Case Number

1

9

CHAR/9

BIL-HIS-CASE-NO

Unique Number Assigned To Each Case By The Responsible District Office

Payee Number

10

18

CHAR/9

BIL-HIS-PAYEE-NO

Unique Identifier Assigned To Each Provider (Ssn Or Tax Id)

Service From

19

26

DATE/8

BIL-HIS-SVC-FR

Beginning Date Of Service

YYYYMMDD

Service To Date

27

34

DATE/8

BIL-HIS-SVC-TO

Ending Date Of Service

YYYYMMDD

Record Type

35

35

CHAR/1

BIL-HIS-RECORD-TYPE

Type Of Record

B = Normal Bill Paid By System

C = Cancelled Check/Adj.

D = Cash Receipt

M = Manual Payment

Payee Data

36

44

CHAR/9

BIL-HIS-R-PAYEE-NO

Claimant’s Id Number

Payee Name

45

79

CHAR/35

Claimant’s Name

Filler

45

77

CHAR/33

Blank

Name Suffix

78

79

CHAR/2

BIL-HIS-PAYEE-DIR-NAME-SFX

This Data Is Available For Bills Paid Prior To 9/4/03

Payee Address

80

114

CHAR/35

BIL-HIS-PAYEE-ADD1

Payee’s Address

Payee Address

115

149

CHAR/35

BIL-HIS-PAYEE-ADD2

Payee’s Address

Payee Address

150

179

CHAR/35

BIL-HIS-PAYEE-ADD3

Payee’s Address

Payee’s City

180

199

CHAR/20

BIL-HIS-PAYEE-CITY

Payee’s State

200

201

CHAR/2

BIL-HIS-PAYEE-STATE

Payee’s Zip Code

202

206

CHAR/5

BIL-HIS-PAYEE-ZIP

4-Digit Zip Reserve

207

210

CHAR/4

BIL-HIS-PAYEE-ZIP-RESERVE

Provider Type

211

211

CHAR/1

BIL-HIS-PROV-TYPE

F = PHARMACY

H = HOSPITAL

P = PHYSICIAN

Reimbursement Code

212

212

CHAR/1

BIL-HIS-REIMB-CD

Indicates Payment Made To The Claimant

Blank = Provider

R = Claimant

Pharmacy Number

213

219

CHAR/7

BIL-HIS-PHARMACY-NO

Pharmacy NABP Number

Pay Center Code

220

225

CHAR/6

BIL-HIS-PAY-CENTER-CODE

Code Used To Identify A Central Payment Center For A Pharmacy Chain

This Data Is Available For Bills Paid Prior To 9/4/03

Clearing House Id

226

228

CHAR/3

BIL-HIS-CLEAR-HOUSE-ID

Clearinghouse Id Number

This Data Is Available For Bills Paid Prior To 9/4/03

Employee Last Name

229

238

CHAR/10

BIL-HIS-EMP-LAST-NAME

Claimant’s Last Name

Employee First Initial

239

239

CHAR/1

BIL-HIS-EMP-FIRST-INIT

Claimant’s First Initial

Area Code

240

243

CHAR/4

BIL-HIS-AREA-CODE

SMSA/MSA Identifier

Per FIPS Code Table

Physician Bill Redefine Area

Procedure Code

244

248

CHAR/5

BIL-HIS-PROC-CODE-1-5

Billed Procedure Code

Valid Cpt-4, HCPC’s, Revenue Center Or OWCP Procedure Code Indicating Services Provided 

Modifier Code

249

250

CHAR/2

BIL-HIS-MODIFIER-CODE

Indicates Different Level Of Service

Appeals Code

251

251

CHAR/1

BIL-HIS-APPEALS-CODE

Fee Schedule Appeal Code

B,F,G,W,1-7,Blank

Filler

252

253

CHAR/2

Blank

Rx Bills Redefine Area

Rx Number

244

250

CHAR/7

BIL-HIS-RX-NO

Prescription Number

Rx Appeal

251

251

CHAR/1

BIL-HIS-RX-APPEAL

Rx Appealed

Rx Refills

252

253

CHAR/2

BIL-HIS-RX-REFILL

Number Of Refills

Medical Bills Redefine Area

Diagnosed Related Group Number

244

246

CHAR/3

BIL-HIS-DRG-NO

Diagnosis Related Group For Inpatient Bills

Filler

247

250

CHAR/4

Blank

Appeal

251

251

CHAR/1

BIL-HIS-APPEAL

Medical Bill Appealed

Y = Yes

N = No

Filler

252

253

CHAR/2

Blank

Fund Adjustment Redefine Area

Transfer Indicator

244

244

CHAR/1

BIL-HIS-FUND-TRANSFER-IND

Funds Have Been Transferred

This Data Is Available For Bills Paid Prior To 9/4/03

Adjustment Indicator

245

245

CHAR/1

BIL-HIS-MAINT-ADJUD-IND

Adjustment Has Been Made

This Data Is Available For Bills Paid Prior To 9/4/03

Filler

246

253

CHAR/8

Blank

Return to All

Category Code

254

254

CHAR/1

BIL-HIS-CATEGORY-CODE

Procedure Code Category

A = Anesthesia

E = Evaluation/Management

M = Medicine

P = Pathology/Laboratory

R = Radiology/Nuclear Med/

       Diagnostic Ultrasound

S = Surgery

Work Unit Value

255

257

CHAR/3

BIL-HIS-WORK-UNIT-VAL

Work Relative Value Unit

000/Refer to EXPANDED RECORD

Practice Unit Value

258

260

CHAR/3

BIL-HIS-PRACT-UNIT-VAL

Practice Expense Relative Value Unit

000/Refer to EXPANDED RECORD

Malpractice Unit Value

261

263

CHAR/3

BIL-HIS-MALPRACT-UNIT-VAL

Malpractice Relative Value Unit

000/Refer to EXPANDED RECORD

Unit Cost

264

266

CHAR/3

BIL-HIS-UNIT-COST

Conversion Factor

000/Refer to EXPANDED RECORD

1-4, Ix  Value

267

269

CHAR/3

BIL-HIS-1-4-IX-VAL

Work Geographic Adjustment Factor

000/Refer to EXPANDED RECORD

Practice Ix Value

270

272

CHAR/3

BIL-HIS-PRACT-IX-VAL

Practice Expense Geographic Adjustment Factor

000/Refer to EXPANDED RECORD

Malpractice Ix Unit

273

275

CHAR/3

BIL-HIS-MALPRACT-IX-VAL

Malpractice Expense Geographic Adjustment Factor

000/Refer to EXPANDED RECORD

Percent Modifier

276

277

CHAR/2

BIL-HIS-MODIFIER-PERCENT

Adjustment Factor For Procedure Code Modifier

00/Refer to EXPANDED RECORD

National Drug Code

278

288

CHAR/11

BIL-HIS-NDC-NO

National Drug Code

2 Yr High Price

289

293

CHAR/5

BIL-HIS-PRICE-2YR-HIGH

Not Used

This Data Is Available For Bills Paid Prior To 9/4/03

Dispense Fee

294

295

CHAR/2

BIL-HIS-DISPENSE-RATE

Allowed Dispensing Fee For Prescription

00/Refer to EXPANDED RECORD

Allowed Fee

296

300

CHAR/5

BIL-HIS-ALLOWED-FEE-AMT

Allowable Cost For Prescription

00000/Refer to EXPANDED RECORD

Drg Amount

296

300

CHAR/5

BIL-HIS-DRG-AMT

Actual Cost, Calculated By Diagnostic Related Group For Inpatient Bills

Servicing State

301

302

CHAR/2

BIL-HIS-SVC-STATE

State Where Service Was Performed

Zip Code

303

307

CHAR/5

BIL-HIS-ZIP-CODE

Zip Code Where Service Was Performed

Prompt Payment

308

308

CHAR/1

BIL-HIS-PROMPT-PMT

Prompt Payment Flag Indicating Contractual Payment Obligation

This Data Is Available For Bills Paid Prior To 9/4/03

Bill Number

309

320

CHAR/12

BIL-HIS-BILL-NO

This Data Is Available For Bills Paid Prior To 9/4/03

Invoice Type

321

321

CHAR/1

BIL-HIS-INVOICE-TYPE

Type Of Invoice

This Data Is Available For Bills Paid Prior To 9/4/03

Invoice Number

322

329

CHAR/8

BIL-HIS-INVOICE-NO

Invoice Number

This Data Is Available For Bills Paid Prior To 9/4/03

Invoice Date

322

329

GROUP (8)

BIL-HIS-INVOICE-DATE

If Invoice Type=D, Date Provider Created The Bill

If Invoice Type=N, Providers Unique Id Number For The Bill

This Data Is Available For Bills Paid Prior To 9/4/03

Tcn

309

325

CHAR/17

BIL-HIS-TCN

Unique Transaction Control Number

This Data Is Unavailable For Bills Paid Prior To 9/4/03

Dispense Rate2

326

329

CHAR/4

BIL-HIS-DISP-RATE-ACS

Dispensing Rate

This Data Is Unavailable For Bills Paid Prior To 9/4/03    0000/Refer to EXPANDED RECORD

Charge Amount

330

334

CHAR/5

BIIL-HIS-CHARGE-AMT

Amount Charged By Provider

00000/Refer to EXPANDED RECORD

Ineligible Amt

335

339

CHAR/5

BIL-HIS-INEL-AMT

Amount Not Covered

00000/Refer to EXPANDED RECORD

Ineligible Code

340

340

CHAR/1

BIL-HIS-INEL-CODE

Ineligible Payment Code

Fee Reduction Amt

341

345

CHAR/5

BIL-HIS-FEE-REDUCTION-AMT

Amount Fee Reduced

00000/Refer to EXPANDED RECORD

Payment Amount

346

350

CHAR/5

BIL-HIS-PAYMENT-AMT

Net Amount Paid

00000/Refer to EXPANDED RECORD

Units

351

355

CHAR/5

BIL-HIS-UNITS

Service Units Billed

00000/Refer to EXPANDED RECORD

Locator Code

356

358

CHAR/3

BIL-HIS-LOCATOR-CODE

UB92 Loc 4; Code Indicates Type Of Institution

Presciber’s Name

359

368

CHAR/10

BIL-HIS-PRESCRIBER-NAME

Physician’s Name

Date Received

369

376

CHAR/8

BIL-HIS-DATE-RCVD

Date Bill Was Received

YYYYMMDD

Date Keyed

377

384

CHAR/8

BIL-HIS-DATE-KEYED

Date Bill Was Keyed For Payment

YYYYMMDD

Date Paid

385

392

CHAR/8

BIL-HIS-DATE-OF PAY

Date Bill Was Paid (Check Date)

YYYYMMDD

Adjustment Date

393

400

CHAR/8

BIL-HIS-DATE-OF-ADJUSTMENT

Date An Adjustment Transaction Was Entered Against A Bill

YYYYMMDD

Authorizing Official

401

403

CHAR/3

BIL-HIS-AUTH-OFFICIAL

Conditional; System Generated Id

3 Character Alpha

Bypass Code

404

404

CHAR/1

BIL-HIS-BYPASS-CODE

Indicates Type Of Payment Or Adjustment

District Office Input Code

405

406

CHAR/2

BIL-HIS-DIST-OFF-INPUT

District Office Code

District Office Control Code

407

408

CHAR/2

BIL-HIS-DIST-OFF-CNTL

District Office Sequent Code

This Data Is Available For Bills Paid Prior To 9/4/03

Error Code

409

409

CHAR/1

BIL-HIS-ERROR-CODE

Not Used

Batch Id Number

410

415

CHAR/6

BIL-HIS-BATCH-NO

The Batch The Bill Was Keyed With

This Data Is Available For Bills Paid Prior To 9/4/03

Operator Identifier

416

423

CHAR/8

BIL-HIS-OPERATOR-IDENT

System Generated Logon Id

This Data Is Available For Bills Paid Prior To 9/4/03

Tcn To Credit

407

423

CHAR/17

BIL-HIS-TCN-TO-CREDIT

Original Case Number

This Data Is Unavailable For Bills Paid Prior To 9/4/03

Payee Case From Code

424

424

CHAR/1

BIL-HIS-PAYEE-CASE-FROM-CD

Code indicates if a change to a case number or provider id

Payee Case From

425

433

CHAR/9

BIL-HIS-PAYEE-CASE-FROM

Original Case Number Or Provider Id

Payee Case To Code

434

434

CHAR/1

BIL-HIS-PAYEE-CASE-TO-CD

Code Indicates If A Change To A Case Number Or Provider Id

Payee Case To

435

443

CHAR/9

BIL-HIS-PAYEE-CASE-TO

Corrected Case Number Or Provider Id

Bill Id Number

444

445

CHAR/2

BIL-HIS-BILL-ID-NO

Not used

000

Bill Line Number

446

448

CHAR/4

BIL-HIS-BILL-LINE-ITEM-NO

Not used

000

Record Sequence

449

450

CHAR/2

BIL-HIS-RECORD-SEQ

Not used

00

Resolver Id

451

453

CHAR/8

BIL-HIS-RESOLVER-IDENT

Irslevy Flag

454

458

CHAR/1

BIL-HIS-IRS-LEVY-FLAG

Not used

Blank

New Tcn

459

475

CHAR/16

BIL-HST-NEW-TCN

Not used

Blank

EXPANDED RECORD

FIELD NAME

START

END

FIELD TYPE

BILL HISTORY REC  NAME

Description

Group Subdivisions

Definition Of Legal Values

476

480

CHAR/5

WORK-UNIT-VAL

Work Relative Value Unit

Numeric Value from CPT4 & HFCA Tables

481

485

CHAR/5

PRACT-UNIT-VAL

Practice Expense Relative Value Unit

Numeric Value from CPT4 & HFCA Tables

486

490

CHAR/5

MALPRACT-UNIT-VAL

Malpractice Relative Value Unit

Numeric Value From CPT4 & HFCA Tables

491

495

CHAR/5

UNIT-COST

Conversion Factor

496

499

CHAR/4

IX-VAL

Work Geographic Adjustment Factor

500

503

CHAR/4

PRACT-IX-VAL

Practice Expense Geographic Adjustment Factor

504

507

CHAR/4

MALPRACT-IX-VAL

Malpractice Expense Geographic Adjustment Factor

508

510

CHAR/3

MODIFIER-PERCENT

Adjustment Factor For Procedure Code Modifier

511

519

CHAR/9

PRICE-2YR-HIGH

This Data Is Available For Bills Paid Prior To 9/4/03

Otherwise Blank

520

526

CHAR/7

DISPENSE-RATE

Allowed Dispensing Fee For Prescription

527

534

CHAR/8

ALLOWED-FEE-AMT

Allowable Cost For Prescription

535

542

CHAR/8

CHARGE-AMT

Provider Charged Amount

543

550

CHAR/8

INEL-AMT

Amount Not Covered

551

558

CHAR/8

FEE-REDUCTION-AMT

Amount Fee Reduced

559

566

CHAR/8

PAYMENT-AMT

Net Amount Paid

567

574

CHAR/8

UNITS

Service Units Billed

575

577

CHAR/3

BILL-ID-NO

Sequential Number Of Bill Within A Batch Of Bills

578

581

CHAR/4

LINE-ITEM-NO

Sequential Number Of Bill Line Item

Modified Element

582

584

CHAR/3

RECORD-SEQ

Modified Element