STANDARD DATA DICTIONARY #368 -- HEALTH CARE CLAIM RFAI (277) FILE 3/24/25 PAGE 1
STORED IN ^IBA(368, *** NO DATA STORED YET *** SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 2.0)
DATA NAME GLOBAL DATA
ELEMENT TITLE LOCATION TYPE
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This file contains all records received from the FSC ASC X12N health Care Claim Request For Additional Information (277) HL7
message.
DD ACCESS: @
RD ACCESS: @
WR ACCESS: @
DEL ACCESS: @
LAYGO ACCESS: @
AUDIT ACCESS: @
CROSS
REFERENCED BY: MESSAGE CONTROL ID(B), TRANSACTION DATE/TIME(C), PATIENT CONTROL NUMBER [D](D), DELETED FLAG(E)
LAST MODIFIED: SEP 2,2016@13:43:18
368,.01 MESSAGE CONTROL ID 0;1 FREE TEXT (Required)
INPUT TRANSFORM: K:$L(X)>20!($L(X)<3)!'(X'?1P.E) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 3-20 characters in length.
DESCRIPTION: This is the Message Control ID field received from the FSC ASC X12N health Care Claim Request For
Additional Information (277) message. The value is received via the MSH-10 segment of the 277 HL
message.
CROSS-REFERENCE: 368^B
1)= S ^IBA(368,"B",$E(X,1,30),DA)=""
2)= K ^IBA(368,"B",$E(X,1,30),DA)
368,.02 REQUEST DATE/TIME 0;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>24!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-24 characters in length.
DESCRIPTION: This is the Request Date/Time field received from the FSC ASC X12N health Care Claim Request For
Additional Information (277) message. The value is received via the RFI-1 segment of the 277 HL
message.
368,.03 TRANSACTION DATE/TIME 0;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>14!($L(X)<14) X
LAST EDITED: JAN 11, 2016
HELP-PROMPT: Answer must be 14 characters in length.
DESCRIPTION: This is the Transaction Date/Time field received from the FSC ASC X12N health Care Claim Request
For Additional Information (277) message. The value is received via the MSH-7 segment of the 277
HL message.
CROSS-REFERENCE: 368^C
1)= S ^IBA(368,"C",$E(X,1,30),DA)=""
2)= K ^IBA(368,"C",$E(X,1,30),DA)
This index will sort the data by the Transaction Date/Time field (#.03).
368,1.01 PAYER NAME 1;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>60!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-60 characters in length.
DESCRIPTION: This is the Payer Name field received from the FSC ASC X12N health Care Claim Request For
Additional Information (277) message. The value is received via the IVC-11.1 segment of the 277 HL
message.
368,1.02 PAYER IDENTIFIER 1;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>80!($L(X)<1) X
LAST EDITED: JUN 02, 2015
HELP-PROMPT: Answer must be 1-80 characters in length.
DESCRIPTION: This is the Payer Identifier field received from the FSC ASC X12N Health Care Claim Request For
Additional Information (277) message. The value is received via the IVC-11.3 segment of the 277
HL7 message.
368,1.03 PAYER CONTACT NAME 1;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>60!($L(X)<1) X
LAST EDITED: JUN 02, 2015
HELP-PROMPT: Answer must be 1-60 characters in length.
DESCRIPTION: This is the Payer Contact Name field received from the FSC ASC X12N Health Care Claim Request For
Additional Information (277) message. The value is received via the CTD-2.1 & CTD-2.2 segments of
the 277 HL7 message.
368,2.01 PAYER CONTACT COMM TYPE 1 2;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: MAR 02, 2016
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This is the Payer Contact Communication Type 1 field received from the FSC ASC X12N Health Care
Claim Request For Additional Information (277) message. The value is received via the CTD-5.1 &
5.2 segment of the 277 HL7 message.
368,2.02 PAYER CONTACT COMM TYPE 2 2;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: JUN 02, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This is the Payer Contact Communication Type 2 field received from the FSC ASC X12N Health Care
Claim Request For Additional Information (277) message. The value is received via the CTD-5.1 &
5.2 segments of the 277 HL7 message.
368,2.03 PAYER CONTACT COMM TYPE 3 2;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: JUN 02, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This is the Payer Contact Communication Type 3 field received from the FSC ASC X12N Health Care
Claim Request For Additional Information (277) message. The value is received via the CTD-5.1 &
5.2 segments of the 277 HL7 message.
368,3.01 PAYER CONTACT COMMUNICATION 1 3;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>250!($L(X)<1) X
LAST EDITED: JAN 14, 2016
HELP-PROMPT: Answer must be 1-250 characters in length.
DESCRIPTION: This is the Payer Contact Communication 1 field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the CTD-5.8 segment of
the 277 HL7 message.
368,4.01 PAYER CONTACT COMMUNICATION 2 4;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>250!($L(X)<1) X
LAST EDITED: JAN 14, 2016
HELP-PROMPT: Answer must be 1-250 characters in length.
DESCRIPTION: This is the Payer Contact Communication 2 field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the CTD-5.8 segment of
the 277 HL7 message.
368,5.01 PAYER CONTACT COMMUNICATION 3 5;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>250!($L(X)<1) X
LAST EDITED: JAN 14, 2016
HELP-PROMPT: Answer must be 1-250 characters in length.
DESCRIPTION: This is the Payer Contact Communication 3 field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the CTD-5.8 segments of
the 277 HL7 message.
368,6.01 INFORMATION RECEIVER NAME 6;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>120!($L(X)<1) X
LAST EDITED: JUN 02, 2015
HELP-PROMPT: Answer must be 1-120 characters in length.
DESCRIPTION: This is the Information Receiver Name field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the PYE-4.1, 5.1, 5.2,
5.3 & 5.4 segments of the 277 HL7 message.
368,6.02 INFORMATION RECEIVER ID 6;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>80!($L(X)<1) X
LAST EDITED: JUN 02, 2015
HELP-PROMPT: Answer must be 1-80 characters in length.
DESCRIPTION: This is the Information Receiver ID field received from the FSC ASC X12N Health Care Claim Request
For Additional Information (277) message. The value is received via the PYE-4 segment of the 277
HL7 message.
368,7.01 SERVICE PROVIDER NAME 7;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>130!($L(X)<1) X
LAST EDITED: JUN 02, 2015
HELP-PROMPT: Answer must be 1-130 characters in length.
DESCRIPTION: This is the Service Provider Name field received from the FSC ASC X12N Health Care Claim Request
For Additional Information (277) message. The value is received via the IVC-10.1 segment of the
277 HL7 message.
368,7.02 SERVICE PROV FED TAXPAYER CODE 7;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: JUN 02, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This is the Service Provider Federal Taxpayer Code field received from the FSC ASC X12N Health Care
Claim Request For Additional Information (277) message. The value is received via the IVC-26
segment of the 277 HL7 message.
368,8.01 SERVICE PROVIDER ID 8;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>80!($L(X)<1) X
LAST EDITED: JUN 02, 2015
HELP-PROMPT: Answer must be 1-80 characters in length.
DESCRIPTION: This is the Service Provider ID field received from the FSC ASC X12N Health Care Claim Request For
Additional Information (277) message. The value is received via the IVC-10.3 segment of the 277
HL7 message.
368,9.01 PATIENT NAME 9;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>130!($L(X)<1) X
LAST EDITED: JUN 02, 2015
HELP-PROMPT: Answer must be 1-130 characters in length.
DESCRIPTION: This is the Patient Name field received from the FSC ASC X12N Health Care Claim Request For
Additional Information (277) message. The value is received via the PID-5.1. 5.2, 5,3, 5,4 & 5.5
segments of the 277 HL7 message.
368,10.01 PATIENT PRIMARY IDENTIFIER 10;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>80!($L(X)<1) X
LAST EDITED: JUN 02, 2015
HELP-PROMPT: Answer must be 1-80 characters in length.
DESCRIPTION: This is the Patient Primary Identifier field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the PID-3.1 segment of
the 277 HL7 message.
368,11.01 PATIENT CONTROL NUMBER 11;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: JUN 03, 2015
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION: This is the Patient Control Number field received from the FSC ASC X12N Health Care Claim Request
For Additional Information (277) message. The value is received via the PID-3.1 segment of the 277
HL7 message.
368,11.02 PAYER CLAIM CONTROL NUMBER 11;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: JUN 03, 2015
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION: This is the Payer Claim Control Number field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the IVC-2 segment of
the 277 HL7 message.
368,11.03 MEDICAL RECORD NUMBER 11;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: JUN 03, 2015
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION: This is the Medical Record Number field received from the FSC ASC X12N Health Care Claim Request
For Additional Information (277) message. The value is received via the PID-3.1 segment of the 277
HL7 message.
368,11.04 CLEARINGHOUSE TRACE NUMBER 11;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION: This is the Clearinghouse Trace Number field received from the FSC ASC X12N health Care Claim
Request For Additional Information (277) message. The value is received via the IVC-3.1 segment of
the 277 HL message.
368,12.01 RESPONSE DUE DATE 12;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>35!($L(X)<1) X
LAST EDITED: JUN 03, 2015
HELP-PROMPT: Answer must be 1-35 characters in length.
DESCRIPTION: This is the Response Due Date field received from the FSC ASC X12N Health Care Claim Request For
Additional Information (277) message. The value is received via the RFI-2 segment of the 277 HL7
message.
368,12.02 REPORT TRANSMISSION CODE 12;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION:
This field will contain the Report Transmission Code.
368,13 STC SEQ 13;0 Multiple #368.013
LAST EDITED: OCT 16, 2015
DESCRIPTION: This multiple will contain Claim Level Status Information from the STC segment received from the
FSC ASC X12N health Care Claim Request For Additional Information (277) HL7 message.
368.013,.01 STC SEQ 0;1 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9999999999)!(X<1)!(X?.E1"."1.N) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Type a number between 1 and 9999999999, 0 decimal digits.
DESCRIPTION:
This field will contain the sequence number for the STC SEQ multiple field.
CROSS-REFERENCE: 368.013^B
1)= S ^IBA(368,DA(1),13,"B",$E(X,1,30),DA)=""
2)= K ^IBA(368,DA(1),13,"B",$E(X,1,30),DA)
368.013,.02 STATUS INFO EFFECTIVE DATE 0;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>8!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-8 characters in length.
DESCRIPTION: This is the Status Information Effective Date field received from the FSC ASC X12N health Care
Claim Request For Additional Information (277) message. The value is received via the OBX-14
segment of the 277 HL message.
368.013,1.01 HEALTH CARE CLAIM STATUS CAT 1;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION: This is the Health Care Claim Status Category Code field received from the FSC ASC X12N health
Care Claim Request For Additional Information (277) message. The value is received via the
OBX-3.4 segment of the 277 HL message.
368.013,1.02 ADDTL INFO REQUEST MOD 1;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION: This is the Additional Information Request Modifier field received from the FSC ASC X12N health
Care Claim Request For Additional Information (277) message. The value is received via the
OBX-3.1 segment of the 277 HL message.
368.013,1.04 CODE LIST QUALIFIER CODE 1;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This is the Code List Qualifier Code field received from the FSC ASC X12N health Care Claim
Request For Additional Information (277) message. The value is received via the OBX-3.3 segment
of the 277 HL message.
368.013,10.01 HEALTH CARE CLAIM STATUS CAT 10;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION: This is the Health Care Claim Status Category Code field received from the FSC ASC X12N health
Care Claim Request For Additional Information (277) message. The value is received via the
OBX-3.4 segment of the 277 HL message.
368.013,10.02 ADDTL INFO REQUEST MOD 10;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION: This is the Additional Information Request Modifier field received from the FSC ASC X12N health
Care Claim Request For Additional Information (277) message. The value is received via the
OBX-3.1 segment of the 277 HL message.
368.013,10.04 CODE LIST QUALIFIER CODE 10;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This is the Code List Qualifier Code field received from the FSC ASC X12N health Care Claim
Request For Additional Information (277) message. The value is received via the OBX-3.3 segment
of the 277 HL message.
368.013,11.01 HEALTH CARE CLAIM STATUS CAT 11;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION: This is the Health Care Claim Status Category Code field received from the FSC ASC X12N health
Care Claim Request For Additional Information (277) message. The value is received via the
OBX-3.4 segment of the 277 HL message.
368.013,11.02 ADDTL INFO REQUEST MOD 11;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION: This is the Additional Information Request Modifier field received from the FSC ASC X12N health
Care Claim Request For Additional Information (277) message. The value is received via the
OBX-3.1 segment of the 277 HL message.
368.013,11.04 CODE LIST QUALIFIER CODE 11;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This is the Code List Qualifier Code field received from the FSC ASC X12N health Care Claim
Request For Additional Information (277) message. The value is received via the OBX-3.3 segment
of the 277 HL message.
368,14.03 CLAIM SERVICE START DATE 14;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>8!($L(X)<8) X
LAST EDITED: JAN 15, 2016
HELP-PROMPT: Answer must be 8 characters in length.
DESCRIPTION:
This is the CLAIM SERVICE START DATE which is the first date from the CLAIM SERVICE PERIOD.
368,14.04 CLAIM SERVICE END DATE 14;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>8!($L(X)<8) X
LAST EDITED: JAN 15, 2016
HELP-PROMPT: Answer must be 8 characters in length.
DESCRIPTION:
This is the CLAIM SERVICE END DATE which is the last date from the CLAIM SERVICE PERIOD.
368,14.05 CLAIM SERVICE PERIOD 14;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>35!($L(X)<1) X
LAST EDITED: OCT 20, 2015
HELP-PROMPT: Answer must be 1-35 characters in length.
DESCRIPTION: This is the Claim Status Period field received from the FSC ASC X12N Health Care Claim Request For
Additional Information (277) message. The value is received via the IVC-7 segment of the 277 HL7
message.
368,15.01 PAYER RESPONSE CONTACT NAME 15;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>60!($L(X)<1) X
LAST EDITED: JUN 04, 2015
HELP-PROMPT: Answer must be 1-60 characters in length.
DESCRIPTION: This is the Payer Response Contact Name field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the CTD-2.1 & 2.2
segments of the 277 HL7 message.
368,16.01 PAYER RESP CONTACT COMM TYPE 1 16;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: JUN 04, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This is the Payer Response Contact Communication Type 1 field received from the FSC ASC X12N Health
Care Claim Request For Additional Information (277) message. The value is received via the CTD-5.1
& 5.2 segments of the 277 HL7 message.
368,16.02 PAYER RESP CONTACT COMM TYPE 2 16;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: JUN 04, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This is the Payer Response Contact Communication Type 2 field received from the FSC ASC X12N Health
Care Claim Request For Additional Information (277) message. The value is received via the CTD-5.1
& 5.2 segments of the 277 HL7 message.
368,16.03 PAYER RESP CONTACT COMM TYPE 3 16;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: JUN 04, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This is the Payer Response Contact Communication Type 3 field received from the FSC ASC X12N Health
Care Claim Request For Additional Information (277) message. The value is received via the CTD-5.1
& 5.2 segments of the 277 HL7 message.
368,17.01 PAYER RESPONSE CONTACT COMM 1 17;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>250!($L(X)<1) X
LAST EDITED: JAN 14, 2016
HELP-PROMPT: Answer must be 1-250 characters in length.
DESCRIPTION: This is the Payer Response Contact Communication 1 field received from the FSC ASC X12N Health Care
Claim Request For Additional Information (277) message. The value is received via the CTD-5.8
segment of the 277 HL7 message.
368,18.01 PAYER RESPONSE CONTACT COMM 2 18;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>250!($L(X)<1) X
LAST EDITED: JAN 14, 2016
HELP-PROMPT: Answer must be 1-250 characters in length.
DESCRIPTION: This is the Payer Response Contact Communication 2 field received from the FSC ASC X12N Health Care
Claim Request For Additional Information (277) message. The value is received via the CTD-5.8
segment of the 277 HL7 message.
368,19.01 PAYER RESPONSE CONTACT COMM 3 19;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>250!($L(X)<1) X
LAST EDITED: JAN 14, 2016
HELP-PROMPT: Answer must be 1-250 characters in length.
DESCRIPTION: This is the Payer Response Contact Communication 3 field received from the FSC ASC X12N Health Care
Claim Request For Additional Information (277) message. The value is received via the CTD-5.8
segment of the 277 HL7 message.
368,20.01 PAYER RESP CONTACT ADDR LINE 1 20;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>55!($L(X)<1) X
LAST EDITED: JUN 04, 2015
HELP-PROMPT: Answer must be 1-55 characters in length.
DESCRIPTION: This is the Payer Response Contact Address Line 1 field received from the FSC ASC X12N Health Care
Claim Request For Additional Information (277) message. The value is received via the CTD-3.1
segment of the 277 HL7 message.
368,20.02 PAYER RESP CONTACT ADDR LINE 2 20;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>55!($L(X)<1) X
LAST EDITED: JUN 04, 2015
HELP-PROMPT: Answer must be 1-55 characters in length.
DESCRIPTION: This is the Payer Response Contact Address Line 2 field received from the FSC ASC X12N Health Care
Claim Request For Additional Information (277) message. The value is received via the CTD-3.2
segment of the 277 HL7 message.
368,20.03 PAYER RESP CONTACT CITY 20;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: JUN 04, 2015
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION: This is the Payer Response Contact City field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the CTD-3.3 segment of
the 277 HL7 message.
368,20.04 PAYER RESP CONTACT STATE 20;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: JUN 04, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This is the Payer Response Contact State field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the CTD-3.4 segment of
the 277 HL7 message.
368,20.05 PAYER RESP CONTACT ZIP CODE 20;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>15!($L(X)<1) X
LAST EDITED: JUN 04, 2015
HELP-PROMPT: Answer must be 1-15 characters in length.
DESCRIPTION: This is the Payer Response Contact Zip Code field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the CTD-3.5 segment of
the 277 HL7 message.
368,20.06 PAYER RESP CONTACT COUNTRY 20;6 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: JUN 04, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This is the Payer Response Contact Country field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the CTD-3.6 segment of
the 277 HL7 message.
368,20.07 PAYER RESP CONT CNTRY SUBDIV 20;7 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This is the Payer Response Contact Country Subdivision field received from the FSC ASC X12N Health
Care Claim Request For Additional Information (277) message. The value is received via the CTD-3.8
segment of the 277 HL7 message.
368,21 STC-SVC LINE STAT INFO SEQ 21;0 Multiple #368.021
DESCRIPTION: This multiple field will contain Service Line Status Information received from the FSC ASC X12N
HEALTH Care Claim Request For Additional Information (277) HL message.
368.021,.01 STC-SVC LINE STAT INFO SEQ 0;1 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9999999999)!(X<1)!(X?.E1"."1.N) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Type a number between 1 and 9999999999, 0 decimal digits.
DESCRIPTION:
This field will contain the sequence number for the STC-SVC Line Stat Info Seq multiple field.
CROSS-REFERENCE: 368.021^B
1)= S ^IBA(368,DA(1),21,"B",$E(X,1,30),DA)=""
2)= K ^IBA(368,DA(1),21,"B",$E(X,1,30),DA)
368.021,.02 PRODUCT/SERVICE ID QUALIFIER 0;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This is the Product/Service ID Qualifier field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the PSL-6.1 segment
of the 277 HL7 message.
368.021,.03 SERVICE IDENTIFICATION CODE 0;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>48!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-48 characters in length.
DESCRIPTION: This is the Service Identification Code field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the PSL-7.1 segment
of the 277 HL7 message.
368.021,.04 PROCEDURE MODIFIER 1 0;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This is the Procedure Modifier field received from the FSC ASC X12N Health Care Claim Request For
Additional Information (277) message. The value is received via the PSL-8.1 segment of the 277
HL7 message.
368.021,.05 PROCEDURE MODIFIER 2 0;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This is the Procedure Modifier field received from the FSC ASC X12N Health Care Claim Request For
Additional Information (277) message. The value is received via the PSL-8.1 segment of the 277
HL7 message.
368.021,.06 PROCEDURE MODIFIER 3 0;6 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This is the Procedure Modifier field received from the FSC ASC X12N Health Care Claim Request For
Additional Information (277) message. The value is received via the PSL-8.1 segment of the 277
HL7 message.
368.021,.07 PROCEDURE MODIFIER 4 0;7 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This is the Procedure Modifier field received from the FSC ASC X12N Health Care Claim Request For
Additional Information (277) message. The value is received via the PSL-8.1 segment of the 277
HL7 message.
368.021,.08 LINE ITEM CHARGE AMOUNT 0;8 FREE TEXT
INPUT TRANSFORM: K:$L(X)>18!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-18 characters in length.
DESCRIPTION: This is the Line Item Charge Amount field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the PSL-16.1.1
segment of the 277 HL7 message.
368.021,.09 REVENUE CODE 0;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>48!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-48 characters in length.
DESCRIPTION: This is the Revenue Code field received from the FSC ASC X12N Health Care Claim Request For
Additional Information (277) message. The value is received via the PSL-22.1 segment of the 277
HL7 message.
368.021,.1 LINE ITEM CONTROL NUMBER 0;10 FREE TEXT
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION: This is the Line Item Control Number field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the PSL 1.1 segment
of the 277 HL7 message.
368.021,.11 SERVICE LINE DATE 0;11 FREE TEXT
INPUT TRANSFORM: K:$L(X)>35!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-35 characters in length.
DESCRIPTION: This is the Service Line Date field received from the FSC ASC X12N Health Care Claim Request For
Additional Information (277) message. The value is received via the PSL 26.1 segment of the 277
HL7 message.
368.021,1.01 SERVICE LINE REF ID QUALIFIER 1;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This field will contain the Service Line Reference ID Qualifier received from the FSC ASC X12N
health Care Claim Request For Additional Information (277) HL7 message.
368.021,99 STC SEQ-SERVICE LINE 99;0 Multiple #368.2199
DESCRIPTION: This multiple field will contain Service Line Status Information received from the FSC ASC X12N
HEALTH Care Claim Request For Additional Information (277) HL message.
368.2199,.01 STC SEQ-SERVICE LINE 0;1 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9999999999)!(X<1)!(X?.E1"."1.N) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Type a number between 1 and 9999999999, 0 decimal digits.
DESCRIPTION:
This field will contain the sequence number for the STC SEQ-Service Line multiple field.
CROSS-REFERENCE: 368.2199^B
1)= S ^IBA(368,DA(2),21,DA(1),99,"B",$E(X,1,30),DA)=""
2)= K ^IBA(368,DA(2),21,DA(1),99,"B",$E(X,1,30),DA)
368.2199,.02 STATUS INFO EFFECTIVE DATE 0;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>8!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-8 characters in length.
DESCRIPTION: This is the Status Information Effective Date field received from the FSC ASC X12N Health Care
Claim Request For Additional Information (277) message. The value is received via the PSL-10
segment of the 277 HL7 message.
368.2199,1.01 HEALTH CARE CLAIM STATUS CAT 1;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION: This is the Health Care Claim Status Category field received from the FSC ASC X12N Health Care
Claim Request For Additional Information (277) message. The value is received via the PSL-20
segment of the 277 HL7 message.
368.2199,1.02 ADDTL INFO REQUEST MOD 1;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION: This is the Additional Information Request Modifier field received from the FSC ASC X12N Health
Care Claim Request For Additional Information (277) message. The value is received via the
PSL-18 segment of the 277 HL7 message.
368.2199,1.04 CODE LIST QUALIFIER CODE 1;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This is the Code List Qualifier Code field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the PSL-17 segment
of the 277 HL7 message.
368.2199,10.01 HEALTH CARE CLAIM STATUS CAT 10;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION: This is the Health Care Claim Status Category field received from the FSC ASC X12N Health Care
Claim Request For Additional Information (277) message. The value is received via the PSL-20
segment of the 277 HL7 message.
368.2199,10.02 ADDTL INFO REQUEST MOD 10;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION: This is the Additional Information Request Modifier field received from the FSC ASC X12N
Health Care Claim Request For Additional Information (277) message. The value is received via
the PSL-18 segment of the 277 HL7 message.
368.2199,10.04 CODE LIST QUALIFIER CODE 10;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This is the Code List Qualifier Code field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the PSL-17 segment
of the 277 HL7 message.
368.2199,11.01 HEALTH CARE CLAIM STATUS CAT 11;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION: This is the Health Care Claim Status Category field received from the FSC ASC X12N Health Care
Claim Request For Additional Information (277) message. The value is received via the PSL-20
segment of the 277 HL7 message.
368.2199,11.02 ADDTL INFO REQUEST MOD 11;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION: This is the Additional Information Request Modifier field received from the FSC ASC X12N
Health Care Claim Request For Additional Information (277) message. The value is received via
the PSL-18 segment of the 277 HL7 message.
368.2199,11.04 CODE LIST QUALIFIER CODE 11;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This is the Code List Qualifier Code field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the PSL-17 segment
of the 277 HL7 message.
368,22.03 PRIMARY LOINC 22;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: NOV 23, 2015
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION: This is the Primary LYNC field received from the FSC ASC X12N Health Care Claim Request for
Additional Information (277) message. The value will be populated with the LOINC code from the
claim level if available, otherwise the LOINC code from the line level.
368,25.01 REFERENCE ID-INST TYPE OF BILL 25;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION: This is the Reference ID-Institutional Type of Bill field received from the FSC ASC X12N Health
Care Claim Request For Additional Information (277) message. The value is received via the
IVC-20.1 segment of the 277 HL7 message.
368,26.01 PAYER CONTACT COMM 1 EXTENSION 26;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>250!($L(X)<1) X
LAST EDITED: JAN 14, 2016
HELP-PROMPT: Answer must be 1-250 characters in length.
DESCRIPTION: This is the Payer Contact Communication 1 Extension field received from the FSC ASC X12N Health
Care Claim Request For Additional Information (277) message. The value is received via the CTD-5.7
segment of the 277 HL7 message.
368,27.01 PAYER CONTACT COMM 2 EXTENSION 27;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>250!($L(X)<1) X
LAST EDITED: JAN 14, 2016
HELP-PROMPT: Answer must be 1-250 characters in length.
DESCRIPTION: This is the Payer Contact Communication 2 Extension field received from the FSC ASC X12N Health
Care Claim Request For Additional Information (277) message. The value is received via the CTD-5.7
segment of the 277 HL7 message.
368,28.01 PAYER CONTACT COMM 3 EXTENSION 28;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>250!($L(X)<1) X
LAST EDITED: JAN 14, 2016
HELP-PROMPT: Answer must be 1-250 characters in length.
DESCRIPTION: This is the Payer Contact Communication 3 Extension field received from the FSC ASC X12N Health
Care Claim Request For Additional Information (277) message. The value is received via the CTD-5.7
segment of the 277 HL7 message.
368,29.01 PAYER RESP CONTACT COMM 1 EXT 29;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>250!($L(X)<1) X
LAST EDITED: JAN 14, 2016
HELP-PROMPT: Answer must be 1-250 characters in length.
DESCRIPTION: This is the Payer Response Contact Communication 1 Extension field received from the FSC ASC X12N
Health Care Claim Request For Additional Information (277) message. The value is received via the
CTD-5.8 segment of the 277 HL7 message.
368,30.01 PAYER RESP CONTACT COMM 2 EXT 30;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>250!($L(X)<1) X
LAST EDITED: JAN 14, 2016
HELP-PROMPT: Answer must be 1-250 characters in length.
DESCRIPTION: This is the Payer Response Contact Communication 2 Extension field received from the FSC ASC X12N
Health Care Claim Request For Additional Information (277) message. The value is received via the
CTD-5.8 segment of the 277 HL7 message.
368,31.01 PAYER RESP CONTACT COMM 3 EXT 31;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>250!($L(X)<1) X
LAST EDITED: JAN 14, 2016
HELP-PROMPT: Answer must be 1-250 characters in length.
DESCRIPTION: This is the Payer Response Contact Communication 3 Extension field received from the FSC ASC X12N
Health Care Claim Request For Additional Information (277) message. The value is received via the
CTD-5.8 segment of the 277 HL7 message.
368,80.01 PAYER ENTITY IDENTIFIER CODE 80;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This is the Payer Entity Identifier Code field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the IVC-11.10 segment
of the 277 HL7 message.
368,80.02 PAYER ENTITY TYPE QUALIFIER 80;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>1!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1 character in length.
DESCRIPTION: This is the Payer Entity Type Qualifier field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the IVC-11.2 segment
of the 277 HL7 message.
368,80.03 PAYER ID CODE QUALIFIER 80;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This is the Payer ID Code Qualifier field received from the FSC ASC X12N Health Care Claim Request
For Additional Information (277) message. The value is received via the IVC-11.7 segment of the
277 HL7 message.
368,80.04 PAYER CONTACT FUNCTION CODE 80;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This is the Payer Contact Function Code field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the CTD-2 segment of
the 277 HL7 message.
368,80.05 INFORMATION RECEIVER ENTITY ID 80;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This is the Payer Contact Function Code field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the PYE-2 segment of
the 277 HL7 message.
368,80.06 INFO RECEIVER ENTITY TYPE 80;6 FREE TEXT
INPUT TRANSFORM: K:$L(X)>1!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1 character in length.
DESCRIPTION: This field will contain the Information Receiver Entity Type field received from the FSC ASC X12N
health Care Claim Request For Additional Information (277) HL7 message
368,80.07 INFO RECEIVER ID QUALIFIER 80;7 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This is the Information Receiver ID Qualifier field received from the FSC ASC X12N Health Care
Claim Request For Additional Information (277) message. The value is received via the PYE-4.7
segment of the 277 HL7 message.
368,80.08 SERVICE PROV ENTITY ID CODE 80;8 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This field will contain the Service Provider Entity ID Code received from the FSC ASC X12N health
Care Claim Request For Additional Information (277) HL7 message.
368,80.09 SERVICE PROV ENTITY TYPE QUAL 80;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: JAN 14, 2016
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This is the Service Provider Entity Type Qualifier field received from the FSC ASC X12N Health Care
Claim Request For Additional Information (277) message. The value is received via the IVC-10.2
segment of the 277 HL7 message.
368,80.1 SERVICE PROVIDER ID QUALIFIER 80;10 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This is the Service Provider ID Qualifier field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the IVC-28 segment of
the 277 HL7 message.
368,80.11 PATIENT ENTITY IDENTIFIER CODE 80;11 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This field will contain the Patient Entity Identifier Code received from the FSC ASC X12N health
Care Claim Request For Additional Information (277) HL7 message.
368,80.12 PATIENT ENTITY TYPE QUALIFIER 80;12 FREE TEXT
INPUT TRANSFORM: K:$L(X)>1!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1 character in length.
DESCRIPTION: This field will contain the Patient Entity Type Qualifier received from the FSC ASC X12N health
Care Claim Request For Additional Information (277) HL7 message.
368,80.13 PATIENT ID CODE QUALIFIER 80;13 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This field will contain the Patient ID Code Qualifier received from the FSC ASC X12N health Care
Claim Request For Additional Information (277) HL7 message.
368,80.14 PAYER CLAIM TRACE TYPE CODE 80;14 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This is the Payer Claim Trace Type Code field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the IVC-2.4 segment of
the 277 HL7 message.
368,80.18 REFERENCE ID QUALIFIER-PT CRTL 80;18 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: NOV 09, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This is the Reference ID Qualifier-Patient Control field received from the FSC ASC X12N Health Care
Claim Request For Additional Information (277) message. The value is received via the IVC-1.4
segment of the 277 HL7 message.
368,80.19 REFERENCE ID QUALIFIER-INST 80;19 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This is the Reference ID Qualifier-Institution field received from the FSC ASC X12N Health Care
Claim Request For Additional Information (277) message. The value is received via the IVC-20.5
segment of the 277 HL7 message.
368,80.2 REFERENCE ID QUALIFIER-MRN 80;20 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This field will contain the Reference ID Qualifier - MRN received from the FSC ASC X12N health Care
Claim Request For Additional Information (277) HL7 message.
368,80.21 REFERENCE ID QUALIFIER-CTN 80;21 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: NOV 10, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This is the Reference ID Qualifier-CTN field received from the FSC ASC X12N Health Care Claim
Request For Additional Information (277) message. The value is received via the IVC-3.4 segment of
the 277 HL7 message.
368,80.22 CLAIM SERVICE DT/TM QUALIFIER 80;22 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This field will contain the Claim Service Date/Time Qualifier received from the FSC ASC X12N health
Care Claim Request For Additional Information (277) HL7 message.
368,80.23 CLAIM SERV DT/TM PERIOD QUAL 80;23 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This field will contain the Claim Service Date/Time Period Qualifier received from the FSC ASC X12N
health Care Claim Request For Additional Information (277) HL7 message.
368,80.24 RESPONSE DUE DT/TM QUALIFIER 80;24 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This field will contain the Response Due Date/Time Qualifier received from the FSC ASC X12N health
Care Claim Request For Additional Information (277) HL7 message.
368,80.25 RESPONSE DUE DT/TM PERIOD QUAL 80;25 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This field will contain the Response Due Date/Time Period Qualifier received from the FSC ASC X12N
health Care Claim Request For Additional Information (277) HL7 message.
368,80.26 CLAIM SUPP INFO REPORT TYPE 80;26 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This is the Claim Supplemental Information Report Type field received from the FSC ASC X12N Health
Care Claim Request For Additional Information (277) message. The value is received via the IVC-5
segment of the 277 HL7 message.
368,80.27 PAYER RESP CONTACT FUNC CODE 80;27 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: NOV 10, 2015
HELP-PROMPT: Answer must be 1-2 characters in length.
DESCRIPTION: This is the Payer Response Contact Function Code field received from the FSC ASC X12N Health Care
Claim Request For Additional Information (277) message. The value is received via the CTD-2
segment of the 277 HL7 message.
368,80.29 SERVICE LINE DT/TM QUALIFIER 80;29 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This field will contain the Service Line Date/Time Qualifier field received from the FSC ASC X12N
health Care Claim Request For Additional Information (277) HL7 message.
368,80.3 SERVICE LINE DT/TM PERIOD QUAL 80;30 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This field will contain the Service Line Date/Time Period Qualifier field received from the FSC ASC
X12N health Care Claim Request For Additional Information (277) HL7 message.
368,100.02 REQUEST DATE/TIME [D] 100;2 DATE
INPUT TRANSFORM: S %DT="ETXR" D ^%DT S X=Y K:X<1 X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Enter the Request Date/Time.
DESCRIPTION:
This field is derived from the REQUEST DATE/TIME field (#.02).
368,100.03 MESSAGE DATE/TIME [D] 100;3 DATE
INPUT TRANSFORM: S %DT="ETXR" D ^%DT S X=Y K:X<1 X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Enter the Message Date/Time.
DESCRIPTION:
This field is derived from the MESSAGE DATE/TIME field (#.03).
368,101.01 PAYER NAME [D] 101;1 POINTER TO INSURANCE COMPANY FILE (#36)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the entries available.
DESCRIPTION:
This field is derived from the PAYER NAME field (#1.01).
368,102.01 PAYER CONTACT COMM TYPE 1 [D] 102;1 POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the entries available.
DESCRIPTION:
This field is derived from the PAYER CONTACT COMMUNICATION TYPE 1 field (#2.01).
368,102.02 PAYER CONTACT COMM TYPE 2 [D] 102;2 POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021)
LAST EDITED: NOV 23, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION:
This field is derived from the PAYER CONTACT COMMUNICATION TYPE 2 field (#2.02).
368,102.03 PAYER CONTACT COMM TYPE 3 [D] 102;3 POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021)
LAST EDITED: NOV 23, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION: This field is derived from the PAYER CONTACT COMMUNICATION TYPE 3 field (#2.03).
368,109.01 PATIENT NAME [D] 109;1 POINTER TO PATIENT FILE (#2)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION:
This field is derived from the PATIENT NAME field (#9.01).
368,111.01 PATIENT CONTROL NUMBER [D] 111;1 POINTER TO BILL/CLAIMS FILE (#399)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION:
This field is derived from the PATIENT CONTROL NUMBER field (#11.01).
CROSS-REFERENCE: 368^D
1)= S ^IBA(368,"D",$E(X,1,30),DA)=""
2)= K ^IBA(368,"D",$E(X,1,30),DA)
368,112.01 RESPONSE DUE DATE [D] 112;1 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:X<1 X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Enter the Response Due Date.
DESCRIPTION:
This field is derived from the RESPONSE DUE DATE field (#12.01).
368,113 STC SEQ [D] 113;0 Multiple #368.0113 (Add New Entry without Asking)
DESCRIPTION: This field will contain the STC SEQ field received from the FSC ASC X12N health Care Claim Request
For Additional Information (277) HL7 message.
368.0113,.01 STC SEQ [D] 0;1 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9999999999)!(X<1)!(X?.E1"."1.N) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Type a number between 1 and 9999999999, 0 decimal digits.
DESCRIPTION: This field will contain the STC SEQ field received from the FSC ASC X12N health Care Claim
Request For Additional Information (277) HL7 message.
CROSS-REFERENCE: 368.0113^B
1)= S ^IBA(368,DA(1),113,"B",$E(X,1,30),DA)=""
2)= K ^IBA(368,DA(1),113,"B",$E(X,1,30),DA)
368.0113,.02 STATUS INFO EFFECTIVE DATE [D] 0;2 DATE
INPUT TRANSFORM: S %DT="ESTX" D ^%DT S X=Y K:X<1 X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Enter the Status Information Effective Date.
DESCRIPTION: This field is derived from the STATUS INFORMATION EFFECTIVE DATE field (#.02) within the STC SEQ
multiple field (#13).
368.0113,1.01 HEALTH CARE CLAIM STAT CAT-1 1;1 POINTER TO X12 277 CLAIM STATUS CATEGORY FILE (#368.001)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION: This field is derived from the HEALTH CARE CLAIM STATUS CATEGORY field (#1.01) within the STC SEQ
multiple field (#13).
368.0113,10.01 HEALTH CARE CLAIM STAT CAT-10 10;1 POINTER TO X12 277 CLAIM STATUS CATEGORY FILE (#368.001)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION: This field is derived from the HEALTH CARE CLAIM STATUS CATEGORY field (#10.01) within the STC
SEQ multiple field (#13).
368.0113,11.01 HEALTH CARE CLAIM STAT CAT-11 11;1 POINTER TO X12 277 CLAIM STATUS CATEGORY FILE (#368.001)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION: This field is derived from the HEALTH CARE CLAIM STATUS CATEGORY field (#11.01) within the STC
SEQ multiple field (#13).
368,114.03 CLAIM SERVICE START DATE [D] 114;3 DATE
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:X<1 X
LAST EDITED: JUN 01, 2016
HELP-PROMPT: Enter the Claim Service Start Date
DESCRIPTION:
This is the CLAIM SERVICE START DATE which is the first date from the CLAIM SERVICE PERIOD.
368,114.04 CLAIM SERVICE END DATE [D] 114;4 DATE
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:X<1 X
LAST EDITED: JUN 01, 2016
HELP-PROMPT: Enter the Claim Service End Date
DESCRIPTION:
This is the CLAIM SERVICE END DATE which is the last date from the CLAIM SERVICE PERIOD.
368,116.01 PAYER RESP CONT COM TYPE 1 [D] 116;1 POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION:
This field is derived from the PAYER RESP CONTACT COMM TYPE 1 field (#16.01).
368,116.02 PAYER RESP CONT COM TYPE 2 [D] 116;2 POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION:
This field is derived from the PAYER RESP CONTACT COMM TYPE 2 field (#16.02).
368,116.03 PAYER RESP CONT COM TYPE 3 [D] 116;3 POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION:
This field is derived from the PAYER RESP CONTACT COMM TYPE 3 field (#16.03).
368,120.04 PAYER RESP CONTACT ADDR ST [D] 120;4 POINTER TO STATE FILE (#5)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION:
This field is derived from the PAYER RESPONSE CONTACT ADDRESS STREET field (#20.04).
368,120.05 PAYER RESP CONT POSTAL/ZIP [D] 120;5 POINTER TO ZIP CODE FILE (#5.11)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION:
This field is derived from the PAYER RESPONSE CONTACT POSTAL/ZIP field (#20.05).
368,120.06 PAYER RESP CONTACT COUNTRY [D] 120;6 POINTER TO COUNTRY CODE FILE (#779.004)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION:
This field is derived from the PAYER RESPONSE CONTACT COUNTRY field (#20.06).
368,121 STC-SVC LINE STAT INFO SEQ [D] 121;0 Multiple #368.0121 (Add New Entry without Asking)
DESCRIPTION: This field will contain the STC-SVC Line Status Information Seq field received from the FSC ASC
X12N health Care Claim Request For Additional Information (277) HL7 message.
368.0121,.01 STC-SVC LINE STAT INFO SEQ [D] 0;1 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9999999999)!(X<1)!(X?.E1"."1.N) X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Type a number between 1 and 9999999999, 0 decimal digits.
DESCRIPTION: This field will contain the STC-SVC Line Status Information Seq field received from the FSC ASC
X12N health Care Claim Request For Additional Information (277) HL7 message.
CROSS-REFERENCE: 368.0121^B
1)= S ^IBA(368,DA(1),121,"B",$E(X,1,30),DA)=""
2)= K ^IBA(368,DA(1),121,"B",$E(X,1,30),DA)
368.0121,.02 PRODUCT/SERVICE ID QUAL [D] 0;2 POINTER TO X12 277 PRODUCT OR SERVICE ID QUAL FILE (#368.002)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION: This field is derived from the PRODUCT/SERVICE ID QUALIFIER field (#.02) within the STC-SVC LINE
STAT INFO SEQ multiple field (#21).
368.0121,.03 SERVICE IDENTIFICATION CODE 0;3 VARIABLE POINTER
FILE ORDER PREFIX LAYGO MESSAGE
399.2 1 R n Revenue Code
81 2 C n CPT codes
50.67 3 N n NDC Codes
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION: This field is derived from the SERVICE IDENTIFICATION CODE field (#.03) within the STC-SVC LINE
STAT INFO SEQ multiple field (#21).
368.0121,.04 PROCEDURE MODIFIER 1 [D] 0;4 POINTER TO CPT MODIFIER FILE (#81.3)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION: This field is derived from the PROCEDURE MODIFIER 1 field (#.04) within the STC-SVC LINE STAT
INFO SEQ multiple field (#21).
368.0121,.05 PROCEDURE MODIFIER 2 [D] 0;5 POINTER TO CPT MODIFIER FILE (#81.3)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION: This field is derived from the PROCEDURE MODIFIER 2 field (#.05) within the STC-SVC LINE STAT
INFO SEQ multiple field (#21).
368.0121,.06 PROCEDURE MODIFIER 3 [D] 0;6 POINTER TO CPT MODIFIER FILE (#81.3)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION: This field is derived from the PROCEDURE MODIFIER 3 field (#.06) within the STC-SVC LINE STAT
INFO SEQ multiple field (#21).
368.0121,.07 PROCEDURE MODIFIER 4 [D] 0;7 POINTER TO CPT MODIFIER FILE (#81.3)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION: This field is derived from the PROCEDURE MODIFIER 4 field (#.07) within the STC-SVC LINE STAT
INFO SEQ multiple field (#21).
368.0121,.08 LINE ITEM CHARGE AMOUNT [D] 0;8 NUMBER
INPUT TRANSFORM: S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>999999999999999)!(X<0)!(X?.E1"."3.N) X
LAST EDITED: NOV 12, 2015
HELP-PROMPT: Type a dollar amount between 0 and 999999999999999, 2 decimal digits.
DESCRIPTION: This field is derived from the LINE ITEM CHARGE AMOUT field (#.08) within the STC-SVC LINE STAT
INFO SEQ multiple field (#21).
368.0121,.09 REVENUE CODE 0;9 POINTER TO REVENUE CODE FILE (#399.2)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION: This field is derived from the REVENUE CODE field (#.09) within the STC-SVC LINE STAT INFO SEQ
multiple field (#21).
368.0121,.11 SERVICE LINE DATE 0;11 DATE
INPUT TRANSFORM: S %DT="ESTX" D ^%DT S X=Y K:X<1 X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Enter the Service Line Date.
DESCRIPTION: This field is derived from the SERVICE LINE DATE field (#.11) within the STC-SVC LINE STAT INFO
SEQ multiple field (#21).
368.0121,99 STC SEQ-SERVICE LINE [D] 99;0 Multiple #368.12199 (Add New Entry without Asking)
DESCRIPTION: This field will contain the SEQ-Service Line field received from the FSC ASC X12N health Care
Claim Request For Additional Information (277) HL7 message.
368.12199,.01 STC SEQ-SERVICE LINE [D] 0;1 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9999999999)!(X<1)!(X?.E1"."1.N) X
LAST EDITED: OCT 29, 2015
HELP-PROMPT: Type a number between 1 and 9999999999, 0 decimal digits.
CROSS-REFERENCE: 368.12199^B
1)= S ^IBA(368,DA(2),121,DA(1),99,"B",$E(X,1,30),DA)=""
2)= K ^IBA(368,DA(2),121,DA(1),99,"B",$E(X,1,30),DA)
368.12199,.02 STATUS INFO EFFECTIVE DATE [D] 0;2 DATE
INPUT TRANSFORM: S %DT="ESTX" D ^%DT S X=Y K:X<1 X
LAST EDITED: DEC 02, 2015
HELP-PROMPT: Enter the Status Information Effective Date
DESCRIPTION: This field is derived from the STATUS INFORMATION EFFECTIVE DATE field (#.02) within the
STC-SVC LINE STAT INFO SEQ multiple field (#21), within the STC SEQ-SERVICE LINE multiple field
(#99).
368.12199,1.01 HEALTH CARE CLAIM STAT CAT-1 1;1 POINTER TO X12 277 CLAIM STATUS CATEGORY FILE (#368.001)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION: This field is derived from the HEALTH CARE CLAIM STATUS CATEGORY-1 field (#1.01) within the
STC-SVC LINE STAT INFO SEQ multiple field (#21), within the STC SEQ-SERVICE LINE multiple field
(#99).
368.12199,10.01 HEALTH CARE CLAIM STAT CAT-10 10;1 POINTER TO X12 277 CLAIM STATUS CATEGORY FILE (#368.001)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION: This field is derived from the HEALTH CARE CLAIM STATUS CATEGORY-10 field (#10.01) within the
STC-SVC LINE STAT INFO SEQ multiple field (#21), within the STC SEQ-SERVICE LINE multiple field
(#99).
368.12199,11.01 HEALTH CARE CLAIM STAT CAT-11 11;1 POINTER TO X12 277 CLAIM STATUS CATEGORY FILE (#368.001)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Answer must be one of the existing entries.
DESCRIPTION: This field is derived from the HEALTH CARE CLAIM STATUS CATEGORY-11 field (#11.01) within the
STC-SVC LINE STAT INFO SEQ multiple field (#21), within the STC SEQ-SERVICE LINE multiple field
(#99).
368,200.01 DELETED FLAG 200;1 SET
'0' FOR Not Deleted;
'1' FOR Deleted;
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Enter 1 to indicate the Message was manually deleted. Otherwise enter 0.
DESCRIPTION:
Used to flag the Message as being manually deleted (1) or still active (0).
CROSS-REFERENCE: 368^E
1)= S ^IBA(368,"E",$E(X,1,30),DA)=""
2)= K ^IBA(368,"E",$E(X,1,30),DA)
368,200.02 DELETED DATE/TIME 200;2 DATE
INPUT TRANSFORM: S %DT="ESTXR" D ^%DT S X=Y K:X<1 X
LAST EDITED: SEP 03, 2015
HELP-PROMPT: Enter date/time the Message was deleted.
DESCRIPTION:
Used to record the date/time the message was manually deleted.
368,200.03 DELETED BY 200;3 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: SEP 03, 2015
HELP-PROMPT: Enter the user who deleted the message.
DESCRIPTION:
The user who manually deleted the message.
368,200.04 REVIEW STATUS 200;4 SET
'0' FOR NOT BEING REVIEWED;
'1' FOR REVIEW IN PROCESS;
LAST EDITED: JAN 25, 2016
HELP-PROMPT: Enter code indicating whether this MRA claim is being reviewed.
DESCRIPTION:
Select code that indicates whether this claim is under review.
CROSS-REFERENCE: ^^TRIGGER^368^200.05
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^IBA(368,D0,200)):^(200),1:"") S X=$P(Y(1),U,5),X=X
S DIU=X K Y S X=DIV N %I,%H,% D NOW^%DTC S X=% S DIH=$G(^IBA(368,DIV(0),200)),DIV=X S $P(^(200),U,5
)=DIV,DIH=368,DIG=200.05 D ^DICR
2)= Q
CREATE VALUE)= NOW
DELETE VALUE)= NO EFFECT
FIELD)= #200.05
CROSS-REFERENCE: ^^TRIGGER^368^200.06
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^IBA(368,D0,200)):^(200),1:"") S X=$P(Y(1),U,6),X=X
S DIU=X K Y S X=DIV S X=DUZ S DIH=$G(^IBA(368,DIV(0),200)),DIV=X S $P(^(200),U,6)=DIV,DIH=368,DIG=2
00.06 D ^DICR
2)= Q
CREATE VALUE)= S X=DUZ
DELETE VALUE)= NO EFFECT
FIELD)= #200.06
368,200.05 REVIEW STATUS DATE/TIME 200;5 DATE
INPUT TRANSFORM: S %DT="ESTXR" D ^%DT S X=Y K:X<1 X
LAST EDITED: SEP 03, 2015
HELP-PROMPT: Enter the date/time the message was marked in progress.
DESCRIPTION:
Used to indicate the date/time the message was marked in progress.
WRITE AUTHORITY: ^
NOTES: TRIGGERED by the REVIEW STATUS field of the HEALTH CARE CLAIM RFAI (277) File
368,200.06 REVIEW STATUS BY 200;6 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: SEP 03, 2015
HELP-PROMPT: Enter the user who marked the message as in progress.
DESCRIPTION:
Used to indicated the user who marked the message as in progress.
WRITE AUTHORITY: ^
NOTES: TRIGGERED by the REVIEW STATUS field of the HEALTH CARE CLAIM RFAI (277) File
368,201 RFAI WORKLIST COMMENTS 201;0 DATE Multiple #368.0201
DESCRIPTION: This multiple is used to store notes by date entered that explain what work needs to done before
the message can be manually deleted.
368.0201,.01 COMMENT ENTERED DATE 0;1 DATE
Comment Entered Date
INPUT TRANSFORM: S %DT="ESTX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Enter the date/time the comment was entered.
DESCRIPTION: This is the date/time the comment was entered into the system. Set automatically. Don't edit
through FileMan.
CROSS-REFERENCE: 368.0201^B
1)= S ^IBA(368,DA(1),201,"B",$E(X,1,30),DA)=""
2)= K ^IBA(368,DA(1),201,"B",$E(X,1,30),DA)
368.0201,.02 COMMENT ENTERED BY 0;2 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: DEC 01, 2015
HELP-PROMPT: Enter the user who entered the comment.
DESCRIPTION: This is the user who entered the comment. Set by the system automatically. Don't edit through
FileMan.
368.0201,.03 COMMENTS 1;0 WORD-PROCESSING #368.0301 (IGNORE "|")
DESCRIPTION: Used to store notes entered by the user working the request that explain what work needs to done
before the message can be manually deleted.
Comments
LAST EDITED: SEP 21, 2015
HELP-PROMPT: Enter any comments that explain what work needs to be done.
DESCRIPTION: Used to store notes entered by the user working the request that explain what work needs to
done before the message can be manually deleted.
FILES POINTED TO FIELDS
BILL/CLAIMS (#399) PATIENT CONTROL NUMBER [D] (#111.01)
COUNTRY CODE (#779.004) PAYER RESP CONTACT COUNTRY [D] (#120.06)
CPT MODIFIER (#81.3) STC-SVC LINE STAT INFO SEQ [D]:PROCEDURE MODIFIER 1 [D] (#.04)
PROCEDURE MODIFIER 2 [D] (#.05)
PROCEDURE MODIFIER 3 [D] (#.06)
PROCEDURE MODIFIER 4 [D] (#.07)
INSURANCE COMPANY (#36) PAYER NAME [D] (#101.01)
NEW PERSON (#200) DELETED BY (#200.03)
REVIEW STATUS BY (#200.06)
RFAI WORKLIST COMMENTS:COMMENT ENTERED BY (#.02)
PATIENT (#2) PATIENT NAME [D] (#109.01)
REVENUE CODE (#399.2) STC-SVC LINE STAT INFO SEQ [D]:REVENUE CODE (#.09)
STATE (#5) PAYER RESP CONTACT ADDR ST [D] (#120.04)
X12 271 CONTACT QUALIFIER
(#365.021) PAYER CONTACT COMM TYPE 1 [D] (#102.01)
PAYER CONTACT COMM TYPE 2 [D] (#102.02)
PAYER CONTACT COMM TYPE 3 [D] (#102.03)
PAYER RESP CONT COM TYPE 1 [D] (#116.01)
PAYER RESP CONT COM TYPE 2 [D] (#116.02)
PAYER RESP CONT COM TYPE 3 [D] (#116.03)
X12 277 CLAIM STATUS CATEGORY
(#368.001) STC SEQ [D]:HEALTH CARE CLAIM STAT CAT-1 (#1.01)
HEALTH CARE CLAIM STAT CAT-10 (#10.01)
HEALTH CARE CLAIM STAT CAT-11 (#11.01)
STC SEQ-SERVICE LINE [D]:HEALTH CARE CLAIM STAT CAT-1 (#1.01)
HEALTH CARE CLAIM STAT CAT-10 (#10.01)
HEALTH CARE CLAIM STAT CAT-11 (#11.01)
X12 277 PRODUCT OR SERVICE ID
(#368.002) STC-SVC LINE STAT INFO SEQ [D]:PRODUCT/SERVICE ID QUAL [D] (#.02)
ZIP CODE (#5.11) PAYER RESP CONT POSTAL/ZIP [D] (#120.05)
INPUT TEMPLATE(S):
PRINT TEMPLATE(S):
SORT TEMPLATE(S):
FORM(S)/BLOCK(S):