Data Element Name | DN |
ACCIDENT DESCRIPTION /CAUSE | 38 |
CAUSE OF INJURY CODE | 37 |
CLAIM ADMINISTRATOR ADDRESS LINE 1 | 10 |
CLAIM ADMINISTRATOR ADDRESS LINE 2 | 11 |
CLAIM ADMINISTRATOR CITY | 12 |
CLAIM ADMINISTRATOR CLAIM NUMBER | 15 |
CLAIM ADMINISTRATOR FEIN | 8 |
CLAIM ADMINISTRATOR NAME | 9 |
CLAIM ADMINISTRATOR POSTAL CODE | 14 |
CLAIM ADMINISTRATOR STATE | 13 |
CLASS CODE(3) | 59 |
DATE DISABILITY BEGAN | 56 |
DATE LAST DAY WORKED | 65 |
DATE OF HIRE(1) | 61 |
DATE OF INJURY | 31 |
DATE OF RETURN TO WORK | 68 |
DATE REPORTED TO CLAIM ADMINISTRATOR | 41 |
DATE REPORTED TO EMPLOYER | 40 |
EMPLOYEE ADDRESS LINE 1(1) | 46 |
EMPLOYEE ADDRESS LINE 2(1) | 47 |
EMPLOYEE CITY(1) | 48 |
EMPLOYEE DATE OF BIRTH | 52 |
EMPLOYEE DATE OF DEATH | 57 |
EMPLOYEE FIRST NAME | 44 |
EMPLOYEE LAST NAME | 43 |
EMPLOYEE MIDDLE INITIAL(1) | 45 |
EMPLOYEE PHONE(1) | 51 |
EMPLOYEE POSTAL CODE(1) | 50 |
EMPLOYEE STATE(1) | 49 |
EMPLOYER ADDRESS LINE 1 | 19 |
EMPLOYER ADDRESS LINE 2 | 20 |
EMPLOYER CITY | 21 |
EMPLOYER FEIN | 16 |
EMPLOYER NAME | 18 |
EMPLOYER POSTAL CODE | 23 |
EMPLOYER STATE | 22 |
EMPLOYMENT STATUS CODE(1) | 58 |
GENDER CODE | 53 |
INDUSTRY CODE | 25 |
INITIAL TREATMENT CODE | 39 |
INSURED REPORT NUMBER | 26 |
INSURER FEIN | 6 |
INSURER NAME | 7 |
JURISDICTION | 4 |
MAINTENANCE TYPE CODE | 2 |
MAINTENANCE TYPE CODE DATE | 3 |
MARITAL STATUS CODE(2) | 54 |
NATURE OF INJURY CODE | 35 |
NUMBER OF DEPENDENTS(2) | 55 |
OCCUPATION DESCRIPTION | 60 |
PART OF BODY INJURED CODE | 36 |
POLICY EFFECTIVE DATE | 29 |
POLICY EXPIRATION DATE | 30 |
POLICY NUMBER | 28 |
POSTAL CODE OF INJURY SITE | 33 |
SALARY CONTINUED INDICATOR | 67 |
SELF INSURED INDICATOR | 24 |
SOCIAL SECURITY NUMBER(4) | 42 |
TIME OF INJURY | 32 |
WAGE(1) | 62 |
WAGE PERIOD(1) | 63 |
Data Element Name | DN |
AGENCY/JURISDICTION CLAIM NUMBER(2)(3) | 5 |
CLAIM ADMINISTRATOR CLAIM NUMBER(4) | 15 |
CLAIM ADMINISTRATOR FEIN(8) | 8 |
DATE OF INJURY(5) | 31 |
EMPLOYEE DATE OF BIRTH(6) | 52 |
EMPLOYEE FIRST NAME(7) | 44 |
EMPLOYEE FEIN(7) | 16 |
INSURER FEIN(4) | 6 |
JURISDICTION(1) | 4 |
MAINTENANCE TYPE CODE(1) | 2 |
MAINTENANCE TYPE CODE DATE(1) | 3 |
TIME OF INJURY(9) | 32 |
TRANSACTION SET ID(1) | 1 |
Data Element Name | DN |
BENEFIT ADJUSTMENT CODE | 92 |
BENEFIT ADJUSTMENT START DATE | 94 |
BENEFIT ADJUSTMENT WEEKLY AMOUNT | 93 |
CLAIM ADMINISTRATOR POSTAL CODE | 14 |
CLAIM STATUS | 73 |
CLAIM TYPE | 74 |
DATE DISABILITY BEGAN | 56 |
DATE OF MAXIMUM MEDICAL IMPROVEMENT | 70 |
DATE OF REPRESENTATION | 76 |
DATE OF RETURN/RELEASE TO WORK | 72 |
EMPLOYEE DATE OF DEATH | 57 |
INSURED REPORT NUMBER | 26 |
LATE REASON CODE | 77 |
NUMBER OF BENEFIT ADJUSTMENTS | 80 |
NUMBER OF DEATH DEPENDENT/PAYEE RELATIONSHIPS | 82 |
NUMBER OF DEPENDENTS | 55 |
NUMBER OF PAID TO DATE/REDUCED EARNINGS/ | |
RECOVERIES | 81 |
NUMBER OF PAYMENTS/ADJUSTMENTS | 79 |
NUMBER OF PERMANENT IMPAIRMENTS | 78 |
PAID TO DATE/ REDUCED EARNINGS/RECOVERIES | |
AMOUNT | 96 |
PAID TO DATE/ REDUCED EARNINGS/RECOVERIES | |
CODE | 95 |
PAYMENT/ADJUSTMENT CODE | 85 |
PAYMENT/ADJUSTMENT DAYS PAID | 91 |
PAYMENT/ADJUSTMENT END DATE | 89 |
PAYMENT/ADJUSTMENT PAID TO DATE | 86 |
PAYMENT/ADJUSTMENT START DATE | 88 |
PAYMENT/ADJUSTMENT WEEKLY AMOUNT | 87 |
PAYMENT/ADJUSTMENT WEEKS PAID | 90 |
PERMANENT IMPAIRMENT BODY PART CODE(1)(2) | 83 |
PERMANENT IMPAIRMENT PERCENTAGE(2) | 84 |
RETURN TO WORK QUALIFIER | 71 |
SALARY CONTINUED INDICATOR | 67 |
WAGE | 62 |
WAGE PERIOD | 63 |
Data Element Name | DN |
ACKNOWLEDGMENT TRANSACTION SET ID | 0110 |
ADA PROCEDURE BILLED CODE | 0719 |
ADA PROCEDURE PAID CODE | 0722 |
ADMISSION DATE | 0513 |
ADMISSION HOUR | 0622 |
ADMISSION TYPE CODE | 0577 |
ADMITTING DIAGNOSIS CODE | 0535 |
APPLICATION ACKNOWLEDGMENT CODE | 0111 |
BILL ADJUSTMENT AMOUNT | 0545 |
BILL ADJUSTMENT GROUP CODE | 0543 |
BILL ADJUSTMENT REASON CODE | 0544 |
BILL ADJUSTMENT UNITS | 0546 |
BILL FREQUENCY TYPE CODE | 0505 |
BILL SUBMISSION REASON CODE | 0508 |
BILLED DRG CODE | 0548 |
BILLING FORMAT CODE | 0503 |
BILLING PROVIDER CITY | 0540 |
BILLING PROVIDER COUNTRY CODE | 0569 |
BILLING PROVIDER FEIN | 0629 |
BILLING PROVIDER FIRST NAME | 0529 |
BILLING PROVIDER LAST/GROUP NAME | 0528 |
BILLING PROVIDER NATIONAL PROVIDER ID | 0634 |
BILLING PROVIDER POSTAL CODE | 0542 |
BILLING PROVIDER PRIMARY ADDRESS | 0538 |
BILLING PROVIDER PRIMARY SPECIALTY CODE | 0537 |
BILLING PROVIDER SECONDARY ADDRESS | 0539 |
BILLING PROVIDER STATE CODE | 0541 |
BILLING PROVIDER STATE LICENSE NUMBER | 0630 |
BILLING PROVIDER UNIQUE BILL IDENTIFICATION | |
NUMBER | 0523 |
BILLING TYPE CODE | 0502 |
CLAIM ADMINISTRATOR CLAIM NUMBER | 0015 |
CLAIM ADMINISTRATOR FEIN | 0187 |
CLAIM ADMINISTRATOR MAILING POSTAL CODE | 0014 |
CLAIM ADMINISTRATOR NAME | 0188 |
COMPOUND DRUG INDICATOR | 0762 |
CONDITION CODE | 0556 |
CONTRACT LINE TYPE CODE | 0741 |
CONTRACT TYPE CODE | 0515 |
DATE INSURER PAID BILL | 0512 |
DATE INSURER RECEIVED BILL | 0511 |
DATE OF BILL | 0510 |
DATE OF INJURY | 0031 |
DATE PROCESSED | 0108 |
DATE TRANSMISSION SENT | 0100 |
DAYS/UNITS BILLED | 0554 |
DAYS/UNITS CODE | 0553 |
DAY(S)/UNIT(S) PAID | 0580 |
DIAGNOSIS CODE | 0522 |
DIAGNOSIS POINTER | 0557 |
DISCHARGE DATE | 0514 |
DISCHARGE HOUR | 0623 |
DISPENSE AS WRITTEN CODE | 0562 |
DRUG NAME | 0563 |
DRUGS/SUPPLIES BILLED AMOUNT | 0572 |
DRUGS/SUPPLIES DISPENSING FEE | 0579 |
DRUGS/SUPPLIES NUMBER OF DAYS | 0571 |
DRUGS/SUPPLIES QUANTITY DISPENSED | 0570 |
ELEMENT ERROR NUMBER | 0116 |
ELEMENT NUMBER | 0115 |
EMPLOYEE FIRST NAME | 0044 |
EMPLOYEE LAST NAME | 0043 |
EMPLOYEE MAILING CITY | 0048 |
EMPLOYEE MAILING POSTAL CODE | 0050 |
EMPLOYEE MIDDLE NAME/INITIAL | 0045 |
EMPLOYEE SOCIAL SECURITY NUMBER | 0042 |
EMPLOYER FEIN | 0016 |
EMPLOYER NAME | 0018 |
FACILITY CITY | 0686 |
FACILITY CODE | 0504 |
FACILITY COUNTRY CODE | 0689 |
FACILITY NAME | 0678 |
FACILITY NATIONAL PROVIDER ID | 0682 |
FACILITY POSTAL CODE | 0688 |
FACILITY PRIMARY ADDRESS | 0684 |
FACILITY SECONDARY ADDRESS | 0685 |
FACILITY STATE CODE | 0687 |
FACILITY STATE LICENSE NUMBER | 0680 |
HCPCS LINE PROCEDURE BILLED CODE | 0714 |
HCPCS LINE PROCEDURE PAID CODE | 0726 |
HCPCS MODIFIER BILLED CODE | 0717 |
HCPCS MODIFIER PAID CODE | 0727 |
HIPPS RATE CODE | 0625 |
INSURER FEIN | 0006 |
INSURER NAME | 0007 |
INSURER POSTAL CODE | 0616 |
JURISDICTION CLAIM NUMBER | 0005 |
JURISDICTION MODIFIER BILLED CODE | 0718 |
JURISDICTION MODIFIER PAID CODE | 0730 |
JURISDICTION PROCEDURE BILLED CODE | 0715 |
JURISDICTION PROCEDURE PAID CODE | 0729 |
JURISDICTION TRACKING NUMBER | 0743 |
LINE ITEM PRIOR ACTUAL AMOUNT PAID | 0761 |
LINE NUMBER | 0547 |
LUMP SUM PAYMENT SETTLEMENT CODE | 0293 |
MANAGED CARE ORGANIZATION FEIN | 0704 |
MANAGED CARE ORGANIZATION IDENTIFICATION | |
NUMBER | 0208 |
MANAGED CARE ORGANIZATION NAME | 0209 |
NDC BILLED CODE | 0721 |
NDC PAID CODE | 0728 |
ORIGINATOR TRANSACTION IDENTIFICATION | |
BATCH CONTROL NUMBER | 0532 |
ORIGINAL TRANSMISSION DATE | 0102 |
ORIGINAL TRANSMISSION TIME | 0103 |
OTHER PROCEDURE CODE | 0736 |
OUTPATIENT REASON FOR VISIT CODE | 0520 |
PAID DRG CODE | 0549 |
PLACE OF SERVICE BILL CODE | 0555 |
PLACE OF SERVICE LINE CODE | 0600 |
PRESCRIPTION DATE(S) RANGE | 0527 |
PRESCRIPTION LINE DATE | 0604 |
PRESCRIPTION LINE NUMBER | 0561 |
PRESENT ON ADMISSION INDICATOR | 0533 |
PRINCIPAL DIAGNOSIS CODE | 0521 |
PRINCIPAL PROCEDURE CODE | 0525 |
PRINCIPLE PROCEDURE DATE | 0550 |
PRIOR ACTUAL AMOUNT PAID | 0760 |
PROCEDURE DATE | 0524 |
PROCEDURE DESCRIPTION | 0551 |
PROVIDER AGREEMENT CODE | 0507 |
PROVIDER AGREEMENT LINE CODE | 0742 |
RECEIVER ID | 0099 |
REFERRING PROVIDER FIRST NAME | 0691 |
REFERRING PROVIDER LAST/GROUP NAME | 0690 |
REFERRING PROVIDER NATIONAL PROVIDER ID | 0699 |
RENDERING BILL PROVIDER FIRST NAME | 0639 |
RENDERING BILL PROVIDER LAST/GROUP NAME | 0638 |
RENDERING BILL PROVIDER NATIONAL PROVIDER | |
ID | 0647 |
RENDERING BILL PROVIDER PRIMARY SPECIALTY | |
CODE | 0651 |
RENDERING BILL PROVIDER STATE LICENSE | |
NUMBER | 0643 |
RENDERING LINE PROVIDER NATIONAL PROVIDER | |
ID | 0592 |
RENDERING LINE PROVIDER FIRST NAME | 0587 |
RENDERING LINE PROVIDER LAST/GROUP NAME | 0589 |
RENDERING LINE PROVIDER PRIMARY SPECIALTY | |
CODE | 0595 |
RENDERING LINE PROVIDER STATE LICENSE | |
NUMBER | 0599 |
REPORTING PERIOD | 0615 |
REVENUE BILLED CODE | 0559 |
REVENUE PAID CODE | 0576 |
SENDER ID | 0098 |
SERVICE ADJUSTMENT AMOUNT | 0733 |
SERVICE ADJUSTMENT GROUP CODE | 0731 |
SERVICE ADJUSTMENT REASON CODE | 0732 |
SERVICE ADJUSTMENT UNITS | 0734 |
SERVICE BILL DATE(S) RANGE | 0509 |
SERVICE LINE DATE(S) RANGE | 0605 |
SUPERVISING PROVIDER FIRST NAME | 0659 |
SUPERVISING PROVIDER LAST/GROUP NAME | 0658 |
SUPERVISING PROVIDER NATIONAL PROVIDER ID | 0667 |
SUPERVISING PROVIDER PRIMARY SPECIALTY CODE | 0671 |
TEST/PRODUCTION INDICATOR | 0104 |
TIME PROCESSED | 0109 |
TIME TRANSMISSION SENT | 0101 |
TOTAL AMOUNT PAID PER BILL | 0516 |
TOTAL AMOUNT PAID PER LINE | 0574 |
TOTAL CHARGE PER BILL | 0501 |
TOTAL CHARGE PER LINE | 0552 |
TRANSACTION TRACKING NUMBER | 0266 |
UNIQUE BILL ID NUMBER | 0500 |
Data Element Name | DN |
PAID TO DATE/REDUCED EARNINGS/RECOVERIES AMOUNT | 96 |
PAID TO DATE/REDUCED EARNINGS/RECOVERIES CODE | 95 |
PAYMENT/ADJUSTMENT CODE | 85 |
PAYMENT/ADJUSTMENT END DATE | 89 |
PAYMENT/ADJUSTMENT DAYS PAID | 91 |
PAYMENT/ADJUSTMENT PAID TO DATE | 86 |
PAYMENT/ADJUSTMENT START DATE | 88 |
PAYMENT/ADJUSTMENT WEEKLY AMOUNT | 87 |
PAYMENT/ADJUSTMENT WEEKS PAID | 90 |
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