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Sub-Field: 162.09

Package: Fee Basis

FEE BASIS PAYMENT(#162)-->162.01-->162.02-->162.03-->162.09

Sub-Field: 162.09


Information

Parent File Name Number Package
162.03 OHI OTHER SUBSCRIBER INFO 162.09 Fee Basis

Details

Field # Name Loc Type Details
.01 PAYER RESP SEQUENCE CODE 0;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>1!($L(X)<1) X
    MAXIMUM LENGTH: 1
  • LAST EDITED:  APR 17, 2017
  • HELP-PROMPT:  Answer must be 1 character in length.
  • DESCRIPTION:  
    Payer Responsibility Sequence Number Code.
  • TECHNICAL DESCR:  
    Payer Responsibility Sequence Number Code (X12 #2320, SBR01).
  • CROSS-REFERENCE:  162.09^B
    1)= S ^FBAAC(DA(4),1,DA(3),1,DA(2),1,DA(1),6,"B",$E(X,1,30),DA)=""
    2)= K ^FBAAC(DA(4),1,DA(3),1,DA(2),1,DA(1),6,"B",$E(X,1,30),DA)
.02 INDIVIDUAL RELATIONSHIP CODE 0;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
    MAXIMUM LENGTH: 2
  • LAST EDITED:  APR 17, 2017
  • HELP-PROMPT:  Answer must be 2 characters in length.
  • DESCRIPTION:  
    Individual Relationship Code.
  • TECHNICAL DESCR:  
    Individual Relationship Code (X12 #2320, SBR02).
.03 INSURED GROUP OR POL NUMBER 0;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
    MAXIMUM LENGTH: 50
  • LAST EDITED:  APR 17, 2017
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    Insured Group or Policy Number.
  • TECHNICAL DESCR:  
    Insured Group or Policy Number (X12 #2320, SBR03).
.04 OTHER INSUR GROUP NAME 0;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>60!($L(X)<1) X
    MAXIMUM LENGTH: 60
  • LAST EDITED:  APR 17, 2017
  • HELP-PROMPT:  Answer must be 1-60 characters in length.
  • DESCRIPTION:  
    Other Insured Group Name.
  • TECHNICAL DESCR:  
    Other Insured Group Name (X12 #2320, SBR04).
.05 INSURANCE TYPE CODE 0;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<1) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  APR 17, 2017
  • HELP-PROMPT:  Answer must be 1-3 characters in length.
  • DESCRIPTION:  
    Insurance Type Code.
  • TECHNICAL DESCR:  
    Insurance Type Code (X12 #2320, SBR05).
.06 CLAIM FILING INDICATOR CODE 0;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<1) X
    MAXIMUM LENGTH: 2
  • LAST EDITED:  APR 17, 2017
  • HELP-PROMPT:  Answer must be 1-2 characters in length.
  • DESCRIPTION:  
    Claim Filing Indicator Code.
  • TECHNICAL DESCR:  
    Claim Filing Indicator Code (X12 #2320, SBR09).
1 CLAIM LEVEL ADJUSTMENTS 1;0 Multiple #162.13 162.13

  • DESCRIPTION:  
    X12, #2320 CAS section - contains the Claim Adjustment Group Code and related to it adjustment codes, amounts and quantities.
  • TECHNICAL DESCR:  
    X12, #2320 CAS section (multiple - up to 5 entries).
2.01 COB PAYER PAID AMT QUAL CODE 2;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<1) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  APR 17, 2017
  • HELP-PROMPT:  Answer must be 1-3 characters in length.
  • DESCRIPTION:  
    COB Payer Paid Amount Qualifier Code.
  • TECHNICAL DESCR:  
    COB Payer Paid Amount- Required when the claim has been adjudicated by the payer identified in loop 2330B or when loop 2010AC is present. AMT01 - Amount Qualifier Code = D (X12, #2320, AMT).
2.02 COB PAYER PAID AMOUNT 2;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 17, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    COB Payer Paid Amount.
  • TECHNICAL DESCR:  
    COB Payer Paid Amount- Required when the claim has been adjudicated by the payer identified in loop 2330B or when loop 2010AC is present. AMT02 - Payer Paid Amount (X12, #2320, AMT).
3.01 REMAIN PAT LIAB AMT QUAL CODE 3;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<1) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  APR 17, 2017
  • HELP-PROMPT:  Answer must be 1-3 characters in length.
  • DESCRIPTION:  
    Remaining Patient Liability Amount Qualifier Code.
  • TECHNICAL DESCR:  Remaining Patient Liability, required when the Other Payer Identified in loop 2330B has adjudicated this claim and provided claim level info only or when the Other Payer Identified in loop 2330B does not
    have the ability to report line item information. AMT01 Amount Qualifier Code = EAF (X12, #2320, AMT).
3.02 REMAIN PAT LIAB AMOUNT 3;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 17, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Remaining Patient Liability Amount.
  • TECHNICAL DESCR:  Remaining Patient Liability, required when the Other Payer Identified in loop 2330B has adjudicated this claim and provided claim level info only or when the Other Payer Identified in loop 2330B does not
    have the ability to report line item information. AMT02 Remaining Patient Liability Amount (X12, #2320, AMT).
4.01 COB TOT NON-COV AMT QUAL CODE 4;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<1) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  APR 17, 2017
  • HELP-PROMPT:  Answer must be 1-3 characters in length.
  • DESCRIPTION:  
    COB Total Non-Covered Amount Qualifier Code.
  • TECHNICAL DESCR:  
    COB Total Non-Covered Amount - Required when the destination payer's cost avoidance policy allows providers to bypass claims submission. AMT01 Amount Qualifier Code = A8 (X12, #2320, AMT).
4.02 COB TOT NON-COV AMOUNT 4;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 17, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    COB Total Non-Covered Amount.
  • TECHNICAL DESCR:  
    COB Total Non-Covered Amount, required when the destination payer's cost avoidance policy allows providers to bypass claims submission. AMT02 Non-Covered Amount (X12, #2320, AMT).
5.01 OTH INS BENEF ASSIGN CERT INFO 5;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>1!($L(X)<1) X
    MAXIMUM LENGTH: 1
  • LAST EDITED:  APR 17, 2017
  • HELP-PROMPT:  Answer must be 1 character in length.
  • DESCRIPTION:  
    Other Insurance Coverage Info - Benefit Assignment Certification Indicator.
  • TECHNICAL DESCR:  
    Other Insurance Coverage Info. OI03 Benefit Assignment Certification Indicator (X12, #2320, OI).
5.02 OTH INS PAT SIGNAT SOURCE CODE 5;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>1!($L(X)<1) X
    MAXIMUM LENGTH: 1
  • LAST EDITED:  APR 17, 2017
  • HELP-PROMPT:  Answer must be 1 character in length.
  • DESCRIPTION:  
    Other Insurance Coverage Info - Patient Signature Source Code.
  • TECHNICAL DESCR:  
    Other Insurance Coverage Info. OI04 Patient Signature Source Code (X12, #2320, OI).
5.03 OTH INS ROI CODE 5;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>1!($L(X)<1) X
    MAXIMUM LENGTH: 1
  • LAST EDITED:  APR 17, 2017
  • HELP-PROMPT:  Answer must be 1 character in length.
  • DESCRIPTION:  
    Other Insurance Coverage Info Release of Information Code.
  • TECHNICAL DESCR:  
    Other Insurance Coverage Info. OI06 Release of Information Code, this is a crosswalk from CLM09 when doing COB (X12, #2320, OI).
6.01 INP ADJ QUANT COV DAYS VIS CNT 6;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>15!($L(X)<1) X
    MAXIMUM LENGTH: 15
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-15 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - Covered Days or Visit Count.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA01 Covered Days or Visit Count (X12, #2320, MIA).
6.02 INP ADJ LIFETIME PSYCH CNT 6;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>15!($L(X)<1) X
    MAXIMUM LENGTH: 15
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-15 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - Lifetime Psychiatric Days Count.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA03 Lifetime Psychiatric Days Count (X12, #2320, MIA).
6.03 INP ADJ REM PAT LIAB AMOUNT 6;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - Remaining Patient Liability Amount.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA04 Remaining Patient Liability Amount (X12, #2320, MIA).
6.04 INP ADJ REF ID-REM CODE MIA05 6;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
    MAXIMUM LENGTH: 50
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - Claim Payment Remark Code.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA05 Claim Payment Remark Code (X12, #2320, MIA).
6.05 INP ADJ AMT-CLM DISPR SHARE 6;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - Claim Disproportionate Share Amount.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA06 Claim Disproportionate Share Amount (X12, #2320, MIA).
6.06 INP ADJ AMT-CLM MSP PASS 6;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - Claim MSP Pass-through Amount.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA07 Claim MSP Pass-through Amount (X12, #2320, MIA).
6.07 INP ADJ AMT-CLM PPS CAPITAL 6;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - Claims PPS Capital Amount.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA08 Claims PPS Capital Amount (X12, #2320, MIA).
6.08 INP ADJ AMT-PPS CAP FSP DRG 6;8 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - PPS-Capital FSP DRG Amount.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA09 PPS-Capital FSP DRG Amount (X12, #2320, MIA).
7.01 INP ADJ AMT-PPS CAP HSP DRG 7;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - PPS-Capital HSP DRG Amount.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA10 PPS-Capital HSP DRG Amount (X12, #2320, MIA).
7.02 INP ADJ AMT-PPS CAP DSH DRG 7;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - PPS-Capital DSH DRG Amount.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA11 PPS-Capital DSH DRG Amount (X12, #2320, MIA).
7.03 INP ADJ AMT-OLD CAPITAL AMN 7;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - Old Capital Amount.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA12 Old Capital Amount (X12, #2320, MIA).
7.04 INP ADJ AMT-PPS CAPIT IME AMT 7;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - PPS-Capital ImE Amount (X12, #2320, MIA).
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA13 PPS-Capital ImE Amount (X12, #2320, MIA).
7.05 INP ADJ AMT-PPS OPER HOSP DRG 7;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - PPS-Operating Hospital Specific DRG Amount.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA14 PPS-Operating Hospital Specific DRG Amount (X12, #2320, MIA).
7.06 INP ADJ COST REPORT DAY COUNT 7;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>15!($L(X)<1) X
    MAXIMUM LENGTH: 15
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-15 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - Cost Report Day Count.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA15 Cost Report Day Count (X12, #2320, MIA).
7.07 INP ADJ AMT-PPS OP FED SPE DRG 7;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - PPS-Operating Federal Specific DRG Amount.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA16 PPS-Operating Federal Specific DRG Amount (X12, #2320, MIA).
7.08 INP ADJ AMT-CLM PPS CAPIT OUTL 7;8 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - Claims PPS Capital Outlier Amount.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA17 Claims PPS Capital Outlier Amount (X12, #2320, MIA).
7.09 INP ADJ AMT-CLM INDIR TEACHING 7;9 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - Claim Indirect Teaching Amount.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA18 Claim Indirect Teaching Amount (X12, #2320, MIA).
7.1 INP ADJ AMT-NON-PAY PROF BILLD 7;10 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - Non-Payable Professional Component Billed Amount.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA19 Non-Payable Professional Component Billed Amount (X12, #2320, MIA).
8.01 INP ADJ REF ID-REM CODE MIA20 8;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
    MAXIMUM LENGTH: 50
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - Claim Payment Remark Code.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA20 Claim Payment Remark Code (X12, #2320, MIA).
8.02 INP ADJ REF ID-REM CODE MIA21 8;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
    MAXIMUM LENGTH: 50
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - Claim Payment Remark Code.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA21 Reference ID - Claim Payment Remark Code (X12, #2320, MIA).
8.03 INP ADJ REF ID-REM CODE MIA22 8;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
    MAXIMUM LENGTH: 50
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - Claim Payment Remark Code (MIA22).
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA22 Reference ID - Claim Payment Remark Code (X12, #2320, MIA).
8.04 INP ADJ REF ID-REM CODE MIA23 8;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
    MAXIMUM LENGTH: 50
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - Claim Payment Remark Code (MIA23).
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA23 Reference ID - Claim Payment Remark Code (X12, #2320, MIA).
8.05 INP ADJ AMT-PPS CAPITAL EXCEPT 8;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Inpatient Adjudication Info - PPS-Capital Exception Amount.
  • TECHNICAL DESCR:  
    Inpatient Adjudication Info - required when inpatient adjudication information is reported in the remittance advice. MIA24 Monetary Amount - PPS Capital Exception (X12, #2320, MIA).
9.01 OUTP ADJ REIMBURSE RATE 9;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>10!($L(X)<1) X
    MAXIMUM LENGTH: 10
  • LAST EDITED:  JUL 13, 2017
  • HELP-PROMPT:  Answer must be 1-10 characters in length.
  • DESCRIPTION:  
    MOA Outpatient Adjudication Info - Reimbursement Rate.
  • TECHNICAL DESCR:  
    MOA Outpatient Adjudication Info. MOA01 Reimbursement Rate. (X12, #2320, MOA).
9.02 OUTP ADJ HCPCS PAYABLE AMT 9;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    MOA Outpatient Adjudication Info - HCPCS Payable Amount.
  • TECHNICAL DESCR:  
    MOA Outpatient Adjudication Info. MOA02 Monetary Amt - HCPCS Payable Amount (X12, #2320, MOA).
9.03 OUTP ADJ REF ID-REM COD MOA03 9;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
    MAXIMUM LENGTH: 50
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    Outpatient Adjudication Info - Remark Code MOA03.
  • TECHNICAL DESCR:  
    MOA Outpatient Adjudication Info. MOA03 Reference ID - Claim Payment Remark Code (X12, #2320, MOA).
9.04 OUTP ADJ REF ID-REM COD MOA04 9;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
    MAXIMUM LENGTH: 50
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    Outpatient Adjudication Info - Remark Code MOA04.
  • TECHNICAL DESCR:  
    MOA Outpatient Adjudication Info. MOA04 Reference ID - Claim Payment Remark Code (X12, #2320, MOA).
10.01 OUTP ADJ REF ID-REM COD MOA05 10;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
    MAXIMUM LENGTH: 50
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    Outpatient Adjudication Info - Remark Code MOA05.
  • TECHNICAL DESCR:  
    MOA Outpatient Adjudication Info. MOA05 Reference ID - Claim Payment Remark Code (X12, #2320, MOA).
10.02 OUTP ADJ REF ID-REM COD MOA06 10;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
    MAXIMUM LENGTH: 50
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    Outpatient Adjudication Info - Remark Code MOA06.
  • TECHNICAL DESCR:  
    MOA Outpatient Adjudication Info. MOA06 Reference ID - Claim Payment Remark Code (X12, #2320, MOA).
10.03 OUTP ADJ REF ID-REM COD MOA07 10;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
    MAXIMUM LENGTH: 50
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    Outpatient Adjudication Info - Remark Code MOA07.
  • TECHNICAL DESCR:  
    MOA Outpatient Adjudication Info. MOA07 Reference ID - Claim Payment Remark Code (X12, #2320, MOA).
10.04 OUTP ADJ ESRD PAYM AMT 10;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Outpatient Adjudication Info - End Stage Renal Disease Payment Amount.
  • TECHNICAL DESCR:  
    Outpatient Adjudication Info - End Stage Renal Disease Payment Amount. MOA08 End Stage Renal Disease Payment Amount (X12, #2320, MOA).
10.05 OUTP ADJ NON PAY PROF BILLED 10;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Outpatient Adjudication Info - Non-Payable Professional Component Billed Amount.
  • TECHNICAL DESCR:  
    MOA Outpatient Adjudication Info. MOA09 Monetary Amt - Non-Payable Professional Component Billed Amount (X12, #2320, MOA).
11.01 OTH SUB ENTITY ID CODE 11;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<2) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 2-3 characters in length.
  • DESCRIPTION:  
    Entity Identifier Code.
  • TECHNICAL DESCR:  
    X12, #2330A, Other Subscriber Name, NM1 Other Subscriber Name, NM101 Entity Identifier Code.
11.02 OTH SUB ENTITY TYPE QUAL 11;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>1!($L(X)<1) X
    MAXIMUM LENGTH: 1
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1 character in length.
  • DESCRIPTION:  
    Entity Type Qualifier.
  • TECHNICAL DESCR:  
    X12, #2330A, Other Subscriber Name, NM1 Other Subscriber Name, NM102 Entity Type Qualifier.
11.03 OTH SUB LAST NAME 11;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>60!($L(X)<1) X
    MAXIMUM LENGTH: 60
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-60 characters in length.
  • DESCRIPTION:  
    Other Insured Last Name.
  • TECHNICAL DESCR:  
    X12, #2330A, Other Subscriber Name, NM1 Other Subscriber Name, NM103 Other Insured Last Name.
11.04 OTH SUB FIRST NAME 11;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>35!($L(X)<1) X
    MAXIMUM LENGTH: 35
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-35 characters in length.
  • DESCRIPTION:  
    Other Insured First Name.
  • TECHNICAL DESCR:  
    X12, #2330A, Other Subscriber Name, NM1 Other Subscriber Name, NM104 Other Insured First Name.
11.05 OTH SUB MIDDLE NAME 11;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>25!($L(X)<1) X
    MAXIMUM LENGTH: 25
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-25 characters in length.
  • DESCRIPTION:  
    Other Insured Middle Name.
  • TECHNICAL DESCR:  
    X12, #2330A, Other Subscriber Name, NM1 Other Subscriber Name, NM105 Other Insured Middle Name.
11.06 OTH SUB NAME SUFFIX 11;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>10!($L(X)<1) X
    MAXIMUM LENGTH: 10
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-10 characters in length.
  • DESCRIPTION:  
    Other Insured Name Suffix.
  • TECHNICAL DESCR:  
    X12, #2330A, Other Subscriber Name, NM1 Other Subscriber Name, NM107 Other Insured Name Suffix.
11.07 OTH SUB ID CODE QUAL 11;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<1) X
    MAXIMUM LENGTH: 2
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-2 characters in length.
  • DESCRIPTION:  
    Identification Code Qualifier.
  • TECHNICAL DESCR:  
    X12, #2330A, Other Subscriber Name, NM1 Other Subscriber Name, NM108 Identification Code Qualifier.
11.08 OTH SUB INSURED ID 11;8 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>80!($L(X)<2) X
    MAXIMUM LENGTH: 80
  • LAST EDITED:  JUL 13, 2017
  • HELP-PROMPT:  Answer must be 2-80 characters in length.
  • DESCRIPTION:  
    Other Insured Identifier.
  • TECHNICAL DESCR:  
    X12, #2330A, Other Subscriber Name, NM1 Other Subscriber Name, NM109 Other Insured Identifier.
12.01 OTH SUB ADDR LINE 1 12;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>55!($L(X)<1) X
    MAXIMUM LENGTH: 55
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-55 characters in length.
  • DESCRIPTION:  
    Other Insured's Address line 1.
  • TECHNICAL DESCR:  
    X12, #2330A, Other Subscriber Name, N3 Other Subscriber Address, N301 Other Insured's Address line 1.
12.02 OTH SUB ADDR LINE 2 12;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>55!($L(X)<1) X
    MAXIMUM LENGTH: 55
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-55 characters in length.
  • DESCRIPTION:  
    Other Insured's Address line 2.
  • TECHNICAL DESCR:  
    X12, #2330A, Other Subscriber Name, N3 Other Subscriber Address, N302 Other Insured's Address line 2.
12.03 OTH SUB CITY NAME 12;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<2) X
    MAXIMUM LENGTH: 30
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 2-30 characters in length.
  • DESCRIPTION:  
    Other Insured City Name.
  • TECHNICAL DESCR:  
    X12, #2330A, Other Subscriber Name, N4 Other Subscriber City, State, Zip, N401 Other Insured City Name.
12.04 OTH SUB STATE CODE 12;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
    MAXIMUM LENGTH: 2
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 2 characters in length.
  • DESCRIPTION:  
    Other Insured State Code.
  • TECHNICAL DESCR:  
    X12, #2330A, Other Subscriber Name, N4 Other Subscriber City, State, Zip, N402 Other Insured State Code.
12.05 OTH SUB POSTAL ZIP 12;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>15!($L(X)<3) X
    MAXIMUM LENGTH: 15
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 3-15 characters in length.
  • DESCRIPTION:  
    Other Insured Postal Zone or ZIP Code.
  • TECHNICAL DESCR:  
    X12, #2330A, Other Subscriber Name, N4 Other Subscriber City, State, Zip, N403 Other Insured Postal Zone or ZIP Code.
12.06 OTH SUB COUNTRY CODE 12;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<2) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 2-3 characters in length.
  • DESCRIPTION:  
    Other Insured Country Code.
  • TECHNICAL DESCR:  
    X12, #2330A, Other Subscriber Name, N4 Other Subscriber City, State, Zip, N404 Other Insured Country Code.
12.07 OTH SUB COUNTRY SUBDIV CODE 12;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<1) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  JUL 13, 2017
  • HELP-PROMPT:  Answer must be 1-3 characters in length.
  • DESCRIPTION:  
    Other Insured Country subdivision code.
  • TECHNICAL DESCR:  
    X12, #2330A, Other Subscriber Name, N4 Other Subscriber City, State, Zip, N407 Other Insured Country subdivision code.
13.01 OTH SUB 2ND ID REF QUAL 1 13;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<2) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 2-3 characters in length.
  • DESCRIPTION:  
    Reference Identification Qualifier 1.
  • TECHNICAL DESCR:  
    X12, #2330A, Other Subscriber Name, REF Other Subscriber secondary ID, REF01 Reference Identification Qualifier 1.
13.02 OTH SUB 2ND ID-ADDTNL ID 1 13;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
    MAXIMUM LENGTH: 50
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    Other Insured Additional Identifier 1.
  • TECHNICAL DESCR:  
    X12, #2330A, Other Subscriber Name, REF Other Subscriber secondary ID, REF02 Other Insured Additional Identifier 1.
13.03 OTH SUB 2ND ID REF QUAL 2 13;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<2) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 2-3 characters in length.
  • DESCRIPTION:  
    Reference Identification Qualifier 2.
  • TECHNICAL DESCR:  
    X12, #2330A, Other Subscriber Name, REF Other Subscriber secondary ID, REF01 Reference Identification Qualifier 2.
13.04 OTH SUB 2ND ID-ADDTNL ID 2 13;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
    MAXIMUM LENGTH: 50
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    Other Insured Additional Identifier 2.
  • TECHNICAL DESCR:  
    X12, #2330A, Other Subscriber Name, REF Other Subscriber secondary ID, REF02 Other Insured Additional Identifier 2.
14.01 OTH PAYER ENTITY ID CODE 14;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<2) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 2-3 characters in length.
  • DESCRIPTION:  
    Entity Identifier Code.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, NM1 Other Payer Name, NM101 Entity Identifier Code.
14.02 OTH PAYER ENTITY TYPE QUAL 14;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>1!($L(X)<1) X
    MAXIMUM LENGTH: 1
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1 character in length.
  • DESCRIPTION:  
    Entity Type Qualifier.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, NM1 Other Payer Name, NM102 Entity Type Qualifier.
14.03 OTH PAYER LAST OR ORG NAME 14;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>60!($L(X)<1) X
    MAXIMUM LENGTH: 60
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-60 characters in length.
  • DESCRIPTION:  
    Other Payer Last or Organization Name.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, NM1 Other Payer Name, NM103 Other Payer Last or Organization Name.
14.04 OTH PAYER ID CODE QUALIFIER 14;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<1) X
    MAXIMUM LENGTH: 2
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-2 characters in length.
  • DESCRIPTION:  
    Identification Code Qualifier.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, NM1 Other Payer Name, NM108 Identification Code Qualifier.
14.05 OTH PAYER PRIMARY IDENTIFIER 14;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>80!($L(X)<2) X
    MAXIMUM LENGTH: 80
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 2-80 characters in length.
  • DESCRIPTION:  
    Other Payer Primary Identifier.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, NM1 Other Payer Name, NM109 Other Payer Primary Identifier.
15.01 OTH PAYER ADDR LINE 1 15;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>55!($L(X)<1) X
    MAXIMUM LENGTH: 55
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-55 characters in length.
  • DESCRIPTION:  
    Other Payer Address Line 1.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, N3 Other Payer Address, N301 Other Payer Address Line 1.
15.02 OTH PAYER ADDR LINE 2 15;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>55!($L(X)<1) X
    MAXIMUM LENGTH: 55
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-55 characters in length.
  • DESCRIPTION:  
    Other Payer Address Line 2.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, N3 Other Payer Address, N302 Other Payer Address Line 2.
15.03 OTH PAYER CITY NAME 15;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<2) X
    MAXIMUM LENGTH: 30
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 2-30 characters in length.
  • DESCRIPTION:  
    Other Payer City Name.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, N4 Other Payer City, State, Zip, N401 Other Payer City Name.
15.04 OTH PAYER STATE CODE 15;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
    MAXIMUM LENGTH: 2
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 2 characters in length.
  • DESCRIPTION:  
    Other Payer State Code.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, N4 Other Payer City, State, Zip, N402 Other Payer State Code.
15.05 OTH PAYER POSTAL ZIP 15;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>15!($L(X)<3) X
    MAXIMUM LENGTH: 15
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 3-15 characters in length.
  • DESCRIPTION:  
    Other Payer Postal Zone or ZIP Code.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, N4 Other Payer City, State, Zip, N403 Other Payer Postal Zone or ZIP Code.
15.06 OTH PAYER COUNTRY CODE 15;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<2) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 2-3 characters in length.
  • DESCRIPTION:  
    Other Payer Country Code.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, N4 Other Payer City, State, Zip, N404 Other Payer Country Code.
15.07 OTH PAYER COUNTRY SUBDIV CODE 15;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<1) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  JUL 13, 2017
  • HELP-PROMPT:  Answer must be 1-3 characters in length.
  • DESCRIPTION:  
    Other Payer Country Subdivision Code.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, N4 Other Payer City, State, Zip, N407 Other Payer Country Subdivision Code.
16.01 OTH PAYER DATE TIME QUAL 16;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<3) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 3 characters in length.
  • DESCRIPTION:  
    Date Time Qualifier.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, DTP Claim Check or Remittance Date, DTP01 Date Time Qualifier.
16.02 OTH PAYER DTIME PER FORM QUAL 16;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<2) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 2-3 characters in length.
  • DESCRIPTION:  
    Date Time Period Format Qualifier.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, DTP Claim Check or Remittance Date, DTP02 Date Time Period Format Qualifier.
16.03 OTH PAYER ADJ OR PAYMENT DATE 16;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>35!($L(X)<1) X
    MAXIMUM LENGTH: 35
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-35 characters in length.
  • DESCRIPTION:  
    Adjudication or Payment Date.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, DTP Claim Check or Remittance Date, DTP03 Adjudication or Payment Date.
17.01 OTH PAYER 2ND REF ID QUAL 1 17;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<2) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 2-3 characters in length.
  • DESCRIPTION:  
    Reference Identification Qualifier 1.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, REF Other Payer Secondary ID, REF01 Reference Identification Qualifier 1.
17.02 OTH PAYER 2NDARY ID 1 17;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
    MAXIMUM LENGTH: 50
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    Other Payer Secondary Identifier 1.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, REF Other Payer Secondary ID, REF02 Other Payer Secondary Identifier 1.
17.03 OTH PAYER 2ND REF ID QUAL 2 17;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<2) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 2-3 characters in length.
  • DESCRIPTION:  
    Reference Identification Qualifier 2.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, REF Other Payer Secondary ID, REF01 Reference Identification Qualifier 2.
17.04 OTH PAYER 2NDARY ID 2 17;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
    MAXIMUM LENGTH: 50
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    Other Payer Secondary Identifier 2.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, REF Other Payer Secondary ID, REF02 Other Payer Secondary Identifier 2.
17.05 OTH PAYER PR AUTH REF ID QUAL 17;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<2) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 2-3 characters in length.
  • DESCRIPTION:  
    Reference Identification Qualifier.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, REF Other Payer Prior Authorization Number, REF01 Reference Identification Qualifier.
17.06 OTH PAYER PRIOR AUTH NUM 17;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
    MAXIMUM LENGTH: 50
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    Other Payer Prior Authorization Number.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, REF Other Payer Prior Authorization Number, REF02 Other Payer Prior Authorization Number.
17.07 OTH PAYER REFFERL REF ID QUAL 17;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<2) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 2-3 characters in length.
  • DESCRIPTION:  
    Reference Identification Qualifier.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, REF Other Payer Referral Number, REF01 Reference Identification Qualifier.
17.08 OTH PAYER REFFERAL NUMBER 17;8 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
    MAXIMUM LENGTH: 50
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    Reference Identification Qualifier.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, REF Other Payer Referral Number, REF01 Reference Identification Qualifier.
18.01 OTH PAYER CLM ADJ REF ID QUAL 18;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<2) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 2-3 characters in length.
  • DESCRIPTION:  
    Reference Identification Qualifier.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, REF Other Payer Claim Adjustment Indicator, REF01 Reference Identification Qualifier.
18.02 OTH PAYER CLAIM ADJ INDICATOR 18;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
    MAXIMUM LENGTH: 50
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    Other Payer Claim Adjustment Indicator.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, REF Other Payer Claim Adjustment Indicator, REF02 Other Payer Claim Adjustment Indicator.
18.03 OTH PAYER CLM CTRL REF ID QUAL 18;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<2) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 2-3 characters in length.
  • DESCRIPTION:  
    Reference Identification Qualifier.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, REF Other Payer Claim Control Number, REF01 Reference Identification Qualifier.
18.04 OTH PAYER CLAIM CTRL NUMBER 18;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
    MAXIMUM LENGTH: 50
  • LAST EDITED:  APR 18, 2017
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    Other Payer Claim Control Number.
  • TECHNICAL DESCR:  
    X12, #2330B, Other Payer Name, REF Other Payer Claim Control Number, REF02 Other Payer Claim Control Number.
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