Case Number

Unique Identifier for each case assigned by the responsible District Office.

Char(9)

Payee Number

Unique Identifier assigned to provider (SSN or Tax ID)

Char(9)

Service From Date

Beginning Date of Service

Date(8)

CCYYMMDD

Service To Date

Ending Date of Service

Date(8)

CCYYMMDD

Record Type

Type of record

Char(1)

B=Normal Bill

C= Cancel Check

D=Debt

M=Manual Check

Payee Number

Payee ID number

Char(9)

Payee Name

Claimant's Name

Char(35)

Payee Address Line 1

Payee's Address

Char(35)

Payee Address Line 2

Payee's Address

Char(35)

Payee Address Line 3

Payee's Address

Char(30)

Payee City

Payee's City

Char(20)

Payee State

Payee's State

Char(2)

Payee Zip

Payee's Zip

Char(5)

Payee Zip 4

Payee's Zip +4

Char(4)

Provider Type

Char(1)

F= Pharmacy

P= Physician

H= Hospital

R=Claimant

Reimbursement Code

Indicates Payment Made to the Claimant

Char(1)

R= Reimbursement made to Claimant

Pharmacy Number

Pharmacy NABP Number

Char(7)

Pay Center Code

Code Used to Identify a Central Payment Center for a Pharmacy Chain

Char(6)

Availiable for bills paid prior to 9/4/03

Clearinghouse ID

Clearinghouse ID Number

Char(3)

Availiable for bills paid prior to 9/4/03

Employee last Name

Employee's Last name (From CMF)

Char(10)

Employee First Initial

Employee's First Initial (From CMF)

Char(1)

Area Code

SMSA/MSA Identifier

Char(4)

FIPS Code table

Redefine - UNIQUE TO Pharmacy Record Type= F

RX Numbers

Prescribes Number

Char(7)

RX Appeals

RX Appealed

Char(1)

RX Refills

Char(2)

Redefine - UNIQUE TO Hospital Record Type= H

Diagnosed related group number

Diagnosis Related Group for Inpatient Bills

Char(3)

Filler

Char(4)

Appeal

Medical Bill Appealed

Char(1)

Y/N= W

Filler

Char(2)

Redefine - UNIQUE TO Physician Record Type= P

Procedure Code

Billed procedure code

Char(5)

CPT-4, HCPC'S, Revenue center or OWCP Procedure code indicating Service Proveded

Modifier Code

Indicates different level of service

Char(2)

Appeals Code

Fee schedule appeal code

Char(1)

B, 1-7

Filler

Char(2)

Redefine - UNIQUE TO Fund Adjustment Data Prior to 09/04/03

Transfer Indicator

Funds have been transferred

Char(1)

0

Adjustment Indicator

Adjustment has been made

Char(1)

0

Filler

Char(8)

Return from Redefine

Category Code

Procedure Code Category

Char(1)

A= Anesthesia

E= Evaluation/Management

M=Medicine

P= Pathology/Laboratory

R= Radiology/Nuclear Med Diagnostic Ultrasound

S= Surgery

Work Unit

Work Relative Unit

Char(3)

000

Practice Unit

Practice Expenses Geographical Adjustment Factor

Char(3)

000

Malpractice Unit

Malpractice Relative Value

Char(3)

000

Unit Cost

Conversion Factor

Char(3)

000

Adjust Factor

Expenses Geographic Adjustment factor

Char(3)

000

Practice Adjustment factor

Practice Expenses Geographic Adjustment Factor

Char(3)

000

Malpractice Adjustment Factor

Malpractice Expenses Geographic Adjustment Factor

Char(3)

000

Percent Modifier

Adjustment factor for Procedure code Modifier

Char(2)

00

National Drug Code

National Drug Code

Char(11)

00000000000

Two-Year High Price

2YR High, Wholesale Price

Char(5)

00000

Dispensing Fee

Allowed Dispensing Fee For Prescription

Char(2)

00

Redefine - UNIQUE TO Pharmacy Record Type= F

Allowed Fee Amount

Allowable cost for prescription

Char(5)

0

Redefine - UNIQUE TO Hospital Record Type= H

DRG Amount

Actual Cost, Calculated by Diagnostic Related Group for Inpatient bills

Char(5)

00000

Servicing State Code

State where Service was Performed

Char(2)

Servicing Zip Code

Zip Code Where Service was Performed

Char(5)

Prompt Payment obligation

Prompt Payment Flag Indicating contractual payment obligation

Char(1)

Redefine - UNIQUE TO Bills Paid Prior To 9/4/03

Bill Number

Bill Number

Char(12)

000000000000

Invoice type

Type of Invoice

Char(1)

0

Invoice number

Invoice number

Char(8)

00000000

Redefine - UNIQUE TO Invoice Type

Invoice Date

If Invoice type=D, Date provider created the bill If Invoice type = N, Providers Unique ID number for the bill

Date(8)

Redefine - UNIQUE TO Bills Paid After 9/4/03

TCN

Unique Transaction Control Number

Char(17)

Dispense Rate

Dispensing rate

Char(4)

0000

Return from Redefine

Provider Charges Amount

Amount Charged by provider

Char(5)

00000

Ineligible Amount

Amount Not Covered

Char(5)

00000

Ineligible code

Ineligible payment code

Char(1)

0

Fee Reduction Amount

Fee Reduced Amount

Char(5)

00000

Amount paid

Net Amount Paid

Char(5)

00000

Service Units Billed

Service Units Billed

Char(5)

00000

Locator Code

UB92 Loc 4; Code Indicates type of Institution

Char(3)

Prescriber's Name

Physician's name

Char(10)

Bill Received Date

Date Bill was received

Date(8)

CCYYMMDD

Bill Date Key

Date Bill was keyed for payment

Date(8)

CCYYMMDD

Bill Paid Date

Check Date/Payment Date

Date(8)

CCYYMMDD

Adjustment Date

Date an adjustment transaction was entered against a bill

Date(8)

CCYYMMDD

Bill Authorizing Official

Conditional; System Generated ID

Char(3)

Three Character Alpha

Bypass Code

Indicates Type of Payment or Adjustment

Char(1)

District Office Input Code

District Office Code

Char(2)

Redefine - UNIQUE TO Bills Paid Prior 9/4/03

District Office Control Code

District Office Sequent Code

Char(2)

Error Code

Internal Processor Only

Char(1)

Batch ID Number

The Batch the Bill was keyed with

Char(6)

Operator Identifier

System Generated Log-on ID

Char(8)

Redefine - UNIQUE TO Bills Paid After 9/4/03

TCN to Credit

Original Case Number

Char(17)

Return from Redefine

Payee Case from Code

Code Indicates if a change to a Case Number or Provider ID

Char(1)

Payee Case from ID

Original Case Number or Provider ID

Char(9)

Payee Case to Code

Code Indicates if a change to a Case Number or Provider ID

Char(1)

Payee Case to ID

Corrected Case Number or Provider ID

Char(9)

Bill ID Number

Sequential number of bill within a batch of bills

Char(2)

Bill Line Number

Sequential Number of bill line item

Char(3)

Record Sequence

Internal process

Char(2)

Resolver ID

ID of Person who resolved the suspended bill

Char(8)

New TCN

New transaction Control Number

Char(17)

Expanded Amount Fields

Work Unit

Work Relative Unit

Char(5)

CPT4 & HFCA Tables

Practice Unit

Practice Expenses Geographical Adjustment Factor

Char(5)

CPT4 & HFCA Tables

Malpractice Unit

Malpractice

Char(5)

CPT4 & HFCA Tables

Unit Cost

Conversion Factor

Char(5)

Adjust Factor

Expenses Geographic Adjustment factor

Char(4)

Practice Adjustment factor

Practice Expenses Geographic Adjustment Factor

Char(4)

Malpractice Adjustment Factor

Malpractice Expenses Geographic Adjustment Factor

Char(4)

Percent Modifier

Adjustment factor for Procedure code Modifier

Char(3)

Two-Year High Price

2YR High, Wholesale Price for RX

Char(10)

Modified Element

Dispensing Fee

Allowed Dispensing Fee For Prescription

Char(7)

Modified Element

Allowed Fee Amount

Allowable cost for prescription

Char(10)

Modified Element

Provider Charged Amount

Amount Charged by provider

Char(10)

Modified Element

Ineligible Amount

Amount Not Covered

Char(10)

Modified Element

Fee Reduction Amount

Fee Reduced

Char(10)

Modified Element

Amount paid

Net Amount Paid

Char(10)

Modified Element

Service Units Billed

Service Units Billed

Char(8)

Bill ID Number

Sequential number of bill within a batch of bills

Char(3)

Bill Line Number

Sequential Number of bill line item

Char(4)

Record Sequence

Internal process

Char(3)