{"aaData": [["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
30
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
30
\n", "
1
\n", "", "
NO
\n", "
6.9
\n", "
29
\n", "
INSURED DEMO (BDT/SEX/PHONE)
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
105
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
60
\n", "
Other Group or Policy Name
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
36
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
2
\n", "
Payer Claim Control Number Qualifier
\n", "", "
TRUE
\n", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
37
\n", "", "
YES
\n", "
70
\n", "
10
\n", "
PURCH SVC CHARGES (BX-20/C)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
19
\n", "
80
\n", "
Claim Note Text
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
20
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
105
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
Insurance Type Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
30
\n", "
61
\n", "
Line Note Text
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
97
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
3
\n", "
Rend Prov Credentials
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
62
\n", "", "
YES
\n", "
23
\n", "
27
\n", "
NON-VA FACILITY ID
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
20
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
2
\n", "
Insurance Type Code
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
110
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
60
\n", "
Other Subscriber Last Name
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
26
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
190
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
2
\n", "
Service ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
195
\n", "
1
\n", "", "
NO
\n", "
15
\n", "
2
\n", "
Product or Service ID Qualifier
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
5
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
13
\n", "
X12 Version Number for HIPAA
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
28
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
2
\n", "
Billing Prov Sec ID Qualifier(3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
30
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
10
\n", "
Subscriber Name Suffix
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
110
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
35
\n", "
Other Subscriber First Name
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
17
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
110
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
25
\n", "
Other Subscriber Middle Name
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
18
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
19
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
8
\n", "
Initial Treatment DT (Spinal)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
8
\n", "
Last X-Ray DT (Spinal)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
1
\n", "
Medicare Assignment Code
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
30
\n", "
Mammography Certification #
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
1
\n", "
Pt. Condition Description (Spinal)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
8
\n", "
Acute Manifestation DT (Spinal)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
55
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
50
\n", "
Lab/Facility Address 2
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
57
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
2
\n", "
Lab/Facility Entity Code
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
57
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
1
\n", "
Lab/Facility Entity Type Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
57
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
57
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
2
\n", "
Lab/Facility Sec ID Qualifier(1)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
57
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "
2
\n", "
Lab/Facility ID Setup
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
57
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
20
\n", "
Lab/Facility Primary ID
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
97
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
2
\n", "
Referring Prov Primary ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
97
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
10
\n", "
Referring Prov Primary ID
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
2
\n", "
Mammography Certification Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
103
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OPR7'
\n", "
OUTPUT
\n", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
103
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "", "
SPRVSING PROV FULL NAME
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
103
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
35
\n", "
Supervising Prov Last Name
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
103
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
25
\n", "
Supervising Prov First Name
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
107
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
15
\n", "
Other Payer Paid Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
103
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
25
\n", "
Supervising Prov Middle Name
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
103
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
10
\n", "
Supervising Prov Name Suffix
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
103
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
2
\n", "
Supervising Prov Primary ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
103
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
30
\n", "
Supervising Prov Primary ID
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
105
\n", "
1
\n", "
0
\n", "
NO
\n", "
9
\n", "
1
\n", "
Other Payer Pt. Signature Source Code
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
112
\n", "
1
\n", "", "
NO
\n", "
2.9
\n", "", "
CLEAN UP OTHER PAYER ADDRESS
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
112
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
55
\n", "
Other Payer Address Line 1
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
112
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
55
\n", "
Other Payer Address Line 2
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
112
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
30
\n", "
Other Payer City Name
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
112
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
2
\n", "
Other Payer State Code
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
112
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
15
\n", "
Other Payer ZIP Code
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
110
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
35
\n", "
Other Subscriber Employer Name
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
113
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
10
\n", "
Other Subscriber Name Suffix
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
110
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
28
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
20
\n", "
Billing Prov Sec ID(3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
28
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
Billing Prov Sec ID Qualifier(4)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
28
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
20
\n", "
Billing Prov Sec ID(4)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
30
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
1
\n", "
Subscriber Gender Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
110
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170
\n", "
1
\n", "
0
\n", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OP1 '
\n", "
OUTPUT
\n", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170
\n", "
1
\n", "
0
\n", "
NO
\n", "
3
\n", "
2
\n", "
Other Payer Att/Rend Entity ID
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170
\n", "
1
\n", "
0
\n", "
NO
\n", "
4
\n", "
1
\n", "
Other Payer Att/Rend Entity Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170
\n", "
1
\n", "
0
\n", "
NO
\n", "
5
\n", "
2
\n", "
Other Payer Att/Rend Sec ID Qualifier(1)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170
\n", "
1
\n", "
0
\n", "
NO
\n", "
6
\n", "
30
\n", "
Other Payer Att/Rend Sec ID(1)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170
\n", "
1
\n", "
0
\n", "
NO
\n", "
7
\n", "
2
\n", "
Other Payer Att/Rend Sec ID Qualifier(2)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170
\n", "
1
\n", "
0
\n", "
NO
\n", "
8
\n", "
30
\n", "
Other Payer Att/Rend Sec ID(2)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170
\n", "
1
\n", "
0
\n", "
NO
\n", "
9
\n", "
2
\n", "
Other Payer Att/Rend Sec ID Qualifier(3)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170
\n", "
1
\n", "
0
\n", "
NO
\n", "
10
\n", "
30
\n", "
Other Payer Att/Rend Sec ID(3)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
171
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OP2 '
\n", "
OUTPUT
\n", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
171
\n", "
1
\n", "
0
\n", "
NO
\n", "
3
\n", "
2
\n", "
Other Payer Operating Phy Entity ID
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
171
\n", "
1
\n", "
0
\n", "
NO
\n", "
4
\n", "
1
\n", "
Other Payer Oper Phy Entity Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
171
\n", "
1
\n", "
0
\n", "
NO
\n", "
5
\n", "
2
\n", "
Other Payer Oper Phy Sec ID Qualifier(1)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
6
\n", "
Service Line #
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
171
\n", "
1
\n", "
0
\n", "
NO
\n", "
6
\n", "
30
\n", "
Other Payer Operating Phy Sec ID(1)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
171
\n", "
1
\n", "
0
\n", "
NO
\n", "
7
\n", "
2
\n", "
Other Payer Oper Phy Sec ID Qualifier(2)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
171
\n", "
1
\n", "
0
\n", "
NO
\n", "
8
\n", "
30
\n", "
Other Payer Operating Phy Sec ID(2)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
171
\n", "
1
\n", "
0
\n", "
NO
\n", "
9
\n", "
2
\n", "
Other Payer Oper Phy Sec ID Qualifier(3)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
171
\n", "
1
\n", "
0
\n", "
NO
\n", "
10
\n", "
30
\n", "
Other Payer Operating Phy Sec ID(3)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
172
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OP3 '
\n", "
OUTPUT
\n", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
172
\n", "
1
\n", "
0
\n", "
NO
\n", "
3
\n", "
2
\n", "
Other Payer Lab/Facility Entity ID
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
172
\n", "
1
\n", "
0
\n", "
NO
\n", "
4
\n", "
1
\n", "
Other Payer Lab/Fac Entity Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
172
\n", "
1
\n", "
0
\n", "
NO
\n", "
5
\n", "
2
\n", "
Other Payer Lab/Fac Sec ID Qualifier(1)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
2
\n", "
Service ID Qualifier
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
172
\n", "
1
\n", "
0
\n", "
NO
\n", "
6
\n", "
30
\n", "
Other Payer Lab/Facility Sec ID(1)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
172
\n", "
1
\n", "
0
\n", "
NO
\n", "
7
\n", "
2
\n", "
Other Payer Lab/Fac Sec ID Qualifier(2)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
172
\n", "
1
\n", "
0
\n", "
NO
\n", "
8
\n", "
30
\n", "
Other Payer Lab/Facility Sec ID(2)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
172
\n", "
1
\n", "
0
\n", "
NO
\n", "
9
\n", "
2
\n", "
Other Payer Lab/Fac Sec ID Qualifier(3)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
172
\n", "
1
\n", "
0
\n", "
NO
\n", "
10
\n", "
30
\n", "
Other Payer Lab/Facility Sec ID(3)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
173
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OP4 '
\n", "
OUTPUT
\n", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
173
\n", "
1
\n", "
0
\n", "
NO
\n", "
3
\n", "
2
\n", "
Other Payer Referring Prov Entity ID
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
173
\n", "
1
\n", "
0
\n", "
NO
\n", "
4
\n", "
1
\n", "
Other Payer Refer Prov Entity Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
173
\n", "
1
\n", "
0
\n", "
NO
\n", "
5
\n", "
2
\n", "
Other Payer Refer Prov Sec ID Qual(1)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
173
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
30
\n", "
Other Payer Referring Prov Sec ID(1)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
9
\n", "
Line Item Charge Amt
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
173
\n", "
1
\n", "
0
\n", "
NO
\n", "
7
\n", "
2
\n", "
Other Payer Refer Prov Sec ID Qual(2)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
173
\n", "
1
\n", "
0
\n", "
NO
\n", "
8
\n", "
30
\n", "
Other Payer Referring Prov Sec ID(2)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
173
\n", "
1
\n", "
0
\n", "
NO
\n", "
9
\n", "
2
\n", "
Other Payer Refer Prov Sec ID Qual(3)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
173
\n", "
1
\n", "
0
\n", "
NO
\n", "
10
\n", "
30
\n", "
Other Payer Referring Prov Sec ID(3)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
6
\n", "
Service Unit Count
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
2
\n", "
Place of Service Code
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
176
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OP7 '
\n", "
OUTPUT
\n", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
176
\n", "
1
\n", "
0
\n", "
NO
\n", "
3
\n", "
2
\n", "
Other Payer Service Facility Entity ID
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
176
\n", "
1
\n", "
0
\n", "
NO
\n", "
4
\n", "
1
\n", "
Other Payer Service Fac Entity Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
176
\n", "
1
\n", "
0
\n", "
NO
\n", "
5
\n", "
2
\n", "
Other Payer Service Fac Sec ID Qual(1)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
176
\n", "
1
\n", "
0
\n", "
NO
\n", "
6
\n", "
30
\n", "
Other Payer Service Facility Sec ID(1)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
176
\n", "
1
\n", "
0
\n", "
NO
\n", "
7
\n", "
2
\n", "
Other Payer Service Fac Sec ID Qual(2)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
176
\n", "
1
\n", "
0
\n", "
NO
\n", "
8
\n", "
30
\n", "
Other Payer Service Facility Sec ID(2)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
176
\n", "
1
\n", "
0
\n", "
NO
\n", "
9
\n", "
2
\n", "
Other Payer Service Fac Sec ID Qual(3)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
176
\n", "
1
\n", "
0
\n", "
NO
\n", "
10
\n", "
30
\n", "
Other Payer Service Facility Sec ID(3)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
177
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OP8 '
\n", "
OUTPUT
\n", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
177
\n", "
1
\n", "
0
\n", "
NO
\n", "
3
\n", "
2
\n", "
Other Payer Supervising Prov Entity ID
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
177
\n", "
1
\n", "
0
\n", "
NO
\n", "
4
\n", "
1
\n", "
Other Payer Super Prov Entity ID Qual
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
177
\n", "
1
\n", "
0
\n", "
NO
\n", "
5
\n", "
2
\n", "
Other Payer Super Prov Sec ID Qual(1)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
177
\n", "
1
\n", "
0
\n", "
NO
\n", "
6
\n", "
30
\n", "
Other Payer Supervising Prov Sec ID(1)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
177
\n", "
1
\n", "
0
\n", "
NO
\n", "
7
\n", "
2
\n", "
Other Payer Super Prov Sec ID Qual(2)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
177
\n", "
1
\n", "
0
\n", "
NO
\n", "
8
\n", "
30
\n", "
Other Payer Supervising Prov Sec ID(2)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
177
\n", "
1
\n", "
0
\n", "
NO
\n", "
9
\n", "
2
\n", "
Other Payer Super Prov Sec ID Qual(3)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
177
\n", "
1
\n", "
0
\n", "
NO
\n", "
10
\n", "
30
\n", "
Other Payer Supervising Prov Sec ID(3)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
8
\n", "
Service DT From
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OP9 '
\n", "
OUTPUT
\n", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178
\n", "
1
\n", "
0
\n", "
NO
\n", "
3
\n", "
2
\n", "
Other Payer Oth Op Prov Entity ID
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178
\n", "
1
\n", "
0
\n", "
NO
\n", "
4
\n", "
1
\n", "
Other Payer Oth Op Prov Entity Qual
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178
\n", "
1
\n", "
0
\n", "
NO
\n", "
5
\n", "
2
\n", "
Other Payer Oth Op Prov Sec ID Qual(1)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178
\n", "
1
\n", "
0
\n", "
NO
\n", "
6
\n", "
30
\n", "
Other Payer Oth Op Prov Sec ID(1)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178
\n", "
1
\n", "
0
\n", "
NO
\n", "
7
\n", "
2
\n", "
Other Payer Oth Op Prov Sec ID Qual(2)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178
\n", "
1
\n", "
0
\n", "
NO
\n", "
8
\n", "
30
\n", "
Other Payer Oth Op Prov Sec ID(2)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178
\n", "
1
\n", "
0
\n", "
NO
\n", "
9
\n", "
2
\n", "
Other Payer Oth Op Prov Sec ID Qual(3)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178
\n", "
1
\n", "
0
\n", "
NO
\n", "
10
\n", "
30
\n", "
Other Payer Oth Op Prov Sec ID(3)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'CL1A'
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
2
\n", "
Diagnosis Code Pointer(1)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
28
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'CI1A'
\n", "
OUTPUT
\n", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
28
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
2
\n", "
Billing Prov Sec ID Qualifier(2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
28
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
20
\n", "
Billing Prov Sec ID(2)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
55
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
32
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
20
\n", "
Subscriber Phone #
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
2
\n", "
Diagnosis Code Pointer(2)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
57
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'SUB2'
\n", "
OUTPUT
\n", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
57
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
20
\n", "
Lab/Facility Sec ID(1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
2
\n", "
Diagnosis Code Pointer(3)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
57
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
2
\n", "
Lab/Facility Sec ID Qualifier(2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
57
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
20
\n", "
Lab/Facility Sec ID(2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
57
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
2
\n", "
Lab/Facility Sec ID Qualifier(3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
57
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
20
\n", "
Lab/Facility Sec ID(3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
101
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OPR5'
\n", "
OUTPUT
\n", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OPR8'
\n", "
OUTPUT
\n", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
2
\n", "
Diagnosis Code Pointer(4)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
99
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OPR3'
\n", "
OUTPUT
\n", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
98
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OPR2'
\n", "
OUTPUT
\n", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
97
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OPR1'
\n", "
OUTPUT
\n", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
96
\n", "
1
\n", "
0
\n", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OPR '
\n", "
OUTPUT
\n", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
98
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
2
\n", "
Attending Prov Sec ID Qualifier (1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
98
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
30
\n", "
Attending Prov Sec ID (1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
98
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
2
\n", "
Attending Prov Sec ID Qualifier (2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
98
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
30
\n", "
Attending Prov Sec ID (2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
98
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
2
\n", "
Attending Prov Sec ID Qualifier (3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
98
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
30
\n", "
Attending Prov Sec ID (3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
185
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
6
\n", "
Service Line Counter
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
98
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
Attending Prov Sec ID Qualifier (4)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
98
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
30
\n", "
Attending Prov Sec ID (4)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
99
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
2
\n", "
Operating Phy Sec ID Qualifier(1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
99
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
30
\n", "
Operating Phy Sec ID(1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
99
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
2
\n", "
Operating Phy Sec ID Qualifier(2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
99
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
30
\n", "
Operating Phy Sec ID(2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
99
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
2
\n", "
Operating Phy Sec ID Qualifier(3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
99
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
30
\n", "
Operating Phy Sec ID(3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
185
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
10
\n", "
Revenue Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
99
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
Operating Phy Sec ID Qualifier(4)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
99
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
30
\n", "
Operating Phy Sec ID(4)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
100
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
2
\n", "
Other Prov Sec ID Qualifier(1)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
100
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
30
\n", "
Other Prov Sec ID(1)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
100
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
2
\n", "
Other Prov Sec ID Qualifier(2)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
100
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
30
\n", "
Other Prov Sec ID(2)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
100
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
2
\n", "
Other Prov Sec ID Qualifier(3)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
100
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
30
\n", "
Other Prov Sec ID(3)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
185
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
10
\n", "
Procedure Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
100
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
Other Prov Sec ID Qualifier(4)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
100
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
30
\n", "
Other Prov Sec ID(4)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
101
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
2
\n", "
Referring Prov Sec ID Qualifier(1)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
101
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
30
\n", "
Referring Prov Sec ID(1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
101
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
2
\n", "
Referring Prov Sec ID Qualifier(2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
101
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
30
\n", "
Referring Prov Sec ID(2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
101
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
2
\n", "
Referring Prov Sec ID Qualifier(3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
101
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
30
\n", "
Referring Prov Sec ID(3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
185
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
6
\n", "
Service Unit Count
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
185
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
2
\n", "
Supervising Prov Sec ID Qualifier(1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
30
\n", "
Supervising Prov Sec ID(1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
2
\n", "
Supervising Prov Sec ID Qualifier(2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
185
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
2
\n", "
Procedure Modifier(1)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
30
\n", "
Supervising Prov Sec ID(2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
2
\n", "
Supervising Prov Sec ID Qualifier(3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
30
\n", "
Supervising Prov Sec ID(3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
Supervising Prov Sec ID Qualifier(4)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
30
\n", "
Supervising Prov Sec ID(4)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
112
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OI4 '
\n", "
OUTPUT
\n", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
113
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OI5 '
\n", "
OUTPUT
\n", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
113
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
55
\n", "
Other Subscriber Address 1
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
185
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
Procedure Modifier(2)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
113
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
55
\n", "
Other Subscriber Address 2
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
113
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
30
\n", "
Other Subscriber City Name
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
113
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
2
\n", "
Other Subscriber State Code
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
113
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
10
\n", "
Other Subscriber ZIP Code
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
113
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
2
\n", "
Other Subscriber Sec ID Qualifier(1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
113
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
30
\n", "
Other Subscriber Sec ID(1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
36
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "
62
\n", "
INSURED EMPLR GRP (NM/CITY/ST)
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
185
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
18
\n", "
Service Line Charge Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
100
\n", "
1
\n", "
0
\n", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OPR4'
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
177
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
171
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
172
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
173
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
176
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
185
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
8
\n", "
Service Date From
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
112
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
113
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
20
\n", "
1
\n", "
1
\n", "
NO
\n", "
9
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
20
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
20
\n", "
1
\n", "
1
\n", "", "
13
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
97
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
1
\n", "
Referring Prov Entity Type Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
97
\n", "
1
\n", "", "
NO
\n", "
15
\n", "
1
\n", "
Operating Phy Entity Type Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
185
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
113
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "
1
\n", "
CLEAN UP OI5
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
20
\n", "
1
\n", "
1
\n", "
NO
\n", "
14
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
20
\n", "
1
\n", "
1
\n", "
NO
\n", "
15
\n", "
1
\n", "
MRA Secondary Indicator
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
190
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
6
\n", "
Service Line Counter
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
190
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
15
\n", "
Prescription #
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
190
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
11
\n", "
National Drug Code(1)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
190
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
190
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
55
\n", "
Drug Name, Quantity, Days Supply
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
190
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
8
\n", "
Service Date (Refill)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
75
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "
99
\n", "
PROCEDURE CODES/DATES
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
3.9
\n", "
70
\n", "
PATIENT FULL NAME
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
1
\n", "", "
YES
\n", "
1
\n", "
78
\n", "
PRINT STATUS (1500 TOP LINE)
\n", "
OUTPUT
\n", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
2
\n", "", "
YES
\n", "
1
\n", "
78
\n", "
MAILING ADDRESS NM (FORM LN 2)
\n", "
OUTPUT
\n", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
3
\n", "
4
\n", "
YES
\n", "
1
\n", "
78
\n", "
MAILING ADDR FULL (FORM LN 3)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
1
\n", "
45
\n", "
CHECK BOX FOR BILL TYPE (BX-1)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
50
\n", "
29
\n", "
INSURED ID # (BX-1A)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
1
\n", "
28
\n", "
PATIENT NAME (BX-2)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
31
\n", "
10
\n", "
PATIENT DOB (BX-3/1)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
42
\n", "
1
\n", "
PATIENT SEX=MALE (BX-3/2A)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
47
\n", "
1
\n", "
PATIENT SEX=FEMALE (BX-3/2B)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
49.9
\n", "
80
\n", "
CURR INSURED DEMOG EXTRACT
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
65
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "
50
\n", "
OCCURRENCE CODE EXTRACT
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
50
\n", "
29
\n", "
INSURED'S NAME (BX-4)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
13
\n", "", "
YES
\n", "
1
\n", "
28
\n", "
PATIENT STR ADDRESS (BX-5/1)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
13
\n", "", "
YES
\n", "
33
\n", "
1
\n", "
PT REL TO INSURED=SELF (BX-6)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
13
\n", "", "
YES
\n", "
38
\n", "
1
\n", "
PT REL TO INSRD=SPOUSE (BX-6)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
13
\n", "", "
YES
\n", "
42
\n", "
1
\n", "
PT REL TO INSRD=CHILD (BX-6)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
13
\n", "", "
YES
\n", "
47
\n", "
1
\n", "
PT REL TO INSRD=OTHER (BX-6)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
13
\n", "", "
YES
\n", "
49.9
\n", "
72
\n", "
CURR INSURED'S FULL ADDR EXTR
\n", "
CALCULATE ONLY
\n", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
13
\n", "", "
YES
\n", "
50
\n", "
29
\n", "
INSURED STR ADDRESS (BX-7/1)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
15
\n", "", "
YES
\n", "
1
\n", "
24
\n", "
PATIENT CITY ADDRESS (BX-5/2A)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
15
\n", "", "
YES
\n", "
26
\n", "
2
\n", "
PATIENT STATE (BX-5/2B)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
13.9
\n", "
13
\n", "
ADMISSION DATE/TIME
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
15
\n", "", "
YES
\n", "
35
\n", "
1
\n", "
PT MARITAL STAT=SINGL (BX-8/A)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
15
\n", "", "
YES
\n", "
41
\n", "
1
\n", "
PT MARITAL STAT=MARRD (BX-8/B)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
15
\n", "", "
YES
\n", "
47
\n", "
1
\n", "
PT MARITAL STAT=OTHER (BX-8/C)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
15
\n", "", "
YES
\n", "
50
\n", "
23
\n", "
INSURED'S CITY (BX-7/2A)
\n", "
OUTPUT
\n", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
15
\n", "", "
YES
\n", "
74
\n", "
2
\n", "
INSURED'S STATE (BX-7/2B)
\n", "
OUTPUT
\n", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
17
\n", "", "
YES
\n", "
1
\n", "
12
\n", "
PATIENT ZIP CODE (BX-5/3A)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
17
\n", "", "
YES
\n", "
15
\n", "
14
\n", "
PATIENT TELEPHONE (BX-5/3B)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
17
\n", "", "
YES
\n", "
35
\n", "
1
\n", "
PT EMPL STAT=EMPLOYD (BX-8/2A)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
17
\n", "", "
YES
\n", "
50
\n", "
12
\n", "
INSURED'S ZIP CODE (BX-7/3A)
\n", "
OUTPUT
\n", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
17
\n", "", "
YES
\n", "
65
\n", "
14
\n", "
INSURED'S PHONE (BX-7/3B)
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
15.9
\n", "
13
\n", "
DISCHARGE DATE/TIME
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
1
\n", "
28
\n", "
OTH INSURED NAME (BX-9/1)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
50
\n", "
29
\n", "
INSURED POLICY GROUP (BX-11)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
21
\n", "", "
YES
\n", "
1
\n", "
28
\n", "
OTH INSURED POLICY # (BX-9A)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
21
\n", "", "
YES
\n", "
35
\n", "
1
\n", "
COND REL TO EMP=YES (BX-10A/A)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
21
\n", "", "
YES
\n", "
41
\n", "
1
\n", "
COND REL TO EMP=NO (BX-10A/B)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
21
\n", "", "
YES
\n", "
53
\n", "
10
\n", "
INSUREDS DOB (BX-11A/1)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
21
\n", "", "
YES
\n", "
68
\n", "
1
\n", "
INSUREDS SEX=MALE (BX-11A/2A)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
21
\n", "", "
YES
\n", "
75
\n", "
1
\n", "
INSURED SEX=FEMALE (BX-11A/2B)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
23
\n", "", "
YES
\n", "
2
\n", "
10
\n", "
OTH INSURED DOB (BX-9B/1)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
23
\n", "", "
YES
\n", "
18
\n", "
1
\n", "
OTH INS SEX=MALE (BX-9B/2A)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
5
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "", "
KILL IBXSAVE ARRAY
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
23
\n", "", "
YES
\n", "
24
\n", "
1
\n", "
OTH INS SEX=FEMALE (BX-9B/2B)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
23
\n", "", "
YES
\n", "
35
\n", "
1
\n", "
COND REL AUTO=YES (BX-10B/A)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
23
\n", "", "
YES
\n", "
41
\n", "
1
\n", "
COND REL AUTO=NO (BX-10B/B)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
23
\n", "", "
YES
\n", "
45
\n", "
2
\n", "
AUTO ACCIDENT STATE (BX-10B/C)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
25
\n", "", "
YES
\n", "
1
\n", "
28
\n", "
OTH INS EMPLR (BX-9C)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
25
\n", "", "
YES
\n", "
35
\n", "
1
\n", "
COND REL TO OTH=YES (BX-10C/A)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
25
\n", "", "
YES
\n", "
41
\n", "
1
\n", "
COND REL TO OTH=NO (BX-10C/B)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
25
\n", "", "
YES
\n", "
50
\n", "
29
\n", "
INSUREDS PLAN NAME (BX-11C)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
27
\n", "", "
YES
\n", "
1
\n", "
28
\n", "
OTH INS PLAN NAME (BX-9D)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
25.99
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "", "
KILL IBXSAVE ARRAY
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
27
\n", "", "
YES
\n", "
30
\n", "
19
\n", "
BOX 10D CMS-1500
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
27
\n", "", "
YES
\n", "
52
\n", "
1
\n", "
ANOTHER PLAN=YES (BX-11D/A)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
27
\n", "", "
YES
\n", "
57
\n", "
1
\n", "
ANOTHER PLAN=NO (BX-11D/B)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
30
\n", "", "
YES
\n", "
4
\n", "
45
\n", "
RELEASE OF INFO SIG (12A)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
30
\n", "", "
YES
\n", "
53
\n", "
26
\n", "
ASSIGN OF BENEFITS SIG (13A)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
31
\n", "", "
YES
\n", "
6
\n", "
25
\n", "
PATIENT SIGNATURE (BX-12)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
31
\n", "", "
YES
\n", "
36
\n", "
13
\n", "
PATIENT SIGNATURE DT (BX-12/2)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
31
\n", "", "
YES
\n", "
56
\n", "
23
\n", "
INSUREDS SIGNATURE (BX-13)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
33
\n", "", "
YES
\n", "
2
\n", "
10
\n", "
DATE OF CURR ILLNESS (BX-14)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
33
\n", "", "
YES
\n", "
37
\n", "
10
\n", "
DATE OF SIMLAR ILLNESS (BX-15)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
36
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "", "
KILL IBXSAVE ARRAY
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
33
\n", "", "
YES
\n", "
54
\n", "
10
\n", "
DT UNABLE TO WRK FR (BX-16/1)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
33
\n", "", "
YES
\n", "
68
\n", "
10
\n", "
DT UNABLE TO WRK TO (BX-16/2)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
34
\n", "", "
YES
\n", "
30
\n", "
2
\n", "
REF PROV OTH ID QUAL (17A/1)
\n", "
OUTPUT
\n", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
34
\n", "", "
YES
\n", "
33
\n", "
16
\n", "
REF PROV OTH ID# (BX 17A/2)
\n", "
OUTPUT
\n", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
35
\n", "", "
YES
\n", "
33
\n", "
16
\n", "
REFERRING PROV NPI# (BX 17B)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
35
\n", "", "
YES
\n", "
54
\n", "
10
\n", "
HOSP FROM DATE (BX-18/1)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
35
\n", "", "
YES
\n", "
68
\n", "
10
\n", "
HOSP TO DATE (BX-18/2)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
36
\n", "", "
YES
\n", "
1
\n", "
48
\n", "
UPPER LINE 1500 (BX-19)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
37
\n", "", "
YES
\n", "
1
\n", "
48
\n", "
LOWER LINE - 1500 (BX-19)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
45
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "", "
KILL IBXSAVE ARRAY
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
37
\n", "", "
YES
\n", "
52
\n", "
1
\n", "
OUTSIDE LAB? YES (BX-20)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
37
\n", "", "
YES
\n", "
61
\n", "
9
\n", "
PURCHASED SVC CHARGE (BX-20/B)
\n", "
OUTPUT
\n", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
37
\n", "", "
YES
\n", "
70
\n", "
9
\n", "
BLANK (BX-20/C)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
39
\n", "", "
YES
\n", "
3
\n", "
8
\n", "
DIAGNOSIS CODE 1 (BX-21.1)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
39
\n", "", "
YES
\n", "
29
\n", "
8
\n", "
DIAGNOSIS CODE 3 (BX-21.3)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
39
\n", "", "
YES
\n", "
50
\n", "
11
\n", "
MEDICAID RESUB CODE (BX-22/A)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
39
\n", "", "
YES
\n", "
62
\n", "
18
\n", "
ORIGINAL REF NO (BX-22/B)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
39
\n", "", "
YES
\n", "
16
\n", "
8
\n", "
DIAGNOSIS CODE 2 (BX-21.2)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
39
\n", "", "
YES
\n", "
42
\n", "
8
\n", "
DIAGNOSIS CODE 4 (BX-21.4)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
41
\n", "", "
YES
\n", "
50
\n", "
29
\n", "
PRIOR AUTH NUMBER (BX-23)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
.5
\n", "", "
SERVICE LN EXTRACT - CMS 1500
\n", "
CALCULATE ONLY
\n", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
1
\n", "
9
\n", "
DATE OF SERV FR (BX-24A/A)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
10
\n", "
9
\n", "
DATE OF SERV TO (BX-24A/B)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
19
\n", "
3
\n", "
PLACE OF SERVICE (BX-24B)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
22
\n", "
3
\n", "
EMG (BX-24C)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
25
\n", "
20
\n", "
PROCEDURE (BX-24D/1)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
45
\n", "
4
\n", "
DIAGNOSIS POINTER (BX-24E)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
50
\n", "
8
\n", "
CHARGES (BX-24F)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
58
\n", "
4
\n", "
UNITS (BX-24G)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
63
\n", "
1
\n", "
EPSDT FAMILY PLAN (BX-24H)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
65
\n", "
2
\n", "
ID QUALIFER (BX-24I)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
68
\n", "
11
\n", "
RENDERING PROVIDER ID (BX-24J)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
1
\n", "", "
CLEAN UP IBXSAVE
\n", "
CALCULATE ONLY
\n", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
57
\n", "", "
YES
\n", "
1
\n", "
15
\n", "
FED TAX ID # (BX-25/1)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
57
\n", "", "
YES
\n", "
19
\n", "
1
\n", "
ID NUMBER=EIN (BX-25/2B)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
57
\n", "", "
YES
\n", "
23
\n", "
14
\n", "
PATIENT ACCT NUMBER (BX-26)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
57
\n", "", "
YES
\n", "
38
\n", "
6
\n", "
ACCEPT ASSIGNMENT (BX-27)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
57
\n", "", "
YES
\n", "
51
\n", "
9
\n", "
TOTAL CHARGE (BX-28)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
57
\n", "", "
YES
\n", "
62
\n", "
8
\n", "
TOTAL PRIOR PAYMENTS (BX-29)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
57
\n", "", "
YES
\n", "
71
\n", "
8
\n", "
TOT CHRG-PRIOR PYMNTS (BX-30)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
75
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "", "
KILL IBXSAVE ARRAY
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
58
\n", "", "
YES
\n", "
66
\n", "
13
\n", "
BILL PROV PHONE# (BX-33/LN 1)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
59
\n", "", "
YES
\n", "
23
\n", "
26
\n", "
SERVICE FACILITY NAME (BX-32/LINE 1)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
59
\n", "", "
YES
\n", "
50
\n", "
29
\n", "
BILLING PROVIDER NAME (BX-33/LN 2)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
1
\n", "
21
\n", "
BLOCK 31 CHR 1-21 (BX-31/LN1)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
58
\n", "", "
YES
\n", "
23
\n", "", "
GET BILL PROV/SVC FAC - CALC ONLY
\n", "
CALCULATE ONLY
\n", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
62
\n", "", "
YES
\n", "
79
\n", "", "
IBXSAVE CLEAN-UP BX 33
\n", "
CALCULATE ONLY
\n", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
23
\n", "
26
\n", "
SERVICE FAC ADR LINE 1 (BX-32/LN 2)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
50
\n", "
29
\n", "
BILLING PROVIDER ADDR (BX-33/LN 3)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
61
\n", "", "
YES
\n", "
1
\n", "
21
\n", "
BLOCK 31 CHR 22-42 (BX-31/LN2)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
61
\n", "", "
YES
\n", "
23
\n", "
26
\n", "
SERVICE FAC CITY/ST/ZIP (BX-32/LN 3)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
80
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "", "
KILL IBXSAVE ARRAY
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
61
\n", "", "
YES
\n", "
50
\n", "
29
\n", "
BILL PROV CITY/ST/ZIP (BX-33/LN 4)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
62
\n", "", "
YES
\n", "
1
\n", "
21
\n", "
BLOCK 31 CHR 43-63 (BX-31/LN3)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
62
\n", "", "
YES
\n", "
24
\n", "
10
\n", "
SERVICE FAC NPI (BX-32A)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
62
\n", "", "
YES
\n", "
35
\n", "
14
\n", "
SERV FAC OTH ID# (BX-32B)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
62
\n", "", "
YES
\n", "
51
\n", "
10
\n", "
BILLING PROVIDER NPI (BX-33A)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
62
\n", "", "
YES
\n", "
62
\n", "
17
\n", "
BILLING PROV OTH ID# (BX-33B)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
63
\n", "", "
NO
\n", "
1.9
\n", "", "
MULTIPLE PAGE CHECK/POPULATE
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
85
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "", "
KILL IBXSAVE ARRAY
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
37
\n", "", "
YES
\n", "
57
\n", "
1
\n", "
OUTSIDE LAB? NO (BX-20)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
90
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "", "
KILL IBXSAVE ARRAY
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
107
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "", "
KILL IBXSAVE ARRAY
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
1
\n", "", "
YES
\n", "
.9
\n", "", "
UB-04 PRE-FORM HOUSEKEEPING
\n", "
CALCULATE ONLY
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
1
\n", "", "
YES
\n", "
35
\n", "
35
\n", "
PRINT STAT (UB-04 TOP LINE)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
2
\n", "", "
YES
\n", "
2
\n", "
24
\n", "
BILLING PROVIDER NAME (FL-1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
3
\n", "", "
YES
\n", "
1
\n", "
25
\n", "
BILLING PROVIDER ADDR (FL-1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
4
\n", "", "
YES
\n", "
1
\n", "
12
\n", "
BILL PROVIDER CITY (FL-1/3/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
4
\n", "", "
YES
\n", "
14
\n", "
2
\n", "
BILL PROVIDER STATE (FL-1/3/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
4
\n", "", "
YES
\n", "
17
\n", "
9
\n", "
BILL PROVIDER ZIP (FL-1/3/3)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
5
\n", "", "
YES
\n", "
1
\n", "
10
\n", "
BILL PROVIDER PHONE (FL-1/4/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
5
\n", "", "
YES
\n", "
13
\n", "
10
\n", "
BILL PROVIDER FAX (FL-1/4/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
5
\n", "", "
YES
\n", "
24
\n", "
2
\n", "
BILL PROV COUNTRY (FL-1/4/3)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "", "
KILL IBXSAVE ARRAY
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
2
\n", "", "
YES
\n", "
27
\n", "
24
\n", "
Pay-to Provider Name (FL-2/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
3
\n", "", "
YES
\n", "
26
\n", "
25
\n", "
Pay-to Provider Address (FL-2/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
4
\n", "", "
YES
\n", "
26
\n", "
16
\n", "
Pay-to Provider City (FL-2/3/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
4
\n", "", "
YES
\n", "
43
\n", "
2
\n", "
Pay-to Provider State (FL-2/3/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
4
\n", "", "
YES
\n", "
46
\n", "
5
\n", "
Pay-to Provider Zip (FL-2/3/3)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
58
\n", "", "
YES
\n", "
1
\n", "
7
\n", "
PRIN PROCEDURE CODE (FL-74/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
5
\n", "", "
YES
\n", "
26
\n", "
25
\n", "
NOT USED (FL-2/4)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
2
\n", "", "
YES
\n", "
54
\n", "
20
\n", "
PATIENT CONTROL NUMBER (FL-3A)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
3
\n", "", "
YES
\n", "
54
\n", "
24
\n", "
MEDICAL RECORD NUMBER (FL-3B)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
3
\n", "", "
YES
\n", "
78
\n", "
4
\n", "
TYPE OF BILL (FL-4)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
4
\n", "", "
YES
\n", "
57
\n", "
4
\n", "
UPPER FORM LOCATOR 5
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
5
\n", "", "
YES
\n", "
51
\n", "
10
\n", "
FED TAX ID # (FL-5/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
5
\n", "", "
YES
\n", "
62
\n", "
6
\n", "
STATEMENT FROM DATE (FL-6A)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
5
\n", "", "
YES
\n", "
69
\n", "
6
\n", "
STATEMENT THRU DATE (FL-6B)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
4
\n", "", "
YES
\n", "
76
\n", "
7
\n", "
NOT USED (FL-7/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
5
\n", "", "
YES
\n", "
75
\n", "
8
\n", "
NOT USED (FL-7/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
6
\n", "", "
YES
\n", "
12
\n", "
19
\n", "
PATIENT ID (FL-8A)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
7
\n", "", "
YES
\n", "
2
\n", "
29
\n", "
PATIENT NAME (FL-8B)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
6
\n", "", "
YES
\n", "
42
\n", "
40
\n", "
PATIENT ADDR. - STREET (FL-9A)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
7
\n", "", "
YES
\n", "
32
\n", "
30
\n", "
PATIENT ADDR. - CITY (FL-9B)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
7
\n", "", "
YES
\n", "
65
\n", "
2
\n", "
PATIENT ADDR. - STATE (FL-9C)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
7
\n", "", "
YES
\n", "
69
\n", "
10
\n", "
PATIENT ADDR. - ZIP (FL-9D)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
1
\n", "
3
\n", "
OCCURRENCE CODE (FL-31/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
5
\n", "
6
\n", "
OCCURRENCE DATE (FL-31/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
11
\n", "
3
\n", "
OCCURRENCE CODE (FL-32/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
15
\n", "
6
\n", "
OCCURRENCE DATE (FL-32/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
21
\n", "
3
\n", "
OCCURRENCE CODE (FL-33/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
25
\n", "
6
\n", "
OCCURRENCE DATE (FL-33/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
31
\n", "
3
\n", "
OCCURRENCE CODE (FL-34/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
35
\n", "
6
\n", "
OCCURRENCE DATE (FL-34/2)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
70
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "", "
KILL IBXSAVE ARRAY
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
41
\n", "
3
\n", "
OCCURRENCE SPAN CODE (FL-35/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
45
\n", "
6
\n", "
OCC SPAN DATE FROM (FL-35/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
52
\n", "
6
\n", "
OCC SPAN DATE TO (FL-35/3)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
7
\n", "", "
YES
\n", "
80
\n", "
3
\n", "
PATIENT ADDR. - CNTRY (FL-9E)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
58
\n", "
3
\n", "
OCCURRENCE SPAN CODE (FL-36/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
62
\n", "
6
\n", "
OCC SPAN DATE FROM (FL-36/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
69
\n", "
6
\n", "
OCC SPAN DATE TO (FL-36/3)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
1
\n", "
1
\n", "
ICD VERSION INDICATOR (FL-66)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
54
\n", "", "
YES
\n", "
2
\n", "
7
\n", "
PRIN DIAG CODE (FL-67/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
65
\n", "", "
YES
\n", "
1
\n", "", "
CHECK FOR MULTIPLE PAGES
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
30
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
8
\n", "
Subscriber Birth DT
\n", "", "
TRUE
\n", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
75
\n", "
8
\n", "
NOT USED (FL-37/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
12
\n", "", "
YES
\n", "
75
\n", "
8
\n", "
NOT USED (FL-37/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
10
\n", "
7
\n", "
OTHER DIAG CODE 10(FL-67J/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
1
\n", "
8
\n", "
PATIENT DOB (FL-10)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
10
\n", "
1
\n", "
PATIENT SEX (FL-11)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
13
\n", "
6
\n", "
ADMISSION DATE (FL-12)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
19
\n", "
2
\n", "
ADMISSION HR (FL-13)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
22
\n", "
1
\n", "
ADMISSION TYPE (FL-14)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
25
\n", "
1
\n", "
ADMISSION SOURCE (FL-15)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
28
\n", "
2
\n", "
DISCHARGE HR (FL-16)
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
80
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "
30
\n", "
VALUE CODE GROUP
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
31
\n", "
3
\n", "
PATIENT STATUS (FL-17)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
13
\n", "", "
YES
\n", "
.5
\n", "", "
CURRENT PAYER NAME EXTRACT
\n", "
CALCULATE ONLY
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
13
\n", "", "
YES
\n", "
.7
\n", "", "
CURRENT PAYER ADDRESS EXTRACT
\n", "
CALCULATE ONLY
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
13
\n", "
5
\n", "
YES
\n", "
1
\n", "
42
\n", "
CURR PAYER NAME/ADDR (FL-38)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
18
\n", "
7
\n", "
OTHER DIAG CODE 11(FL-67K/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
26
\n", "
7
\n", "
OTHER DIAG CODE 12(FL-67L/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
14
\n", "", "
YES
\n", "
40
\n", "", "
VALUE CODE EXTRACT (FL-39:41)
\n", "
CALCULATE ONLY
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
14
\n", "", "
YES
\n", "
41
\n", "", "
VALUE CODE SORT (FL-39:41)
\n", "
CALCULATE ONLY
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
14
\n", "", "
YES
\n", "
42
\n", "", "
VALUE CODE REBUILD (FL-39:41)
\n", "
CALCULATE ONLY
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
14
\n", "", "
YES
\n", "
44
\n", "
3
\n", "
VALUE CODES CD 1 (FL-39a:d/1)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
110
\n", "
1
\n", "", "
NO
\n", "
3.9
\n", "
60
\n", "
OTHER INSURED FULL NAME
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
14
\n", "", "
YES
\n", "
47
\n", "
10
\n", "
VALUE CODES AMT 1 (FL-39a:d/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
14
\n", "", "
YES
\n", "
57
\n", "
3
\n", "
VALUE CODES CD 2 (FL-40a:d/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
14
\n", "", "
YES
\n", "
60
\n", "
10
\n", "
VALUE CODES AMT 2 (FL-40a:d/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
14
\n", "", "
YES
\n", "
70
\n", "
3
\n", "
VALUE CODES CD 3 (FL-41a:d/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
14
\n", "", "
YES
\n", "
73
\n", "
10
\n", "
VALUE CODES AMT 3 (FL-41a:d/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
34
\n", "
3
\n", "
CONDITION CODE 1 (FL-18)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
33.8
\n", "", "
EXTRACT CONDITION CODES
\n", "
CALCULATE ONLY
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
37
\n", "
3
\n", "
CONDITION CODE 2 (FL-19)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
40
\n", "
3
\n", "
CONDITION CODE 3 (FL-20)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
43
\n", "
3
\n", "
CONDITION CODE 4 (FL-21)
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
105
\n", "
1
\n", "", "
NO
\n", "
5.9
\n", "
30
\n", "
OTHER INSURED DEMOGRAPHICS
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
46
\n", "
3
\n", "
CONDITION CODE 5 (FL-22)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
49
\n", "
3
\n", "
CONDITION CODE 6 (FL-23)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
52
\n", "
3
\n", "
CONDITION CODE 7 (FL-24)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
55
\n", "
3
\n", "
CONDITION CODE 8 (FL-25)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
58
\n", "
3
\n", "
CONDITION CODE 9 (FL-26)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
61
\n", "
3
\n", "
CONDITION CODE 10 (FL-27)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
64
\n", "
3
\n", "
CONDITION CODE 11 (FL-28)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
67
\n", "
3
\n", "
ACCIDENT STATE (FL-29)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
70
\n", "
13
\n", "
RESERVED (FL-30/2)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
42
\n", "", "
YES
\n", "
68
\n", "
15
\n", "
BILLING PROVIDER NPI (FL-56)
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
110
\n", "
1
\n", "", "
NO
\n", "
6.9
\n", "
100
\n", "
OTHER INSURED EMPLOYER GROUP
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
43
\n", "", "
YES
\n", "
1
\n", "
23
\n", "
PAYER NAME (FL-50A:C)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
43
\n", "", "
YES
\n", "
24
\n", "
15
\n", "
HEALTH PLAN ID (FL-51A:C)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
43
\n", "", "
YES
\n", "
39
\n", "
2
\n", "
RELEASE OF INFO (FL-52A:C)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
43
\n", "", "
YES
\n", "
42
\n", "
2
\n", "
ASSIGN OF BENEFITS (FL-53A:C)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
43
\n", "", "
YES
\n", "
44
\n", "
10
\n", "
PRIOR PAYMENTS (FL-54A:C)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
43
\n", "", "
YES
\n", "
54
\n", "
11
\n", "
EST AMOUNT DUE (FL-55A:C)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
54
\n", "", "
YES
\n", "
10
\n", "
7
\n", "
OTHER DIAG CODE 1 (FL-67A/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
54
\n", "", "
YES
\n", "
18
\n", "
7
\n", "
OTHER DIAG CODE 2 (FL-67B/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
54
\n", "", "
YES
\n", "
26
\n", "
7
\n", "
OTHER DIAG CODE 3 (FL-67C/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
54
\n", "", "
YES
\n", "
34
\n", "
7
\n", "
OTHER DIAG CODE 4 (FL-67D/1/1)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Cert. Condition Indicator (Homebound)
\n", "", "
TRUE
\n", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
54
\n", "", "
YES
\n", "
42
\n", "
7
\n", "
OTHER DIAG CODE 5 (FL-67E/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
54
\n", "", "
YES
\n", "
50
\n", "
7
\n", "
OTHER DIAG CODE 6 (FL-67F/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
54
\n", "", "
YES
\n", "
58
\n", "
7
\n", "
OTHER DIAG CODE 7 (FL-67G/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
54
\n", "", "
YES
\n", "
66
\n", "
7
\n", "
OTHER DIAG CODE 8 (FL-67H/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
2
\n", "
7
\n", "
OTHER DIAG CODE 9 (FL-67I/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
34
\n", "
7
\n", "
OTHER DIAG CODE 13(FL-67M/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
42
\n", "
7
\n", "
OTHER DIAG CODE 14(FL-67N/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
50
\n", "
7
\n", "
OTHER DIAG CODE 15(FL-67O/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
58
\n", "
7
\n", "
OTHER DIAG CODE 16(FL-67P/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
66
\n", "
7
\n", "
OTHER DIAG CODE 17(FL-67Q/1/1)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
33
\n", "
10
\n", "
Facility Type Code (Prof)
\n", "", "
TRUE
\n", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
43
\n", "", "
YES
\n", "
68
\n", "
15
\n", "
OTHER PRV ID (FL-57A:C)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
47
\n", "", "
YES
\n", "
1
\n", "
26
\n", "
INSUREDS NAME (FL-58A:C)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
47
\n", "", "
YES
\n", "
27
\n", "
3
\n", "
PATIENT RELATION (FL-59A:C)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
47
\n", "", "
YES
\n", "
30
\n", "
20
\n", "
INSUREDS UNIQUE ID (FL-60A:C)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
47
\n", "", "
YES
\n", "
50
\n", "
15
\n", "
GROUP NAME (FL-61A:C)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
47
\n", "", "
YES
\n", "
65
\n", "
18
\n", "
INSURANCE GROUP NO (FL-62A:C)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
51
\n", "", "
YES
\n", "
1
\n", "
31
\n", "
TREATMNT AUTH CODES (FL-63A:C)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
51
\n", "", "
YES
\n", "
32
\n", "
26
\n", "
DOCUMENT CNTRL NUM (FL-64A:C)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
51
\n", "", "
YES
\n", "
58
\n", "
25
\n", "
EMPLOYER NAME (FL-65A:C)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
8
\n", "", "
YES
\n", "
72
\n", "
11
\n", "
NOT USED (FL-30/1)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
5
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
10
\n", "
Batch Number
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
5
\n", "
7
\n", "
ADM DIAG CODE (FL-69)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
49
\n", "
7
\n", "
ECI (FL-72A/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
58
\n", "", "
YES
\n", "
10
\n", "
6
\n", "
PRIN PROCEDURE DATE (FL-74/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
58
\n", "", "
YES
\n", "
16
\n", "
7
\n", "
OTHER PROC CODE 1 (FL-74A/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
58
\n", "", "
YES
\n", "
25
\n", "
6
\n", "
OTHER PROC DATE 1 (FL-74A/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
58
\n", "", "
YES
\n", "
31
\n", "
7
\n", "
OTHER PROC CODE 2 (FL-74B/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
58
\n", "", "
YES
\n", "
40
\n", "
6
\n", "
OTHER PROC DATE 2 (FL-74B/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
1
\n", "
7
\n", "
OTHER PROC CODE 3 (FL-74C/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
10
\n", "
6
\n", "
OTHER PROC DATE 3 (FL-74C/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
16
\n", "
7
\n", "
OTHER PROC CODE 4 (FL-74D/1)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
5
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
8
\n", "
Batch Date
\n", "", "
TRUE
\n", "
NO
\n"], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
25
\n", "
6
\n", "
OTHER PROC DATE 4 (FL-74D/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
31
\n", "
7
\n", "
OTHER PROC CODE 5 (FL-74E/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
40
\n", "
7
\n", "
OTHER PROC DATE 5 (FL-74E/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
54
\n", "", "
YES
\n", "
9
\n", "
1
\n", "
PRIN DIAG POA (FL-67/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
54
\n", "", "
YES
\n", "
17
\n", "
1
\n", "
OTHER DIAG 1 POA (FL-67A/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
54
\n", "", "
YES
\n", "
25
\n", "
1
\n", "
OTHER DIAG 2 POA (FL-67B/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
54
\n", "", "
YES
\n", "
33
\n", "
1
\n", "
OTHER DIAG 3 POA (FL-67C/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
54
\n", "", "
YES
\n", "
41
\n", "
1
\n", "
OTHER DIAG 4 POA (FL-67D/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
54
\n", "", "
YES
\n", "
49
\n", "
1
\n", "
OTHER DIAG 5 POA (FL-67E/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
54
\n", "", "
YES
\n", "
57
\n", "
1
\n", "
OTHER DIAG 6 POA (FL-67F/1/2)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
5
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
10
\n", "
Batch Reference Number
\n", "", "
TRUE
\n", "
NO
\n"], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
54
\n", "", "
YES
\n", "
65
\n", "
1
\n", "
OTHER DIAG 7 POA (FL-67G/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
54
\n", "", "
YES
\n", "
73
\n", "
1
\n", "
OTHER DIAG 8 POA (FL-67H/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
9
\n", "
1
\n", "
OTHER DIAG 9 POA (FL-67I/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
17
\n", "
1
\n", "
OTHER DIAG 10 POA (FL-67J/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
25
\n", "
1
\n", "
OTHER DIAG 11 POA (FL-67K/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
33
\n", "
1
\n", "
OTHER DIAG 12 POA (FL-67L/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
41
\n", "
1
\n", "
OTHER DIAG 13 POA (FL-67M/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
49
\n", "
1
\n", "
OTHER DIAG 14 POA (FL-67N/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
57
\n", "
1
\n", "
OTHER DIAG 15 POA (FL-67O/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
65
\n", "
1
\n", "
OTHER DIAG 16 POA (FL-67P/1/2)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
32
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
55
\n", "
Subscriber Address 1
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
55
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
60
\n", "
Lab/Facility Name
\n", "", "
TRUE
\n", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
73
\n", "
1
\n", "
OTHER DIAG 17 POA (FL-67Q/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
54
\n", "", "
YES
\n", "
75
\n", "
8
\n", "
RESERVED BY NUBC (FL-68/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
74
\n", "
9
\n", "
RESERVED BY NUBC (FL-68/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
.8
\n", "", "
PROCEDURE EXTRACT
\n", "
CALCULATE ONLY
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
.9
\n", "", "
REV CODE EXTRACT (FL-42:49)
\n", "
CALCULATE ONLY
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
1
\n", "
5
\n", "
REVENUE CODE (FL-42)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
6
\n", "
25
\n", "
REV CODE DESCRIPTION (FL-43)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
17
\n", "
7
\n", "
PATIENT REASON DX (FL-70/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
24
\n", "
7
\n", "
PATIENT REASON DX (FL-70/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
31
\n", "
7
\n", "
PATIENT REASON DX (FL-70/1/3)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
55
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
55
\n", "
Lab/Facility Address 1
\n", "", "
TRUE
\n", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
43
\n", "
4
\n", "
PPS CODE (FL-71)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
56
\n", "
1
\n", "
ECI POA (FL-72A/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
57
\n", "
7
\n", "
ECI (FL-72B/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
64
\n", "
1
\n", "
ECI POA (FL-72B/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
65
\n", "
7
\n", "
ECI (FL-72C/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
72
\n", "
1
\n", "
ECI POA (FL-72C/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
74
\n", "
9
\n", "
RESERVED BY NUBC (FL-73)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
31
\n", "
15
\n", "
HCPCS/RATES (FL-44)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
46
\n", "
7
\n", "
SERVICE DATE (FL-45)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
57
\n", "", "
YES
\n", "
46
\n", "
4
\n", "
RESERVED BY NUBC (FL-75/1)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
55
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
30
\n", "
Lab/Facility City Name
\n", "", "
TRUE
\n", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
58
\n", "", "
YES
\n", "
46
\n", "
4
\n", "
RESERVED BY NUBC (FL-75/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
59
\n", "", "
YES
\n", "
46
\n", "
4
\n", "
RESERVED BY NUBC (FL-75/3)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
46
\n", "
4
\n", "
RESERVED BY NUBC (FL-75/4)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
61
\n", "
4
\n", "
YES
\n", "
1
\n", "
24
\n", "
REMARKS (FL-80)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
2
\n", "", "
YES
\n", "
26
\n", "", "
GATHER PAY-TO PROVIDER DATA FOR FL-2
\n", "
CALCULATE ONLY
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
61
\n", "", "
YES
\n", "
27
\n", "
2
\n", "
CODE CODE LEFT (FL-81/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
61
\n", "", "
YES
\n", "
29
\n", "
10
\n", "
CODE CODE MIDDLE (FL-81/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
61
\n", "", "
YES
\n", "
39
\n", "
12
\n", "
CODE CODE RIGHT (FL-81/1/3)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
55
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
2
\n", "
Lab/Facility State Code
\n", "", "
TRUE
\n", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
58
\n", "", "
YES
\n", "
53
\n", "
16
\n", "
ATTENDING NAME (FL-76/2/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
58
\n", "", "
YES
\n", "
71
\n", "
12
\n", "
ATTENDING NAME (FL-76/2/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
53
\n", "
16
\n", "
OPERATING NAME (FL-77/2/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
71
\n", "
12
\n", "
OPERATING NAME (FL-77/2/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
53
\n", "
7
\n", "
SERVICE UNITS (FL-46)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
60
\n", "
10
\n", "
TOTAL CHARGES (FL-47)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
62
\n", "", "
YES
\n", "
53
\n", "
16
\n", "
OTHER NAME (FL-78/2/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
62
\n", "", "
YES
\n", "
71
\n", "
12
\n", "
OTHER NAME (FL-78/2/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
64
\n", "", "
YES
\n", "
53
\n", "
16
\n", "
OTHER NAME (FL-79/2/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
64
\n", "", "
YES
\n", "
71
\n", "
12
\n", "
OTHER NAME (FL-79/2/2)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
55
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
15
\n", "
Lab/Facility ZIP Code
\n", "", "
TRUE
\n", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
57
\n", "", "
YES
\n", "
59
\n", "
11
\n", "
ATTENDING NPI (FL-76/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
57
\n", "", "
YES
\n", "
72
\n", "
2
\n", "
ATTENDING ID QUAL (FL-76/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
57
\n", "", "
YES
\n", "
74
\n", "
9
\n", "
ATTENDING OTHER ID (FL-76/1/3)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
59
\n", "", "
YES
\n", "
59
\n", "
11
\n", "
OPERATING NPI (FL-77/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
59
\n", "", "
YES
\n", "
72
\n", "
2
\n", "
OPERATING ID QUAL (FL-77/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
59
\n", "", "
YES
\n", "
74
\n", "
9
\n", "
OPERATING OTHER ID (FL-77/1/3)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
61
\n", "", "
YES
\n", "
59
\n", "
11
\n", "
OTHER PROVIDER NPI (FL-78/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
61
\n", "", "
YES
\n", "
72
\n", "
2
\n", "
OTHER PROV ID QUAL (FL-78/1/3)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
61
\n", "", "
YES
\n", "
74
\n", "
9
\n", "
OTHER PROV ID (FL-78/1/4)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
70
\n", "
10
\n", "
NON-COVERED CHARGES (FL-48)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
5
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
30
\n", "
Receiver ID Number
\n", "", "
TRUE
\n", "
NO
\n"], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
80
\n", "
3
\n", "
RESERVED (FL-49)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
63
\n", "", "
YES
\n", "
59
\n", "
11
\n", "
OTHER NPI (FL-79/1/2)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
63
\n", "", "
YES
\n", "
72
\n", "
2
\n", "
OTHER PROV ID QUAL (FL-79/1/3)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
63
\n", "", "
YES
\n", "
74
\n", "
9
\n", "
OTHER PROV ID (FL-79/1/4)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
63
\n", "", "
YES
\n", "
56
\n", "
2
\n", "
PROV TYPE QUAL (FL-79/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
61
\n", "", "
YES
\n", "
56
\n", "
2
\n", "
PROV TYPE QUAL (FL-78/1/1)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
41
\n", "", "
YES
\n", "
1
\n", "
4
\n", "
RESERVED (FL-41/23)
\n", "
OUTPUT
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
41
\n", "", "
YES
\n", "
46
\n", "
6
\n", "
CREATION DATE (FL-45/23)
\n", "", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
74.9
\n", "", "
CLEAN UP IBXSAVE OCCS
\n", "
CALCULATE ONLY
\n", "", ""], ["UB-04", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
33.9
\n", "", "
SORT CONDITION CODES
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
15
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
30
\n", "
Billing Prov Organization Name
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
15
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
35
\n", "
Billing Prov Address 1
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
15
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
2
\n", "
Billing Prov State Code
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
36
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
30
\n", "
Insured Employer Name
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
15
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
9
\n", "
Billing Prov ZIP Code
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
38
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'CI6 '
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
38
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
3
\n", "
Subscriber Primary ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
38
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
80
\n", "
Subscriber Primary ID
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
38
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
3
\n", "
Subscriber Sec ID Qualifier(1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
38
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
50
\n", "
Subscriber Sec ID(1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
15
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
30
\n", "
Billing Prov City Name
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
37
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'CI5 '
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
37
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
3
\n", "
Payer Primary ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
37
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
20
\n", "
Payer Primary ID
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
110
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
3
\n", "
Other Subscriber Primary ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
37
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
3
\n", "
Payer Sec ID Qualifier(1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
37
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
30
\n", "
Payer Sec ID(1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
37
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
3
\n", "
Payer Sec ID Qualifier(2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
37
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
30
\n", "
Payer Sec ID(2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
38
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "", "
EXTRACT SUBSCRIBER ID's
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
15
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
20
\n", "
Communication # (Phone)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
114
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OI6 '
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
114
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
114
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
3
\n", "
Other Payer Primary ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
114
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
30
\n", "
Other Payer Primary ID
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
114
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
3
\n", "
Other Payer Sec ID Qualifier(1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
114
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
30
\n", "
Other Payer Sec ID(1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
114
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
3
\n", "
Other Payer Sec ID Qualifier(2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
114
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
30
\n", "
Other Payer Sec ID(2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
114
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
2
\n", "
Other Payer ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
114
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
30
\n", "
Other Payer Primary ID (HPID)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
113
\n", "
1
\n", "", "
NO
\n", "
8.5
\n", "", "
OTH INS SUBSCRIBER ID EXTRACT
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
3
\n", "
Initial Treatment DT Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
3
\n", "
Acute Manifestation DT Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
3
\n", "
Last X-Ray DT Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
20
\n", "
10
\n", "
Pt. Name Suffix
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
20
\n", "
3
\n", "
Billing Note Text Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
21
\n", "
80
\n", "
Billing Note Text
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
20
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
35
\n", "
Payer Address 1
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
114
\n", "
1
\n", "", "
NO
\n", "
10.1
\n", "", "
PAYER SEC ID CLEAR
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
20
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
30
\n", "
Payer City Name
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
15
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
20
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
2
\n", "
Payer State Code
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
15
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
16
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
17
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
18
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
97
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
112
\n", "
1
\n", "", "
NO
\n", "
2.8
\n", "", "
EXTRACT OTHER PAYER FULL ADDRESS
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
112
\n", "
1
\n", "", "
NO
\n", "
99
\n", "", "
IBXSAVE CLEAN-UP
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
90
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
1
\n", "
POA Indicator
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
20
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
15
\n", "
Payer ZIP Code
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
35
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
50
\n", "
Insured Group or Policy #
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
35
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
60
\n", "
Insured Group Name
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
15
\n", "
1
\n", "", "
NO
\n", "
2.5
\n", "", "
GET BILLING PROVIDER - CALC ONLY
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
15
\n", "
1
\n", "", "
NO
\n", "
99
\n", "", "
IBXSAVE CLEAN-UP PRV
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
2
\n", "
Code List Qualifier Code (DR)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
5
\n", "
Industry Code (PPS)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
55
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "", "
GET SERVICE FACILITY INFO (CALC ONLY)
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
55
\n", "
1
\n", "", "
NO
\n", "
99
\n", "", "
IBXSAVE CLEAN-UP SUB
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
17
\n", "
3
\n", "
Patient Reason for Visit Qualifier (1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
18
\n", "
10
\n", "
Patient Reason for Visit (1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
19
\n", "
3
\n", "
Patient Reason for Visit Qualifier (2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
20
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
30
\n", "
Payer Name
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
20
\n", "
10
\n", "
Patient Reason for Visit (2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
21
\n", "
3
\n", "
Patient Reason for Visit Qualifier (3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
22
\n", "
10
\n", "
Patient Reason for Visit (3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
16
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'PRV1'
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
16
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "", "
GET PAY-TO PROVIDER DATA
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
16
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
2
\n", "
Entity ID Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
16
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
1
\n", "
Entity Type Qualifier
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
16
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
16
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
16
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
9.99
\n", "
1
\n", "", "
NO
\n", "
.9
\n", "", "
SET BATCH HDR NODE
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
16
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
55
\n", "
Pay-To Provider Address 1
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
16
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
55
\n", "
Pay-To Provider Address 2
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
16
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
30
\n", "
Pay-To Provider City Name
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
16
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
2
\n", "
Pay-To Provider State Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
16
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
15
\n", "
Pay-To Provider ZIP Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
15
\n", "
3
\n", "
Code List Qualifier Code (BJ)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
16
\n", "
10
\n", "
Industry Code (Admitting DX)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.8
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'AMB '
\n", "
OUTPUT
\n", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.8
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
2
\n", "
Ambulance Addr Type Qual
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.9
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'AMB1'
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
10
\n", "
Procedure Code
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.8
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
55
\n", "
Ambulance Address 1
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.8
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
55
\n", "
Ambulance Address 2
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.8
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
30
\n", "
Ambulance City
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.8
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
2
\n", "
Ambulance State
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.8
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
15
\n", "
Ambulance Zip Code
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.9
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
2
\n", "
Amb Patient Weight Units
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.9
\n", "
1
\n", "
1
\n", "
NO
\n", "
3
\n", "
3
\n", "
Amb Patient Weight
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.9
\n", "
1
\n", "
1
\n", "
NO
\n", "
4
\n", "
1
\n", "
Amb Transport Reason Code
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.9
\n", "
1
\n", "
1
\n", "
NO
\n", "
5
\n", "
2
\n", "
Amb Distance Units
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.9
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
15
\n", "
Amb Transport Distance
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
107
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
18
\n", "
COB Total Non-Covered Amount
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.9
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
80
\n", "
Amb Round Trip Purpose
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.8
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
60
\n", "
Ambulance Drop Off Location
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
15
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
17
\n", "
Billing Prov Primary ID
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
15
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
2
\n", "
Billing Prov Primary ID Qual
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
29
\n", "
3
\n", "
Prop/Cas Date 1st Cont Qual
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
30
\n", "
8
\n", "
Prop/Cas Date of 1st Contact
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
23
\n", "
3
\n", "
Disability Date Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
22.8
\n", "
8
\n", "
Disability Start Date
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
22.9
\n", "
8
\n", "
Disability End Date
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
24
\n", "
17
\n", "
Disability Date(s)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
20
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
25
\n", "
3
\n", "
Assume Care Date Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
26
\n", "
8
\n", "
Assume Care Date
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
27
\n", "
3
\n", "
Relinquish Care Date Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
51
\n", "
1
\n", "", "
NO
\n", "
28
\n", "
8
\n", "
Relinquish Care Date
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
15
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
2
\n", "
Billing Prov Taxonomy Code Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
15
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
10
\n", "
Billing Prov Taxonomy Code
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
36
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
2
\n", "
Prior Authorization Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
36
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
Referral Number Qualifier
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
36
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
50
\n", "
Referral Number
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
52
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'CL1B'
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "", "
KILL IBXSAVE ARRAY
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
52
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
2
\n", "
Attachment Report Type
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
52
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
2
\n", "
Attachment Report Transmission Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
52
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
2
\n", "
Attachment Control Qualifier
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
52
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
30
\n", "
Attachment Control Number
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
45
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
3
\n", "
Prop/Cas Claim Number Qualifier
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
45
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
50
\n", "
Prop/Cas Claim Number
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
45
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
2
\n", "
Prop/Cas Contact Name Qualifier
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
45
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
60
\n", "
Prop/Cas Contact Name
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
45
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
2
\n", "
Prop/Cas Contact Tele Qualifier
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
45
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
10
\n", "
Prop/Cas Contact Telephone
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
110
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "", "
KILL IBXSAVE ARRAY
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
45
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
2
\n", "
Prop/Cas Contact Ext Qualifier
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
45
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
10
\n", "
Prop/Cas contact Extension
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
77
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'SPC '
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
77
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
3
\n", "
Primary Surgical Proc Code Qualifier
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
77
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
10
\n", "
Primary Surgical Proc Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
77
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
3
\n", "
Secondary Surgical Proc Code Qualifier
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
77
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
10
\n", "
Secondary Surgical Proc Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
57
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
2
\n", "
Lab/Facility Primary ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.2
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OPR9'
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.2
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "", "
Rendering Provider Name
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.2
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
2
\n", "
Rendering Provider qualifier
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.2
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
1
\n", "
Rendering Provider type
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.2
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
35
\n", "
Rendering Provider Last Name
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.2
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
25
\n", "
Rendering Provider First Name
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.2
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
25
\n", "
Rendering Provider Middle Name
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.2
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
10
\n", "
Rendering Provider Name Suffix
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.2
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
Rendering Provider Primary ID Qualifier
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.2
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
30
\n", "
Rendering Provider Primary ID
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.2
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
2
\n", "
Rendering Provider Taxonomy Qualifier
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.2
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
10
\n", "
Rendering Provider Taxonomy
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.4
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OPRA'
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.4
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
2
\n", "
Rendering provider sec ID Qualifier (1)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.4
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
30
\n", "
Rendering provider sec ID (1)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.4
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
2
\n", "
Rendering provider sec ID Qualifier (2)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.4
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
30
\n", "
Rendering provider sec ID (2)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.4
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
2
\n", "
Rendering provider sec ID Qualifier (3)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.4
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
30
\n", "
Rendering provider sec ID (3)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.4
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
Rendering provider sec ID Qualifier (4)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.4
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
30
\n", "
Rendering provider sec ID (4)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170.5
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OP1A'
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170.5
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170.5
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
2
\n", "
Other Payer Attending Entity ID
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "", "", "
170.5
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
1
\n", "
Other Payer Attending Entity Type Qual
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170.5
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
2
\n", "
Other Payer Attending Sec ID Qual (1)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170.5
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
30
\n", "
Other Payer Attending Sec ID (1)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170.5
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
2
\n", "
Other Payer Attending Sec ID Qual (2)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170.5
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
30
\n", "
Other Payer Attending Sec ID (2)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170.5
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
2
\n", "
Other Payer Attending Sec ID Qual (3)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170.5
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
30
\n", "
Other Payer Attending Sec ID (3)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
190
\n", "
1
\n", "", "", "
11
\n", "
3
\n", "
Prescription date qualifier
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
190
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
8
\n", "
Prescription date
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
112
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
2
\n", "
Other Payer Referral Number qualifier
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
112
\n", "
1
\n", "", "", "
12
\n", "
50
\n", "
Other Payer Referral Number
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
112
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
3
\n", "
Other payer Check Qualifier
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
112
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
8
\n", "
Other payer Check Date
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
112
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
2
\n", "
Other payer claim status
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'LDAT'
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
6
\n", "
Service Line Counter
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "", "
LDAT DATA EXTRACT
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
2
\n", "
Attachment Report Type
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
2
\n", "
Attachment Report Transmission Code
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
2
\n", "
Attachment Control Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
30
\n", "
Attachment Control Number
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
2
\n", "
OB Anesthesia Additional Units Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
5
\n", "
OB Anesthesia Additional Units
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
5
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'GEN '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
2
\n", "
Line Item Control Number Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
20
\n", "
Line Item Control Number
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
20
\n", "
Purchase Service Provider ID
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
8
\n", "
Purchase Service Amount
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "
1
\n", "
Cleanup
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
192
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'LOPE'
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
192
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "
1
\n", "
LOPE DATA EXTRACT
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
192
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
6
\n", "
Service Line Counter
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
192
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
2
\n", "
Operating Physician Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
55
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'SUB '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
192
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
60
\n", "
Operating Physician Last Name
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
192
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
35
\n", "
Operating Physician First Name
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
192
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
1
\n", "
Operating Physician Middle Initial
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
192
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
10
\n", "
Operating Physician Suffix
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
192
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
Primary ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
192
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
10
\n", "
Primary ID
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
192
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
2
\n", "
Secondary ID Qualifier (1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
192
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
10
\n", "
Secondary ID (1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
192
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
2
\n", "
Secondary ID Qualifier (2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
192
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
10
\n", "
Secondary ID (2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
192
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
2
\n", "
Secondary ID Qualifier (3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
192
\n", "
1
\n", "", "
NO
\n", "
15
\n", "
10
\n", "
Secondary ID (3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
192
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "
1
\n", "
Cleanup
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'LOP1'
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
6
\n", "
Service Line Counter
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "
1
\n", "
LOP1 DATA EXTRACT
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
2
\n", "
Other Operating Physician Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
60
\n", "
Other Operating Physician Last Name
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
15
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'PRV '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
35
\n", "
Other Operating Physician First Name
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
1
\n", "
Other Operating Physician Middle Initial
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
10
\n", "
Other Operating Physician Suffix
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
Primary ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
10
\n", "
Primary ID
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
2
\n", "
Secondary ID Qualifier (1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
10
\n", "
Secondary ID (1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
2
\n", "
Secondary ID Qualifier (2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
10
\n", "
Secondary ID (2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
2
\n", "
Secondary ID Qualifier (3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
20
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'CI1 '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193
\n", "
1
\n", "", "
NO
\n", "
15
\n", "
10
\n", "
Secondary ID (3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "
1
\n", "
Cleanup
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.3
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'LREN'
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.3
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "
1
\n", "
LREN DATA EXTRACT
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.3
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
6
\n", "
Service Line Counter
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.3
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
2
\n", "
Rendering Provider Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.3
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
60
\n", "
Rendering Provider Last Name
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.3
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
35
\n", "
Rendering Provider First Name
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.3
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
1
\n", "
Rendering Provider Middle Initial
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.3
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
10
\n", "
Rendering Provider Suffix
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.3
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
Primary ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.3
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
10
\n", "
Primary ID
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.3
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
2
\n", "
Secondary ID Qualifier (1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.3
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
10
\n", "
Secondary ID (1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.3
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
2
\n", "
Secondary ID Qualifier (2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.3
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
10
\n", "
Secondary ID (2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.3
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
2
\n", "
Secondary ID Qualifier (3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.3
\n", "
1
\n", "", "
NO
\n", "
15
\n", "
10
\n", "
Secondary ID (3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
30
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'CI2 '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.3
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "
1
\n", "
Cleanup
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.3
\n", "
1
\n", "", "
NO
\n", "
16
\n", "
2
\n", "
Taxonomy Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.3
\n", "
1
\n", "", "
NO
\n", "
17
\n", "
10
\n", "
Taxonomy Code
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.6
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'LPUR'
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.6
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "
1
\n", "
LPUR DATA EXTRACT
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.6
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
6
\n", "
Service Line Counter
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.6
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
2
\n", "
Purchase Service Provider Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.6
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
2
\n", "
Primary ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
35
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'CI3 '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.6
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
10
\n", "
Primary ID
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.6
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
2
\n", "
Secondary ID Qualifier (1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.6
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
10
\n", "
Secondary ID (1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
193.6
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "
1
\n", "
Cleanup
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'LSUP'
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "
1
\n", "
LSUP DATA EXTRACT
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
6
\n", "
Service Line Counter
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
2
\n", "
Supervising Provider Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
60
\n", "
Supervising Provider Last Name
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
35
\n", "
Supervising Provider First Name
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'PT1 '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
1
\n", "
Supervising Provider Middle Initial
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
10
\n", "
Supervising Provider Suffix
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
Primary ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
10
\n", "
Primary ID
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
2
\n", "
Secondary ID Qualifier (1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
10
\n", "
Secondary ID (1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
2
\n", "
Secondary ID Qualifier (2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
10
\n", "
Secondary ID (2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
2
\n", "
Secondary ID Qualifier (3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194
\n", "
1
\n", "", "
NO
\n", "
15
\n", "
10
\n", "
Secondary ID (3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
45
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'PT2 '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "
1
\n", "
Cleanup
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.3
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'LREF'
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.3
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "
1
\n", "
LREF DATA EXTRACT
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.3
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
6
\n", "
Service Line Counter
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.3
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
2
\n", "
Referring Provider Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.3
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
60
\n", "
Referring Provider Last Name
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.3
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
35
\n", "
Referring Provider First Name
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.3
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
1
\n", "
Referring Provider Middle Initial
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'CL1 '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.3
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
10
\n", "
Referring Provider Suffix
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.3
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
Primary ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.3
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
10
\n", "
Primary ID
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.3
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
2
\n", "
Secondary ID Qualifier (1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.3
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
10
\n", "
Secondary ID (1)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.3
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
2
\n", "
Secondary ID Qualifier (2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.3
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
10
\n", "
Secondary ID (2)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.3
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
2
\n", "
Secondary ID Qualifier (3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.3
\n", "
1
\n", "", "
NO
\n", "
15
\n", "
10
\n", "
Secondary ID (3)
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.3
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "
1
\n", "
Cleanup
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'UB1 '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
57
\n", "
1
\n", "", "
NO
\n", "
99
\n", "
1
\n", "
SUB2 Clean Up
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
28
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "
1
\n", "
CI1A Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
28
\n", "
1
\n", "", "
NO
\n", "
99
\n", "
1
\n", "
CI1A Clean Up
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
96
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "
1
\n", "
OPR Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
96
\n", "
1
\n", "", "
NO
\n", "
99.5
\n", "
1
\n", "
OPR Cleanup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
97
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "
1
\n", "
OPR1 Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
97
\n", "
1
\n", "", "
NO
\n", "
99.5
\n", "
1
\n", "
OPR1 Cleanup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
98
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "
1
\n", "
OPR2 Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
98
\n", "
1
\n", "", "
NO
\n", "
99.5
\n", "
1
\n", "
OPR2 Cleanup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
99
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "
1
\n", "
OPR3 Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
99
\n", "
1
\n", "", "
NO
\n", "
99.5
\n", "", "
OPR3 Cleanup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
100
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "", "
OPR4 Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
100
\n", "
1
\n", "", "
NO
\n", "
99.5
\n", "", "
OPR4 Cleanup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
101
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "", "
OPR5 Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
101
\n", "
1
\n", "", "
NO
\n", "
99.5
\n", "", "
OPR5 Clean up
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
103
\n", "
1
\n", "", "
NO
\n", "
99.5
\n", "", "
OPR7 Clean up
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "", "
OPR8 Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104
\n", "
1
\n", "", "
NO
\n", "
99.5
\n", "", "
OPR8 Cleanup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.2
\n", "
1
\n", "", "
NO
\n", "
99.5
\n", "", "
OPR9 Cleanup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.4
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "", "
OPRA Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.4
\n", "
1
\n", "", "
NO
\n", "
99.5
\n", "", "
OPRA Cleanup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "", "
OP1 Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170
\n", "
1
\n", "", "
NO
\n", "
99.5
\n", "", "
OP1 Cleanup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170.5
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "", "
OP1A Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
170.5
\n", "
1
\n", "", "
NO
\n", "
99.5
\n", "", "
OP1A Cleanup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
171
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "", "
OP2 Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
171
\n", "
1
\n", "", "
NO
\n", "
99.5
\n", "", "
OP2 Cleanup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
173
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "", "
OP4 Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
173
\n", "
1
\n", "", "
NO
\n", "
99.5
\n", "", "
OP4 Cleanup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
177
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "", "
OP8 Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
30
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
35
\n", "
Subscriber First Name
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "", "
OP9 Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178
\n", "
1
\n", "", "
NO
\n", "
99.5
\n", "", "
OP9 Cleanup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
114
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "
1
\n", "
OI6 Cleanup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
112
\n", "
1
\n", "", "
NO
\n", "
7.9
\n", "", "
COB DATA SETUP
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
107
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
3
\n", "
Remaining patient Liability qualifier
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
107
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
15
\n", "
Remaining Patient Liability
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
195
\n", "
1
\n", "", "
NO
\n", "
18
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
22
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.8
\n", "
1
\n", "
1
\n", "
NO
\n", "
1.9
\n", "
2
\n", "
Ambulance Record Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.8
\n", "
1
\n", "
1
\n", "
NO
\n", "
99.9
\n", "
1
\n", "
AMB Cleanup Record
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.9
\n", "
1
\n", "
1
\n", "
NO
\n", "
1.9
\n", "
1
\n", "
AMB1 Record Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.9
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
80
\n", "
Amb Stretcher Purpose
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.9
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "
1
\n", "
AMB1 Clean up
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.91
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'AMB2'
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.91
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "
1
\n", "
AMB2 Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.91
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
2
\n", "
Amb Code Category
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.91
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
1
\n", "
Amb Certification Condition Indicator
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.91
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
3
\n", "
Amb Condition Code [1]
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.91
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
3
\n", "
Amb Condition Code [2]
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.91
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
3
\n", "
Amb Condition Code [3]
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.91
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
3
\n", "
Amb Condition Code [4]
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.91
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
3
\n", "
Amb Condition Code [5]
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.91
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "
1
\n", "
AMB2 Clean up
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
115
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
50
\n", "
Other Payer Claim Control number
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
195
\n", "
1
\n", "", "
NO
\n", "
16
\n", "
3
\n", "
Remaining Liability Qualifier
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
195
\n", "
1
\n", "", "
NO
\n", "
17
\n", "
15
\n", "
Remaining Liability
\n", "", "
TRUE
\n", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
23
\n", "", "", "
53
\n", "
25
\n", "
CLAIM ID (BX 11b)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
37
\n", "
1
\n", "", "", "
9
\n", "
80
\n", "
Payer Primary ID (HPID)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
23
\n", "", "", "
50
\n", "
2
\n", "
CLAIM QUAL (BX 11b)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
185
\n", "
1
\n", "", "
NO
\n", "
15
\n", "
48
\n", "
NDC
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
185
\n", "
1
\n", "", "", "
16
\n", "
15
\n", "
National Drug Unit Count
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
185
\n", "
1
\n", "", "", "
17
\n", "
2
\n", "
Unit or Basis of Measurement Code
\n", "
OUTPUT
\n", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
35
\n", "", "", "
4
\n", "
26
\n", "
REFERRING PROV NAME (BX 17)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
35
\n", "", "", "
1
\n", "
2
\n", "
REFERRING PROV QUAL (BX 17)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
33
\n", "", "", "
16
\n", "
3
\n", "
CURRENT DATE QUAL (BX 14)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
33
\n", "", "", "
31
\n", "
3
\n", "
OTHER DATE QUAL (BX 15)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
38
\n", "", "", "
42
\n", "
1
\n", "
DIAGNOSIS IND (BOX 21A)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
40
\n", "", "", "
3
\n", "
8
\n", "
DIAGNOSIS CODE 5 (BX-21.5)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
40
\n", "", "", "
16
\n", "
8
\n", "
DIAGNOSIS CODE 6 (BX-21.6)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
40
\n", "", "", "
29
\n", "
8
\n", "
DIAGNOSIS CODE 7 (BX-21.7)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
40
\n", "", "", "
42
\n", "
8
\n", "
DIAGNOSIS CODE 8 (BX-21.8)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
41
\n", "", "", "
3
\n", "
8
\n", "
DIAGNOSIS CODE 9 (BX-21.9)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
41
\n", "", "", "
16
\n", "
8
\n", "
DIAGNOSIS CODE 10 (BX-21.10)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
41
\n", "", "", "
29
\n", "
8
\n", "
DIAGNOSIS CODE 11 (BX-21.11)
\n", "", "", ""], ["CMS-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
41
\n", "", "", "
42
\n", "
8
\n", "
DIAGNOSIS CODE 12 (BX-21.12)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
37
\n", "
1
\n", "", "", "
8
\n", "
2
\n", "
Payer ID Qualifier
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191
\n", "
1
\n", "", "", "
15
\n", "
80
\n", "
Description (NOC Procedure)
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
32
\n", "
1
\n", "
1
\n", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'CI2A'
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
32
\n", "
1
\n", "
1
\n", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
36
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'CI3A'
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
107
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OI1A'
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
107
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
62
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'DN1 '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
62
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
3
\n", "
ORTHO BANDING QUALIFIER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
28
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
2
\n", "
Billing Prov Sec ID Qualifier(1)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
62
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
35
\n", "
ORTHO BANDING DATE
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
62
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
15
\n", "
ORTHO TX MONTHS COUNT
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
62
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
15
\n", "
ORTHO TX MTHS CT TRANS
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
62
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
80
\n", "
ORTHO TX INDICATOR
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
63
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'DN2 '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
63
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
50
\n", "
TOOTH NUMBER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
63
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
2
\n", "
TOOTH STATUS CODE
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
63
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
3
\n", "
TOOTH CODE LIST QUALIFIER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
101
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
3
\n", "
REFERRING PROVIDER CODE
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
28
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
20
\n", "
Billing Prov Sec ID(1)
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
101
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
3
\n", "
REFERRING PROVIDER CODE QUALIFIER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
101
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
50
\n", "
REFERRING PROVIDER TAXONOMY
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.6
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OPRB'
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.6
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
3
\n", "
ASST SURGEON QUALIFIER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.6
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
1
\n", "
ASST SURGEON TYPE
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.6
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
60
\n", "
ASST SURGEON LAST NAME
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.6
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
35
\n", "
ASST SURGEON FIRST NAME
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.6
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
25
\n", "
ASST SURGEON MIDDLE NAME
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.6
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
10
\n", "
ASST SURGEON NAME SUFFIX
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.6
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
ASST SURGEON PRIMARY ID QUALIFIER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.6
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
80
\n", "
ASST SURGEON PRIMARY ID
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.6
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
3
\n", "
ASST SURGEON TAXONOMY QUALIFIER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.6
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
10
\n", "
ASST SURGEON TAXONOMY
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.6
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "", "
OPRB Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.6
\n", "
1
\n", "", "
NO
\n", "
99.5
\n", "", "
OPRB Cleanup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.61
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OPRC'
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.61
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
3
\n", "
ASST SURGEON SEC ID QUALIFIER (1)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.61
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
50
\n", "
ASST SURGEON SEC ID (1)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.61
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "", "
OPRC Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.61
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
3
\n", "
ASST SURGEON SEC ID QUALIFIER (2)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.61
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
50
\n", "
ASST SURGEON SEC ID (2)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.61
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
3
\n", "
ASST SURGEON SEC ID QUALIFIER (3)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.61
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
50
\n", "
ASST SURGEON SEC ID (3)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.61
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
3
\n", "
ASST SURGEON SEC ID QUALIFIER (4)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.61
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
50
\n", "
ASST SURGEON SEC ID (4)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
104.61
\n", "
1
\n", "", "
NO
\n", "
99.5
\n", "", "
OPRC Cleanup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178.1
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OP10'
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178.1
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "", "
OP10 Setup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178.1
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
PAYER RESPONSIBILITY SEQ # CODE
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178.1
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
3
\n", "
OTHER PAYER ASST SURGEON ENTITY ID
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
110
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178.1
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
1
\n", "
OTHER PAYER ASST SURGEON ENTITY QUAL
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178.1
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
3
\n", "
OTHER PAYER ASST SURGEON SEC ID QUAL(1)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178.1
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
50
\n", "
OTHER PAYER ASST SURGEON SEC ID(1)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178.1
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
3
\n", "
OTHER PAYER ASST SURGEON SEC ID QUAL(2)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178.1
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
50
\n", "
OTHER PAYER ASST SURGEON SEC ID(2)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178.1
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
3
\n", "
OTHER PAYER ASST SURGEON SEC ID QUAL(3)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178.1
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
50
\n", "
OTHER PAYER ASST SURGEON SEC ID(3)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
178.1
\n", "
1
\n", "", "
NO
\n", "
99.5
\n", "", "
OP10 Cleanup
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'DEN '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
6
\n", "
SERVICE LINE #
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
3
\n", "
DATE/TIME QUALIFIER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
35
\n", "
SERVICE DATE
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
2
\n", "
SERVICE ID QUALIFIER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
48
\n", "
PROCEDURE CODE
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
2
\n", "
PROCEDURE MODIFIER(1)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
PROCEDURE MODIFIER(2)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
2
\n", "
PROCEDURE MODIFIER(3)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
2
\n", "
PROCEDURE MODIFIER(4)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
80
\n", "
PROCEDURE CODE DESCRIPTION
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
18
\n", "
LINE ITEM CHARGE AMT
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
2
\n", "
PLACE OF SERVICE CODE
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
3
\n", "
ORAL CAVITY DESIGNATION(1)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186
\n", "
1
\n", "", "
NO
\n", "
15
\n", "
3
\n", "
ORAL CAVITY DESIGNATION(2)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186
\n", "
1
\n", "", "
NO
\n", "
16
\n", "
3
\n", "
ORAL CAVITY DESIGNATION(3)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186
\n", "
1
\n", "", "
NO
\n", "
17
\n", "
3
\n", "
ORAL CAVITY DESIGNATION(4)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186
\n", "
1
\n", "", "
NO
\n", "
18
\n", "
3
\n", "
ORAL CAVITY DESIGNATION(5)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186
\n", "
1
\n", "", "
NO
\n", "
19
\n", "
1
\n", "
PROSTHESIS CROWN INLAY CODE
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.1
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'DEN1'
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.1
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
6
\n", "
SERVICE LINE #
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.1
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
15
\n", "
PROCEDURE COUNT
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.1
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
2
\n", "
DIAGNOSIS CODE POINTER(1)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.1
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
2
\n", "
DIAGNOSIS CODE POINTER(2)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.1
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
2
\n", "
DIAGNOSIS CODE POINTER(3)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.1
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
2
\n", "
DIAGNOSIS CODE POINTER(4)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.1
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
3
\n", "
PRIOR PLACEMENT DATE QUALIFIER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.1
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
35
\n", "
PRIOR PLACEMENT DATE
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.1
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
3
\n", "
ORTHO BANDING DATE QUALIFIER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.1
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
35
\n", "
ORTHO BANDING DATE
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.1
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
3
\n", "
REPLACEMENT DATE QUALIFIER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.1
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
35
\n", "
REPLACEMENT DATE
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.1
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
3
\n", "
TREATMENT START DATE QUALIFIER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.1
\n", "
1
\n", "", "
NO
\n", "
15
\n", "
35
\n", "
TREATMENT START DATE
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.1
\n", "
1
\n", "", "
NO
\n", "
16
\n", "
3
\n", "
TREATMENT COMPLETION DATE QUALIFIER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.1
\n", "
1
\n", "", "
NO
\n", "
17
\n", "
35
\n", "
TREATMENT COMPLETION DATE
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.2
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'DEN2'
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.2
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
6
\n", "
SERVICE LINE #
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.2
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
3
\n", "
TOOTH CODE QUALIFIER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.2
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
30
\n", "
TOOTH CODE
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.2
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
2
\n", "
TOOTH SURFACE(1)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.2
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
2
\n", "
TOOTH SURFACE(2)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.2
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
2
\n", "
TOOTH SURFACE(3)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.2
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
TOOTH SURFACE(4)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
186.2
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
2
\n", "
TOOTH SURFACE(5)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.5
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'LSUR'
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.5
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
6
\n", "
SERVICE LINE COUNTER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.5
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
3
\n", "
ASST SURGEON QUALIFIER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.5
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
60
\n", "
ASST SURGEON LAST NAME
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.5
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
35
\n", "
ASST SURGEON FIRST NAME
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.5
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
25
\n", "
ASST SURGEON MIDDLE NAME
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.5
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
10
\n", "
ASST SURGEON NAME SUFFIX
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.5
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
ASST SURGEON PRIMARY ID QUALIFIER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.5
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
10
\n", "
ASST SURGEON PRIMARY ID
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.5
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "", "
LSUR DATA EXTRACT
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
55
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.6
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
5
\n", "
RECORD ID 'LSR1'
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.6
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "", "
LSR1 DATA EXTRACT
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.6
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
6
\n", "
SERVICE LINE COUNTER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.6
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
3
\n", "
ASST SURGEON SECONDARY ID QUALIFIER(1)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.6
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
15
\n", "
ASST SURGEON SECONDARY ID(1)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.6
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
3
\n", "
ASST SURGEON SECONDARY ID QUALIFIER(2)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.6
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
15
\n", "
ASST SURGEON SECONDARY ID(2)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.6
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
3
\n", "
ASST SURGEON SECONDARY ID QUALIFIER(3)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.6
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
15
\n", "
ASST SURGEON SECONDARY ID(3)
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.6
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
2
\n", "
ASST SURGEON TAXONOMY QUALIFIER
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
194.6
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
10
\n", "
ASST SURGEON TAXONOMY CODE
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
205
\n", "
1
\n", "", "", "
1
\n", "
4
\n", "
CMN RECORD ID 'LQ '
\n", "
OUTPUT
\n", "
FALSE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
205
\n", "
1
\n", "", "", "
3
\n", "
30
\n", "
CMN FORM TYPE QUALIFIER
\n", "
OUTPUT
\n", "
FALSE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
205
\n", "
1
\n", "", "", "
2
\n", "
6
\n", "
SERVICE LINE #
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
205
\n", "
1
\n", "", "", "
4
\n", "
10
\n", "
CMN INDUSTRY CODE
\n", "
OUTPUT
\n", "
FALSE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.4
\n", "
1
\n", "", "", "
3
\n", "
1
\n", "
CMN CERTIFICATION TYPE
\n", "
OUTPUT
\n", "", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.4
\n", "
1
\n", "", "", "
14
\n", "
3
\n", "
CMN CERTIFICATION TYPE QUAL
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.7
\n", "
1
\n", "", "", "
3
\n", "
2
\n", "
CMN MEASUREMENT REFERENCE ID CODE
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "", "
15
\n", "
4
\n", "
CMN PATIENT WEIGHT (LBS)
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "", "
14
\n", "
2
\n", "
CMN PATIENT WEIGHT MODIFIER
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.4
\n", "
1
\n", "", "", "
5
\n", "
2
\n", "
CMN MONTHS DME EQUIPMENT NEEDED
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.4
\n", "
1
\n", "", "", "
11
\n", "
8
\n", "
CMN DATE THERAPY STARTED
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.4
\n", "
1
\n", "", "", "
10
\n", "
3
\n", "
CMN DATE THERAPY STARTED QUALIFIER
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.4
\n", "
1
\n", "", "", "
13
\n", "
8
\n", "
CMN LAST CERTIFICATION DATE
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.4
\n", "
1
\n", "", "", "
12
\n", "
3
\n", "
CMN LAST CERTIFICATION DATE QUALIFIER
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
65
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OC1 '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.4
\n", "
1
\n", "", "", "
15
\n", "
8
\n", "
CMN RECERTIFICATION/REVISION DATE
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.4
\n", "
1
\n", "", "", "
9
\n", "
3
\n", "
CMN REPLACEMENT ITEM?
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
70
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OS1 '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
75
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'PC1 '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "", "", "
205
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "
1
\n", "
LQ DATA EXTRACT
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "", "", "
210
\n", "
1
\n", "", "
NO
\n", "
1.5
\n", "
1
\n", "
FRM DATA EXTRACT
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
210
\n", "
1
\n", "", "", "
1
\n", "
4
\n", "
CMN RECORD ID 'FRM '
\n", "
OUTPUT
\n", "
FALSE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
210
\n", "
1
\n", "", "", "
2
\n", "
6
\n", "
SERVICE LINE #
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
80
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'VC1 '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "", "", "
210
\n", "
1
\n", "", "", "
3
\n", "
20
\n", "
CMN QUESTION NUMBER/LETTER
\n", "
OUTPUT
\n", "
FALSE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
210
\n", "
1
\n", "", "", "
4
\n", "
1
\n", "
CMN QUESTION RESPONSE Y/N
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
210
\n", "
1
\n", "", "", "
5
\n", "
50
\n", "
CMN QUESTION RESPONSE REF ID
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
210
\n", "
1
\n", "", "", "
6
\n", "
8
\n", "
CMN QUESTION RESPONSE DATE
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
210
\n", "
1
\n", "", "", "
7
\n", "
6
\n", "
CMN QUESTION RESPONSE % & DECIMAL
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.4
\n", "
1
\n", "", "", "
2
\n", "
6
\n", "
SERVICE LINE #
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.4
\n", "
1
\n", "", "", "
1.5
\n", "
1
\n", "
CMN DATA EXTRACT
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.4
\n", "
1
\n", "", "", "
1
\n", "
4
\n", "
CMN RECORD ID 'CMN '
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
85
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'CC1 '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.4
\n", "
1
\n", "", "", "
4
\n", "
2
\n", "
CMN UNIT OR BASIS FOR MEASUREMENT CODE
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.4
\n", "
1
\n", "", "", "
7
\n", "
1
\n", "
CMN CERTIFICATION CONDITION INDICATOR
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.4
\n", "
1
\n", "", "", "
8
\n", "
3
\n", "
CMN CONDITION INDICATOR
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.4
\n", "
1
\n", "", "", "
16
\n", "
2
\n", "
CMN ATTACHMENT REPORT TYPE CODE
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.4
\n", "
1
\n", "", "", "
17
\n", "
2
\n", "
CMN ATTACHMENT TRANSMISSION CODE
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.4
\n", "
1
\n", "", "", "
6
\n", "
2
\n", "
CMN CODE CATEGORY
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.7
\n", "
1
\n", "", "", "
1
\n", "
4
\n", "
CMN RECORD ID 'MEA '
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.7
\n", "
1
\n", "", "", "
1.5
\n", "
1
\n", "
MEA DATA EXTRACT
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
90
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'DC1 '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.7
\n", "
1
\n", "", "", "
2
\n", "
6
\n", "
SERVICE LINE #
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.7
\n", "
1
\n", "", "", "
4
\n", "
3
\n", "
CMN MEASUREMENT QUALIFIER
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
191.7
\n", "
1
\n", "", "", "
5
\n", "
20
\n", "
CMN TEST RESULTS
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
185
\n", "
1
\n", "", "
NO
\n", "
18
\n", "
2
\n", "
Procedure Modifier(3)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
185
\n", "
1
\n", "", "
NO
\n", "
19
\n", "
2
\n", "
Procedure Modifier(4)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
105
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OI1 '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
110
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'OI2 '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'PRF '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
185
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'INS '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
190
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'RX1 '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
30
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
60
\n", "
Subscriber Last Name
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
30
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
25
\n", "
Subscriber Middle Name
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
2
\n", "
Pt. Relationship to Insured
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
15
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
30
\n", "
Billing Prov Address 2
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
30
\n", "
Pt. Last Name
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
20
\n", "
Pt. First Name
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
25
\n", "
Pt. Middle Name
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
35
\n", "
Pt. Address 1
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
35
\n", "
Pt. Address 2
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
30
\n", "
Pt. City Name
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
2
\n", "
Pt. State Code
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
9
\n", "
Pt. ZIP Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
8
\n", "
Pt. Birth DT
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
1
\n", "
Pt. Gender Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
30
\n", "
1
\n", "", "
NO
\n", "
2.9
\n", "", "
INSURED FULL NAME
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
15
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
40
\n", "
1
\n", "", "
NO
\n", "
16
\n", "
20
\n", "
Medical Record Number
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
45
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
38
\n", "
Pt. Control #
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
1
\n", "
Facility Type Code (Inst)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
1
\n", "
Claim Frequency Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
2
\n", "
Claim Type
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
8
\n", "
Statement To DT
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
1
\n", "
Release of Information Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
70
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
8
\n", "
Occurrence Span Code DT (To)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
8
\n", "
Service DT To
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
5
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
3
\n", "
Site Number
\n", "", "
TRUE
\n", "
NO
\n"], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
1
\n", "", "
YES
\n", "
1
\n", "
80
\n", "
PRINT STAT (HCFA-1500 TOP LN)
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
1
\n", "
Assignment of Benefits Indicator
\n", "", "
TRUE
\n", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
2
\n", "", "
YES
\n", "
1
\n", "
80
\n", "
MAILING ADDRESS NM (FORM LN 2)
\n", "
OUTPUT
\n", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
50
\n", "
28
\n", "
INSURED ID # (BX-1A)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
1
\n", "
28
\n", "
PATIENT NAME (BX-2)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
31
\n", "
10
\n", "
PATIENT DOB (BX-3/1)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
42
\n", "
1
\n", "
PATIENT SEX=MALE (BX-3/2A)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
47
\n", "
1
\n", "
PATIENT SEX=FEMALE (BX-3/2B)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
2
\n", "
Bill Status
\n", "", "
TRUE
\n", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
50
\n", "
28
\n", "
INSURED'S NAME (BX-4)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
13
\n", "", "
YES
\n", "
1
\n", "
28
\n", "
PATIENT STR ADDRESS (BX-5/1)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
13
\n", "", "
YES
\n", "
33
\n", "
1
\n", "
PT REL TO INSURED=SELF (BX-6)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
13
\n", "", "
YES
\n", "
38
\n", "
1
\n", "
PT REL TO INSRD=SPOUSE (BX-6)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
13
\n", "", "
YES
\n", "
42
\n", "
1
\n", "
PT REL TO INSRD=CHILD (BX-6)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
13
\n", "", "
YES
\n", "
47
\n", "
1
\n", "
PT REL TO INSRD=OTHER (BX-6)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
13
\n", "", "
YES
\n", "
50
\n", "
28
\n", "
INSURED STR ADDRESS (BX-7/1)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
15
\n", "", "
YES
\n", "
1
\n", "
28
\n", "
PATIENT CITY ADDRESS (BX-5/2A)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
15
\n", "", "
YES
\n", "
26
\n", "
2
\n", "
PATIENT STATE (BX-5/2B)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
15
\n", "", "
YES
\n", "
35
\n", "
1
\n", "
PT MARITAL STAT=SINGL (BX-8/A)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
8
\n", "
Statement From DT
\n", "", "
TRUE
\n", "
NO
\n"], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
15
\n", "", "
YES
\n", "
41
\n", "
1
\n", "
PT MARITAL STAT=MARRD (BX-8/B)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
15
\n", "", "
YES
\n", "
47
\n", "
1
\n", "
PT MARITAL STAT=OTHER (BX-8/C)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
17
\n", "", "
YES
\n", "
1
\n", "
12
\n", "
PATIENT ZIP CODE (BX-5/3A)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
17
\n", "", "
YES
\n", "
15
\n", "
16
\n", "
PATIENT TELEPHONE (BX-5/3B)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
17
\n", "", "
YES
\n", "
35
\n", "
1
\n", "
PT EMPL STAT=EMPLOYD (BX-8/2A)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
1
\n", "
28
\n", "
OTH INSURED NAME (BX-9/1)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
50
\n", "
28
\n", "
INSURED POLICY GROUP (BX-11)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
21
\n", "", "
YES
\n", "
1
\n", "
28
\n", "
OTH INSURED POLICY # (BX-9A)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
21
\n", "", "
YES
\n", "
35
\n", "
1
\n", "
COND REL TO EMP=YES (BX-10A/A)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
21
\n", "", "
YES
\n", "
41
\n", "
1
\n", "
COND REL TO EMP=NO (BX-10A/B)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
18
\n", "
Estimated Claim Due Amount
\n", "", "
TRUE
\n", "
NO
\n"], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
21
\n", "", "
YES
\n", "
54
\n", "
10
\n", "
INSUREDS DOB (BX-11A/1)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
21
\n", "", "
YES
\n", "
68
\n", "
1
\n", "
INSUREDS SEX=MALE (BX-11A/2A)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
21
\n", "", "
YES
\n", "
75
\n", "
1
\n", "
INSURED SEX=FEMALE (BX-11A/2B)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
23
\n", "", "
YES
\n", "
2
\n", "
10
\n", "
OTH INSURED DOB (BX-9B/1)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
23
\n", "", "
YES
\n", "
18
\n", "
1
\n", "
OTH INS SEX=MALE (BX-9B/2A)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
23
\n", "", "
YES
\n", "
24
\n", "
1
\n", "
OTH INS SEX=FEMALE (BX-9B/2B)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
23
\n", "", "
YES
\n", "
35
\n", "
1
\n", "
COND REL AUTO=YES (BX-10B/A)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
23
\n", "", "
YES
\n", "
41
\n", "
1
\n", "
COND REL AUTO=NO (BX-10B/B)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
23
\n", "", "
YES
\n", "
45
\n", "
2
\n", "
AUTO ACCIDENT STATE (BX-10B/C)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
23
\n", "", "
YES
\n", "
50
\n", "
28
\n", "
INSURED EMPLOYR NAME (BX-11B)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
18
\n", "
Total Claim Charge Amount
\n", "", "
TRUE
\n", "
NO
\n"], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
25
\n", "", "
YES
\n", "
1
\n", "
28
\n", "
OTH INS EMPLR (BX-9C)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
25
\n", "", "
YES
\n", "
35
\n", "
1
\n", "
COND REL TO OTH=YES (BX-10C/A)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
25
\n", "", "
YES
\n", "
41
\n", "
1
\n", "
COND REL TO OTH=NO (BX-10C/B)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
25
\n", "", "
YES
\n", "
50
\n", "
28
\n", "
INSUREDS PLAN NAME (BX-11C)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
27
\n", "", "
YES
\n", "
1
\n", "
28
\n", "
OTH INS PLAN NAME (BX-9D)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
27
\n", "", "
YES
\n", "
52
\n", "
1
\n", "
ANOTHER PLAN=YES (BX-11D/A)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
27
\n", "", "
YES
\n", "
57
\n", "
1
\n", "
ANOTHER PLAN=NO (BX-11D/B)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
31
\n", "", "
YES
\n", "
6
\n", "
25
\n", "
PATIENT SIGNATURE (BX-12)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
31
\n", "", "
YES
\n", "
57
\n", "
22
\n", "
INSUREDS SIGNATURE (BX-13)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
33
\n", "", "
YES
\n", "
2
\n", "
10
\n", "
DATE OF CURR ILLNESS (BX-14)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
8
\n", "
Admission/Start of Care DT
\n", "", "
TRUE
\n", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
33
\n", "", "
YES
\n", "
37
\n", "
10
\n", "
DATE OF SIMLAR ILLNESS (BX-15)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
33
\n", "", "
YES
\n", "
54
\n", "
10
\n", "
DT UNABLE TO WRK FR (BX-16/1)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
33
\n", "", "
YES
\n", "
68
\n", "
10
\n", "
DT UNABLE TO WRK TO (BX-16/2)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
35
\n", "", "
YES
\n", "
54
\n", "
10
\n", "
HOSP FROM DATE (BX-18/1)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
35
\n", "", "
YES
\n", "
68
\n", "
10
\n", "
HOSP TO DATE (BX-18/2)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
36
\n", "", "
YES
\n", "
1
\n", "
48
\n", "
UPPER LINE HCFA (BX-19)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
37
\n", "", "
YES
\n", "
1
\n", "
48
\n", "
LOWER LINE - HCFA (BX-19)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
37
\n", "", "
YES
\n", "
52
\n", "
11
\n", "
OUTSIDE LAB (BX-20/1B)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
39
\n", "", "
YES
\n", "
3
\n", "
7
\n", "
DIAGNOSIS CODE 1 (BX-21.1)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
39
\n", "", "
YES
\n", "
31
\n", "
7
\n", "
DIAGNOSIS CODE 3 (BX-21.3)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
YES
\n", "
15
\n", "
4
\n", "
Admission Hour
\n", "", "
TRUE
\n", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
41
\n", "", "
YES
\n", "
3
\n", "
7
\n", "
DIAGNOSIS CODE 2 (BX-21.2)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
41
\n", "", "
YES
\n", "
31
\n", "
7
\n", "
DIAGNOSIS CODE 4 (BX-21.4)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
41
\n", "", "
YES
\n", "
50
\n", "
30
\n", "
PRIOR AUTH NUMBER (BX-23)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
1
\n", "
9
\n", "
DATE OF SERV FR (BX-24A/A)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
10
\n", "
9
\n", "
DATE OF SERV TO (BX-24A/B)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
19
\n", "
3
\n", "
PLACE OF SERVICE (BX-24B)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
22
\n", "
3
\n", "
TYPE OF SERVICE (BX-24C)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
25
\n", "
17
\n", "
PROCEDURE (BX-24D/1)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
42
\n", "
7
\n", "
DIAGNOSIS CODE REFS (BX-24E)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
16
\n", "
8
\n", "
Discharge DT
\n", "", "
TRUE
\n", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
49
\n", "
10
\n", "
CHARGES (BX-24F)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
59
\n", "
3
\n", "
UNITS (BX-24G)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
57
\n", "", "
YES
\n", "
1
\n", "
16
\n", "
FED TAX ID # (BX-25/1)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
57
\n", "", "
YES
\n", "
19
\n", "
1
\n", "
ID NUMBER=EIN (BX-25/2B)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
57
\n", "", "
YES
\n", "
23
\n", "
14
\n", "
PATIENT ACCT NUMBER (BX-26)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
57
\n", "", "
YES
\n", "
50
\n", "
10
\n", "
TOTAL CHARGE (BX-28)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
59
\n", "", "
YES
\n", "
23
\n", "
26
\n", "
FACILITY NAME (BX-32/LINE 1)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
59
\n", "", "
YES
\n", "
50
\n", "
30
\n", "
AGENT CASHIER NM (BX-33/LN 1)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
1
\n", "
21
\n", "
BLOCK 31 CHR 1-21 (BX-31/LN1)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
23
\n", "
26
\n", "
FAC ADR LINE 1 (BX-32/LN 2)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
YES
\n", "
17
\n", "
4
\n", "
Discharge Hour
\n", "", "
TRUE
\n", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
50
\n", "
30
\n", "
AGENT CASH ADR LN1 (BX-33/LN2)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
61
\n", "", "
YES
\n", "
1
\n", "
21
\n", "
BLOCK 31 CHR 22-42 (BX-31/LN2)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
61
\n", "", "
YES
\n", "
23
\n", "
27
\n", "
FAC CITY/ST/ZIP (BX-32/LN 3)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
61
\n", "", "
YES
\n", "
50
\n", "
30
\n", "
AG CA CITY/ST/ZIP (BX-33/LN 3)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
62
\n", "", "
YES
\n", "
1
\n", "
21
\n", "
BLOCK 31 CHR 43-63 (BX-31/LN3)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
3
\n", "
4
\n", "
YES
\n", "
1
\n", "
80
\n", "
MAILING ADDR FULL (FORM LN 3)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
185
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
18
\n", "
Service Line Non-covered Charge Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
18
\n", "
8
\n", "
Onset of Current Illness/Symptom DT
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
190
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
10
\n", "
National Drug Unit Count
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
190
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'BGN '
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Segment Delimiter
\n", "", "
TRUE
\n", "
YES
\n"], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
22.8
\n", "", "
FACILITY STR ADDR 1 EXTRACT
\n", "
CALCULATE ONLY
\n", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
22.9
\n", "", "
FACILITY STR ADDR 2 EXTRACT
\n", "
CALCULATE ONLY
\n", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
61
\n", "", "
YES
\n", "
49.7
\n", "", "
AGENT CASHIER CITY EXTRACT
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
19
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
61
\n", "", "
YES
\n", "
49.8
\n", "", "
AGENT CASHIER STATE EXTRACT
\n", "
CALCULATE ONLY
\n", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
61
\n", "", "
YES
\n", "
49.9
\n", "", "
AGENT CASHIER ZIP EXTRACT
\n", "
CALCULATE ONLY
\n", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
.5
\n", "", "
SERVICE LN EXTRACT - HCFA 1500
\n", "
CALCULATE ONLY
\n", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
63
\n", "", "
NO
\n", "
1.9
\n", "", "
MULTIPLE PAGE CHECK/POPULATE
\n", "
CALCULATE ONLY
\n", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
57
\n", "", "
YES
\n", "
63
\n", "
7
\n", "
TOTAL PRIOR PAYMENTS (BX-29)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
57
\n", "", "
YES
\n", "
72
\n", "
7
\n", "
TOT CHRG-PRIOR PYMNTS (BX-30)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
80.1
\n", "", "
CLEAN UP IBXSAVE
\n", "
CALCULATE ONLY
\n", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
1
\n", "
46
\n", "
CHECK BOX FOR BILL TYPE
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
27
\n", "", "
YES
\n", "
30
\n", "
20
\n", "
BOX 10D HCFA 1500
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
35
\n", "", "
YES
\n", "
1
\n", "
26
\n", "
BOX 17 HCFA 1500
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
32
\n", "
1
\n", "", "
NO
\n", "
2.9
\n", "
72
\n", "
INSURED ADDR (STR/CITY/ST/ZIP)
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
20
\n", "
8
\n", "
Last Worked DT
\n", "", "
TRUE
\n", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
35
\n", "", "
YES
\n", "
28
\n", "
21
\n", "
BOX 17a HCFA 1500
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
37
\n", "", "
YES
\n", "
60
\n", "
10
\n", "
LAB CHARGES (BX-20/B)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
39
\n", "", "
YES
\n", "
50
\n", "
11
\n", "
MEDICAID RESUB CODE (BX-22/A)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
39
\n", "", "
YES
\n", "
62
\n", "
18
\n", "
ORIGINAL REF NO (BX-22/B)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
57
\n", "", "
YES
\n", "
38
\n", "
6
\n", "
ACCEPT ASSIGNMENT (BX-27)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
62
\n", "
3
\n", "
EPSDT FAMILY PLAN (BX-24H)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
65
\n", "
3
\n", "
EMG (BX-24I)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
68
\n", "
3
\n", "
COB (BX-24J)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
71
\n", "
10
\n", "
LOCAL USE (BX-24K)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
21
\n", "
8
\n", "
Work Return DT
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
15
\n", "
2
\n", "
Procedure Modifier(1)
\n", "", "
TRUE
\n", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
1
\n", "", "
YES
\n", "
1
\n", "
4
\n", "
SIGNATURE REQ FLAG - TOP LINE
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
1
\n", "", "
YES
\n", "
35
\n", "
35
\n", "
PRINT STAT (UB92 TOP LINE)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
2
\n", "", "
YES
\n", "
1
\n", "
25
\n", "
AGENT CASH MAIL SYMB (FL-1/1)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
2
\n", "", "
YES
\n", "
27
\n", "
30
\n", "
UB92 FORM LOCATOR 2 (FL-2/1)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
3
\n", "", "
YES
\n", "
1
\n", "
25
\n", "
AGENT CASHIER ADDRESS (FL-1/2)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
3
\n", "", "
YES
\n", "
27
\n", "
31
\n", "
UB92 FORM LOCATOR 2 (FL-2/2)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
3
\n", "", "
YES
\n", "
58
\n", "
20
\n", "
PATIENT CONTROL NUMBER (FL-3)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
3
\n", "", "
YES
\n", "
78
\n", "
4
\n", "
UB92 TYPE OF BILL (FL-4)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
4
\n", "", "
YES
\n", "
1
\n", "
25
\n", "
AGENT CASH CIT/ST/ZIP (FL-1/3)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
22
\n", "
1
\n", "
Admission Source Code
\n", "", "
TRUE
\n", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
4
\n", "", "
YES
\n", "
69
\n", "
13
\n", "
FORM LOCATOR 11 (FL-11/1)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
5
\n", "", "
YES
\n", "
1
\n", "
25
\n", "
AGENT CASH PHONE (FL-1/4)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
5
\n", "", "
YES
\n", "
27
\n", "
10
\n", "
FED TAX ID # (FL-5)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
5
\n", "", "
YES
\n", "
38
\n", "
6
\n", "
STATEMENT FROM DATE (FL-6A)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
5
\n", "", "
YES
\n", "
45
\n", "
6
\n", "
STATEMENT THRU DATE (FL-6B)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
5
\n", "", "
YES
\n", "
52
\n", "
4
\n", "
COVERED DAYS (FL-7)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
5
\n", "", "
YES
\n", "
56
\n", "
5
\n", "
NON-COVERED DAYS (FL-8)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
5
\n", "", "
YES
\n", "
61
\n", "
4
\n", "
FORM LOCATOR 9 (FL-9)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
5
\n", "", "
YES
\n", "
65
\n", "
4
\n", "
FORM LOCATOR 10 (FL-10)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
5
\n", "", "
YES
\n", "
68
\n", "
14
\n", "
FORM LOCATOR 11 (FL-11/2)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
23
\n", "
1
\n", "
Admission Type Code
\n", "", "
TRUE
\n", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
7
\n", "", "
YES
\n", "
1
\n", "
30
\n", "
PATIENT NAME (FL-12)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
7
\n", "", "
YES
\n", "
32
\n", "
49
\n", "
PATIENT SHORT ADDRESS (FL-13)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
8
\n", "", "
YES
\n", "
76
\n", "
6
\n", "
FORM LOCATOR 31 (FL-31/1)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
1
\n", "
8
\n", "
PATIENT DOB (FL-14)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
10
\n", "
1
\n", "
PATIENT SEX (FL-15)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
13
\n", "
1
\n", "
PATIENT MARITAL STATUS (FL-16)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
15
\n", "
6
\n", "
ADMISSION DATE (FL-17)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
22
\n", "
2
\n", "
ADMISSION HR (FL-18)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
26
\n", "
1
\n", "
ADMISSION TYPE (FL-19)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
29
\n", "
1
\n", "
ADMISSION SOURCE (FL-20)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
24
\n", "
2
\n", "
Pt. Status Code
\n", "", "
TRUE
\n", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
31
\n", "
2
\n", "
DISCHARGE HR (FL-21)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
34
\n", "
3
\n", "
PATIENT STATUS (FL-22)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
37
\n", "
18
\n", "
MEDICAL RECORD NUMBER (FL-23)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
54.9
\n", "", "
EXTRACT CONDITION CODES
\n", "
CALCULATE ONLY
\n", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
55
\n", "
3
\n", "
CONDITION CODE 1 (FL-24)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
58
\n", "
3
\n", "
CONDITION CODE 2 (FL-25)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
61
\n", "
3
\n", "
CONDITION CODE 3 (FL-26)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
64
\n", "
3
\n", "
CONDITION CODE 4 (FL-27)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
67
\n", "
3
\n", "
CONDITION CODE 5 (FL-28)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
70
\n", "
3
\n", "
CONDITION CODE 6 (FL-29)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
32
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
55
\n", "
Subscriber Address 2
\n", "", "
TRUE
\n", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
73
\n", "
3
\n", "
CONDITION CODE 7 (FL-30)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
75
\n", "
7
\n", "
FORM LOCATOR 31 (FL-31/2)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
10
\n", "", "
YES
\n", "
58
\n", "
24
\n", "
FORM LOCATOR 37A
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
1
\n", "
3
\n", "
OCCURRENCE CODE (FL-32/1)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
4
\n", "
7
\n", "
OCCURRENCE DATE (FL-32/2)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
14
\n", "
7
\n", "
OCCURRENCE DATE (FL-33/2)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
26
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
24
\n", "
7
\n", "
OCCURRENCE DATE (FL-34/2)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
34
\n", "
7
\n", "
OCCURRENCE DATE (FL-35/2)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
41
\n", "
3
\n", "
OCCURRENCE SPAN CODE (FL-36/1)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
44
\n", "
7
\n", "
OCC SPAN DATE FROM (FL-36/2)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
51
\n", "
7
\n", "
OCC SPAN DATE TO (FL-36/3)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
27
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
13
\n", "", "
YES
\n", "
1
\n", "
42
\n", "
RESPONSIBLE PARTY NM (FL-38/1)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
14
\n", "", "
YES
\n", "
1
\n", "
42
\n", "
RESP PARTY ADDR LN 1 (FL-38/2)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
14
\n", "", "
YES
\n", "
43.9
\n", "", "
VALUE CODE EXTRACT (FL-39:41)
\n", "
CALCULATE ONLY
\n", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
14
\n", "", "
YES
\n", "
44
\n", "
3
\n", "
VALUE CODES CD 1 (FL-39a:d/1)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
14
\n", "", "
YES
\n", "
46
\n", "
10
\n", "
VALUE CODES AMT 1 (FL-39a:d/2)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
14
\n", "", "
YES
\n", "
57
\n", "
3
\n", "
VALUE CODES CD 2 (FL-40a:d/1)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
14
\n", "", "
YES
\n", "
59
\n", "
10
\n", "
VALUE CODES AMT 2 (FL-40a:d/2)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
14
\n", "", "
YES
\n", "
70
\n", "
3
\n", "
VALUE CODES CD 3 (FL-41a:d/1)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
14
\n", "", "
YES
\n", "
72
\n", "
10
\n", "
VALUE CODES AMT 3 (FL-41a:d/2)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
15
\n", "", "
YES
\n", "
1
\n", "
42
\n", "
RESP PARTY ADDR LN 2 (FL-38/3)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
16
\n", "", "
YES
\n", "
1
\n", "
42
\n", "
RESP PARTY ADDR LN 3 (FL-38/4)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
17
\n", "", "
YES
\n", "
1
\n", "
42
\n", "
RESP PARTY ADDR LN 4 (FL-38/5)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
.9
\n", "", "
REV CODE EXTRACT (FL-42:49)
\n", "
CALCULATE ONLY
\n", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
1
\n", "
5
\n", "
REVENUE CODE (FL-42)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
6
\n", "
25
\n", "
REV CODE DESCRIPTION (FL-43)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
31
\n", "
10
\n", "
HCPCS/RATES (FL-44)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
41
\n", "
7
\n", "
SERVICE DATE (FL-45)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
48
\n", "
6
\n", "
SERVICE UNITS (FL-46)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
54
\n", "
13
\n", "
TOTAL CHARGES (FL-47)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
67
\n", "
11
\n", "
NON-COVERED CHARGES (FL-48)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
78
\n", "
4
\n", "
FORM LOCATOR 49 (FL-49)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
42
\n", "", "
YES
\n", "
68
\n", "
14
\n", "
FORM LOCATOR 56 LN 1 (FL-56/1)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
32
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
30
\n", "
Subscriber City Name
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
28
\n", "
2
\n", "
Accident/Employ Related Causes (Auto)
\n", "", "
TRUE
\n", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
43
\n", "", "
YES
\n", "
67
\n", "
15
\n", "
FORM LOCATOR 56 LN 2 (FL-56/2)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
44
\n", "", "
YES
\n", "
67
\n", "
15
\n", "
FORM LOCATOR 56 LN 3 (FL-56/3)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
45
\n", "", "
YES
\n", "
67
\n", "
15
\n", "
FORM LOCATOR 56 LN 4 (FL-56/4)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
46
\n", "", "
YES
\n", "
67
\n", "
15
\n", "
FORM LOCATOR 56 LN 5 (FL-56/5)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
43
\n", "", "
YES
\n", "
1
\n", "
25
\n", "
PAYER NAME (FL-50A:C)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
43
\n", "", "
YES
\n", "
27
\n", "
13
\n", "
PROVIDER NUMBER (FL-51A:C)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
43
\n", "", "
YES
\n", "
41
\n", "
1
\n", "
RELEASE OF INFO (FL-52A:C)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
43
\n", "", "
YES
\n", "
44
\n", "
1
\n", "
ASSIGN OF BENEFITS (FL-53A:C)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
43
\n", "", "
YES
\n", "
46
\n", "
10
\n", "
PRIOR PAYMENTS (FL-54A:C)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
43
\n", "", "
YES
\n", "
57
\n", "
10
\n", "
EST AMOUNT DUE (FL-55A:C)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
29
\n", "
2
\n", "
Accident/Employ Related Causes (Employ)
\n", "", "
TRUE
\n", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
46
\n", "", "
YES
\n", "
2
\n", "
28
\n", "
FORM LOCATOR 57 (FL-57)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
46
\n", "", "
YES
\n", "
46
\n", "
11
\n", "
PT PRIOR PAYMENTS (FL-54/4)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
46
\n", "", "
YES
\n", "
57
\n", "
11
\n", "
DUE FRM PATIENT FL55 (FL-55/4)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
48
\n", "", "
YES
\n", "
1
\n", "
25
\n", "
INSUREDS NAME (FL-58A:C)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
48
\n", "", "
YES
\n", "
27
\n", "
3
\n", "
PATIENT RELATION (FL-59A:C)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
48
\n", "", "
YES
\n", "
30
\n", "
19
\n", "
CERT-SSN-HIC-ID NO (FL-60A:C)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
48
\n", "", "
YES
\n", "
50
\n", "
14
\n", "
GROUP NAME (FL-61A:C)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
48
\n", "", "
YES
\n", "
65
\n", "
17
\n", "
INSURANCE GROUP NO (FL-62A:C)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
52
\n", "", "
YES
\n", "
1
\n", "
18
\n", "
TREATMNT AUTH CODES (FL-63A:C)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
52
\n", "", "
YES
\n", "
20
\n", "
2
\n", "
EMPL STATUS CODE (FL-64A:C)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
30
\n", "
2
\n", "
Accident/Employ Related Causes (Other)
\n", "", "
TRUE
\n", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
52
\n", "", "
YES
\n", "
22
\n", "
24
\n", "
EMPLOYER NAME (FL-65A:C)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
52
\n", "", "
YES
\n", "
47
\n", "
34
\n", "
EMPLOYER LOCATION (FL-66)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
55
\n", "", "
YES
\n", "
79
\n", "
3
\n", "
FORM LOCATOR 78 (FL-78/1)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
1
\n", "
7
\n", "
PRIN DIAG CODE (FL-67)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
8
\n", "
7
\n", "
OTHER DIAG CODE 1 (FL-68)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
15
\n", "
7
\n", "
OTHER DIAG CODE 2 (FL-69)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
22
\n", "
7
\n", "
OTHER DIAG CODE 3 (FL-70)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
29
\n", "
7
\n", "
OTHER DIAG CODE 4 (FL-71)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
36
\n", "
7
\n", "
OTHER DIAG CODE 5 (FL-72)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
31
\n", "
2
\n", "
Auto Accident State Code
\n", "", "
TRUE
\n", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
43
\n", "
7
\n", "
OTHER DIAG CODE 6 (FL-73)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
50
\n", "
7
\n", "
OTHER DIAG CODE 7 (FL-74)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
57
\n", "
7
\n", "
OTHER DIAG CODE 8 (FL-75)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
65
\n", "
7
\n", "
ADM DIAG CODE (FL-76)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
72
\n", "
7
\n", "
E-CODE (FL-77)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
56
\n", "", "
YES
\n", "
78
\n", "
4
\n", "
FORM LOCATOR 78 (FL-78/2)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
57
\n", "", "
YES
\n", "
59
\n", "
23
\n", "
ATTENDING PHYS ID (FL-82/1)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
58
\n", "", "
YES
\n", "
1
\n", "
1
\n", "
PROC CODING METHOD (FL-79)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
19
\n", "", "
YES
\n", "
.8
\n", "", "
PROCEDURE EXTRACT
\n", "
CALCULATE ONLY
\n", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
58
\n", "", "
YES
\n", "
4
\n", "
8
\n", "
PRIN PROCEDURE CODE (FL-80/1)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
32
\n", "
1
\n", "
Provider Signature On File
\n", "", "
TRUE
\n", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
58
\n", "", "
YES
\n", "
12
\n", "
7
\n", "
PRIN PROCEDURE DATE (FL-80/2)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
58
\n", "", "
YES
\n", "
19
\n", "
8
\n", "
OTHER PROC CODE 1 (FL-81/1.1)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
58
\n", "", "
YES
\n", "
27
\n", "
7
\n", "
OTHER PROC DATE 1 (FL-81/1.2)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
58
\n", "", "
YES
\n", "
34
\n", "
8
\n", "
OTHER PROC CODE 2 (FL-81/1.3)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
58
\n", "", "
YES
\n", "
42
\n", "
7
\n", "
OTHER PROC DATE 2 (FL-81/1.4)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
58
\n", "", "
YES
\n", "
51
\n", "
31
\n", "
ATTENDING PHYS ID (FL-82/2)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
4
\n", "
8
\n", "
OTHER PROC CODE 3 (FL-81/2.1)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
12
\n", "
7
\n", "
OTHER PROC DATE 3 (FL-81/2.2)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
19
\n", "
8
\n", "
OTHER PROC CODE 4 (FL-81/2.3)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
27
\n", "
7
\n", "
OTHER PROC DATE 4 (FL-81/2.4)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
2
\n", "
Special Program Indicator
\n", "", "
TRUE
\n", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
34
\n", "
8
\n", "
OTHER PROC CODE 5 (FL-81/2.5)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
42
\n", "
7
\n", "
OTHER PROC DATE 5 (FL-81/2.6)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
60
\n", "", "
YES
\n", "
51
\n", "
31
\n", "
OTHER PHYS ID (FL-83/2)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
59
\n", "", "
YES
\n", "
57
\n", "
25
\n", "
OTHER PHYS ID (FL-83/1)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
61
\n", "", "
YES
\n", "
8
\n", "
27
\n", "
REMARKS LINE 1 (FL-84a)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
61
\n", "", "
YES
\n", "
57
\n", "
24
\n", "
OTHER PHYS ID (FL-83/3)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
62
\n", "", "
YES
\n", "
1
\n", "
48
\n", "
REMARKS LINE 2 (FL-84b)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
62
\n", "", "
YES
\n", "
50
\n", "
30
\n", "
OTH PHYS ID (FL-83/4)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
63
\n", "", "
YES
\n", "
1
\n", "
48
\n", "
REMARKS LINE 3 (FL-84c)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
64
\n", "", "
YES
\n", "
1
\n", "
48
\n", "
REMARKS LINE 4 (FL-84d)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
60
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
8
\n", "
Last Seen DT
\n", "", "
TRUE
\n", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
64
\n", "", "
YES
\n", "
51
\n", "
22
\n", "
PROVIDER REP LINE 1 (FL-85/1A)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
64
\n", "", "
YES
\n", "
73
\n", "
8
\n", "
PROVIDER REP DATE (FL-85/1B)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
1
\n", "", "
YES
\n", "
.9
\n", "", "
UB92 PRE-FORM HOUSEKEEPING
\n", "
CALCULATE ONLY
\n", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "", "
11
\n", "
3
\n", "
OCCURRENCE CODE (FL-33/1)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "", "
21
\n", "
3
\n", "
OCCURRENCE CODE (FL-34/1)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "", "
31
\n", "
3
\n", "
OCCURRENCE CODE (FL-35/1)
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
4
\n", "", "
YES
\n", "
.91
\n", "", "
AGENT CASHIER CITY EXTRACT
\n", "
CALCULATE ONLY
\n", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
4
\n", "", "
YES
\n", "
.92
\n", "", "
AGENT CASHIER STATE EXTRACT
\n", "
CALCULATE ONLY
\n", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
4
\n", "", "
YES
\n", "
.93
\n", "", "
AGENT CASHIER ZIP CODE EXTRACT
\n", "
CALCULATE ONLY
\n", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
14
\n", "", "
YES
\n", "
.9
\n", "", "
RESP PARTY ADDRESS EXTRACT
\n", "
CALCULATE ONLY
\n", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
65
\n", "", "
YES
\n", "
80.1
\n", "", "
CHECK FOR MULTIPLE PAGES
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
1
\n", "
Type of Bill Classification
\n", "", "
TRUE
\n", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
15
\n", "", "
YES
\n", "
50
\n", "
24
\n", "
INSURED'S CITY (BX-7/2A)
\n", "
OUTPUT
\n", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
15
\n", "", "
YES
\n", "
74
\n", "
2
\n", "
INSURED'S STATE (BX-7/2B)
\n", "
OUTPUT
\n", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
17
\n", "", "
YES
\n", "
50
\n", "
13
\n", "
INSURED'S ZIP CODE (BX-7/3A)
\n", "
OUTPUT
\n", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
17
\n", "", "
YES
\n", "
65
\n", "
15
\n", "
INSURED'S PHONE (BX-7/3B)
\n", "
OUTPUT
\n", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
13
\n", "", "
YES
\n", "
49.9
\n", "
72
\n", "
CURR INSURED'S FULL ADDR EXTR
\n", "
CALCULATE ONLY
\n", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
49.9
\n", "
80
\n", "
CURR INSURED DEMOG EXTRACT
\n", "
CALCULATE ONLY
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
55
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
15
\n", "
Total Purchased Service Amount
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
34
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
35
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
62
\n", "", "
YES
\n", "
67
\n", "
13
\n", "
VA GRP # (BX-33/LN5B)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
32
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
2
\n", "
Subscriber State Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
45
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
20
\n", "
Pt. Phone
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
25.99
\n", "
1
\n", "", "
NO
\n", "
.9
\n", "", "
SET INSURANCE CO HDR NODE
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
20
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
35
\n", "
Payer Address 2
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
36
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
2
\n", "
Type of Pay/Source of Pay
\n", "", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
45
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
8
\n", "
Insured or Pt. Death DT
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
25
\n", "
8
\n", "
Last Menstrual Period DT
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
107
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
2
\n", "
COB Total Non-Covered Amount Qualifier
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
105
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
2
\n", "
Claim Filing Indicator (Type of Payer)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
107
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
20
\n", "
Other Payer Prior Auth Qual
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
115
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'COB1'
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
115
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
115
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
65
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
8
\n", "
Occurrence Code DT
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
115
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
115
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
115
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
1
\n", "
BLANK
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
120
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'MOA1'
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
120
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
120
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
3
\n", "
Outpatient Reimbursement Rate
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
120
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
15
\n", "
HCPCS Payable Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
65
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
3
\n", "
Occurrence Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
120
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
15
\n", "
Remarks Code(1)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
120
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
15
\n", "
Remarks Code(2)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
120
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
15
\n", "
Remarks Code(3)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
120
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
15
\n", "
Remarks Code(4)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
120
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
15
\n", "
ESRD Payment Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
120
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
15
\n", "
Non-payable Prof Component Billed Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
125
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'MIA1'
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
125
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
125
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
4
\n", "
Covered Days or Visits Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
70
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
8
\n", "
Occurrence Span Code DT (From)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
125
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
15
\n", "
Claim DRG Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
125
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
10
\n", "
DRG Used
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
125
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
15
\n", "
Claim Disproportionate Share Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
125
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
15
\n", "
Claim MSP Pass-through Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
125
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
15
\n", "
Claim PPS Capital Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
125
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
15
\n", "
PPS-Capital FSP DRG Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
125
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
15
\n", "
PPS-Capital HSP DRG Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
125
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
15
\n", "
PPS-Capital DSH DRG Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
125
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
15
\n", "
Old Capital Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
130
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'MIA2'
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
70
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
3
\n", "
Occurrence Span Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
130
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
130
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
4
\n", "
PPS-Capital IME Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
130
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
15
\n", "
PPS-Operating Hospital Specific DRG Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
130
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
4
\n", "
Cost Report Day Count
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
130
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
15
\n", "
PPS-Operating Federal Specific DRG Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
130
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
15
\n", "
Claim PPS Capital Outlier Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
130
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
15
\n", "
Claim Indirect Teaching Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
130
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
15
\n", "
Non-Payable Prof Component Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
130
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
10
\n", "
Claim Payment Remark Code(1)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
130
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
10
\n", "
Claim Payment Remark Code(2)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
75
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
8
\n", "
Procedure DT
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
130
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
10
\n", "
Claim Payment Remark Code(3)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
130
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
10
\n", "
Claim Payment Remark Code(4)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
130
\n", "
1
\n", "", "
NO
\n", "
15
\n", "
15
\n", "
PPS-Capital Exception Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'CCAS'
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
2
\n", "
Adjustment Group Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
5
\n", "
Adjustment Reason Code(1)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
15
\n", "
Adjustment Amt(1)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
6
\n", "
Adjustment Quantity(1)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
16
\n", "
2
\n", "
Procedure Modifier(2)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
75
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
10
\n", "
Procedure Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
17
\n", "
2
\n", "
Procedure Modifier(3)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
18
\n", "
2
\n", "
Procedure Modifier(4)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
19
\n", "
1
\n", "
Emergency Indicator
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
20
\n", "
2
\n", "
Units/Basis for Measurement Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
185
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
2
\n", "
Units/Basis for Measurement Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
195
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'LCOB'
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
195
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
6
\n", "
Service Line Counter
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
195
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
20
\n", "
Payer Primary ID
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
195
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
15
\n", "
Service Line Paid Amt
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
195
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
20
\n", "
Procedure Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
75
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
3
\n", "
Procedure Code Qualifier
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
195
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
10
\n", "
Service Line Revenue Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
195
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
2
\n", "
Procedure Modifier(1)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
195
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
Procedure Modifier(2)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
195
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
2
\n", "
Procedure Modifier(3)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
195
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
2
\n", "
Procedure Modifier(4)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
195
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
80
\n", "
Procedure Code Description
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
195
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
15
\n", "
Paid Service Unit Count
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
195
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
6
\n", "
Bundled Line #
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
1
\n", "
4
\n", "
RECORD ID 'LCAS'
\n", "", "
TRUE
\n", "
YES
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
6
\n", "
Service Line Counter
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
80
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
3
\n", "
Value Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
2
\n", "
Claim Adjustment Group Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
5
\n", "
Adjustment Reason Code(1)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
15
\n", "
Adjustment Amt(1)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
6
\n", "
Adjustment Quantity(1)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
99.9
\n", "", "
KILL IBXSAVE ARRAY
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
20
\n", "
1
\n", "", "
NO
\n", "
2.9
\n", "", "
CURRENT INSURANCE FULL ADDRESS
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
115
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "", "
OTHER INS DATA
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
120
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "", "
OTHER INS COB MOA DATA
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
125
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "", "
OTHER INS COB MIA(1) DATA
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
80
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
9
\n", "
Value Code Dollars
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "", "
OTHER INS COB ADJ DATA
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
5
\n", "
Adjustment Reason Code(2)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
5
\n", "
Adjustment Reason Code(3)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
5
\n", "
Adjustment Reason Code(4)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
16
\n", "
5
\n", "
Adjustment Reason Code(5)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
19
\n", "
5
\n", "
Adjustment Reason Code(6)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
15
\n", "
Adjustment Amt(2)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
15
\n", "
Adjustment Amt(3)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
15
\n", "
Adjustment Amt(4)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
32
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
9
\n", "
Subscriber ZIP Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
17
\n", "
15
\n", "
Adjustment Amt(5)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
20
\n", "
15
\n", "
Adjustment Amt(6)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
6
\n", "
Adjustment Quantity(2)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
6
\n", "
Adjustment Quantity(3)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
15
\n", "
6
\n", "
Adjustment Quantity(4)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
18
\n", "
6
\n", "
Adjustment Quantity(5)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
135
\n", "
1
\n", "", "
NO
\n", "
21
\n", "
6
\n", "
Adjustment Quantity(6)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
5
\n", "
Adjustment Reason Code(2)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
5
\n", "
Adjustment Reason Code(3)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
5
\n", "
Adjustment Reason Code(4)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
85
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
2
\n", "
Condition Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
16
\n", "
5
\n", "
Adjustment Reason Code(5)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
19
\n", "
5
\n", "
Adjustment Reason Code(6)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
15
\n", "
Adjustment Amt(2)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
15
\n", "
Adjustment Amt(3)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
15
\n", "
Adjustment Amt(4)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
17
\n", "
15
\n", "
Adjustment Amt(5)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
20
\n", "
15
\n", "
Adjustment Amt(6)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
6
\n", "
Adjustment Quantity(2)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
6
\n", "
Adjustment Quantity(3)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
15
\n", "
6
\n", "
Adjustment Quantity(4)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
90
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
10
\n", "
Diagnosis Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
18
\n", "
6
\n", "
Adjustment Quantity(5)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
200
\n", "
1
\n", "", "
NO
\n", "
21
\n", "
6
\n", "
Adjustment Quantity(6)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
120
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
15
\n", "
Remarks Code(5)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
130
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
10
\n", "
Claim Payment Remark Code(5)
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
90
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
3
\n", "
Diagnosis Code Qualifier
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
96
\n", "
1
\n", "", "
NO
\n", "
16
\n", "
2
\n", "
Attending Prov Taxonomy Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
96
\n", "
1
\n", "", "
NO
\n", "
15
\n", "
10
\n", "
Referring Prov Name Suffix
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
96
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
20
\n", "
Referring Prov First Name
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
96
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
20
\n", "
Referring Prov Last Name
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
96
\n", "
1
\n", "", "
NO
\n", "
12
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
96
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
20
\n", "
Attending Prov Last Name
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
96
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
20
\n", "
Attending Prov First Name
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
96
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
10
\n", "
Attending Prov Name Suffix
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
96
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
96
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
20
\n", "
Other Prov Last Name
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
96
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
20
\n", "
Other Prov First Name
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
96
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
10
\n", "
Other Prov Name Suffix
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
96
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
20
\n", "
Operating Phy Last Name
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
96
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
20
\n", "
Operating Phy First Name
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
105
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
1
\n", "
Payer Responsibility Sequence # Code
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
96
\n", "
1
\n", "", "
NO
\n", "
11
\n", "
10
\n", "
Operating Phy Name Suffix
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
96
\n", "
1
\n", "", "
NO
\n", "
17
\n", "
10
\n", "
Attending Prov Taxonomy
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
36
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
4
\n", "", "
YES
\n", "
33
\n", "
5
\n", "
UPPER FORM LOCATOR 5
\n", "
OUTPUT
\n", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
11
\n", "", "
YES
\n", "
58
\n", "
24
\n", "
FORM LOCATOR 37B
\n", "", "", ""], ["LEGACY UB-92", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
12
\n", "", "
YES
\n", "
58
\n", "
24
\n", "
FORM LOCATOR 37C
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
107
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
50
\n", "
Other Payer Prior Auth/Referral #
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
36
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
50
\n", "
Prior Authorization #
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
185
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
2
\n", "
Service ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
62
\n", "", "
YES
\n", "
52
\n", "
12
\n", "
VA PIN # (BX-33/LN5A)
\n", "
OUTPUT
\n", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
105
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
35
\n", "
Other Payer Last or Organization Name
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
37
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
50
\n", "
1
\n", "", "
NO
\n", "
38
\n", "
8
\n", "
Accident DT
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
9
\n", "", "
YES
\n", "
2
\n", "
49
\n", "
INS TYPE CHECK BOX (BX-1)
\n", "
OUTPUT
\n", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
31
\n", "", "
YES
\n", "
36
\n", "
13
\n", "
PATIENT SIGNATURE DT (BX-12/2)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
15
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", "
NO
\n"], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
105
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
2
\n", "
Pt. Relationship to Insured
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
57
\n", "
1
\n", "", "
NO
\n", "
13
\n", "
10
\n", "
CLIA #
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
55
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
55
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
1
\n", "
Purchased Serv Flag
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
97
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
1
\n", "
Attending Prov Entity Type Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
21
\n", "
2
\n", "
Service ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
22
\n", "
48
\n", "
NDC
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
195
\n", "
1
\n", "", "
NO
\n", "
14
\n", "
8
\n", "
Adjudication or Payment DT
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
23
\n", "
15
\n", "
National Drug Unit Count
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
24
\n", "
1
\n", "
Hospice Employee Indicator
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
25
\n", "
2
\n", "
Unit or Basis of Measurement Code
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
105
\n", "
1
\n", "", "
NO
\n", "
4
\n", "
50
\n", "
Other Group or Policy #
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
27
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
28
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
180
\n", "
1
\n", "", "
NO
\n", "
29
\n", "
1
\n", "
EPSDT Indicator
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
195
\n", "
1
\n", "", "
NO
\n", "
1.9
\n", "", "
EXTRACT LINE LEVEL ADJUSTMENTS
\n", "
CALCULATE ONLY
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
97
\n", "
1
\n", "", "
NO
\n", "
2
\n", "
2
\n", "
Attending Prov Primary ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
97
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
10
\n", "
Attending Prov Primary ID
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
110
\n", "
1
\n", "", "
NO
\n", "
10
\n", "
1
\n", "
BLANK
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
110
\n", "
1
\n", "", "
NO
\n", "
3
\n", "
80
\n", "
Other Subscriber Primary ID
\n", "", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
97
\n", "
1
\n", "", "
NO
\n", "
7
\n", "
1
\n", "
Other Oper Prov Entity Type Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
97
\n", "
1
\n", "", "
NO
\n", "
5
\n", "
2
\n", "
Other Oper Prov Primary ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
97
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
10
\n", "
Other Oper Prov Primary ID
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
97
\n", "
1
\n", "", "
NO
\n", "
8
\n", "
2
\n", "
Operating Phy Primary ID Qualifier
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
97
\n", "
1
\n", "", "
NO
\n", "
9
\n", "
10
\n", "
Operating Phy Primary ID
\n", "
OUTPUT
\n", "
TRUE
\n", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
30
\n", "", "
YES
\n", "
3
\n", "
45
\n", "
RELEASE OF INFO SIG (12A)
\n", "", "", ""], ["LEGACY HCFA-1500", "
NATIONAL,NO EDIT
\n", "", "
1
\n", "
30
\n", "", "
YES
\n", "
51
\n", "
28
\n", "
ASSIGN OF BENEFITS SIG (13A)
\n", "", "", ""], ["IB 837 TRANSMISSION", "
NATIONAL,NO EDIT
\n", "", "
36
\n", "
1
\n", "", "
NO
\n", "
6
\n", "
50
\n", "
Payer Claim Control Number
\n", "", "
TRUE
\n", ""]]}