File BENEFICIARY_TRAVEL_CLAIM(392) Data List
| Claim DATE/TIME |
AMOUNT PAYABLE |
DIVISION |
WHO ENTERED INTO FILE |
DATE ENTERED INTO THE FILE |
COREFLS CARRIER |
NAME |
PLACE OF DEPARTURE [LINE 1] |
PLACE OF DEPARTURE [LINE 2] |
PLACE OF DEPARTURE [LINE 3] |
CITY OF DEPARTURE |
STATE OF DEPARTURE |
ZIP CODE/DEPARTURE |
DESTINATION [LINE 1] |
DESTINATION [LINE 2] |
DESTINATION [LINE 3] |
CITY OF DESTINATION |
STATE OF DESTINATION |
ZIP CODE/DESTINATION |
ELIGIBILITY |
ONE WAY/ROUND TRIP |
MILEAGE/ONE WAY |
TOTAL MILEAGE AMOUNT |
MEALS & LODGING |
FERRY, BRIDGES, ETC. |
SC PERCENTAGE |
AUTHORIZING PERSON |
ATTENDANT/PAYEE |
C&P REVIEW VISIT |
BT CLAIM ELIGIBILITY CODE |
BT CLAIM ELIGIBILITY ADDITION |
SC APPOINTMENT |
QUALIFIED APPOINTMENT |
MODE OF TRANSPORTATION |
DENIAL LETTER ISSUED |
DENIAL LETTER ISSUED DATE |
CLAIM DENIED |
DATE CLAIM DENIED |
CLAIM DENIED REASON |
CERTIFICATION DATE |
REMARKS |
BUS PASS OR TICKET |
BUS PASS EXPIRATION DATE |
COMMON CARRIER DATE REIMBURSED |
COMMON CARRIER FEE |
COMMON CARRIER REQUIRED |
TYPE OF CLAIM |
SPECIAL MODE OF TRANSPORTATION |
INVOICE NUMBER |
DATE INVOICE RECEIVED |
ACCOUNT |
TOTAL INVOICE AMOUNT |
BASE RATE FEE |
MILEAGE FEE |
NO SHOW/NO LOAD FEE |
WAIT TIME FEE |
EXTRA CREW FEE |
SPECIAL EQUIPMENT FEE |
SPECIAL MODE RT/ONE-WAY |
SPECIAL MODE TOTAL MILES |
OTHER SM TRANSPORTATION |
CARRIER |
PRE-AUTHORIZED |
SPECIAL MODE VENDOR |
SPECIAL MODE OTHER REMARKS |
SP MODE DEPARTURE ADDRESS1 |
SP MODE DEPARTURE ADDRESS2 |
SP MODE DEPARTURE CITY |
SP MODE DEPARTURE STATE |
SP MODE DEPARTURE ZIP CODE |
SP MODE DESTINATION 1 |
SP MODE DESTINATION 2 |
MOST ECON. COST |
SP MODE DESTINATION 3 |
SP MODE DESTINATION CITY |
SP MODE DESTINATION STATE |
SP MODE DESTINATION ZIP CODE |
PRE-AUTHORIZED BY |
SPECIAL MODE CLAIM AUTHORIZED |
DATE/TIME AUTHORIZED |
DEDUCTIBLE AMOUNT |