| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | claim date/time(+) | 0;1 | DATE-TIME | B | Enter the date/time of the Bene Travel Claim. | |
| 2 | name(+) | 0;2 | POINTER | 2 | C | Enter the patient that is related to this Bene Travel Claim. |
| 3 | eligibility | 0;3 | POINTER | 8 | AE | This field contains the eligibililty of the patient for this Bene Travel Claim. |
| 4 | sc percentage | 0;4 | NUMERIC | Enter the SC percentage of this patient related to this Bene Travel Claim. | ||
| 5 | certification date | 0;5 | POINTER | 392.2 | This field contains the Beneficiary Travel Certification date. | |
| 6 | account(+) | 0;6 | POINTER | 392.3 | AC | This field is a pointer to the Beneficiary Travel Account file and contains the account number assigned to an individual beneficiary travel claim. |
| 7 | carrier(+) | 0;7 | POINTER | 440 | AS | This field points to the Vendor File and contains the Carrier providing services for this Bene Travel Claim. |
| 8 | most econ. cost | 0;8 | NUMERIC | This field contains the most economical cost amount (whatever cost less) for this Bene Travel Claim. | ||
| 9 | deductible amount | 0;9 | NUMERIC | This field contains the deductible amount applied to this Bene Travel Claim. | ||
| 10 | amount payable | 0;10 | NUMERIC | This field contains the amount payable (cost minus any applied deductible) for this Bene Travel Claim. | ||
| 11 | division(+) | 0;11 | POINTER | 40.8 | This field contains the medical center division related to this Bene Travel Claim. | |
| 12 | who entered into file | 0;12 | POINTER | 200 | The name of the user who first entered this patient into the Beneficiary Travel Claim file. | |
| 13 | date entered into the file | 0;13 | DATE-TIME | D | The date this beneficiary travel claim was entered into this file. | |
| 14 | corefls carrier | 0;14 | POINTER | 392.31 | AFLS | This field contains the COREFLS Carrier for this Bene Travel Claim. |
| 21 | place of departure [line 1] | D;1 | FREE TEXT | This field contains the first line of the address for the place of departure for this Bene Travel Claim. | ||
| 22 | place of departure [line 2] | D;2 | FREE TEXT | This field contains the second line of the address for the place of departure for this Bene Travel Claim. | ||
| 23 | place of departure [line 3] | D;3 | FREE TEXT | This field contains the third line of the address for the place of departure for this Bene Travel Claim. | ||
| 24 | city of departure | D;4 | FREE TEXT | This field contains the name of the city in the address for the place of departure for this Bene Travel Claim. | ||
| 24.1 | state of departure | D;5 | POINTER | 5 | This field points to the State File and uses this for the state in the address for the place of departure for this Bene Travel Claim. | |
| 24.2 | zip code/departure | D;6 | FREE TEXT | This field contains the 5-digit zip code used in the address for the place of departure for this Bene Travel Claim. | ||
| 25 | destination [line 1] | T;1 | FREE TEXT | This field contains the first line of the address for place of destination for this Bene Travel Claim. | ||
| 26 | destination [line 2] | T;2 | FREE TEXT | This field contains the second line of the address for the place of destination for this Bene Travel Claim. | ||
| 27 | destination [line 3] | T;3 | FREE TEXT | This field contains the third line of the address for the place of destination for this Bene Travel Claim. | ||
| 28 | city of destination | T;4 | FREE TEXT | This field contains the name of the city in the address for the place of destination for this Bene Travel Claim. | ||
| 28.1 | state of destination | T;5 | POINTER | 5 | This field points the the STATE file and contains the state used in the address for the place of destination for this Bene Travel Claim. | |
| 28.2 | zip code/destination | T;6 | FREE TEXT | This field contains the 5-digit zip code used in the address for the place of destination for this Bene Travel Claim. | ||
| 31 | one way/round trip(+) | M;1 | SET OF CODES | 1:ONE WAY 2:ROUND TRIP | This field indicates one way or round trip for this Bene Travel Claim. | |
| 32 | mileage/one way(+) | M;2 | NUMERIC | This field contains the one way mileage for this Bene Travel Calim. | ||
| 33 | total mileage amount | M;3 | NUMERIC | This is a numeric field containing the total mileage entered for a specific beneficiary travel claim. | ||
| 34 | meals & lodging | M;4 | NUMERIC | This field contains meals and lodging costs for this Bene Travel Claim. | ||
| 35 | ferry, bridges, etc. | M;5 | NUMERIC | This field contains ferry, bridges, etc. costs for this Bene Travel Claim. | ||
| 41 | authorizing person | A;1 | POINTER | 200 | This field points the person file to indicate who the authorizing person responsible for this Bene Travel Claim. | |
| 42 | attendant/payee | A;2 | FREE TEXT | This field contains the 'Last, First Middle' name format of the attendent/payee of this Bene Travel Claim. | ||
| 43 | c&p review visit | A;3 | BOOLEAN | 0:NO 1:YES | This field indicates whether this is a C&P review visit and should be paid at the C&P review visit mileage rate as indicated in the BT parameters for this Bene Travel Claim. | |
| 43.1 | bt claim eligibility code | 1;2 | POINTER | 392.41 | This is the reason patient is eligible for BT. | |
| 43.2 | bt claim eligibility addition | 1;1 | FREE TEXT | This is additional information or explanation if 'Other Eligibility Reason' was entered in the BT CLAIM ELIGIBILITY CODE (#43.1) field. | ||
| 43.4 | sc appointment | A;12 | BOOLEAN | 0:NO 1:YES | This field contains 1(Yes) or 0(No) on whether or not the patients appointment was a SC appointment. | |
| 43.5 | qualified appointment | A;11 | BOOLEAN | 0:NO 1:YES | The field will contain the a 1(yes) or 0(no) on whether or not the patients appointment was a qualified appointment for BT reimburstment. | |
| 44 | mode of transportation(+) | A;4 | POINTER | 392.43 | This field indicates the mode of transportation used for this Beneficiary Travel Claim. | |
| 45 | denial letter issued | A;6 | BOOLEAN | 0:NO 1:YES | Field indicates whether or not a BT claim denial letter was issued. | |
| 45.1 | denial letter issued date | A;7 | DATE-TIME | Date and time the BT claim was denied and letter was issued. | ||
| 45.2 | claim denied | A;8 | BOOLEAN | 0:NO 1:YES | This field will inform whether a claim has been approved or denied. | |
| 45.3 | date claim denied | A;9 | DATE-TIME | This field contains the date the claim was denied. | ||
| 45.4 | claim denied reason | A;10 | POINTER | 392.8 | Reason claim was denied. | |
| 51 | remarks | R;1 | FREE TEXT | This field contains remarks related to this Beneficiary Travel Claim. | ||
| 52 | bus pass or ticket | B;1 | SET OF CODES | P:PASS T:TICKET | This field stores the type of ticket that the veteran used when riding the bus. The type of ticket determines how the veteran is reimbursed. | |
| 53 | bus pass expiration date | B;2 | DATE-TIME | This field holds the expiration date of the bus pass and can only be filled in if the BUS PASS OR TICKET (#52) field is set to pass. The bus pass expiration date can't before the claim date. | ||
| 54 | common carrier date reimbursed(+) | C;1 | DATE-TIME | This field holds the date of reimbursement for use of common carrier transportation. | ||
| 55 | common carrier fee(+) | C;2 | NUMERIC | This is the amount charged for use of the common carrier transportation. | ||
| 55.1 | common carrier required(+) | C;3 | BOOLEAN | 1:YES 0:NO | Field is used to indicate whether or not the use of a common carrier was best or only way to travel to a VA medical center. | |
| 56 | type of claim(+) | 0;15 | SET OF CODES | M:MILEAGE S:SPECIAL MODE | This field indicates what type of claim this is. | |
| 57 | special mode of transportation(+) | SP;1 | POINTER | 392.42 | This is the type of Special Mode of Transportation. | |
| 58 | invoice number(+) | SP;2 | FREE TEXT | The field contains the invoice number from the vendor who provided the special mode of transportation for the patient. | ||
| 59 | date invoice received | SP;3 | DATE-TIME | This is the date the invoice was received by the VA from either the patient or the vendor for the special mode transportation. | ||
| 60 | total invoice amount(+) | SP;4 | NUMERIC | This is the total of all charges by a vendor for the transportation of the patient by special mode. This includes all cost and special add-on fees. | ||
| 61 | base rate fee(+) | SP;5 | NUMERIC | This is the base rate fee if any, charged by the vendor for transporting the patient by special mode. | ||
| 62 | mileage fee(+) | SP;6 | NUMERIC | This is the per mile amount charged by the vendor for transporting the patient by special mode. | ||
| 63 | no show/no load fee | SP;7 | NUMERIC | Vendor's charge for a no-show patient. | ||
| 64 | wait time fee | SP;8 | NUMERIC | This is the fee charged by the vendor to wait for the patient. | ||
| 65 | extra crew fee | SP;9 | NUMERIC | This is the fee charged by the vendor when extra crew is provided by the vendor to transport the patient by special mode. | ||
| 66 | special equipment fee | SP;10 | NUMERIC | This is the fee charged by the vendor to provide special equipment during the special mode transportation. | ||
| 67 | special mode rt/one-way(+) | SP;11 | SET OF CODES | R:ROUND TRIP O:ONE WAY | This field indicates whether the special mode transportation was round trip or one way. | |
| 68 | special mode total miles(+) | SP;12 | NUMERIC | This is the total mileage for the special mode transportation trip. | ||
| 69 | other sm transportation | SP;25 | FREE TEXT | Other types of special mode transportation used when 'OTHER' is selected from the SPECIAL MODE OF TRANSPORTATION (#57) field. | ||
| 70 | pre-authorized(+) | SP;13 | BOOLEAN | 1:YES 0:NO | This field indicates whether the transportation for the Special Mode trip was pre-authorized. | |
| 71 | special mode vendor(+) | SP;14 | POINTER | 440 | This is the vendor who supplied the special mode transportation for the patient. | |
| 72 | special mode other remarks | SP;26 | FREE TEXT | This field is any additional information about the special mode of transportation claim. | ||
| 73 | sp mode departure address1(+) | SPAD;1 | FREE TEXT | Line one of the address the patient departed from for this claim. It defaults to line one of the patient's home address. | ||
| 74 | sp mode departure address2 | SPAD;2 | FREE TEXT | This is the second line of the departure address of the patient. It defaults to the patient's 2nd line of their home address. | ||
| 75 | sp mode departure city(+) | SPAD;3 | FREE TEXT | This is the city the patient departed from for this claim. It defaults to the patient's home address city. | ||
| 76 | sp mode departure state(+) | SPAD;4 | POINTER | 5 | This is the state from which the patient departed for the claim. It defaults to the state from the patient's home address. | |
| 77 | sp mode departure zip code(+) | SPAD;5 | FREE TEXT | This is the patient's departure ZIP code for this claim. It defaults to the ZIP code from the patient's home address. | ||
| 78 | sp mode destination 1(+) | SPAD;6 | FREE TEXT | This is line one of the destination address. It defaults to the site's address. | ||
| 79 | sp mode destination 2 | SPAD;7 | FREE TEXT | This is line 2 of the destination address. It defaults to the site's address line 2. | ||
| 80 | sp mode destination 3 | SPAD;8 | FREE TEXT | This is the third line of the site's address. It defaults to the site's address line 3. | ||
| 81 | sp mode destination city(+) | SPAD;9 | FREE TEXT | This is the city the site is located in. It defaults to the site's city. | ||
| 82 | sp mode destination state(+) | SPAD;10 | POINTER | 5 | This is the destination state of the site. It defaults to the site's state. | |
| 83 | sp mode destination zip code(+) | SPAD;11 | FREE TEXT | This is the destination ZIP code of the site. It defaults to the site's ZIP code. | ||
| 84 | pre-authorized by | SP;16 | POINTER | 200 | This is User who PRE-AUTHORIZED the Claim. By default it's user who entered the claim. | |
| 85 | special mode claim authorized | SP;15 | BOOLEAN | 1:YES 0:NO | This field indicates whether Special Mode transportation is authorized or denied. | |
| 86 | date/time authorized | SP;17 | DATE-TIME | This is the date/time the travel was authorized if not a pre-authorized trip. |
Not Referenced