File EXPLANATION_OF_BENEFITS(361.1) Data List
| BILL |
PAYER NAME |
PAYER ID |
EOB TYPE |
ENTRY DATE/TIME |
EOB PAID DATE |
TRACE NUMBER |
CROSSED OVER NAME |
CROSSED OVER ID |
DRG CODE USED |
DRG WEIGHT USED |
DISCHARGE FRACTION |
CLAIM STATUS |
ICN |
INSURANCE SEQUENCE |
REVIEW STATUS |
MANUAL ENTRY? |
MANUALLY ENTERED BY |
TRANSMIT BILL |
FINAL REVIEW ACTION |
CLAIM STATUS CODE |
PARTIAL EOB |
PAYER PAID AMT |
PATIENT RESPONSIBILITY AMT |
COVERED AMT |
DISCOUNT AMT |
PER DAY LIMIT AMT |
INTEREST AMT |
TAX AMT |
TOTAL BEFORE TAXES AMT |
STATEMENT START DATE |
STATEMENT END DATE |
CLAIM RECEIVED DATE |
COVERAGE EXPIRATION DATE |
CORRECTED PRIORITY PAYER NAME |
CORRECTED PRIORITY PAYER TYPE |
CORRECTED PRIORITY PAYER ID |
OTHER SUBSCRIBER NAME |
835 CLAIM LEVEL ADJUSTMENTS |
BATCH NUMBER |
RETURN MESSAGE ID |
LAST EDITED BY |
LAST EDITED DATE |
MESSAGE CHECKSUM |
MOVE/COPY/REMOVE HISTORY |
EEOB REMOVED |
PLB DUPLICATE |
ERA DETAIL |
835 LINE LEVEL ADJUSTMENTS |
TOTAL ALLOWED AMT |
TOTAL SUBMITTED CHARGES |
NEGATIVE REIMBURSEMENT AMT |
HPID/OEID |
MESSAGE STORAGE ERRORS |
REVIEW DATE/TIME |
PAYER CONTACT NAME |
CONTACT NUMBER 1 |
CONTACT TYPE 1 |
CONTACT NUMBER 2 |
CONTACT TYPE 2 |
CONTACT NUMBER 3 |
CONTACT TYPE 3 |
M-CARE OUTP REIMBURS. RATE |
M-CARE OUTP HCPCS PAYMNT AMT |
M-CARE OUTP REMARKS CODE-1 |
M-CARE OUTP REMARKS CODE-2 |
M-CARE OUTP REMARKS CODE-3 |
M-CARE OUTP REMARKS CODE-4 |
M-CARE OUTP REMARKS CODE-5 |
M-CARE ESRD PAID AMT |
M-CARE NON-PAYABLE PROF COMP |
AUTO BILL MESSAGE |
AUTO BILL MESSAGE DATE/TIME |
M-CARE INP COV. DAYS/VISIT CT |
M-CARE INP LIFETM PSYCH DY CT |
M-CARE INP CLAIM DRG AMT |
M-CARE INP CAP EXCEPTION AMT |
M-CARE INP DISPROP. SHARE AMT |
M-CARE INP MSP PASS THRU AMT |
M-CARE INP PPS CAPITAL AMT |
M-CARE INP PPS CAP FSP-DRG AMT |
M-CARE INP PPS CAP HSP-DRG AMT |
M-CARE INP PPS CAP DSH-DRG AMT |
M-CARE INP OLD CAPITAL AMT |
M-CARE INP PPS CAPITAL IME AMT |
M-CARE INP PPS OP HOS DRG AMT |
M-CARE INP COST REPORT DAY CT |
M-CARE INP PPS OP FED DRG AMT |
M-CARE INP PPS CAP OUTLIER AMT |
M-CARE INP INDIRECT TEACH AMT |
M-CARE INP NON-PAY PROF COMP |
MEDICARE NON-COVERED DAYS |
M-CARE INP PYMNT REMARK CODE-1 |
REMARK CODE-1 SHORT TEXT |
M-CARE INP PYMNT REMARK CODE-2 |
REMARK CODE-2 SHORT TEXT |
M-CARE INP PYMNT REMARK CODE-3 |
REMARK CODE-3 SHORT TEXT |
M-CARE INP PYMNT REMARK CODE-4 |
REMARK CODE-4 SHORT TEXT |
M-CARE INP PYMNT REMARK CODE-5 |
REMARK CODE-5 SHORT TEXT |
NEW PATIENT NAME |
NEW PATIENT ID |
CORRECTED DATA MESSAGE |
ORIGINAL 06 RECORD DATA |
MAILMAN HEADER INFORMATION |
TRANSFERRED IN |
AR AMOUNTS DISTRIBUTION |