| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | line segment | 0;1 | NUMERIC | B | This is the number assigned to a specific line segment. | |
| .02 | ext line id | 0;2 | FREE TEXT | This is the User's transaction/line item identifier. (Required) | ||
| .03 | org group id | 0;3 | FREE TEXT | This is the Organization Group Identifier for the claim. (Optional) If a null value is sent, CM will internally store a default value of 1. | ||
| .04 | org id | 0;4 | FREE TEXT | This is the Organization identifier for the claim. (Optional) If the value is null, ClaimsManager will store a default value of 1. | ||
| .05 | line status | 0;5 | SET OF CODES | A:ACTIVE P:PROFILED D:DELETED | Default values are 'A' for Active, 'P' for Profiled and 'D' for Deleted. (Required) The user can supply other values at setup within ClaimsManager. PLEASE NOTE: If other codes are added within ClaimsManager, they must also be added to this field. | |
| .06 | beg date of service | 0;6 | FREE TEXT | This is the Beginning Date of Service in (YYYYMMDD) format. (Required) | ||
| .07 | end date of service | 0;7 | FREE TEXT | This is the End Date of Service in (YYYYMMDD) format. (Required) | ||
| .08 | place of service | 0;8 | FREE TEXT | This is the identifier for Place of Service. (Required) | ||
| .09 | submitted procedure code | 0;9 | FREE TEXT | This field contains the Submitted Procedure Code. (Required) | ||
| .1 | adjusted procedure code | 0;10 | FREE TEXT | This field contains the Adjusted Procedure Code. (Optional) | ||
| .11 | submitted amount | 0;11 | FREE TEXT | This is the Submitted Amount. (Optional) | ||
| .12 | pre authorization code | 0;12 | FREE TEXT | This is the Pre-Authorization Code. (Optioinal) | ||
| .13 | service provider id | 0;13 | FREE TEXT | This is the Servicing Provider ID. (Optional) Identifies a provider reccord stored in the database. If ClaimsManager finds no match, it adds this ID to the PROVIDER table. If an ID is supplied, a DEPARTMENT must also be supplied. | ||
| 1.01 | srvc prv last name | 1;1 | FREE TEXT | This is the Service Providers Last Name. (Optional) | ||
| 1.02 | srvc prv middle name | 1;2 | FREE TEXT | This is the Service Providers Middle Name. (Optional) | ||
| 1.03 | srvc prv first name | 1;3 | FREE TEXT | This is the Service Providers First Name. (Optional) | ||
| 1.04 | srvc prv title | 1;4 | FREE TEXT | This is the Service Providers Title. (Optional) | ||
| 1.05 | srvc prv dept | 1;5 | FREE TEXT | This is the Servicing Providers Department. (Optional) Identifies a department record stored in the database. If CM finds no match, it 'could' add this department ID to the Reference table. | ||
| 1.06 | srvc prv spec | 1;6 | FREE TEXT | This is the Servicing Provider Specialty. (Optional) Identifies a specialty record stored in the database. If CM finds no match, it 'could' add this specialty to the Reference table. If this ID is supplied, a Department must also be present. | ||
| 1.07 | srvc prv degree id | 1;7 | FREE TEXT | This is the Servicing Providers Degree ID. (Optional) | ||
| 1.08 | srvc prv upin | 1;8 | FREE TEXT | This is the Servicing Provider UPIN code. (Optional) | ||
| 1.09 | bill prv id | 1;9 | FREE TEXT | This is the Billing Provider Identifier. (Required) Identifies a provider record stored in the database. If CM finds no match, it adds this ID to the PROVIDER table. If no ID is supplied, CM stored the default provider. DFLT is supplied but the User can change this string at setup in CM. Only one string is used for all physicians. If an ID is supplied, a Department must also be present. | ||
| 2.01 | bill prv last name | 2;1 | FREE TEXT | This is the Billing Provider Last name. (Optional) | ||
| 2.02 | bill prv middle name | 2;2 | FREE TEXT | This is the Billing Provider Middle name. (Optional) | ||
| 2.03 | bill prv first name | 2;3 | FREE TEXT | This is the Billing Provider First name. (Optional) | ||
| 2.04 | bill prv title | 2;4 | FREE TEXT | This is the Billing Provider Title. (Optional) | ||
| 2.05 | bill prv dept | 2;5 | FREE TEXT | This is the Billing Provider Department. (Required) Identifies a Department record stored in the database. If CM finds no match, it 'could' add this Department ID to the Reference table. | ||
| 2.06 | bill prv spec | 2;6 | FREE TEXT | This is the Billing Provider Specialty. (Required) Identifies a Specialty record stored in the database. If CM finds no match, it 'could' add this specialty to the Reference table. | ||
| 2.07 | bill prv degree id | 2;7 | FREE TEXT | This is the Billing Provider Degree ID. (Optional) | ||
| 2.08 | bill prv upin | 2;8 | FREE TEXT | This is the Billing Provider UPIN code. (Optional) | ||
| 2.09 | primary payer id | 2;9 | FREE TEXT | This is the Primary Payer or FSC identifier. (Required) | ||
| 2.1 | secondary payer id | 2;10 | FREE TEXT | This is the Secondary Payer or FSC identifier. (Optional) | ||
| 2.11 | type of service | 2;11 | FREE TEXT | This is the Type of Service. (Optional) | ||
| 2.12 | units | 2;12 | FREE TEXT | This is the number of units for this line item. (Required) | ||
| 3.01 | modifiers | 3;1 | FREE TEXT | This is a storage location for the comma delimited string of CPT Modifiers for the associated line segment. |
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