File HEALTH_CARE_CLAIM_RFAI__277_(368) Data List
| MESSAGE CONTROL ID |
REQUEST DATE/TIME |
TRANSACTION DATE/TIME |
PAYER NAME |
PAYER IDENTIFIER |
PAYER CONTACT NAME |
PATIENT PRIMARY IDENTIFIER |
REQUEST DATE/TIME [D] |
MESSAGE DATE/TIME [D] |
PAYER NAME [D] |
PAYER CONTACT COMM TYPE 1 [D] |
PAYER CONTACT COMM TYPE 2 [D] |
PAYER CONTACT COMM TYPE 3 [D] |
PATIENT NAME [D] |
PATIENT CONTROL NUMBER |
PAYER CLAIM CONTROL NUMBER |
MEDICAL RECORD NUMBER |
CLEARINGHOUSE TRACE NUMBER |
PATIENT CONTROL NUMBER [D] |
RESPONSE DUE DATE [D] |
STC SEQ [D] |
CLAIM SERVICE START DATE [D] |
CLAIM SERVICE END DATE [D] |
PAYER RESP CONT COM TYPE 1 [D] |
PAYER RESP CONT COM TYPE 2 [D] |
PAYER RESP CONT COM TYPE 3 [D] |
RESPONSE DUE DATE |
REPORT TRANSMISSION CODE |
PAYER RESP CONTACT ADDR ST [D] |
PAYER RESP CONT POSTAL/ZIP [D] |
PAYER RESP CONTACT COUNTRY [D] |
STC-SVC LINE STAT INFO SEQ [D] |
STC SEQ |
CLAIM SERVICE START DATE |
CLAIM SERVICE END DATE |
CLAIM SERVICE PERIOD |
PAYER RESPONSE CONTACT NAME |
PAYER RESP CONTACT COMM TYPE 1 |
PAYER RESP CONTACT COMM TYPE 2 |
PAYER RESP CONTACT COMM TYPE 3 |
PAYER RESPONSE CONTACT COMM 1 |
PAYER RESPONSE CONTACT COMM 2 |
PAYER RESPONSE CONTACT COMM 3 |
PAYER CONTACT COMM TYPE 1 |
PAYER CONTACT COMM TYPE 2 |
PAYER CONTACT COMM TYPE 3 |
PAYER RESP CONTACT ADDR LINE 1 |
PAYER RESP CONTACT ADDR LINE 2 |
PAYER RESP CONTACT CITY |
PAYER RESP CONTACT STATE |
PAYER RESP CONTACT ZIP CODE |
PAYER RESP CONTACT COUNTRY |
PAYER RESP CONT CNTRY SUBDIV |
DELETED FLAG |
DELETED DATE/TIME |
DELETED BY |
REVIEW STATUS |
REVIEW STATUS DATE/TIME |
REVIEW STATUS BY |
RFAI WORKLIST COMMENTS |
STC-SVC LINE STAT INFO SEQ |
PRIMARY LOINC |
REFERENCE ID-INST TYPE OF BILL |
PAYER CONTACT COMM 1 EXTENSION |
PAYER CONTACT COMM 2 EXTENSION |
PAYER CONTACT COMM 3 EXTENSION |
PAYER RESP CONTACT COMM 1 EXT |
PAYER CONTACT COMMUNICATION 1 |
PAYER RESP CONTACT COMM 2 EXT |
PAYER RESP CONTACT COMM 3 EXT |
PAYER CONTACT COMMUNICATION 2 |
PAYER CONTACT COMMUNICATION 3 |
INFORMATION RECEIVER NAME |
INFORMATION RECEIVER ID |
SERVICE PROVIDER NAME |
SERVICE PROV FED TAXPAYER CODE |
SERVICE PROVIDER ID |
PAYER ENTITY IDENTIFIER CODE |
PAYER ENTITY TYPE QUALIFIER |
PAYER ID CODE QUALIFIER |
PAYER CONTACT FUNCTION CODE |
INFORMATION RECEIVER ENTITY ID |
INFO RECEIVER ENTITY TYPE |
INFO RECEIVER ID QUALIFIER |
SERVICE PROV ENTITY ID CODE |
SERVICE PROV ENTITY TYPE QUAL |
SERVICE PROVIDER ID QUALIFIER |
PATIENT ENTITY IDENTIFIER CODE |
PATIENT ENTITY TYPE QUALIFIER |
PATIENT ID CODE QUALIFIER |
PAYER CLAIM TRACE TYPE CODE |
REFERENCE ID QUALIFIER-PT CRTL |
REFERENCE ID QUALIFIER-INST |
REFERENCE ID QUALIFIER-MRN |
REFERENCE ID QUALIFIER-CTN |
CLAIM SERVICE DT/TM QUALIFIER |
CLAIM SERV DT/TM PERIOD QUAL |
RESPONSE DUE DT/TM QUALIFIER |
RESPONSE DUE DT/TM PERIOD QUAL |
CLAIM SUPP INFO REPORT TYPE |
PAYER RESP CONTACT FUNC CODE |
SERVICE LINE DT/TM QUALIFIER |
SERVICE LINE DT/TM PERIOD QUAL |
PATIENT NAME |