN (#184)
361.1,8 AR AMOUNTS DISTRIBUTION 8;0 Multiple #361.18 (Add New Entry without Asking)
DESCRIPTION: This is the list of bills that AR has determined will apply to this ERA along with the amount that
was paid/retracted.
361.18,.01 BILL # 0;1 FREE TEXT (Required) (Multiply asked)
INPUT TRANSFORM: K:$L(X)>15!($L(X)<1) X
LAST EDITED: MAR 18, 2003
HELP-PROMPT: Answer must be 1-15 characters in length.
DESCRIPTION:
This is the free text bill # that AR has determined this ERA has referenced.
CROSS-REFERENCE: 361.18^B
1)= S ^IBM(361.1,DA(1),8,"B",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,DA(1),8,"B",$E(X,1,30),DA)
CROSS-REFERENCE: 361.1^C
1)= S ^IBM(361.1,"C",$E(X,1,30),DA(1),DA)=""
2)= K ^IBM(361.1,"C",$E(X,1,30),DA(1),DA)
3)= Do not delete
361.18,.02 AMOUNT 0;2 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?."-".N.1".".2N!(X>9999999999999)!(X<-9999999999999) X
LAST EDITED: MAR 13, 2003
HELP-PROMPT: Type a Dollar Amount between -9999999999999 and 9999999999999, 2 Decimal Digits
DESCRIPTION: This is the amount of money from this ERA that AR has determined applies to the corresponding
bill.
361.18,.03 BILL REFERENCE 0;3 POINTER TO BILL/CLAIMS FILE (#399)
LAST EDITED: MAR 18, 2003
HELP-PROMPT: Enter the IB bill reference for this distribution amount
DESCRIPTION: This is the actual pointer to file 399 for the bill referenced in this distribution record. If
this data is missing, the amount was posted to suspense.
CROSS-REFERENCE: 361.1^C
1)= S ^IBM(361.1,"C",$E(X,1,30),DA(1),DA)=""
2)= K ^IBM(361.1,"C",$E(X,1,30),DA(1),DA)
3)= Do not delete
CROSS-REFERENCE: 361.18^AC
1)= S ^IBM(361.1,DA(1),8,"AC",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,DA(1),8,"AC",$E(X,1,30),DA)
3)= Do not delete
361.1,10 835 CLAIM LEVEL ADJUSTMENTS 10;0 SET Multiple #361.11
LAST EDITED: OCT 06, 1998
DESCRIPTION: This is the list of claim level adjustments, including general category of adjustment, reason code,
amount and quantity.
TECHNICAL DESCR:
This data is received from the EOB on the 835 data segment 'CAS' on a claim level basis.
361.11,.01 ADJUSTMENT CATEGORY (GRP CODE) 0;1 SET (Required) (Multiply asked)
'CO' FOR Contractual Obligations;
'CR' FOR Corrections and Reversals;
'OA' FOR Other Adjustments;
'PI' FOR Payor Initiated Reductions;
'PR' FOR Patient Responsibility;
'MM' FOR Medicare Message;
LAST EDITED: JAN 19, 1999
HELP-PROMPT: Enter the group code associated with the adjustment
DESCRIPTION:
This is the group code as reported on the EOB for the adjustment
TECHNICAL DESCR:
This data is found in the electronic eob (835) in the data element CAS-01
CROSS-REFERENCE: 361.11^B
1)= S ^IBM(361.1,DA(1),10,"B",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,DA(1),10,"B",$E(X,1,30),DA)
361.11,1 REASONS 1;0 Multiple #361.111
DESCRIPTION:
This is the list of reasons returned for claim-level adjustments to the claim.
361.111,.01 REASON CODE 0;1 FREE TEXT (Multiply asked)
INPUT TRANSFORM: K:$L(X)>20!($L(X)<1) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Answer must be 1-20 characters in length.
DESCRIPTION:
This is the reason code for the adjustment
TECHNICAL DESCR:
This data is found in the electronic eob (835) in the data elements CAS-02,5,8,11,14,17
CROSS-REFERENCE: 361.111^B
1)= S ^IBM(361.1,DA(2),10,DA(1),1,"B",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,DA(2),10,DA(1),1,"B",$E(X,1,30),DA)
361.111,.02 AMOUNT 0;2 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?."-".N.1".".2N!(X>9999999999)!(X<-9999999999)!(X?.E1"."3.N) X
LAST EDITED: OCT 14, 2003
HELP-PROMPT: Type a Dollar amount between -9999999999 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is the adjusted amount for the reason code
TECHNICAL DESCR:
This data is found in the electronic eob (835) in the data elements CAS-03,6,9,12,15,18
361.111,.03 QUANTITY 0;3 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>99999)!(X<-99999)!(X?.E1"."1.N) X
LAST EDITED: AUG 22, 2003
HELP-PROMPT: Type a number between -99999 and 99999, 0 Decimal Digits
DESCRIPTION:
This is the quantity for the item adjusted
TECHNICAL DESCR:
This data is found in the electronic eob (835) in the data elements CAS-04,7,10,13,16,19
361.111,.04 REASON TEXT 0;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>190!($L(X)<1) X
LAST EDITED: OCT 07, 1998
HELP-PROMPT: Answer must be 1-190 characters in length.
DESCRIPTION:
This is the free text interpretation of the reason code, if available
TECHNICAL DESCR: This is provided by the Austin AAC to accelerate the recognition of these codes. It may be an
abbreviated version of the actual message.
361.1,15 835 LINE LEVEL ADJUSTMENTS 15;0 Multiple #361.115 (Add New Entry without Asking)
DESCRIPTION: This is the list of line level adjustments, including general category of adjustment, reason code,
amount and quantity.
TECHNICAL DESCR:
This data is received from the EOB on the 835 data segment 'CAS' on a line level basis.
361.115,.01 ADJUSTMENT SEQUENCE # 0;1 NUMBER (Multiply asked)
INPUT TRANSFORM: K:+X'=X!(X>9999)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: OCT 21, 2019
HELP-PROMPT: Type a Number between 1 and 9999, 0 Decimal Digits
DESCRIPTION:
This is a sequence # for the adjustment. It has no value to the COB process.
CROSS-REFERENCE: 361.115^B
1)= S ^IBM(361.1,DA(1),15,"B",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,DA(1),15,"B",$E(X,1,30),DA)
361.115,.02 PAYER ID CODE 0;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<1) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Answer must be 1-20 characters in length.
361.115,.03 AMOUNT PAID 0;3 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?."-".N.1".".2N!(X>9999999999)!(X<-9999999999)!(X?.E1"."3.N) X
LAST EDITED: SEP 12, 2003
HELP-PROMPT: Type a Dollar amount between -9999999999 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is the amount that was actually paid on this procedure.
TECHNICAL DESCR:
This data is found in the electronic 835 at the SVC03 data element.
361.115,.04 PROCEDURE 0;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>15!($L(X)<3) X
LAST EDITED: OCT 06, 2003
HELP-PROMPT: Answer must be 3-15 characters in length.
DESCRIPTION:
This is the procedure for which payment was considered.
TECHNICAL DESCR:
This data is found in the electronic 835 at the SVC01-02 data element.
361.115,.09 DESCRIPTION 0;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>80!($L(X)<1) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Answer must be 1-80 characters in length.
DESCRIPTION:
This is the procedure description as reported on the EOB.
TECHNICAL DESCR:
This data is found in the electronic 835 at the SVC01-07 data element.
361.115,.1 REVENUE CODE 0;10 POINTER TO REVENUE CODE FILE (#399.2)
LAST EDITED: OCT 06, 1998
DESCRIPTION:
This is the revenue code that is associated with the procedure being billed.
TECHNICAL DESCR: This data element is used only for Institutional claims and can be found in the electronic EOB
(835) in the SVC-04 data element.
361.115,.11 PAID UNITS OF SERVICE 0;11 NUMBER (Required)
INPUT TRANSFORM: K:+X'=X!(X>99999999)!(X<0)!(X?.E1"."2.N) X
LAST EDITED: AUG 23, 2004
HELP-PROMPT: Type a number between 0 and 99999999, 1 Decimal Digit
DESCRIPTION:
This is the number of units of service that were actually reimbursed.
TECHNICAL DESCR:
This data is found in the electronic 835 at the SVC05 data element.
361.115,.12 REFERENCED LINE # 0;12 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>999)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: FEB 02, 1999
HELP-PROMPT: Type a Number between 1 and 999, 0 Decimal Digits
DESCRIPTION: This is the line # on the original bill that is referenced by this adjustment. If bundling or
unbundling has occurred, this is the line # that has the actual adjustment information attached
to it.
TECHNICAL DESCR:
This data is calculated from the results of the 835 or EOB.
CROSS-REFERENCE: 361.115^AC
1)= S ^IBM(361.1,DA(1),15,"AC",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,DA(1),15,"AC",$E(X,1,30),DA)
3)= Please do not delete
This xref is the 'key' field for sorting the lines level adjustments by VISTA line number so the
adjustments can be placed in the proper sequence when the 837 COB data is assembled.
361.115,.13 ALLOWED AMOUNT 0;13 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: FEB 02, 1999
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is the amount MEDICARE will allow for this service line
TECHNICAL DESCR: This data can be found in the electronic EOB (835) at the AMT-02 (qualifier 'B6') data element at
the line item level.
361.115,.14 PER DIEM AMOUNT 0;14 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: FEB 02, 1999
HELP-PROMPT: Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is the per diem amount reported by MEDICARE for this service line.
TECHNICAL DESCR: This data can be found in the electronic EOB (835) at the AMT-02 (qualifier 'DY') data element at
the line item level.
361.115,.15 ORIGINAL PROCEDURE 0;15 FREE TEXT
INPUT TRANSFORM: K:$L(X)>15!($L(X)<1) X
LAST EDITED: OCT 28, 1999
HELP-PROMPT: Answer must be 1-15 characters in length.
DESCRIPTION: If this adjustment indicates bundling or unbundling occurred (paid procedure was not the original
submitted procedure), this is the procedure that was originally sent for payment on the claim.
This field will only have data in it if the procedure was part of a bundling or unbundling
process.
TECHNICAL DESCR: If there is data in this field, there will be one or more procedures that will need additional
line items output for 837 COB due to bundling/unbundling of procedures by the payer.
361.115,.16 SERVICE DATE FROM 0;16 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: MAR 24, 2003
HELP-PROMPT: Enter the date the service was performed
DESCRIPTION:
This is the first date of service for the claim.
361.115,.17 SERVICE DATE TO 0;17 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: MAR 24, 2003
HELP-PROMPT: Enter the date the service was performed
DESCRIPTION:
This is the last date of service for the claim.
361.115,.18 PROCEDURE TYPE 0;18 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: MAR 25, 2003
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION:
This is the code representing the type of procedure as reported in this record.
361.115,1 ADJUSTMENTS 1;0 SET Multiple #361.1151 (Add New Entry without Asking)
DESCRIPTION: This is the list of line level adjustments, including general category of adjustment, reason
code, amount and quantity.
361.1151,.01 GROUP CODE 0;1 SET (Multiply asked)
'CO' FOR Contractual Obligations;
'CR' FOR Corrections and Reversals;
'OA' FOR Other Adjustments;
'PI' FOR Payor Initiated Reductions;
'PR' FOR Patient Responsibility;
'LQ' FOR Line Item Remark Code WebMD Kludge;
LAST EDITED: OCT 30, 2003
CROSS-REFERENCE: 361.1151^B
1)= S ^IBM(361.1,DA(2),15,DA(1),1,"B",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,DA(2),15,DA(1),1,"B",$E(X,1,30),DA)
361.1151,1 REASONS 1;0 Multiple #361.11511 (Add New Entry without Asking)
DESCRIPTION:
This is the list of reasons returned for line-level adjustments to the claim.
361.11511,.01 REASON CODE 0;1 FREE TEXT (Multiply asked)
INPUT TRANSFORM: K:$L(X)>10!($L(X)<1) X
LAST EDITED: OCT 06, 1998
HELP-PROMPT: Answer must be 1-10 characters in length.
DESCRIPTION:
This is the reason code for the adjustment
TECHNICAL DESCR:
This data is found in the electronic eob (835) in the data elements CAS-02,5,8,11,14,17
CROSS-REFERENCE: 361.11511^B
1)= S ^IBM(361.1,DA(3),15,DA(2),1,DA(1),1,"B",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,DA(3),15,DA(2),1,DA(1),1,"B",$E(X,1,30),DA)
361.11511,.02 AMOUNT 0;2 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?."-".N.1".".2N!(X>9999999999)!(X<-9999999999) X
LAST EDITED: APR 11, 2003
HELP-PROMPT: Type a Dollar Amount between -9999999999 and 9999999999, 2 Decimal Digits
DESCRIPTION:
This is the adjusted amount for the reason code
TECHNICAL DESCR:
This data is found in the electronic eob (835) in the data elements CAS-03,6,9,12,15,18
361.11511,.03 QUANTITY 0;3 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9999999)!(X<-9999999)!(X?.E1"."1.N) X
LAST EDITED: AUG 22, 2003
HELP-PROMPT: Type a number between -9999999 and 9999999, 0 Decimal Digits
DESCRIPTION:
This is the quantity for the item adjusted
TECHNICAL DESCR:
This data is found in the electronic eob (835) in the data elements CAS-04,7,10,13,16,19
361.11511,.04 REASON TEXT 0;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>190!($L(X)<1) X
LAST EDITED: OCT 07, 1998
HELP-PROMPT: Answer must be 1-190 characters in length.
DESCRIPTION:
This is the free text interpretation of the reason code, if available
TECHNICAL DESCR: This is provided by the Austin AAC to accelerate the recognition of these codes. It may be
an abbreviated version of the actual message.
361.1151,2 PAYER POLICY REFERENCE 2;0 Multiple #361.11512 (Add New Entry without Asking)
DESCRIPTION: These are the payer policy references listed on the payer web site. Up to 5 payer policy
references are allowed on the 835 record.
361.11512,.01 PAYER POLICY REFERENCE 0;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: AUG 26, 2010
HELP-PROMPT: Enter the payer policy reference (1-50characters) used on the payer web site.
DESCRIPTION:
This is the payer policy reference used on the payer web site.
TECHNICAL DESCR:
From 835 record: 2110 REF02 where REF01 = "OK"
CROSS-REFERENCE: 361.11512^B
1)= S ^IBM(361.1,DA(3),15,DA(2),1,DA(1),2,"B",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,DA(3),15,DA(2),1,DA(1),2,"B",$E(X,1,30),DA)
361.115,2 PAID MODIFIERS 2;0 Multiple #361.1152 (Add New Entry without Asking)
361.1152,.01 PAID MODIFIERS 0;1 FREE TEXT (Multiply asked)
INPUT TRANSFORM: K:$L(X)>2!($L(X)<2) X
LAST EDITED: JUN 18, 2003
HELP-PROMPT: Answer must be 2 characters in length.
DESCRIPTION:
This field contains the procedure modifiers used to pay on this line item.
CROSS-REFERENCE: 361.1152^B
1)= S ^IBM(361.1,DA(2),15,DA(1),2,"B",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,DA(2),15,DA(1),2,"B",$E(X,1,30),DA)
361.115,4 LINE ITEM REMARK 4;0 Multiple #361.1154 (Add New Entry without Asking)
361.1154,.01 LINE ITEM REMARK 0;1 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>99999)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: AUG 17, 2004
HELP-PROMPT: Type a Number between 1 and 99999, 0 Decimal Digits
DESCRIPTION:
This is the sequential number used to enumerate the line item remarks in the ERA.
CROSS-REFERENCE: 361.1154^B
1)= S ^IBM(361.1,DA(2),15,DA(1),4,"B",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,DA(2),15,DA(1),4,"B",$E(X,1,30),DA)
361.1154,.02 LINE ITEM REMARK CODE 0;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>10!($L(X)<1) X
LAST EDITED: AUG 17, 2004
HELP-PROMPT: Answer must be 1-10 characters in length.
DESCRIPTION:
This is the remark code provided by MEDICARE for this line item.
361.1154,.03 LINE ITEM REMARK CODE TEXT 0;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>190!($L(X)<1) X
LAST EDITED: AUG 17, 2004
HELP-PROMPT: Answer must be 1-190 characters in length.
DESCRIPTION:
This is the free text explanation of the remark code in this record.
361.115,6 SERVICE SUPPLEMENTAL QUANTITY 6;0 Multiple #361.1156
DESCRIPTION: This multiple stores up to 5 Service Supplemental Quantity entries as received on the
41 record of the 835 ERA, pieces 5 through 9.
361.1156,.01 SEQUENCE NUMBER 0;1 NUMBER (Multiply asked)
INPUT TRANSFORM: K:+X'=X!(X>5)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: NOV 01, 2019
HELP-PROMPT: Type a number between 1 and 5, 0 decimal digits.
DESCRIPTION: This is the sequence number of the service supplemental quantity as received on the
41 record of the 835 ERA, pieces 5 through 9.
CROSS-REFERENCE: 361.1156^B
1)= S ^IBM(361.1,DA(2),15,DA(1),6,"B",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,DA(2),15,DA(1),6,"B",$E(X,1,30),DA)
361.1156,.02 SERVICE SUPPLEMENTAL QUANTITY 0;2 NUMBER (Required)
INPUT TRANSFORM: K:+X'=X!(X>999999999)!(X<0)!(X?.E1"."10N.N) X
LAST EDITED: NOV 01, 2019
HELP-PROMPT: Type a number between 0 and 999999999, 9 decimal digits.
DESCRIPTION: This is the service supplemental quantity as received on one of the pieces 5 through
9 of the 41 record of the 835 ERA.
361.115,7 SERVICE PAYMENT QUALIFIER 7;0 Multiple #361.1157
DESCRIPTION: This stores the Service Payment Qualifier and Reference Identification entries as
received on the 43 record of the 835 ERA.
361.1157,.01 SERVICE PAYMENT QUALIFIER 0;1 FREE TEXT (Multiply asked)
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
MAXIMUM LENGTH: 3
LAST EDITED: NOV 01, 2019
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This is the Service Payment Qualifier data as received on the 43 record of the 835
ERA.
CROSS-REFERENCE: 361.1157^B
1)= S ^IBM(361.1,DA(2),15,DA(1),7,"B",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,DA(2),15,DA(1),7,"B",$E(X,1,30),DA)
361.1157,.02 REFERENCE IDENTIFICATION 0;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
MAXIMUM LENGTH: 50
LAST EDITED: NOV 01, 2019
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION: This is the Reference Identification data as received on the 43 record of the 835
ERA.
361.1,20 MESSAGE STORAGE ERRORS ERR;0 WORD-PROCESSING #361.12 (NOWRAP)
LAST EDITED: JUN 26, 2003
HELP-PROMPT: Enter the text of the error message
DESCRIPTION: This is the text of all the errors encountered for this EOB when attempting to load it from the
EDI MESSAGES file.
361.1,21 REVIEW DATE/TIME 21;0 DATE Multiple #361.121 (Add New Entry without Asking)
LAST EDITED: AUG 25, 1999
361.121,.01 REVIEW DATE/TIME 0;1 DATE (Multiply asked)
INPUT TRANSFORM: S %DT="ESTXR" D ^%DT S X=Y K:Y<1 X
LAST EDITED: AUG 25, 1999
HELP-PROMPT: Enter the date/time this EOB is being reviewed.
DESCRIPTION:
This is the date/time that this EOB was selected for review.
CROSS-REFERENCE: 361.121^B
1)= S ^IBM(361.1,DA(1),21,"B",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,DA(1),21,"B",$E(X,1,30),DA)
361.121,.02 REVIEWED BY 0;2 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: AUG 02, 1999
HELP-PROMPT: Enter the name of the person reviewing this EOB.
DESCRIPTION:
This is the name of the person who is reviewing this EOB.
361.121,1 COMMENTS 1;0 WORD-PROCESSING #361.1211
LAST EDITED: AUG 02, 1999
HELP-PROMPT: Enter a description of the actions taken during this EOB review.
DESCRIPTION: This is a description of any unusual occurrences that might have taken place in the process of
reviewing this EOB. It also contains any notes relating to the final review of the EOB.
361.1,25.01 PAYER CONTACT NAME 25;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: MAR 24, 2003
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION: This is the name of the contact the payer has provided for questions concerning this particular
claim's adjudication.
361.1,25.02 CONTACT NUMBER 1 25;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>60!($L(X)<1) X
LAST EDITED: AUG 02, 2010
HELP-PROMPT: Answer must be 1-60 characters in length.
DESCRIPTION:
This is a phone #/telephone extension or email address for the contact.
361.1,25.03 CONTACT TYPE 1 25;3 SET
'EM' FOR E-MAIL;
'FX' FOR FAX;
'TE' FOR TELEPHONE;
'EX' FOR TELEPHONE EXTENSION;
LAST EDITED: MAR 24, 2003
HELP-PROMPT: Enter the code for the type of contact information.
DESCRIPTION: This is the code that describes the type of contact information provided in the CONTACT NUMBER 1
field.
361.1,25.04 CONTACT NUMBER 2 25;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>60!($L(X)<1) X
LAST EDITED: AUG 02, 2010
HELP-PROMPT: Answer must be 1-60 characters in length.
DESCRIPTION:
This is a phone #/telephone extension or email address for the contact.
361.1,25.05 CONTACT TYPE 2 25;5 SET
'EM' FOR E-MAIL;
'FX' FOR FAX;
'TE' FOR TELEPHONE;
'EX' FOR TELEPHONE EXTENSION;
LAST EDITED: MAR 24, 2003
HELP-PROMPT: Enter the code for the type of contact information.
DESCRIPTION: This is the code that describes the type of contact information provided in the CONTACT NUMBER 2
field.
361.1,25.06 CONTACT NUMBER 3 25;6 FREE TEXT
INPUT TRANSFORM: K:$L(X)>60!($L(X)<1) X
LAST EDITED: AUG 02, 2010
HELP-PROMPT: Answer must be 1-60 characters in length.
DESCRIPTION:
This is a phone #/telephone extension or email address for the contact.
361.1,25.07 CONTACT TYPE 3 25;7 SET
'EM' FOR E-MAIL;
'FX' FOR FAX;
'TE' FOR TELEPHONE;
'EX' FOR TELEPHONE EXTENSION;
LAST EDITED: MAR 24, 2003
HELP-PROMPT: Enter the code for the type of contact information.
DESCRIPTION: This is the code that describes the type of contact information provided in the CONTACT NUMBER 3
field.
361.1,30.01 AUTO BILL MESSAGE 30;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200!($L(X)<2) X
LAST EDITED: MAY 15, 2003
HELP-PROMPT: Answer must be 2-200 characters in length
DESCRIPTION: This field contains reason messages or error messages that describe why this EOB record was not
automatically turned into a secondary or tertiary bill.
361.1,30.02 AUTO BILL MESSAGE DATE/TIME 30;2 DATE
INPUT TRANSFORM: S %DT="ESTX" D ^%DT S X=Y K:X<1 X
LAST EDITED: MAY 15, 2003
DESCRIPTION:
This is the date/time that the automatic bill generation failure message was filed.
361.1,61.01 ORIGINAL 06 RECORD DATA 6.1;E1,200 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200!($L(X)<1) X
LAST EDITED: JAN 17, 2008
HELP-PROMPT: Answer must be 1-200 characters in length
DESCRIPTION: This field contains the original "06" record type on the 835 transmission from Austin. It contains
the corrected patient name and/or the corrected patient ID directly from the payer.
361.1,62.01 MAILMAN HEADER INFORMATION 6.2;E1,200 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200!($L(X)<1) X
LAST EDITED: JAN 17, 2008
HELP-PROMPT: Answer must be 1-200 characters in length
DESCRIPTION:
This field contains MailMan header data which is returned from the MailMan utility $$NET^XMRENT.
361.1,100.01 BATCH NUMBER 100;1 POINTER TO EDI TRANSMISSION BATCH FILE (#364.1)
LAST EDITED: JUL 08, 1999
HELP-PROMPT: Enter the batch number the bill was in when the EOB was received
DESCRIPTION:
This is the number of the batch the bill was in when the EOB message was received.
361.1,100.02 RETURN MESSAGE ID 100;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<1) X
LAST EDITED: FEB 11, 1999
HELP-PROMPT: Answer must be 1-20 characters in length.
DESCRIPTION: This is the ID of the return message that this EOB was delivered in. It is used to ensure these
EOB messages don't get added to this file more than once.
CROSS-REFERENCE: 361.1^AC
1)= S ^IBM(361.1,"AC",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,"AC",$E(X,1,30),DA)
3)= Please do not delete
Used to assure messages only update this file once.
361.1,100.03 LAST EDITED BY 100;3 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: MAY 28, 1999
HELP-PROMPT: Enter the name of the person who last edited this EOB record.
DESCRIPTION:
This is the name of the person who last edited this EOB record.
NOTES: TRIGGERED by the REVIEW STATUS field of the EXPLANATION OF BENEFITS File
361.1,100.04 LAST EDITED DATE 100;4 DATE
INPUT TRANSFORM: S %DT="ETXR" D ^%DT S X=Y K:Y<1 X
LAST EDITED: MAY 28, 1999
HELP-PROMPT: Enter the last date/time this EOB record was edited.
DESCRIPTION:
This is the last date/time this EOB record was edited.
NOTES: TRIGGERED by the REVIEW STATUS field of the EXPLANATION OF BENEFITS File
361.1,100.05 MESSAGE CHECKSUM 100;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>10!($L(X)<1) X
LAST EDITED: MAY 08, 2003
HELP-PROMPT: Answer must be 1-10 characters in length.
DESCRIPTION: This field contains the calculated checksum value of the X12 835 transaction data from the payer.
It is a unique number which is mathematically generated based on the actual data in the 835 flat
file received from Austin.
This number will be used to identify and eliminate duplicate 835 transmissions into VistA.
TECHNICAL DESCR:
This field should not be set manually.
361.1,101 MOVE/COPY/REMOVE HISTORY 101;0 DATE Multiple #361.1101 (Add New Entry without Asking)
LAST EDITED: JAN 23, 2014
DESCRIPTION: This multiple contains a record for each time an EEOB is moved or copied. Removing an EEOB also
creates a record in this multiple.
TECHNICAL DESCR:
Updated from EEOB Move/Copy/Remove option and Worklist Split/Edit Line protocol.
INDEXED BY: DATE/TIME EEOB MOVED (AMCCF)
361.1101,.01 DATE/TIME EEOB MOVED 0;1 DATE (Required)
INPUT TRANSFORM: S %DT="ESTXR" D ^%DT S X=Y K:X<1 X
LAST EDITED: JUN 02, 2020
HELP-PROMPT: Enter date/time EEOB was moved or copied or removed.
DESCRIPTION:
This is the Date/Time the move, copy or remove action was performed.
CROSS-REFERENCE: 361.1101^B
1)= S ^IBM(361.1,DA(1),101,"B",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,DA(1),101,"B",$E(X,1,30),DA)
CROSS-REFERENCE: 361.1^AEOB
1)= S ^IBM(361.1,"AEOB",$E(X,1,30),DA(1),DA)=""
2)= K ^IBM(361.1,"AEOB",$E(X,1,30),DA(1),DA)
This cross reference is used by the RCDPE EEOB MOVE/COPY/RMOVE AUDIT RPT option.
FIELD INDEX: AMCCF (#309) MUMPS IR ACTION
Short Descr: Updates List of ERA level changes for MCCF Extract
Description: When any of the defined fields in this subfile are updated, search the ELECTRONIC REMITTANCE
ADVICE (#344.4) file for entries that contain pointers to the superfile (EXPLANATION OF BENEFITS
(#361.1)) entry. If found, update the MCCF DATE/TIME (#9) field for those entries to NOW.
Set Logic: D EOB^RCTAS10I(DA(1)) Q
Kill Logic: Q
X(1): DATE/TIME EEOB MOVED (361.1101,.01) (forwards)
NO RE-INDEXING ALLOWED!
361.1101,.02 EEOB MOVE/COPY/REMOVE BY 0;2 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: JAN 23, 2014
HELP-PROMPT: Select the person who moved, copied or removed the EEOB.
DESCRIPTION: This is person who moved or copied the EEOB to a new claim or removed EEOB from the current
claim.
361.1101,.03 MOVE/COPY/REMOVE REASON 0;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>100!($L(X)<1)!($TR(X," ","")="") X
LAST EDITED: JAN 23, 2014
HELP-PROMPT: Answer must be 1-100 characters in length.
DESCRIPTION:
Justification for moving EEOB to new claim or claims or removing EEOB from current claim.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
361.1101,.04 ORIGINAL BILL NUMBER 0;4 POINTER TO BILL/CLAIMS FILE (#399)
LAST EDITED: SEP 05, 2011
HELP-PROMPT: Enter original claim number for this EOB.
DESCRIPTION:
Original claim number for this EOB.
361.1101,.05 MOVE/COPY/REMOVE EVENT 0;5 SET
'M' FOR Move;
'C' FOR Copy;
'R' FOR Remove;
LAST EDITED: JAN 23, 2014
HELP-PROMPT: Indicate whether the EEOB was moved, copied or removed.
DESCRIPTION: This field indicates whether a move, copy or delete action was performed. It is automatically
updated by the EEOB Move/Copy/Remove option and the Split/Edit a Line option.
361.1101,.06 OTHER CLAIM NUMBERS 1;0 POINTER Multiple #361.11016 (Add New Entry without Asking)
DESCRIPTION:
This multiple contains the other claim numbers that the EOB was copied to.
361.11016,.01 OTHER CLAIM NUMBERS 0;1 POINTER TO BILL/CLAIMS FILE (#399) (Required)
LAST EDITED: SEP 05, 2011
HELP-PROMPT: Enter other claim number the EOB was copied to.
DESCRIPTION:
This is another claim number that the EOB was copied to.
CROSS-REFERENCE: 361.11016^B
1)= S ^IBM(361.1,DA(2),101,DA(1),1,"B",$E(X,1,30),DA)=""
2)= K ^IBM(361.1,DA(2),101,DA(1),1,"B",$E(X,1,30),DA)
361.1,102 EEOB REMOVED 102;1 SET
ELECTRONIC EXPLANATION OF BENEFITS REMOVED
'1' FOR REMOVED;
LAST EDITED: MAY 06, 2014
HELP-PROMPT: Enter 1 to indicate that the EEOB has been removed.
DESCRIPTION: This field indicates that the ELECTRONIC EXPLANATION OF BENEFITS (EEOB) detail on the record has
been filed against the wrong claim and should be ignored by all reporting options.
RECORD INDEXES: AMCCF (#308)
361.1,103 PLB DUPLICATE 102;2 SET
'1' FOR DUPLICATE;
LAST EDITED: APR 04, 2017
HELP-PROMPT: Enter 1 if the EOB is a duplicate from an ERA with a PLB adjustment
DESCRIPTION: This field indicates if the EOB is a potential duplicate. THe field is populated if an EOB on an
incoming ERA has the same checksum as an existing EOB and the ERA has a Payer Level Balance (PLB)
adjustment.
TECHNICAL DESCR: This field is used to suppress secondary claim generation if a duplicate EOB is the result of an
ERA with a Payer Level Balance (PLB) adjustment.
361.1,104 ERA DETAIL 102;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<4)!'(X?1N.N1","1N.N1",") X
MAXIMUM LENGTH: 20
LAST EDITED: FEB 06, 2019
HELP-PROMPT: Enter the ERA detail reference in the form nn,nnnnn,
DESCRIPTION: If the EOB was created from an electronic payment, the ERA DETAIL field will contain a reference to
the ERA detail line from which it was created. The ERA DETAIL field will remain the same through
moves and copies of the EOB providing a method of a linking the EOB back to the detail line that
created it.
TECHNICAL DESCR: This is a free text field linking EOB to the ERA detail line from which it was created. It has the
form "IEN34441,IEN3444," where IEN34441 is the internal entry number from sub-file 344.41 and
IEN3444 is the internal entry number from file 344.4. The field will be automatically populated by
the system.
FILES POINTED TO FIELDS
BILL/CLAIMS (#399) BILL (#.01)
MOVE/COPY/REMOVE HISTORY:ORIGINAL BILL NUMBER (#.04)
OTHER CLAIM NUMBERS:OTHER CLAIM NUMBERS (#.01)
AR AMOUNTS DISTRIBUTION:BILL REFERENCE (#.03)
EDI TRANSMISSION BATCH (#364.1) BATCH NUMBER (#100.01)
EDI TRANSMIT BILL (#364) TRANSMIT BILL (#.19)
INSURANCE COMPANY (#36) PAYER NAME (#.02)
NEW PERSON (#200) MANUALLY ENTERED BY (#.18)
LAST EDITED BY (#100.03)
MOVE/COPY/REMOVE HISTORY:EEOB MOVE/COPY/REMOVE BY (#.02)
REVIEW DATE/TIME:REVIEWED BY (#.02)
REVENUE CODE (#399.2) 835 LINE LEVEL ADJUSTMENTS:REVENUE CODE (#.1)
File #361.1
Record Indexes:
ABD (#131) RECORD REGULAR IR SORTING ONLY
Short Descr: This xref provides an index by bill # and EOB date
Set Logic: S ^IBM(361.1,"ABD",X2(1),X2(2),DA)=""
Set Cond: I X2(1)=""!(X2(2)="") S X=0
Kill Logic: K ^IBM(361.1,"ABD",X1(1),X1(2),DA)
Kill Cond: I X1(1)=""!(X1(2)="") S X=0
Whole Kill: K ^IBM(361.1,"ABD")
X(1): BILL (361.1,.01) (Subscr 1) (forwards)
X(2): EOB PAID DATE (361.1,.06) (Subscr 2) (forwards)
ABS (#132) RECORD REGULAR IR SORTING ONLY
Short Descr: Cross reference bill # and insurance company sequence.
Set Logic: S ^IBM(361.1,"ABS",X2(1),X2(2),DA)=""
Set Cond: I X2(1)=""!(X2(2)="") S X=0
Kill Logic: K ^IBM(361.1,"ABS",X1(1),X1(2),DA)
Kill Cond: I X1(1)=""!(X1(2)="") S X=0
Whole Kill: K ^IBM(361.1,"ABS")
X(1): BILL (361.1,.01) (Subscr 1) (forwards)
X(2): INSURANCE SEQUENCE (361.1,.15) (Subscr 2) (forwards)
AEDT (#988) RECORD REGULAR IR SORTING ONLY
Short Descr: EOB TYPE / DATE AND TIME
Description: Creates an index by EOB TYPE and DATE/TIME.
Set Logic: S ^IBM(361.1,"AEDT",X(1),X(2),DA)=""
Kill Logic: K ^IBM(361.1,"AEDT",X(1),X(2),DA)
Whole Kill: K ^IBM(361.1,"AEDT")
X(1): EOB TYPE (361.1,.04) (Subscr 1) (forwards)
X(2): ENTRY DATE/TIME (361.1,.05) (Subscr 2) (forwards)
AMCCF (#308) RECORD MUMPS IR ACTION
Short Descr: Updates List of ERA level changes for MCCF Extract
Description: When any of the defined fields are updated, search the ELECTRONIC REMITTANCE ADVICE (#344.4) file for entries
that contain pointers to this entry. If found, update the MCCF DATE/TIME (#9) field in those entries to NOW.
Set Logic: D EOB^RCTAS10I(DA) Q
Kill Logic: Q
X(1): BILL (361.1,.01) (forwards)
X(2): ENTRY DATE/TIME (361.1,.05) (forwards)
X(3): EEOB REMOVED (361.1,102) (forwards)
NO RE-INDEXING ALLOWED!
AMRA (#307) RECORD REGULAR IR SORTING ONLY
Short Descr: Index by EOB type and Review Status
Set Logic: S ^IBM(361.1,"AMRA",X(1),X(2),DA)=""
Kill Logic: K ^IBM(361.1,"AMRA",X(1),X(2),DA)
Whole Kill: K ^IBM(361.1,"AMRA")
X(1): EOB TYPE (361.1,.04) (Subscr 1) (forwards)
X(2): REVIEW STATUS (361.1,.16) (Subscr 2) (forwards)
ATIN (#184) RECORD REGULAR IR SORTING ONLY
Short Descr: Xref by date filed and transferred from
Set Logic: S ^IBM(361.1,"ATIN",X(1),$E(X(2),1,30),DA)=""
Kill Logic: K ^IBM(361.1,"ATIN",X(1),$E(X(2),1,30),DA)
Whole Kill: K ^IBM(361.1,"ATIN")
X(1): ENTRY DATE/TIME (361.1,.05) (Subscr 1) (forwards)
X(2): TRANSFERRED IN (361.1,7.01) (Subscr 2) (Len 30) (forwards)
ATRID (#297) RECORD REGULAR IR SORTING ONLY
Short Descr: Xref by bank trace # and ins co id for uniqueness
Set Logic: S ^IBM(361.1,"ATRID",$E(X(1),1,50),$E(X(2),1,30),DA)=""
Set Cond: S X='X(3)
Kill Logic: K ^IBM(361.1,"ATRID",$E(X(1),1,50),$E(X(2),1,30),DA)
Whole Kill: K ^IBM(361.1,"ATRID")
X(1): TRACE NUMBER (361.1,.07) (Subscr 1) (Len 50) (forwards)
X(2): PAYER ID (361.1,.03) (Subscr 2) (Len 30) (forwards)
X(3): EOB TYPE (361.1,.04) (forwards)
INPUT TEMPLATE(S):
PRINT TEMPLATE(S):
SORT TEMPLATE(S):
FORM(S)/BLOCK(S):