Medical Claim Service Lines

field name object type validation description primary key claimline string required the unique identifier for this claim service line may be a combination of claim id + service line number claim primary key claimline string required the unique identifier for this claim group block of business id group string required identifier for corresponding block of business, account, or root level division group id group string required identifier for corresponding client/group group name group string required name of group group tin group string required tin (tax id) of group group hierarchy 1 group string optional first level breakdown of group (location) group hierarchy 1 description group string optional description of first level breakdown group hierarchy 2 group string optional second level breakdown of group (division) group hierarchy 2 description group string optional description of second level breakdown group hierarchy 3 group string optional third level breakdown of group group hierarchy 3 description group string optional description of third level breakdown group funding arrangment group string optional self funded, fully insured, etc subscriber primary key subscriber string required a key that defines the uniqueness of this subscriber this should match the key used in other datasets subscriber id subscriber string required member identifier (or subscriber if subscriberprimarykey is equivalent to primarykey) often shared among a family this member will be considered the subscriber if the subscriberprimarykey is equal to this row's primarykey) subscriber person code subscriber string required person code corresponding to this member often 00 for member and 01, 02, 03, etc for dependents in the order they were registered subscriber alternate id subscriber string optional alternative identifier of member subscriber ssn subscriber ssn recommended ssn for member some vendors will not be able to accept a family without at least a subscriber ssn subscriber employer id subscriber string optional employee identifier of subscriber subscriber first name subscriber string required first name of member subscriber middle name subscriber string required middle name of member subscriber last name subscriber string required last name of member subscriber date of birth subscriber yyyymmdd required date of birth of member subscriber address line 1 subscriber string required address line 1 of member subscriber address line 2 subscriber string optional address line 2 of member subscriber address line 3 subscriber string optional address line 3 of member subscriber city subscriber string required city of member subscriber state subscriber enum required two character state code conforming to the iso 3166 2\ us subdivision codes such as al, ak, az, ar, ca, co, etc subscriber postal code subscriber string required postal code of member may include 6 or 10 characters subscriber country code subscriber enum required two character country code conforming to iso 3166 1 alpha 2 member primary key member string required a key that defines the uniqueness of this member this should match the key used in other datasets member id member string required member identifier (or subscriber if subscriberprimarykey is equivalent to primarykey) often shared among a family this member will be considered the subscriber if the subscriberprimarykey is equal to this row's primarykey) member person code member string required person code corresponding to this member often 00 for member and 01, 02, 03, etc for dependents in the order they were registered member alternate id member string optional alternative identifier of member member relationship member enum required member's relationship to subscriber e g , su = subscriber/self, sp = spouse, ch = child, de = other dependent, etc member ssn member ssn recommended ssn for member some vendors will not be able to accept a family without at least a subscriber ssn member first name member string required first name of member member middle name member string required middle name of member member last name member string required last name of member member preferred first name member string optional preferred first name of member, if applicable and known member prefix member string optional prefix (e g , mr , mrs , dr ) for member member suffix member string optional suffix (e g , jr , sr , iii) for member member gender member enum required gender of member f, m, o, u = female, male, other, unknown member sex member enum required sex of member f, m, o, u = female, male, other, unknown member date of birth member yyyymmdd required date of birth of member member date of death member yyyymmdd optional date of death for member member address line 1 member string required address line 1 of member member address line 2 member string optional address line 2 of member member address line 3 member string optional address line 3 of member member city member string required city of member member state member enum required two character state code conforming to the iso 3166 2\ us subdivision codes such as al, ak, az, ar, ca, co, etc member postal code member string required postal code of member may include 6 or 10 characters member county member string optional county of member member country member enum required two character country code conforming to iso 3166 1 alpha 2 member coverage status coverage enum required coverage status of member a,d,h,i,p,r,s,t = active,deceased,hold,inactive,pending,retired,suspended,terminated claim id claimline string required claim number / identifier if you use claim segments, you could exclude it here to provide greater optionality to group claims together based on segment/suffix claim segment claimline string conditionally required claim segment/suffix/extension often used to identify reversal or correction claims sometimes it is a suffix of the claim id/number required if used and not included in claim id claim parent id claimline string conditionally required id of the parent claim, if applicable must include the unique claim number claim alternate id claimline string recommended if there is an alternate id for the claim it is recommended that it be included claim line number claimline string required claim line number claim status claimline string required claim status code paid, denied, pending, finalized, rejected, withdrawn, in process claim source claimline string optional edi, key product claimline enum required mm = medical, rx = prescription drug, vi = vision, de = dental, fx = flex claim form type claimline string required ub04, hcfa, etc plan id plan string required id of the plan plan name plan string required the name given to the plan plan year plan yyyy required the plan year that this claim applies to plan tpa id plan string recommended id of the third party administrator (tpa) for member plan tpa name plan string recommended name of the third party administrator (tpa) for member deductible year plan yyyy optional deductible year for the plan network id claimline string recommended id of the pricer of the claim network name claimline string recommended name of the pricer of the claim network status indicator claimline string required in = in network, on = out of network contract id claimline string recommended identifier of the contract applicable to this claim pricing methodology claimline string optional percent of charges, per diem, usual and customary, etc service start date claimline yyyymmdd required date of service start service end date claimline yyyymmdd required date of service end received date claimline yyyymmdd required the date that the claim was recieved adjudication date claimline yyyymmdd conditionally required date of adjudication paid date claimline yyyymmdd conditionally required date claim was paid clean claim date claimline yyyymmdd required date the claim was considered clean last modified date claimline yyyymmdd required date the claim was last modified current illness start date claimline yyyymmdd recommended date the current illness started admission date claimline yyyymmdd conditionally required date patient was admitted to hospital discharge date claimline yyyymmdd conditionally required date patient was discharged from hospital discharge status claimline string conditionally required status of patient's stay at hosital admission indicator claimline string conditionally required claim admission indicator inpatient admission status claimline enum optional inpatient admission status y = inpatient and n = outpatient length of stay claimline string conditionally required length of stay of the patient for the claim total charge claimline string required original total amount billed total allowed claimline decimal as string required maximum amount insurer will cover for this service line qpa allowed claimline decimal as string optional qualifying payment amount as determined for nsa compliance total paid claimline decimal as string required total amount paid for a service total paid = plan paid + member pay amount plan paid claimline decimal as string required amount paid by insurance plan part of total paid surcharge amount claimline decimal as string optional the surcharge amount added to claim that increases total payment amount this field should only be used for medical claims for pharmacy claims, taxes are captured separately cob other paid claimline decimal as string conditionally required amount paid by other insurance if applicable cob other allowed claimline decimal as string conditionally required amount allowed by other insurance if applicable cob other member pay amount claimline decimal as string conditionally required amount of member payment determined by other insurance if applicable cob savings claimline decimal as string conditionally required amount of savings due to cob cob other insurance type claimline enum optional other insurance type other, medicare, medicaid copay amount claimline decimal as string required fixed amount member pays when receiving service part of member pay amount deductible amount claimline decimal as string required amount member pays before insurance starts to pay part of member pay amount coinsurance amount claimline decimal as string required amount member pays after deductible has been met part of member pay amount coinsurance percentage claimline decimal as string optional the applicable coinsurance percentage member pay amount claimline decimal as string required amount member is responsible for member pay amount = copay amount + deductible amount + coinsurance amount + ineligible amount ineligible amount claimline decimal as string required amount not covered by payer discount amount claimline decimal as string required amount by which cost of service is reduced reflected in difference between total charge and total allowed precert penalty amount claimline decimal as string optional precertification penalty amount added to claim part of member's liability hra amount claimline decimal as string required amount employer contributes to cover health care expenses could be part of total paid usual customary reasonable amount claimline decimal as string recommended amount of usual, customary, and reasonable total adjustment claimline decimal as string optional total amount claim line was adjusted total disallowed claimline decimal as string optional total disallowed amount for claim line total paid to provider claimline decimal as string optional total amount paid to provider for the claim line patient out of pocket claimline decimal as string optional total amount patient paid toward oop for the claim line patient paid claimline decimal as string optional total amount patient paid for the claim line patient responsibility claimline decimal as string optional total patient responsibility for the claim payee claimline string recommended m = member, p= provider, o other when member is payee, indicates a member reimbursement check number claimline string optional check number for payment of claim subrogation status claimline enum optional subrogration status of claim if applicable acc = accident, mt = mass tort, n =none, wc = workers comp o = other subrogation paid amount claimline decimal as string recommended amount paid by due to accident/etc via subrogation benefit code claimline string optional code for benefit applied to claim line benefit description claimline string optional description of benefit applied to claim line diagnosis code system claimline string required identifies icd9 vs icd10 diagnosis codes primary claimline string required icd 9 or icd 10 code(s) that appear on a claim there can be multiple icd codes sent diagnosis codes description primary claimline string required icd 9 or icd 10 code(s) description that appear on a claim diagnosis codes 1 claimline string recommended auxiliary diagnosis codes diagnosis codes description 1 claimline string optional auxiliary diagnosis codes description diagnosis codes 2 claimline string recommended auxiliary diagnosis codes diagnosis codes description 2 claimline string optional auxiliary diagnosis codes description diagnosis codes 3 claimline string recommended auxiliary diagnosis codes diagnosis codes description 3 claimline string optional auxiliary diagnosis codes description diagnosis codes 4 claimline string recommended auxiliary diagnosis codes diagnosis codes description 4 claimline string optional auxiliary diagnosis codes description diagnosis codes 5 claimline string recommended auxiliary diagnosis codes diagnosis codes description 5 claimline string optional auxiliary diagnosis codes description diagnosis codes 6 claimline string recommended auxiliary diagnosis codes diagnosis codes description 6 claimline string optional auxiliary diagnosis codes description diagnosis codes 7 claimline string recommended auxiliary diagnosis codes diagnosis codes description 7 claimline string optional auxiliary diagnosis codes description diagnosis codes 8 claimline string recommended auxiliary diagnosis codes diagnosis codes description 8 claimline string optional auxiliary diagnosis codes description diagnosis codes 9 claimline string recommended auxiliary diagnosis codes diagnosis codes description 9 claimline string optional auxiliary diagnosis codes description diagnosis codes 10 claimline string recommended auxiliary diagnosis codes diagnosis codes description 10 claimline string optional auxiliary diagnosis codes description diagnosis codes 11 claimline string recommended auxiliary diagnosis codes diagnosis codes description 11 claimline string optional auxiliary diagnosis codes description diagnosis codes 12 claimline string recommended auxiliary diagnosis codes diagnosis codes description 12 claimline string optional auxiliary diagnosis codes description diagnosis codes 13 claimline string recommended auxiliary diagnosis codes diagnosis codes description 13 claimline string optional auxiliary diagnosis codes description diagnosis codes 14 claimline string recommended auxiliary diagnosis codes diagnosis codes description 14 claimline string optional auxiliary diagnosis codes description diagnosis codes 15 claimline string recommended auxiliary diagnosis codes diagnosis codes description 15 claimline string optional auxiliary diagnosis codes description diagnosis codes 16 claimline string recommended auxiliary diagnosis codes diagnosis codes description 16 claimline string optional auxiliary diagnosis codes description diagnosis codes 17 claimline string recommended auxiliary diagnosis codes diagnosis codes description 17 claimline string optional auxiliary diagnosis codes description diagnosis codes 18 claimline string recommended auxiliary diagnosis codes diagnosis codes description 18 claimline string optional auxiliary diagnosis codes description drg code claimline string required drg code drg description claimline string required drg code description procedure code system claimline string required coding system hcpcs, cpt, icd, pcs procedure code claimline string required code of the procedure procedure code description claimline string required description of the procedure code procedure code modifier 1 claimline string conditionally required code for modifications to procedure procedure code modifier 2 claimline string conditionally required code for modifications to procedure procedure code modifier 3 claimline string conditionally required code for modifications to procedure procedure code modifier 4 claimline string conditionally required code for modifications to procedure procedure code modifier 5 claimline string conditionally required code for modifications to procedure number of units claimline string conditionally required number of units place of service code claimline string required cms place of service code set place of service description claimline string required cms place of service code description revenue code 1 claimline string required revenue code revenue code 2 claimline string conditionally required revenue code revenue code 3 claimline string conditionally required revenue code revenue code 4 claimline string conditionally required revenue code revenue code 5 claimline string conditionally required revenue code bill type code claimline string required cms bill type code bill type description claimline string required bill type code description charge type code claimline string recommended charge type code charge type description claimline string recommended charge type code description reason code 1 claimline string required the code(s) indicating adjudication results such as ineligible or remark codes reason description 1 claimline string required the description for each ineligible and or remark code above reason code 2 claimline string conditionally required auxiliary code + description reason description 2 claimline string conditionally required auxiliary code + description reason code 3 claimline string conditionally required auxiliary code + description reason description 3 claimline string conditionally required auxiliary code + description reason code 4 claimline string conditionally required auxiliary code + description reason description 4 claimline string conditionally required auxiliary code + description reason code 5 claimline string conditionally required auxiliary code + description reason description 5 claimline string conditionally required auxiliary code + description authorization primary key claimline string conditionally required prior authorization number/id service type code claimline string required code for the type of service created date claimline yyyymmdd optional date claim line was created facility primary key provider string required unique identifier for the facility where the service was provided facility name provider string required name of the facility where the service was provided facility tin provider string required tax identification number of the facility facility npi provider string recommended national provider identifier of the facility facility id provider string optional internal identifier of the facillity facility address line 1 provider string required address of the facility facility address line 2 provider string optional address line 2 of the facility facility state provider string required state where the facility is located facility city provider string required city where the facility is located facility country provider string required country where the facility is located facility postal code provider string required postal code of the facility facility phone provider string optional phone number of the facility rendering physician primary key provider string required unique identifier for the physician who rendered the service rendering physician first name provider string required first name of the rendering physician rendering physician last name provider string required last name of the rendering physician rendering physician npi provider string recommended national provider identifier of the rendering physician rendering physician tin provider string required tax identification number of the rendering physician rendering physician id provider string optional internal identifier of the rendering physician rendering physician address line 1 provider string required first line of the rendering physician's address rendering physician address line 2 provider string optional second line of the rendering physician's address, if applicable rendering physician city provider string required city where the rendering physician is located rendering physician state provider string required state where the rendering physician is located rendering physician postal code provider string required postal code of the rendering physician rendering physician country provider string required country code of the rendering physician rendering provider specialty code provider string required specialty code of the rendering provider rendering provider specialty code description provider string required description of the specialty code of the rendering provider rendering physician phone provider string optional phone number of the rendering physician billing provider primary key provider string required unique identifier for the billing provider billing provider name provider string required name of the billing provider billing provider npi provider string recommended national provider identifier of the billing provider billing provider tin provider string required tax identification number of the billing provider billing provider id provider string optional internal identifier for the billing provider billing provider specialty code provider string required specialty code of the billing provider billing provider specialty code description provider string required description of the specialty code of the billing provider billing provider address line 1 provider string required first line of the billing provider's address billing provider address line 2 provider string optional second line of the billing provider's address, if applicable billing provider city provider string required city where the billing provider is located billing provider state provider string required state where the billing provider is located billing provider postal code provider string required postal code of the billing provider billing provider country provider string required country code of the billing provider billing provider phone provider string optional phone number of the billing provider attending physician first name claimline string optional first name of the attending physician attending physician last name claimline string optional last name of the attending physician attending physician npi claimline string optional attending physician npi attending physician specialty code claimline string optional attending physician specialty code attending physician id claimline string optional attending physician internal or other id referring physician first name claimline string optional first name of the referring physician referring physician last name claimline string optional last name of the referring physician referring physician npi claimline string optional referring physician npi referring physician specialty code claimline string optional referring physician specialty code referring physician id claimline string optional referring physician internal or other id operating physician first name claimline string optional first name of the operating physician operating physician last name claimline string optional last name of the operating physician operating physician npi claimline string optional operating physician npi operating physician specialty code claimline string optional operating physician specialty code operating physician id claimline string optional operating physician internal or other id custom 1 private claimline string optional custom field custom 2 private claimline string optional custom field custom 3 private claimline string optional custom field custom 4 private claimline string optional custom field custom 5 private claimline string optional custom field custom 6 private claimline string optional custom field custom 7 private claimline string optional custom field custom 8 private claimline string optional custom field custom 9 private claimline string optional custom field custom 10 private claimline string optional custom field custom 11 private claimline string optional custom field custom 12 private claimline string optional custom field custom 13 private claimline string optional custom field custom 14 private claimline string optional custom field custom 15 private claimline string optional custom field custom 16 private claimline string optional custom field custom 17 private claimline string optional custom field custom 18 private claimline string optional custom field custom 19 private claimline string optional custom field custom 20 private claimline string optional custom field custom 21 private claimline string optional custom field custom 22 private claimline string optional custom field custom 23 private claimline string optional custom field custom 24 private claimline string optional custom field custom 25 private claimline string optional custom field custom 26 private claimline string optional custom field custom 27 private claimline string optional custom field custom 28 private claimline string optional custom field custom 29 private claimline string optional custom field custom 30 private claimline string optional custom field