| FileMan FileNo | FileMan Filename | Package | 
|---|---|---|
| 368 | HEALTH CARE CLAIM RFAI (277) | Integrated Billing | 
| Package | Total | FileMan Files | 
|---|---|---|
| Integrated Billing | 6 | BILL/CLAIMS(#399)[111.01] REVENUE CODE(#399.2)[#368.0121(.03), #368.0121(.09)] INSURANCE COMPANY(#36)[101.01] X12 271 CONTACT QUALIFIER(#365.021)[102.01, 102.02, 102.03, 116.01, 116.02, 116.03] X12 277 CLAIM STATUS CATEGORY(#368.001)[#368.0113(1.01), #368.0113(10.01), #368.0113(11.01), #368.12199(1.01), #368.12199(10.01), #368.12199(11.01)] X12 277 PRODUCT OR SERVICE ID QUAL(#368.002)[#368.0121(.02)] | 
| Kernel | 3 | STATE(#5)[120.04]    NEW PERSON(#200)[200.03, 200.06, #368.0201(.02)] ZIP CODE(#5.11)[120.05]  | 
| CPT HCPCS Codes | 2 | CPT MODIFIER(#81.3)[#368.0121(.04), #368.0121(.05), #368.0121(.06), #368.0121(.07)] CPT(#81)[#368.0121(.03)] | 
| Health Level Seven | 1 | COUNTRY CODE(#779.004)[120.06] | 
| National Drug File | 1 | NDC/UPN(#50.67)[#368.0121(.03)] | 
| Registration | 1 | PATIENT(#2)[109.01] | 
| Field # | Name | Loc | Type | Details | 
|---|---|---|---|---|
| .01 | MESSAGE CONTROL ID | 0;1 | FREE TEXT | ************************REQUIRED FIELD************************ 
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| .02 | REQUEST DATE/TIME | 0;2 | FREE TEXT | 
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| .03 | TRANSACTION DATE/TIME | 0;3 | FREE TEXT | 
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| 1.01 | PAYER NAME | 1;1 | FREE TEXT | 
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| 1.02 | PAYER IDENTIFIER | 1;2 | FREE TEXT | 
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| 1.03 | PAYER CONTACT NAME | 1;3 | FREE TEXT | 
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| 2.01 | PAYER CONTACT COMM TYPE 1 | 2;1 | FREE TEXT | 
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| 2.02 | PAYER CONTACT COMM TYPE 2 | 2;2 | FREE TEXT | 
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| 2.03 | PAYER CONTACT COMM TYPE 3 | 2;3 | FREE TEXT | 
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| 3.01 | PAYER CONTACT COMMUNICATION 1 | 3;1 | FREE TEXT | 
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| 4.01 | PAYER CONTACT COMMUNICATION 2 | 4;1 | FREE TEXT | 
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| 5.01 | PAYER CONTACT COMMUNICATION 3 | 5;1 | FREE TEXT | 
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| 6.01 | INFORMATION RECEIVER NAME | 6;1 | FREE TEXT | 
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| 6.02 | INFORMATION RECEIVER ID | 6;2 | FREE TEXT | 
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| 7.01 | SERVICE PROVIDER NAME | 7;1 | FREE TEXT | 
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| 7.02 | SERVICE PROV FED TAXPAYER CODE | 7;2 | FREE TEXT | 
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| 8.01 | SERVICE PROVIDER ID | 8;1 | FREE TEXT | 
  | 
| 9.01 | PATIENT NAME | 9;1 | FREE TEXT | 
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| 10.01 | PATIENT PRIMARY IDENTIFIER | 10;1 | FREE TEXT | 
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| 11.01 | PATIENT CONTROL NUMBER | 11;1 | FREE TEXT | 
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| 11.02 | PAYER CLAIM CONTROL NUMBER | 11;2 | FREE TEXT | 
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| 11.03 | MEDICAL RECORD NUMBER | 11;3 | FREE TEXT | 
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| 11.04 | CLEARINGHOUSE TRACE NUMBER | 11;4 | FREE TEXT | 
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| 12.01 | RESPONSE DUE DATE | 12;1 | FREE TEXT | 
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| 12.02 | REPORT TRANSMISSION CODE | 12;2 | FREE TEXT | 
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| 13 | STC SEQ | 13;0 | Multiple #368.013 | 368.013
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| 14.03 | CLAIM SERVICE START DATE | 14;3 | FREE TEXT | 
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| 14.04 | CLAIM SERVICE END DATE | 14;4 | FREE TEXT | 
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| 14.05 | CLAIM SERVICE PERIOD | 14;5 | FREE TEXT | 
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| 15.01 | PAYER RESPONSE CONTACT NAME | 15;1 | FREE TEXT | 
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| 16.01 | PAYER RESP CONTACT COMM TYPE 1 | 16;1 | FREE TEXT | 
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| 16.02 | PAYER RESP CONTACT COMM TYPE 2 | 16;2 | FREE TEXT | 
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| 16.03 | PAYER RESP CONTACT COMM TYPE 3 | 16;3 | FREE TEXT | 
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| 17.01 | PAYER RESPONSE CONTACT COMM 1 | 17;1 | FREE TEXT | 
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| 18.01 | PAYER RESPONSE CONTACT COMM 2 | 18;1 | FREE TEXT | 
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| 19.01 | PAYER RESPONSE CONTACT COMM 3 | 19;1 | FREE TEXT | 
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| 20.01 | PAYER RESP CONTACT ADDR LINE 1 | 20;1 | FREE TEXT | 
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| 20.02 | PAYER RESP CONTACT ADDR LINE 2 | 20;2 | FREE TEXT | 
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| 20.03 | PAYER RESP CONTACT CITY | 20;3 | FREE TEXT | 
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| 20.04 | PAYER RESP CONTACT STATE | 20;4 | FREE TEXT | 
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| 20.05 | PAYER RESP CONTACT ZIP CODE | 20;5 | FREE TEXT | 
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| 20.06 | PAYER RESP CONTACT COUNTRY | 20;6 | FREE TEXT | 
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| 20.07 | PAYER RESP CONT CNTRY SUBDIV | 20;7 | FREE TEXT | 
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| 21 | STC-SVC LINE STAT INFO SEQ | 21;0 | Multiple #368.021 | 368.021
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| 22.03 | PRIMARY LOINC | 22;3 | FREE TEXT | 
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| 25.01 | REFERENCE ID-INST TYPE OF BILL | 25;1 | FREE TEXT | 
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| 26.01 | PAYER CONTACT COMM 1 EXTENSION | 26;1 | FREE TEXT | 
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| 27.01 | PAYER CONTACT COMM 2 EXTENSION | 27;1 | FREE TEXT | 
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| 28.01 | PAYER CONTACT COMM 3 EXTENSION | 28;1 | FREE TEXT | 
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| 29.01 | PAYER RESP CONTACT COMM 1 EXT | 29;1 | FREE TEXT | 
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| 30.01 | PAYER RESP CONTACT COMM 2 EXT | 30;1 | FREE TEXT | 
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| 31.01 | PAYER RESP CONTACT COMM 3 EXT | 31;1 | FREE TEXT | 
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| 80.01 | PAYER ENTITY IDENTIFIER CODE | 80;1 | FREE TEXT | 
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| 80.02 | PAYER ENTITY TYPE QUALIFIER | 80;2 | FREE TEXT | 
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| 80.03 | PAYER ID CODE QUALIFIER | 80;3 | FREE TEXT | 
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| 80.04 | PAYER CONTACT FUNCTION CODE | 80;4 | FREE TEXT | 
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| 80.05 | INFORMATION RECEIVER ENTITY ID | 80;5 | FREE TEXT | 
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| 80.06 | INFO RECEIVER ENTITY TYPE | 80;6 | FREE TEXT | 
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| 80.07 | INFO RECEIVER ID QUALIFIER | 80;7 | FREE TEXT | 
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| 80.08 | SERVICE PROV ENTITY ID CODE | 80;8 | FREE TEXT | 
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| 80.09 | SERVICE PROV ENTITY TYPE QUAL | 80;9 | FREE TEXT | 
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| 80.1 | SERVICE PROVIDER ID QUALIFIER | 80;10 | FREE TEXT | 
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| 80.11 | PATIENT ENTITY IDENTIFIER CODE | 80;11 | FREE TEXT | 
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| 80.12 | PATIENT ENTITY TYPE QUALIFIER | 80;12 | FREE TEXT | 
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| 80.13 | PATIENT ID CODE QUALIFIER | 80;13 | FREE TEXT | 
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| 80.14 | PAYER CLAIM TRACE TYPE CODE | 80;14 | FREE TEXT | 
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| 80.18 | REFERENCE ID QUALIFIER-PT CRTL | 80;18 | FREE TEXT | 
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| 80.19 | REFERENCE ID QUALIFIER-INST | 80;19 | FREE TEXT | 
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| 80.2 | REFERENCE ID QUALIFIER-MRN | 80;20 | FREE TEXT | 
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| 80.21 | REFERENCE ID QUALIFIER-CTN | 80;21 | FREE TEXT | 
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| 80.22 | CLAIM SERVICE DT/TM QUALIFIER | 80;22 | FREE TEXT | 
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| 80.23 | CLAIM SERV DT/TM PERIOD QUAL | 80;23 | FREE TEXT | 
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| 80.24 | RESPONSE DUE DT/TM QUALIFIER | 80;24 | FREE TEXT | 
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| 80.25 | RESPONSE DUE DT/TM PERIOD QUAL | 80;25 | FREE TEXT | 
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| 80.26 | CLAIM SUPP INFO REPORT TYPE | 80;26 | FREE TEXT | 
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| 80.27 | PAYER RESP CONTACT FUNC CODE | 80;27 | FREE TEXT | 
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| 80.29 | SERVICE LINE DT/TM QUALIFIER | 80;29 | FREE TEXT | 
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| 80.3 | SERVICE LINE DT/TM PERIOD QUAL | 80;30 | FREE TEXT | 
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| 100.02 | REQUEST DATE/TIME [D] | 100;2 | DATE | 
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| 100.03 | MESSAGE DATE/TIME [D] | 100;3 | DATE | 
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| 101.01 | PAYER NAME [D] | 101;1 | POINTER TO INSURANCE COMPANY FILE (#36) | INSURANCE COMPANY(#36)
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| 102.01 | PAYER CONTACT COMM TYPE 1 [D] | 102;1 | POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021) | X12 271 CONTACT QUALIFIER(#365.021)
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| 102.02 | PAYER CONTACT COMM TYPE 2 [D] | 102;2 | POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021) | X12 271 CONTACT QUALIFIER(#365.021)
  | 
| 102.03 | PAYER CONTACT COMM TYPE 3 [D] | 102;3 | POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021) | X12 271 CONTACT QUALIFIER(#365.021)
  | 
| 109.01 | PATIENT NAME [D] | 109;1 | POINTER TO PATIENT FILE (#2) | PATIENT(#2)
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| 111.01 | PATIENT CONTROL NUMBER [D] | 111;1 | POINTER TO BILL/CLAIMS FILE (#399) | BILL/CLAIMS(#399)
  | 
| 112.01 | RESPONSE DUE DATE [D] | 112;1 | DATE | 
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| 113 | STC SEQ [D] | 113;0 | Multiple #368.0113 | 368.0113
  | 
| 114.03 | CLAIM SERVICE START DATE [D] | 114;3 | DATE | 
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| 114.04 | CLAIM SERVICE END DATE [D] | 114;4 | DATE | 
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| 116.01 | PAYER RESP CONT COM TYPE 1 [D] | 116;1 | POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021) | X12 271 CONTACT QUALIFIER(#365.021)
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| 116.02 | PAYER RESP CONT COM TYPE 2 [D] | 116;2 | POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021) | X12 271 CONTACT QUALIFIER(#365.021)
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| 116.03 | PAYER RESP CONT COM TYPE 3 [D] | 116;3 | POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021) | X12 271 CONTACT QUALIFIER(#365.021)
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| 120.04 | PAYER RESP CONTACT ADDR ST [D] | 120;4 | POINTER TO STATE FILE (#5) | STATE(#5)
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| 120.05 | PAYER RESP CONT POSTAL/ZIP [D] | 120;5 | POINTER TO ZIP CODE FILE (#5.11) | ZIP CODE(#5.11)
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| 120.06 | PAYER RESP CONTACT COUNTRY [D] | 120;6 | POINTER TO COUNTRY CODE FILE (#779.004) | COUNTRY CODE(#779.004)
  | 
| 121 | STC-SVC LINE STAT INFO SEQ [D] | 121;0 | Multiple #368.0121 | 368.0121
  | 
| 200.01 | DELETED FLAG | 200;1 | SET | 
 
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| 200.02 | DELETED DATE/TIME | 200;2 | DATE | 
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| 200.03 | DELETED BY | 200;3 | POINTER TO NEW PERSON FILE (#200) | NEW PERSON(#200)
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| 200.04 | REVIEW STATUS | 200;4 | SET | 
 
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| 200.05 | REVIEW STATUS DATE/TIME | 200;5 | DATE | 
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| 200.06 | REVIEW STATUS BY | 200;6 | POINTER TO NEW PERSON FILE (#200) | NEW PERSON(#200)
  | 
| 201 | RFAI WORKLIST COMMENTS | 201;0 | DATE Multiple #368.0201 | 368.0201
  |