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Sub-Field: 162.3711

Package: Fee Basis

FEE BASIS PAYMENT(#162)-->162.01-->162.02-->162.03-->162.371-->162.3711

Sub-Field: 162.3711


Information

Parent File Name Number Package
162.371 LINE ADJUDICATION INFORMATION 162.3711 Fee Basis

Details

Field # Name Loc Type Details
.01 OTHER PRIMARY PAYER ID 0;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>80!($L(X)<2) X
    MAXIMUM LENGTH: 80
  • LAST EDITED:  JUL 06, 2017
  • HELP-PROMPT:  Answer must be 2-80 characters in length.
  • DESCRIPTION:  
    Other Primary Payer Identifier.
  • TECHNICAL DESCR:  
    X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line Adjudication Info, SVD01 Other Primary Payer Identifier.
  • CROSS-REFERENCE:  162.3711^B
    1)= S ^FBAAC(DA(5),1,DA(4),1,DA(3),1,DA(2),11,DA(1),1,"B",$E(X,1,30),DA)=""
    2)= K ^FBAAC(DA(5),1,DA(4),1,DA(3),1,DA(2),11,DA(1),1,"B",$E(X,1,30),DA)
.02 SERVICE LINE PAID AMT 0;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  JUL 06, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Service Line Paid Amount.
  • TECHNICAL DESCR:  
    X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line Adjudication Info, SVD02 Service Line Paid Amount.
1.01 PROD OR SERV ID QUAL 1;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
    MAXIMUM LENGTH: 2
  • LAST EDITED:  JUL 06, 2017
  • HELP-PROMPT:  Answer must be 2 characters in length.
  • DESCRIPTION:  
    Product or Service ID Qualifier.
  • TECHNICAL DESCR:  
    X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line Adjudication Info, SVD03-1 Product or Service ID Qualifier.
1.02 PROCEDURE CODE 1;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>48!($L(X)<1) X
    MAXIMUM LENGTH: 48
  • LAST EDITED:  JUL 06, 2017
  • HELP-PROMPT:  Answer must be 1-48 characters in length.
  • DESCRIPTION:  
    Procedure Code.
  • TECHNICAL DESCR:  
    X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line Adjudication Info, SVD03-2 Procedure Code.
1.03 PROC MODIF SVD03-3 1;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
    MAXIMUM LENGTH: 2
  • LAST EDITED:  JUL 06, 2017
  • HELP-PROMPT:  Answer must be 2 characters in length.
  • DESCRIPTION:  
    Procedure Modifier.
  • TECHNICAL DESCR:  
    X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line Adjudication Info, SVD03-3 Procedure Modifier.
1.04 PROC MODIF SVD03-4 1;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
    MAXIMUM LENGTH: 2
  • LAST EDITED:  JUL 06, 2017
  • HELP-PROMPT:  Answer must be 2 characters in length.
  • DESCRIPTION:  
    Procedure Modifier.
  • TECHNICAL DESCR:  
    X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line Adjudication Info, SVD03-4 Procedure Modifier.
1.05 PROC MODIF SVD03-5 1;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
    MAXIMUM LENGTH: 2
  • LAST EDITED:  JUL 06, 2017
  • HELP-PROMPT:  Answer must be 2 characters in length.
  • DESCRIPTION:  
    Procedure Modifier.
  • TECHNICAL DESCR:  
    X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line Adjudication Info, SVD03-5 Procedure Modifier.
1.06 PROC MODIF SVD03-6 1;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
    MAXIMUM LENGTH: 2
  • LAST EDITED:  JUL 06, 2017
  • HELP-PROMPT:  Answer must be 2 characters in length.
  • DESCRIPTION:  
    Procedure Modifier.
  • TECHNICAL DESCR:  
    X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line Adjudication Info, SVD03-6 Procedure Modifier.
1.07 PROC CODE DESCRIPTION 1;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>80!($L(X)<1) X
    MAXIMUM LENGTH: 80
  • LAST EDITED:  JUL 06, 2017
  • HELP-PROMPT:  Answer must be 1-80 characters in length.
  • DESCRIPTION:  
    Procedure Code Description.
  • TECHNICAL DESCR:  
    X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line Adjudication Info, SVD03-7 Procedure Code Description.
1.08 PRODUCT OR SERV ID 1;8 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>48!($L(X)<1) X
    MAXIMUM LENGTH: 48
  • LAST EDITED:  JUL 06, 2017
  • HELP-PROMPT:  Answer must be 1-48 characters in length.
  • DESCRIPTION:  
    Product or Service ID.
  • TECHNICAL DESCR:  
    X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line Adjudication Info, SVD04 Product or Service ID.
1.09 PAID SERV UNIT CNT 1;9 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>15!($L(X)<1) X
    MAXIMUM LENGTH: 15
  • LAST EDITED:  JUL 06, 2017
  • HELP-PROMPT:  Answer must be 1-15 characters in length.
  • DESCRIPTION:  
    Paid Service Unit Count.
  • TECHNICAL DESCR:  
    X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line Adjudication Info, SVD05 Paid Service Unit Count.
1.1 BUNDL OR UNBUNDL LINE NUM 1;10 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>6!($L(X)<1) X
    MAXIMUM LENGTH: 6
  • LAST EDITED:  JUL 06, 2017
  • HELP-PROMPT:  Answer must be 1-6 characters in length.
  • DESCRIPTION:  
    Bundled or Unbundled Line Number.
  • TECHNICAL DESCR:  
    X12, #2400, Service Line Number, 2430 Line Adjudication Information, SVD Line Adjudication Info, SVD06 Bundled or Unbundled Line Number.
2 LINE ADJUSTMENT 2;0 Multiple #162.37112 162.37112

  • DESCRIPTION:  
    This multiple contains the Claim Adjustment Group Code and adjustment codes, amounts and quantities related to it.
  • TECHNICAL DESCR:  
    CAS Line Adjustment multiple.
3.01 LN CHK DATE TIME QUALIFIER 3;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<3) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  JUL 06, 2017
  • HELP-PROMPT:  Answer must be 3 characters in length.
  • DESCRIPTION:  
    Date Time Qualifier.
  • TECHNICAL DESCR:  
    X12, #2400, Service Line Number, 2430 Line Adjudication Information, DTP Line Check or Remittance Advice, DTP01 Date Time Qualifier.
3.02 LN CHK DATE TIME PER FORM QUAL 3;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<2) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  JUL 06, 2017
  • HELP-PROMPT:  Answer must be 2-3 characters in length.
  • DESCRIPTION:  
    Date Time Period Format Qualifier.
  • TECHNICAL DESCR:  
    X12, #2400, Service Line Number, 2430 Line Adjudication Information, DTP Line Check or Remittance Advice, DTP02 Date Time Period Format Qualifier.
3.03 LN CHK ADJ OR PAYMENT DATE 3;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>35!($L(X)<1) X
    MAXIMUM LENGTH: 35
  • LAST EDITED:  JUL 06, 2017
  • HELP-PROMPT:  Answer must be 1-35 characters in length.
  • DESCRIPTION:  
    Adjudication or Payment Date.
  • TECHNICAL DESCR:  
    X12, #2400, Service Line Number, 2430 Line Adjudication Information, DTP Line Check or Remittance Advice, DTP03 Adjudication or Payment Date.
4.01 REMAIN PAT LIAB AMT QUAL CODE 4;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<1) X
    MAXIMUM LENGTH: 3
  • LAST EDITED:  JUL 06, 2017
  • HELP-PROMPT:  Answer must be 1-3 characters in length.
  • DESCRIPTION:  
    Amount Qualifier Code.
  • TECHNICAL DESCR:  
    X12, #2400, Service Line Number, 2430 Line Adjudication Information, AMT Remaining Patient Liability, AMT01 Amount Qualifier Code.
4.02 REMAIN PAT LIABILITY AMOUNT 4;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>18!($L(X)<1) X
    MAXIMUM LENGTH: 18
  • LAST EDITED:  JUL 06, 2017
  • HELP-PROMPT:  Answer must be 1-18 characters in length.
  • DESCRIPTION:  
    Remaining Patient Liability Amount.
  • TECHNICAL DESCR:  
    X12, #2400, Service Line Number, 2430 Line Adjudication Information, AMT Remaining Patient Liability, AMT02 Remaining Patient Liability Amount.
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