XEROX 11D-Claims Payment and Reporting 4intf
11.4 Claims Payment and Reporting Interface Functionality
The interfaces supported by Claims Payment and Reporting are:
PDCS Adjudicated Claims Interface
MMIS Warrant State Treasury Interface
Capitation Tape RA Interface
Waiver Programs Paid and Denied Claims Interface and Waiver Programs Suspended Claims Interface
Immunization Claims Interface (OBSOLETE)
Immunization Claims Interface for New Mexico State Immunization Information System (SIIS) (OBSOLETE)
IRS 1099 Claims Interface
Paid Claims Interface Furnished To Mercer Consulting
DRAMS Claims Interface
HMS Claims Interface
HMS Encounter Claims Interface
Wells Fargo Payment Interface
Wells Fargo Rejects Interface
Wells Fargo Returns and Notification of Change Interface
Laser Check Printing Interface
X835 Electronic Remittance Advice IRL
X820 Premium Payment IRL
Spectrum Informatics – Claims Interface
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE
PDCS ADJUDICATED CLAIMS INTERFACE
|Description: |
|The PDCS system edits, prices and adjudicates pharmacy claims independently of the MMIS. A file of adjudicated pharmacy claims with statuses of “to be paid” or “to be denied” is produced by the |
|PDCS system daily. The MMIS/PDCS interface reads this file and transfers the complete pharmacy claim record to the MMIS active claims database. Once on the active claim database, the Claims |
|Payment and Reporting function processes the claims in exactly the same way it processes MMIS adjudicated claims. The pharmacy claims will be included in the provider’s payments and on the |
|various remittance reports. Pharmacy claims with a status of “to be paid” or “to be denied” will have their status changed to the final dispositions of paid or denied. They will then be moved to|
|the claims history database and be deleted from the active claims database. The pharmacy claims are stored on the claims history database for thirty-six months and are available for inquiry and |
|reporting within the MMIS. |
|Source Files: |
|XEROX Prescription Drug Card System adjudicated claims dataset. |
|Target Tables: |
|C_HDR_TB |
|C_HDR_DRUG_TB |
|C_LI_TB |
|C_LI_DRUG_TB |
|C_LI_EXC_TB |
|C_LI_BSE_CHG_TB |
|C_HDR_ADJ_VD_TB |
|C_HDR_RLTD_HIST_TB |
|C_LI_TPL_BLNG_TB |
|C_HDR_ENCTR_TB |
|C_LI_CAS_TB |
|C_HDR_MCARE_TB |
| |
|Target Files: |
|A sequential file of TPL billing records is produced by this interface to be included in the nightly batch TPL process. |
|Reports: |
|RC063 - PDCS Claim Update Error Report |
|RC063 - PDCS Claim Totals |
|Remarks: See Chapter 8, PDCS Claims Update Error Report, for report detail. |
| |
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE LAYOUT
INPUT FILE
PDCS ADJUDICATED CLAIMS INTERFACE
000010******************************************************************00001000
000020* *00001100
000030* w1c40541 is the pdcs claims extract layout, generated by pdcs. *00002000
000040* *00003000
000050******************************************************************00004000
000060******************************************************************00005000
000070* --------- CSR CHANGES --------- *00006000
000080* *00007000
000090* CSR CHANGE ANALYST *00008000
000100* NBR DATE NAME DESCRIPTION OF CHANGE *00009000
000110* *00009100
000120*hipaa14 08/11/2003 J. SHERRY NEW COPYBOOK FOR OMNICAID *00009200
*PBMD0 10/05/11 M.RAMEY ADD NEW FIELDS FOR PBM D.0 *PBMD0
000130* TO END OF COPYBOOK. *PBMD0
000140******************************************************************00009400
000150* important note: * 00040000
000160* * 00050000
000170* do not replace this with an omnicaid generated layout. * 00060000
000180* * 00100000
000190***************************************************************** 00110000
000200* * 00120000
000210 01 W1C40541-C-CNTL-PHRM-IO-VW. 00130000
000220 05 W1C40541-C-CNTL-ONL-COMMON-VW. 00140000
000230 10 W1C40541-C-CNTL-EXE-MODE-CD 00150000
000240 PIC X(00001). 00160000
000250 10 W1C40541-C-CNTL-EXC-ADR-NUM 00170000
000260 PIC S9(00008) COMP. 00180000
000270 10 W1C40541-C-CNTL-PROC-CD 00190000
000280 PIC X(00001). 00200000
000290 10 W1C40541-C-CNTL-EVNT-SRC-CD 00210000
000300 PIC X(00008). 00220000
000310 05 W1C40541-C-PHRM-VW. 00230000
000320 10 W1C40541-C-HDR-COMMON-VW. 00240000
000330 15 W1C40541-C-SORT-DAT 00250000
000340 PIC X(00060). 00260000
000350 15 W1C40541-C-COUNTERS-VW. 00270000
000360 20 W1C40541-C-CNT-EXC-NUM 00280000
000370 PIC S9(00004) COMP. 00290000
000380 20 W1C40541-C-CNT-COE-NUM 00300000
000390 PIC S9(00004) COMP. 00310000
000400 20 W1C40541-C-CNT-RLTD-HST-NUM 00320000
000410 PIC S9(00004) COMP. 00330000
000420 20 W1C40541-C-CNT-DUR-PPS-NUM 00340000
000430 PIC S9(00004) COMP. 00350000
000440 20 W1C40541-C-CNT-CLINICAL-NUM 00360000
000450 PIC S9(00004) COMP. 00370000
000460 20 W1C40541-C-CNT-DIAG-NUM 00380000
000470 PIC S9(00004) COMP. 00390000
000480 20 W1C40541-C-CNT-OTHR-AMT-NUM 00400000
000490 PIC S9(00004) COMP. 00410000
000500 20 W1C40541-C-CNT-COB-ID-NUM 00420000
000510 PIC S9(00004) COMP. 00430000
000520 20 W1C40541-C-CNT-LI-NUM 00440000
000530 PIC S9(00004) COMP. 00450000
000540 20 W1C40541-C-CNT-PROC-MOD-NUM 00460000
000550 PIC S9(00004) COMP. 00470000
000560 20 W1C40541-C-CNT-BSE-CHG-NUM 00480000
000570 PIC S9(00004) COMP. 00490000
000580 20 W1C40541-C-CNT-TPL-BLNG-NUM 00500000
000590 PIC S9(00004) COMP. 00510000
000600 20 W1C40541-C-CNT-OVRD-EOB-NUM 00520000
000610 PIC S9(00004) COMP. 00530000
000620 20 W1C40541-C-CNT-OVRD-EXC-NUM 00540000
000630 PIC S9(00004) COMP. 00550000
000640 15 W1C40541-C-HDR-TB. 00560000
000650 20 W1C40541-R-CUST-PART-NUM 00570000
000660 PIC S9(00004) COMP. 00580000
000670 20 W1C40541-B-SYS-ID 00590000
000680 PIC S9(00009) COMP. 00600000
000690 20 W1C40541-C-TCN-NUM 00610000
000700 PIC S9(00017) COMP-3. 00620000
000710 20 W1C40541-C-CNTL-ORGN-CD 00630000
000720 PIC X(00001). 00640000
000730 20 W1C40541-C-BAT-MED-SRC-CD 00650000
000740 PIC X(00001). 00660000
000750 20 W1C40541-C-BAT-JLN-DT-NUM 00670000
000760 PIC X(00005). 00680000
000770**** 20 W1C40541-C-BAT-IMG-CNTL-NUM 00690000
000780 20 FILLER PIC X(00001). 00700000
000790 20 W1C40541-C-BAT-NUM 00710000
000800 PIC X(00004). 00720000
000810 20 W1C40541-C-BAT-TY-CD 00730000
000820 PIC X(00001). 00740000
000830 20 W1C40541-B-FST-NAM 00750000
000840 PIC X(00015). 00760000
000850 20 W1C40541-B-LAST-NAM 00770000
000860 PIC X(00021). 00780000
000870 20 W1C40541-B-MI-NAM 00790000
000880 PIC X(00001). 00800000
000890 20 W1C40541-B-RACE-CD 00810000
000900 PIC X(00001). 00820000
000910 20 W1C40541-B-GENDER-CD 00830000
000920 PIC X(00001). 00840000
000930 20 W1C40541-C-PAT-REL-CD 00850000
000940 PIC S9(00004) COMP. 00860000
000950 20 W1C40541-C-PAT-LOC-CD 00870000
000960 PIC S9(00004) COMP. 00880000
000970 20 W1C40541-C-PRGNCY-IND 00890000
000980 PIC X(00001). 00900000
000990 20 W1C40541-A-AUTH-NUM 00910000
001000 PIC X(00020). 00920000
001010 20 W1C40541-C-PA-BASIS-REQ-CD 00930000
001020 PIC X(00002). 00940000
001030 20 W1C40541-C-PA-REQ-BEG-DT 00950000
001040 PIC X(00010). 00960000
001050 20 W1C40541-C-PA-REQ-END-DT 00970000
001060 PIC X(00010). 00980000
001070 20 W1C40541-C-PA-SUP-DOC-TX 00990000
001080 PIC X(00070). 01000000
001090 20 W1C40541-C-INTMDRY-AUTH-CD 01010000
001100 PIC S9(00004) COMP. 01020000
001110 20 W1C40541-C-INTMDRY-AUTH-ID 01030000
001120 PIC X(00011). 01040000
001130 20 W1C40541-C-CLM-REF-ID-NUM 01050000
001140 PIC X(00030). 01060000
001150 20 W1C40541-C-BLNG-NTRPRS-ID 01070000
001160 PIC X(00015). 01080000
001170 20 W1C40541-C-ATTACH-1ST-CD 01090000
001180 PIC X(00002). 01100000
001190 20 W1C40541-C-ATTACH-2ND-CD 01110000
001200 PIC X(00002). 01120000
001210 20 W1C40541-C-ATTACH-3RD-CD 01130000
001220 PIC X(00002). 01140000
001230 20 W1C40541-C-HDR-RMK-IND 01150000
001240 PIC X(00001). 01160000
001250 20 W1C40541-C-OTHR-INSR-IND 01170000
001260 PIC 9(00004) COMP. 01180000
001270 20 W1C40541-P-BORDER-CD 01190000
001280 PIC X(00001). 01200000
001290 20 W1C40541-C-COST-AVOID-IND 01210000
001300 PIC X(00001). 01220000
001310 20 W1C40541-C-HDR-RA-NUM 01230000
001320 PIC S9(00009) COMP. 01240000
001330 20 W1C40541-C-EXC-LOCN-CD 01250000
001340 PIC X(00003). 01260000
001350 20 W1C40541-C-EXC-LOCN-ID 01270000
001360 PIC X(00008). 01280000
001370 20 W1C40541-C-SUSP-LOCN-EXC-CD 01290000
001380 PIC X(00004). 01300000
001390 20 W1C40541-C-OVRRD-EXC-LOC-CD 01310000
001400 PIC X(00003). 01320000
001410 20 W1C40541-C-COST-CENTER-CD 01330000
001420 PIC X(00005). 01340000
001430 20 W1C40541-C-CYCL-NUM 01350000
001440 PIC S9(00004) COMP. 01360000
001450 20 W1C40541-C-OVRRD-SEC-EOB-ID 01370000
001460 PIC X(00007). 01380000
001470 20 W1C40541-C-CALC-TOT-AMT 01390000
001480 PIC S9(00009)V9(00002) COMP-3. 01400000
001490 20 W1C40541-C-TOT-TPL-AMT 01410000
001500 PIC S9(00009)V9(00002) COMP-3. 01420000
001510 20 W1C40541-C-TOT-NET-CHRG-AMT 01430000
001520 PIC S9(00009)V9(00002) COMP-3. 01440000
001530 20 W1C40541-C-PREV-REIMB-AMT 01450000
001540 PIC S9(00009)V9(00002) COMP-3. 01460000
001550 20 W1C40541-C-PREV-REIMB-CD 01470000
001560 PIC X(00001). 01480000
001570 20 W1C40541-P-PC-ALT-ID-CD 01490000
001580 PIC X(00002). 01500000
001590 20 W1C40541-P-PC-ALT-ID 01510000
001600 PIC X(00015). 01520000
001610 20 W1C40541-B-DOB-DT 01530000
001620 PIC X(00010). 01540000
001630 20 W1C40541-C-HDR-ENTRD-DT 01550000
001640 PIC X(00010). 01560000
001650 20 W1C40541-C-BILLED-DT 01570000
001660 PIC X(00010). 01580000
001670 20 W1C40541-C-INV-BILL-DT 01590000
001680 PIC X(00010). 01600000
001690 20 W1C40541-C-EXC-LOCN-DT 01610000
001700 PIC X(00010). 01620000
001710 20 W1C40541-C-HDR-BATCH-DT 01630000
001720 PIC X(00010). 01640000
001730 20 W1C40541-C-HDR-LST-CYCL-DT 01650000
001740 PIC X(00010). 01660000
001750 20 W1C40541-C-HDR-ORIG-PD-DT 01670000
001760 PIC X(00010). 01680000
001770 20 W1C40541-C-HDR-SUSP-DT 01690000
001780 PIC X(00010). 01700000
001790 20 W1C40541-C-HDR-HX-DT 01710000
001800 PIC X(00010). 01720000
001810 20 W1C40541-C-ADJUD-TM 01730000
001820 PIC X(00008). 01740000
001830 20 W1C40541-C-HDR-INJURY-DT 01750000
001840 PIC X(00010). 01760000
001850 20 W1C40541-C-SWTCH-VNDR-CD 01770000
001860 PIC S9(00004) COMP. 01780000
001870 20 W1C40541-C-TXN-ELPSED-NUM 01790000
001880 PIC 9(00004)V9(00006) COMP-3. 01800000
001890 20 W1C40541-B-RPT-ALT-ID 01810000
001900 PIC X(00020). 01820000
001910 20 W1C40541-B-PAT-ALT-ID 01830000
001920 PIC X(00020). 01840000
001930 20 W1C40541-B-PAT-ALT-ID-CD 01850000
001940 PIC X(00002). 01860000
001950 20 W1C40541-C-SUB-CAPITATED-CD 01870000
001960 PIC X(00002). 01880000
001970 20 W1C40541-C-NCPDP-TXN-CD 01890000
001980 PIC X(00002). 01900000
001990 20 W1C40541-G-AUD-USER-ID 01910000
002000 PIC X(00008). 01920000
002010 20 W1C40541-G-AUD-TS 01930000
002020 PIC X(00026). 01940000
002030 15 W1C40541-C-LI-DRUG-MAIN-VW. 01950000
002040 20 W1C40541-R-CUST-ID 01960000
002050 PIC X(00006). 01970000
002060 20 W1C40541-R-GROUP-ID 01980000
002070 PIC X(00008). 01990000
002080 20 W1C40541-R-PLAN-ID 02000000
002090 PIC X(00003). 02010000
002100 20 W1C40541-C-HDR-SVC-FST-DT 02020000
002110 PIC X(00010). 02030000
002120 20 W1C40541-C-HDR-STAT-CD 02040000
002130 PIC X(00001). 02050000
002140 20 W1C40541-C-HDR-TXN-TY-CD 02060000
002150 PIC X(00001). 02070000
002160 20 W1C40541-C-BAT-DOC-TY-CD 02080000
002170 PIC X(00001). 02090000
002180 20 W1C40541-B-MBR-NUM 02100000
002190 PIC S9(00004) COMP. 02110000
002200 20 W1C40541-B-CRDHLD-ALT-ID-CD 02120000
002210 PIC X(00002). 02130000
002220 20 W1C40541-B-CRDHLDR-ALT-ID 02140000
002230 PIC X(00020). 02150000
002240 20 W1C40541-C-HDR-TY-CD 02160000
002250 PIC X(00001). 02170000
002260 20 W1C40541-C-TOT-CHRG-AMT 02180000
002270 PIC S9(00009)V9(00002) COMP-3. 02190000
002280 20 W1C40541-C-RX-SVC-REF-CD 02200000
002290 PIC X(00001). 02210000
002300 20 W1C40541-C-RX-SVC-REF-NUM 02220000
002310 PIC 9(00008) COMP. 02230000
002320 20 W1C40541-C-RX-REFILL-NUM 02240000
002330 PIC S9(00002) COMP-3. 02250000
002340 20 W1C40541-C-DRUG-RX-OVRRD-CD 02260000
002350 PIC X(00002). 02270000
002360 20 W1C40541-C-HDR-ALLOW-AMT 02280000
002370 PIC S9(00009)V9(00002) COMP-3. 02290000
002380 20 W1C40541-C-OVER-MAX-AMT 02300000
002390 PIC S9(00005)V9(00002) COMP-3. 02310000
002400 20 W1C40541-C-TOT-COPAY-AMT 02320000
002410 PIC S9(00009)V9(00002) COMP-3. 02330000
002420 20 W1C40541-C-HDR-ADJUD-DT 02340000
002430 PIC X(00010). 02350000
002440 20 W1C40541-C-PD-DAYS-SPLY-AMT 02360000
002450 PIC S9(00003) COMP-3. 02370000
002460 20 W1C40541-C-HDR-PD-QTY-AMT 02380000
002470 PIC S9(00008)V9(00003) COMP-3. 02390000
002480 20 W1C40541-C-DISP-FEE-AMT 02400000
002490 PIC S9(00009)V9(00002) COMP-3. 02410000
002500 20 W1C40541-C-DRUG-SLS-TAX-AMT 02420000
002510 PIC S9(00005)V9(00002) COMP-3. 02430000
002520 20 W1C40541-C-DRUG-SUB-QTY-AMT 02440000
002530 PIC S9(00008)V9(00003) COMP-3. 02450000
002540 20 W1C40541-C-INPUT-FRM-CD 02460000
002550 PIC X(00001). 02470000
002560 20 W1C40541-C-PAT-LIAB-AMT 02480000
002570 PIC S9(00009)V9(00002) COMP-3. 02490000
002580 20 W1C40541-C-BLNG-PROV-TY-CD 02500000
002590 PIC X(00003). 02510000
002600 20 W1C40541-C-BLNG-PROV-ID 02520000
002610 PIC 9(00008) COMP. 02530000
002620 20 W1C40541-P-PAY-TO-PROV-NUM 02540000
002630 PIC X(00015). 02550000
002640 20 W1C40541-B-HH-SYS-ID 02560000
002650 PIC S9(00009) COMP. 02570000
002660 20 W1C40541-C-BAT-PYMT-TY-CD 02580000
002670 PIC X(00001). 02590000
002680 20 W1C40541-C-CREDIT-CD 02600000
002690 PIC X(00001). 02610000
002700 20 W1C40541-C-HDR-CLNT-AGE 02620000
002710 PIC S9(00004) COMP. 02630000
002720 20 W1C40541-C-TOT-REIMB-AMT 02640000
002730 PIC S9(00009)V9(00002) COMP-3. 02650000
002740 20 W1C40541-C-HDR-PD-DT 02660000
002750 PIC X(00010). 02670000
002760 20 W1C40541-C-HDR-ID-CD 02680000
002770 PIC X(00002). 02690000
002780 20 W1C40541-C-DRUG-TEST-IND 02700000
002790 PIC X(00001). 02710000
002800 20 W1C40541-C-PA-TYP-CD 02720000
002810 PIC S9(00004) COMP. 02730000
002820 20 W1C40541-C-HDR-DRUG-DED-AMT 02740000
002830 PIC S9(00009)V9(00002) COMP-3. 02750000
002840 20 W1C40541-P-SVC-PH-ALT-ID-CD 02760000
002850 PIC X(00002). 02770000
002860 20 W1C40541-P-SVC-PHARM-ALT-ID 02780000
002870 PIC X(00015). 02790000
002880 20 W1C40541-C-HDR-DOC-NUM 02800000
002890 PIC X(00006). 02810000
002900 20 W1C40541-P-PRSC-ALT-ID-CD 02820000
002910 PIC X(00002). 02830000
002920 20 W1C40541-P-PRSC-ALT-ID 02840000
002930 PIC X(00015). 02850000
002940 20 W1C40541-C-SUB-DAY-SPLY-AMT 02860000
002950 PIC S9(00003) COMP-3. 02870000
002960 20 W1C40541-C-DRUG-PRESCR-DT 02880000
002970 PIC X(00010). 02890000
002980 20 W1C40541-C-DRUG-CMPND-CD 02900000
002990 PIC X(00001). 02910000
003000 20 W1C40541-C-DISP-STATUS-CD 02920000
003010 PIC X(00001). 02930000
003020 20 W1C40541-C-DAILY-RPT-IND 02940000
003030 PIC X(00001). 02950000
003040 20 W1C40541-R-DUPCK-EXMT-IND 02960000
003050 PIC X(00001). 02970000
003060 20 W1C40541-R-MO-GROUP-ID 02980000
003070 PIC X(00006). 02990000
003080 15 W1C40541-C-LI-DRUG-DTL-GRP. 03000000
003090 20 W1C40541-C-LI-DRUG-DTL-VW 03010000
003100 OCCURS 0040 TIMES 03020000
003110 INDEXED BY W1C40541-C-LI-DRUG-DTL-VW-X . 03030000
003120 25 W1C40541-C-LI-NUM 03040000
003130 PIC S9(00004) COMP. 03050000
003140 25 W1C40541-C-DRUG-GEN-CD-NUM 03060000
003150 PIC X(00005). 03070000
003160 25 W1C40541-C-DRUG-DEA-CD 03080000
003170 PIC X(00001). 03090000
003180 25 W1C40541-C-DRUG-ROUTE-CD 03100000
003190 PIC X(00001). 03110000
003200 25 W1C40541-R-DRG-THR-CHAR3-CD 03120000
003210 PIC X(00003). 03130000
003220 25 W1C40541-R-DRUG-GCN-SEQ-NUM 03140000
003230 PIC S9(00006) COMP-3. 03150000
003240 25 W1C40541-R-DRUG-GEN-PRD-CD 03160000
003250 PIC X(00001). 03170000
003260 25 W1C40541-R-DRUG-CD 03180000
003270 PIC X(00011). 03190000
003280 25 W1C40541-C-BSE-AMT-SRC-CD 03200000
003290 PIC X(00002). 03210000
003300 25 W1C40541-C-DRUG-MAINT-IND 03220000
003310 PIC X(00001). 03230000
003320 25 W1C40541-C-PROD-SVC-ID-CD 03240000
003330 PIC X(00002). 03250000
003340 25 W1C40541-C-PROD-SVC-ID 03260000
003350 PIC X(00019). 03270000
003360 25 W1C40541-C-LI-BSE-AMT 03280000
003370 PIC S9(00007)V9(00002) COMP-3. 03290000
003380 25 W1C40541-C-CALC-ALLOW-AMT 03300000
003390 PIC S9(00009)V9(00002) COMP-3. 03310000
003400 25 W1C40541-C-LI-ALLOW-AMT 03320000
003410 PIC S9(00009)V9(00002) COMP-3. 03330000
003420 25 W1C40541-C-LI-ING-ALLOW-AMT 03340000
003430 PIC S9(00007)V9(00002) COMP-3. 03350000
003440 25 W1C40541-C-SUBM-ING-QTY-AMT 03360000
003450 PIC S9(00008)V9(00003) COMP-3. 03370000
003460 25 W1C40541-C-SUBM-ING-CST-AMT 03380000
003470 PIC S9(00007)V9(00002) COMP-3. 03390000
003480 25 W1C40541-C-LI-PD-QTY-AMT 03400000
003490 PIC S9(00008)V9(00003) COMP-3. 03410000
003500 25 W1C40541-C-DISCT-RATE-AMT 03420000
003510 PIC S9(00007)V9(00002) COMP-3. 03430000
003520 25 W1C40541-C-INGRED-DISCT-PCT 03440000
003530 PIC S9(00003)V9(00002) COMP-3. 03450000
003540 25 W1C40541-C-BASIS-COST-CD 03460000
003550 PIC X(00002). 03470000
003560 25 W1C40541-C-REIMB-STAT-CD 03480000
003570 PIC X(00001). 03490000
003580 25 W1C40541-A-ID 03500000
003590 PIC S9(00011) COMP-3. 03510000
003600 25 W1C40541-A-LI-NUM 03520000
003610 PIC S9(00004) COMP. 03530000
003620 25 W1C40541-C-PRIOR-AUTH-IND 03540000
003630 PIC X(00001). 03550000
003640 25 W1C40541-C-LI-REIMB-AMT 03560000
003650 PIC S9(00007)V9(00002) COMP-3. 03570000
003660 25 W1C40541-C-DRUG-NAM 03580000
003670 PIC X(00030). 03590000
003680 15 W1C40541-C-LI-EXC-GRP. 03600000
003690 20 W1C40541-C-LI-EXC-VW 03610000
003700 OCCURS 0025 TIMES 03620000
003710 INDEXED BY W1C40541-C-LI-EXC-VW-X . 03630000
003720 25 W1C40541-C-LI-NUM 03640000
003730 PIC S9(00004) COMP. 03650000
003740 25 W1C40541-R-CLM-EXC-CD 03660000
003750 PIC X(00004). 03670000
003760 25 W1C40541-C-LI-EXC-CLRK-ID 03680000
003770 PIC X(00008). 03690000
003780 25 W1C40541-C-EXC-STAT-CD 03700000
003790 PIC X(00001). 03710000
003800 25 W1C40541-R-EXC-FORCE-APP-CD 03720000
003810 PIC X(00001). 03730000
003820 25 W1C40541-R-FORCE-DENY-CD 03740000
003830 PIC X(00001). 03750000
003840 25 W1C40541-R-EXC-EOB-ADJUD-CD 03760000
003850 PIC X(00004). 03770000
003860 25 W1C40541-R-CLM-ADJUD-REJ-CD 03780000
003870 PIC X(00003). 03790000
003880 25 W1C40541-A-PA-PROG-CD 03800000
003890 PIC X(00012). 03810000
003900 25 W1C40541-A-PA-PROG-LI-NUM 03820000
003910 PIC S9(00004) COMP. 03830000
003920 15 W1C40541-C-HDR-PARAM-ERR-VW. 03840000
003930 20 W1C40541-C-ERR-PARAM-CD 03850000
003940 PIC X(00004). 03860000
003950 20 W1C40541-C-ERR-PROG-ID 03870000
003960 PIC X(00008). 03880000
003970 20 W1C40541-C-ERR-MSG-DAT 03890000
003980 PIC X(00010). 03900000
003990 15 W1C40541-C-HDR-ADJ-VD-VW. 03910000
004000 20 W1C40541-C-KEYED-REPLCD-NUM 03920000
004010 PIC S9(00017) COMP-3. 03930000
004020 20 W1C40541-C-HDR-ADJ-RSN-CD 03940000
004030 PIC X(00003). 03950000
004040 20 W1C40541-C-REPLCD-TCN-NUM 03960000
004050 PIC S9(00017) COMP-3. 03970000
004060 20 W1C40541-C-HDR-ADJ-STAT-CD 03980000
004070 PIC X(00001). 03990000
004080 20 W1C40541-C-REPLCMT-TCN-NUM 04000000
004090 PIC S9(00017) COMP-3. 04010000
004100 20 W1C40541-F-FCN-DT 04020000
004110 PIC X(00010). 04030000
004120 20 W1C40541-F-FCN-MED-CD 04040000
004130 PIC X(00001). 04050000
004140 20 W1C40541-F-FCN-NUM 04060000
004150 PIC S9(00009) COMP. 04070000
004160 20 W1C40541-C-ADJ-ORIG-TCN-NUM 04080000
004170 PIC S9(00017) COMP-3. 04090000
004180 20 W1C40541-C-ADJ-SEQ-NUM 04100000
004190 PIC S9(00004) COMP. 04110000
004200 15 W1C40541-C-HDR-COE-GRP. 04120000
004210 20 W1C40541-C-HDR-COE-VW 04130000
004220 OCCURS 0004 TIMES 04140000
004230 INDEXED BY W1C40541-C-HDR-COE-VW-X . 04150000
004240 25 W1C40541-C-SEQ-NUM 04160000
004250 PIC S9(00004) COMP. 04170000
004260 25 W1C40541-R-PLAN-ID 04180000
004270 PIC X(00003). 04190000
004280 25 W1C40541-B-COE-COA-CD 04200000
004290 PIC X(00003). 04210000
004300 25 W1C40541-B-FED-MATCH-CD 04220000
004310 PIC X(00001). 04230000
004320 25 W1C40541-B-FED-CAT-CD 04240000
004330 PIC X(00001). 04250000
004340 25 W1C40541-B-MONEY-CD 04260000
004350 PIC X(00001). 04270000
004360 25 W1C40541-B-AID-CTGRY-CD 04280000
004370 PIC X(00005). 04290000
004380 25 W1C40541-G-ADR-CNTY-CD 04300000
004390 PIC X(00003). 04310000
004400 10 W1C40541-C-HDR-WARRANT-VW. 04320000
004410 15 W1C40541-C-HDR-RA-NUM 04330000
004420 PIC S9(00009) COMP. 04340000
004430 15 W1C40541-C-HDR-WARR-NUM 04350000
004440 PIC X(00011). 04360000
004450 15 W1C40541-C-HDR-WARR-MED-CD 04370000
004460 PIC X(00001). 04380000
004470 15 W1C40541-C-HDR-WARR-AMT 04390000
004480 PIC S9(00013)V9(00002) COMP-3. 04400000
004490 15 W1C40541-C-HDR-WARR-DT 04410000
004500 PIC X(00010). 04420000
004510 10 W1C40541-C-HDR-DRUG-VW. 04430000
004520 15 W1C40541-C-DAW-CD 04440000
004530 PIC X(00001). 04450000
004540 15 W1C40541-C-SUBM-INCNTVE-AMT 04460000
004550 PIC S9(00007)V9(00002) COMP-3. 04470000
004560 15 W1C40541-C-SUBM-PCT-RT-AMT 04480000
004570 PIC S9(00005)V9(00002) COMP-3. 04490000
004580 15 W1C40541-C-SUBM-PCT-TX-AMT 04500000
004590 PIC S9(00007)V9(00002) COMP-3. 04510000
004600 15 W1C40541-C-SUBM-PCT-TX-CD 04520000
004610 PIC X(00002). 04530000
004620 15 W1C40541-C-QTY-PRSC-AMT 04540000
004630 PIC S9(00007)V9(00002) COMP-3. 04550000
004640 15 W1C40541-C-ELIG-OVRRD-IND 04560000
004650 PIC X(00001). 04570000
004660 15 W1C40541-C-MGMT-OVRRD-IND 04580000
004670 PIC X(00001). 04590000
004680 15 W1C40541-C-UNIT-DOSE-CD 04600000
004690 PIC S9(00004) COMP. 04610000
004700 15 W1C40541-C-DSG-FM-DESC-CD 04620000
004710 PIC X(00002). 04630000
004720 15 W1C40541-C-DISP-UNT-FM-CD 04640000
004730 PIC X(00001). 04650000
004740 15 W1C40541-C-RT-OF-ADMIN-CD 04660000
004750 PIC S9(00004) COMP. 04670000
004760 15 W1C40541-C-HDR-DRUG-XREF-CD 04680000
004770 PIC X(00015). 04690000
004780 15 W1C40541-C-ASOC-RX-SVC-NUM 04700000
004790 PIC S9(00008) COMP. 04710000
004800 15 W1C40541-C-ASOC-RX-SVC-DT 04720000
004810 PIC X(00010). 04730000
004820 15 W1C40541-C-INT-DISP-QTY-AMT 04740000
004830 PIC S9(00007)V9(00002) COMP-3. 04750000
004840 15 W1C40541-C-INT-DISP-DAY-NUM 04760000
004850 PIC S9(00004) COMP. 04770000
004860 15 W1C40541-C-ORG-PROD-SVC-CD 04780000
004870 PIC X(00002). 04790000
004880 15 W1C40541-C-ORG-PROD-SVC-ID 04800000
004890 PIC X(00019). 04810000
004900 15 W1C40541-C-ORG-QTY-PRSC-AMT 04820000
004910 PIC S9(00007)V9(00002) COMP-3. 04830000
004920 15 W1C40541-C-REFIL-AUTH-NUM 04840000
004930 PIC S9(00002) COMP-3. 04850000
004940 15 W1C40541-C-SUBM-INGRED-AMT 04860000
004950 PIC S9(00009)V9(00002) COMP-3. 04870000
004960 15 W1C40541-C-DRUG-VERSN-NUM 04880000
004970 PIC X(00002). 04890000
004980 15 W1C40541-C-DRUG-ENTRD-TM 04900000
004990 PIC X(00008). 04910000
005000 15 W1C40541-C-DRUG-PAYEE-CD 04920000
005010 PIC X(00001). 04930000
005020 15 W1C40541-C-DRUG-PROV-ST-CD 04940000
005030 PIC X(00002). 04950000
005040 15 W1C40541-C-DRUG-CNTY-CD 04960000
005050 PIC X(00003). 04970000
005060 15 W1C40541-C-DRUG-ZIP-NUM 04980000
005070 PIC S9(00009) COMP-3. 04990000
005080 15 W1C40541-C-DRUG-NETWRK-CD 05000000
005090 PIC X(00006). 05010000
005100 15 W1C40541-C-EMPL-LAST-NAM 05020000
005110 PIC X(00020). 05030000
005120 15 W1C40541-C-EMPL-FST-NAM 05040000
005130 PIC X(00012). 05050000
005140 15 W1C40541-C-EMPL-MI-NAM 05060000
005150 PIC X(00001). 05070000
005160 15 W1C40541-C-DRUG-DEPT-CD 05080000
005170 PIC X(00030). 05090000
005180 15 W1C40541-C-DRUG-CVRG-CD 05100000
005190 PIC X(00001). 05110000
005200 15 W1C40541-C-RECIP-CNTY-CD 05120000
005210 PIC X(00003). 05130000
005220 15 W1C40541-C-RECIP-ZIP-CD 05140000
005230 PIC X(00015). 05150000
005240 15 W1C40541-C-DRUG-RPT-CLM-IND 05160000
005250 PIC X(00001). 05170000
005260 15 W1C40541-P-PHARM-ALT-ID-CD 05180000
005270 PIC X(00002). 05190000
005280 15 W1C40541-P-PHARM-ALT-ID 05200000
005290 PIC X(00015). 05210000
005300 15 W1C40541-C-PRSC-LIC-NUM 05220000
005310 PIC X(00015). 05230000
005320 15 W1C40541-C-DRUG-DSP-FEE-PCT 05240000
005330 PIC S9(00003)V9(00002) COMP-3. 05250000
005340 15 W1C40541-C-DRUG-COPAY-PCT 05260000
005350 PIC S9(00003)V9(00002) COMP-3. 05270000
005360 15 W1C40541-C-SUBM-TAX-AMT 05280000
005370 PIC S9(00007)V9(00002) COMP-3. 05290000
005380 15 W1C40541-C-DRUG-IFACE-TY-CD 05300000
005390 PIC X(00001). 05310000
005400 15 W1C40541-C-IFACE-CLM-ID 05320000
005410 PIC X(00030). 05330000
005420 15 W1C40541-C-IFACE-CLM-CR-CD 05340000
005430 PIC X(00017). 05350000
005440 15 W1C40541-C-FCN-NUM 05360000
005450 PIC S9(00009) COMP-3. 05370000
005460 15 W1C40541-C-PROV-ON-REVW-IND 05380000
005470 PIC X(00001). 05390000
005480 15 W1C40541-C-DRUG-TPL-IND 05400000
005490 PIC X(00001). 05410000
005500 15 W1C40541-C-DRUG-GROSS-AMT 05420000
005510 PIC S9(00005)V9(00002) COMP-3. 05430000
005520 15 W1C40541-C-RX-ORGN-CD 05440000
005530 PIC 9(00004) COMP. 05450000
005540 15 W1C40541-C-LVL-OF-SVC-CD 05460000
005550 PIC 9(00004) COMP. 05470000
005560 15 W1C40541-C-CLNC-ID 05480000
005570 PIC X(00006). 05490000
005580 15 W1C40541-C-BAS-DAYS-SPLY-CD 05500000
005590 PIC X(00001). 05510000
005600 15 W1C40541-C-SUBM-PRO-FEE-AMT 05520000
005610 PIC S9(00007)V9(00002) COMP-3. 05530000
005620 15 W1C40541-C-SUBM-DSP-FEE-AMT 05540000
005630 PIC S9(00007)V9(00002) COMP-3. 05550000
005640 15 W1C40541-C-PAT-DAW-DIF-AMT 05560000
005650 PIC S9(00009)V9(00002) COMP-3. 05570000
005660 10 W1C40541-C-HDR-RLTD-HIST-GRP. 05580000
005670 15 W1C40541-C-HDR-RLTD-HIST-VW 05590000
005680 OCCURS 0025 TIMES 05600000
005690 INDEXED BY W1C40541-C-HDR-RLTD-HIST-VW-X . 05610000
005700 20 W1C40541-C-LI-NUM 05620000
005710 PIC S9(00004) COMP. 05630000
005720 20 W1C40541-C-RLTD-LI-TCN-NUM 05640000
005730 PIC S9(00017) COMP-3. 05650000
005740 20 W1C40541-C-RLTD-LI-NUM 05660000
005750 PIC S9(00004) COMP. 05670000
005760 20 W1C40542-R-CLM-EXC-CD 05680000
005770 PIC X(00004). 05690000
005780 20 W1C40542-R-RSN-FOR-SVC-CD 05700000
005790 PIC X(00002). 05710000
005800 20 W1C40542-C-HDR-PD-DT 05720000
005810 PIC X(00010). 05730000
005820 20 W1C40542-C-EXC-STAT-CD 05740000
005830 PIC X(00001). 05750000
005840 20 W1C40542-C-HDR-TY-CD 05760000
005850 PIC X(00001). 05770000
005860 20 W1C40541-C-SYS-REPLCD-IND 05780000
005870 PIC X(00001). 05790000
005880 20 W1C40542-R-CLM-ADJUD-REJ-CD 05800000
005890 PIC X(00003). 05810000
005900 10 W1C40541-C-HDR-DUR-PPS-GRP. 05820000
005910 15 W1C40541-C-HDR-DUR-PPS-VW 05830000
005920 OCCURS 0009 TIMES 05840000
005930 INDEXED BY W1C40541-C-HDR-DUR-PPS-VW-X . 05850000
005940 20 W1C40541-C-SEQ-NUM 05860000
005950 PIC S9(00004) COMP. 05870000
005960 20 W1C40541-R-RSN-FOR-SVC-CD 05880000
005970 PIC X(00002). 05890000
005980 20 W1C40541-C-DUR-PPS-CD 05900000
005990 PIC X(00002). 05910000
006000 20 W1C40541-C-DUR-RSLT-SVC-CD 05920000
006010 PIC X(00002). 05930000
006020 20 W1C40541-C-DUR-LVL-EFRT-CD 05940000
006030 PIC S9(00004) COMP. 05950000
006040 20 W1C40541-C-DUR-CO-AGT-ID-CD 05960000
006050 PIC X(00002). 05970000
006060 20 W1C40541-C-DUR-CO-AGT-ID 05980000
006070 PIC X(00019). 05990000
006080 10 W1C40541-C-HDR-CLINICAL-GRP. 06000000
006090 15 W1C40541-C-HDR-CLINICAL-VW 06010000
006100 OCCURS 0005 TIMES 06020000
006110 INDEXED BY W1C40541-C-HDR-CLINICAL-VW-X . 06030000
006120 20 W1C40541-C-SEQ-NUM 06040000
006130 PIC S9(00004) COMP. 06050000
006140 20 W1C40541-C-CLIN-MSRMT-DT 06060000
006150 PIC X(00010). 06070000
006160 20 W1C40541-C-CLIN-MSRMT-TM 06080000
006170 PIC X(00008). 06090000
006180 20 W1C40541-C-CLIN-MSRMT-DM-CD 06100000
006190 PIC X(00002). 06110000
006200 20 W1C40541-C-CLIN-MSRMT-UN-CD 06120000
006210 PIC X(00002). 06130000
006220 20 W1C40541-C-CLIN-MSRMT-DESC 06140000
006230 PIC X(00015). 06150000
006240 10 W1C40541-C-HDR-DIAG-GRP. 06160000
006250 15 W1C40541-C-HDR-DIAG-VW 06170000
006260 OCCURS 0005 TIMES 06180000
006270 INDEXED BY W1C40541-C-HDR-DIAG-VW-X . 06190000
006280 20 W1C40541-C-SEQ-NUM 06200000
006290 PIC S9(00004) COMP. 06210000
006300 20 W1C40541-C-DIAG-QL-CD 06220000
006310 PIC X(00002). 06230000
006320 20 W1C40541-R-DIAG-CD 06240000
006330 PIC X(00010). 06250000
006340 10 W1C40541-C-HDR-OTHR-AMT-GRP. 06260000
006350 15 W1C40541-C-HDR-OTHR-AMT-VW 06270000
006360 OCCURS 0003 TIMES 06280000
006370 INDEXED BY W1C40541-C-HDR-OTHR-AMT-VW-X . 06290000
006380 20 W1C40541-C-SEQ-NUM 06300000
006390 PIC S9(00004) COMP. 06310000
006400 20 W1C40541-C-SUBM-OTHR-AMT-CD 06320000
006410 PIC X(00002). 06330000
006420 20 W1C40541-C-SUBM-OTHR-AMT 06340000
006430 PIC S9(00007)V9(00002) COMP-3. 06350000
006440 10 W1C40541-C-HDR-COB-GRP. 06360000
006450 15 W1C40541-C-HDR-COB-VW 06370000
006460 OCCURS 0005 TIMES 06380000
006470 INDEXED BY W1C40541-C-HDR-COB-VW-X . 06390000
006480 20 W1C40541-C-COB-SEQ-NUM 06400000
006490 PIC S9(00004) COMP. 06410000
006500 20 W1C40541-C-PYR-HIERARCHY-CD 06420000
006510 PIC X(00002). 06430000
006520 20 W1C40541-C-PAYERID-CD 06440000
006530 PIC X(00002). 06450000
006540 20 W1C40541-C-PAYER-ID 06460000
006550 PIC X(00010). 06470000
006560 20 W1C40541-C-PAYERID-DT 06480000
006570 PIC X(00010). 06490000
006580 20 W1C40541-C-CNT-COB-PAID-NUM 06500000
006590 PIC S9(00004) COMP. 06510000
006600 20 W1C40541-C-CNT-COB-REJ-NUM 06520000
006610 PIC S9(00004) COMP. 06530000
006620 20 W1C40541-C-HDR-COB-PAID-GRP. 06540000
006630 25 W1C40541-C-HDR-COB-PAID-VW 06550000
006640 OCCURS 0009 TIMES 06560000
006650 INDEXED BY W1C40541-C-HDR-COB-PAID-VW-X . 06570000
006660 30 W1C40542-C-COB-SEQ-NUM 06580000
006670 PIC S9(00004) COMP. 06590000
006680 30 W1C40541-C-COB-PAID-SEQ-NUM 06600000
006690 PIC S9(00004) COMP. 06610000
006700 30 W1C40541-C-PAYERID-PD-CD 06620000
006710 PIC X(00002). 06630000
006720 30 W1C40541-C-PAYERID-PD-AMT 06640000
006730 PIC S9(00007)V9(00002) COMP-3. 06650000
006740 20 W1C40541-C-HDR-COB-REJ-GRP. 06660000
006750 25 W1C40541-C-HDR-COB-REJ-VW 06670000
006760 OCCURS 0005 TIMES 06680000
006770 INDEXED BY W1C40541-C-HDR-COB-REJ-VW-X . 06690000
006780 30 W1C40543-C-COB-SEQ-NUM 06700000
006790 PIC S9(00004) COMP. 06710000
006800 30 W1C40541-C-COB-REJ-SEQ-NUM 06720000
006810 PIC S9(00004) COMP. 06730000
006820 30 W1C40541-C-PAYERID-REJ-CD 06740000
006830 PIC X(00003). 06750000
006840 10 W1C40541-C-HDR-PROC-MOD-GRP. 06760000
006850 15 W1C40541-C-HDR-PROC-MOD-VW 06770000
006860 OCCURS 0004 TIMES 06780000
006870 INDEXED BY W1C40541-C-HDR-PROC-MOD-VW-X . 06790000
006880 20 W1C40541-C-SEQ-NUM 06800000
006890 PIC S9(00004) COMP. 06810000
006900 20 W1C40541-R-PROC-MOD-CD 06820000
006910 PIC X(00002). 06830000
006920 10 W1C40541-C-LI-BSE-CHG-PHRM-GRP. 06840000
006930 15 W1C40541-C-LI-BSE-CHG-VW 06850000
006940 OCCURS 0008 TIMES 06860000
006950 INDEXED BY W1C40541-C-LI-BSE-CHG-VW-X . 06870000
006960 20 W1C40541-C-LI-NUM 06880000
006970 PIC S9(00004) COMP. 06890000
006980 20 W1C40541-C-SEQ-NUM 06900000
006990 PIC S9(00004) COMP. 06910000
007000 20 W1C40541-C-BSE-CHNG-RSN-CD 06920000
007010 PIC X(00002). 06930000
007020 20 W1C40541-C-BSE-AMT-CHG-AMT 06940000
007030 PIC S9(00007)V9(00002) COMP-3. 06950000
007040 10 W1C40541-C-LI-TPL-BLNG-GRP. 06960000
007050 15 W1C40541-C-LI-TPL-BLNG-VW 06970000
007060 OCCURS 0006 TIMES 06980000
007070 INDEXED BY W1C40541-C-LI-TPL-BLNG-VW-X . 06990000
007080 20 W1C40541-C-LI-NUM 07000000
007090 PIC S9(00004) COMP. 07010000
007100 20 W1C40541-T-PLCY-NUM 07020000
007110 PIC X(00020). 07030000
007120 20 W1C40541-T-PLCY-SEQ-NUM 07040000
007130 PIC S9(00004) COMP. 07050000
007140 20 W1C40541-T-PLCY-RESRC-CD 07060000
007150 PIC X(00002). 07070000
007160 20 W1C40541-T-CARR-ID 07080000
007170 PIC X(00010). 07090000
007180 20 W1C40541-T-CVRG-PLCY-CD 07100000
007190 PIC X(00002). 07110000
007200 10 W1C40541-C-HDR-OVRRD-EOB-P-GRP. 07120000
007210 15 W1C40541-C-HDR-OVRRD-EOB-VW 07130000
007220 OCCURS 0020 TIMES 07140000
007230 INDEXED BY W1C40541-C-HDR-OVRRD-EOB-VW-X . 07150000
007240 20 W1C40541-C-LI-NUM 07160000
007250 PIC S9(00004) COMP. 07170000
007260 20 W1C40541-C-SEQ-NUM 07180000
007270 PIC S9(00004) COMP. 07190000
007280 20 W1C40541-C-OVRRD-EOB-CD 07200000
007290 PIC X(00004). 07210000
007300 20 W1C40541-C-OVRRD-EOB-ID 07220000
007310 PIC X(00007). 07230000
007320 10 W1C40541-C-HDR-OVRRD-EXC-P-GRP. 07240000
007330 15 W1C40541-C-HDR-OVRRD-EXC-VW 07250000
007340 OCCURS 0020 TIMES 07260000
007350 INDEXED BY W1C40541-C-HDR-OVRRD-EXC-VW-X . 07270000
007360 20 W1C40541-C-LI-NUM 07280000
007370 PIC S9(00004) COMP. 07290000
007380 20 W1C40541-C-SEQ-NUM 07300000
007390 PIC S9(00004) COMP. 07310000
007400 20 W1C40541-C-OVRRD-EXC-CD 07320000
007410 PIC X(00004). 07330000
007420 20 W1C40541-C-OVRRD-EXC-ID 07340000
007430 PIC X(00007). 07350000
007440 10 W1C40541-X12835-FIELDS-TBL OCCURS 40 TIMES 07360000
007450 INDEXED BY W1C40541-X12835-FIELDS-X. 07370000
007460 15 W1C40541-LI-NUM 07380000
007470 PIC S9(00004) COMP. 07390000
007480 15 W1C40541-CAS-GROUP-ID 07400000
007490 PIC X(2). 07410000
007500 15 W1C40541-X12835-ADJ-RSN-CD-TBL OCCURS 6 TIMES 07420000
007510 INDEXED BY W1C40541-ARC-X. 07430000
007520 20 W1C40541-X12835-ARC PIC X(5). 07440000
007530 20 W1C40541-X12835-ARC-AMT PIC S9(9)V99. 07450000
007540 15 W1C40541-X12835-REMARK-CD-TBL OCCURS 25 TIMES 07460000
007550 INDEXED BY W1C40541-REMARK-X. 07470000
007560 20 W1C40541-REMARK-CD PIC X(5). 07480000
05 W1C405D0-DO-FIELDS. PBMD0
10 W1C405D0-C-HDR-COMMON-VW. PBMD0
15 W1C405D0-C-PAT-SVC-LOC-CD-D0 PBMD0
PIC S9(00004) COMP. PBMD0
15 W1C405D0-C-PAT-RES-CD-D0 PBMD0
PIC S9(00004) COMP. PBMD0
15 W1C405D0-C-LI-DRUG-MAIN-VW. PBMD0
20 W1C405D0-C-RX-SVC-REF-NUM-D0 PBMD0
PIC 9(00012). PBMD0
20 W1C405D0-C-DRUG-RX-OVRRD-GP-D0. PBMD0
25 W1C405D0-C-DRUG-RX-OVRD1-CD-D0 PBMD0
PIC X(2). PBMD0
25 W1C405D0-C-DRUG-RX-OVRD2-CD-D0 PBMD0
PIC X(2). PBMD0
25 W1C405D0-C-DRUG-RX-OVRD3-CD-D0 PBMD0
PIC X(2). PBMD0
20 W1C405D0-C-DRUG-RX-OVRRD-CD-D0 REDEFINES PBMD0
W1C405D0-C-DRUG-RX-OVRRD-GP-D0. PBMD0
25 W1C405D0-C-DRUG-RX-OVRD-CDS-D0 PBMD0
OCCURS 3 TIMES PBMD0
INDEXED BY W1C405D0-C-DRUG-RX-D0-VW-X PBMD0
PIC X(0002). PBMD0
15 W1C405D0-C-ASOC-RX-SVC-NUM-D0 PBMD0
PIC 9(00012). PBMD0
15 W1C405D0-C-HDR-DIAG-GRP-D0. PBMD0
20 W1C405D0-C-HDR-DIAG-VW-D0 PBMD0
OCCURS 0005 TIMES PBMD0
INDEXED BY W1C405D0-C-HDR-DIAG-VW-X . PBMD0
25 W1C405D0-C-SEQ-NUM-D0 PBMD0
PIC S9(00004) COMP. PBMD0
25 W1C405D0-C-DIAG-QL-CD-D0 PBMD0
PIC X(00002). PBMD0
25 W1C405D0-R-DIAG-CD-D0 PBMD0
PIC X(00015). PBMD0
10 W1C405D0-C-HDR-DRUG-VW. PBMD0
15 W1C405D0-C-CLM-RT-ADMIN-CD-D0 PBMD0
PIC X(00011). PBMD0
10 W1C405D0-C-HDR-COB-GRP. PBMD0
15 W1C405D0-C-HDR-COB-VW PBMD0
OCCURS 0005 TIMES PBMD0
INDEXED BY W1C405D0-C-HDR-COB-VW-X. PBMD0
20 W1C405D0-C-HDR-COB-PAT-GRP-D0. PBMD0
25 W1C405D0-C-HDR-COB-PAT-VW-D0 PBMD0
OCCURS 0025 TIMES PBMD0
INDEXED BY W1C405D0-C-HDR-COB-PAT-VW-X. PBMD0
30 W1C405D0-C-COB-SEQ-NUM-D0 PBMD0
PIC S9(00004) COMP. PBMD0
30 W1C405D0-C-COB-PAT-SEQ-NUM-D0 PBMD0
PIC S9(00004) COMP. PBMD0
30 W1C405D0-C-COB-PAT-RESP-CD-D0 PBMD0
PIC X(00002). PBMD0
30 W1C405D0-C-COB-PAT-RESP-AMT-D0 PBMD0
PIC S9(00008)V9(00002) COMP-3. PBMD0
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE EXHIBIT
INPUT FILE
PDCS ADJUDICATED CLAIMS INTERFACE
|Source Field |Target Table |Target Column |Std Edit |Req |Def |Specifications |Note |
| | | | | | | |Ref |
|Same approach as C-ADJ-REPLCD-TCN |C_HDR_ADJ_VD_TB |C-KEYED-REPLCD-NUM |N/A |N/A |N/A | |16 |
|W1C40541-C-HDR-ADJ-RSN-CD |C_HDR_ADJ_VD_TB |C-HDR-ADJ-RSN-CD |N/A |N/A |N/A | |30 |
|W1C40541-C-REPLCD-TCN-NUM |C_HDR_ADJ_VD_TB |C-REPLCD-TCN-NUM |N/A |N/A |N/A |Adjustments load with TCN-TO-CREDIT. Left |16 |
| | | | | | |blank on the original | |
|N/A |C_HDR_ADJ_VD_TB |C-HDR-ADJ-STAT-CD |N/A |N/A |N/A |Spaces | |
|W1C40541-C-REPLCMT-TCN-NUM |C_HDR_ADJ_VD_TB |C-REPLCMT-TCN-NUM |N/A |N/A |N/A | |16 |
|W1C40541-F-FCN-DT |C_HDR_ADJ_VD_TB |F-FCN-DT |N/A |C |N/A | |33 |
|W1C40541-F-FCN-MED-CD |C_HDR_ADJ_VD_TB |F-FCN-MED-CD |N/A |C |N/A | |33 |
|W1C40541-F-FCN-NUM |C_HDR_ADJ_VD_TB |F-FCN-NUM |N/A |C |N/A | |33 |
|If the TCN-TO-CREDIT didn’t exist on this |C_HDR_ADJ_VD_TB |C-ADJ-ORIG-TCN-NUM |N/A |N/A |N/A | |16 |
|table previously, use it. Otherwise, use | | | | | | | |
|the ORIGINAL-TCN from the one that does. | | | | | | | |
|N/A |C_HDR_ADJ_VD_TB |C-ADJ-SEQ-NUM |N/A |N/A |N/A | |16 |
|W1C40541-C-TCN-NUM |C_HDR_COE_TB |C-TCN-NUM | | | | |15 |
|N/A |C_HDR_COE_TB |C-SEQ-NUM | | | | |6 |
|N/A |C_HDR_COE_TB |B-GEO-CNTY-CD |N/A |N/A |N/A | |6 |
|N/A |C_HDR_COE_TB |B-COE-CD | | | | |6 |
|N/A |C_HDR_COE_TB |B-FED-MTCH-CD | | | | |6 |
|N/A |C_HDR_COE_TB |B-FED-CAT-CD | | | | |6 |
|N/A |C_HDR_COE_TB |B-ADMIN-CNTY-CD | | | | |6 |
|N/A |C_HDR_COE_TB |B-MONEY-CD | | | | |6 |
|W1C40541-C-TCN-NUM |C_HDR_DRUG_TB |C-TCN-NUM |N/A |N/A |N/A | |15 |
|W1C40541-P-SVC-PHARM-ALT-ID |C_HDR_DRUG_TB |C-NABP-PROV-ID |N/A |N/A |N/A | |2 |
|W1C40541-P-PRSC-ALT-ID |C_HDR_DRUG_TB |C-PRESCR-PROV-ID |N/A |N/A |N/A | |11 |
|W1C40541-P-PRSC-ALT-ID |C_HDR_DRUG_TB |C-PRESCR-NPI-ID |N/A |N/A |N/A | |11 |
|W1C40541-C-RX-ORGN-CD |C_HDR_DRUG_TB |C-RX-ORGN-CD |N/A |N/A |N/A | | |
|W1C40541-C-DAW-CD |C_HDR_DRUG_TB |C-DAW-CD |N/A |N/A |N/A | | |
|W1C40541-C-DRUG-RX-OVRRD-CD |C_HDR_DRUG_TB |C-DRUG-RX-OVRRD-CD |N/A |N/A |N/A | | |
|W1C40541-C-ELIG-OVRRD-IND |C_HDR_DRUG_TB |C-ELIG-OVRRD-IND |N/A |N/A |N/A | | |
|W1C40541-C-MGMT-OVRRD-IND |C_HDR_DRUG_TB |C-MGMT-OVRRD-IND |N/A |N/A |N/A | | |
|W1C40541-C-UNIT-DOSE-CD |C_HDR_DRUG_TB |C-UNIT-DOSE-CD |N/A |N/A |N/A | | |
|W1C40541-C-DRUG-CMPND-CD |C_HDR_DRUG_TB |C-DRUG-CMPND-CD |N/A |N/A |N/A | | |
|W1C40541-C-PA-TYP-CD |C_HDR_DRUG_TB |C-HDR-DRUG-CERT-CD |N/A |N/A |N/A | | |
|W1C40541-C-HDR-DRUG-XREF-CD |C_HDR_DRUG_TB |C-HDR-DRUG-XREF-CD |N/A |N/A |N/A | | |
|W1C40541-F-FCN-NUM |C_HDR_DRUG_TB |C-FCN-NUM |N/A |N/A |N/A | | |
|W1C40541-C-RX-SVC-REF-NUM |C_HDR_DRUG_TB |C-HDR-DRUG-RX-NUM |N/A |N/A |N/A | | |
|W1C40541-C-RX-REFILL-NUM |C_HDR_DRUG_TB |C-RX-REFLL-NUM |N/A |N/A |N/A | | |
|W1C40541-C-DRUG-PRESCR-DT |C_HDR_DRUG_TB |C-DRUG-PRESCR-DT |N/A |N/A |N/A | | |
|W1C40541-C-DRUG-SUB-QTY-AMT |C_HDR_DRUG_TB |C-DRUG-SUB-QTY-AMT |N/A |N/A |N/A | | |
|W1C40541-C-HDR-PD-QTY-AMT |C_HDR_DRUG_TB |C-DRUG-PD-QTY-AMT |N/A |N/A |N/A | | |
|W1C40541-C-REFIL-AUTH-NUM |C_HDR_DRUG_TB |C-NUM-REFILLS-AMT |N/A |N/A |N/A | | |
|W1C40541-C-PD-DAYS-SPLY-AMT |C_HDR_DRUG_TB |C-SUB-DAY-SPLY-AMT |N/A |N/A |N/A | | |
|W1C40541-C-PD-DAYS-SPLY-AMT |C_HDR_DRUG_TB |C-PD-DAYS-SPLY-AMT |N/A |N/A |N/A | | |
|W1C40541-C-HDR-SVC-FST-DT |C_HDR_DRUG_TB |C-DRUG-FILLED-DT |N/A |N/A |N/A | | |
|W1C40541-C-LI-ING-ALLOW-AMT |C_HDR_DRUG_TB |C-ALLW-INGRED-AMT |N/A |N/A |N/A | |20 |
|W1C40541-C-DISP-FEE-AMT |C_HDR_DRUG_TB |C-DISP-FEE-AMT |N/A |N/A |N/A | | |
|W1C40541-R-GROUP-ID |C_HDR_DRUG_TB |C-DRUG-GROUP-ID |N/A |N/A |N/A | | |
|W1C40541-R-CUST-ID |C_HDR_DRUG_TB |C-DRUG-CLIENT-ID |N/A |N/A |N/A | | |
|W1C40541-C-DRUG-VERSN-NUM |C_HDR_DRUG_TB |C-DRUG-VERSN-NUM |N/A |N/A |N/A | | |
|W1C40541-C-HDR-ADJUD-DT |C_HDR_DRUG_TB |C-DRUG-EXTRACT-DT |N/A |N/A |N/A | | |
|N/A |C_HDR_DRUG_TB |C-DRUG-PROV-NUM |N/A |N/A |N/A |Zero | |
|W1C40541-P-PRSC-ALT-ID |C_HDR_DRUG_TB |C-DRUG-DEA-NUM |N/A |N/A |N/A | | |
|W1C40541-C-DRUG-CVRG-CD |C_HDR_DRUG_TB |C-DRUG-CVRG-CD |N/A |N/A |N/A | | |
|W1C40541-R-PLAN-ID |C_HDR_DRUG_TB |C-DRUG-PLAN-ID |N/A |N/A |N/A | | |
|W1C40541-C-PYR-HIERARCHY-CD |C_HDR_DRUG_TB |C-DRUG-COB-IND |N/A |N/A |N/A | |21 |
|W1C40541-P-PRSC-ALT-ID |C_HDR_DRUG_TB |C-PHYS-DEA-ID |N/A |N/A |N/A | |11 |
|W1C40541-C-PRSC-LIC-NUM |C_HDR_DRUG_TB |C-PRSC-LIC-NUM |N/A |N/A |N/A | | |
|W1C40541-C-DRUG-IFACE-TY-CD |C_HDR_DRUG_TB |C-DRUG-IFACE-TY-CD |N/A |N/A |N/A | | |
|W1C40541-C-PROV-ON-REVW-IND |C_HDR_DRUG_TB |C-PROV-ON-REVW-IND |N/A |N/A |N/A | | |
|W1C40541-C-DRUG-TPL-IND |C_HDR_DRUG_TB |C-DRUG-COB-CHS-IND |N/A |N/A |N/A | |17 |
|W1C40541-C-OTHR-INSR-IND |C_HDR_DRUG_TB |C-DRUG-OTH-INS-IND |N/A |N/A |N/A | | |
|W1C40541-C-DRUG-TPL-IND |C_HDR_DRUG_TB |C-DRUG-TPL-IND |N/A |N/A |N/A | | |
|W1C40541-C-PAT-LOC-CD |C_HDR_DRUG_TB |C-PAT-LOCN-CD |N/A |N/A |N/A | | |
|W1C40541-C-PA-TYP-CD |C_HDR_DRUG_TB |C-PA-TY-CD |N/A |N/A |N/A | | |
|W1C40541-C-DISP-STATUS-CD |C_HDR_DRUG_TB |C-DISP-STAT-CD |N/A |N/A |N/A | | |
|N/A |C_HDR_DRUG_TB |C-MCARE-RX-IND |N/A |N/A |N/A |Set to “N” | |
|W1C40541-C-RT-OF-ADMIN-CD |C_HDR_DRUG_TB |C-RT-OF-ADMIN-CD |N/A |N/A |N/A | | |
|W1C40541-C-DSG-FM-DESC-CD |C_HDR_DRUG_TB |C-DSG-FM-DESC-CD |N/A |N/A |N/A | | |
|W1C40541-C-DISP-UNT-FM-CD |C_HDR_DRUG_TB |C-DISP-UNT-FM-CD |N/A |N/A |N/A | | |
|W1C40541-C-ASOC-RX-SVC-NUM |C_HDR_DRUG_TB |C-ASSOC-RX-SVC-NUM |N/A |N/A |N/A | | |
|W1C40541-C-ASOC-RX-SVC-DT |C_HDR_DRUG_TB |C-ASSOC-RX-SVC-DT |N/A |N/A |N/A | | |
|W1C40541-C-INT-DISP-QTY-AMT |C_HDR_DRUG_TB |C-INT-DISP-QTY-AMT |N/A |N/A |N/A | | |
|W1C40541-C-INT-DISP-DAY-NUM |C_HDR_DRUG_TB |C-INT-DISP-DAY-NUM |N/A |N/A |N/A | | |
|W1C40541-C-ORG-PROD-SVC-CD |C_HDR_DRUG_TB |C-ORG-DRUG-CD |N/A |N/A |N/A | | |
|W1C40541-C-ORG-QTY-PRSC-AMT |C_HDR_DRUG_TB |C-ORG-PRSC-QTY-AMT |N/A |N/A |N/A | | |
|W1C40541-C-QTY-PRSC-AMT |C_HDR_DRUG_TB |C-QTY-PRESCR-AMT |N/A |N/A |N/A | | |
|W1C40541-C-IFACE-CLM-ID |C_HDR_DRUG_TB |C-IFACE-CLM-ID |N/A |N/A |N/A | | |
|W1C40541-C-IFACE-CLM-CR-CD |C_HDR_DRUG_TB |C-IFACE-CLM-CR-CD |N/A |N/A |N/A | | |
|W1C40541-C-TCN-NUM |C_HDR_RLTD_HIST_TB |C-TCN-NUM |N/A |N/A |N/A | |15 |
|N/A |C_HDR_RLTD_HIST_TB |C-LI-NUM |N/A |N/A |N/A |Incremented by 1 for each related history | |
| | | | | | |entry. | |
|W1C40541-C-RLTD-LI-TCN-NUM |C_HDR_RLTD_HIST_TB |C-RLTD-LI-TCN-NUM |N/A |N/A |N/A | |15 |
|N/A |C_HDR_RLTD_HIST_TB |C-RLTD-LI-NUM |N/A |N/A |N/A |Zero | |
|W1C40542-R-CLM-EXC-CD |C_HDR_RLTD_HIST_TB |R-CLM-EXC-CD |N/A |N/A |N/A | |23 |
|N/A |C_HDR_RLTD_HIST_TB |C-HDR-PD-DT |N/A |N/A |N/A |Populate with the paid date of the related | |
| | | | | | |TCN on the MMIS. | |
|N/A |C_HDR_RLTD_HIST_TB |C-EXC-STAT-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_RLTD_HIST_TB |C-HDR-TY-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_RLTD_HIST_TB |C-SYS-REPLCD-IND |N/A |N/A |N/A |Spaces | |
|W1C40541-CRDHLDR-ALT-ID |C_HDR_TB |B-SYS-ID |N/A |N/A |N/A | |14 |
|W1C40541-C-TCN-NUM |C_HDR_TB |C-TCN-NUM |N/A |N/A |N/A | |15 |
|N/A |C_HDR_TB |C-XCN-NUM |N/A |N/A |N/A |Spaces | |
|W1C40541-C-HDR-ID-CD |C_HDR_TB |C-HDR-ID-CD |N/A |N/A |N/A |Always “62” | |
|N/A |C_HDR_TB |C-HDR-EMC-CD |N/A |N/A |N/A |Spaces | |
|W1C40541-R-PLAN-ID OR |C_HDR_TB |C-HDR-SUBMITTER-ID |N/A |N/A |N/A | |5 |
|W1C40541-C-IFACE-CLM-ID | | | | | | | |
|W1C40541-C-CNTL-ORGN-CD |C_HDR_TB |C-CNTL-ORGN-CD |N/A |N/A |N/A |“T” for tape | |
|W1C40541-C-HDR-STAT-CD |C_HDR_TB |C-HDR-STAT-CD |N/A |N/A |N/A | |12 |
|W1C40541-C-BAT-PYMT-TY-CD |C_HDR_TB |C-HDR-TXN-TY-CD |N/A |N/A |N/A | |18 |
|N/A |C_HDR_TB |C-HDR-TY-CD |N/A |N/A |N/A |“R” for pharmacy, “K” for DMERC |36 |
|N/A |C_HDR_TB |C-BAT-MED-SRC-CD |N/A |N/A |N/A |“1” for PDCS | |
|W1C40541-C-HDR-TXN-TY-CD |C_HDR_TB |C-BAT-JLN-DT-NUM |N/A |N/A |N/A | | |
|N/A |C_HDR_TB |C-BT-IMGD-CNTL-NUM |N/A |N/A |N/A |Zero | |
|N/A |C_HDR_TB |C-BAT-NUM |N/A |N/A |N/A |Starting with “1”, incremented by 1 for | |
| | | | | | |each 990 PDCS claims. | |
|W1C40541-C-BAT-DOC-TY-CD |C_HDR_TB |C-BAT-DOC-TY-CD |N/A |N/A |N/A | |19 |
|W1C40541-C-BAT-PYMT-TY-CD |C_HDR_TB |C-BAT-PYMT-TY-CD |N/A |N/A |N/A | |1 |
|N/A |C_HDR_TB |C-BAT-TY-CD |N/A |N/A |N/A |Always an “R” for pharmacy | |
|W1C40541-C-HDR-DOC-NUM |C_HDR_TB |C-HDR-DOC-NUM |N/A |N/A |N/A | | |
|N/A |C_HDR_TB |C-CLNT-MCARE-CD |N/A |N/A |N/A |Spaces | |
|W1C40541-B-FST-NAM |C_HDR_TB |B-FST-NAM |N/A |N/A |N/A | | |
|W1C40541-B-LAST-NAM |C_HDR_TB |B-LAST-NAM |N/A |N/A |N/A | | |
|W1C40541-B-MI-NAM |C_HDR_TB |B-MI-NAM |N/A |N/A |N/A | | |
|W1C40541-CRDHLDR-ALT-ID |C_HDR_TB |B-ALT-ID |N/A |N/A |N/A | |14 |
|N/A |C_HDR_TB |B-CURR-ID |N/A |N/A |N/A |FROM B_DETAIL_TB |7 |
|N/A |C_HDR_TB |B-RACE-CD |N/A |N/A |N/A |FROM B_DETAIL_TB |7 |
|N/A |C_HDR_TB |B-MAJ-PROG-CD |N/A |N/A |N/A |FROM B_COE_EDIT_TB |8 |
|W1C40541-B-GENDER-CD |C_HDR_TB |B-GENDER-CD |N/A |N/A |N/A | | |
|N/A |C_HDR_TB |T-MSQ-TY-CD |N/A |N/A |N/A |Spaces | |
|W1C40541-A-ID |C_HDR_TB |A-ID |N/A |N/A |N/A |Move the data from the first line item on | |
| | | | | | |the PDCS claim. | |
|W1C40541-P-SVC-PHARM-ALT-ID |C_HDR_TB |C-BLNG-PROV-ID |N/A |N/A |N/A |FROM P_PROV_TB |2 |
|N/A |C_HDR_TB |C-BLNG-NTRPRS-ID |N/A |N/A |N/A |FROM P_PROV_TB | |
|N/A |C_HDR_TB |C-BLNG-PROV-TY-CD |N/A |N/A |N/A |FROM P_PROV_TB | |
|N/A |C_HDR_TB |C-PROV-SIGN-IND |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |C-ATTACH-1ST-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |C-ATTACH-2ND-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |C-ATTACH-3RD-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |C-ATTACH-4TH-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |C-ATTACH-5TH-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |C-HDR-ADJUD-TM |N/A |N/A |N/A |01.01.01 | |
|N/A |C_HDR_TB |C-EPSDT-CERT1-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |C-EPSDT-CERT2-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |C-ANES-REL-PROC-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |R-ICD-VER-CD |N/A |N/A |N/A |If Header LDOS is < 10/1/2015, move 09 to | |
| | | | | | |this field. If Header LDOS >= 10/1/2015, | |
| | | | | | |move 10 to this field. | |
|N/A |C_HDR_TB |C-HDR-FUT-1-IND |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |C-HDR-FUT-2-IND |N/A |N/A |N/A |Spaces | |
| |C_HDR_TB |C-HDR-RMK-IND |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |C-HDR-PAT-ACCT-NUM |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |C-CREDIT-CD |N/A |N/A |N/A |Move spaces to C-CREDIT-CD on incoming |16 |
| | | | | | |claims, when an adjustment is encountered | |
| | | | | | |this field must be updated to complete on | |
| | | | | | |the original claim | |
|N/A |C_HDR_TB |C-OTHR-INSR-IND |N/A |N/A |N/A |Set to “N” | |
|N/A |C_HDR_TB |P-LOCN-CD |N/A |N/A |N/A |P_PROV_TB | |
|N/A |C_HDR_TB |P-PROF-TECH-IND |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |P-IHS-IND |N/A |N/A |N/A |Spaces | |
|W1C40541-C-COST-AVOID-IND |C_HDR_TB |C-COST-AVOID-IND |N/A |N/A |N/A | | |
|W1C40541-C-PRIOR-AUTH-IND |C_HDR_TB |C-PRIOR-AUTH-IND |N/A |N/A |N/A | |26 |
|N/A |C_HDR_TB |C-DAILY-RPT-IND |N/A |N/A |N/A |Set TO “Y” | |
|N/A |C_HDR_TB |C-HDR-RA-NUM |N/A |N/A |N/A |Zero |3 |
|W1C40541-C-EXC-LOCN-CD |C_HDR_TB |C-EXC-LOCN-CD |N/A |N/A |N/A | | |
|W1C40541-C-EXC-LOCN-ID |C_HDR_TB |C-EXC-LOCN-ID |N/A |N/A |N/A | | |
|N/A |C_HDR_TB |C-SUSP-LOCN-EXC-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |C-OVRRD-EXC-LOC-CD |N/A |N/A |N/A |Spaces | |
|W1C40541-C-COST-CENTER-CD |C_HDR_TB |C-COST-CENTER-CD |N/A |N/A |N/A | | |
|N/A |C_HDR_TB |C-CYCL-NUM |N/A |N/A |N/A |Set to “1” | |
|W1C40541-C-HDR-CLNT-AGE |C_HDR_TB |C-HDR-CLNT-AGE |N/A |N/A |N/A | | |
|W1C40541-C-TOT-CHRG-AMT |C_HDR_TB |C-TOT-CHRG-AMT |N/A |N/A |N/A | | |
|W1C40541-C-HDR-ALLOW-AMT |C_HDR_TB |C-CALC-TOT-AMT |N/A |N/A |N/A | | |
|W1C40541-C-SUBM-OTHR-AMT |C_HDR_TB |C-TOT-TPL-AMT |N/A |N/A |N/A | | |
|W1C40541-C-TOT-NET-CHRG-AMT |C_HDR_TB |C-TOT-NET-CHRG-AMT |N/A |N/A |N/A | | |
|W1C40541-C-TOT-REIMB-AMT |C_HDR_TB |C-TOT-REIMB-AMT |N/A |N/A |N/A | | |
|W1C40541-C-TOT-COPAY-AMT |C_HDR_TB |C-TOT-COPAY-AMT |N/A |N/A |N/A |If the txn is an encounter, then load with | |
|Or W1C40541-C-PAT-LIAB-AMT | | | | | |W1C40541-C-PAT-LIAB-AMT. Otherwise, load | |
| | | | | | |with W1C40541-C-TOT-COPAY-AMT. | |
|W1C40541-C-REIMB-STAT-CD |C_HDR_TB |C-REIMB-STAT-CD |N/A |N/A |N/A | |29 |
|N/A |C_HDR_TB |C-PREV-REIMB-AMT |N/A |N/A |N/A |Populated from the C_TOT_REIMB_AMT from the|4 |
| | | | | | |previous claim. | |
|N/A |C_HDR_TB |C-PREV-REIMB-CD |N/A |N/A |N/A |Populated from the C_REIMB_STAT_CD from the|4 |
| | | | | | |previous claim. | |
|W1C40541-B-DOB-DT |C_HDR_TB |B-DOB-DT |N/A |N/A |N/A | | |
|W1C40541-B-DOB-DT |C_HDR_TB |C-SUBM-CLNT-DOB-DT |N/A |N/A |N/A | | |
|W1C40541-C-HDR-ENTRD-DT |C_HDR_TB |C-HDR-ENTRD-DT |N/A |N/A |N/A | | |
|W1C40541-C-HDR-ADJUD-DT |C_HDR_TB |C-HDR-ADJUD-DT |N/A |N/A |N/A | | |
|N/A |C_HDR_TB |C-HDR-ITERM-ADJ-DT |N/A |N/A |N/A |01/01/0001 | |
|W1C40541-C-BILLED-DT |C_HDR_TB |C-BILLED-DT |N/A |N/A |N/A | | |
|W1C40541-C-EXC-LOCN-DT |C_HDR_TB |C-EXC-LOCN-DT |N/A |N/A |N/A | | |
|W1C40541-C-HDR-BATCH-DT |C_HDR_TB |C-HDR-BATCH-DT |N/A |N/A |N/A | | |
|W1C40541-C-HDR-SVC-FST-DT |C_HDR_TB |C-HDR-SVC-FST-DT |N/A |N/A |N/A | | |
|W1C40541-C-HDR-SVC-FST-DT |C_HDR_TB |C-HDR-SVC-LST-DT |N/A |N/A |N/A | | |
|W1C40541-C-HDR-LST-CYCL-DT |C_HDR_TB |C-HDR-LST-CYCL-DT |N/A |N/A |N/A | | |
|N/A |C_HDR_TB |C-HDR-PD-DT |N/A |N/A |N/A |Populated by MMIS payment cycle | |
|N/A |C_HDR_TB |C-HDR-ORIG-PD-DT |N/A |N/A |N/A |Set to DB2 low date for original claims. |4 |
| | | | | | |For adjustments, populated from the | |
| | | | | | |C_HDR_PD_DT from the previous claim. | |
|N/A |C_HDR_TB |C-HDR-SUSP-DT |N/A |N/A |N/A |01/01/0001 | |
|W1C40541-C-HDR-HX-DT |C_HDR_TB |C-HDR-HX-DATE |N/A |N/A |N/A | |3 |
|N/A |C_HDR_TB |G-AUD-USER-ID |N/A |N/A |N/A |NMC6500 | |
|N/A |C_HDR_TB |G-AUD-DT |N/A |N/A |N/A |Processing Date | |
|N/A |C_HDR_TB |G-AUD-TM |N/A |N/A |N/A |Processing Time | |
|W1C40541-F-FCN-DT + |C_HDR_TB |C-RLTD-FCN-NUM |N/A |N/A |N/A | |9 |
|W1C40541-F-FCN-NUM | | | | | | | |
|W1C40541-C-BSE-AMT-SRC-CD |C_HDR_TB |C-BSE-AMT-SRC-CD |N/A |N/A |N/A | |13 |
|W1C40541-R-DRG-THR-CHAR3-CD |C_HDR_TB |C-COS-CD |N/A |N/A |N/A | |22 |
|N/A |C_HDR_TB |C-BLNG-NPI-ID |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |C-BLNG-TXNMY-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |C-BLNG-PROV-ZIP-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |C-BLNG-SPECL-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |C-MED-REC-NUM |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |P-PROFIT-IND |N/A |N/A |N/A |P_PROV_TB | |
|N/A |C_HDR_TB |P-TAX-DISCT-IND |N/A |N/A |N/A |P_PROV_TB | |
|N/A |C_HDR_TB |P-PSY-SOC-IND |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |C-FAM-PLN-CC-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |F-RSN-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_TB |C-TOT-TPL-DIR-AMT |N/A |N/A |N/A |Zero | |
|N/A |C_HDR_TB |C-HD-TPL-COPAY-AMT |N/A |N/A |N/A |Zero | |
|N/A |C_HDR_TB |C-MED-REC-NUM |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-ELIG-TWO-PASS-CD |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-NSF-X12N-CD |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-MCARE-STAT-CD |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-PAT-LIAB-AMT |N/A |N/A |N/A |Zero | |
|N/A |C-HDR-TB |C-HDR-CLIA-NUM |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-HDR-DENT-OCCP-DT |N/A |N/A |N/A |“0001-01-01” | |
|N/A |C-HDR-TB |C-HDR-DENT-AUTO-DT |N/A |N/A |N/A |“0001-01-01” | |
|N/A |C-HDR-TB |C-HDR-DENT-OTHR-DT |N/A |N/A |N/A |“0001-01-01” | |
|N/A |C-HDR-TB |C-REF-PROV-ID |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-REF-NPI-ID |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-OCCUP-RLTD-IND |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-AUTO-RLTD-IND |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-OTHR-RLTD-IND |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-ILLNESS-DT |N/A |N/A |N/A |“0001-01-01” | |
|N/A |C-HDR-TB |C-ADMIT-DT |N/A |N/A |N/A |“0001-01-01” | |
|N/A |C-HDR-TB |C-DISCH-DT |N/A |N/A |N/A |“0001-01-01” | |
|N/A |C-HDR-TB |R-DRG-CD |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-OTHR-PROV-ID |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-OTHR-PROV-NPI-ID |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-OPR-PROV-ID |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-OPR-NPI-ID |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-ATNDG-PROV-ID |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-ATNDG-NPI-ID |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-ATNDG-TXNMY-CD |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-LTC-PROV-ID |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-PAT-STAT-CD |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-ADM-SRC-CD |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-TY-OF-ADM-CD |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-TY-OF-BLL-1-2-CD |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-TY-OF-BILL-3-CD |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-UB-04-A-DIAG-CD |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-UB-04-ADM-HR-CD |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-UB-04-DISCH-HR-CD |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-PRCNG-PROCESS-CD |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-UB-04-ABORT-IND |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-HDR-FAM-PLNG-IND |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-UB-04-STERIL-IND |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-UB-04-HYSTER-IND |N/A |N/A |N/A |Spaces | |
|W1C40541-C-LI-BSE-AMT |C-HDR-TB |C-HDR-BSE-AMT |N/A |N/A |N/A |Accumulated from line items | |
|W1C40541-C-CALC-ALLOW-AMT |C-HDR-TB |C-CALC-ALLOW-AMT |N/A |N/A |N/A |Accumulated from line items | |
|W1C40541-C-LI-ALLOW-AMT |C-HDR-TB |C-HDR-ALLOW-AMT |N/A |N/A |N/A |Accumulated from line items | |
|N/A |C-HDR-TB |C-NCVRD-CHRG-AMT |N/A |N/A |N/A |Zero | |
|N/A |C-HDR-TB |C-CVRD-DAYS-NUM |N/A |N/A |N/A |Zero | |
|N/A |C-HDR-TB |C-NCVRD-DAYS-NUM |N/A |N/A |N/A |Zero | |
|N/A |C-HDR-TB |C-OUTLIER-DAYS-NUM |N/A |N/A |N/A |Zero | |
|N/A |C-HDR-TB |C-CALC-DAYS-NUM |N/A |N/A |N/A |Zero | |
|N/A |C-HDR-TB |C-DRG-PD-DAYS-NUM |N/A |N/A |N/A |Zero | |
|N/A |C-HDR-TB |B-GUARANTEE-NUM |N/A |N/A |N/A |Zero | |
|W1C40541-C-BAT-MED-SRC-CD |C-HDR-TB |C-ORIG-PAPER-IND |N/A |N/A |N/A |If the PDCS claim was entered through exam | |
| | | | | | |entry, move ‘Y’ to this field. | |
|W1C40541-C-BASIS-COST-CD |C-HDR-TB |C-PRCNG-PROCESS-CD |N/A |N/A |N/A |The W1C40541-C-BASIS-COST-CD from the first| |
| | | | | | |line item on the claim is used to populate | |
| | | | | | |the C-PRCNG-PROCESS-CD on the header table.| |
|N/A |C-HDR-TB |C-TY-OF-BLL-PFX-CD |N/A |N/A |N/A |Spaces | |
|W1C40541-C-HDR-ENTRD-DT |C-HDR-TB |C-CREATION-DT |N/A |N/A |N/A | | |
|N/A |C-HDR-TB |C-SVC-FACI-NPI-ID |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |R_CD_REL_WT_AMT |N/A |N/A |N/A |Zero | |
|N/A |C-HDR-TB |C_BLNG_TAX_ID |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C_BLNG_SSN_NUM |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-FUT-PROV-ID |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |H_PLN_NUM |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |H_PLN_TY_CD |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |H_PLN_BEG_DT |N/A |N/A |N/A |‘0001-01-01’ | |
|N/A |C-HDR-TB |C-HDR-FUT-1-CD |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-HDR-FUT-2-CD |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-HDR-FUT-1-IND |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-HDR-FUT--IND |N/A |N/A |N/A |Spaces | |
|N/A |C-HDR-TB |C-HDR-FUT-1-AMT |N/A |N/A |N/A |Zero | |
|N/A |C-HDR-TB |C-HDR-FUT-2-AMT |N/A |N/A |N/A |Zero | |
|W1C40541-C-TCN-NUM |C_LI_BSE_CHG_TB |C-TCN-NUM |N/A |N/A |N/A | |15, 24 |
|N/A |C_LI_BSE_CHG_TB |C-LI-NUM |N/A |N/A |N/A |Constant “00” |24 |
|N/A |C_LI_BSE_CHG_TB |C-SEQ-NUM |N/A |N/A |N/A |Constant “01” |24 |
|N/A |C_LI_BSE_CHG_TB |C-BSE-CHNG-RSN-CD |N/A |N/A |N/A |Constant “03” (COPAY) |24 |
|W1C40541-C-TOT-COPAY-AMT |C_LI_BSE_CHG_TB |C-BSE-AMT-CHG-AMT |N/A |N/A |N/A | |24 |
|W1C40541-CRDHLDR-ALT-ID |C_LI_DRUG_TB |B-SYS-ID |N/A |N/A |N/A | |14 |
|W1C40541-C-TCN-NUM |C_LI_DRUG_TB |C-TCN-NUM |N/A |N/A |N/A | |15 |
|W1C40541-C-LI-NUM |C_LI_DRUG_TB |C-LI-NUM |N/A |N/A |N/A | | |
|W1C40541-R-DRG-THR-CHAR3-CD |C_LI_DRUG_TB |R-DRG-THR-CHAR3-CD |N/A |N/A |N/A | | |
|W1C40541-R-DRUG-GEN-PRD-CD |C_LI_DRUG_TB |C-DRUG-GEN-PRD-CD |N/A |N/A |N/A |Generic = 1 and Branded = 2 | |
|W1C40541-C-DRUG-GEN-CD-NUM |C_LI_DRUG_TB |C-DRUG-GEN-CD-NUM |N/A |N/A |N/A | | |
|W1C40541-C-BSE-AMT-SRC-CD |C_LI_DRUG_TB |C-BSE-AMT-SRC-CD |N/A |N/A |N/A | | |
|W1C40541-C-DRUG-MAINT-IND |C_LI_DRUG_TB |C-DRUG-MAINT-IND |N/A |N/A |N/A | | |
|W1C40541-C-DRUG-ROUTE-CD |C_LI_DRUG_TB |C-DRUG-ROUTE-CD |N/A |N/A |N/A | | |
|W1C40541-R-DRUG-GCN-SEQ-NUM |C_LI_DRUG_TB |R-DRUG-GCN-SEQ-NUM |N/A |N/A |N/A | | |
|W1C40541-C-LI-ING-ALLOW-AMT |C_LI_DRUG_TB |C_LI_ALLOW_ING_AMT |N/A |N/A |N/A | | |
|W1C40541-C-DRUG-DEA-CD |C_LI_DRUG_TB |R_DRUG_DEA_CD |N/A |N/A |N/A | | |
|W1C40541-C-SUBM-ING-QTY-AMT |C_LI_DRUG_TB |C_LI_SUB_QTY_AMT |N/A |N/A |N/A | | |
|W1C40541-C-LI-PD-QTY-AMT |C_LI_DRUG_TB |C_LI_PD_QTY_AMT |N/A |N/A |N/A | | |
|W1C40541-C-BASIS-COST-CD |C_LI_DRUG_TB |C-PRCNG-PROCESS-CD |N/A |N/A |N/A | | |
|W1C40541-C-TCN-NUM |C_LI_EXC_TB |C-TCN-NUM |N/A |N/A |N/A | |15 |
|N/A |C_LI_EXC_TB |C-LI-NUM |N/A |N/A |N/A |“00” | |
|W1C40541-R-CLM-EXC-CD |C_LI_EXC_TB |R-CLM-EXC-CD |N/A |N/A |N/A | |23 |
|W1C40541-C-LI-EXC-CLRK-ID |C_LI_EXC_TB |C-LI-EXC-CLRK-ID |N/A |N/A |N/A | | |
|W1C40541-C-EXC-STAT-CD |C_LI_EXC_TB |R-CLM-EXC-STAT-CD |N/A |N/A |N/A | |25 |
|N/A |C_LI_EXC_TB |R-EXC-FORCE-APP-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_EXC_TB |R-FORCE-DENY-CD |N/A |N/A |N/A |Spaces | |
|W1C40541-C-TCN-NUM |C_LI_TB |C-TCN-NUM |N/A |N/A |N/A | |15 |
|W1C40541-C-LI-NUM |C_LI_TB |C-LI-NUM |N/A |N/A |N/A | | |
|W1C40541-R-DRUG-CD |C_LI_TB |R-DRUG-CD |N/A |N/A |N/A | | |
|N/A |C_LI_TB |R-PL-OF-SVC-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |R-SVC-AREA-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-SVC-COMPONENT-CD |N/A |N/A |N/A |Spaces | |
|W1C40541-A-LI-NUM |C_LI_TB |A-LI-NUM |N/A |N/A |N/A | | |
|W1C40541-C-PRIOR-AUTH-IND |C_LI_TB |C-PRIOR-AUTH-IND |N/A |N/A |N/A | | |
|W1C40541-A-ID |C_LI_TB |C-LI-AUTH-ID |N/A |N/A |N/A | | |
|N/A |C_LI_TB |C-LI-CLIA-NUM |N/A |N/A |N/A |Spaces | |
|W1C40541-C-BSE-AMT-SRC-CD |C_LI_TB |C-BSE-AMT-SRC-CD |N/A |N/A |N/A | | |
|N/A |C_LI_TB |C-PRCNG-PROCESS-CD |N/A |N/A |N/A |Spaces | |
|W1C40541-R-DRG-THR-CHAR3-CD |C_LI_TB |C-COS-CD |N/A |N/A |N/A | |22 |
|W1C40541-C-REIMB-STAT-CD |C_LI_TB |C-REIMB-STAT-CD |N/A |N/A |N/A | |29 |
|N/A |C_LI_TB |C-COST-AVOID-IND |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-ONCE-IN-LFTM-IND |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-LI-DUPL-CHK-IND |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-ALLOW-UNTS-IND |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-LI-ABORT-IND |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-LI-STERIL-IND |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-LI-FAM-PLNG-IND |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-LI-HYSTER-IND |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-MULTI-SURG-IND |N/A |N/A |N/A |Spaces | |
|W1C40541-C-HDR-SVC-FST-DT |C_LI_TB |C-LI-FST-DOS-DT |N/A |N/A |N/A | | |
|W1C40541-C-HDR-SVC-FST-DT |C_LI_TB |C-LI-LAST-DOS-DT |N/A |N/A |N/A | | |
|N/A |C_LI_TB |C-MC-ENCTR-PD-AMT |N/A |N/A |N/A |Zero | |
|N/A |C_LI_TB |C-LI-TPL-COPAY-AMT |N/A |N/A |N/A |Zero | |
|N/A |C_LI_TB |C-LI-SUBM-CHRG-AMT |N/A |N/A |N/A |Zero | |
|W1C40541-C-LI-BSE-AMT |C_LI_TB |C-LI-BSE-AMT |N/A |N/A |N/A | | |
|W1C40541-C-CALC-ALLOW-AMT |C_LI_TB |C-LI-CLC-ALLW-AMT |N/A |N/A |N/A | | |
|W1C40541-C-LI-ALLOW-AMT |C_LI_TB |C-LI-ALLW-CHRG-AMT |N/A |N/A |N/A | | |
|W1C40541-C-LI-REIMB-AMT |C_LI_TB |C-LI-REIMB-AMT |N/A |N/A |N/A | | |
|W1C40541-C-CLIN-MSRMT-UN-CD |C_LI_TB |C-LI-UNT-MSR-CD |N/A |N/A |N/A | | |
| |C_LI_TB |C-LI-UNT-MSR-NUM |N/A |N/A |N/A | | |
|W1C40541-C-SUBM-ING-QTY-AMT |C_LI_TB |C-LI-SUBM-UNT-NUM |N/A |N/A |N/A | | |
|N/A |C_LI_TB |C-LI-ALLOW-UNT-NUM |N/A |N/A |N/A |Zero | |
|W1C40541-C-LI-PD-QTY-AMT |C_LI_TB |C-LI-REIMB-UNT-NUM |N/A |N/A |N/A | | |
|N/A |C_LI_TB |C-LI-FLLWP-LMT-DT |N/A |N/A |N/A |01/01/0001 | |
|N/A |C_LI_TB |R-PROC-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-PROC-MOD-1ST-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-PROC-MOD-2ND-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-PROC-MOD-3RD-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-PROC-MOD-4TH-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-DIAG-1ST-RLTD-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-DIAG-2ND-RLTD-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-DIAG-3RD-RLTD-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-DIAG-4TH-RLTD-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-DIAG-5TH-RLTD-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-DIAG-6TH-RLTD-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-DIAG-7TH-RLTD-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-DIAG-8TH-RLTD-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |R-PROC-ORAL-CAV-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |R-PROC-TOOTH-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-DENT-1ST-SURF-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-DENT-2ND-SURF-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-DENT-3RD-SURF-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-DENT-4TH-SURF-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-DENT-5TH-SURF-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-RNDR-PROV-ID |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-RNDR-NPI-ID |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-RNDR-TXNMY-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-RNDR-NTRPRS-ID |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-DSTN-PROV-ID |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |P-TY-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |P-SPECL-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-SUBM-FAM-PLN-IND |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-SUBM-EPSDT-IND |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |R-REV-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |R-REV-TY-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |B-LEVEL-OF-CARE-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-LI-UB-04-RATE-AMT |N/A |N/A |N/A |Zero | |
|N/A |C_LI_TB |C-NN-CVRD-CHRG-AMT |N/A |N/A |N/A |Zero | |
|N/A |C_LI_TB |C-HDR-FUT-1-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-HDR-FUT-2-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-HDR-FUT-1-IND |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-HDR-FUT--IND |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-HDR-FUT-1-AMT |N/A |N/A |N/A |Zero | |
|N/A |C_LI_TB |C-HDR-FUT-2-AMT |N/A |N/A |N/A |Zero | |
|N/A |C_LI_TB |C-LI-ATT-1ST-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-LI-ATT-2ND-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-LI-ATT-3RD-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-LI-FUT-3-AMT |N/A |N/A |N/A |Zero | |
|N/A |C_LI_TB |C-LI-FUT-4-AMT |N/A |N/A |N/A |Zero | |
|N/A |C_LI_TB |C-LI-NDC-UNT-CD |N/A |N/A |N/A |Spaces | |
|N/A |C_LI_TB |C-LI-NDC-UNT-NUM |N/A |N/A |N/A |Zero | |
|N/A |C_LI_TB |C-LI-COST-CNTR-CD |N/A |N/A |N/A |Spaces | |
|W1C40541-C-TCN-NUM |C_HDR_ENCTR_TB |C-TCN-NUM |N/A |N/A |N/A | |15 |
|W1C40541-R-PLAN-ID | |C-MC-PROV-ID |N/A |N/A |N/A |Populated only for encounter claims. |5 |
| |C_HDR_TB | | | | | | |
|W1C40541-R-PLAN-ID | |H-PLN-NUM |N/A |N/A |N/A | |32 |
| |C_HDR_TB | | | | | | |
|W1C40541-C-IFACE-CLM-ID |C_HDR_ENCTR_TB |C-MCO-TCN-DAT |N/A |N/A |N/A | | |
|N/A | |H-PLN-BEG-DT |N/A |N/A |N/A |01/01/0001 | |
| |C_HDR_TB | | | | | | |
|W1C40541-R-PLAN-ID | |H_PLN_TY_CD |N/A |N/A |N/A | |32 |
| |C_HDR_TB | | | | | | |
| |C_HDR_ENCTR_TB |C_SUB_CAP_CD |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_ENCTR_TB |C_MC_ENCTR_RECD_DT |N/A |N/A |N/A |0001-01-01 | |
|N/A |C_HDR_ENCTR_TB |C_MC_ENCTR_PD_DT |N/A |N/A |N/A |0001-01-01 | |
| |C_HDR_ENCTR_TB |C_MC_ENCTR_PD_AMT |N/A |N/A |N/A |Zero | |
|W1C40541-C-TCN-NUM |C_LI_TPL_BLNG_TB |C-TCN-NUM |N/A |N/A |N/A | |15, 31 |
|N/A |C_LI_TPL_BLNG_TB |C-LI-NUM |N/A |N/A |N/A |Zero |31 |
|N/A |C_LI_TPL_BLNG_TB |T-PLCY-NUM |N/A |N/A |N/A |From T_CVRG_CLNT_TB |31 |
|N/A |C_LI_TPL_BLNG_TB |T-PLCY-SEQ-NUM |N/A |N/A |N/A |From T_CVRG_CLNT_TB |31 |
|N/A |C_LI_TPL_BLNG_TB |T-PLCY-RESRC-CD |N/A |N/A |N/A |From T_CVRG_PLCY_TB |31 |
|N/A |C_LI_TPL_BLNG_TB |T-CARR-ID |N/A |N/A |N/A |From T_CVRG_CLNT_TB |31 |
|N/A |C_LI_TPL_BLNG_TB |T-CVRG-PLCY-CD |N/A |N/A |N/A |From T_CVRG_CODE_TB |31 |
| |C_HDR_MCARE_TB | | | | | |27 |
|N/A |C_HDR_COB_TB |C_COB_NN_CVRD_AMT |N/A |N/A |N/A |Zero | |
|N/A |C_HDR_COB_TB |C_HDR_RMK_CD |N/A |N/A |N/A |Spaces | |
|N/A |C_HDR_COB_TB |C_COB_DRG_AMT |N/A |N/A |N/A |Zero | |
|N/A |C_HDR_COB_TB |C_COB_DSP_SHR_AMT |N/A |N/A |N/A |Zero | |
|N/A |C_HDR_COB_TB |C_COB_CAP_IME_AMT |N/A |N/A |N/A |Zero | |
|N/A |C_HDR_COB_TB |C_COB_REIMB_PCT |N/A |N/A |N/A |Zero | |
|N/A |C_HDR_COB_TB |C_COB_HCPCS_AMT |N/A |N/A |N/A |Zero | |
|N/A |C_HDR_COB_TB |C_COB_ESRD_AMT |N/A |N/A |N/A |Zero | |
|N/A |C_HDR_COB_TB |C_COB_NONP_PC_AMT |N/A |N/A |N/A |Zero | |
|W1C40541-C-TCN-NUM |C_LI_CAS_TB |C_TCN_NUM |N/A |N/A |N/A | | |
|W1C40541-LI-NUM OF |C_LI_CAS_TB |C_LI_NUM |N/A |N/A |N/A | | |
|W1C40541-X12835-FIELDS-TBL | | | | | | | |
| |C_LI_CAS_TB |C_CAS_PYR_ID |N/A |N/A |N/A |NMMAD | |
| |C_LI_CAS_TB |C_CAS_PROC_CD |N/A |N/A |N/A |Spaces | |
| |C_LI_CAS_TB |C_CAS_GRP_CD |N/A |N/A |N/A | |28 |
|W1C40541-X12835-ARC |C_LI_CAS_TB |C_CAS_RSN_CD |N/A |N/A |N/A | |28 |
| |C_LI_CAS_TB |C_CAS_AMT |N/A |N/A |N/A | | |
| |C_LI_CAS_TB |C_CAS_UNT_NUM |N/A |N/A |N/A |Zero | |
|W1C40541-C-TCN-NUM |C_HDR_MCARE_TB |C_TCN_NUM |N/A |N/A |N/A | |34, 15 |
|W1C40541-P-SVC-PHARM-ALT-ID |C_HDR_MCARE_TB |C_MCARE_PROV_ID |N/A |N/A |N/A |Populate C_MCARE_PROV_ID with |34 |
| | | | | | |W1C40541-P-SVC-PHARM-ALT-ID if | |
| | | | | | |W1C40541-P-SVC-PH-ALT-ID-CD = ‘04’. | |
| |C_HDR_MCARE_TB |C_MCARE_CLM_NUM |N/A |N/A |N/A |spaces |34 |
|W1C40541-C-PAYER-ID of |C_HDR_MCARE_TB |C_HD_MCARE_CARR_ID |N/A |N/A |N/A |Use occurrence of W1C40541-C-HDR-COB-VW |34 |
|W1C40541-C-HDR-COB-VW | | | | | |where W1C40541-C-PAYERID-CD = ‘99’. | |
|W1C40541-CRDHLDR-ALT-ID |C_HDR_MCARE_TB |C_MCARE_HIC_ID |N/A |N/A |N/A |Populate C_MCRE_HIC_ID with |34 |
| | | | | | |W1C40541-CRDHLDR-ALT-ID if | |
| | | | | | |W1C40541-B-CRDHLD-ALT-ID-CD = ‘07’ | |
| | | | | | |(Medicare ID) | |
|W1C40541-C-PAYERID-DT of |C_HDR_MCARE_TB |C_HD_MCARE_EOMB_DT |N/A |N/A |N/A | |34 |
|W1C40541-C-HDR-COB-VW | | | | | | | |
| |C_HDR_MCARE_TB |C_HDR_MCAR_STAT_CD |N/A |N/A |N/A |Set to ‘P’aid if C_MCARE_ALLOW_AMT > 0, |34 |
| | | | | | |otherwise set to ‘D’enied. | |
|N/A |C_HDR_MCARE_TB |C_MCARE_ALLOW_AMT |N/A |N/A |N/A |Set to C_MCARE_DED_AMT + C_MCARE_COINS_AMT |34 |
| | | | | | |+ C_MCARE_PD_AMT | |
|W1C40541-C-PAYERID-PD-AMT of |C_HDR_MCARE_TB |C_MCARE_DED_AMT |N/A |N/A |N/A |Use occurrence of W1C40541-C-HDR-COB-VW |34, 35 |
|W1C40541-C-HDR-COB-PAID-VW of | | | | | |where W1C40541-C-PAYERID-CD = ‘99’ and the | |
|W1C40541-C-HDR-COB-VW | | | | | |occurrence of W1C40541-C-HDR-COB-VW where | |
| | | | | | |W1C40541-C-PAYERID-PD-CD = ‘99’. Use the | |
| | | | | | |first occurrence of ‘99’. | |
|W1C40541-C-PAYERID-PD-AMT of |C_HDR_MCARE_TB |C_MCARE_COINS_AMT |N/A |N/A |N/A |Use occurrence of W1C40541-C-HDR-COB-VW |34, 35 |
|W1C40541-C-HDR-COB-PAID-VW of | | | | | |where W1C40541-C-PAYERID-CD = ‘99’ and the | |
|W1C40541-C-HDR-COB-VW | | | | | |occurrence of W1C40541-C-HDR-COB-VW where | |
| | | | | | |W1C40541-C-PAYERID-PD-CD = ‘99’. Add the | |
| | | | | | |second occurrence of ‘99’ (coinsurance) and| |
| | | | | | |the third occurrence of ‘99’ (copay). | |
|N/A |C_HDR_MCARE_TB |C_MCARE_PSY_AMT |N/A |N/A |N/A |Zero |34 |
|N/A |C_HDR_MCARE_TB |C_MCARE_O_PR_AMT |N/A |N/A |N/A |Zero |34 |
|W1C40541-C-PAYERID-PD-AMT of |C_HDR_MCARE_TB |C_MCARE_PD_AMT |N/A |N/A |N/A |Use occurrence of W1C40541-C-HDR-COB-VW |34 |
|W1C40541-C-HDR-COB-PAID-VW of | | | | | |where W1C40541-C-PAYERID-CD = ‘99’ and the | |
|W1C40541-C-HDR-COB-VW | | | | | |occurrence of W1C40541-C-HDR-COB-VW where | |
| | | | | | |W1C40541-C-PAYERID-PD-CD = ‘08’. | |
|N/A |C_HDR_MCARE_TB |C_HDR_MCAR_DED_AMT |N/A |N/A |N/A |Set to C_MCARE_DED_AMT |34 |
|N/A |C_HDR_MCARE_TB |C_HDR_MCAR_COI_AMT |N/A |N/A |N/A |Set to C_MCARE_COINS_AMT |34 |
|N/A |C_HDR_MCARE_TB |C_HDR_MCAR_PSY_AMT |N/A |N/A |N/A |Zero |34 |
|N/A |C_HDR_MCARE_TB |C_HD_MCAR_O_PR_AMT |N/A |N/A |N/A |Zero |34 |
|W1C405D0-C-PAT-SVC-LOC-CD-D0 |N/A |N/A |N/A |N/A |N/A |Not used for D.0 Implementation | |
|W1C405D0-C-PAT-RES-CD-D0 |N/A |N/A |N/A |N/A |N/A |Not used for D.0 Implementation | |
|W1C405D0-C-RX-SVC-REF-NUM-D0 |C_HDR_TB |C-HDR-DRUG-RX-NUM |N/A |N/A |N/A |If W1C40541-C-DRUG-VERSN-NUM = ‘D0’, move | |
| | | | | | |this field to C-HDR-DRUG-RX-NUM, otherwise | |
| | | | | | |move W1C40541-C-RX-SVC-REF-NUM to | |
| | | | | | |C-HDR-DRUG-RX-NUM. | |
|W1C405D0-C-DRUG-RX-OVRD1-CD-D0 |C_HDR_DRUG_TB |C-DRUG-RX-OVRRD-CD |N/A |N/A |N/A |If W1C40541-C-DRUG-VERSN-NUM = ‘D0’, move | |
| | | | | | |this field to C-DRUG-RX-OVRRD-CD, otherwise| |
| | | | | | |move W1C40541-C-DRUG-RX-OVRRD-CD to | |
| | | | | | |C-DRUG-RX-OVRRD-CD. | |
|W1C405D0-C-DRUG-RX-OVRD2-CD-D0 |N/A |N/A |N/A |N/A |N/A |Not used for D.0 Implementation | |
|W1C405D0-C-DRUG-RX-OVRD3-CD-D0 |N/A |N/A |N/A |N/A |N/A |Not used for D.0 Implementation | |
|W1C405D0-C-ASOC-RX-SVC-NUM-D0 |C-HDR-DRUG-TB |C-ASSOC-RX-SVC-NUM | | | |If W1C40541-C-DRUG-VERSN-NUM = ‘D0’, move | |
| | | | | | |this field to C-ASSOC-RX-SVC-NUM, otherwise| |
| | | | | | |move W1C40541-C-ASOC-RX-SVC-NUM to | |
| | | | | | |C-ASSOC-RX-SVC-NUM | |
|W1C405D0-C-SEQ-NUM-D0 |N/A |N/A |N/A |N/A |N/A |Not used for D.0 Implementation | |
|W1C405D0-C-DIAG-QL-CD-D0 |N/A |N/A |N/A |N/A |N/A |Not used for D.0 Implementation | |
|W1C405D0-R-DIAG-CD-D0 |N/A |N/A |N/A |N/A |N/A |Not used for D.0 Implementation | |
|W1C405D0-C-CLM-RT-ADMIN-CD-D0 |N/A |N/A |N/A |N/A |N/A |Not used for D.0 Implementation | |
|W1C405D0-C-COB-SEQ-NUM-D0 |N/A |N/A |N/A |N/A |N/A |Not used for D.0 Implementation | |
|W1C405D0-C-COB-PAT-SEQ-NUM-D0 |N/A |N/A |N/A |N/A |N/A |Not used for D.0 Implementation | |
|W1C405D0-C-COB-PAT-RESP-CD-D0 |N/A |N/A |N/A |N/A |N/A |Not used for D.0 Implementation | |
|W1C405D0-C-COB-PAT-RESP-AMT-D0 |N/A |N/A |N/A |N/A |N/A |Not used for D.0 Implementation | |
Notes:
1. Convert PDCS valid values of C-BAT-PYMT-TY-CD as follows:
|PDCS C-BAT-PYMT-TY-CD |MMIS C-BAT-PYMT-TY-CD |
|0 = Normal Pay Provider |0 = Normal Pay Provider |
|2 = Debit Gross Adjustment | |
|3 = Credit Gross Adjustment | |
|A = Credit Claim Adjustment | |
|B = Credit Claim Credit | |
|C = Credit Mass Adjustment | |
|D = Credit Mass Credit | |
|E = Adjustment Claim Adjustment | |
|F = Adjustment Mass Adjustment | |
|1 = History Only - No Pay Provider |1 = History Only |
|6 = History Only - Debit Gross Adjustment | |
|7 = History Only - Credit Gross Adjustment | |
|G = History Credit for Adjustment | |
|H = History Credit for Credit | |
|I = History Credit for Mass Adjustment | |
|J = History Credit for Mass Credit | |
|K = History Adjustment from Credit Adjustment | |
|L = History Adjustment from Mass Adjustment | |
2. The W1C40541-P-SVC-PH-ALT-ID-CD field contains a qualifier which will indicate what type of provider id is carried in the W1C40541-P-SVC-PHARM-ALT-ID field. A value of ‘01’ indicates NPI, ‘07’ indicates NABP, ‘04’ indicates Medicare.
NABP:
Non-encounter claims determine the MMIS provider ID by looking up the NABP from PDCS on the MMIS provider table. The program uses the first seven characters of the PDCS NABP, then cross-references the NABP number to a provider who is active on the claim FDOS and whose NABP number is an exact match or matches on the first seven digits followed by a dash. The program also gets the billing provider for a PDCS reversal from the original claim rather than cross referencing the NABP number from the reversal in order to avoid taking money from providers who were not paid in the first place.
If the PDCS NABP is zero, or cannot be found on the MMIS provider table for the claim FDOS, and the claim is denied, the claim is bypassed. If the claim is paid and an MMIS provider cannot be identified, reject the claim, placing it on a reject file that will be re-processed daily until the problem with the provider identification has been resolved.
For encounter claims, if the PDCS provider number is non-zero, it is moved to the MMIS provider field. If it is zero, and the claim is denied, move “99999998” to the MMIS provider. If the claim is paid and the PDCS provider is zero, reject the claim, placing it on a reject file that will be re-processed daily until the problem with the provider identification has been resolved.
If the PDCS claim is for an adjustment, the MMIS billing provider id is populated from the billing provider id on the original claim. This insures that the claim is credited to the same provider that was originally paid, despite changes that might have occurred to the NABP number cross-reference since the claim was originally paid.
NPI:
FFS and encounter claims will be processed similarly. In both cases, the NPI Cross-Match Module (CMM) will be called using the NPI and FDOS supplied on the claim to find a NM provider id. Since it is a drug claim, a taxonomy code is unnecessary. The CMM will search for providers that match on NPI with a pharmacy provider type. For FFS claims, if a pharmacy provider cannot be found on the MMIS provider table for the claim FDOS, and the claim is denied, the claim is bypassed. If the claim is paid and an MMIS provider cannot be identified, reject the claim, placing it on a reject file that will be re-processed daily until the problem with the provider identification has been resolved.
For denied encounter claims where an MMIS provider cannot be identified, move “99999998” to the MMIS provider. If paid encounter claims where an MMIS provider cannot be identified, reject the claim, placing it on a reject file that will be re-processed daily until the problem with the provider identification has been resolved.
Once the MMIS provider is identified, the C-NABP-PROV-ID field on the claim will be populated from the NABP on the provider record.
Medicare:
If the W1C40541-P-SVC-PH-ALT-ID-CD = ‘04’ (Medicare ID), the W1C40541-P-SVC-PHARM-ALT-ID is processed against the P_MCARE_TB and the Provider table to find the pharmacy (Type 416 or 417) Provider ID.
For denied encounter claims where an MMIS provider cannot be identified, move “99999998” to the MMIS provider. If paid encounter claims where an MMIS provider cannot be identified, reject the claim, placing it on a reject file that will be re-processed daily until the problem with the provider identification has been resolved.
3. Will be populated by the MMIS payment cycle.
4. If the input claim is for an adjustment, the program reads the MMIS claims header table using the TCN to credit on the PDCS claim to obtain the original paid date, reimbursement amount, status, and billing provider.
5. For encounter claims, the MMIS managed care provider id is determined from the PDCS drug plan id by reading all of the rows in the Managed Care Plan Detail Table that cover the cycle date. The Managed Care Plan Detail Table contains the corresponding PDCS plan id and recoupment plan id for each of the MCO plans. Then, it compares the plan id / recoupment plan id on the PDCS claim with the plan id from the Plan Detail table. When it finds a match it moves the P_ID from the Plan Detail table into the managed care provider id and the C-HDR-SUBMITTER-ID. For Fee-For-Service claims, the C-HDR-SUBMITTER-ID will be set from the W1C40541-C-IFACE-CLM-ID.
6. The fields on the C_HDR_COE_TB are populated from data contained on the Client COE span table for the client for the date and plan on the PDCS claim. Only non-voided COE spans that contain COE and Fed match combinations that belong under the same drug plan as is shown on the PDCS claim are considered. If the program cannot find a COE span for the claim DOS, the COE & Fed Match Code from the PDCS claim are moved to the C_HDR_COE_TB. If the program cannot find a COE span for the claim DOS, the COE from the PDCS claim is blank, then the transaction will be rejected. If there is more than one COE span for the claim DOS that match the PDCS plan id, then the system classifies the span within eligibility groups and selects a COE span.
On ‘reversal’ transactions, the COE & Fed Match Code from the PDCS input record are used. If the COE value is blank on the PDCS input, then the COE value from the replaced claim will be used. If both COE values are blank, then the transaction will be rejected.
Classify and Prioritize Candidate Eligibility Entries Within Eligibility Groups
In order to assign the appropriate COE to the claim the system sorts all candidate eligibility entries into one of four eligibility groups:
• Regular Medicaid.
• HCBW Medicaid
• QMB
• All state funds
Candidate eligibility entries are assigned to an eligibility group according to the following rules:
• If the federal match code of the eligibility entry is “2” (all state funds), the eligibility group assigned is “state-funded” (including state-funded HCBW).
• If the federal match code is not “2” (all state-funds) and the COE is “041” (QMB) or “044” (QMB aged), the eligibility group is “QMB.”
• If the federal match code is not “2” (all state-funds) and the COE is “090” through “096,” the eligibility group is “HCBW-Medicaid.”
• If none of the above conditions are true, the eligibility group is “regular Medicaid.”
After an eligibility entry is assigned to an eligibility group, the system obtains the Absolute Hierarchy Number for each entry by accessing the COE Edit table.
The order of the four eligibility groups shown above is the order that COEs are assigned. The state wants to pay claims out of regular Medicaid funds first, state funded funds last. However, if one of the COEs is QMB, and the other is for special needs (COE 051, 053, 054) or waivers (085, 097, 098, 099) then the non-QMB takes precedence, even if they are state funded. If there is more than one span within an eligibility group, the span with the lowest Absolute Hierarchy Number is used.
7. The client detail record is read using the client system id from the PDCS claim.
8. The major program code associated with the COE/FM combination assigned to the claim is retrieved from the B_COE_EDIT_TB and is moved to the claim.
9. Concatenate W1C40541-F-FCN-DT and W1C40541-F-FCN-NUM to populate the 15 character C-RLTD-FCN-NUM in MMIS.
10. This note is not used.
11. Check the W1C40541-P-PRSC-ALT-ID-CD to determine the type of ID being sent by PDCS in the prescribing physician field. If the code is ‘12’, it is a DEA number. In that case, read the MMIS provider file to get the most recent, active provider with that DEA for the claim first DOS. Populate C-PRESCR-PROV-ID with the Medicaid provider id from this record. Populate C-PHYS-DEA-ID with the DEA number. If the code is ‘01’, call the NPI Cross-Match Module (CMM) using the NPI and FDOS supplied on the claim to find a NM provider id and populate C-PRESCR-PROV-ID with it. Populate C-PHYS-DEA-ID with the DEA number associated with the NM provider id. If the code is ‘04’, the id is a Medicare id. In that case, use the P-SVC-PHARM-ALT-ID to access the P_MCARE_TB to find a NM provider id and populate C-PRESCR-PROV-ID with it. The DEA numbers are left as blanks.
12. In PDCS X2, this is now a straight move from the input file.
13. Use W1C40541-C-BSE-AMT-SRC-CD from the first line item.
14. The following notes apply to the contingency interface:
W1C40541-CRDHLDR-ALT-ID contains the MMIS B-SYS-ID in the first nine positions, unless the PDCS claim is denied, in which case it is possible that W1C40541-CRDHLDR-ALT-ID contains a client alternate id. If the B-SYS-ID passed from PDCS doesn’t exist on the client tables, then the program tries to locate the client alternate id passed from PDCS on the client alternate id table. If found, the program populates B-SYS-ID with the client system ID found on that table. If not found, and the PDCS claim is a paid claim, then reject the claim.
For the X2 interface, use W1C40541-CRDHLDR-ALT-ID to read the client cross reference table (B_ALT_ID_TB) to get the B-SYS-ID.
For DMERC claims where the W1C40541-B-CRDHLD-ALT-ID-CD = ‘07’, use W1C40541-CRDHLDR-ALT-ID to read the B_DETAIL_TB to get the B-SYS-ID and B_CURR_ID.
15. The PDCS and MMIS TCNs are both 17 digits.
X2 = JJJJJ + M + Bbbb + DDDDDD + A
Where JJJJJ = julian date
M = medium indicator
Bbbb = batch number (B is always ‘0’)
DDDDDD = document number
A = adjustment indicator
becomes:
MMIS = 1 + JJJJJ + M + BBB + DDDDDD + A
Where 1 = hardcoded ‘1’
JJJJJ = julian date
M = medium indicator
BBB = bbb of X2 batch number
DDDDDD = document number
A = adjustment indicator
We effectively add a ‘1’ to the front and drop the high-order digit (always a zero) from the Batch number.
16. The program first reads the claim adjustment table to determine if the W1C40541-C-REPLCD-TCN-NUM is the original TCN in the adjustment chain. It then reads claim history to find the claim being replaced. The current interface doesn’t populate the C-ADJ-SEQ-NUM when creating drug adjustment records. For the contingency, leave it this way unless we have time to figure out how to populate it so the rows are number consecutively beginning with “1”.
17. If PDCS W1C40541-C-SUBM-OTHR-AMT is greater than zero, move spaces to C-DRUG-COB-CHS-IND. Otherwise move PDCS field W1C40541-C-DRUG-TPL-IND to it.
18. Straight move from PDCS (placeholder to keep from having to renumber).
19. For the contingency interface, determine the C-BAT-DOC-TY-CD as it is currently. That is, if W1C40541-R-CUST-ID “NMENCO”, move “E” to MMIS C-BAT-DOC-TY-CD, otherwise, if the last digit of the PDCS TCN is 1 or 2, move “A” (adjustment) else move “C” for Fee for Service. For X2, do the following: If W1C40541-R-CUST-ID “NMENCO”, move “E” to MMIS C-BAT-DOC-TY-CD, otherwise move the PDCS W1C40541-C-BAT-DOC-TY-CD.
20. Accumulate the amounts in W1C40541-C-LI-ING-ALLOW-AMT for all of the line items, then subtract (W1C40541-C-DISP-FEE-AMT + W1C40541-C-TOT-TPL-AMT + W1C40541-C-TOT-COPAY-AMT).
21. The interface program reviews all occurrences of W1C40541-C-PYR-HIERARCHY-CD. If there is a non-blank value, move “Y” to C-DRUG-COB-IND.
22. The interface program determines C-COS-CD from W1C40541-R-DRG-THR-CHAR3-CD as follows. (For the C-COS-CD on the claims main header table, use the W1C40541-R-DRG-THR-CHAR3-CD from the first line item) :
|PDCS W1C40541-R-DRG-THR-CHAR3-CD |MMIS C-COS-CD |
|G8A THRU G8C |60 (Family Planning) |
|G9A | |
|X1A THRU X1C | |
|G8F | |
|G9B | |
|C5A THRU C5U |43 (Med Supply) |
|X0A THRU Y9Z | |
|C1W | |
|U6W | |
|All others | |
|If P-IHS-IND = ‘Y’, |23 (IHS Outpatient Hospital) |
|otherwise |13 (prescribed drug) |
23. In PDCS X2, this is now just a straight move.
24. A row is written to the MMIS C_LI_BSE_CHG_TB only if the PDCS W1C40541-C-TOT-COPAY-AMT is greater than zero.
25. In PDCS X2, this is now just a straight move.
26. Use W1C40541-C-PRIOR-AUTH-IND from the first line item.
27. For the contingency, no rows will be written to the MMIS Medicare table. For X2, it will need to be populated for drug crossovers.
28. If the CAS reason code is “3”, the group code is set to “PR”, otherwise it is set to “CO”. Leading zeros are stripped from W1C40541-X12835-ARC before moving it to C-CAS-RSN-CD.
29. Straight move from PDCS (placeholder to keep from having to renumber).
30. For the contingency, replace the leading blank on the pdcs adjustment reason with a zero. For X2, we can probably just do a direct move.
31. For paid, non-encounter claims with an indicator from PDCS showing that there is other coverage and it should be considered a “pay & chase” situation (W1C40541-C-DRUG-TPL-IND = “Y”), the system attempts to insert rows to the MMIS claim TPL line item table. It will insert rows to this table only if it finds data for the client on the MMIS TPL client, policy, and coverage tables for the date of service on the claim, with standard drug or HMO drug coverage, and with one of the following resources: Absent Parent, Casualty, EPSDT, Health Insurance, Other Insurance, Pregnant, Unassigned. One row is written for each unique carrier/policy/coverage/resource combination. Along with inserting rows to this table, the program writes a sequential extract record that will be used by the TPL subsystem to add rows to the TPL billing table.
32. The W1C40541-R-PLAN-ID is translated to the B-LCKN-TY-CD using the following table:
|W1C40541-R-PLAN-ID |B-LCKN-TY-CD |
|796, 797, 808, 809, 814, 815 |MCO |
|816, 817 |PDL |
|850, 851, 857, 858, 859, 860, 861, 862 |SCI |
|855, 856 |SEB |
The B-SYS-ID, B-LCKN-TY-CD, and W1C40541-HDR-SVC-FST-DT are then used to fetch the H-PLN-NUM and H-PLN-TY-CD from the H_PLN_DETAIL_TB and the B_MC_COHRT_HST_TB where the B_SYS_ID and B_LCKN_TY_CD are on the B_MC_COHRT_HST_TB, the H_PLN_TY_CD is equal on both tables and both tables have a date range that includes the W1C40541-HDR-SVC-FST-DT.
33. The FCN fields on the C_HDR_ADJ_VD_TB are populated in the row added for the adjustment. This is the row that shows the adjustment TCN and points back to the claim being adjusted. The FCN fields are initialized to blank and low date for the row on the C_HDR_ADJ_VD_TB that is added for the original TCN, which shows what claim is replacing it.
34. The Medicare Header Table is only populated for DMERC claims (Medicare pharmacy part B crossover, or C-HDR-TY-CD = ‘K’). The program will determine a claim is a DMERC claim by looking at the PDCS plan id in field W1C40541-R-PLAN-ID. If it is one of the following plans, the claim is a DMERC claim:
• 021 QMB Medicare Crossover Plan
• 031 Medicare D Nursing Home Medicare Crossover Plan
• 041 Medicare D Fee For Service Medicare Crossover Plan
• 101 Hospice Medicare Crossover Plan
• 301 Nursing Home Medicare Crossover Plan
• 401 Fee for Service Medicare Crossover Plan
• 421 MCO Medicre Crossover Plan
• 501 Working Disabled Medicare Crossover Plan
• 601 SCHIP Medicare Crossover Plan
• 901 QMB & State Waivers Medicare Crossover Plan
• 911 CMS Medicare Crossover Plan
This list of PDCS DMERC plan ids is maintained on the MMIS System List 4912.
35. There can be three occurrences where W1C40541-C-PAYERID-PD-CD = ‘99’, and the three different fields are positional.
1st occurrence - Patient’s Deductible Amount
2nd occurrence - Patient’s Coinsurance Amount
3rd occurrence - Patient’s Copay Amount
36. Use the PDCS plan id in field W1C40541-R-PLAN-ID to read the MMIS System List 4912. If the plan is on the system list, then it is claim type ‘K’, otherwise it is claim type “R”.
37. If the claim is a CRDTOFADJS claim (C-HDR-TXN-TY-CD = ‘2’) then C-BLNG-PROV-ID, C-BLNG-PROV-TY-CD, F-RSN-CD, H-PLN-TY-CD, B-COE-CD, and B-FED-MTCH-CD will be carried over from the original claim instead of being recalculated.
____________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE
MMIS WARRANT STATE TREASURY INTERFACE
|Description: |
|This interface reads the Payorder Check Record file produced during payment processing and creates the State Check transaction file to be sent to the State Treasurer. |
|Source File: |File Description: |
|Payorder Check Record File |Created during payment process. Contains a record for each warrant produced. |
|Target Files: |File Description: |
|MMIS warrant Interface file to the State Treasury. |Detail transaction for each warrant produced by the MMIS in the payment cycle. One warrant balance record |
| |is written as the last record on the file. To be sent to the State Treasury for processing. |
| | |
|Reports: |
|N/A |
|Remarks: |
|Per project 241794, the warrant file has been separated so that now there are two warrant files produced for the State treasury. One file is for the issued warrants and one is for the |
|cancelled warrants. Each uses the same layout and specifications detailed below. |
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE LAYOUT
OUTPUT FILE
MMIS WARRANT STATE TREASURY INTERFACE
01 WARRANT-BAL-REC.
05 WARRANT-BAL-AMOUNT PIC 9(10)V99 VALUE ZERO.
05 FILLER PIC X(05) VALUE SPACES.
05 WARRANT-BAL-NUM PIC 9(07) VALUE 9999999.
05 WARRANT-BAL-SOURCE PIC X VALUE 'P'.
05 WARRANT-BAL-COUNT PIC 9(7) VALUE ZERO.
05 FILLER PIC X(88) VALUE SPACES.
01 WARRANT-DETAIL.
05 WARRANT-DTL-AMOUNT PIC 9(09)V99 VALUE ZERO.
05 WARRANT-DTL-VOUCHER PIC 9(06) VALUE ZERO.
05 WARRANT-DTL-NUMBER PIC 9(06) VALUE ZERO.
05 WARRANT-DTL-SOURCE PIC X VALUE 'P'.
05 WARRANT-DTL-AGENCY PIC X(03) VALUE '630'.
05 WARRANT-DTL-ACCOUNT PIC XX VALUE '05'.
05 WARRANT-DTL-ISS-DATE.
SET TO ZERO ON VOID TRANSACTIONS
10 WARRANT-DTL-ISS-MM PIC 99 VALUE ZERO.
10 WARRANT-DTL-ISS-DD PIC 99 VALUE ZERO.
10 WARRANT-DTL-ISS-YY PIC 99 VALUE ZERO.
05 WARRANT-DTL-CXL-DATE.
SET TO ZERO ON ISSUE TRANSACTIONS
10 WARRANT-DTL-CXL-MM PIC 99 VALUE ZERO.
10 WARRANT-DTL-CXL-DD PIC 99 VALUE ZERO.
10 WARRANT-DTL-CXL-YY PIC 99 VALUE ZERO.
05 WARRANT-DTL-PAYEE PIC X(24) VALUE SPACES.
05 WARRANT-DTL-TCODE PIC XX VALUE '90'.
05 WARRANT-DTL-SIGN PIC X VALUE '+'. SET TO '-' ON VOID TRANSACTIONS
05 FILLER PIC X(51) VALUE SPACES.
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
MMIS WARRANT STATE TREASURY INTERFACE
DETAIL RECORD
|Source Table |Source Field |Target Field | Req | | |Note |
| | | | |Def |Specifications |Ref |
|N/A |N/A |WARRANT-DTL-VOUCHER |N/A |N/A |Zeros | |
|N/A |PAY-CHK-9-CHECK-NUM |WARRANT-DTL-NUMBER |N/A |N/A | | |
|N/A |N/A |WARRANT-DTL-SOURCE |N/A |N/A |Value of “P” | |
|N/A |N/A |WARRANT-DTL-AGENCY |N/A |N/A |Value of “630” | |
|N/A |N/A |WARRANT-DTL-ACCOUNT |N/A |N/A |Value of “05” | |
|N/A |PAY-CHK-CHECK-DATE |WARRANT-DTL-ISS-DATE |N/A |N/A |If PAY-CHK-REC-TYPE not = “S” or “V”, else move zeros | |
| | | | | |to WARRANT-DTL-ISS-DATE | |
|N/A |PAY-CHK-CHECK-DATE |WARRANT-DTL-CXL-DATE |N/A |N/A |If PAY-CHK-REC-TYPE = “S” or “V”, else move zeros to | |
| | | | | |WARRANT-DTL-CXL-DATE | |
|N/A |PAY-CHK-PAYEE-NAME |WARRANT-DTL-PAYEE |N/A |N/A | | |
|N/A |N/A |WARRANT-DTL-TCODE |N/A |N/A |Value of “90” | |
|N/A |N/A |WARRANT-DTL-SIGN |N/A |N/A |Value of “-“ if PAY-CHK-REC-TYPE not = “S” or “V”, | |
| | | | | |else Value of “+”. | |
________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
MMIS WARRANT STATE TREASURY INTERFACE
BALANCE RECORD
|Source Table |Source Field |Target Field | Req | | |Note |
| | | | |Def |Specifications |Ref |
|N/A |N/A |WARRANT-BAL-NUM |N/A |N/A |9999999 | |
|N/A |N/A |WARRANT-BAL-SOURCE |N/A |N/A |Value of “P” | |
|N/A |N/A |WARRANT-BAL-COUNT |N/A |N/A |Total count of warrants produced, not including | |
| | | | | |PAY-CHK-REC-TYPE = “S” (spoiled) | |
________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE
CAPITATION TAPE RA INTERFACE
|Description: |
|This program takes the weekly claims file and extracts all capitation claims for each of the managed care providers. Data is then extracted from each claim record and used to format the MCO |
|claims detail extract record. In addition, for each provider, summing the debit/credit amounts from each provider’s group of claims generates a ‘total’ record. |
|Source Tables: |
|Claim Header Table (C_HDR_TB) |
|Claim Line Item Table (C_LI_TB) |
|Claim Exception Table (C_LI_EXC_TB) |
|Target Files: |
|MCO Weekly Claims Extract File |
|Reports: |
|N/A |
|Remarks: |
|N/A |
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE LAYOUT
OUTPUT FILE
CAPITATION TAPE RA INTERFACE
01 WFC47050-CLAIMS-EXTRACT-REC.
05 WFC47050-DETAIL-REC.
10 WFC47050-REC-TYPE PIC X(1).
88 DETAIL-RECORD VALUE '1'.
10 WFC47050-C-BLNG-PROV-ID PIC X(9).
10 WFC47050-C-HDR-SVC-FST-DT PIC 9(08).
10 WFC47050-C-HDR-SVC-FST-DT-RE REDEFINES
WFC47050-C-HDR-SVC-FST-DT.
15 WFC47050-C-HDR-SVC-FST-CC PIC X(02).
15 WFC47050-C-HDR-SVC-FST-YY PIC X(02).
15 WFC47050-C-HDR-SVC-FST-MM PIC X(02).
15 WFC47050-C-HDR-SVC-FST-DD PIC X(02).
10 WFC47050-C-HDR-SVC-LST-DT PIC 9(08).
10 WFC47050-C-HDR-SVC-LST-DT-RE REDEFINES
WFC47050-C-HDR-SVC-LST-DT.
15 WFC47050-C-HDR-SVC-LST-CC PIC X(02).
15 WFC47050-C-HDR-SVC-LST-YY PIC X(02).
15 WFC47050-C-HDR-SVC-LST-MM PIC X(02).
15 WFC47050-C-HDR-SVC-LST-DD PIC X(02).
10 WFC47050-C-HDR-PD-DT PIC 9(08).
10 WFC47050-C-HDR-PD-DT-RE REDEFINES
WFC47050-C-HDR-PD-DT.
15 WFC47050-C-HDR-PD-CC PIC X(02).
15 WFC47050-C-HDR-PD-YY PIC X(02).
15 WFC47050-C-HDR-PD-MM PIC X(02).
15 WFC47050-C-HDR-PD-DD PIC X(02).
10 WFC47050-BILLED-CHARGES PIC S9(7)V99
SIGN TRAILING SEPARATE.
10 WFC47050-BILLED-CHARGES-RE REDEFINES
WFC47050-BILLED-CHARGES
PIC X(10).
10 WFC47050-C-TOT-REIMB-AMT PIC S9(7)V99
SIGN TRAILING SEPARATE.
10 WFC47050-C-TOT-REIMB-AMT-RE REDEFINES
WFC47050-C-TOT-REIMB-AMT PIC X(10).
10 WFC47050-C-HDR-RA-NUM PIC 9(09).
10 WFC47050-C-HDR-RA-NUM-RE REDEFINES
WFC47050-C-HDR-RA-NUM PIC X(09).
10 WFC47050-C-HDR-STAT-CD PIC X.
88 WFC47050-STAT-ACCEPTED VALUE 'A'.
88 WFC47050-STAT-TO-BE-DENIED VALUE 'C'.
88 WFC47050-STAT-DENIED VALUE 'D'.
88 WFC47050-STAT-IN-PROCESS VALUE 'I'.
88 WFC47050-STAT-TO-BE-PAID VALUE 'O'.
88 WFC47050-STAT-PAID VALUE 'P'.
88 WFC47050-STAT-SUSPENDED VALUE 'S'.
10 WFC47050-B-CURR-ID PIC X(14).
10 WFC47050-RECIP-MCD-CARD-ID-NO
PIC X(14).
10 WFC47050-RECIP-NAME.
15 WFC47050-B-LAST-NAM PIC X(21).
15 WFC47050-B-FST-NAM PIC X(15).
15 WFC47050-B-MI-NAM PIC X.
10 WFC47050-C-TCN-NUM PIC 9(17).
10 WFC47050-C-HDR-TXN-TY-CD PIC X(01).
88 WFC47050-TXN-TY-ORIG VALUE '0'.
88 WFC47050-TXN-TY-VOID VALUE '1'.
88 WFC47050-TXN-TY-CREDIT VALUE '2'.
88 WFC47050-TXN-TY-DEBIT VALUE '3'.
10 WFC47050-PROC-CODE.
15 WFC47050-R-PROC-CD PIC X(05).
15 FILLER PIC X(06).
10 WFC47050-C-HDR-PAT-ACCT-NUM PIC X(20).
10 WFC47050-ERRORS OCCURS 10 TIMES
INDEXED BY WFC47050-ERRORS-X1.
15 WFC47050-R-CLM-EXC-CD PIC X(04).
15 WFC47050-C-EXC-STAT-CD PIC X(01).
10 WFC47050-B-COE-CD PIC X(03).
10 WFC47050-R-REV-TY-CD PIC X(01).
10 WFC47050-H-COHRT-NUM PIC X(03).
10 FILLER PIC X(15).
05 WFC47050-TOTAL-REC REDEFINES WFC47050-DETAIL-REC.
10 WFC47050-REC-TYPE PIC X(1).
88 TOTAL-RECORD VALUE '9'.
10 WFC47050-TOT-PROV-NO PIC X(9).
10 FILLER PIC X(25).
10 WFC47050-TOT-PAY-AMT PIC S9(9)V99
SIGN TRAILING SEPARATE.
10 FILLER PIC X(184).
10 WFC47050-TOT-REV-TY-CD PIC X(01).
10 FILLER PIC X(18).
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
CAPITATION TAPE RA INTERFACE
|Source |Source |Target | | | |Note |
|Table |Column |Field |Req |Def |Specifications |Ref |
|C_HDR_TB |C_MC_PROV_ID |WFC47050-C-BLNG-PROV-ID |N/A |N/A | | |
|C_HDR_TB |C_HDR_SVC_FST_DT |WFC47050-C-HDR-SVC-FST-DT |N/A |N/A | | |
|C_HDR_TB |C_HDR_SVC_LST_DT |WFC47050-C-HDR-SVC-LST-DT |N/A |N/A | | |
|C_HDR_TB |C_HDR_PD_DT |WFC47050-C-HDR-PD-DT |N/A |N/A | | |
|C_LI_TB |C_LI_SUBM_CHRG_AMT |WFC47050-BILLED-CHARGES |N/A |N/A | | |
|C_HDR_TB |C_TOT_REIMB_AMT |WFC47050-C-TOT-REIMB-AMT |N/A |N/A | | |
|C_HDR_TB |C_HDR_RA_NUM |WFC47050-C-HDR-RA-NUM |N/A |N/A | | |
|C_HDR_TB |C_HDR_STAT_CD |WFC47050-C-HDR-STAT-CD |N/A |N/A | | |
|C_HDR_TB |B_SYS_ID |WFC47050- RECIP-MCD-CARD-ID-NO |N/A |N/A |This is the “swipe card” id. | |
|C_HDR_TB |B_ALT_ID |WFC47050-B-ORIG-ID |N/A |N/A |This will be the B_ALT_ID with the earliest date | |
| | | | | |on the file | |
|C_HDR_TB |B_FST_NAM |WFC47050-B-LAST-NAM WFC47050-B-FST-NAM |N/A |N/A | | |
| |B_LAST_NAM |WFC47050-B-MI-NAM | | | | |
| |B_MI_NAM | | | | | |
|C_HDR_TB |C_PHP_TCN_DAT |WFC47050-C-TCN-NUM |N/A |N/A | | |
|C_HDR_TB |C_HDR_TXN_TY_CD |WFC47050-C-HDR-TXN-TY-CD |N/A |N/A | | |
|C_LI_TB |R_PROC_CODE |WFC47050-R-PROC-CD |N/A |N/A | | |
|C_HDR_TB |C_HDR_PAT_ACCT_DAT |WFC47050-C-HDR-PAT-ACCT-NUM |N/A |N/A |Not currently mapped | |
|C_LI_EXC_TB |R_CLM_EXC_CD |WFC47050-R-CLM-EXC-CD |N/A |N/A |For all claim exceptions (both header and line | |
| | | | | |level) | |
|C_LI_EXC_TB |R_CLM_EXC_DISP_CD |WFC47050-C-EXC-STAT-CD |N/A |N/A |For all claim exceptions (both header and line | |
| | | | | |level) | |
|C_HDR_TB |B_COE_CD |WFC47050-B-COE-CD |N/A |N/A | | |
|C_LI_TB |R-REV-TY-CD |WFC47050-R-REV-TY-CD |N/A |N/A | | |
|X_LI_CAP_TB |H_COHRT_NUM |WFC47050-H-COHRT-NUM |N/A |N/A | | |
| | |WFC47050-REC-TYPE |N/A |9(01) |9 = Total Record | |
|C_HDR_TB |C_MC_PROV_ID |WFC47050-TOT-PROV-NO |N/A |N/A | | |
|C_HDR_TB |C_TOT_REIMB_AMT |WFC47050-TOT-PAY-AMT |N/A |N/A |Sum of WFC47050-C-TOT-REIMB-AMT | |
|C_LI_TB |R-REV-TY-CD |WFC47050-TOT-REV-TY-CD |N/A |N/A | | |
________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE
WAIVER PROGRAMS PAID AND DENIED CLAIMS INTERFACE
WAIVER PROGRAMS SUSPENDED CLAIMS INTERFACE
|Description: |
|This program takes the weekly claims file and extracts all waiver claims. Data is extracted from each claim record and used to format a file for the New Mexico Department of Health. |
|Source Tables: |
|Claim Header Table (C_HDR_TB) |
|Target Files: |
|DOH Weekly Waiver Paid and Denied Claims Extract File |
|DOH Weekly Waiver Suspended Claims Extract File |
|Reports: |
|N/A |
|Remarks: |
|There are 2 physical tape extracts coming out of this process with the exact same file layout. File one is for the paid and denied claims. File two is for the suspended claims. |
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE LAYOUT
OUTPUT FILE
WAIVER PROGRAMS PAID AND DENIED CLAIMS INTERFACE
WAIVER PROGRAMS SUSPENDED CLAIMS INTERFACE
01 CLM-HIST-BASE-EXTRACT-REC.
05 CLM-HIST-UNIQUE-KEY.
10 CLM-INTERNAL-CNTL-NUM PIC 9(17).
10 FILLER PIC X(01).
05 CLM-BATCH-TYPE PIC X(02).
05 FILLER PIC X(01).
05 CLM-CLAIM-TYPE PIC X(01).
05 FILLER PIC X(01).
05 C_HDR_TXN_TY_CD PIC X(01)
05 CLM-BILL-PROVIDER-NUM PIC X(08).
05 FILLER PIC X(01).
05 FILLER PIC X(01).
05 B_Sys_id PIC 9(9)
05 RCP-ORIGINAL-ID-NUMBER PIC 9(14).
05 FILLER PIC X(01).
05 RCP-CURRENT-ID-NUMBER PIC 9(14).
05 FILLER PIC X(01).
05 DRH-RECIP-FIRST NAME PIC X(15)
05 DRH-RECIP-MIDDLE-INIT PIC X(1)
05 DRH-RECIP-LAST NAME PIC X(21)
05 CLM-RECIP-BIRTHDATE PIC 9(08).
05 FILLER PIC X(01).
05 LINE ITEM # PIC 9(XX)
05 PRC-BASE-PROC-CODE PIC X(07).
05 FILLER PIC X(01).
05 CLM-BASE-PROC-MODIFIER PIC X(02).
05 FILLER PIC X(01).
05 CLM-BASE-PROC-MODIFIER-2 PIC X(02).
05 FILLER PIC X(01)
05 CLM-BASE-PROC-MODIFIER-3 PIC X(02).
05 FILLER PIC X(01).
05 CLM-BASE-PROC-MODIFIER-4 PIC X(02)
05 FILLER PIC X(01).
05 FILLER PIC X(01).
05 FILLER PIC X(01).
05 CLM-LINE ITEM SUBMITTED UNITS-OF-SVC PIC +99999.99.
05 FILLER PIC X(01).
05 CLM-LINE ITEM UNITS-ALLOWED PIC +99999.99.
05 FILLER PIC X(01).
05 CLM-LINE ITEM SVC-DATE-FROM PIC 9(08).
05 FILLER PIC X(01).
05 CLM-LINE ITEM SVC-DATE-THRU PIC 9(08).
05 FILLER PIC X(01).
05 C-LI-REIMB_STAT_CD PIC X(01)
05 CLM-BILLING-DATE PIC 9(08).
05 FILLER PIC X(01).
05 CLM-PAYMENT-DATE PIC 9(08).
05 FILLER PIC X(01).
05 CLM-BILLED-AMT-LI PIC +9999999.99.
05 FILLER PIC X(01).
05 CLM-TOT-BILLED-AMT PIC +9999999.99.
05 FILLER PIC X(01).
05 CLM-TPL-PAYMENT-LI PIC +9999999.99.
05 FILLER PIC X(01).
05 CLM-TPL-TOTAL-PAID PIC +9999999.99.
05 FILLER PIC X(01).
05 CLM-LINE ITEM ALLOWED-AMOUNT PIC +9999999.99.
05 FILLER PIC X(01).
05 CLM-LINE ITEM AMOUNT-PAID PIC +9999999.99.
05 CLM-ERROR-LI-NUM PIC 9 (3)
05 CLM-LI-ERROR-CODE PIC X(4)
05 CLM-LI-ERROR-STATUS-CD PIC X(1)
05 CLM-LI-ERROR-DESCRIPTION PIC X(30)
05 FILLER PIC X(01).
05 CLM-PA-NUMBER PIC X(11).
05 CLM PA LI NUMBER PIC 9(XX)
05 FILLER PIC X(01).
05 FILLER PIC X(01).
05 FILLER PIC X(01).
05 CLM-DIAGNOSIS-1 PIC X(10).
05 FILLER PIC X(01).
05 CLM-DIAGNOSIS-2 PIC X(10).
05 FILLER PIC X(01).
05 CLM-DIAGNOSIS-3 PIC X(10).
05 FILLER PIC X(01).
05 CLM-DIAGNOSIS-4 PIC X(10).
05 FILLER PIC X(01).
05 CLM-DIAGNOSIS-5 PIC X(10).
05 FILLER PIC X(01).
05 CLM-COST-CENTER PIC X(10).
05 FILLER PIC X(01).
05 CLM-FORMER-ICN PIC 9(17).
05 FILLER PIC X(01).
05 RCP-SEX-CODE PIC X(01).
05 FILLER PIC X(01).
05 RCP-ELIG-CATEGORY PIC X(03).
05 FILLER PIC X(01).
05 RCP-FEDERAL-MATCH-CODE PIC X(01).
05 FILLER PIC X(01).
05 RCP-GEO-COUNTY-CODE PIC X(02).
05 FILLER PIC X(01).
05 RCP-ADMIN-COUNTY-CODE PIC X(02).
05 FILLER PIC X(01).
05 CLM-BILLING-PROV-TYPE PIC X(03).
05 FILLER PIC X(01).
05 CLM-BILLING-PROV-SPEC PIC X(03).
05 FILLER PIC X(01).
05 CLM-BILL-PRV-LOCATION PIC X(03).
05 FILLER PIC X(01).
05 CLM-BILL-PRV-CNTY-IND PIC X(01).
05 FILLER PIC X(01).
05 FILLER PIC X(01).
05 CLM-REMITTANCE-ID PIC 9(07).
05 FILLER PIC X(01).
05 CLM-CHECK-NUMBER PIC 9(11).
05 FILLER PIC X(01).
05 CLM-SVC-PRV-CAT-OF-SVC PIC X(02).
05 FILLER PIC X(01).
05 CLM-CLAIM-STATUS PIC X(01).
05 CLM-CREDIT-CODE PIC X(01)
05 FILLER PIC X(01).
05 FILLER PIC X(01).
05 CLM-TAX-AMOUNT PIC +99999.99.
05 FILLER PIC X(01).
05 CLM-RECIPIENT-AGE PIC 9(03).
05 FILLER PIC X(01).
05 FILLER PIC X(01).
05 FILLER PIC X(01).
05 FILLER PIC X(01).
05 FILLER PIC X(01).
05 FILLER PIC X(01).
05 CLM-ADJUSTMENT PIC X(02).
05 FILLER PIC X(01).
05 FILLER PIC X(01).
05 FILLER PIC X(01).
05 FILLER PIC X(01).
05 FILLER PIC X(01).
05 FILLER PIC X(01).
05 CLM-MEDICAL-REC-NO PIC X(15).
05 FILLER PIC X(01).
05 CLM-DATE-TIME.
10 CLM-AUDIT-TIME PIC X(10).
10 FILLER PIC X(02).
05 FILLER PIC X(01).
05 CLM-UNITS-REIMBURSED PIC +9999999.99.
05 E-SIGN01 PIC X(01).
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
WAIVER PROGRAMS PAID AND DENIED CLAIMS INTERFACE
WAIVER PROGRAMS SUSPENDED CLAIMS INTERFACE
|Source |Source |Target | | | |Note |
|Table |Column |Field |Req |Def |Specifications |Ref |
| |C-BAT-TY-CD |CLM-INVOICE-TYPE |N/A | | | |
|C_HDR_TB |C_HDR_TY_CD |CLM-CLAIM-TYPE |N/A | | | |
|C_HDR_TB |C_HDR_TXN_TY_CD |C_HDR_TXN_TY_CD | | | | |
|C_HDR_TB |C_BLNG_PROV_ID |CLM-BILL-PROVIDER-NUM |N/A | | | |
|C_HDR_TB |B_SYS_ID |RCP-SYSTEM-ID-NUMBER |N/A |Zeros | | |
|C_HDR_TB |B_ALT_ID |RCP-ORIGINAL-ID-NUMBER |N/A |Zeros | | |
|C_HDR_TB |B_SYS_ID |RCP-CURRENT-ID-NUMBER |N/A |Zeros | | |
|C_HDR_TB |B_FST_NAM |RCP-FIRST-NAME | | | | |
|C_HDR_TB |B_MI_NAM |RCP-MI | | | | |
|C_HDR_TB |B_LAST_NAM |RCP-LAST-NAME | | | | |
|C_HDR_TB |B_DOB_DT |CLM-RECIP-BIRTHDATE |N/A |Zeros | | |
|C_LI_TB |C_LI_NUM |CLM – LINE ITEM NUMBER |N/A | | | |
|C_LI_TB |R_PROC_CD |PRC-BASE-PROC-CODE |N/A | | | |
|C_LI_TB |C_PROC_MOD_1ST_CD |CLM-BASE-PROC-MODIFIER |N/A | | | |
|C_LI_TB |C_PROC_MOD_2ND_CD |CLM-BASE-PROC-MODIFIER-2 |N/A | | | |
|C_LI_TB |C_PROC_MOD_3RD_CD |CLM-BASE-PROC-MODIFIER-3 |N/A | | | |
|C_LI_TB |C_PROC_MOD_4TH_CD |CLM-BASE-PROC-MODIFIER-4 |N/A | | | |
|C_LI_TB |C_LI_SUBM_UNT_NUM |CLM-LI-SUBM-UNITS-OF-SVC |N/A |Zeros | | |
|C_LI_TB |C_LI_ALLOW_UNT_NUM |CLM-LI-UNITS-ALLOWED |N/A |Zeros | | |
|C_LI_TB |C_LI_REIMB_UNT_NUM |CLM-LI-UNITS REIMB | | | | |
|C_LI_TB |C_LI_FST_DOS_DT |CLM-LI-SVC-DATE-FROM |N/A |Zeros | | |
|C_LI_TB |C_LI_LAST_DOS_DT |CLM-LI-SVC-DATE-THRU |N/A |Zeros | | |
|C_LI_TB |C-REIMB_STAT_CD |C-LI-REIMB_STAT_CD | | | | |
|C_HDR_TB |C_BILLED_DT |CLM-BILLING-DATE |N/A |Zeros | | |
|C_HDR_TB |C_HDR_PD_DT |CLM-PAYMENT-DATE |N/A | | | |
|C_HDR_TB |C_HDR_ORIG_PD_DT | |N/A | | | |
|C_LI_TB |C_LI_SUBM_CHRG_AMT |CLM-BILLED-AMT-LI |N/A |Zeros | | |
|C_HDR_TB |C_TOT_CHRG_AMT |CLM-TOT-BILLED-AMT |N/A |Zeros | | |
| | |CLM-TPL-PAYMENT-LI |N/A |Zeros | | |
|C_HDR_TB |C_TOT_TPL_AMT |CLM-TPL-TOTAL-PAID |N/A |Zeros | | |
|C_LI_TB |C_LI_ALLW_CHRG_AMT |CLM-LI-ALLOWED-AMOUNT |N/A |Zeros | | |
|C_LI_TB |C_LI_REIMB_AMT |CLM-LI-AMOUNT-PAID |N/A |Zeros | | |
|C_LI_EXC_TB |C_LI_NUM |CLM-ERROR-LI-NUM | | | | |
|C_LI_EXC_TB |R_CLM_EXC_CD |CLM-LI-ERROR-CODE | | | |1 |
|C_LI_EXC_TB |C_EXC_STAT_CD |CLM-LI-ERROR-STATUS-CD | | | | |
|R_CLM_EXC_TB |R_EXC_SHORT_DESC |CLM-LI-ERROR-DESCRIPTION | | | | |
|C_HDR_TB |A_ID |CLM-PA-NUMBER |N/A | | | |
|C_LI_TB |A_LI_NUM |CLM-PA-LI-NUMBER |N/A | | | |
|C_HDR_DIAG_TB |R_DIAG_CD |CLM-DIAGNOSIS-1 |N/A | | | |
|C_HDR_DIAG_TB |R_DIAG_CD |CLM-DIAGNOSIS-2 |N/A | | | |
|C_HDR_DIAG_TB |R_DIAG_CD |CLM-DIAGNOSIS-3 |N/A | | | |
|C_HDR_DIAG_TB |R_DIAG_CD |CLM-DIAGNOSIS-4 |N/A | | | |
|C_HDR_DIAG_TB |R_DIAG_CD |CLM-DIAGNOSIS-5 |N/A | | | |
|C_HDR_TB |C_COST_CENTER_CD |CLM-COST-CENTER |N/A | | | |
|C_HDR_ADJ_VD_TB |C_REPLACED_TCN_NUM |CLM-FORMER-ICN |N/A |Zeros | | |
|C_HDR_TB |B_GENDER_CD |RCP-SEX-CODE |N/A |Spaces | | |
|C_HDR_COE_TB |B_COE_CD |RCP-ELIG-CATEGORY |N/A |Zeros | | |
|C_HDR_COE_TB |B_FED_MTCH_CD |RCP-FEDERAL-MATCH-CODE |N/A |Zeros | | |
|C_HDR_COE_TB |B_GEO_CNTY_CD |RCP-GEO-COUNTY-CODE |N/A |Zeros | | |
|C_HDR_COE_TB |B_ADMIN_CNTY_CD |RCP-ADMIN-COUNTY-CODE |N/A |Zeros | | |
|C_HDR_TB |C_BLNG_PROV_TY_CD |CLM-BILLING-PROV-TYPE |N/A | | | |
|P_SPECL_TB |P_SPECL_CD |CLM-BILLING-PROV-SPEC |N/A | | | |
|P_ADDR_TB |P_CNTY_CD |CLM-BILL-PRV-LOCATION |N/A |Zeros | | |
|P_PROV_TB |P_LOCN_CD |CLM-BILL-PRV-CNTY-IND |N/A |Zeros | | |
|C_PROV_PMT_HIST_TB |C_HDR_RA_NUM |CLM-REMITTANCE-ID |N/A |Zeros | | |
|C_PROV_PMT_HIST_TB |C_HDR_WARR_NUM |CLM-CHECK-NUMBER |N/A |Zeros | | |
|C_LI_TB |C_COS_CD |CLM-SVC-PRV-CAT-OF-SVC |N/A | | | |
|C_HDR_TB |C_HDR_STAT_CD |CLM-CLAIM-STATUS |N/A | | | |
|C_HDR_TB |C-CREDIT CD |CLM-CREDIT -CODE | | | | |
|C_LI_BSE_CHG_TB |C_BASE_AMT_CHG_AMT |CLM-TAX-AMOUNT |N/A |Zeros | | |
| |If C_BSE_CHNG_RSN_CD = 07 | | | | | |
|C_HDR_TB |C_HDR_CLNT_AGE |CLM-RECIPIENT-AGE |N/A |Zeros | | |
|C_HDR_TB |C_HDR_TXN_TY_CD |CLM-ADJUSTMENT |N/A | | | |
|C_HDR_TB |C_HDR_PAT_ACCT_NUM |CLM-MEDICAL-REC-NO |N/A | | | |
|C_HDR_TB |G-AUD-DT |CLM-AUDIT-DATE | | | | |
|C_LI_TB |C-LI-REIMB-UNT-NUM |CLM-UNITS-REIMBURSED | | | | |
Notes:
1. Layout only accommodates one exception code. Therefore the first denied exception is reported. If none found then the first denied-rpt exception is reported. If none found then the first force-deny exception is reported. If none found then the first exception found is reported.
________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE
IMMUNIZATION CLAIMS INTERFACE
(OBSOLETE)
|Description: |
|This program takes the weekly claims file and extracts all immunization claims for clients under 21. Data is extracted from each claim record and used to format a file for the New Mexico |
|Department of Health. |
|Source Tables: |
|Claim Header Table (C_HDR_TB) |
|Target Files: |
|DOH Weekly Immunization Claims Extract File |
|Reports: |
|N/A |
|Remarks: |
|N/A |
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE LAYOUT
OUTPUT FILE
IMMUNIZATION CLAIMS INTERFACE
(OBSOLETE)
01 NMCE-CLMS-EXTRACT-REC.
05 NMCE-RECIP-SSN-ID PIC X(14).
05 NMCE-RECIP-NAME PIC X(36).
05 NMCE-RECIP-DOB PIC X(08).
05 NMCE-RECIP-SEX PIC X(01).
05 NMCE-RECIP-RACE PIC X(02).
05 NMCE-RECIP-MAIL-ADDR-1 PIC X(25).
05 NMCE-RECIP-MAIL-ADDR-2 PIC X(25).
05 NMCE-RECIP-MAIL-CITY PIC X(15).
05 NMCE-RECIP-MAIL-STATE PIC X(02).
05 NMCE-RECIP-MAIL-ZIP PIC X(05).
05 NMCE-PAYEE-NAME PIC X(35).
05 NMCE-BILLING-PROV-NO PIC X(09).
05 NMCE-FROM-DOS PIC X(08).
05 NMCE-PROCEDURE PIC X(05).
05 NMCE-PROC-MOD PIC X(02).
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
IMMUNIZATION CLAIMS INTERFACE
(OBSOLETE)
|Source |Source |Target | | | |Note |
|Table |Column |Field |Req |Def |Specifications |Ref |
|B_DETAIL_TB |R-SOC-SEC-NO |B_SSN_NUM |N/A | | | |
|B_DETAIL_TB |R-RECIP-NAME |B_LAST_NAM |N/A | | | |
|B_DETAIL_TB | |B_FST_NAM |N/A | | | |
|B_DETAIL_TB |R-RECIP-DATE-OF-BIRTH |B_DOB_DT |N/A | | | |
|B_DETAIL_TB |R-RECIP-SEX |B_GENDER_CD |N/A |M, F, O | | |
|B_DETAIL_TB |R-RECIP-RACE |B_RACE_CD |N/A | | | |
|B_ADR_TB |R-MAIL-ADDRESS-LINE-1 |B_LINE1_AD |N/A | | | |
|B_ADR_TB |R-MAIL-ADDRESS-LINE-2 |B_LINE2_AD |N/A | | | |
|B_ADR_TB |R-MAIL-ADDRESS-CITY |B_CITY_NAM |N/A | | | |
|B_ADR_TB |R-MAIL-ADDRESS-STATE |B_ST_CD |N/A | | | |
|B_ADR_TB |R-MAIL-ADDRESS-ZIP-CODE |B_ZIP5_CD |N/A | | | |
|P_PROV_TB |R-REP-PAYEE-NAME |P_NAM |N/A | | | |
|C_HDR_TB |A-PROV-NO |C_BLNG_PROV_ID |N/A | | | |
|C_HDR_TB |A-FROM-DATE |C_HDR_SVC_FST_DT |N/A | | | |
|C_LI_TB |A-PROC |R_PROC_CD |N/A | | | |
|C_LI_TB |A-PROC-MODIFIER |R_PROC_MOD_1ST_CD |N/A | | | |
|C_LI_TB | |R_PROC_MOD_2ND_CD |N/A | | | |
________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE
IMMUNIZATION CLAIMS INTERFACE FOR STATE IMMUNIZATION INFORMATION SYSTEM (SIIS)
(OBSOLETE)
|Description: |
|This program takes the weekly adjudicated claims file and extracts all immunization claims for clients under 19. Data is extracted from each claim record and used to format a file for the New|
|Mexico State Immunization Information System (SIIS). In addition to the immunization records extracted, the process creates two client files. The first client file consists of the client |
|associated with the immunization record(s) produced. The second client file is a file of client information for clients (under 19) than have had some changes since the last run that are not on|
|the other file. |
|Source Tables: |
|Client Detail Table (BDTAILTB) |
|Client Address Table (BADDRSTB) |
|Client COE Span Table (BCOESPTB) |
|Provider Detail Table (PROVRDTB) |
|List Detail Table (GSLDTLTB) |
|Target Files: |
|Weekly SIIS Immunization Extract File |
|Weekly SIIS Client Extract File |
|Weekly SIIS Client Delta File |
|Reports: |
|N/A |
|Remarks: |
|N/A |
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE LAYOUT
OUTPUT FILE
IMMUNIZATION CLAIMS INTERFACE FOR STATE IMMUNIZATION INFORMATION SYSTEM (SIIS)
(OBSOLETE)
01 WF-100-IMMUNIZATION-REC.
05 WF-100-CLNT-REC-IND PIC X(24).
05 WF-100-VACC-GRP PIC X(16).
05 WF-100-PROC-CD PIC X(05).
05 WF-100-TRADE-NAM PIC X(24).
05 WF-100-VACC-DT PIC X(08).
05 WF-100-ADM-ROUTE-CD PIC X(02).
05 WF-100-BODY-SITE-CD PIC X(04).
05 WF-100-REACTION-CD PIC X(08).
05 WF-100-MAN-CD PIC X(04).
05 WF-100-IMMUN-INFO-SRC PIC X(02).
05 WF-100-LOT-NUM PIC X(30).
05 WF-100-PROV-NAM PIC X(50).
05 WF-100-ADMIN-BY-NAM PIC X(50).
05 WF-100-SITE-NAM PIC X(30).
05 WF-100-SEND-ORG PIC X(05).
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
IMMUNIZATION CLAIMS INTERFACE FOR STATE IMMUNIZATION INFORMATION SYSTEM (SIIS)
(OBSOLETE)
|Source |Source |Target | | | |Note |
|Table / File |Column / Field |Field |Req |Def |Specifications |Ref |
| | |WF-100-VACC-GRP |N |Spaces | | |
|Adjudicated Claims File |W1C41551-R-PROC-CD or |WF-100-PROC-CD |A | | |2, 3 |
| |W1C41521-R-PROC-CD | | | | | |
| | |WF-100-TRADE-NAM |N |Spaces | | |
|Adjudicated Claims File |W1C41551-C-LI-FST-DOS-DT or |WF-100-VACC-DT |A | |Convert input format from YYYYMMDD to | |
| |W1C41521-C-LI-FST-DOS-DT | | | |MMDDYYYY | |
| | |WF-100-ADM-ROUTE-CD |N |Spaces | | |
| | |WF-100-BODY-SITE-CD |N |Spaces | | |
| | |WF-100-REACTION-CD |N |Spaces | | |
| | |WF-100-MAN-CD |N |Spaces | | |
| | |WF-100-IMMUN-INFO-SRC |N |“01” | | |
| | |WF-100-LOT-NUM |N |Spaces | | |
|P_PROV_TB |P_NAM |WF-100-PROV-NAM |N | |Use the rendering provider | |
| | | | | |W1C41551-C-RNDR-PROV-ID or | |
| | | | | |W1C415221-C-RNDR-PROV-ID to obtain the P_NAM.| |
| | | | | |If not found use the billing provider | |
| | | | | |W1C41551-C-BLNG-PROV-ID. | |
| | |WF-100-ADMIN-BY-NAM |N |Spaces | | |
| | |WF-100-SITE-NAM |N |Spaces | | |
| | | WF-100-SEND-ORG |N |“MMIS” |Move ‘MMIS’ to this field | |
| | | | | | | |
________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
Notes:
1. W1C41551-B-SYS-ID will need to be converted to display format when it is moved to the output record.
2. Depending on the claim type, format W1C41551 or W1C41521 will be utilized to find the procedure code on the line item.
3. The CPT procedure code must be checked against system list 4020 to insure it’s a valid immunization procedure.
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE LAYOUT
OUTPUT FILE
IMMUNIZATION CLAIMS INTERFACE FOR STATE IMMUNIZATION INFORMATION SYSTEM (SIIS)
(OBSOLETE)
01 WF-200-CLIENT-REC.
05 WF-200-CLNT-REC-IND PIC X(24).
05 WF-200-CLNT-STAT PIC X(01).
05 WF-200-CLNT-FST-NAM PIC X(25).
05 WF-200-CLNT-MI-NAM PIC X(25).
05 WF-200-CLNT-LAST-NAM PIC X(35)
05 WF-200-CLNT-SFX PIC X(10).
05 WF-200-CLNT-DOB PIC X(08).
05 WF-200-CLNT-DOD PIC X(08).
05 WF-200-MOM-FST-NAM PIC X(25).
05 WF-200-MOM-MAID-NAM PIC X(35).
05 WF-200-CLNT-SEX PIC X(01).
05 WF-200-CLNT-RACE-CD PIC X(01).
05 WF-200-CLNT-ETHN-CD PIC X(02).
05 FILLER PIC X(09).
05 WF-200-CNT-ALLOW PIC X(02).
05 WF-200-CONSENT PIC X(01).
05 WF-200-CHART-NUM PIC X(20).
05 WF-200-REP-FST-NAM PIC X(25).
05 WF-200-REP-MI-NAM PIC X(25).
05 WF-200-REP-LAST-NAM PIC X(35).
05 WF-200-REP-RELATION PIC X(02).
05 WF-200-STREET-ADDR PIC X(55).
05 WF-200-STREET-ADDR2 PIC X(55).
05 WF-200-OTHR-ADDR PIC X(55).
05 WF-200-CITY-NAM PIC X(52).
05 WF-200-ST-CD PIC X(02).
05 WF-200-ZIP-CD PIC X(09).
05 WF-200-COUNTY-CD PIC X(05).
05 WF-200-PHONE-NUM PIC X(17).
05 WF-200-SEND-ORG PIC X(05).
05 FILLER PIC X(26).
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
IMMUNIZATION CLAIMS INTERFACE FOR STATE IMMUNIZATION INFORMATION SYSTEM (SIIS)
(OBSOLETE)
|Source |Source |Target | | | |Note |
|Table / File |Column / Field |Field |Req |Def |Specifications |Ref |
| | |WF-200-CLNT-STAT |N | |If B_DOD_DT is greater than 0001-01-01, then| |
| | | | | |populate this field with “D” otherwise | |
| | | | | |populate this field with “A”. | |
|B_DETAIL_TB |B_FST_NAM |WF-200-CLNT-FST-NAM |A | | | |
|B_DETAIL_TB |B_MI_NAM |WF-200-CLNT-MI-NAM |N | | | |
|B_DETAIL_TB |B_LAST_NAM |WF-200-CLNT-LAST-NAM |A | | | |
|B_DETAIL_TB |B_SFX_NAM |WF-200-CLNT-SFX |N | | | |
|B_DETAIL_TB |B_DOB_DT |WF-200-CLNT-DOB |A | |Input Format: YYYY-MM-DD | |
| | | | | |Output Format: MMDDYYYY | |
|B_DETAIL_TB |B_DOD_DT |WF-200-CLNT-DOD |N |Spaces |If B_DOD_DT is greater than 0001-01-01, then | |
| | | | | |populate this field otherwise default it to | |
| | | | | |spaces. | |
| | | | | |Input Format: YYYY-MM-DD | |
| | | | | |Output Format: MMDDYYYY | |
| | |WF-200-MOM-FST-NAM |N |Spaces | | |
| | |WF-200-MOM-MAID-NAM |N |Spaces | | |
|B_DETAIL_TB |B_GENDER_CD |WF-200-CLNT-SEX |N | | | |
|B_DETAIL_TB |B_RACE_CD |WF-200-CLNT-RACE-CD |N |Spaces |Convert to SIIS code (using B_RACE_CD) | |
| | | | | |When '1' move 'W' | |
| | | | | |When '2' move 'H' | |
| | | | | |When '3' move 'I' | |
| | | | | |When '4' move 'A' | |
| | | | | |When '5' move 'B' | |
| | | | | |When '6' move 'O' | |
| | | | | |When '7' move 'U' | |
| | | | | |Otherwise move spaces | |
| | |WF-200-CLNT-ETHN-CD |N | |When B_RACE_CD = '2' move 'H, otherwise | |
| | | | | |move ‘NH’ to this field | |
| | |WF-200-CNT-ALLOW |N | |Default to “02” | |
| | |WF-200-CONSENT |N |Spaces | | |
|B_DETAIL_TB |B_SYS_ID |WF-200-CHART-NUM |N | | | |
|B_DETAIL_TB |B_REP_FST_NAM |WF-200-REP-FST-NAM |N | | | |
|B_DETAIL_TB |B_REP_MI_NAM |WF-200-REP-MI-NAM |N | | | |
|B_DETAIL_TB |B_REP_LAST_NAM |WF-200-REP-LAST-NAM |N | | | |
| | |WF-200-REP-RELATION |N |“G8” |Default to “G8” | |
|B_ADR_TRB |B_LINE1_AD |WF-200-STREET-ADDR |N | | | |
|B_ADR_TRB |B_LINE2_AD |WF-200-STREET-ADDR2 |N | | | |
|B_ADR_TRB | |WF-200-OTHR-ADDR |N | | | |
|B_ADR_TRB |B_CITY_NAM |WF-200-CITY-NAM |N | | | |
|B_ADR_TRB |B_ST_CD |WF-200-ST-CD |N | | | |
|B_ADR_TRB |B_ZIP5_CD and B_ZIP4_CD |WF-200-ZIP-CD |N | | | |
| B_COE_SPN_TB |B_GEO_CNTY_CD |WF-200-COUNTY-CD |N |Spaces |Convert county code using SIIS crosswalk: | |
| | | | | | | |
| | | | | |WHEN '01' MOVE '35001' | |
| | | | | |WHEN '35' MOVE '35001' | |
| | | | | |WHEN '36' MOVE '35001' | |
| | | | | |WHEN '39' MOVE '35001' | |
| | | | | |WHEN '02' MOVE '35003' | |
| | | | | |WHEN '03' MOVE '35005' | |
| | | | | |WHEN '33' MOVE '35006' | |
| | | | | |WHEN '04' MOVE '35007' | |
| | | | | |WHEN '05' MOVE '35009' | |
| | | | | |WHEN '06' MOVE '35011' | |
| | | | | |WHEN '07' MOVE '35013' | |
| | | | | |WHEN '38' MOVE '35013' | |
| | | | | |WHEN '08' MOVE '35015' | |
| | | | | |WHEN '34' MOVE '35015' | |
| | | | | |WHEN '09' MOVE '35017' | |
| | | | | |WHEN '10' MOVE '35019' | |
| | | | | |WHEN '11' MOVE '35021' | |
| | | | | |WHEN '12' MOVE '35023' | |
| | | | | |WHEN '13' MOVE '35025' | |
| | | | | |WHEN '37' MOVE '35025' | |
| | | | | |WHEN '14' MOVE '35027' | |
| | | | | |WHEN '15' MOVE '35028' | |
| | | | | |WHEN '16' MOVE '35029' | |
| | | | | |WHEN '17' MOVE '35031' | |
| | | | | |WHEN '18' MOVE '35033' | |
| | | | | |WHEN '19' MOVE '35035' | |
| | | | | |WHEN '20' MOVE '35037' | |
| | | | | |WHEN '21' MOVE '35039' | |
| | | | | |WHEN '22' MOVE '35041' | |
| | | | | |WHEN '23' MOVE '35043' | |
| | | | | |WHEN '24' MOVE '35045' | |
| | | | | |WHEN '25' MOVE '35047' | |
| | | | | |WHEN '26' MOVE '35049' | |
| | | | | |WHEN '27' MOVE '35051' | |
| | | | | |WHEN '28' MOVE '35053' | |
| | | | | |WHEN '29' MOVE '35055' | |
| | | | | |WHEN '30' MOVE '35057' | |
| | | | | |WHEN '31' MOVE '35059' | |
| | | | | |WHEN '32' MOVE '35061' | |
| | | | | |WHEN OTHER | |
| | | | | |MOVE SPACES | |
|B_DETAIL_TB |B_PHON_NUM |WF-200-PHONE-NUM |N | | | |
| | |WF-200-SEND-ORG |N |“MMIS” |Default to “MMIS” | |
________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
Notes:
1. B-SYS-ID will need to be converted to display format when it is moved to the output record
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE
IRS 1099 CLAIMS INTERFACE
|Description: |
|The program NMMC1099 creates an output file that is sent to the Internal Revenue Service to report amounts for 1099, in addition to producing 1099’s that are mailed to providers. |
|Source Tables/Files: |
|CPVCLMTB, the provider claims summary table |
|PADDRSTB is the provider address table |
|PROVDRTB, the provider table unloaded as a flat-file |
| |
|NEWM.PRUN.CARD.FILE – Input Information with State Address |
|OmniCaid System list 4813—2nd notify providers |
|OmniCaid System list 4814—correction providers |
| |
|Target Files: |
|IRS 1099 file, actual 1099’s |
|Reports: |
|1099 Report Sorted by Provider ID |
|1099 detail Report Sorted by Tax ID, SSN |
|Remarks: |
| |
|The Claims summary table (which carries current year and 4 years worth of provider financial history information) operates by annually shifting the current year into 1-year old history, |
|changing 1-year old history into 2 year old history etc., and resetting all of the YTD amounts for the current year to zero. NMCA6800 will run prior to the 1099’s, effectively “freezing” the |
|claims summary table for 1099 processing by performing this shift. When the current year becomes 1-year old frozen history, this level is the basis for the 1099’s. (The various levels are |
|accessed through column C_SUM_TM_PER_CD. Values are “Y” = current year, “1” = prior year, “2” = 2 years ago etc. |
|Remarks cont’d: |
|The only 2 levels of interest are “Y”, when testing before January, and “1”, when running actual 1099’s or testing after January 1st. You can set this value in the parameter file, but it is |
|unnecessary since program NMMC1099 figures it out automatically.). |
| |
|Every year there will be a new list of providers who should be set to “Second Notify”. The OmniCaid system uses System List 4813 to allow users to input these provider ID’s. Second notify |
|providers are providers for whom the IRS has sent notices to the State 2 or 3 years in a row, stating that the provider info was incorrect. This flag on the 1099 and the IRS file tells the IRS|
|not to bother the State anymore with these notices. |
| |
|Correction provider ID’s are entered using System List 4814. A correction run will, in actuality, be a full 1099 run. It will produce new reports and a completely new IRS file. The only |
|difference will be that physical, printable 1099's will only be produced for the "correction Provider ID's and the corrected 1099's will be marked “X” in the correction box. The actual input |
|files must be modified by a programmer to correct the 1099 information. This may involve modification of the provider table flat-file, the DB2 claims summary table, or the provider address |
|table, depending on the type of errors. If for instance a provider did not receive a 1099 because he was mistakenly processed as a non-profit provider, but really was a profit provider or vice|
|versa, then the Provider Table flat file record containing that provider’s profit-indicator must be modified, probably using FileAid. If an amount is wrong then the Claims Summary table must |
|be modified, most likely using SPUFI or something similar. There is also a possibility that the 2nd notifies were not entered into the system list correctly, so the 2nd notify system list must|
|be corrected and the provider ID’s of the missed 2nd notifies must also be entered into the correction system list. These modifications will produce new 1099’s for these Provider ID’s, if they|
|still qualify for a 1099. If not, then no 1099 will be produced but the IRS file will be updated accordingly, reflecting no 1099, so you always want to execute a correction run after any type |
|of input modification, even if it results in no 1099 being produced. |
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE LAYOUT
OUTPUT FILE
IRS 1099 CLAIMS INTERFACE
01 WFC81450-IRS-RECORD-TYPE-T.
*****TRANSMITTER "T" RECORD.
05 WFC81450-IRS-TYPE-IND-T PIC X(01) VALUE 'T'.
05 WFC81450-IRS-PYMNT-YRT PIC X(04) VALUE ' '.
05 WFC81450-IRS-PRIOR-YR-DATA-IND PIC X(01) VALUE SPACE.
05 WFC81450-IRS-TRANMITTER-TIN PIC X(09)
***** VALUE '581089164'.
VALUE '582479287'.
05 WFC81450-IRS-TRANSMITTER-TCC PIC X(05) VALUE '07407'.
**** 05 WFC81450-IRS-REPLACEMENT-A-C PIC X(02) VALUE SPACES.
**** 05 FILLER PIC X(05) VALUE SPACES.
05 FILLER PIC X(07) VALUE SPACES.
05 WFC81450-IRS-TEST-FILE-IND PIC X(01) VALUE SPACE.
05 WFC81450-IRS-FOREIGN-ENT-IND PIC X(01) VALUE SPACE.
05 WFC81450-IRS-TRANSMITTER-NAME PIC X(40) VALUE
'ACS STATE HEALTHCARE '.
05 WFC81450-IRS-TRANSMITTER-NAME2 PIC X(40) VALUE SPACES.
05 WFC81450-IRS-COMPANY-NAME PIC X(40) VALUE
'ACS STATE HEALTHCARE '.
05 WFC81450-IRS-COMPANY-NAME2 PIC X(40) VALUE SPACES.
05 WFC81450-IRS-COMPANY-ADDRESS PIC X(40) VALUE
'9040 ROSWELL RD '.
05 WFC81450-IRS-COMPANY-CITY PIC X(40) VALUE
'ATLANTA '.
05 WFC81450-IRS-COMPANY-STATE PIC X(02) VALUE 'GA'.
05 WFC81450-IRS-COMPANY-ZIP PIC X(09)
VALUE '30350 '.
05 FILLER PIC X(15) VALUE SPACES.
05 WFC81450-IRS-TOT-NUM-PAYEES PIC 9(08) VALUE 0.
05 WFC81450-IRS-CONTACT-NAME PIC X(40) VALUE
'CHRISTINE MARSHALL '.
05 WFC81450-IRS-CONTACT-PHONE-EXT PIC X(15) VALUE
'7708291018 '.
**** 05 WFC81450-IRS-CONTACT-EMAIL PIC X(35) VALUE
05 WFC81450-IRS-CONTACT-EMAIL PIC X(50) VALUE
'CHRISTINE.MARSHALL@XEROX- '.
**** 05 WFC81450-IRS-MAG-TAPE-FILE-IND PIC X(02) VALUE ' '.
**** 05 WFC81450-IRS-ELECTR-FILE-NAM PIC X(15) VALUE SPACES.
**** 05 WFC81450-IRS-TRANS-MEDIA-NUM PIC X(06) VALUE SPACES.
**** 05 FILLER PIC X(83) VALUE SPACES.
05 FILLER PIC X(91) VALUE SPACES.
05 WFC81450-IRS-REC-SEQ-NUM-T PIC X(08) VALUE '00000001'.
05 FILLER PIC X(10) VALUE SPACES.
05 WFC81450-IRS-VENDOR-IND PIC X(01) VALUE 'I'.
05 FILLER PIC X(232) VALUE SPACES.
01 WFC81450-IRS-RECORD-TYPE-A.
*****PAYER "A" RECORD.
05 WFC81450-IRS-TYPE-IND-A PIC X(01) VALUE 'A'.
05 WFC81450-IRS-PYMNT-YRA PIC X(04) VALUE ' '.
05 FILLER PIC X(06) VALUE SPACES.
05 WFC81450-IRS-PAYER-TIN PIC X(09)
VALUE '856000565'.
05 WFC81450-IRS-PAYER-NAME-CTRL PIC X(04) VALUE SPACES.
05 WFC81450-IRS-LAST-FILING-IND PIC X(01) VALUE SPACE.
*** 05 WFC81450-IRS-COMB-FED-ST-FILER PIC X(01) VALUE ' '.
*** 05 WFC81450-IRS-TYP-RTN PIC X(01) VALUE 'A'.
05 WFC81450-IRS-TYP-RTN PIC X(02) VALUE 'A '.
*** 05 WFC81450-IRS-AMOUNT-CODES PIC X(12) VALUE
*** 05 WFC81450-IRS-AMOUNT-CODES PIC X(14) VALUE
*** '6 '.
05 WFC81450-IRS-AMOUNT-CODES PIC X(16) VALUE
'6 '.
** 05 FILLER PIC X(08) VALUE SPACES.
**** 05 FILLER PIC X(06) VALUE SPACES.
**** 05 WFC81450-IRS-ORIGINAL-FILE-IND PIC X(01) VALUE '1'.
**** 05 WFC81450-IRS-REPLACE-FILE-IND PIC X(01) VALUE SPACE.
**** 05 WFC81450-IRS-CORRECT-FILE-IND PIC X(01) VALUE SPACE.
**** 05 FILLER PIC X(01) VALUE SPACE.
*** 05 FILLER PIC X(10) VALUE SPACE.
05 FILLER PIC X(08) VALUE SPACE.
05 WFC81450-IRS-FRGNN-ENTITY-IND PIC X(01) VALUE SPACE.
05 WFC81450-IRS-PAYER-NAME1 PIC X(40) VALUE
'STATE OF NEW MEXICO '.
05 WFC81450-IRS-PAYER-NAME2 PIC X(40) VALUE
'DEPARTMENT OF HUMAN SERVICES '.
05 WFC81450-IRS-XFER-AGENT-IND PIC X(01) VALUE '0'.
05 WFC81450-IRS-PAYER-SHIP-ADDR PIC X(40) VALUE
'POST OFFICE BOX 2348 '.
05 WFC81450-IRS-PAYER-SHIP-CITY PIC X(40) VALUE
'SANTA FE '.
05 WFC81450-IRS-PAYER-SHIP-STATE PIC X(02) VALUE 'NM'.
05 WFC81450-IRS-PAYER-SHIP-ZIP PIC X(09)
VALUE '875042348'.
05 WFC81450-IRS-PAYER-PHONE-EXT PIC X(15) VALUE
'5052469988 '.
05 FILLER PIC X(260) VALUE SPACES.
05 WFC81450-IRS-REC-SEQ-NUM-A PIC X(08) VALUE ZEROS.
05 FILLER PIC X(243) VALUE SPACES.
01 WFC81450-IRS-RECORD-TYPE-B.
*****PAYEE "B" RECORD.
05 WFC81450-IRS-TYPE-INDB PIC X(01) VALUE 'B'.
05 WFC81450-IRS-PYMNT-YRB PIC X(04) VALUE SPACES.
05 WFC81450-IRS-CORR-RETURN-IND PIC X(01) VALUE SPACE.
05 WFC81450-IRS-NAME-CONTROL PIC X(04) VALUE SPACES.
05 WFC81450-IRS-TYPE-TIN-IND PIC X(01) VALUE SPACE.
05 WFC81450-IRS-PAYEE-TIN PIC X(09) VALUE SPACES.
05 WFC81450-IRS-PAYER-ACCOUNT-NUM PIC X(20) VALUE SPACES.
05 WFC81450-IRS-PAYER-OFFICE-CODE PIC X(04) VALUE SPACES.
05 FILLER PIC X(10) VALUE SPACE.
05 WFC81450-IRS-PYMNT-AMT1 PIC 9(10)V99 VALUE 0.
05 WFC81450-IRS-PYMNT-AMT2 PIC 9(10)V99 VALUE 0.
05 WFC81450-IRS-PYMNT-AMT3 PIC 9(10)V99 VALUE 0.
05 WFC81450-IRS-PYMNT-AMT4 PIC 9(10)V99 VALUE 0.
05 WFC81450-IRS-PYMNT-AMT5 PIC 9(10)V99 VALUE 0.
05 WFC81450-IRS-PYMNT-AMT6 PIC 9(10)V99 VALUE 0.
05 WFC81450-IRS-PYMNT-AMT7 PIC 9(10)V99 VALUE 0.
05 WFC81450-IRS-PYMNT-AMT8 PIC 9(10)V99 VALUE 0.
05 WFC81450-IRS-PYMNT-AMT9 PIC 9(10)V99 VALUE 0.
05 WFC81450-IRS-PYMNT-AMTA PIC 9(10)V99 VALUE 0.
05 WFC81450-IRS-PYMNT-AMTB PIC 9(10)V99 VALUE 0.
05 WFC81450-IRS-PYMNT-AMTC PIC 9(10)V99 VALUE 0.
05 WFC81450-IRS-PYMNT-AMTD PIC 9(10)V99 VALUE 0.
05 WFC81450-IRS-PYMNT-AMTE PIC 9(10)V99 VALUE 0.
05 WFC81450-IRS-PYMNT-AMTF PIC 9(10)V99 VALUE 0.
05 WFC81450-IRS-PYMNT-AMTG PIC 9(10)V99 VALUE 0.
**** 05 FILLER PIC X(48) VALUE SPACES.
**** 05 FILLER PIC X(24) VALUE SPACES.
05 WFC81450-IRS-FOREIGN-IND PIC X VALUE SPACE.
05 WFC81450-IRS-PAYEE-NAME1 PIC X(40) VALUE SPACES.
05 WFC81450-IRS-PAYEE-NAME2 PIC X(40) VALUE SPACES.
05 FILLER PIC X(40) VALUE SPACES.
05 WFC81450-IRS-PAYEE-ADDR PIC X(40) VALUE SPACES.
05 FILLER PIC X(40) VALUE SPACES.
05 WFC81450-IRS-PAYEE-CITY PIC X(40) VALUE SPACES.
05 WFC81450-IRS-PAYEE-STATE PIC X(02) VALUE SPACES.
05 WFC81450-IRS-PAYEE-ZIP PIC X(09) VALUE SPACES.
05 FILLER PIC X(01) VALUE SPACES.
05 WFC81450-IRS-REC-SEQ-NUM-B PIC X(08) VALUE ZEROS.
05 FILLER PIC X(36) VALUE SPACES.
05 WFC81450-IRS-SECOND-TIN-NOTICE PIC X(01) VALUE SPACE.
05 FILLER PIC X(02) VALUE SPACES.
05 WFC81450-IRS-DIRECT-SALES-IND PIC X(01) VALUE SPACE.
*** 05 FILLER PIC X(115) VALUE SPACES.
05 WFC81450-FATCA-FILING-IND PIC X(01) VALUE SPACES.
05 FILLER PIC X(114) VALUE SPACES.
05 WFC81450-IRS-SPECIAL-DATA PIC X(60) VALUE SPACES.
05 WFC81450-IRS-ST-INC-TAX-WTHLD PIC 9(10)V99 VALUE 0.
05 WFC81450-IRS-LOC-INC-TAX-WTHLD PIC 9(10)V99 VALUE 0.
05 WFC81450-IRS-COMB-FED-ST-CODE PIC X(02) VALUE SPACE.
05 FILLER PIC X(02) VALUE SPACE.
01 WFC81450-IRS-RECORD-TYPE-C.
*****END OF PAYOR "C" RECORD.
05 WFC81450-IRS-TYPE-INDC PIC X(01) VALUE 'C'.
05 WFC81450-IRS-NUM-PAYEES PIC 9(08) VALUE 0.
05 FILLER PIC X(06) VALUE SPACES.
05 WFC81450-IRS-TOT-AMT1 PIC 9(16)V99 VALUE 0.
05 WFC81450-IRS-TOT-AMT2 PIC 9(16)V99 VALUE 0.
05 WFC81450-IRS-TOT-AMT3 PIC 9(16)V99 VALUE 0.
05 WFC81450-IRS-TOT-AMT4 PIC 9(16)V99 VALUE 0.
05 WFC81450-IRS-TOT-AMT5 PIC 9(16)V99 VALUE 0.
05 WFC81450-IRS-TOT-AMT6 PIC 9(16)V99 VALUE 0.
05 WFC81450-IRS-TOT-AMT7 PIC 9(16)V99 VALUE 0.
05 WFC81450-IRS-TOT-AMT8 PIC 9(16)V99 VALUE 0.
05 WFC81450-IRS-TOT-AMT9 PIC 9(16)V99 VALUE 0.
05 WFC81450-IRS-TOT-AMTA PIC 9(16)V99 VALUE 0.
05 WFC81450-IRS-TOT-AMTB PIC 9(16)V99 VALUE 0.
05 WFC81450-IRS-TOT-AMTC PIC 9(16)V99 VALUE 0.
05 WFC81450-IRS-TOT-AMTD PIC 9(16)V99 VALUE 0.
05 WFC81450-IRS-TOT-AMTE PIC 9(16)V99 VALUE 0.
05 WFC81450-IRS-TOT-AMTF PIC 9(16)V99 VALUE 0.
05 WFC81450-IRS-TOT-AMTG PIC 9(16)V99 VALUE 0.
**** 05 FILLER PIC X(268) VALUE SPACES.
**** 05 FILLER PIC X(232) VALUE SPACES.
05 FILLER PIC X(196) VALUE SPACES.
05 WFC81450-IRS-REC-SEQ-NUM-C PIC X(08) VALUE ZEROS.
05 FILLER PIC X(243) VALUE SPACES.
01 WFC81450-IRS-RECORD-TYPE-F.
*****END OF TRANSMISSION "F" RECORD.
05 WFC81450-IRS-TYPE-INDF PIC X(01) VALUE 'F'.
05 WFC81450-IRS-NUM-PAYERS PIC 9(08) VALUE 1.
05 FILLER PIC X(21) VALUE ZEROES.
05 FILLER PIC X(19) VALUE SPACES.
05 WFC81450-IRS-TOT-NUM-PAYEES-F PIC 9(08) VALUE ZEROS.
05 FILLER PIC X(442) VALUE SPACES.
05 WFC81450-IRS-REC-SEQ-NUM-F PIC 9(08) VALUE ZEROS.
05 FILLER PIC X(243) VALUE SPACES.
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
IRS 1099 CLAIMS INTERFACE
|Source |Source |Target | | | |Note |
|Table |Column |Field |Req |Def |Specifications |Ref |
|DCLP-PROV-TB |P-DBA-NAM |WFC81450-IRS-PAYEE-NAME1 | | | | |
|DCLC-PROV-CLM-SUM-TB |P-ID |WFC81450-IRS-PAYER-ACCOUNT-NUM | | | | |
|DCLC-PROV-CLM-SUM-TB |C-CLM-TOTAL-AMT |WFC81450-IRS-PYMNT-AMT6 | | | | |
|DCLP-PROV-TB |P-FED-TAX-ID |WFC81450-IRS-PAYEE-TIN | | | | |
|DCLP-PROV-TB |P-SSN-NUM |WFC81450-IRS-PAYEE-TIN | | | | |
|1-OR-2 |N/A |WFC81450-IRS-TYPE-TIN-IND | | | | |
|DCLP-ADDR-TB |P-CITY-NAM |WFC81450-IRS-PAYEE-CITY | | | | |
|DCLP-ADDR-TB |P-ST-CD |WFC81450-IRS-PAYEE-STATE | | | | |
|CALCULATED |N/A |WFC81450-IRS-NUM-PAYEES | | | | |
|CALCULATED |N/A |WFC81450-IRS-TOT-AMT6 | | | | |
|P_ADDR_TB |P_LINE1_AD |WFC81450-IRS-PAYEE-ADDR | | | | |
|P_ADDR_TB |P_CITY_NAM |WFC81450-IRS-PAYEE-CITY | | | | |
|P_ADDR_TB |P_ST_CD |WFC81450-IRS-PAYEE-STATE | | | | |
|P_ADDR_TB |P_ZIP4_CD |WFC81450-IRS-PAYEE-ZIP | | | | |
|P_ADDR_TB |P_ZIP5_CD |WFC81450-IRS-PAYEE-ZIP | | | | |
_______________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
IRS 1099 CLAIMS INTERFACE
IRS RECORD TYPE T (Transmitter)
|Source |Source |Target | | | |Note |
|Table / File |Column / Field |Field |Req |Def |Specifications |Ref |
| Parameter Card | |WFC81450-IRS-PYMNT-YRT |A |X(04) |Current or Previous Year |1 |
| | |WFC81450-IRS-PRIOR-YR-DATA-IND |A |X(01) |SPACES | |
| | |WFC81450-IRS-TRANMITTER-TIN |A |X(09) |'582479287' | |
| | |WFC81450-IRS-TRANSMITTER-TCC |A |X(05) |'07407' | |
| | |WFC81450-IRS-TEST-FILE-IND |A |X(01) |SPACES | |
| | |WFC81450-IRS-FOREIGN-ENT-IND |A |X(01) |SPACES | |
| | |WFC81450-IRS-TRANSMITTER-NAME |A |X(40) |'ACS STATE HEALTHCARE’ | |
| | |WFC81450-IRS-TRANSMITTER-NAME2 |A |X(40) |SPACES | |
| | |WFC81450-IRS-COMPANY-NAME |A |X(40) |'ACS STATE HEALTHCARE’ | |
| | |WFC81450-IRS-COMPANY-NAME2 |A |X(40) |SPACES | |
| | |WFC81450-IRS-COMPANY-ADDRESS |A |X(40) |'9040 ROSWELL RD’ | |
| | |WFC81450-IRS-COMPANY-CITY |A |X(40) |‘ATLANTA’ | |
| | |WFC81450-IRS-COMPANY-STATE |A |X(02) |‘GA’ | |
| | |WFC81450-IRS-COMPANY-ZIP |A |X(09) |'30350’ | |
| | |WFC81450-IRS-TOT-NUM-PAYEES |A |9(08) |0 | |
| | |WFC81450-IRS-CONTACT-NAME |A |X(40) |'CHRISTINE MARSHALL’ | |
| | |WFC81450-IRS-CONTACT-PHONE-EXT |A |X(15) |'7708291018’ | |
| | |WFC81450-IRS-CONTACT-EMAIL |A |X(50) |'CHRISTINE.MARSHALL@XEROX-’ | |
| | |WFC81450-IRS-REC-SEQ-NUM-T |A |X(08) |'00000001' | |
| | |WFC81450-IRS-VENDOR-IND |A |X(01) |'I' | |
_
_______________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
Notes:
1) Payment year is determined from the input parameter card. A year may be specified or if spaces the program will calculate the date. If the run month is greater the 6 (June) then it is the current year else it is the prior year.
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
IRS 1099 CLAIMS INTERFACE
IRS RECORD TYPE A (Payer)
|Source |Source |Target | | | |Note |
|Table / File |Column / Field |Field |Req |Def |Specifications |Ref |
| Parameter Card | | WFC81450-IRS-PYMNT-YRA |A |X(04) |Current or Previous Year |1 |
| | | WFC81450-IRS-PAYER-TIN |A |X(09) |'856000565' | |
| | | WFC81450-IRS-PAYER-NAME-CTRL |A |X(04) | SPACES | |
| | | WFC81450-IRS-LAST-FILING-IND |A |X(01) | SPACE | |
| | | WFC81450-IRS-TYP-RTN |A |X(02) | ‘A ’ | |
| | | WFC81450-IRS-AMOUNT-CODES |A |X(14) | ‘6” | |
| | | WFC81450-IRS-FRGNN-ENTITY-IND |A | X(01) | SPACE | |
| | | WFC81450-IRS-PAYER-NAME1 |A | X(40) | 'STATE OF NEW MEXICO’ | |
| | | WFC81450-IRS-PAYER-NAME2 |A | X(40) | 'DEPARTMENT OF HUMAN SERVICES’ | |
| | | WFC81450-IRS-XFER-AGENT-IND |A | X(01) | ‘0’ | |
| | | WFC81450-IRS-PAYER-SHIP-ADD |A | X(40) | 'POST OFFICE BOX 2348’ | |
| | | WFC81450-IRS-PAYER-SHIP-CITY |A | X(40) | 'SANTA FE’ | |
| | | WFC81450-IRS-PAYER-SHIP-STATE |A | X(02) | ‘MN’ | |
| | | WFC81450-IRS-PAYER-SHIP-ZIP |A | X(09) | '875042348' | |
| | | WFC81450-IRS-PAYER-PHONE-EXT |A | X(15) | '5052469988’ | |
| | | WFC81450-IRS-REC-SEQ-NUM-A |A | X(08) | Calculated |2 |
________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
Notes:
1) Payment year is determined from the input parameter card. A year may be specified or if spaces the program will calculate the date. If the run month is greater the 6 (June) then it is the current year else it is the prior year.
2) This should always be the second record in the file and should have a sequence number of ‘00000002’. It is possible to have multiple payers in a file and that is why this is a calculated field
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
IRS 1099 CLAIMS INTERFACE
IRS RECORD TYPE B (Payee)
|Source |Source |Target | | | |Note |
|Table / File |Column / Field |Field |Req |Def |Specifications |Ref |
| Parameter Card | | WFC81450-IRS-PYMNT-YRB |A |X(04) |Current or Previous Year |1 |
| | | WFC81450-IRS-CORR-RETURN-IND |A |X(01) |SPACE | |
| | | WFC81450-IRS-NAME-CONTROL | A |X(04) |SPACES | |
|PROV-TB |P-FED-TAX-ID | WFC81450-IRS-TYPE-TIN-IND | | |If P-FED-TAX-ID > Spaces set to ‘1’| |
| |P-SSN-NUM | |A |X(01) |else | |
| | | | | |If P-SSN-NUM > Spaces set to ‘2’ | |
| PROV-TB |P-FED-TAX-ID | WFC81450-IRS-PAYEE-TIN | | |If P-FED-TAX-ID > Spaces set | |
| |P-SSN-NUM | |A |X(09) |P-FED-TAX-ID else | |
| | | | | |If P-SSN-NUM > Spaces set P-SSN-NUM| |
| PROV-CLM-SUM-TB |P-ID | WFC81450-IRS-PAYER-ACCOUNT-NUM |A |X(20) | | |
| | | WFC81450-IRS-PAYER-OFFICE-CODE |A |X(04) | SPACES | |
| | | WFC81450-IRS-PYMNT-AMT1 |A |9(10)V99 | 0 | |
| | | WFC81450-IRS-PYMNT-AMT2 |A |9(10)V99 | 0 | |
| | | WFC81450-IRS-PYMNT-AMT3 |A |9(10)V99 | 0 | |
| | | WFC81450-IRS-PYMNT-AMT4 |A |9(10)V99 | 0 | |
| | | WFC81450-IRS-PYMNT-AMT5 |A |9(10)V99 | 0 | |
| PROV-CLM-SUM-TB | C-CLM-TOTAL-AMT | WFC81450-IRS-PYMNT-AMT6 |A |9(10)V99 | | |
| | | WFC81450-IRS-PYMNT-AMT7 |A |9(10)V99 | 0 | |
| | | WFC81450-IRS-PYMNT-AMT8 |A |9(10)V99 | 0 | |
| | | WFC81450-IRS-PYMNT-AMT9 |A |9(10)V99 | 0 | |
| | | WFC81450-IRS-PYMNT-AMTA |A |9(10)V99 | 0 | |
| | | WFC81450-IRS-PYMNT-AMTB |A |9(10)V99 | 0 | |
| | | WFC81450-IRS-PYMNT-AMTC |A |9(10)V99 | 0 | |
| | | WFC81450-IRS-PYMNT-AMTD |A |9(10)V99 | 0 | |
| | | WFC81450-IRS-PYMNT-AMTE |A |9(10)V99 | 0 | |
| | | WFC81450-IRS-PYMNT-AMTF |A |9(10)V99 | 0 | |
| | | WFC81450-IRS-PYMNT-AMTG |A |9(10)V99 | 0 | |
| | | WFC81450-IRS-FOREIGN-IND |A |X(01) |SPACE | |
|PROV-TB |P-DBA-NAM | | | |If P-DBA-NAM > Spaces set to | |
| |P-NAM |WFC81450-IRS-PAYEE-NAME1 |A |X(40) |P-DBA-NAM | |
| | | | | |Else set to P-NAM | |
|P_ADDR_TB |P-LINE1-AD | WFC81450-IRS-PAYEE-NAME2 |A |X(40) | |2 |
|P_ADDR_TB |P-LINE1-AD | WFC81450-IRS-PAYEE-ADDR |A |X(40) | |3 |
| |P-LINE2-AD | | | | | |
|P_ADDR_TB |P-CITY-NAM | WFC81450-IRS-PAYEE-CITY |A |X(40) | | |
|P_ADDR_TB |P-ST-CD | WFC81450-IRS-PAYEE-STATE |A |X(02) | | |
|P_ADDR_TB |P-ZIP5-CD | WFC81450-IRS-PAYEE-ZIP |A |X(09) |Concatenate P-ZIP4-CD after | |
| |P-ZIP4-CD | | | |P-ZIP5-CD | |
| | | WFC81450-IRS-REC-SEQ-NUM-B |A |X(08) |Incremented by 1 for each record | |
|G_LIST_DTL_TB |G_LIST_STRT_LMT | WFC81450-IRS-SECOND-TIN-NOTICE |A |X(01) |Set to 2 when PROV-ID = a | |
|LIST = 4813 | | | | |G_LIST_STRT_LMT entry | |
| | | WFC81450-IRS-DIRECT-SALES-IND |A |X(01) |SPACE | |
| | | WFC81450-FATCA-FILING-IND |A |X(01) |SPACE | |
| | | WFC81450-IRS-SPECIAL-DATA |A |X(60) |SPACES | |
| | | WFC81450-IRS-ST-INC-TAX-WTHLD |A |9(10)V99 |0 | |
| | | WFC81450-IRS-LOC-INC-TAX-WTHLD |A |9(10)V99 |0 | |
| | | WFC81450-IRS-COMB-FED-ST-CODE |A |X(02) |SPACES | |
________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
Notes:
1) Payment year is determined from the input parameter card. A year may be specified or if spaces the program will calculate the date. If the run month is greater the 6 (June) then it is the current year else it is the prior year.
2) IF P-LINE1-AD (1:1) NOT NUMERIC
AND P-LINE1-AD (1:1) NOT = '#'
AND P-LINE1-AD (1:2) NOT = 'P.'
AND P-LINE1-AD (1:3) NOT = 'P O'
AND P-LINE1-AD (1:3) NOT = 'PO '
AND P-LINE1-AD (1:3) NOT = 'RT '
AND P-LINE1-AD (1:3) NOT = 'RT.'
AND P-LINE1-AD (1:4) NOT = 'BOX '
AND P-LINE1-AD (1:5) NOT = 'BLDG '
AND P-LINE1-AD (1:6) NOT = 'ROUTE '
AND P-LINE1-AD (1:6) NOT = 'SUITE '
AND P-LINE1-AD (1:7) NOT = 'DRAWER '
3) IF P-LINE1-AD (1:1) NUMERIC
OR P-LINE1-AD (1:1) = '#'
OR P-LINE1-AD (1:2) = 'P.'
OR P-LINE1-AD (1:3) = 'P O'
OR P-LINE1-AD (1:3) = 'PO '
OR P-LINE1-AD (1:3) = 'RT '
OR P-LINE1-AD (1:3) = 'RT.'
OR P-LINE1-AD (1:4) = 'BOX '
OR P-LINE1-AD (1:5) = 'BLDG '
OR P-LINE1-AD (1:6) = 'ROUTE '
OR P-LINE1-AD (1:6) = 'SUITE '
OR P-LINE1-AD (1:7) = 'DRAWER '
IF P-LINE2-AD EQUAL TO SPACES
SET TO P-LINE1-AD
ELSE
NEXT SENTENCE
ELSE
SET TO P-LINE2-AD.
IF P-LINE1-AD (1:2) = 'P.'
OR P-LINE1-AD (1:3) = 'P O'
OR P-LINE1-AD (1:3) = 'PO '
SET TO P-LINE1-AD
ELSE
IF P-LINE2-AD (1:2) = 'P.'
OR P-LINE2-AD (1:3) = 'P O'
OR P-LINE2-AD (1:3) = 'PO '
SET TO P-LINE2-AD
ELSE
IF P-LINE1-AD (1:6) = 'SUITE '
SET TO
STRING P-LINE2-AD
DELIMITED BY ' '
', '
DELIMITED BY SIZE
P-LINE1-AD
DELIMITED BY ' '
ELSE
IF P-LINE2-AD (1:6) = 'SUITE '
SET TO
STRING P-LINE1-AD
DELIMITED BY ' '
', '
DELIMITED BY SIZE
P-LINE2-AD
DELIMITED BY ' '
ELSE
IF P-LINE1-AD (1:5) = 'BLDG '
OR P-LINE1-AD (1:1) = '#'
SET TO P-LINE2-AD
ELSE
SET TO P-LINE1-AD.
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
IRS 1099 CLAIMS INTERFACE
IRS RECORD TYPE C (End of Payer)
|Source |Source |Target | | | |Note |
|Table / File |Column / Field |Field |Req |Def |Specifications |Ref |
| | | WFC81450-IRS-NUM-PAYEES |A |9(08) | Total number of Payees receiving | |
| | | | | |1099s for this Payer | |
| | | WFC81450-IRS-TOT-AMT1 |A |9(16)V99 | | |
| | | WFC81450-IRS-TOT-AMT2 | A |9(16)V99 | 0 | |
| | | WFC81450-IRS-TOT-AMT3 |A |9(16)V99 | 0 | |
| | | WFC81450-IRS-TOT-AMT4 |A |9(16)V99 | 0 | |
| | | WFC81450-IRS-TOT-AMT5 |A |9(16)V99 | 0 | |
| | | WFC81450-IRS-TOT-AMT6 |A |9(16)V99 | Sum of Amount 6 for all Payees | |
| | | WFC81450-IRS-TOT-AMT7 |A |9(16)V99 | 0 | |
| | | WFC81450-IRS-TOT-AMT8 |A |9(16)V99 | 0 | |
| | | WFC81450-IRS-TOT-AMT9 |A |9(16)V99 | 0 | |
| | | WFC81450-IRS-TOT-AMTA |A |9(16)V99 | 0 | |
| | | WFC81450-IRS-TOT-AMTB |A |9(16)V99 | 0 | |
| | | WFC81450-IRS-TOT-AMTC |A |9(16)V99 | 0 | |
| | | WFC81450-IRS-TOT-AMTD |A |9(16)V99 | 0 | |
| | | WFC81450-IRS-TOT-AMTE |A |9(16)V99 | 0 | |
| | | WFC81450-IRS-TOT-AMTF |A |9(16)V99 | 0 | |
| | | WFC81450-IRS-TOT-AMTG |A |9(16)V99 | 0 | |
| | | WFC81450-IRS-REC-SEQ-NUM-C |A |X(08) |The next sequence number after the | |
| | | | | |last Payee record for this Payer | |
________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
IRS 1099 CLAIMS INTERFACE
IRS RECORD TYPE F (End of Transmission)
|Source |Source |Target | | | |Note |
|Table / File |Column / Field |Field |Req |Def |Specifications |Ref |
| | | WFC81450-IRS-NUM-PAYERS |A |9(08) |1 | |
| | | WFC81450-IRS-TOT-NUM-PAYEES-F |A |9(08) |Total number of Payees receiving | |
| | | | | |1099s | |
| | | WFC81450-IRS-REC-SEQ-NUM-F | A |9(08) | The next sequence number after the| |
| | | | | |last End of Payer record | |
________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
Notes:
1) Payment year is determined from the input parameter card. A year may be specified or if spaces the program will calculate the date. If the run month is greater the 6 (June) then it is the current year else it is the prior year.
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE OF PAID CLAIMS
FURNISHED TO MERCER CONSULTING
|Description: |
|This interface is created on an as-requested basis to provide Mercer Consulting with a history of paid claims. This interface reads the monthly sequential claims adjudication files. It will |
|then generate 7 output files that are divided into Fee For Service professional/dental claims, institutional claims, drug claims, and financial claims, as well as Encounter professional/dental|
|claims, institutional claims, and drug claims. |
| |
|Each file will contain one file header, multiple claim header/claim line items, and a file trailer. Note that the financial claims will not contain claim line item data, the other files will.|
|Source File: |File Description: |
|NEWM.PROD.C4570SC.mmmyy |FFS claims |
|NEWM.PROD.C4502SC.mmmyy |Encounter claims |
|Where mmm is the month abbreviation, ie JAN, and yy is the year. The sources of the| |
|data on these sequential flat files are the following MMIS claims tables. | |
| | |
|X_HDR_COE_TB | |
|X_HDR_DIAG_TB |Claims Client Category of Eligibility Table |
|X_HDR_DRUG_TB |Claims Diagnosis Table |
|X_HDR_ENCTR_TB |Claims Header Drug Table |
|X_HDR_TB |Claims Encounter Table |
|X_HDR_COND_CD_TB |Claims Header Table |
|X_HDR_ICD_TB |Claims Condition Code Table |
|X_HDR_OCC_CD_TB |Claims ICD Code Table |
|X_HDR_OCC_SPN_TB |Claims Occurrence Code Table |
|X_HDR_VALU_CD_TB |Claims Occurrence Span Table |
|X_LI_BSE_CHG_TB |Claims Value Code Table |
|X_LI_DRUG_TB |Claims Line Item Base Change Table |
|X_LI_TB |Claims Line Item Drug Table |
|X_HDR_ADJ_VD_TB |Claims Line Item Table |
| |Claims Adjustment / Void Table |
| | |
|Target Files: |File Description: |
|WFC69050-C-HDR-FFS-PROF-REC | |
|WFC69051-C-HDR-FFS-INST-REC | |
|WFC69052-C-HDR-FFS-DRUG-REC | |
|WFC69053-C-HDR-ENCTR-PROF-REC | |
|WFC69054-C-HDR-ENCTR-INST-REC | |
|WFC69055-C-HDR-ENCTR-DRUG-REC | |
|WFC69056-C-HDR-FFS-FIN-REC | |
|Reports: |
|N/A |
|Remarks: |
| |
|The selection criteria for claims to be included on the output files is as follows: |
| |
|Claims must be Paid status |
|Payment Date must be between 1/1/2007 and 3/31/2010 |
|Encounter claims must be plan type ‘H’ (Behavioral Health HIO) |
| |
|Note that this means that history-only claims, adjustment/void claims, and financial claims are all included on the output file. |
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE LAYOUT
OUTPUT FILE OF PAID CLAIMS
FURNISHED TO MERCER CONSULTING
FFS PROFESSIONAL / DENTAL LAYOUT
000010*****************************************************************
000020* *
000030* MEMBER: WFC69050 *
000040* NAME: C-HDR-FFS-PROF-REC *
000050* C-DTL-FFS-PROF-REC *
000060* SUBSYSTEM: C CLAIMS *
000070* *
000080* FEE FOR SERVICE CLAIMS PROF/DENTAL FILE HEADER *
000090* PROF/DENTAL FILE DETAIL *
000100* *
000110*****************************************************************
000120* *
000130 01 WFC69050-C-HDR-FFS-PROF-REC.
000140 05 WFC69050-HDR-RECORD-ID-CODE PIC X(01).
000150 05 WFC69050-HDR-C-TCN-NUM PIC X(17).
000160 05 WFC69050-HDR-B-SYS-ID PIC 9(09).
000170 05 WFC69050-B-DOB-DT PIC X(10).
000180 05 WFC69050-C-HDR-CLNT-AGE PIC 9(03).
000190 05 WFC69050-B-GENDER-CD PIC X(01).
000200 05 WFC69050-B-RACE-CD PIC X(01).
000210 05 WFC69050-B-COE-CD PIC X(03).
000220 05 WFC69050-B-FED-MTCH-CD PIC X(01).
000230 05 WFC69050-B-GEO-CNTY-CD PIC X(02).
000240 05 WFC69050-B-ADM-CNTY-CD PIC X(02).
000250 05 WFC69050-B-MAJ-PROG-CD PIC X(01).
000260 05 WFC69050-C-HDR-TY-CD PIC X(01).
000270 05 WFC69050-C-PD-LAST-CHAIN-IND PIC X(01).
000280 05 WFC69050-C-REF-PROV-ID PIC X(08).
000290 05 WFC69050-C-BILL-PROV-ID PIC X(08).
000300 05 WFC69050-C-BILL-PROV-TY PIC X(03).
000310 05 WFC69050-P-IHS-IND PIC X(01).
000320 05 WFC69050-A-PRIOR-AUTH-ID PIC X(11).
000330 05 WFC69050-C-COST-CENTER-CD PIC X(05).
000340 05 WFC69050-C-TOT-REIMB-AMT PIC S9(09)V99.
000350 05 WFC69050-C-HDR-SVC-FST-DT PIC X(10).
000360 05 WFC69050-C-HDR-PD-DT PIC X(10).
000370 05 WFC69050-R-DIAG-CD-1 PIC X(10).
000380 05 WFC69050-R-DIAG-CD-2 PIC X(10).
000390 05 WFC69050-R-DIAG-CD-3 PIC X(10).
000400 05 WFC69050-R-DIAG-CD-4 PIC X(10).
000410 05 WFC69050-R-DIAG-CD-5 PIC X(10).
000420 05 WFC69050-R-DIAG-CD-6 PIC X(10).
000430 05 WFC69050-R-DIAG-CD-7 PIC X(10).
000440 05 WFC69050-R-DIAG-CD-8 PIC X(10).
000450 05 WFC69050-C-TOT-TPL-AMT PIC S9(09)V99.
000460 05 WFC69050-C-TOT-COPAY-AMT PIC S9(09)V99.
000470
000480 01 WFC69050-C-DTL-FFS-PROF-REC.
000490 05 WFC69050-DTL-RECORD-ID-CODE PIC X(01).
000500 05 WFC69050-DTL-C-TCN-NUM PIC X(17).
000510 05 WFC69050-DTL-C-LI-NUM PIC 9(03).
000520 05 WFC69050-DTL-B-SYS-ID PIC 9(09).
000530 05 WFC69050-C-REND-PROV-ID PIC X(08).
000540 05 WFC69050-C-REND-PROV-TY PIC X(03).
000550 05 WFC69050-C-REND-SPECL-CD PIC X(03).
000560 05 WFC69050-C-DSTN-PROV-ID PIC X(08).
000570 05 WFC69050-C-REIMB-STAT-CD PIC X(01).
000580 05 WFC69050-C-LI-FST-DOS-DT PIC X(10).
000590 05 WFC69050-C-LI-LAST-DOS-DT PIC X(10).
000600 05 WFC69050-R-PL-OF-SVC-CD PIC X(02).
000610 05 WFC69050-C-COS-CD PIC X(02).
000620 05 WFC69050-R-PROC-CD PIC X(07).
000630 05 WFC69050-C-PROC-MOD-CD-1 PIC X(02).
000640 05 WFC69050-C-PROC-MOD-CD-2 PIC X(02).
000650 05 WFC69050-C-PROC-MOD-CD-3 PIC X(02).
000660 05 WFC69050-C-PROC-MOD-CD-4 PIC X(02).
000670 05 WFC69050-C-SUBM-FAM-PLAN-IND PIC X(01).
000680 05 WFC69050-C-SUBM-EPSDT-IND PIC X(01).
000690 05 WFC69050-C-LI-ABORT-IND PIC X(01).
000700 05 WFC69050-C-LI-STERIL-IND PIC X(01).
000710 05 WFC69050-C-LI-FAM-PLAN-IND PIC X(01).
000720 05 WFC69050-C-LI-HYSTER-IND PIC X(01).
000730 05 WFC69050-C-LI-SUBM-UNT-NUM PIC S9(07)V99.
000740 05 WFC69050-C-LI-ALLOW-UNT-NUM PIC S9(07)V99.
000750 05 WFC69050-C-LI-REIMB-UNT-NUM PIC S9(07)V99.
000760 05 WFC69050-C-LI-SUBM-CHRG-AMT PIC S9(09)V99.
000770 05 WFC69050-C-LI-REIMB-CHRG-AMT PIC S9(09)V99.
000780 05 WFC69050-C-LI-REIMB-AMT PIC S9(09)V99.
000790 05 WFC69050-C-COPAY-AMT PIC S9(09)V99.
000800 05 WFC69050-C-TPL-AMT PIC S9(09)V99.
000810 05 WFC69050-C-PAT-LIAB-AMT PIC S9(09)V99.
000820 05 WFC69050-C-TAX-AMT PIC S9(09)V99.
000830 05 WFC69050-C-DIAG-1ST-RLTD-CD PIC X(01).
000840 05 WFC69050-C-DIAG-2ND-RLTD-CD PIC X(01).
000850 05 WFC69050-C-DIAG-3RD-RLTD-CD PIC X(01).
000860 05 WFC69050-C-DIAG-4TH-RLTD-CD PIC X(01).
000870 05 WFC69050-C-DIAG-5TH-RLTD-CD PIC X(01).
000880 05 WFC69050-C-DIAG-6TH-RLTD-CD PIC X(01).
000890 05 WFC69050-C-DIAG-7TH-RLTD-CD PIC X(01).
000900 05 WFC69050-C-DIAG-8TH-RLTD-CD PIC X(01).
FFS INSTITUTIONAL LAYOUT
000010*****************************************************************
000020* *
000030* MEMBER: WFC69051 *
000040* NAME: C-HDR-FFS-INST-REC *
000050* C-DTL-FFS-INST-REC *
000060* SUBSYSTEM: C CLAIMS *
000070* *
000080* FEE FOR SERVICE CLAIMS INSTITUTIONAL FILE HEADER *
000090* INSTITUTIONAL FILE DETAIL *
000100* *
000110*****************************************************************
000120* *
000130 01 WFC69051-C-HDR-FFS-INST-REC.
000140 05 WFC69051-HDR-RECORD-ID-CODE PIC X(01).
000150 05 WFC69051-HDR-C-TCN-NUM PIC X(17).
000160 05 WFC69051-HDR-B-SYS-ID PIC 9(09).
000170 05 WFC69051-B-DOB-DT PIC X(10).
000180 05 WFC69051-C-HDR-CLNT-AGE PIC 9(03).
000190 05 WFC69051-B-GENDER-CD PIC X(01).
000200 05 WFC69051-B-RACE-CD PIC X(01).
000210 05 WFC69051-B-COE-CD PIC X(03).
000220 05 WFC69051-B-FED-MTCH-CD PIC X(01).
000230 05 WFC69051-B-GEO-CNTY-CD PIC X(02).
000240 05 WFC69051-B-ADM-CNTY-CD PIC X(02).
000250 05 WFC69051-B-MAJ-PROG-CD PIC X(01).
000260 05 WFC69051-C-HDR-TY-CD PIC X(01).
000270 05 WFC69051-C-PD-LAST-CHAIN-IND PIC X(01).
000280 05 WFC69051-C-BILL-PROV-ID PIC X(08).
000290 05 WFC69051-C-BILL-PROV-TY PIC X(03).
000300 05 WFC69051-P-IHS-IND PIC X(01).
000310 05 WFC69051-A-PRIOR-AUTH-ID PIC X(11).
000320 05 WFC69051-C-COST-CENTER-CD PIC X(05).
000330 05 WFC69051-C-ATTEND-PROV-ID PIC X(08).
000340 05 WFC69051-C-LTC-PROV-ID PIC X(08).
000350 05 WFC69051-R-DRG-CD PIC X(05).
000360 05 WFC69051-C-PAT-STAT-CD PIC X(02).
000370 05 WFC69051-C-TY-BILL-FACILITY PIC X(01).
000380 05 WFC69051-C-TY-BILL-CLASS PIC X(01).
000390 05 WFC69051-C-TY-BILL-FREQ PIC X(01).
000400 05 WFC69051-C-HDR-SVC-FST-DT PIC X(10).
000410 05 WFC69051-C-HDR-SVC-LST-DT PIC X(10).
000420 05 WFC69051-C-HDR-PD-DT PIC X(10).
000430 05 WFC69051-C-ADMIT-DT PIC X(10).
000440 05 WFC69051-C-DISCH-DT PIC X(10).
000450 05 WFC69051-C-ADMIT-DIAG-CD PIC X(10).
000460 05 WFC69051-C-ADM-SRC-CD PIC X(01).
000470 05 WFC69051-C-TY-OF-ADM-CD PIC X(01).
000480 05 WFC69051-C-CALC-DAYS-NUM PIC 9(04).
000490 05 WFC69051-C-CVRD-DAYS-NUM PIC 9(04).
000500 05 WFC69051-C-NCVRD-DAYS-NUM PIC 9(04).
000510 05 WFC69051-C-PAT-LIAB-AMT PIC s9(09)V99.
000520 05 WFC69051-C-NCVRD-CHRG-AMT PIC s9(09)V99.
000530 05 WFC69051-C-HDR-ALLOW-AMT PIC s9(09)V99.
000540 05 WFC69051-C-TOT-REIMB-AMT PIC s9(09)V99.
000550 05 WFC69051-C-OCC-CD1 PIC X(02).
000560 05 WFC69051-C-OCC-CD2 PIC X(02).
000570 05 WFC69051-C-OCC-CD3 PIC X(02).
000580 05 WFC69051-C-OCC-SPN-CD PIC X(02).
000590 05 WFC69051-C-OCC-SPN-FR-DT-1 PIC X(10).
000600 05 WFC69051-C-OCC-SPN-THRU-DT-1 PIC X(10).
000610 05 WFC69051-C-COND-CD-1 PIC X(02).
000620 05 WFC69051-C-COND-CD-2 PIC X(02).
000630 05 WFC69051-C-COND-CD-3 PIC X(02).
000640 05 WFC69051-C-VALU-CD-1 PIC X(02).
000650 05 WFC69051-C-VALU-CD-2 PIC X(02).
000660 05 WFC69051-C-VALU-CD-3 PIC X(02).
000670 05 WFC69051-R-ICD9-CD-1 PIC X(07).
000680 05 WFC69051-R-ICD9-CD-2 PIC X(07).
000690 05 WFC69051-R-ICD9-CD-3 PIC X(07).
000700 05 WFC69051-R-ICD9-CD-4 PIC X(07).
000710 05 WFC69051-R-ICD9-CD-5 PIC X(07).
000720 05 WFC69051-R-ICD9-CD-6 PIC X(07).
000730 05 WFC69051-R-DIAG-CD-1 PIC X(10).
000740 05 WFC69051-R-DIAG-CD-2 PIC X(10).
000750 05 WFC69051-R-DIAG-CD-3 PIC X(10).
000760 05 WFC69051-R-DIAG-CD-4 PIC X(10).
000770 05 WFC69051-R-DIAG-CD-5 PIC X(10).
000780 05 WFC69051-R-DIAG-CD-6 PIC X(10).
000790 05 WFC69051-R-DIAG-CD-7 PIC X(10).
000800 05 WFC69051-R-DIAG-CD-8 PIC X(10).
000810 05 WFC69051-C-TOT-TPL-AMT PIC S9(09)V99.
000820 05 WFC69051-C-TOT-COPAY-AMT PIC S9(09)V99.
000830 05 WFC69051-C-HDR-TAX-AMT PIC S9(09)V99.
000840
000850 01 WFC69051-C-DTL-FFS-INST-REC.
000860 05 WFC69051-DTL-RECORD-ID-CODE PIC X(01).
000870 05 WFC69051-DTL-C-TCN-NUM PIC X(17).
000880 05 WFC69051-DTL-C-LI-NUM PIC 9(03).
000890 05 WFC69051-DTL-B-SYS-ID PIC 9(09).
000900 05 WFC69051-R-REV-CD PIC X(07).
000910 05 WFC69051-R-REV-TY-CD PIC X(01).
000920 05 WFC69051-C-REIMB-STAT-CD PIC X(01).
000930 05 WFC69051-R-PROC-CD PIC X(07).
000940 05 WFC69051-C-COS-CD PIC X(02).
000950 05 WFC69051-C-REND-PROV-ID PIC X(08).
000960 05 WFC69051-P-REND-TY-CD PIC X(03).
000970 05 WFC69051-P-REND-SPECL-CD PIC X(03).
000980 05 WFC69051-C-LI-FST-DOX-DT PIC X(10).
000990 05 WFC69051-C-LI-SUBM-UNT-NUM PIC S9(07)V99.
001000 05 WFC69051-C-LI-ALLOW-UNT-NUM PIC S9(07)V99.
001010 05 WFC69051-C-LI-REIMB-UNT-NUM PIC S9(07)V99.
001020 05 WFC69051-C-LI-SUBM-CHRG-AMT PIC s9(09)V99.
001030 05 WFC69051-C-LI-ALLOW-CHRG-AMT PIC s9(09)V99.
001040 05 WFC69051-C-LI-REIMB-AMT PIC s9(09)V99.
001050 05 WFC69051-C-NN-CVRD-CHRG-AMT PIC s9(09)V99.
001060 05 WFC69051-C-COPAY-AMT PIC s9(09)V99.
001070 05 WFC69051-C-TPL-AMT PIC s9(09)V99.
001080 05 WFC69051-C-PAT-LIAB-AMT PIC s9(09)V99.
001090 05 WFC69051-C-TAX-AMT PIC s9(09)V99.
001100 05 WFC69051-B-LEVEL-OF-CARE-CD PIC X(03).
FFS DRUG LAYOUT
000010*****************************************************************
000020* *
000030* MEMBER: WFC69052 *
000040* NAME: C-HDR-FFS-DRUG-REC *
000050* C-DTL-FFS-DRUG-REC *
000060* SUBSYSTEM: C CLAIMS *
000070* *
000080* FEE FOR SERVICE CLAIMS DRUG FILE HEADER *
000090* DRUG FILE DETAIL *
000100* *
000110*****************************************************************
000120* *
000130 01 WFC69052-C-HDR-FFS-DRUG-REC.
000140 05 WFC69052-HDR-RECORD-ID-CODE PIC X(01).
000150 05 WFC69052-HDR-C-TCN-NUM PIC X(17).
000160 05 WFC69052-HDR-B-SYS-ID PIC 9(09).
000170 05 WFC69052-B-DOB-DT PIC X(10).
000180 05 WFC69052-C-HDR-TY-CD PIC X(01).
000190 05 WFC69052-A-PRIOR-AUTH-ID PIC X(11).
000200 05 WFC69052-C-COST-CENTER-CD PIC X(05).
000210 05 WFC69052-C-HDR-CLNT-AGE PIC 9(03).
000220 05 WFC69052-B-GENDER-CD PIC X(01).
000230 05 WFC69052-B-RACE-CD PIC X(01).
000240 05 WFC69052-B-COE-CD PIC X(03).
000250 05 WFC69052-B-FED-MTCH-CD PIC X(01).
000260 05 WFC69052-B-GEO-CNTY-CD PIC X(02).
000270 05 WFC69052-B-ADM-CNTY-CD PIC X(02).
000280 05 WFC69052-B-MAJ-PROG-CD PIC X(01).
000290 05 WFC69052-C-PD-LAST-CHAIN-IND PIC X(01).
000300 05 WFC69052-C-HDR-SVC-FST-DT PIC X(10).
000310 05 WFC69052-C-HDR-PD-DT PIC X(10).
000320 05 WFC69052-C-DRUG-FILLED-DT PIC X(10).
000330 05 WFC69052-C-BILL-PROV-ID PIC X(08).
000340 05 WFC69052-P-IHS-IND PIC X(01).
000350 05 WFC69052-C-PRESCR-PROV-ID PIC X(09).
000360 05 WFC69052-C-HDR-DRUG-RX-NUM PIC 9(09).
000370 05 WFC69052-C-DAW-CD PIC X(01).
000380 05 WFC69052-C-DRUG-SUB-QTY PIC S9(08)V999.
000390 05 WFC69052-C-DRUG-PD-QTY PIC S9(08)V999.
000400 05 WFC69052-C-SUB-DAYS-SPLY PIC 9(03).
000410 05 WFC69052-C-PD-DAYS-SPLY PIC 9(03).
000420 05 WFC69052-C-COS-CD PIC X(02).
000430 05 WFC69052-C-DRUG-CMPND-CD PIC X(01).
000440 05 WFC69052-C-ALLOW-INGRED-AMT PIC S9(09)V99.
000450 05 WFC69052-C-DISP-FEE-AMT PIC S9(09)V99.
000460 05 WFC69052-C-TOT-CHRG-AMT PIC S9(09)V99.
000470 05 WFC69052-C-HDR-ALLOW-AMT PIC S9(09)V99.
000480 05 WFC69052-C-TOT-REIMB-AMT PIC S9(09)V99.
000490 05 WFC69052-C-COPAY-AMT PIC S9(09)V99.
000500 05 WFC69052-C-TOT-TPL-AMT PIC S9(09)V99.
000510
000520 01 WFC69052-C-DTL-FFS-DRUG-REC.
000530 05 WFC69052-DTL-RECORD-ID-CODE PIC X(01).
000540 05 WFC69052-DTL-C-TCN-NUM PIC X(17).
000550 05 WFC69052-DTL-C-LI-NUM PIC 9(03).
000560 05 WFC69052-C-REIMB-STAT-CD PIC X(01).
000570 05 WFC69052-DTL-B-SYS-ID PIC 9(09).
000580 05 WFC69052-R-DRUG-CD PIC X(11).
000590 05 WFC69052-R-DRUG-GCN-SEQ-NUM PIC 9(07).
000600 05 WFC69052-R-DRUG-THER-CLS-NUM PIC X(03).
000610 05 WFC69052-C-DRUG-GEN-PRD-CD PIC X(01).
000620 05 WFC69052-C-DRUG-GEN-CD PIC X(05).
000630 05 WFC69052-C-DRUG-MAINT-IND PIC X(01).
000640 05 WFC69052-C-DRUG-ROUTE-CD PIC X(01).
000650 05 WFC69052-C-DRUG-DEA-CD PIC X(01).
000660 05 WFC69052-C-LI-ALLOW-INGRED-AMT PIC S9(09)V99.
FFS FINANCIAL LAYOUT
000010*****************************************************************
000020* *
000030* MEMBER: WFC69056 *
000040* NAME: C-HDR-FFS-FIN-REC *
000060* SUBSYSTEM: C CLAIMS *
000070* *
000080* FEE FOR SERVICE FINANCIAL CLAIMS *
000100* *
000110*****************************************************************
000120* *
000130 01 WFC69056-C-HDR-FFS-FIN-REC.
000140 05 WFC69056-HDR-RECORD-ID-CODE PIC X(01).
000150 05 WFC69056-HDR-C-TCN-NUM PIC X(17).
000160 05 WFC69056-HDR-B-SYS-ID PIC 9(09).
000170 05 WFC69056-B-DOB-DT PIC X(10).
000180 05 WFC69056-C-HDR-CLNT-AGE PIC 9(03).
000190 05 WFC69056-B-GENDER-CD PIC X(01).
000200 05 WFC69056-B-RACE-CD PIC X(01).
000210 05 WFC69056-B-COE-CD PIC X(03).
000220 05 WFC69056-B-FED-MTCH-CD PIC X(01).
000230 05 WFC69056-B-GEO-CNTY-CD PIC X(02).
000240 05 WFC69056-B-ADM-CNTY-CD PIC X(02).
000250 05 WFC69056-B-MAJ-PROG-CD PIC X(01).
000260 05 WFC69056-C-HDR-TY-CD PIC X(01).
000270 05 WFC69056-C-PD-LAST-CHAIN-IND PIC X(01).
000280 05 WFC69056-C-REF-PROV-ID PIC X(08).
000290 05 WFC69056-C-BILL-PROV-ID PIC X(08).
000300 05 WFC69056-C-BILL-PROV-TY PIC X(03).
000310 05 WFC69056-P-IHS-IND PIC X(01).
000320 05 WFC69056-A-PRIOR-AUTH-ID PIC X(11).
000330 05 WFC69056-C-COST-CENTER-CD PIC X(05).
000340 05 WFC69056-C-TOT-REIMB-AMT PIC S9(09)V99.
000350 05 WFC69056-C-HDR-SVC-FST-DT PIC X(10).
000360 05 WFC69056-C-HDR-PD-DT PIC X(10).
000370 05 WFC69056-R-DIAG-CD-1 PIC X(10).
000380 05 WFC69056-R-DIAG-CD-2 PIC X(10).
000390 05 WFC69056-R-DIAG-CD-3 PIC X(10).
000400 05 WFC69056-R-DIAG-CD-4 PIC X(10).
000410 05 WFC69056-R-DIAG-CD-5 PIC X(10).
000420 05 WFC69056-R-DIAG-CD-6 PIC X(10).
000430 05 WFC69056-R-DIAG-CD-7 PIC X(10).
000440 05 WFC69056-R-DIAG-CD-8 PIC X(10).
000450 05 WFC69056-C-TOT-TPL-AMT PIC S9(09)V99.
000460 05 WFC69056-C-TOT-COPAY-AMT PIC S9(09)V99.
000461 05 WFC69056-C-KEYED-REPLCD-NUM PIC S9(00017).
000464 05 WFC69056-C-HDR-ADJ-RSN-CD PIC X(00003).
000466 05 WFC69056-C-REPLCD-TCN-NUM PIC S9(00017).
000468 05 WFC69056-C-HDR-ADJ-STAT-CD PIC X(00001).
000470 05 WFC69056-C-REPLCMT-TCN-NUM PIC S9(00017).
000472 05 WFC69056-F-FCN-DT PIC X(00010).
000474 05 WFC69056-F-FCN-MED-CD PIC X(00001).
000476 05 WFC69056-F-FCN-NUM PIC S9(00003).
000478 05 WFC69056-C-ADJ-ORIG-TCN-NUM PIC S9(00017).
000480 05 WFC69056-C-ADJ-SEQ-NUM PIC S9(00002).
ENCOUNTER PROFESSIONAL / DENTAL LAYOUT
000010*****************************************************************
000020* *
000030* MEMBER: WFC69053 *
000040* NAME: C-HDR-ENCTR-PROF-REC *
000050* C-DTL-ENCTR-PROF-REC *
000060* SUBSYSTEM: C CLAIMS *
000070* *
000080* ENCOUNTER CLAIMS PROF/DENTAL FILE HEADER *
000090* PROF/DENTAL FILE DETAIL *
000100* *
000110*****************************************************************
000120* *
000130 01 WFC69053-C-HDR-ENCTR-PROF-REC.
000140 05 WFC69053-HDR-RECORD-ID-CODE PIC X(01).
000150 05 WFC69053-HDR-C-TCN-NUM PIC X(17).
000160 05 WFC69053-HDR-B-SYS-ID PIC 9(09).
000170 05 WFC69053-B-DOB-DT PIC X(10).
000180 05 WFC69053-C-HDR-CLNT-AGE PIC 9(03).
000190 05 WFC69053-B-GENDER-CD PIC X(01).
000200 05 WFC69053-B-RACE-CD PIC X(01).
000210 05 WFC69053-B-COE-CD PIC X(03).
000220 05 WFC69053-B-FED-MTCH-CD PIC X(01).
000230 05 WFC69053-B-GEO-CNTY-CD PIC X(02).
000240 05 WFC69053-B-ADM-CNTY-CD PIC X(02).
000250 05 WFC69053-B-MAJ-PROG-CD PIC X(01).
000260 05 WFC69053-C-HDR-TY-CD PIC X(01).
000270 05 WFC69053-C-PD-LAST-CHAIN-IND PIC X(01).
000280 05 WFC69053-C-MC-PROV-ID PIC X(08).
000290 05 WFC69053-C-MC-ENCT-PD-AMT PIC S9(09)V99.
000300 05 WFC69053-C-SUB-CAP-CD PIC X(01).
000310 05 WFC69053-C-NETWORK-BILL-ID PIC X(15).
000320 05 WFC69053-C-NETOWORK-REF-ID PIC X(15).
000330 05 WFC69053-C-NETWORK-REND-ID PIC X(15).
000340 05 WFC69053-C-MC-TCN-DAT PIC X(20).
000350 05 WFC69053-C-PROCESS-DT PIC X(10).
000360 05 WFC69053-C-REF-PROV-ID PIC X(08).
000370 05 WFC69053-C-BILL-PROV-ID PIC X(08).
000380 05 WFC69053-C-BILL-PROV-TY PIC X(03).
000390 05 WFC69053-P-IHS-IND PIC X(01).
000400 05 WFC69053-A-PRIOR-AUTH-ID PIC X(11).
000410 05 WFC69053-C-COST-CENTER-CD PIC X(05).
000420 05 WFC69053-C-TOT-REIMB-AMT PIC S9(09)V99.
000430 05 WFC69053-C-HDR-SVC-FST-DT PIC X(10).
000440 05 WFC69053-C-HDR-PD-DT PIC X(10).
000450 05 WFC69053-R-DIAG-CD-1 PIC X(10).
000460 05 WFC69053-R-DIAG-CD-2 PIC X(10).
000470 05 WFC69053-R-DIAG-CD-3 PIC X(10).
000480 05 WFC69053-R-DIAG-CD-4 PIC X(10).
000490 05 WFC69053-R-DIAG-CD-5 PIC X(10).
000500 05 WFC69053-R-DIAG-CD-6 PIC X(10).
000510 05 WFC69053-R-DIAG-CD-7 PIC X(10).
000520 05 WFC69053-R-DIAG-CD-8 PIC X(10).
000530 05 WFC69053-C-TOT-TPL-AMT PIC S9(09)V99.
000540 05 WFC69053-C-TOT-COPAY-AMT PIC S9(09)V99.
000550
000560 01 WFC69053-C-DTL-ENCTR-PROF-REC.
000570 05 WFC69053-DTL-RECORD-ID-CODE PIC X(01).
000580 05 WFC69053-DTL-C-TCN-NUM PIC X(17).
000590 05 WFC69053-DTL-C-LI-NUM PIC 9(03).
000600 05 WFC69053-DTL-B-SYS-ID PIC 9(09).
000610 05 WFC69053-C-REND-PROV-ID PIC X(08).
000620 05 WFC69053-C-REND-PROV-TY PIC X(03).
000630 05 WFC69053-C-REND-SPECL-CD PIC X(03).
000640 05 WFC69053-C-DSTN-PROV-ID PIC X(08).
000650 05 WFC69053-C-REIMB-STAT-CD PIC X(01).
000660 05 WFC69053-C-LI-FST-DOS-DT PIC X(10).
000670 05 WFC69053-C-LI-LAST-DOS-DT PIC X(10).
000680 05 WFC69053-R-PL-OF-SVC-CD PIC X(02).
000690 05 WFC69053-C-COS-CD PIC X(02).
000700 05 WFC69053-R-PROC-CD PIC X(07).
000710 05 WFC69053-C-PROC-MOD-CD-1 PIC X(02).
000720 05 WFC69053-C-PROC-MOD-CD-2 PIC X(02).
000730 05 WFC69053-C-PROC-MOD-CD-3 PIC X(02).
000740 05 WFC69053-C-PROC-MOD-CD-4 PIC X(02).
000750 05 WFC69053-C-SUBM-FAM-PLAN-IND PIC X(01).
000760 05 WFC69053-C-SUBM-EPSDT-IND PIC X(01).
000770 05 WFC69053-C-LI-ABORT-IND PIC X(01).
000780 05 WFC69053-C-LI-STERIL-IND PIC X(01).
000790 05 WFC69053-C-LI-FAM-PLAN-IND PIC X(01).
000800 05 WFC69053-C-LI-HYSTER-IND PIC X(01).
000810 05 WFC69053-C-LI-SUBM-UNT-NUM PIC S9(07)V99.
000820 05 WFC69053-C-LI-ALLOW-UNT-NUM PIC S9(07)V99.
000830 05 WFC69053-C-LI-REIMB-UNT-NUM PIC S9(07)V99.
000840 05 WFC69053-C-LI-SUBM-CHRG-AMT PIC S9(09)V99.
000850 05 WFC69053-C-LI-REIMB-CHRG-AMT PIC S9(09)V99.
000860 05 WFC69053-C-LI-REIMB-AMT PIC S9(09)V99.
000870 05 WFC69053-C-COPAY-AMT PIC S9(09)V99.
000880 05 WFC69053-C-TPL-AMT PIC S9(09)V99.
000890 05 WFC69053-C-PAT-LIAB-AMT PIC S9(09)V99.
000900 05 WFC69053-C-TAX-AMT PIC S9(09)V99.
000910 05 WFC69053-C-DIAG-1ST-RLTD-CD PIC X(01).
000920 05 WFC69053-C-DIAG-2ND-RLTD-CD PIC X(01).
000930 05 WFC69053-C-DIAG-3RD-RLTD-CD PIC X(01).
000940 05 WFC69053-C-DIAG-4TH-RLTD-CD PIC X(01).
000950 05 WFC69053-C-DIAG-5TH-RLTD-CD PIC X(01).
000960 05 WFC69053-C-DIAG-6TH-RLTD-CD PIC X(01).
000970 05 WFC69053-C-DIAG-7TH-RLTD-CD PIC X(01).
000980 05 WFC69053-C-DIAG-8TH-RLTD-CD PIC X(01).
ENCOUNTER INSTITUTIONAL LAYOUT
000010*****************************************************************
000020* *
000030* MEMBER: WFC69054 *
000040* NAME: C-HDR-ENCTR-INST-REC *
000050* C-DTL-ENCTR-INST-REC *
000060* SUBSYSTEM: C CLAIMS *
000070* *
000080* ENCOUNTER CLAIMS INSTITUTIONAL FILE HEADER *
000090* INSTITUTIONAL FILE DETAIL *
000100* *
000110*****************************************************************
000120* *
000130 01 WFC69054-C-HDR-ENCTR-INST-REC.
000140 05 WFC69054-HDR-RECORD-ID-CODE PIC X(01).
000150 05 WFC69054-HDR-C-TCN-NUM PIC X(17).
000160 05 WFC69054-HDR-B-SYS-ID PIC 9(09).
000170 05 WFC69054-B-DOB-DT PIC X(10).
000180 05 WFC69054-C-HDR-CLNT-AGE PIC 9(03).
000190 05 WFC69054-B-GENDER-CD PIC X(01).
000200 05 WFC69054-B-RACE-CD PIC X(01).
000210 05 WFC69054-B-COE-CD PIC X(03).
000220 05 WFC69054-B-FED-MTCH-CD PIC X(01).
000230 05 WFC69054-B-GEO-CNTY-CD PIC X(02).
000240 05 WFC69054-B-ADM-CNTY-CD PIC X(02).
000250 05 WFC69054-B-MAJ-PROG-CD PIC X(01).
000260 05 WFC69054-C-HDR-TY-CD PIC X(01).
000270 05 WFC69054-C-PD-LAST-CHAIN-IND PIC X(01).
000280 05 WFC69054-C-MC-PROV-ID PIC X(08).
000290 05 WFC69054-C-BILL-PROV-ID PIC X(08).
000300 05 WFC69054-C-BILL-PROV-TY PIC X(03).
000310 05 WFC69054-P-IHS-IND PIC X(01).
000320 05 WFC69054-A-PRIOR-AUTH-ID PIC X(11).
000330 05 WFC69054-C-COST-CENTER-CD PIC X(05).
000340 05 WFC69054-C-ATTEND-PROV-ID PIC X(08).
000350 05 WFC69054-C-LTC-PROV-ID PIC X(08).
000360 05 WFC69054-R-DRG-CD PIC X(05).
000370 05 WFC69054-C-PAT-STAT-CD PIC X(02).
000380 05 WFC69054-C-TY-BILL-FACILITY PIC X(01).
000390 05 WFC69054-C-TY-BILL-CLASS PIC X(01).
000400 05 WFC69054-C-TY-BILL-FREQ PIC X(01).
000410 05 WFC69054-C-HDR-SVC-FST-DT PIC X(10).
000420 05 WFC69054-C-HDR-SVC-LST-DT PIC X(10).
000430 05 WFC69054-C-HDR-PD-DT PIC X(10).
000440 05 WFC69054-C-PROCESS-DT PIC X(10).
000450 05 WFC69054-C-ADMIT-DT PIC X(10).
000460 05 WFC69054-C-DISCH-DT PIC X(10).
000470 05 WFC69054-C-ADMIT-DIAG-CD PIC X(10).
000480 05 WFC69054-C-ADM-SRC-CD PIC X(01).
000490 05 WFC69054-C-TY-OF-ADM-CD PIC X(01).
000500 05 WFC69054-C-CALC-DAYS-NUM PIC 9(04).
000510 05 WFC69054-C-CVRD-DAYS-NUM PIC 9(04).
000520 05 WFC69054-C-NCVRD-DAYS-NUM PIC 9(04).
000530 05 WFC69054-C-PAT-LIAB-AMT PIC S9(09)V99.
000540 05 WFC69054-C-NCVRD-CHRG-AMT PIC S9(09)V99.
000550 05 WFC69054-C-HDR-ALLOW-AMT PIC S9(09)V99.
000560 05 WFC69054-C-SUB-CAP-CD PIC X(01).
000570 05 WFC69054-C-NETWORK-BILL-ID PIC X(15).
000580 05 WFC69054-C-NETOWORK-REF-ID PIC X(15).
000590 05 WFC69054-C-NETWORK-REND-ID PIC X(15).
000600 05 WFC69054-C-MC-TCN-DAT PIC X(20).
000610 05 WFC69054-C-MC-ENCT-PD-AMT PIC S9(09)V99.
000620 05 WFC69054-C-TOT-REIMB-AMT PIC S9(09)V99.
000630 05 WFC69054-C-OCC-CD1 PIC X(02).
000640 05 WFC69054-C-OCC-CD2 PIC X(02).
000650 05 WFC69054-C-OCC-CD3 PIC X(02).
000660 05 WFC69054-C-OCC-SPN-CD PIC X(02).
000670 05 WFC69054-C-OCC-SPN-FR-DT-1 PIC X(10).
000680 05 WFC69054-C-OCC-SPN-THRU-DT-1 PIC X(10).
000690 05 WFC69054-C-COND-CD-1 PIC X(02).
000700 05 WFC69054-C-COND-CD-2 PIC X(02).
000710 05 WFC69054-C-COND-CD-3 PIC X(02).
000720 05 WFC69054-C-VALU-CD-1 PIC X(02).
000730 05 WFC69054-C-VALU-CD-2 PIC X(02).
000740 05 WFC69054-C-VALU-CD-3 PIC X(02).
000750 05 WFC69054-R-ICD9-CD-1 PIC X(07).
000760 05 WFC69054-R-ICD9-CD-2 PIC X(07).
000770 05 WFC69054-R-ICD9-CD-3 PIC X(07).
000780 05 WFC69054-R-ICD9-CD-4 PIC X(07).
000790 05 WFC69054-R-ICD9-CD-5 PIC X(07).
000800 05 WFC69054-R-ICD9-CD-6 PIC X(07).
000810 05 WFC69054-R-DIAG-CD-1 PIC X(10).
000820 05 WFC69054-R-DIAG-CD-2 PIC X(10).
000830 05 WFC69054-R-DIAG-CD-3 PIC X(10).
000840 05 WFC69054-R-DIAG-CD-4 PIC X(10).
000850 05 WFC69054-R-DIAG-CD-5 PIC X(10).
000860 05 WFC69054-R-DIAG-CD-6 PIC X(10).
000870 05 WFC69054-R-DIAG-CD-7 PIC X(10).
000880 05 WFC69054-R-DIAG-CD-8 PIC X(10).
000890 05 WFC69054-C-TOT-TPL-AMT PIC S9(09)V99.
000900 05 WFC69054-C-TOT-COPAY-AMT PIC S9(09)V99.
000910 05 WFC69054-C-HDR-TAX-AMT PIC S9(09)V99.
000920
000930 01 WFC69054-C-DTL-ENCTR-INST-REC.
000940 05 WFC69054-DTL-RECORD-ID-CODE PIC X(01).
000950 05 WFC69054-DTL-C-TCN-NUM PIC X(17).
000960 05 WFC69054-DTL-C-LI-NUM PIC 9(03).
000970 05 WFC69054-DTL-B-SYS-ID PIC 9(09).
000980 05 WFC69054-R-REV-CD PIC X(07).
000990 05 WFC69054-R-REV-TY-CD PIC X(01).
001000 05 WFC69054-C-REIMB-STAT-CD PIC X(01).
001010 05 WFC69054-R-PROC-CD PIC X(07).
001020 05 WFC69054-C-COS-CD PIC X(02).
001030 05 WFC69054-C-REND-PROV-ID PIC X(08).
001040 05 WFC69054-P-REND-TY-CD PIC X(03).
001050 05 WFC69054-P-REND-SPECL-CD PIC X(03).
001060 05 WFC69054-C-LI-FST-DOX-DT PIC X(10).
001070 05 WFC69054-C-LI-SUBM-UNT-NUM PIC S9(07)V99.
001080 05 WFC69054-C-LI-ALLOW-UNT-NUM PIC S9(07)V99.
001090 05 WFC69054-C-LI-REIMB-UNT-NUM PIC S9(07)V99.
001100 05 WFC69054-C-LI-SUBM-CHRG-AMT PIC S9(09)V99.
001110 05 WFC69054-C-LI-ALLOW-CHRG-AMT PIC S9(09)V99.
001120 05 WFC69054-C-LI-REIMB-AMT PIC S9(09)V99.
001130 05 WFC69054-C-NN-CVRD-CHRG-AMT PIC S9(09)V99.
001140 05 WFC69054-C-COPAY-AMT PIC S9(09)V99.
001150 05 WFC69054-C-TPL-AMT PIC S9(09)V99.
001160 05 WFC69054-C-PAT-LIAB-AMT PIC S9(09)V99.
001170 05 WFC69054-C-TAX-AMT PIC S9(09)V99.
001180 05 WFC69054-B-LEVEL-OF-CARE-CD PIC X(03).
ENCOUNTER DRUG LAYOUT
000010*****************************************************************
000020* *
000030* MEMBER: WFC69055 *
000040* NAME: C-HDR-ENCTR-DRUG-REC *
000050* C-DTL-ENCTR-DRUG-REC *
000060* SUBSYSTEM: C CLAIMS *
000070* *
000080* ENCOUNTER CLAIMS DRUG FILE HEADER *
000090* DRUG FILE DETAIL *
000100* *
000110*****************************************************************
000120* *
000130 01 WFC69055-C-HDR-ENCTR-DRUG-REC.
000140 05 WFC69055-HDR-RECORD-ID-CODE PIC X(01).
000150 05 WFC69055-HDR-C-TCN-NUM PIC X(17).
000160 05 WFC69055-HDR-B-SYS-ID PIC 9(09).
000170 05 WFC69055-B-DOB-DT PIC X(10).
000180 05 WFC69055-C-HDR-TY-CD PIC X(01).
000190 05 WFC69055-A-PRIOR-AUTH-ID PIC X(11).
000200 05 WFC69055-C-COST-CENTER-CD PIC X(05).
000210 05 WFC69055-C-HDR-CLNT-AGE PIC 9(03).
000220 05 WFC69055-B-GENDER-CD PIC X(01).
000230 05 WFC69055-B-RACE-CD PIC X(01).
000240 05 WFC69055-B-COE-CD PIC X(03).
000250 05 WFC69055-B-FED-MTCH-CD PIC X(01).
000260 05 WFC69055-B-GEO-CNTY-CD PIC X(02).
000270 05 WFC69055-B-ADM-CNTY-CD PIC X(02).
000280 05 WFC69055-B-MAJ-PROG-CD PIC X(01).
000290 05 WFC69055-C-PD-LAST-CHAIN-IND PIC X(01).
000300 05 WFC69055-C-HDR-SVC-FST-DT PIC X(10).
000310 05 WFC69055-C-HDR-PD-DT PIC X(10).
000320 05 WFC69055-C-DRUG-FILLED-DT PIC X(10).
000330 05 WFC69055-C-BILL-PROV-ID PIC X(08).
000340 05 WFC69055-C-MC-PROV-ID PIC X(08).
000350 05 WFC69055-C-MC-ENCT-PD-AMT PIC S9(09)V99.
000360 05 WFC69055-C-SUB-CAP-CD PIC X(01).
000370 05 WFC69055-C-NETWORK-BILL-ID PIC X(15).
000380 05 WFC69055-C-NETOWORK-REF-ID PIC X(15).
000390 05 WFC69055-C-NETWORK-REND-ID PIC X(15).
000400 05 WFC69055-C-MC-TCN-DAT PIC X(20).
000410 05 WFC69055-C-PROCESS-DT PIC X(10).
000420 05 WFC69055-P-IHS-IND PIC X(01).
000430 05 WFC69055-C-PRESCR-PROV-ID PIC X(08).
000440 05 WFC69055-C-HDR-DRUG-RX-NUM PIC 9(09).
000450 05 WFC69055-C-DAW-CD PIC X(01).
000460 05 WFC69055-C-DRUG-SUB-QTY PIC S9(08)V999.
000470 05 WFC69055-C-DRUG-PD-QTY PIC S9(08)V999.
000480 05 WFC69055-C-SUB-DAYS-SPLY PIC 9(03).
000490 05 WFC69055-C-PD-DAYS-SPLY PIC 9(03).
000500 05 WFC69055-C-COS-CD PIC X(02).
000510 05 WFC69055-C-DRUG-CMPND-CD PIC X(01).
000520 05 WFC69055-C-ALLOW-INGRED-AMT PIC S9(09)V99.
000530 05 WFC69055-C-DISP-FEE-AMT PIC S9(09)V99.
000540 05 WFC69055-C-TOT-CHRG-AMT PIC S9(09)V99.
000550 05 WFC69055-C-HDR-ALLOW-AMT PIC S9(09)V99.
000560 05 WFC69055-C-TOT-REIMB-AMT PIC S9(09)V99.
000570 05 WFC69055-C-COPAY-AMT PIC S9(09)V99.
000580 05 WFC69055-C-TOT-TPL-AMT PIC S9(09)V99.
000600 01 WFC69055-C-DTL-ENCTR-DRUG-REC.
000610 05 WFC69055-DTL-RECORD-ID-CODE PIC X(01).
000620 05 WFC69055-DTL-C-TCN-NUM PIC X(17).
000630 05 WFC69055-DTL-C-LI-NUM PIC 9(03).
000640 05 WFC69055-C-REIMB-STAT-CD PIC X(01).
000650 05 WFC69055-DTL-B-SYS-ID PIC 9(09).
000660 05 WFC69055-R-DRUG-CD PIC X(11).
000670 05 WFC69055-R-DRUG-GCN-SEQ-NUM PIC 9(07).
000680 05 WFC69055-R-DRUG-THER-CLS-NUM PIC X(03).
000690 05 WFC69055-C-DRUG-GEN-PRD-CD PIC X(01).
000700 05 WFC69055-C-DRUG-GEN-CD PIC X(05).
000710 05 WFC69055-C-DRUG-MAINT-IND PIC X(01).
000720 05 WFC69055-C-DRUG-ROUTE-CD PIC X(01).
000730 05 WFC69055-C-DRUG-DEA-CD PIC X(01).
000740 05 WFC69055-C-LI-ALLOW-INGRED-AMT PIC S9(09)V99.
000750
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE OF PAID CLAIMS
FURNISHED TO MERCER CONSULTING
|Source Table |Source Field |Target Field | Req | | |Note |
| | | | |Def |Specifications |Ref |
|N/A |N/A |WFC69050-HDR-RECORD-ID-CODE |A |N/A | |1 |
|X_HDR_TB |HDR_C_TCN_NUM |WFC69050-HDR-C-TCN-NUM |A |N/A | | |
|X_HDR_TB |HDR_B_SYS_ID |WFC69050-HDR-B-SYS-ID |A |N/A | | |
|X_HDR_TB |B_DOB_DT |WFC69050-B-DOB-DT |A |N/A | | |
|X_HDR_TB |C_HDR_CLNT_AGE |WFC69050-C-HDR-CLNT-AGE |A |N/A | | |
|X_HDR_TB |B_GENDER_CD |WFC69050-B-GENDER-CD |A |N/A | | |
|X_HDR_TB |B_RACE_CD |WFC69050-B-RACE-CD |A |N/A | | |
|X_HDR_COE_TB |B_COE_CD |WFC69050-B-COE-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_FED_MTCH_CD |WFC69050-B-FED-MTCH-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_GEO_CNTY_CD |WFC69050-B-GEO-CNTY-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_ADMIN_CNTY_CD |WFC69050-B-ADM-CNTY-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_TB |B_MAJ_PROG_CD |WFC69050-B-MAJ-PROG-CD |A |N/A | | |
|X_HDR_TB |C_HDR_TY_CD |WFC69050-C-HDR-TY-CD |A |N/A | | |
|N/A |N/A |WFC69050-C-PD-LAST-CHAIN-IND |N | Space | | |
|X_HDR_TB |C_REF_PROV_ID |WFC69050-C-REF-PROV-ID |A |N/A | | |
|X_HDR_TB |C_BLNG_PROV_ID |WFC69050-C-BILL-PROV-ID |A |N/A | | |
|X_HDR_TB |C_BLNG_PROV_TY |WFC69050-C-BILL-PROV-TY |A |N/A | | |
|X_HDR_TB |P_IHS_IND |WFC69050-P-IHS-IND |A |N/A | | |
|X_HDR_TB |A_ID |WFC69050-A-PRIOR-AUTH-ID |A |N/A | | |
|X_HDR_TB |C_COST_CENTER_CD |WFC69050-C-COST-CENTER-CD |A |N/A | | |
|X_HDR_TB |C_TOT_REIMB_AMT |WFC69050-C-TOT-REIMB-AMT |A |N/A | | |
|X_HDR_TB |C_HDR_SVC_FST_DT |WFC69050-C-HDR-SVC-FST-DT |A |N/A | | |
|X_HDR_TB |C_HDR_PD_DT |WFC69050-C-HDR-PD-DT |A |N/A | | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69050-R-DIAG-CD-1 |C |N/A |Taken from HDR with seq. number = 1 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69050-R-DIAG-CD-2 |C |N/A |Taken from HDR with seq. number = 2 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69050-R-DIAG-CD-3 |C |N/A |Taken from HDR with seq. number = 3 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69050-R-DIAG-CD-4 |C |N/A |Taken from HDR with seq. number = 4 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69050-R-DIAG-CD-5 |C |N/A |Taken from HDR with seq. number = 5 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69050-R-DIAG-CD-6 |C |N/A |Taken from HDR with seq. number = 6 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69050-R-DIAG-CD-7 |C |N/A |Taken from HDR with seq. number = 7 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69050-R-DIAG-CD-8 |C |N/A |Taken from HDR with seq. number = 8 | |
|X_HDR_TB |C_TOT_TPL_AMT |WFC69050-C-TOT-TPL-AMT |A |N/A | | |
|X_HDR_TB |C_TOT_COPAY_AMT |WFC69050-C-TOT-COPAY-AMT |A |N/A | | |
|N/A |N/A |WFC69050-C-DTL-FFS-PROF-REC |A |N/A |Group level record name. | |
|N/A |N/A |WFC69050-DTL-RECORD-ID-CODE |A |N/A | |1 |
|X_LI_TB |C_TCN_NUM |WFC69050-DTL-C-TCN-NUM |A |N/A | | |
|X_LI_TB |C_LI_NUM |WFC69050-DTL-C-LI-NUM |A |N/A | | |
|X_LI_TB |B_SYS_ID |WFC69050-DTL-B-SYS-ID |A |N/A | | |
|X_LI_TB |C-RNDR-PROV-ID |WFC69050-C-REND-PROV-ID |A |N/A | | |
|X_LI_TB |P-TY-CD |WFC69050-C-REND-PROV-TY |A |N/A | | |
|X_LI_TB |P-SPECL-CD |WFC69050-C-REND-SPECL-CD |A |N/A | | |
|X_LI_TB |C_DSTN_PROV_ID |WFC69050-C-DSTN-PROV-ID |A |N/A | | |
|X_LI_TB |C_REIMB_STAT_CD |WFC69050-C-REIMB-STAT-CD |A |N/A | | |
|X_LI_TB |C_LI_FST_DOS_DT |WFC69050-C-LI-FST-DOS-DT |A |N/A | | |
|X_LI_TB |C_LI_LAST_DOS_DT |WFC69050-C-LI-LAST-DOS-DT |A |N/A | | |
|X_LI_TB |R_PL_OF_SVC_CD |WFC69050-R-PL-OF-SVC-CD |A |N/A | | |
|X_LI_TB |C_COS_CD |WFC69050-C-COS-CD |A |N/A | | |
|X_LI_TB |R_PROC_CD |WFC69050-R-PROC-CD |A |N/A | | |
|X_LI_TB |C_PROC_MOD_1ST_CD |WFC69050-C-PROC-MOD-CD-1 |A |N/A | | |
|X_LI_TB |C_PROC_MOD_2ND-CD |WFC69050-C-PROC-MOD-CD-2 |A |N/A | | |
|X_LI_TB |C_PROC_MOD_3RD_CD |WFC69050-C-PROC-MOD-CD-3 |A |N/A | | |
|X_LI_TB |C_PROC_MOD_4TH_CD |WFC69050-C-PROC-MOD-CD-4 |A |N/A | | |
|X_LI_TB |C_SUBM_FAM_PLN_IND |WFC69050-C-SUBM-FAM-PLAN-IND |A |N/A | | |
|X_LI_TB |C_SUBM_EPSDT_IND |WFC69050-C-SUBM-EPSDT-IND |A |N/A | | |
|X_LI_TB |C_LI_ABORT_IND |WFC69050-C-LI-ABORT-IND |A |N/A | | |
|X_LI_TB |C_LI_STERIL_IND |WFC69050-C-LI-STERIL-IND |A |N/A | | |
|X_LI_TB |C_LI_FAM_PLNG_IND |WFC69050-C-LI-FAM-PLAN-IND |A |N/A | | |
|X_LI_TB |C_LI_HYSTER_IND |WFC69050-C-LI-HYSTER-IND |A |N/A | | |
|X_LI_TB |C_LI_SUBM_UNT_NUM |WFC69050-C-LI-SUBM-UNT-NUM |A |N/A | | |
|X_LI_TB |C_LI_ALLOW_UNT_NUM |WFC69050-C-LI-ALLOW-UNT-NUM |A |N/A | | |
|X_LI_TB |C_LI_REIMB_UNT_NUM |WFC69050-C-LI-REIMB-UNT-NUM |A |N/A | | |
|X_LI_TB |C_LI_SUBM_CHRG_AMT |WFC69050-C-LI-SUBM-CHRG-AMT |A |N/A | | |
|X_LI_TB |C_LI_REIMB_CHRG_AMT |WFC69050-C-LI-REIMB-CHRG-AMT |A |N/A | | |
|X_LI_TB |C_LI_REIMB_AMT |WFC69050-C-LI-REIMB-AMT |A |N/A | | |
|X_LI_BSE_CHG_TB |C_BSE_AMT_CHG_AMT |WFC69050-C-COPAY-AMT |C |N/A |Only when BSE_CHNG_RSN_CD = COPAY | |
|X_LI_BSE_CHG_TB |C_BSE_AMT_CHG_AMT |WFC69050-C-TPL-AMT |C |N/A |Only when BSE_CHNG_RSN_CD = TPL | |
|X_LI_BSE_CHG_TB |C_BSE_AMT_CHG_AMT |WFC69050-C-PAT-LIAB-AMT |C |N/A |Only when BSE_CHNG_RSN_CD = PAT LIAB | |
|X_LI_BSE_CHG_TB |C_BSE_AMT_CHG_AMT |WFC69050-C-TAX-AMT |C |N/A |Only when BSE_CHNG_RSN_CD = TAX | |
|X_LI_TB |C_DIAG_1ST_RLTD_CD |WFC69050-C-DIAG-1ST-RLTD-CD |A |N/A | | |
|X_LI_TB |C_DIAG_2ND_RLTD_CD |WFC69050-C-DIAG-2ND-RLTD-CD |A |N/A | | |
|X_LI_TB |C_DIAG_3RD_RLTD_CD |WFC69050-C-DIAG-3RD-RLTD-CD |A |N/A | | |
|X_LI_TB |C_DIAG_4TH_RLTD_CD |WFC69050-C-DIAG-4TH-RLTD-CD |A |N/A | | |
|X_LI_TB |C_DIAG_5TH_RLTD_CD |WFC69050-C-DIAG-5TH-RLTD-CD |A |N/A | | |
|X_LI_TB |C_DIAG_6TH_RLTD_CD |WFC69050-C-DIAG-6TH-RLTD-CD |A |N/A | | |
|X_LI_TB |C_DIAG_7TH_RLTD_CD |WFC69050-C-DIAG-7TH-RLTD-CD |A |N/A | | |
|X_LI_TB |C_DIAG_8TH_RLTD_CD |WFC69050-C-DIAG-8TH-RLTD-CD |A |N/A | | |
|N/A |N/A |WFC69051-C-HDR-FFS-INST-REC |A |N/A |Group level record name. | |
|N/A |N/A |WFC69051-HDR-RECORD-ID-CODE |A |N/A | |1 |
|X_HDR_TB |HDR_C_TCN_NUM |WFC69051-HDR-C-TCN-NUM |A |N/A | | |
|X_HDR_TB |HDR_B_SYS_ID |WFC69051-HDR-B-SYS-ID |A |N/A | | |
|X_HDR_TB |B_DOB_DT |WFC69051-B-DOB-DT |A |N/A | | |
|X_HDR_TB |C_HDR_CLNT_AGE |WFC69051-C-HDR-CLNT-AGE |A |N/A | | |
|X_HDR_TB |B_GENDER_CD |WFC69051-B-GENDER-CD |A |N/A | | |
|X_HDR_TB |B_RACE_CD |WFC69051-B-RACE-CD |A |N/A | | |
|X_HDR_COE_TB |B_COE_CD |WFC69051-B-COE-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_FED_MTCH_CD |WFC69051-B-FED-MTCH-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_GEO_CNTY_CD |WFC69051-B-GEO-CNTY-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_ADMIN_CNTY_CD |WFC69051-B-ADM-CNTY-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_TB |B_MAJ_PROG_CD |WFC69051-B-MAJ-PROG-CD |A |N/A | | |
|X_HDR_TB |C_HDR_TY_CD |WFC69051-C-HDR-TY-CD |A |N/A | | |
| | |WFC69051-C-PD-LAST-CHAIN-IND |N | Spaces | | |
|X_HDR_TB |C_BLNG_PROV_ID |WFC69051-C-BILL-PROV-ID |A |N/A | | |
|X_HDR_TB |C_BLNG_PROV_TY |WFC69051-C-BILL-PROV-TY |A |N/A | | |
|X_HDR_TB |P_IHS_IND |WFC69051-P-IHS-IND |A |N/A | | |
|X_HDR_TB |A_ID |WFC69051-A-PRIOR-AUTH-ID |A |N/A | | |
|X_HDR_TB |C_COST_CENTER_CD |WFC69051-C-COST-CENTER-CD |A |N/A | | |
|X_HDR_TB |C_ATNDG_PROV_ID |WFC69051-C-ATTEND-PROV-ID |A |N/A | | |
|X_HDR_TB |C_LTC_PROV_ID |WFC69051-C-LTC-PROV-ID |A |N/A | | |
|X_HDR_TB |R_DRG_CD |WFC69051-R-DRG-CD |A |N/A | | |
|X_HDR_TB |C_PAT_STAT_CD |WFC69051-C-PAT-STAT-CD |A |N/A | | |
|X_HDR_TB |C_TY_OF_BLL_TY_1_2_CD |WFC69051-C-TY-BILL-FACILITY |A |N/A |Moves 1st character of source field | |
|X_HDR_TB |C_TY_OF_BLL_TY_1_2_CD |WFC69051-C-TY-BILL-CLASS |A |N/A |Moves 2nd character of source field | |
|X_HDR_TB |C_TY_OF_BLL_TY_1_2_CD |WFC69051-C-TY-BILL-FREQ |A |N/A |Moves 3rd character of source field | |
|X_HDR_TB |C_HDR_SVC_FST_DT |WFC69051-C-HDR-SVC-FST-DT |A |N/A | | |
|X_HDR_TB |C_HDR_SVC_LST_DT |WFC69051-C-HDR-SVC-LST-DT |A |N/A | | |
|X_HDR_TB |C_HDR_PD_DT |WFC69051-C-HDR-PD-DT |A |N/A | | |
|X_HDR_TB |C_ADMIT_DT |WFC69051-C-ADMIT-DT |A |N/A | | |
|X_HDR_TB |C_DISCH_DT |WFC69051-C-DISCH-DT |A |N/A | | |
|X_HDR_TB |C_ADMIT_DIAG_CD |WFC69051-C-ADMIT-DIAG-CD |A |N/A | | |
|X_HDR_TB |C_ADM_SRC_CD |WFC69051-C-ADM-SRC-CD |A |N/A | | |
|X_HDR_TB |C_TY_OF_ADM_CD |WFC69051-C-TY-OF-ADM-CD |A |N/A | | |
|X_HDR_TB |C_CALC_DAYS_NUM |WFC69051-C-CALC-DAYS-NUM |A |N/A | | |
|X_HDR_TB |C_CVRD_DAYS_NUM |WFC69051-C-CVRD-DAYS-NUM |A |N/A | | |
|X_HDR_TB |C_NCVRD_DAYS_NUM |WFC69051-C-NCVRD-DAYS-NUM |A |N/A | | |
|X_HDR_TB |C_PAT_LIAB_AMT |WFC69051-C-PAT-LIAB-AMT |A |N/A | | |
|X_HDR_TB |C_NCVRD_CHRG_AMT |WFC69051-C-NCVRD-CHRG-AMT |A |N/A | | |
|X_HDR_TB |C_HDR_ALLOW_AMT |WFC69051-C-HDR-ALLOW-AMT |A |N/A | | |
|X_HDR_TB |C_TOT_REIMB_AMT |WFC69051-C-TOT-REIMB-AMT |A |N/A | | |
|X_HDR_OCC_CD_TB |C_OCC_CD |WFC69051-C-OCC-CD1 |C |N/A |Taken from HDR with seq. number = 1 | |
|X_HDR_OCC_CD_TB |C_OCC_CD |WFC69051-C-OCC-CD2 |C |N/A |Taken from HDR with seq. number = 2 | |
|X_HDR_OCC_CD_TB |C_OCC_CD |WFC69051-C-OCC-CD3 |C |N/A |Taken from HDR with seq. number = 3 | |
|X_HDR_OCC_SPN_TB |C_OCC_SPN_CD |WFC69051-C-OCC-SPN-CD |A |N/A | | |
|X_HDR_OCC_SPN_TB |C_OCC_SPN_FR_DT |WFC69051-C-OCC-SPN-FR-DT-1 |C |N/A |Taken from HDR with seq. number = 1 | |
|X_HDR_OCC_SPN_TB |C_OCC_SPN_THRU_DT |WFC69051-C-OCC-SPN-THRU-DT-1 |C |N/A |Taken from HDR with seq. number = 1 | |
|X_HDR_COND_CD_TB |C_COND_CD |WFC69051-C-COND-CD-1 |C |N/A |Taken from HDR with seq. number = 1 | |
|X_HDR_COND_CD_TB |C_COND_CD |WFC69051-C-COND-CD-2 |C |N/A |Taken from HDR with seq. number = 2 | |
|X_HDR_COND_CD_TB |C_COND_CD |WFC69051-C-COND-CD-3 |C |N/A |Taken from HDR with seq. number = 3 | |
|X_HDR_VALU_CD_TB |C_VALU_CD |WFC69051-C-VALU-CD-1 |C |N/A |Taken from HDR with seq. number = 1 | |
|X_HDR_VALU_CD_TB |C_VALU_CD |WFC69051-C-VALU-CD-2 |C |N/A |Taken from HDR with seq. number = 2 | |
|X_HDR_VALU_CD_TB |C_VALU_CD |WFC69051-C-VALU-CD-3 |C |N/A |Taken from HDR with seq. number = 3 | |
|X_HDR_ICD_TB |R_ICD9_CD |WFC69051-R-ICD9-CD-1 |C |N/A |Taken from HDR with seq. number = 1 | |
|X_HDR_ICD_TB |R_ICD9_CD |WFC69051-R-ICD9-CD-2 |C |N/A |Taken from HDR with seq. number = 2 | |
|X_HDR_ICD_TB |R_ICD9_CD |WFC69051-R-ICD9-CD-3 |C |N/A |Taken from HDR with seq. number = 3 | |
|X_HDR_ICD_TB |R_ICD9_CD |WFC69051-R-ICD9-CD-4 |C |N/A |Taken from HDR with seq. number = 4 | |
|X_HDR_ICD_TB |R_ICD9_CD |WFC69051-R-ICD9-CD-5 |C |N/A |Taken from HDR with seq. number = 5 | |
|X_HDR_ICD_TB |R_ICD9_CD |WFC69051-R-ICD9-CD-6 |C |N/A |Taken from HDR with seq. number = 6 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69051-R-DIAG-CD-1 |C |N/A |Taken from HDR with seq. number = 1 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69051-R-DIAG-CD-2 |C |N/A |Taken from HDR with seq. number = 2 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69051-R-DIAG-CD-3 |C |N/A |Taken from HDR with seq. number = 3 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69051-R-DIAG-CD-4 |C |N/A |Taken from HDR with seq. number = 4 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69051-R-DIAG-CD-5 |C |N/A |Taken from HDR with seq. number = 5 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69051-R-DIAG-CD-6 |C |N/A |Taken from HDR with seq. number = 6 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69051-R-DIAG-CD-7 |C |N/A |Taken from HDR with seq. number = 7 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69051-R-DIAG-CD-8 |C |N/A |Taken from HDR with seq. number = 8 | |
|X_HDR_TB |C_TOT_TPL_AMT |WFC69051-C-TOT-TPL-AMT |A |N/A | | |
|X_HDR_TB |C_TOT_COPAY_AMT |WFC69051-C-TOT-COPAY-AMT |A |N/A | | |
|X_LI_BSE_CHG_TB |C_HDR_TAX_AMT |WFC69051-C-HDR-TAX-AMT |A |N/A | | |
|N/A |N/A |WFC69051-C-DTL-FFS-INST-REC |A |N/A |Group level record name. | |
|N/A |N/A |WFC69051-DTL-RECORD-ID-CODE |A |N/A | |1 |
|X_LI_TB |C_TCN_NUM |WFC69051-DTL-C-TCN-NUM |A |N/A | | |
|X_LI_TB |C_LI_NUM |WFC69051-DTL-C-LI-NUM |A |N/A | | |
|X_LI_TB |B_SYS_ID |WFC69051-DTL-B-SYS-ID |A |N/A | | |
|X_LI_TB |R_REV_CD |WFC69051-R-REV-CD |A |N/A | | |
|X_LI_TB |R_REV_TY_CD |WFC69051-R-REV-TY-CD |A |N/A | | |
|X_LI_TB |C_REIMB_STAT_CD |WFC69051-C-REIMB-STAT-CD |A |N/A | | |
|X_LI_TB |R_PROC_CD |WFC69051-R-PROC-CD |A |N/A | | |
|X_LI_TB |C_COS_CD |WFC69051-C-COS-CD |A |N/A | | |
|X_LI_TB |C_RNDR_PROV_ID |WFC69051-C-REND-PROV-ID |A |N/A | | |
|X_LI_TB |P_RNDR_TY_CD |WFC69051-P-REND-TY-CD |A |N/A | | |
|X_LI_TB |P_RNDR_SPECL_CD |WFC69051-P-REND-SPECL-CD |A |N/A | | |
|X_LI_TB |C_LI_FST_DOS_DT |WFC69051-C-LI-FST-DOX-DT |A |N/A | | |
|X_LI_TB |C_LI_SUBM_UNT_NUM |WFC69051-C-LI-SUBM-UNT-NUM |A |N/A | | |
|X_LI_TB |C_LI_ALLOW_UNT_NUM |WFC69051-C-LI-ALLOW-UNT-NUM |A |N/A | | |
|X_LI_TB |C_LI_REIMB_UNT_NUM |WFC69051-C-LI-REIMB-UNT-NUM |A |N/A | | |
|X_LI_TB |C_LI_SUBM_CHRG_AMT |WFC69051-C-LI-SUBM-CHRG-AMT |A |N/A | | |
|X_LI_TB |C_LI_ALLW_CHRG_AMT |WFC69051-C-LI-ALLOW-CHRG-AMT |A |N/A | | |
|X_LI_TB |C_LI_REIMB_AMT |WFC69051-C-LI-REIMB-AMT |A |N/A | | |
|X_LI_TB |C_NN_CVRD_CHRG_AMT |WFC69051-C-NN-CVRD-CHRG-AMT |A |N/A | | |
|X_LI_BSE_CHG_TB |C_BSE_AMT_CHG_AMT |WFC69051-C-COPAY-AMT |C |N/A |Only when BSE_CHNG_RSN_CD = COPAY | |
|X_LI_BSE_CHG_TB |C_BSE_AMT_CHG_AMT |WFC69051-C-TPL-AMT |C |N/A |Only when BSE_CHNG_RSN_CD = TPL | |
|X_LI_BSE_CHG_TB |C_BSE_AMT_CHG_AMT |WFC69051-C-PAT-LIAB-AMT |C |N/A |Only when BSE_CHNG_RSN_CD = PAT LIAB | |
|X_LI_BSE_CHG_TB |C_BSE_AMT_CHG_AMT |WFC69051-C-TAX-AMT |C |N/A |Only when BSE_CHNG_RSN_CD = TAX | |
|X_LI_TB |B_LEVEL_OF_CARE_CD |WFC69051-B-LEVEL-OF-CARE-CD |A |N/A | | |
|N/A |N/A |WFC69052-C-HDR-FFS-DRUG-REC |A |N/A |Group level record name. | |
|N/A |N/A |WFC69052-HDR-RECORD-ID-CODE |A |N/A | |1 |
|X_HDR_TB |HDR_C_TCN_NUM |WFC69052-HDR-C-TCN-NUM |A |N/A | | |
|X_HDR_TB |HDR_B_SYS_ID |WFC69052-HDR-B-SYS-ID |A |N/A | | |
|X_HDR_TB |B_DOB_DT |WFC69052-B-DOB-DT |A |N/A | | |
|X_HDR_TB |C_HDR_TY_CD |WFC69052-C-HDR-TY-CD |A |N/A | | |
|X_HDR_TB |A_ID |WFC69052-A-PRIOR-AUTH-ID |A |N/A | | |
|X_HDR_TB |C_COST_CENTER_CD |WFC69052-C-COST-CENTER-CD |A |N/A | | |
|X_HDR_TB |C_HDR_CLNT_AGE |WFC69052-C-HDR-CLNT-AGE |A |N/A | | |
|X_HDR_TB |B_GENDER_CD |WFC69052-B-GENDER-CD |A |N/A | | |
|X_HDR_TB |B_RACE_CD |WFC69052-B-RACE-CD |A |N/A | | |
|X_HDR_COE_TB |B_COE_CD |WFC69052-B-COE-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_FED_MTCH_CD |WFC69052-B-FED-MTCH-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_GEO_CNTY_CD |WFC69052-B-GEO-CNTY-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_ADMIN_CNTY_CD |WFC69052-B-ADM-CNTY-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_TB |B_MAJ_PROG_CD |WFC69052-B-MAJ-PROG-CD |A |N/A | | |
|N/A |N/A |WFC69052-C-PD-LAST-CHAIN-IND |N |Spaces | | |
|X_HDR_TB |C_HDR_SVC_FST_DT |WFC69052-C-HDR-SVC-FST-DT |A |N/A | | |
|X_HDR_TB |C_HDR_PD_DT |WFC69052-C-HDR-PD-DT |A |N/A | | |
|X_HDR_DRUG_TB |C_DRUG_FILLED_DT |WFC69052-C-DRUG-FILLED-DT |A |N/A | | |
|X_HDR_TB |C_BLNG_PROV_ID |WFC69052-C-BILL-PROV-ID |A |N/A | | |
|X_HDR_TB |P_IHS_IND |WFC69052-P-IHS-IND |A |N/A | | |
|X_HDR_DRUG_TB |C_PRESCR_PROV_ID |WFC69052-C-PRESCR-PROV-ID |A |N/A | | |
|X_HDR_DRUG_TB |C_HDR_DRUG_RX_NUM |WFC69052-C-HDR-DRUG-RX-NUM |A |N/A | | |
|X_HDR_DRUG_TB |C_DAW_CD |WFC69052-C-DAW-CD |A |N/A | | |
|X_HDR_DRUG_TB |C_DRUG_SUB_QTY-AMT |WFC69052-C-DRUG-SUB-QTY |A |N/A | | |
|X_HDR_DRUG_TB |C_DRUG_PD_QTY-AMT |WFC69052-C-DRUG-PD-QTY |A |N/A | | |
|X_HDR_DRUG_TB |C_SUB_DAY_SPLY-AMT |WFC69052-C-SUB-DAYS-SPLY |A |N/A | | |
|X_HDR_DRUG_TB |C_PD_DAYS_SPLY-AMT |WFC69052-C-PD-DAYS-SPLY |A |N/A | | |
|X_HDR_TB |C_COS_CD |WFC69052-C-COS-CD |A |N/A | | |
|X_HDR_DRUG_TB |C_DRUG_CMPND_CD |WFC69052-C-DRUG-CMPND-CD |A |N/A | | |
|X_HDR_DRUG_TB |C_ALLW_INGRED_AMT |WFC69052-C-ALLOW-INGRED-AMT |A |N/A | | |
|X_HDR_DRUG_TB |C_DISP_FEE_AMT |WFC69052-C-DISP-FEE-AMT |A |N/A | | |
|X_HDR_TB |C_TOT_CHRG_AMT |WFC69052-C-TOT-CHRG-AMT |A |N/A | | |
|X_HDR_TB |C_HDR_ALLOW_AMT |WFC69052-C-HDR-ALLOW-AMT |A |N/A | | |
|X_HDR_TB |C_TOT_REIMB_AMT |WFC69052-C-TOT-REIMB-AMT |A |N/A | | |
|X_HDR_TB |C_TOT-COPAY_AMT |WFC69052-C-COPAY-AMT |A |N/A | | |
|X_HDR_TB |C_TOT_TPL_AMT |WFC69052-C-TOT-TPL-AMT |A |N/A | | |
|N/A |N/A |WFC69052-C-DTL-FFS-DRUG-REC |A |N/A |Group level record name. | |
|N/A |N/A |WFC69052-DTL-RECORD-ID-CODE |A |N/A | |1 |
|X_LI_DRUG_TB |C_TCN_NUM |WFC69052-DTL-C-TCN-NUM |A |N/A | | |
|X_LI_DRUG_TB |C_LI_NUM |WFC69052-DTL-C-LI-NUM |A |N/A | | |
|X_LI_TB |C_REIMB_STAT_CD |WFC69052-C-REIMB-STAT-CD |A |N/A | | |
|X_LI_DRUG_TB |B_SYS_ID |WFC69052-DTL-B-SYS-ID |A |N/A | | |
|X_LI_TB |R_DRUG_CD |WFC69052-R-DRUG-CD |A |N/A | | |
|X_LI_DRUG_TB |R_DRUG_GCN_SEQ_NUM |WFC69052-R-DRUG-GCN-SEQ-NUM |A |N/A | | |
|X_LI_DRUG_TB |R_DRUG_THR_CHAR3-CD |WFC69052-R-DRUG-THER-CLS-NUM |A |N/A | | |
|X_LI_DRUG_TB |C_DRUG_GEN_PRD_CD |WFC69052-C-DRUG-GEN-PRD-CD |A |N/A | | |
|X_LI_DRUG_TB |C_DRUG_GEN_CD-NUM |WFC69052-C-DRUG-GEN-CD |A |N/A | | |
|X_LI_DRUG_TB |C_DRUG_MAINT_IND |WFC69052-C-DRUG-MAINT-IND |A |N/A | | |
|X_LI_DRUG_TB |C_DRUG_ROUTE_CD |WFC69052-C-DRUG-ROUTE-CD |A |N/A | | |
|X_LI_DRUG_TB |C_DRUG_DEA_CD |WFC69052-C-DRUG-DEA-CD |A |N/A | | |
|X_LI_DRUG_TB |C_LI_ALLOW_ING_AMT |WFC69052-C-LI-ALLOW-INGRED-AMT |A |N/A | | |
|N/A |N/A |WFC69053-C-HDR-ENCTR-PROF-REC |A |N/A |Group level record name. | |
|N/A |N/A |WFC69053-HDR-RECORD-ID-CODE |A |N/A | |1 |
|X_HDR_TB |HDR_C_TCN_NUM |WFC69053-HDR-C-TCN-NUM |A |N/A | | |
|X_HDR_TB |HDR_B_SYS_ID |WFC69053-HDR-B-SYS-ID |A |N/A | | |
|X_HDR_TB |B_DOB_DT |WFC69053-B-DOB-DT |A |N/A | | |
|X_HDR_TB |C_HDR_CLNT_AGE |WFC69053-C-HDR-CLNT-AGE |A |N/A | | |
|X_HDR_TB |B_GENDER_CD |WFC69053-B-GENDER-CD |A |N/A | | |
|X_HDR_TB |B_RACE_CD |WFC69053-B-RACE-CD |A |N/A | | |
|X_HDR_COE_TB |B_COE_CD |WFC69053-B-COE-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_FED_MTCH_CD |WFC69053-B-FED-MTCH-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_GEO_CNTY_CD |WFC69053-B-GEO-CNTY-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_ADMIN_CNTY_CD |WFC69053-B-ADM-CNTY-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_TB |B_MAJ_PROG_CD |WFC69053-B-MAJ-PROG-CD |A |N/A | | |
|X_HDR_TB |C_HDR_TY_CD |WFC69053-C-HDR-TY-CD |A |N/A | | |
|N/A |N/A |WFC69053-C-PD-LAST-CHAIN-IND |N |Spaces | | |
|X_HDR_ENCTR_TB |C_MC_PROV_ID |WFC69053-C-MC-PROV-ID |A |N/A | | |
|X_HDR_ENCTR_TB |C_MC_ENCT_PD_AMT |WFC69053-C-MC-ENCT-PD-AMT |A |N/A | | |
|X_HDR_ENCTR_TB |C_SUB_CAP_CD |WFC69053-C-SUB-CAP-CD |A |N/A | | |
|X_HDR_ENCTR_TB |C_NETWORK_BILL_ID |WFC69053-C-NETWORK-BILL-ID |N |Spaces | | |
|X_HDR_ENCTR_TB |C_NETOWORK_REF_ID |WFC69053-C-NETOWORK-REF-ID |N |Spaces | | |
|X_HDR_ENCTR_TB |C_NETWORK_REND_ID |WFC69053-C-NETWORK-REND-ID |N |Spaces | | |
|X_HDR_ENCTR_TB |C_MC_TCN_DAT |WFC69053-C-MC-TCN-DAT |A |N/A | | |
|X_HDR_TB |C_PROCESS_DT |WFC69053-C-PROCESS-DT |A |N/A | | |
|X_HDR_TB |C_REF_PROV_ID |WFC69053-C-REF-PROV-ID |A |N/A | | |
|X_HDR_TB |C_BLNG_PROV_ID |WFC69053-C-BILL-PROV-ID |A |N/A | | |
|X_HDR_TB |C_BLNG_PROV_TY |WFC69053-C-BILL-PROV-TY |A |N/A | | |
|X_HDR_TB |P_IHS_IND |WFC69053-P-IHS-IND |A |N/A | | |
|X_HDR_TB |A_ID |WFC69053-A-PRIOR-AUTH-ID |A |N/A | | |
|X_HDR_TB |C_COST_CENTER_CD |WFC69053-C-COST-CENTER-CD |A |N/A | | |
|X_HDR_TB |C_TOT_REIMB_AMT |WFC69053-C-TOT-REIMB-AMT |A |N/A | | |
|X_HDR_TB |C_HDR_SVC_FST_DT |WFC69053-C-HDR-SVC-FST-DT |A |N/A | | |
|X_HDR_TB |C_HDR_PD_DT |WFC69053-C-HDR-PD-DT |A |N/A | | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69053-R-DIAG-CD-1 |C |N/A |Taken from HDR with seq. number 1 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69053-R-DIAG-CD-2 |C |N/A |Taken from HDR with seq. number 2 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69053-R-DIAG-CD-3 |C |N/A |Taken from HDR with seq. number 3 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69053-R-DIAG-CD-4 |C |N/A |Taken from HDR with seq. number 4 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69053-R-DIAG-CD-5 |C |N/A |Taken from HDR with seq. number 5 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69053-R-DIAG-CD-6 |C |N/A |Taken from HDR with seq. number 6 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69053-R-DIAG-CD-7 |C |N/A |Taken from HDR with seq. number 7 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69053-R-DIAG-CD-8 |C |N/A |Taken from HDR with seq. number 8 | |
|X_HDR_TB |C_TOT_TPL_AMT |WFC69053-C-TOT-TPL-AMT |A |N/A | | |
|X_HDR_TB |C_TOT_COPAY_AMT |WFC69053-C-TOT-COPAY-AMT |A |N/A | | |
|N/A |N/A |WFC69053-C-DTL-ENCTR-PROF-REC |A |N/A |Group level record name. | |
|N/A |N/A |WFC69053-DTL-RECORD-ID-CODE |A |N/A | |1 |
|X_LI_TB |C_TCN_NUM |WFC69053-DTL-C-TCN-NUM |A |N/A | | |
|X_LI_TB |C_LI_NUM |WFC69053-DTL-C-LI-NUM |A |N/A | | |
|X_LI_TB |B_SYS_ID |WFC69053-DTL-B-SYS-ID |A |N/A | | |
|X_LI_TB |C_RNDR_PROV_ID |WFC69053-C-REND-PROV-ID |A |N/A | | |
|X_LI_TB |C_RNDR_PROV_TY |WFC69053-C-REND-PROV-TY |A |N/A | | |
|X_LI_TB |C_RNDR_SPECL_CD |WFC69053-C-REND-SPECL-CD |A |N/A | | |
|X_LI_TB |C_DSTN_PROV_ID |WFC69053-C-DSTN-PROV-ID |A |N/A | | |
|X_LI_TB |C_REIMB_STAT_CD |WFC69053-C-REIMB-STAT-CD |A |N/A | | |
|X_LI_TB |C_LI_FST_DOS_DT |WFC69053-C-LI-FST-DOS-DT |A |N/A | | |
|X_LI_TB |C_LI_LAST_DOS_DT |WFC69053-C-LI-LAST-DOS-DT |A |N/A | | |
|X_LI_TB |R_PL_OF_SVC_CD |WFC69053-R-PL-OF-SVC-CD |A |N/A | | |
|X_LI_TB |C_COS_CD |WFC69053-C-COS-CD |A |N/A | | |
|X_LI_TB |R_PROC_CD |WFC69053-R-PROC-CD |A |N/A | | |
|X_LI_TB |C_PROC_MOD_1ST_CD |WFC69053-C-PROC-MOD-CD-1 |A |N/A | | |
|X_LI_TB |C_PROC_MOD_2ND-CD |WFC69053-C-PROC-MOD-CD-2 |A |N/A | | |
|X_LI_TB |C_PROC_MOD_3RD_CD |WFC69053-C-PROC-MOD-CD-3 |A |N/A | | |
|X_LI_TB |C_PROC_MOD_4TH_CD |WFC69053-C-PROC-MOD-CD-4 |A |N/A | | |
|X_LI_TB |C_SUBM_FAM_PLN_IND |WFC69053-C-SUBM-FAM-PLAN-IND |A |N/A | | |
|X_LI_TB |C_SUBM_EPSDT_IND |WFC69053-C-SUBM-EPSDT-IND |A |N/A | | |
|X_LI_TB |C_LI_ABORT_IND |WFC69053-C-LI-ABORT-IND |A |N/A | | |
|X_LI_TB |C_LI_STERIL_IND |WFC69053-C-LI-STERIL-IND |A |N/A | | |
|X_LI_TB |C_LI_FAM_PLAN_IND |WFC69053-C-LI-FAM-PLAN-IND |A |N/A | | |
|X_LI_TB |C_LI_HYSTER_IND |WFC69053-C-LI-HYSTER-IND |A |N/A | | |
|X_LI_TB |C_LI_SUBM_UNT_NUM |WFC69053-C-LI-SUBM-UNT-NUM |A |N/A | | |
|X_LI_TB |C_LI_ALLOW_UNT_NUM |WFC69053-C-LI-ALLOW-UNT-NUM |A |N/A | | |
|X_LI_TB |C_LI_REIMB_UNT_NUM |WFC69053-C-LI-REIMB-UNT-NUM |A |N/A | | |
|X_LI_TB |C_LI_SUBM_CHRG_AMT |WFC69053-C-LI-SUBM-CHRG-AMT |A |N/A | | |
|X_LI_TB |C_LI_REIMB_CHRG_AMT |WFC69053-C-LI-REIMB-CHRG-AMT |A |N/A | | |
|X_LI_TB |C_LI_REIMB_AMT |WFC69053-C-LI-REIMB-AMT |A |N/A | | |
|X_LI_BSE_CHG_TB |C_BSE_AMT_CHG_AMT |WFC69053-C-COPAY-AMT |C |N/A |Only when BSE_CHNG_RSN_CD = COPAY | |
|X_LI_BSE_CHG_TB |C_BSE_AMT_CHG_AMT |WFC69053-C-TPL-AMT |C |N/A |Only when BSE_CHNG_RSN_CD = TPL | |
|X_LI_BSE_CHG_TB |C_BSE_AMT_CHG_AMT |WFC69053-C-PAT-LIAB-AMT |C |N/A |Only when BSE_CHNG_RSN_CD = PAT LIAB | |
|X_LI_BSE_CHG_TB |C_BSE_AMT_CHG_AMT |WFC69053-C-TAX-AMT |C |N/A |Only when BSE_CHNG_RSN_CD = TAX | |
|X_LI_TB |C_DIAG_1ST_RLTD_CD |WFC69053-C-DIAG-1ST-RLTD-CD |A |N/A | | |
|X_LI_TB |C_DIAG_2ND_RLTD_CD |WFC69053-C-DIAG-2ND-RLTD-CD |A |N/A | | |
|X_LI_TB |C_DIAG_3RD_RLTD_CD |WFC69053-C-DIAG-3RD-RLTD-CD |A |N/A | | |
|X_LI_TB |C_DIAG_4TH_RLTD_CD |WFC69053-C-DIAG-4TH-RLTD-CD |A |N/A | | |
|X_LI_TB |C_DIAG_5TH_RLTD_CD |WFC69053-C-DIAG-5TH-RLTD-CD |A |N/A | | |
|X_LI_TB |C_DIAG_6TH_RLTD_CD |WFC69053-C-DIAG-6TH-RLTD-CD |A |N/A | | |
|X_LI_TB |C_DIAG_7TH_RLTD_CD |WFC69053-C-DIAG-7TH-RLTD-CD |A |N/A | | |
|X_LI_TB |C_DIAG_8TH_RLTD_CD |WFC69053-C-DIAG-8TH-RLTD-CD |A |N/A | | |
|N/A |N/A |WFC69054-C-HDR-ENCTR-INST-REC |A |N/A |Group level record name. | |
|N/A |N/A |WFC69054-HDR-RECORD-ID-CODE |A |N/A | |1 |
|X_HDR_TB |HDR_C_TCN_NUM |WFC69054-HDR-C-TCN-NUM |A |N/A | | |
|X_HDR_TB |HDR_B_SYS_ID |WFC69054-HDR-B-SYS-ID |A |N/A | | |
|X_HDR_TB |B_DOB_DT |WFC69054-B-DOB-DT |A |N/A | | |
|X_HDR_TB |C_HDR_CLNT_AGE |WFC69054-C-HDR-CLNT-AGE |A |N/A | | |
|X_HDR_TB |B_GENDER_CD |WFC69054-B-GENDER-CD |A |N/A | | |
|X_HDR_TB |B_RACE_CD |WFC69054-B-RACE-CD |A |N/A | | |
|X_HDR_COE_TB |B_COE_CD |WFC69054-B-COE-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_FED_MTCH_CD |WFC69054-B-FED-MTCH-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_GEO_CNTY_CD |WFC69054-B-GEO-CNTY-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_ADMIN_CNTY_CD |WFC69054-B-ADM-CNTY-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_TB |B_MAJ_PROG_CD |WFC69054-B-MAJ-PROG-CD |A |N/A | | |
|X_HDR_TB |C_HDR_TY_CD |WFC69054-C-HDR-TY-CD |A |N/A | | |
|N/A |N/A |WFC69054-C-PD-LAST-CHAIN-IND |N |Spaces | | |
|X_HDR_ENCTR_TB |C_MC_PROV_ID |WFC69054-C-MC-PROV-ID |A |N/A | | |
|X_HDR_TB |C_BLNG_PROV_ID |WFC69054-C-BILL-PROV-ID |A |N/A | | |
|X_HDR_TB |C_BLNG_PROV_TY |WFC69054-C-BILL-PROV-TY |A |N/A | | |
|X_HDR_TB |P_IHS_IND |WFC69054-P-IHS-IND |A |N/A | | |
|X_HDR_TB |A_ID |WFC69054-A-PRIOR-AUTH-ID |A |N/A | | |
|X_HDR_TB |C_COST_CENTER_CD |WFC69054-C-COST-CENTER-CD |A |N/A | | |
|X_HDR_TB |C_ATNDG_PROV_ID |WFC69054-C-ATTEND-PROV-ID |A |N/A | | |
|X_HDR_TB |C_LTC_PROV_ID |WFC69054-C-LTC-PROV-ID |A |N/A | | |
|X_HDR_TB |R_DRG_CD |WFC69054-R-DRG-CD |A |N/A | | |
|X_HDR_TB |C_PAT_STAT_CD |WFC69054-C-PAT-STAT-CD |A |N/A | | |
|X_HDR_TB |C_TY_OF_BLL_TY_1_2_CD |WFC69054-C-TY-BILL-FACILITY |A |N/A |Moves 1st character of source field | |
|X_HDR_TB |C_TY_OF_BLL_TY_1_2_CD |WFC69054-C-TY-BILL-CLASS |A |N/A |Moves 2nd character of source field | |
|X_HDR_TB |C_TY_OF_BLL_TY_1_2_CD |WFC69054-C-TY-BILL-FREQ |A |N/A |Moves 3rd character of source field | |
|X_HDR_TB |C_HDR_SVC_FST_DT |WFC69054-C-HDR-SVC-FST-DT |A |N/A | | |
|X_HDR_TB |C_HDR_SVC_LST_DT |WFC69054-C-HDR-SVC-LST-DT |A |N/A | | |
|X_HDR_TB |C_HDR_PD_DT |WFC69054-C-HDR-PD-DT |A |N/A | | |
|X_HDR_TB |C_PROCESS_DT |WFC69054-C-PROCESS-DT |A |N/A | | |
|X_HDR_TB |C_ADMIT_DT |WFC69054-C-ADMIT-DT |A |N/A | | |
|X_HDR_TB |C_DISCH_DT |WFC69054-C-DISCH-DT |A |N/A | | |
|X_HDR_TB |C_UB-04-A_DIAG_CD |WFC69054-C-ADMIT-DIAG-CD |A |N/A | | |
|X_HDR_TB |C_ADM_SRC_CD |WFC69054-C-ADM-SRC-CD |A |N/A | | |
|X_HDR_TB |C_TY_OF_ADM_CD |WFC69054-C-TY-OF-ADM-CD |A |N/A | | |
|X_HDR_TB |C_CALC_DAYS_NUM |WFC69054-C-CALC-DAYS-NUM |A |N/A | | |
|X_HDR_TB |C_CVRD_DAYS_NUM |WFC69054-C-CVRD-DAYS-NUM |A |N/A | | |
|X_HDR_TB |C_NCVRD_DAYS_NUM |WFC69054-C-NCVRD-DAYS-NUM |A |N/A | | |
|X_HDR_TB |C_PAT_LIAB_AMT |WFC69054-C-PAT-LIAB-AMT |A |N/A | | |
|X_HDR_TB |C_NCVRD_CHRG_AMT |WFC69054-C-NCVRD-CHRG-AMT |A |N/A | | |
|X_HDR_TB |C_HDR_ALLOW_AMT |WFC69054-C-HDR-ALLOW-AMT |A |N/A | | |
|X_HDR_ENCTR_TB |C_SUB_CAP_CD |WFC69054-C-SUB-CAP-CD |A |N/A | | |
|X_HDR_ENCTR_TB |C_NETWORK_BLNG_ID |WFC69054-C-NETWORK-BILL-ID |N |Spaces | | |
|X_HDR_ENCTR_TB |C_NETWORK_REF_ID |WFC69054-C-NETOWORK-REF-ID |N |Spaces | | |
|X_HDR_ENCTR_TB |C_NETWORK_RNDR_ID |WFC69054-C-NETWORK-REND-ID |N |Spaces | | |
|X_HDR_ENCTR_TB |C_MCO_TCN_DAT |WFC69054-C-MC-TCN-DAT |A |N/A | | |
|X_HDR_ENCTR_TB |C_MC_ENCT_PD_AMT |WFC69054-C-MC-ENCT-PD-AMT |A |N/A | | |
|X_HDR_TB |C_TOT_REIMB_AMT |WFC69054-C-TOT-REIMB-AMT |A |N/A | | |
|X_HDR_OCC_CD_TB |C_OCC_CD |WFC69054-C-OCC-CD1 |C |N/A |Taken from HDR with seq. number = 1 | |
|X_HDR_OCC_CD_TB |C_OCC_CD |WFC69054-C-OCC-CD2 |C |N/A |Taken from HDR with seq. number = 2 | |
|X_HDR_OCC_CD_TB |C_OCC_CD |WFC69054-C-OCC-CD3 |C |N/A |Taken from HDR with seq. number = 3 | |
|X_HDR_OCC_SPN_TB |C_OCC_SPN_CD |WFC69054-C-OCC-SPN-CD |A |N/A | | |
|X_HDR_OCC_SPN_TB |C_OCC_SPN_FR_DT |WFC69054-C-OCC-SPN-FR-DT-1 |C |N/A |Taken from HDR with seq. number = 1 | |
|X_HDR_OCC_SPN_TB |C_OCC_SPN_THRU_DT |WFC69054-C-OCC-SPN-THRU-DT-1 |C |N/A |Taken from HDR with seq. number = 1 | |
|X_HDR_COND_CD_TB |C_COND_CD |WFC69054-C-COND-CD-1 |C |N/A |Taken from HDR with seq. number = 1 | |
|X_HDR_COND_CD_TB |C_COND_CD |WFC69054-C-COND-CD-2 |C |N/A |Taken from HDR with seq. number = 2 | |
|X_HDR_COND_CD_TB |C_COND_CD |WFC69054-C-COND-CD-3 |C |N/A |Taken from HDR with seq. number = 3 | |
|X_HDR_VALU_CD_TB |C_VALU_CD |WFC69054-C-VALU-CD-1 |C |N/A |Taken from HDR with seq. number = 1 | |
|X_HDR_VALU_CD_TB |C_VALU_CD |WFC69054-C-VALU-CD-2 |C |N/A |Taken from HDR with seq. number = 2 | |
|X_HDR_VALU_CD_TB |C_VALU_CD |WFC69054-C-VALU-CD-3 |C |N/A |Taken from HDR with seq. number = 3 | |
|X_HDR_ICD_TB |R_ICD9_CD |WFC69054-R-ICD9-CD-1 |C |N/A |Taken from HDR with seq. number = 1 | |
|X_HDR_ICD_TB |R_ICD9_CD |WFC69054-R-ICD9-CD-2 |C |N/A |Taken from HDR with seq. number = 2 | |
|X_HDR_ICD_TB |R_ICD9_CD |WFC69054-R-ICD9-CD-3 |C |N/A |Taken from HDR with seq. number = 3 | |
|X_HDR_ICD_TB |R_ICD9_CD |WFC69054-R-ICD9-CD-4 |C |N/A |Taken from HDR with seq. number = 4 | |
|X_HDR_ICD_TB |R_ICD9_CD |WFC69054-R-ICD9-CD-5 |C |N/A |Taken from HDR with seq. number = 5 | |
|X_HDR_ICD_TB |R_ICD9_CD |WFC69054-R-ICD9-CD-6 |C |N/A |Taken from HDR with seq. number = 6 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69054-R-DIAG-CD-1 |C |N/A |Taken from HDR with seq. number = 1 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69054-R-DIAG-CD-2 |C |N/A |Taken from HDR with seq. number = 2 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69054-R-DIAG-CD-3 |C |N/A |Taken from HDR with seq. number = 3 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69054-R-DIAG-CD-4 |C |N/A |Taken from HDR with seq. number = 4 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69054-R-DIAG-CD-5 |C |N/A |Taken from HDR with seq. number = 5 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69054-R-DIAG-CD-6 |C |N/A |Taken from HDR with seq. number = 6 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69054-R-DIAG-CD-7 |C |N/A |Taken from HDR with seq. number = 7 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69054-R-DIAG-CD-8 |C |N/A |Taken from HDR with seq. number = 8 | |
|X_HDR_TB |C_TOT_TPL_AMT |WFC69054-C-TOT-TPL-AMT |A |N/A | | |
|X_HDR_TB |C_TOT_COPAY_AMT |WFC69054-C-TOT-COPAY-AMT |A |N/A | | |
|X_LI_BSE_CHG_TB |C_HDR_TAX_AMT |WFC69054-C-HDR-TAX-AMT |A |N/A | | |
|N/A |N/A |WFC69054-C-DTL-ENCTR-INST-REC |A |N/A |Group level record name. | |
|N/A |N/A |WFC69054-DTL-RECORD-ID-CODE |A |N/A | |1 |
|X_LI_TB |C_TCN_NUM |WFC69054-DTL-C-TCN-NUM |A |N/A | | |
|X_LI_TB |C_LI_NUM |WFC69054-DTL-C-LI-NUM |A |N/A | | |
|X_LI_TB |B_SYS_ID |WFC69054-DTL-B-SYS-ID |A |N/A | | |
|X_LI_TB |R_REV_CD |WFC69054-R-REV-CD |A |N/A | | |
|X_LI_TB |R_REV_TY_CD |WFC69054-R-REV-TY-CD |A |N/A | | |
|X_LI_TB |C_REIMB_STAT_CD |WFC69054-C-REIMB-STAT-CD |A |N/A | | |
|X_LI_TB |R_PROC_CD |WFC69054-R-PROC-CD |A |N/A | | |
|X_LI_TB |C_COS_CD |WFC69054-C-COS-CD |A |N/A | | |
|X_LI_TB |C_RNDR_PROV_ID |WFC69054-C-REND-PROV-ID |A |N/A | | |
|X_LI_TB |P_TY_CD |WFC69054-P-REND-TY-CD |A |N/A | | |
|X_LI_TB |P_SPECL_CD |WFC69054-P-REND-SPECL-CD |A |N/A | | |
|X_LI_TB |C_LI_FST_DOS_DT |WFC69054-C-LI-FST-DOX-DT |A |N/A | | |
|X_LI_TB |C_LI_SUBM_UNT_NUM |WFC69054-C-LI-SUBM-UNT-NUM |A |N/A | | |
|X_LI_TB |C_LI_ALLW_UNT_NUM |WFC69054-C-LI-ALLOW-UNT-NUM |A |N/A | | |
|X_LI_TB |C_LI_REIMB_UNT_NUM |WFC69054-C-LI-REIMB-UNT-NUM |A |N/A | | |
|X_LI_TB |C_LI_SUBM_CHRG_AMT |WFC69054-C-LI-SUBM-CHRG-AMT |A |N/A | | |
|X_LI_TB |C_LI_ALLOW_CHRG_AMT |WFC69054-C-LI-ALLOW-CHRG-AMT |A |N/A | | |
|X_LI_TB |C_LI_REIMB_AMT |WFC69054-C-LI-REIMB-AMT |A |N/A | | |
|X_LI_TB |C_NN_CVRD_CHRG_AMT |WFC69054-C-NN-CVRD-CHRG-AMT |A |N/A | | |
|X_LI_BSE_CHG_TB |C_BSE_AMT_CHG_AMT |WFC69054-C-COPAY-AMT |C |N/A |Only when BSE_CHNG_RSN_CD = COPAY | |
|X_LI_BSE_CHG_TB |C_BSE_AMT_CHG_AMT |WFC69054-C-TPL-AMT |C |N/A |Only when BSE_CHNG_RSN_CD = TPL | |
|X_LI_BSE_CHG_TB |C_BSE_AMT_CHG_AMT |WFC69054-C-PAT-LIAB-AMT |C |N/A |Only when BSE_CHNG_RSN_CD = PAT LIAB | |
|X_LI_BSE_CHG_TB |C_BSE_AMT_CHG_AMT |WFC69054-C-TAX-AMT |C |N/A |Only when BSE_CHNG_RSN_CD = TAX | |
|X_LI_TB |B_LEVEL_OF_CARE_CD |WFC69054-B-LEVEL-OF-CARE-CD |A |N/A | | |
|N/A |N/A |WFC69055-C-HDR-ENCTR-DRUG-REC |A |N/A |Group level record name. | |
|N/A |N/A |WFC69055-HDR-RECORD-ID-CODE |A |N/A | |1 |
|X_HDR_TB |HDR_C_TCN_NUM |WFC69055-HDR-C-TCN-NUM |A |N/A | | |
|X_HDR_TB |HDR_B_SYS_ID |WFC69055-HDR-B-SYS-ID |A |N/A | | |
|X_HDR_TB |B_DOB_DT |WFC69055-B-DOB-DT |A |N/A | | |
|X_HDR_TB |C_HDR_TY_CD |WFC69055-C-HDR-TY-CD |A |N/A | | |
|X_HDR_TB |A_ID |WFC69055-A-PRIOR-AUTH-ID |A |N/A | | |
|X_HDR_TB |C_COST_CENTER_CD |WFC69055-C-COST-CENTER-CD |A |N/A | | |
|X_HDR_TB |C_HDR_CLNT_AGE |WFC69055-C-HDR-CLNT-AGE |A |N/A | | |
|X_HDR_TB |B_GENDER_CD |WFC69055-B-GENDER-CD |A |N/A | | |
|X_HDR_TB |B_RACE_CD |WFC69055-B-RACE-CD |A |N/A | | |
|X_HDR_COE_TB |B_COE_CD |WFC69055-B-COE-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_FED_MTCH_CD |WFC69055-B-FED-MTCH-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_GEO_CNTY_CD |WFC69055-B-GEO-CNTY-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_ADMIN_CNTY_CD |WFC69055-B-ADM-CNTY-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_TB |B_MAJ_PROG_CD |WFC69055-B-MAJ-PROG-CD |A |N/A | | |
|N/A |N/A |WFC69055-C-PD-LAST-CHAIN-IND |N |Spaces | | |
|X_HDR_TB |C_HDR_SVC_FST_DT |WFC69055-C-HDR-SVC-FST-DT |A |N/A | | |
|X_HDR_TB |C_HDR_PD_DT |WFC69055-C-HDR-PD-DT |A |N/A | | |
|X_HDR_DRUG_TB |C_DRUG_FILLED_DT |WFC69055-C-DRUG-FILLED-DT |A |N/A | | |
|X_HDR_TB |C_BLNG_PROV_ID |WFC69055-C-BILL-PROV-ID |A |N/A | | |
|X_HDR_ENCTR_TB |C_MC_PROV_ID |WFC69055-C-MC-PROV-ID |A |N/A | | |
|X_HDR_ENCTR_TB |C_MC_ENCT_PD_AMT |WFC69055-C-MC-ENCT-PD-AMT |A |N/A | | |
|X_HDR_ENCTR_TB |C_SUB_CAP_CD |WFC69055-C-SUB-CAP-CD |A |N/A | | |
|X_HDR_ENCTR_TB |C_NETWORK_BLNG_ID |WFC69055-C-NETWORK-BILL-ID |N |Spaces | | |
|X_HDR_ENCTR_TB |C_NETWORK_REF_ID |WFC69055-C-NETOWORK-REF-ID |N |Spaces | | |
|X_HDR_ENCTR_TB |C_NETWORK_RNDR_ID |WFC69055-C-NETWORK-REND-ID |N |Spaces | | |
|X_HDR_ENCTR_TB |C_MCO_TCN_DAT |WFC69055-C-MC-TCN-DAT |A |N/A | | |
|X_HDR_TB |C_PROCESS_DT |WFC69055-C-PROCESS-DT |A |N/A | | |
|X_HDR_TB |P_IHS_IND |WFC69055-P-IHS-IND |A |N/A | | |
|X_HDR_DRUG_TB |C_PRESCR_PROV_ID |WFC69055-C-PRESCR-PROV-ID |A |N/A | | |
|X_HDR_DRUG_TB |C_HDR_DRUG_RX_NUM |WFC69055-C-HDR-DRUG-RX-NUM |A |N/A | | |
|X_HDR_DRUG_TB |C_DAW_CD |WFC69055-C-DAW-CD |A |N/A | | |
|X_HDR_DRUG_TB |C_DRUG_SUB_QTY_AMT |WFC69055-C-DRUG-SUB-QTY |A |N/A | | |
|X_HDR_DRUG_TB |C_DRUG_PD_QTY_AMT |WFC69055-C-DRUG-PD-QTY |A |N/A | | |
|X_HDR_DRUG_TB |C_SUB_DAY_SPLY_AMT |WFC69055-C-SUB-DAYS-SPLY |A |N/A | | |
|X_HDR_DRUG_TB |C_PD_DAYS_SPLY-AMT |WFC69055-C-PD-DAYS-SPLY |A |N/A | | |
|X_HDR_TB |C_COS_CD |WFC69055-C-COS-CD |A |N/A | | |
|X_HDR_DRUG_TB |C_DRUG_CMPND_CD |WFC69055-C-DRUG-CMPND-CD |A |N/A | | |
|X_HDR_DRUG_TB |C_ALLW_INGRED_AMT |WFC69055-C-ALLOW-INGRED-AMT |A |N/A | | |
|X_HDR_DRUG_TB |C_DISP_FEE_AMT |WFC69055-C-DISP-FEE-AMT |A |N/A | | |
|X_HDR_TB |C_TOT_CHRG_AMT |WFC69055-C-TOT-CHRG-AMT |A |N/A | | |
|X_HDR_TB |C_HDR_ALLOW_AMT |WFC69055-C-HDR-ALLOW-AMT |A |N/A | | |
|X_HDR_TB |C_TOT_REIMB_AMT |WFC69055-C-TOT-REIMB-AMT |A |N/A | | |
|X_HDR_TB |C_TOT_COPAY_AMT |WFC69055-C-COPAY-AMT |A |N/A | | |
|X_HDR_TB |C_TOT_TPL_AMT |WFC69055-C-TOT-TPL-AMT |A |N/A | | |
|N/A |N/A |WFC69055-C-DTL-ENCTR-DRUG-REC |A |N/A |Group level record name. | |
|N/A |N/A |WFC69055-DTL-RECORD-ID-CODE |A |N/A | |1 |
|X_LI_DRUG_TB |C_TCN_NUM |WFC69055-DTL-C-TCN-NUM |A |N/A | | |
|X_LI_DRUG_TB |C_LI_NUM |WFC69055-DTL-C-LI-NUM |A |N/A | | |
|X_LI_TB |C_REIMB_STAT_CD |WFC69055-C-REIMB-STAT-CD |A |N/A | | |
|X_LI_DRUG_TB |B_SYS_ID |WFC69055-DTL-B-SYS-ID |A |N/A | | |
|X_LI_TB |R_DRUG_CD |WFC69055-R-DRUG-CD |A |N/A | | |
|X_LI_DRUG_TB |R_DRUG_GCN_SEQ_NUM |WFC69055-R-DRUG-GCN-SEQ-NUM |A |N/A | | |
|X_LI_DRUG_TB |R_DRUG_THR_CHAR3-CD |WFC69055-R-DRUG-THER-CLS-NUM |A |N/A | | |
|X_LI_DRUG_TB |C_DRUG_GEN_PRD_CD |WFC69055-C-DRUG-GEN-PRD-CD |A |N/A | | |
|X_LI_DRUG_TB |C_DRUG_GEN_CD_NUM |WFC69055-C-DRUG-GEN-CD |A |N/A | | |
|X_LI_DRUG_TB |C_DRUG_MAINT_IND |WFC69055-C-DRUG-MAINT-IND |A |N/A | | |
|X_LI_DRUG_TB |C_DRUG_ROUTE_CD |WFC69055-C-DRUG-ROUTE-CD |A |N/A | | |
|X_LI_DRUG_TB |C_DRUG_DEA_CD |WFC69055-C-DRUG-DEA-CD |A |N/A | | |
|X_LI_DRUG_TB |C_LI_ALLOW_ING_AMT |WFC69055-C-LI-ALLOW-INGRED-AMT |A |N/A | | |
|N/A |N/A |WFC69056-C-HDR-FFS-PROF-REC |A |N/A |Group level record name. | |
|N/A |N/A |WFC69056-HDR-RECORD-ID-CODE |A |N/A | |1 |
|X_HDR_TB |HDR_C_TCN_NUM |WFC69056-HDR-C-TCN-NUM |A |N/A | | |
|X_HDR_TB |HDR_B_SYS_ID |WFC69056-HDR-B-SYS-ID |A |N/A | | |
|X_HDR_TB |B_DOB_DT |WFC69056-B-DOB-DT |A |N/A | | |
|X_HDR_TB |C_HDR_CLNT_AGE |WFC69056-C-HDR-CLNT-AGE |A |N/A | | |
|X_HDR_TB |B_GENDER_CD |WFC69056-B-GENDER-CD |A |N/A | | |
|X_HDR_TB |B_RACE_CD |WFC69056-B-RACE-CD |A |N/A | | |
|X_HDR_COE_TB |B_COE_CD |WFC69056-B-COE-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_FED_MTCH_CD |WFC69056-B-FED-MTCH-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_GEO_CNTY_CD |WFC69056-B-GEO-CNTY-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_COE_TB |B_ADMIN_CNTY_CD |WFC69056-B-ADM-CNTY-CD |A |N/A |Taken from the first COE span on the claim, if there| |
| | | | | |are multiple | |
|X_HDR_TB |B_MAJ_PROG_CD |WFC69056-B-MAJ-PROG-CD |A |N/A | | |
|X_HDR_TB |C_HDR_TY_CD |WFC69056-C-HDR-TY-CD |A |N/A | | |
|N/A |N/A |WFC69056-C-PD-LAST-CHAIN-IND |N |Spaces | | |
|X_HDR_TB |C_REF_PROV_ID |WFC69056-C-REF-PROV-ID |A |N/A | | |
|X_HDR_TB |C_BLNG_PROV_ID |WFC69056-C-BILL-PROV-ID |A |N/A | | |
|X_HDR_TB |C_BLNG_PROV_TY |WFC69056-C-BILL-PROV-TY |A |N/A | | |
|X_HDR_TB |P_IHS_IND |WFC69056-P-IHS-IND |A |N/A | | |
|X_HDR_TB |A_ID |WFC69056-A-PRIOR-AUTH-ID |A |N/A | | |
|X_HDR_TB |C_COST_CENTER_CD |WFC69056-C-COST-CENTER-CD |A |N/A | | |
|X_HDR_TB |C_TOT_REIMB_AMT |WFC69056-C-TOT-REIMB-AMT |A |N/A | | |
|X_HDR_TB |C_HDR_SVC_FST_DT |WFC69056-C-HDR-SVC-FST-DT |A |N/A | | |
|X_HDR_TB |C_HDR_PD_DT |WFC69056-C-HDR-PD-DT |A |N/A | | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69056-R-DIAG-CD-1 |C |N/A |Taken from HDR with seq. number = 1 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69056-R-DIAG-CD-2 |C |N/A |Taken from HDR with seq. number = 2 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69056-R-DIAG-CD-3 |C |N/A |Taken from HDR with seq. number = 3 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69056-R-DIAG-CD-4 |C |N/A |Taken from HDR with seq. number = 4 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69056-R-DIAG-CD-5 |C |N/A |Taken from HDR with seq. number = 5 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69056-R-DIAG-CD-6 |C |N/A |Taken from HDR with seq. number = 6 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69056-R-DIAG-CD-7 |C |N/A |Taken from HDR with seq. number = 7 | |
|X_HDR_DIAG_TB |R_DIAG_CD |WFC69056-R-DIAG-CD-8 |C |N/A |Taken from HDR with seq. number = 8 | |
|X_HDR_TB |C_TOT_TPL_AMT |WFC69056-C-TOT-TPL-AMT |A |N/A | | |
|X_HDR_TB |C_TOT_COPAY_AMT |WFC69056-C-TOT-COPAY-AMT |A |N/A | | |
|X-HDR-ADJ-VD-TB |C-KEYED-REPLCD-NUM |WFC69056-C-KEYED-REPLCD-NUM |C |N/A | | |
|X-HDR-ADJ-VD-TB |C-HDR-ADJ-RSN-CD |WFC69056-C-HDR-ADJ-RSN-CD |C |N/A | | |
|X-HDR-ADJ-VD-TB |C-REPLCD-TCN-NUM |WFC69056-C-REPLCD-TCN-NUM |C |N/A | | |
|X-HDR-ADJ-VD-TB |C-HDR-ADJ-STAT-CD |WFC69056-C-HDR-ADJ-STAT-CD |C |N/A | | |
|X-HDR-ADJ-VD-TB |C-REPLCMT-TCN-NUM |WFC69056-C-REPLCMT-TCN-NUM |C |N/A | | |
|X-HDR-ADJ-VD-TB |F-FCN-DT |WFC69056-F-FCN-DT |C |N/A | | |
|X-HDR-ADJ-VD-TB |F-FCN-MED-CD |WFC69056-F-FCN-MED-CD |C |N/A | | |
|X-HDR-ADJ-VD-TB |F-FCN-NUM |WFC69056-F-FCN-NUM |C |N/A | | |
|X-HDR-ADJ-VD-TB |C-ADJ-ORIG-TCN-NUM |WFC69056-C-ADJ-ORIG-TCN-NUM |C |N/A | | |
|X-HDR-ADJ-VD-TB |C-ADJ-SEQ-NUM |WFC69056-C-ADJ-SEQ-NUM |C |N/A | | |
Notes:
1. Header/Detail Record ID Code can contain one of the following values: H=file header, C=claim header, L=claim line item, or T=file trailer.
______________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE
DRAMS CLAIMS INTERFACE
|Description: |
|The MMIS extracts paid claim data for certain procedure codes, such as J* codes, to send to the DRAMS system for drug rebate processing. The PDCS system will supply the DRAMS system with paid |
|pharmacy claims data. This interface is for those non-pharmacy claims that contain procedure codes for which CMS allows the states to collect drug rebates. |
|Source Files: |
|XEROX weekly adjudicated claims dataset. |
|Target Files: |
|A sequential file of paid claim records is produced by this interface to be sent to the DRAMS system. |
|Reports: |
|Process Summary |
|Remarks: The following claims are selected from the weekly adjudicated claims file: |
|Paid Status |
|FFS claims or encounter claim with MCO ID = 000M1808, 000M1796, 000M1814, 42101522, 876027041, 21535353, 16785851, 38900882 |
|Major Program of Medicaid |
|Primary COE on the claim does not have a Federal Match Code of 2 (State-Funded) |
|Claim type is Practitioner, Lab, Medical Supplies, Outpatient, or Part B crossover. For Part B claims, only line items with no Medicare Allowed Amount are considered. |
|Procedure code on the claim line item matches one of the procedure codes in system list 4021 or 4820 or 4821. The claim line item reimbursement status is not denied. |
|Claims for the Indian Health Service (IHS) claims are excluded (claims with billing provider type code of ‘221’ or an IHS indicator of ‘Y’ |
| |
|Note that there is one extract record generated for each claim line item that meets the criteria. |
|Note that NDC is edited in the claims adjudication process. See edits 0519, 0520, and 0528 in Chapter 10, exhibit C |
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE LAYOUT
OUTPUT FILE
DRAMS CLAIMS INTERFACE
01 WFC48350-CLAIM-WORK.
05 WFC48350-FIRST-CHAR PIC X(01).
05 WFC48350-CLAIM-ID PIC X(20).
05 WFC48350-PROVIDER-ID PIC X(20).
05 WFC48350-LABELER-CODE PIC X(05).
05 WFC48350-PRODUCT-CODE PIC X(04).
05 WFC48350-PACKAGE-SIZE PIC X(02).
05 WFC48350-FILLER PIC X(16).
05 WFC48350-FIRST-NAME PIC X(30).
05 WFC48350-LAST-NAME PIC X(30).
05 WFC48350-MID-INIT PIC X(01).
05 WFC48350-AGE PIC 9(03).
05 WFC48350-GENDER PIC X(01).
05 WFC48350-RX-NUM PIC X(20).
05 WFC48350-SERVICE-DT PIC X(10).
05 WFC48350-PAID-DT PIC X(10).
05 WFC48350-DAW-IND PIC X(01).
05 WFC48350-LTC-IND PIC X(01).
05 WFC48350-SUPPLIED-DAYS PIC X(03).
05 WFC48350-NUM-OF-UNITS PIC 9(12)V99.
05 WFC48350-SUBMITTED-AMT PIC 9(11)V99.
05 WFC48350-ALLOWED-AMT PIC 9(10)V99.
05 WFC48350-TPL-AMT PIC 9(11)V99.
05 WFC48350-COPAY-AMT PIC 9(11)V99.
05 WFC48350-REIMBURSEMENT-AMT PIC 9(11)V99.
05 WFC48350-ADJUSTMENT-CD PIC X(01).
05 WFC48350-PREV-CLAIM-ID PIC X(20).
05 WFC48350-FILLER PIC X(02).
05 WFC48350-NUM-REFILL PIC X(04).
05 WFC48350-FILLER PIC X(09).
05 WFC48350-CLIENT-ID PIC X(10).
05 WFC48350-GROUP-ID PIC X(01).
05 WFC48350-PLAN-ID PIC X(10).
05 WFC48350-INGRED-AMT PIC X(15).
05 WFC48350-DISPENSING-FEE PIC X(15).
05 WFC48350-PATIENT-ID PIC X(20).
05 WFC48350-MEMBER-NUMBER PIC X(04).
05 WFC48350-CLM-STS-CD PIC X(01).
05 WFC48350-DEDUCTIBLE-AMOUNT PIC X(13).
05 WFC48350-BASIS-OF-PAYMENT-CD PIC X(02).
05 WFC48350-340B-CLAIM-IND PIC X(01).
05 WFC48350-LINE-NUMBER PIC 9(04).
05 WFC48350-COMPOUND-CD PIC X(01).
05 WFC48350-PROCEDURE-CODE PIC X(10).
05 WFC48350-ADJUDICATED-DT PIC X(10).
05 WFC48350-SOURCE-VERSION-CODE PIC X(10).
05 WFC48350-NDC-20 PIC X(20).
05 WFC48350-COUNTY-CD PIC X(10).
05 WFC48350-HCPC-UNITS PIC X(14).
05 WFC48350-HCPC-UNIT-TYPE-CD PIC X(10).
05 WFC48350-SUPP-REBATE-IND PIC X(01).
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
DRAMS CLAIMS INTERFACE
|Source |Source |Target | | | |Note |
|Table / File |Column / Field |Field |Req |Def |Specifications |Ref |
|Adjudicated Claims File |W1C41551-C-TCN-NUM |WFC48350-CLAIM-ID |A |N | | |
|Adjudicated Claims File |W1C41551-C-BLNG-PROV-ID |WFC48350-PROVIDER-ID |A |N |Bypass the line item if the provider type | |
| | | | | |code associated with the provider id is ‘221’| |
| | | | | |or if W1C41521-P-IHS-IND = ‘Y’ (IHS | |
| | | | | |indicator) | |
|Adjudicated Claims File |W1C41551-R-DRUG-CD |WFC48350-LABELER-CODE |N |N |First 5 chars of W1C41551-R-DRUG-CD |6 |
|Adjudicated Claims File |W1C41551-R-DRUG-CD |WFC48350-PRODUCT-CODE |N |N |Chars 6-9 of W1C41551-R-DRUG-CD |6 |
|Adjudicated Claims File |W1C41551-R-DRUG-CD |WFC48350-PACKAGE-SIZE |N |N |Last 2 chars of W1C41551-R-DRUG-CD |6 |
|N/A |N/A |WFC48350-FILLER |N |Spaces | | |
|Adjudicated Claims File |W1C41551-B-FST-NAM |WFC48350-FIRST-NAME |N |Spaces | | |
|Adjudicated Claims File |W1C41551-B-LAST-NAM |WFC48350-LAST-NAME |A |N | | |
|Adjudicated Claims File |W1C41551-B-MI-NAM |WFC48350-MID-INIT |N |Spaces | | |
|Adjudicated Claims File |W1C41551-C-HDR-CLNT-AGE |WFC48350-AGE |N |Zeros | | |
|Adjudicated Claims File |W1C41551-B-GENDER-CD |WFC48350-GENDER |N |N | | |
|N/A |N/A |WFC48350-RX-NUM |N |Spaces | | |
|Adjudicated Claims File |W1C41551-C-LI-FST-DOS-DT |WFC48350-SERVICE-DT |A |N | | |
|Adjudicated Claims File |W1C41551-C-HDR-PD-DT |WFC48350-PAID-DT |A |N | | |
|N/A |N/A |WFC48350-DAW-IND |N |Spaces | | |
|N/A |N/A |WFC48350-LTC-IND |N |Spaces | | |
|N/A |N/A |WFC48350-SUPPLIED-DAYS |N |Spaces | | |
|Adjudicated Claims File |W1C41551-C-LI-SUBM-UNT-NUM |WFC48350-NUM-OF-UNITS |A |N | |1 |
|Adjudicated Claims File |W1C41551-C-LI-SUBM-CHRG-AMT |WFC48350-SUBMITTED-AMT |N |N | |1 |
|Adjudicated Claims File |W1C41551-C-LI-ALLW-CHRG-AMT |WFC48350-ALLOWED-AMT |N |N | |1 |
|Adjudicated Claims File |W1C41551-C-BSE-AMT-CHG-AMT |WFC48350-TPL-AMT |N |N |IF W1C41551-C-BSE-CHNG-RSN-CD |1, 2, 7 |
| | | | | |(W1C41551-C-LI-NUM, W1C41551-C-SEQ-NUM) = | |
| | | | | |‘04’ then populate this field with | |
| | | | | |W1C41551-C-BSE-AMT-CHG-AMT(W1C41551-C-LI-NUM,| |
| | | | | |W1C41551-C-SEQ-NUM) | |
|Adjudicated Claims File |W1C41551-C-BSE-AMT-CHG-AMT |WFC48350-COPAY-AMT |N |N |IF W1C41551-C-BSE-CHNG-RSN-CD |1, 3 |
| | | | | |(W1C41551-C-LI-NUM, W1C41551-C-SEQ-NUM) = | |
| | | | | |‘03’ then populate this field with | |
| | | | | |W1C41551-C-BSE-AMT-CHG-AMT(W1C41551-C-LI-NUM,| |
| | | | | |W1C41551-C-SEQ-NUM) | |
|Adjudicated Claims File |W1C41551-C-LI-REIMB-AMT |WFC48350-REIMBURSEMENT-AMT |A |N | |1 |
|Adjudicated Claims File |W1C41551-C-HDR-TXN-TY-CD |WFC48350-ADJUSTMENT-CD |A |N | |4 |
|Adjudicated Claims File |W1C41551-C-REPLCD-TCN-NUM |WFC48350-PREV-CLAIM-ID |C |N |Spaces for original claims | |
|N/A |N/A |WFC48350-FILLER |N |Spaces | | |
|N/A |N/A |WFC48350-NUM-REFILL |N |Spaces | | |
|N/A |N/A |WFC48350-FILLER |N |Spaces | | |
|N/A |N/A |WFC48350-CLIENT-ID |A |‘NEWMEX’ | | |
|N/A |N/A |WFC48350-GROUP-ID |A |‘MED’ | | |
|Adjudicated Claims File |W1C41551-B-COE-CD |WFC48350-PLAN-ID |A |N | |5 |
| |W1C41551-B-FED-MTCH-CD | | | | | |
|N/A |N/A |WFC48350-INGRED-AMT |N |Spaces | | |
|N/A |N/A |WFC48350-DISPENSING-FEE |N |Spaces | | |
|Adjudicated Claims File |W1C41551-B-SYS-ID |WFC48350-PATIENT-ID |A |N |‘00003’ followed by the 9 digits in client | |
| | | | | |system id | |
|N/A |N/A |WFC48350-MEMBER-NUMBER |N |Spaces | | |
|Adjudicated Claims File |W1C41551-C-REIMB-STAT-CD |WFC48350-CLM-STS-CD |N |N |Bypass the line item if | |
| | | | | |W1C41551-C-REIMB-STAT-CD = ‘D’enied | |
|N/A |N/A |WFC48350-DEDUCTIBLE-AMOUNT |N |Spaces | | |
|N/A |N/A |WFC48350-BASIS-OF-PAYMENT-CD |N |Spaces | | |
|N/A |N/A |WFC48350-340B-CLAIM-IND |N |N |Move ‘1’ to this field if the line contains | |
| | | | | |modifier UD | |
|Adjudicated Claims File |W1C41551-C-LI-NUM |WFC48350-LINE-NUMBER |N |N | | |
|N/A |N/A |WFC48350-COMPOUND-CD |N |Spaces | | |
|Adjudicated Claims File |W1C41551-R-PROC-CD |WFC48350-PROCEDURE-CODE |A |N |Must be one of the procedure codes in system | |
| | | | | |list 4021 or 4820 | |
|Adjudicated Claims File |W1C41551-C-HDR-ADJUD-DT |WFC48350-ADJUDICATED-DT |N |N | | |
|N/A |N/A |WFC48350-SOURCE-VERSION-CODE |N |Spaces | | |
|Adjudicated Claims File |W1C41551-R-DRUG-CD |WFC48350-NDC-20 |N |N | |6 |
|N/A |N/A |WFC48350-COUNTY-CD |N |Spaces | | |
|N/A |N/A |WFC48350-HCPC-UNITS |N |Spaces | | |
|N/A |N/A |WFC48350-HCPC-UNIT-TYPE-CD |N |Spaces | | |
________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
Notes:
1. Numerics are left-justified with decimal points present, no zero padding.
2. If there is a base change reason code associated with this line item that indicates TPL then use the base change amount attached to that reason
3. If there is a base change reason code associated with this line item that indicates Copay then use the base change amount attached to that reason
4. Determine the DRAMS adjustment code from the MMIS transaction type as follows:
|W1C41551-C-HDR-TXN-TY-CD |WFB48350-ADJUSTMENT-CD |
|0 |O |
|1 |V |
|2 |Q |
|3 |R |
5. The Category of Eligibility (COE) and Federal Match code (FM) combination determine the plan id as follows for FFS claims.
|COE / FM |PLAN ID |
|074 / 1 |500 (working disabled) |
|071 / 1 |600 (SCHIPS) |
|029 / 1 |700 (Family Planning) |
|All others |400 (regular FFS) |
For encounters, H_PLN_DETAIL_TB is read and the plan ID is populated with the PDCS plan ID.
6. For multi-source codes, if there is no NDC is on the claim or a bad NDC is on the claim (NDC code not equal 11 digits), PDCS will error the claim off during their processing.
7. For single-source codes, if there is no NDC on the claim, or a bad NDC (NCD code not equal to 11 digits), PDCS will populate the NDC from their crosswalk. Otherwise, PDCS will use the NDC submitted from the Omnicaid claim.
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE
HMS CLAIMS INTERFACE
|Description: |
|This interface consists of a copy of the flat file of monthly paid and denied claims, which is sent to HMS (Maximus). The layouts are the Omnicaid internal flat file layouts. A control totals |
|file is produced containing a table identifier, date produced, and a record count. |
|NEWM.PROD.C4570SC.&MTHYR, where MTH is a three character abbreviation for the month, and YR is a two digit number for the year, eg NEWM.PROD.C4570SC.APR07. This file is created during the |
|monthly reporting process. Contains a record for each claim adjudicated during the prior month. |
|Target Files: |
|HMS claims file. |
|Reports: |
|N/A |
|Remarks: |
|Detailed output file layouts and specifications are not included for this interface since it is a simple copy of the Omnicaid monthly claims file. |
|A example follows of the control totals file for the FFS claims: |
|FFSCLAIM 2016-03-09 002506756 |
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE
HMS CLAIMS INTERFACE
Record Layout:
*Layout used if the claim is Credit Adjustment
*
01 W1C45221-C-EXT-ADJ-REC.
05 W1C45221-C-SORT-GRP.
10 W1C45221-C-SORT-DAT
PIC X(00030).
10 W1C45221-C-LI-REC-STRT-NUM
PIC 9(00004) COMP.
05 W1C45221-C-COUNTERS-VW.
10 W1C45221-C-CNT-COE-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-COND-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-OCC-CD-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-OCC-SPN-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-VALU-CD-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-ICD-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-DIAG-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-COB-NUM
PIC S9(00004) COMP.
10 W1C45221-C-HDR-CAS-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-LOCN-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-OVRD-EOB-NUM
PIC S9(00004) COMP.
10 W1C45221-C-HDR-OVRD-EOB-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-OVRD-EXC-NUM
PIC S9(00004) COMP.
10 W1C45221-C-HDR-OVRD-EXC-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-RLTD-HST-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-LI-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-LI-MCARE-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-LI-COB-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-LI-CAS-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-BSE-CHG-NUM
PIC S9(00004) COMP.
10 W1C45221-C-HDR-BSE-CHG-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-EXC-NUM
PIC S9(00004) COMP.
10 W1C45221-C-HDR-EXC-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-LI-TPL-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-LI-CAP-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-LI-DRUG-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-UNUSED-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-AUX-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CNT-LI-AUX-NUM
PIC S9(00004) COMP.
05 W1C45221-C-HDR-TB.
10 W1C45221-C-TCN-NUM PIC S9(00017) COMP-3.
10 W1C45221-C-XCN-NUM PIC X(00031).
10 W1C45221-C-HDR-ID-CD
PIC X(00002).
10 W1C45221-C-HDR-EMC-CD
PIC X(00001).
10 W1C45221-C-HDR-SUBMITTER-ID
PIC X(00016).
10 W1C45221-C-CNTL-ORGN-CD
PIC X(00001).
10 W1C45221-C-HDR-STAT-CD
PIC X(00001).
10 W1C45221-C-HDR-TXN-TY-CD
PIC X(00001).
10 W1C45221-C-HDR-TY-CD
PIC X(00001).
10 W1C45221-C-BAT-MED-SRC-CD
PIC X(00001).
10 W1C45221-C-BAT-JLN-DT-NUM
PIC X(00005).
10 W1C45221-C-BT-IMGD-CNTL-NUM
PIC X(00002).
10 W1C45221-C-BAT-NUM PIC X(00003).
10 W1C45221-C-BAT-DOC-TY-CD
PIC X(00001).
10 W1C45221-C-BAT-PYMT-TY-CD
PIC X(00001).
10 W1C45221-C-BAT-TY-CD
PIC X(00001).
10 W1C45221-C-HDR-DOC-NUM
PIC X(00006).
10 W1C45221-C-NSF-X12N-CD
PIC X(00001).
10 W1C45221-C-MCARE-STAT-CD
PIC X(00001).
10 W1C45221-C-CLNT-MCARE-CD
PIC X(00001).
10 W1C45221-B-SYS-ID PIC S9(00009) COMP.
10 W1C45221-B-FST-NAM PIC X(00015).
10 W1C45221-B-LAST-NAM
PIC X(00021).
10 W1C45221-B-MI-NAM PIC X(00001).
10 W1C45221-B-ALT-ID PIC X(00014).
10 W1C45221-B-CURR-ID PIC X(00014).
10 W1C45221-B-RACE-CD PIC X(00001).
10 W1C45221-B-GENDER-CD
PIC X(00001).
10 W1C45221-B-MAJ-PROG-CD
PIC X(00001).
10 W1C45221-T-MSQ-TY-CD
PIC X(00001).
10 W1C45221-A-ID PIC X(00011).
10 W1C45221-C-BLNG-PROV-ID
PIC X(00008).
10 W1C45221-C-BLNG-NPI-ID
PIC X(00010).
10 W1C45221-C-BLNG-TXNMY-CD
PIC X(00010).
10 W1C45221-C-BLNG-PROV-ZIP-CD
PIC X(00009).
10 W1C45221-C-BLNG-PROV-TY-CD
PIC X(00003).
10 W1C45221-C-BLNG-SPECL-CD
PIC X(00003).
10 W1C45221-C-BLNG-NTRPRS-ID
PIC X(00008).
10 W1C45221-C-PROV-SIGN-IND
PIC X(00001).
10 W1C45221-C-ATTACH-1ST-CD
PIC X(00002).
10 W1C45221-C-ATTACH-2ND-CD
PIC X(00002).
10 W1C45221-C-ATTACH-3RD-CD
PIC X(00002).
10 W1C45221-C-ATTACH-4TH-CD
PIC X(00002).
10 W1C45221-C-ATTACH-5TH-CD
PIC X(00002).
10 W1C45221-C-HDR-RMK-IND
PIC X(00001).
10 W1C45221-C-HDR-PAT-ACCT-NUM
PIC X(00020).
10 W1C45221-C-MED-REC-NUM
PIC X(00024).
10 W1C45221-C-ELIG-TWO-PASS-CD
PIC X(00001).
10 W1C45221-C-CREDIT-CD
PIC X(00001).
10 W1C45221-C-OTHR-INSR-IND
PIC X(00001).
10 W1C45221-P-LOCN-CD PIC X(00001).
10 W1C45221-P-PROFIT-IND
PIC X(00001).
10 W1C45221-P-TAX-DISCT-IND
PIC X(00001).
10 W1C45221-P-PROF-TECH-IND
PIC X(00001).
10 W1C45221-P-IHS-IND PIC X(00001).
10 W1C45221-P-PSY-SOC-IND
PIC X(00001).
10 W1C45221-C-COST-AVOID-IND
PIC X(00001).
10 W1C45221-C-PRIOR-AUTH-IND
PIC X(00001).
10 W1C45221-C-DAILY-RPT-IND
PIC X(00001).
10 W1C45221-C-HDR-RA-NUM
PIC S9(00009) COMP.
10 W1C45221-C-EXC-LOCN-CD
PIC X(00003).
10 W1C45221-C-EXC-LOCN-ID
PIC X(00007).
10 W1C45221-C-SUSP-LOCN-EXC-CD
PIC X(00004).
10 W1C45221-C-OVRRD-EXC-LOC-CD
PIC X(00003).
10 W1C45221-C-COST-CENTER-CD
PIC X(00005).
10 W1C45221-C-FAM-PLN-CC-CD
PIC X(00005).
10 W1C45221-C-RLTD-FCN-NUM
PIC X(00015).
10 W1C45221-F-RSN-CD PIC X(00003).
10 W1C45221-C-CYCL-NUM
PIC S9(00002) COMP.
10 W1C45221-C-HDR-CLNT-AGE
PIC S9(00003) COMP.
10 W1C45221-C-TOT-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C45221-C-CALC-TOT-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C45221-C-TOT-TPL-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C45221-C-TOT-TPL-DIR-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C45221-C-HD-TPL-COPAY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C45221-C-TOT-NET-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C45221-C-TOT-REIMB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C45221-C-TOT-COPAY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C45221-C-REIMB-STAT-CD
PIC X(00001).
10 W1C45221-C-PREV-REIMB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C45221-C-PREV-REIMB-CD
PIC X(00001).
10 W1C45221-C-PAT-LIAB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C45221-B-DOB-DT PIC X(00010).
10 W1C45221-C-SUBM-CLNT-DOB-DT
PIC X(00010).
10 W1C45221-C-HDR-ENTRD-DT
PIC X(00010).
10 W1C45221-C-HDR-ADJUD-DT
PIC X(00010).
10 W1C45221-C-HDR-ADJUD-TM
PIC X(00008).
10 W1C45221-C-HDR-ITERM-ADJ-DT
PIC X(00010).
10 W1C45221-C-BILLED-DT
PIC X(00010).
10 W1C45221-C-EXC-LOCN-DT
PIC X(00010).
10 W1C45221-C-HDR-BATCH-DT
PIC X(00010).
10 W1C45221-C-HDR-SVC-FST-DT
PIC X(00010).
10 W1C45221-C-HDR-SVC-LST-DT
PIC X(00010).
10 W1C45221-C-HDR-LST-CYCL-DT
PIC X(00010).
10 W1C45221-C-HDR-PD-DT
PIC X(00010).
10 W1C45221-C-HDR-ORIG-PD-DT
PIC X(00010).
10 W1C45221-C-HDR-SUSP-DT
PIC X(00010).
10 W1C45221-C-HDR-HX-DT
PIC X(00010).
10 W1C45221-C-HDR-CLIA-NUM
PIC X(00010).
10 W1C45221-C-HDR-DENT-OCCP-DT
PIC X(00010).
10 W1C45221-C-HDR-DENT-AUTO-DT
PIC X(00010).
10 W1C45221-C-HDR-DENT-OTHR-DT
PIC X(00010).
10 W1C45221-C-REF-PROV-ID
PIC X(00008).
10 W1C45221-C-REF-NPI-ID
PIC X(00010).
10 W1C45221-C-OCCUP-RLTD-IND
PIC X(00001).
10 W1C45221-C-AUTO-RLTD-IND
PIC X(00001).
10 W1C45221-C-OTHR-RLTD-IND
PIC X(00001).
10 W1C45221-C-ILLNESS-DT
PIC X(00010).
10 W1C45221-C-ADMIT-DT
PIC X(00010).
10 W1C45221-C-DISCH-DT
PIC X(00010).
10 W1C45221-R-DRG-CD PIC X(00005).
10 W1C45221-C-OTHR-PROV-ID
PIC X(00008).
10 W1C45221-C-OTHR-PROV-NPI-ID
PIC X(00010).
10 W1C45221-C-OPR-PROV-ID
PIC X(00008).
10 W1C45221-C-OPR-NPI-ID
PIC X(00010).
10 W1C45221-C-ATNDG-PROV-ID
PIC X(00008).
10 W1C45221-C-ATNDG-NPI-ID
PIC X(00010).
10 W1C45221-C-ATNDG-TXNMY-CD
PIC X(00010).
10 W1C45221-C-LTC-PROV-ID
PIC X(00008).
10 W1C45221-C-PAT-STAT-CD
PIC X(00002).
10 W1C45221-C-ADM-SRC-CD
PIC X(00001).
10 W1C45221-C-TY-OF-ADM-CD
PIC X(00001).
10 W1C45221-C-TY-OF-BLL-PFX-CD
PIC X(00001).
10 W1C45221-C-TY-OF-BLL-1-2-CD
PIC X(00002).
10 W1C45221-C-TY-OF-BILL-3-CD
PIC X(00001).
10 W1C45221-C-COS-CD PIC X(00002).
10 W1C45221-C-UB92-A-DIAG-CD
PIC X(00010).
10 W1C45221-C-UB92-ADM-HR-CD
PIC X(00002).
10 W1C45221-C-UB92-DISCH-HR-CD
PIC X(00002).
10 W1C45221-C-BSE-AMT-SRC-CD
PIC X(00002).
10 W1C45221-C-PRCNG-PROCESS-CD
PIC X(00002).
10 W1C45221-C-UB92-ABORT-IND
PIC X(00001).
10 W1C45221-C-HDR-FAM-PLNG-IND
PIC X(00001).
10 W1C45221-C-UB92-STERIL-IND
PIC X(00001).
10 W1C45221-C-UB92-HYSTER-IND
PIC X(00001).
10 W1C45221-C-HDR-BSE-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C45221-C-CALC-ALLOW-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C45221-C-HDR-ALLOW-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C45221-C-NCVRD-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C45221-C-CVRD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C45221-C-NCVRD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C45221-C-OUTLIER-DAYS-NUM
PIC S9(00004) COMP.
10 W1C45221-C-CALC-DAYS-NUM
PIC S9(00004) COMP.
10 W1C45221-C-DRG-PD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C45221-B-GUARANTEE-NUM
PIC X(00012).
10 W1C45221-C-ORIG-PAPER-IND
PIC X(00001).
10 W1C45221-C-CREATION-DT
PIC X(00010).
10 W1C45221-C-SVC-FACI-NPI-ID
PIC X(00010).
10 W1C45221-R-CD-REL-WT-AMT
PIC S9(00004)V9(00005) COMP-3.
10 W1C45221-C-BLNG-TAX-ID
PIC X(00009).
10 W1C45221-C-BLNG-SSN-NUM
PIC X(00009).
10 W1C45221-C-FUT-PROV-ID
PIC X(00008).
10 W1C45221-C-MC-PROV-ID
PIC X(00008).
10 W1C45221-H-PLN-NUM PIC X(00004).
10 W1C45221-H-PLN-TY-CD
PIC X(00001).
10 W1C45221-H-PLN-BEG-DT
PIC X(00010).
10 W1C45221-C-HDR-FUT-1-CD
PIC X(00003).
10 W1C45221-C-HDR-FUT-2-CD
PIC X(00003).
10 W1C45221-B-PARENT-IND
PIC X(00001).
10 W1C45221-C-HDR-AUD-IND
PIC X(00001).
10 W1C45221-C-HDR-FUT-1-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C45221-C-HDR-FUT-2-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C45221-C-EPSDT-CERT1-CD
PIC X(00003).
10 W1C45221-C-EPSDT-CERT2-CD
PIC X(00003).
10 W1C45221-C-ANES-REL-PROC-CD
PIC X(00007).
10 W1C45221-R-ICD-VER-CD
PIC X(00002).
10 W1C45221-C-HDR-FUT-1-IND
PIC X(00001).
10 W1C45221-C-HDR-FUT-2-IND
PIC X(00001).
10 W1C45221-G-AUD-USER-ID
PIC X(00007).
10 W1C45221-G-AUD-DT PIC X(00010).
10 W1C45221-G-AUD-TM PIC X(00008).
05 W1C45221-C-LI-EXC-GRP.
10 W1C45221-C-LI-EXC-VW
OCCURS 0 TO 1000 TIMES
DEPENDING ON W1C45221-C-CNT-EXC-NUM
INDEXED BY W1C45221-C-LI-EXC-VW-X .
15 W1C45221-C-LI-NUM
PIC S9(00003) COMP.
15 W1C45221-R-CLM-EXC-CD
PIC X(00004).
15 W1C45221-C-LI-EXC-CLRK-ID
PIC X(00007).
15 W1C45221-C-EXC-STAT-CD
PIC X(00001).
15 W1C45221-R-EXC-FORCE-APP-CD
PIC X(00001).
15 W1C45221-R-FORCE-DENY-CD
PIC X(00001).
05 W1C45221-C-HDR-PARAM-ERR-VW.
10 W1C45221-C-ERR-PARAM-CD
PIC X(00004).
10 W1C45221-C-ERR-PROG-ID
PIC X(00008).
10 W1C45221-C-ERR-MSG-DAT
PIC X(00010).
05 W1C45221-C-HDR-ADJ-VD-VW.
10 W1C45221-C-KEYED-REPLCD-NUM
PIC S9(00017) COMP-3.
10 W1C45221-C-HDR-ADJ-RSN-CD
PIC X(00003).
10 W1C45221-C-REPLCD-TCN-NUM
PIC S9(00017) COMP-3.
10 W1C45221-C-HDR-ADJ-STAT-CD
PIC X(00001).
10 W1C45221-C-REPLCMT-TCN-NUM
PIC S9(00017) COMP-3.
10 W1C45221-F-FCN-DT PIC X(00010).
10 W1C45221-F-FCN-MED-CD
PIC X(00001).
10 W1C45221-F-FCN-NUM PIC S9(00003) COMP.
10 W1C45221-C-ADJ-ORIG-TCN-NUM
PIC S9(00017) COMP-3.
10 W1C45221-C-ADJ-SEQ-NUM
PIC S9(00002) COMP.
05 W1C45221-C-HDR-COE-GRP.
10 W1C45221-C-HDR-COE-VW
OCCURS 0 TO 0004 TIMES
DEPENDING ON W1C45221-C-CNT-COE-NUM
INDEXED BY W1C45221-C-HDR-COE-VW-X .
15 W1C45221-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C45221-B-COE-CD
PIC X(00003).
15 W1C45221-B-FED-MTCH-CD
PIC X(00001).
15 W1C45221-B-FED-CAT-CD
PIC X(00001).
15 W1C45221-B-GEO-CNTY-CD
PIC X(00002).
15 W1C45221-B-ADMIN-CNTY-CD
PIC X(00002).
15 W1C45221-B-MONEY-CD
PIC X(00001).
05 W1C45221-C-HDR-FIN-TXN-VW.
10 W1C45221-C-ACCOUNTING-CD
PIC X(00008).
10 W1C45221-F-PYE-PYR-CD
PIC X(00001).
05 W1C45221-C-HDR-WARRANT-VW.
10 W1C45221-C-HDR-RA-NUM
PIC S9(00009) COMP.
10 W1C45221-C-HDR-WARR-NUM
PIC X(00011).
10 W1C45221-C-HDR-WARR-MED-CD
PIC X(00001).
10 W1C45221-C-HDR-WARR-AMT
PIC S9(00013)V9(00002) COMP-3.
10 W1C45221-C-HDR-WARR-DT
PIC X(00010).
10 W1C45221-C-EFT-TRC-ID
PIC X(00015).
05 W1C45221-C-HDR-ENCTR-VW.
10 W1C45221-C-MCO-TCN-DAT
PIC X(00020).
10 W1C45221-C-SUB-CAP-CD
PIC X(00001).
10 W1C45221-C-MC-ENCTR-PD-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C45221-C-MC-ENCTR-PD-DT
PIC X(00010).
10 W1C45221-C-MC-ENCTR-RECD-DT
PIC X(00010).
*Layout used if the claim is Pharmacy - Header Level
* *
01 W1C51691-C-LI-PHRM-COMMON-VW.
05 W1C51691-C-SORT-GRP.
10 W1C51691-C-SORT-DAT
PIC X(00030).
10 W1C51691-C-LI-REC-STRT-NUM
PIC 9(00004) COMP.
05 W1C51691-C-COUNTERS-VW.
10 W1C51691-C-CNT-COE-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-COND-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-OCC-CD-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-OCC-SPN-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-VALU-CD-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-ICD-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-DIAG-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-COB-NUM
PIC S9(00004) COMP.
10 W1C51691-C-HDR-CAS-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-LOCN-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-OVRD-EOB-NUM
PIC S9(00004) COMP.
10 W1C51691-C-HDR-OVRD-EOB-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-OVRD-EXC-NUM
PIC S9(00004) COMP.
10 W1C51691-C-HDR-OVRD-EXC-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-RLTD-HST-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-LI-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-LI-MCARE-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-LI-COB-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-LI-CAS-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-BSE-CHG-NUM
PIC S9(00004) COMP.
10 W1C51691-C-HDR-BSE-CHG-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-EXC-NUM
PIC S9(00004) COMP.
10 W1C51691-C-HDR-EXC-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-LI-TPL-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-LI-CAP-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-LI-DRUG-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-UNUSED-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-AUX-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CNT-LI-AUX-NUM
PIC S9(00004) COMP.
05 W1C51691-C-HDR-TB.
10 W1C51691-C-TCN-NUM PIC S9(00017) COMP-3.
10 W1C51691-C-XCN-NUM PIC X(00031).
10 W1C51691-C-HDR-ID-CD
PIC X(00002).
10 W1C51691-C-HDR-EMC-CD
PIC X(00001).
10 W1C51691-C-HDR-SUBMITTER-ID
PIC X(00016).
10 W1C51691-C-CNTL-ORGN-CD
PIC X(00001).
10 W1C51691-C-HDR-STAT-CD
PIC X(00001).
10 W1C51691-C-HDR-TXN-TY-CD
PIC X(00001).
10 W1C51691-C-HDR-TY-CD
PIC X(00001).
10 W1C51691-C-BAT-MED-SRC-CD
PIC X(00001).
10 W1C51691-C-BAT-JLN-DT-NUM
PIC X(00005).
10 W1C51691-C-BT-IMGD-CNTL-NUM
PIC X(00002).
10 W1C51691-C-BAT-NUM PIC X(00003).
10 W1C51691-C-BAT-DOC-TY-CD
PIC X(00001).
10 W1C51691-C-BAT-PYMT-TY-CD
PIC X(00001).
10 W1C51691-C-BAT-TY-CD
PIC X(00001).
10 W1C51691-C-HDR-DOC-NUM
PIC X(00006).
10 W1C51691-C-NSF-X12N-CD
PIC X(00001).
10 W1C51691-C-MCARE-STAT-CD
PIC X(00001).
10 W1C51691-C-CLNT-MCARE-CD
PIC X(00001).
10 W1C51691-B-SYS-ID PIC S9(00009) COMP.
10 W1C51691-B-FST-NAM PIC X(00015).
10 W1C51691-B-LAST-NAM
PIC X(00021).
10 W1C51691-B-MI-NAM PIC X(00001).
10 W1C51691-B-ALT-ID PIC X(00014).
10 W1C51691-B-CURR-ID PIC X(00014).
10 W1C51691-B-RACE-CD PIC X(00001).
10 W1C51691-B-GENDER-CD
PIC X(00001).
10 W1C51691-B-MAJ-PROG-CD
PIC X(00001).
10 W1C51691-T-MSQ-TY-CD
PIC X(00001).
10 W1C51691-A-ID PIC X(00011).
10 W1C51691-C-BLNG-PROV-ID
PIC X(00008).
10 W1C51691-C-BLNG-NPI-ID
PIC X(00010).
10 W1C51691-C-BLNG-TXNMY-CD
PIC X(00010).
10 W1C51691-C-BLNG-PROV-ZIP-CD
PIC X(00009).
10 W1C51691-C-BLNG-PROV-TY-CD
PIC X(00003).
10 W1C51691-C-BLNG-SPECL-CD
PIC X(00003).
10 W1C51691-C-BLNG-NTRPRS-ID
PIC X(00008).
10 W1C51691-C-PROV-SIGN-IND
PIC X(00001).
10 W1C51691-C-ATTACH-1ST-CD
PIC X(00002).
10 W1C51691-C-ATTACH-2ND-CD
PIC X(00002).
10 W1C51691-C-ATTACH-3RD-CD
PIC X(00002).
10 W1C51691-C-ATTACH-4TH-CD
PIC X(00002).
10 W1C51691-C-ATTACH-5TH-CD
PIC X(00002).
10 W1C51691-C-HDR-RMK-IND
PIC X(00001).
10 W1C51691-C-HDR-PAT-ACCT-NUM
PIC X(00020).
10 W1C51691-C-MED-REC-NUM
PIC X(00024).
10 W1C51691-C-ELIG-TWO-PASS-CD
PIC X(00001).
10 W1C51691-C-CREDIT-CD
PIC X(00001).
10 W1C51691-C-OTHR-INSR-IND
PIC X(00001).
10 W1C51691-P-LOCN-CD PIC X(00001).
10 W1C51691-P-PROFIT-IND
PIC X(00001).
10 W1C51691-P-TAX-DISCT-IND
PIC X(00001).
10 W1C51691-P-PROF-TECH-IND
PIC X(00001).
10 W1C51691-P-IHS-IND PIC X(00001).
10 W1C51691-P-PSY-SOC-IND
PIC X(00001).
10 W1C51691-C-COST-AVOID-IND
PIC X(00001).
10 W1C51691-C-PRIOR-AUTH-IND
PIC X(00001).
10 W1C51691-C-DAILY-RPT-IND
PIC X(00001).
10 W1C51691-C-HDR-RA-NUM
PIC S9(00009) COMP.
10 W1C51691-C-EXC-LOCN-CD
PIC X(00003).
10 W1C51691-C-EXC-LOCN-ID
PIC X(00007).
10 W1C51691-C-SUSP-LOCN-EXC-CD
PIC X(00004).
10 W1C51691-C-OVRRD-EXC-LOC-CD
PIC X(00003).
10 W1C51691-C-COST-CENTER-CD
PIC X(00005).
10 W1C51691-C-FAM-PLN-CC-CD
PIC X(00005).
10 W1C51691-C-RLTD-FCN-NUM
PIC X(00015).
10 W1C51691-F-RSN-CD PIC X(00003).
10 W1C51691-C-CYCL-NUM
PIC S9(00002) COMP.
10 W1C51691-C-HDR-CLNT-AGE
PIC S9(00003) COMP.
10 W1C51691-C-TOT-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C51691-C-CALC-TOT-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C51691-C-TOT-TPL-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C51691-C-TOT-TPL-DIR-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C51691-C-HD-TPL-COPAY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C51691-C-TOT-NET-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C51691-C-TOT-REIMB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C51691-C-TOT-COPAY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C51691-C-REIMB-STAT-CD
PIC X(00001).
10 W1C51691-C-PREV-REIMB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C51691-C-PREV-REIMB-CD
PIC X(00001).
10 W1C51691-C-PAT-LIAB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C51691-B-DOB-DT PIC X(00010).
10 W1C51691-C-SUBM-CLNT-DOB-DT
PIC X(00010).
10 W1C51691-C-HDR-ENTRD-DT
PIC X(00010).
10 W1C51691-C-HDR-ADJUD-DT
PIC X(00010).
10 W1C51691-C-HDR-ADJUD-TM
PIC X(00008).
10 W1C51691-C-HDR-ITERM-ADJ-DT
PIC X(00010).
10 W1C51691-C-BILLED-DT
PIC X(00010).
10 W1C51691-C-EXC-LOCN-DT
PIC X(00010).
10 W1C51691-C-HDR-BATCH-DT
PIC X(00010).
10 W1C51691-C-HDR-SVC-FST-DT
PIC X(00010).
10 W1C51691-C-HDR-SVC-LST-DT
PIC X(00010).
10 W1C51691-C-HDR-LST-CYCL-DT
PIC X(00010).
10 W1C51691-C-HDR-PD-DT
PIC X(00010).
10 W1C51691-C-HDR-ORIG-PD-DT
PIC X(00010).
10 W1C51691-C-HDR-SUSP-DT
PIC X(00010).
10 W1C51691-C-HDR-HX-DT
PIC X(00010).
10 W1C51691-C-HDR-CLIA-NUM
PIC X(00010).
10 W1C51691-C-HDR-DENT-OCCP-DT
PIC X(00010).
10 W1C51691-C-HDR-DENT-AUTO-DT
PIC X(00010).
10 W1C51691-C-HDR-DENT-OTHR-DT
PIC X(00010).
10 W1C51691-C-REF-PROV-ID
PIC X(00008).
10 W1C51691-C-REF-NPI-ID
PIC X(00010).
10 W1C51691-C-OCCUP-RLTD-IND
PIC X(00001).
10 W1C51691-C-AUTO-RLTD-IND
PIC X(00001).
10 W1C51691-C-OTHR-RLTD-IND
PIC X(00001).
10 W1C51691-C-ILLNESS-DT
PIC X(00010).
10 W1C51691-C-ADMIT-DT
PIC X(00010).
10 W1C51691-C-DISCH-DT
PIC X(00010).
10 W1C51691-R-DRG-CD PIC X(00005).
10 W1C51691-C-OTHR-PROV-ID
PIC X(00008).
10 W1C51691-C-OTHR-PROV-NPI-ID
PIC X(00010).
10 W1C51691-C-OPR-PROV-ID
PIC X(00008).
10 W1C51691-C-OPR-NPI-ID
PIC X(00010).
10 W1C51691-C-ATNDG-PROV-ID
PIC X(00008).
10 W1C51691-C-ATNDG-NPI-ID
PIC X(00010).
10 W1C51691-C-ATNDG-TXNMY-CD
PIC X(00010).
10 W1C51691-C-LTC-PROV-ID
PIC X(00008).
10 W1C51691-C-PAT-STAT-CD
PIC X(00002).
10 W1C51691-C-ADM-SRC-CD
PIC X(00001).
10 W1C51691-C-TY-OF-ADM-CD
PIC X(00001).
10 W1C51691-C-TY-OF-BLL-PFX-CD
PIC X(00001).
10 W1C51691-C-TY-OF-BLL-1-2-CD
PIC X(00002).
10 W1C51691-C-TY-OF-BILL-3-CD
PIC X(00001).
10 W1C51691-C-COS-CD PIC X(00002).
10 W1C51691-C-UB92-A-DIAG-CD
PIC X(00010).
10 W1C51691-C-UB92-ADM-HR-CD
PIC X(00002).
10 W1C51691-C-UB92-DISCH-HR-CD
PIC X(00002).
10 W1C51691-C-BSE-AMT-SRC-CD
PIC X(00002).
10 W1C51691-C-PRCNG-PROCESS-CD
PIC X(00002).
10 W1C51691-C-UB92-ABORT-IND
PIC X(00001).
10 W1C51691-C-HDR-FAM-PLNG-IND
PIC X(00001).
10 W1C51691-C-UB92-STERIL-IND
PIC X(00001).
10 W1C51691-C-UB92-HYSTER-IND
PIC X(00001).
10 W1C51691-C-HDR-BSE-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C51691-C-CALC-ALLOW-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C51691-C-HDR-ALLOW-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C51691-C-NCVRD-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C51691-C-CVRD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C51691-C-NCVRD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C51691-C-OUTLIER-DAYS-NUM
PIC S9(00004) COMP.
10 W1C51691-C-CALC-DAYS-NUM
PIC S9(00004) COMP.
10 W1C51691-C-DRG-PD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C51691-B-GUARANTEE-NUM
PIC X(00012).
10 W1C51691-C-ORIG-PAPER-IND
PIC X(00001).
10 W1C51691-C-CREATION-DT
PIC X(00010).
10 W1C51691-C-SVC-FACI-NPI-ID
PIC X(00010).
10 W1C51691-R-CD-REL-WT-AMT
PIC S9(00004)V9(00005) COMP-3.
10 W1C51691-C-BLNG-TAX-ID
PIC X(00009).
10 W1C51691-C-BLNG-SSN-NUM
PIC X(00009).
10 W1C51691-C-FUT-PROV-ID
PIC X(00008).
10 W1C51691-C-MC-PROV-ID
PIC X(00008).
10 W1C51691-H-PLN-NUM PIC X(00004).
10 W1C51691-H-PLN-TY-CD
PIC X(00001).
10 W1C51691-H-PLN-BEG-DT
PIC X(00010).
10 W1C51691-C-HDR-FUT-1-CD
PIC X(00003).
10 W1C51691-C-HDR-FUT-2-CD
PIC X(00003).
10 W1C51691-B-PARENT-IND
PIC X(00001).
10 W1C51691-C-HDR-AUD-IND
PIC X(00001).
10 W1C51691-C-HDR-FUT-1-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C51691-C-HDR-FUT-2-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C51691-C-EPSDT-CERT1-CD
PIC X(00003).
10 W1C51691-C-EPSDT-CERT2-CD
PIC X(00003).
10 W1C51691-C-ANES-REL-PROC-CD
PIC X(00007).
10 W1C51691-R-ICD-VER-CD
PIC X(00002).
10 W1C51691-C-HDR-FUT-1-IND
PIC X(00001).
10 W1C51691-C-HDR-FUT-2-IND
PIC X(00001).
10 W1C51691-G-AUD-USER-ID
PIC X(00007).
10 W1C51691-G-AUD-DT PIC X(00010).
10 W1C51691-G-AUD-TM PIC X(00008).
05 W1C51691-C-LI-CNT-DRUG-GRP.
10 W1C51691-C-LI-REC-NUM
PIC S9(00004) COMP.
10 W1C51691-C-LI-DRUG-REC-NUM
PIC S9(00004) COMP.
10 W1C51691-C-LI-BSE-CHG-NUM
PIC S9(00004) COMP.
10 W1C51691-C-LI-EXC-NUM
PIC S9(00004) COMP.
10 W1C51691-C-LI-CAS-NUM
PIC S9(00004) COMP.
10 W1C51691-C-LI-AUX-NUM
PIC S9(00004) COMP.
05 W1C51691-C-LI-PHRM-GRP-PHYS.
10 W1C51691-C-LI-VW
OCCURS 0 TO 0014 TIMES
DEPENDING ON W1C51691-C-LI-REC-NUM
INDEXED BY W1C51691-C-LI-VW-X .
15 W1C51691-C-LI-NUM
PIC S9(00003) COMP.
15 W1C51691-R-PROC-CD
PIC X(00007).
15 W1C51691-C-PROC-MOD-1ST-CD
PIC X(00002).
15 W1C51691-C-PROC-MOD-2ND-CD
PIC X(00002).
15 W1C51691-C-PROC-MOD-3RD-CD
PIC X(00002).
15 W1C51691-C-PROC-MOD-4TH-CD
PIC X(00002).
15 W1C51691-R-PL-OF-SVC-CD
PIC X(00002).
15 W1C51691-R-SVC-AREA-CD
PIC X(00001).
15 W1C51691-C-SVC-COMPONENT-CD
PIC X(00001).
15 W1C51691-A-LI-NUM
PIC S9(00003) COMP.
15 W1C51691-C-PRIOR-AUTH-IND
PIC X(00001).
15 W1C51691-C-LI-AUTH-ID
PIC X(00011).
15 W1C51691-C-LI-CLIA-NUM
PIC X(00010).
15 W1C51691-C-BSE-AMT-SRC-CD
PIC X(00002).
15 W1C51691-C-PRCNG-PROCESS-CD
PIC X(00002).
15 W1C51691-C-COS-CD
PIC X(00002).
15 W1C51691-C-REIMB-STAT-CD
PIC X(00001).
15 W1C51691-C-COST-AVOID-IND
PIC X(00001).
15 W1C51691-C-ONCE-IN-LFTM-IND
PIC X(00001).
15 W1C51691-C-LI-DUPL-CHK-IND
PIC X(00001).
15 W1C51691-C-ALLOW-UNTS-IND
PIC X(00001).
15 W1C51691-C-LI-ABORT-IND
PIC X(00001).
15 W1C51691-C-LI-STERIL-IND
PIC X(00001).
15 W1C51691-C-LI-FAM-PLNG-IND
PIC X(00001).
15 W1C51691-C-LI-HYSTER-IND
PIC X(00001).
15 W1C51691-C-MULTI-SURG-IND
PIC X(00001).
15 W1C51691-C-LI-FST-DOS-DT
PIC X(00010).
15 W1C51691-C-LI-LAST-DOS-DT
PIC X(00010).
15 W1C51691-C-MC-ENCTR-PD-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C51691-C-LI-TPL-COPAY-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C51691-C-LI-SUBM-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C51691-C-LI-BSE-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C51691-C-LI-CLC-ALLW-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C51691-C-LI-ALLW-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C51691-C-LI-REIMB-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C51691-C-LI-UNT-MSR-CD
PIC X(00002).
15 W1C51691-C-LI-UNT-MSR-NUM
PIC S9(00007)V9(00002) COMP-3.
15 W1C51691-C-LI-SUBM-UNT-NUM
PIC S9(00007)V9(00002) COMP-3.
15 W1C51691-C-LI-ALLOW-UNT-NUM
PIC S9(00007)V9(00002) COMP-3.
15 W1C51691-C-LI-REIMB-UNT-NUM
PIC S9(00007)V9(00002) COMP-3.
15 W1C51691-C-LI-FLLWP-LMT-DT
PIC X(00010).
15 W1C51691-R-DRUG-CD
PIC X(00011).
15 W1C51691-C-DIAG-1ST-RLTD-CD
PIC X(00001).
15 W1C51691-C-DIAG-2ND-RLTD-CD
PIC X(00001).
15 W1C51691-C-DIAG-3RD-RLTD-CD
PIC X(00001).
15 W1C51691-C-DIAG-4TH-RLTD-CD
PIC X(00001).
15 W1C51691-C-DIAG-5TH-RLTD-CD
PIC X(00001).
15 W1C51691-C-DIAG-6TH-RLTD-CD
PIC X(00001).
15 W1C51691-C-DIAG-7TH-RLTD-CD
PIC X(00001).
15 W1C51691-C-DIAG-8TH-RLTD-CD
PIC X(00001).
15 W1C51691-R-PROC-ORAL-CAV-CD
PIC X(00002).
15 W1C51691-R-PROC-TOOTH-CD
PIC X(00002).
15 W1C51691-C-DENT-1ST-SURF-CD
PIC X(00001).
15 W1C51691-C-DENT-2ND-SURF-CD
PIC X(00001).
15 W1C51691-C-DENT-3RD-SURF-CD
PIC X(00001).
15 W1C51691-C-DENT-4TH-SURF-CD
PIC X(00001).
15 W1C51691-C-DENT-5TH-SURF-CD
PIC X(00001).
15 W1C51691-C-RNDR-PROV-ID
PIC X(00008).
15 W1C51691-C-RNDR-NPI-ID
PIC X(00010).
15 W1C51691-C-RNDR-TXNMY-CD
PIC X(00010).
15 W1C51691-C-RNDR-NTRPRS-ID
PIC X(00008).
15 W1C51691-C-DSTN-PROV-ID
PIC X(00008).
15 W1C51691-P-TY-CD
PIC X(00003).
15 W1C51691-P-SPECL-CD
PIC X(00003).
15 W1C51691-C-SUBM-FAM-PLN-IND
PIC X(00001).
15 W1C51691-C-SUBM-EPSDT-IND
PIC X(00001).
15 W1C51691-R-REV-CD
PIC X(00007).
15 W1C51691-R-REV-TY-CD
PIC X(00001).
15 W1C51691-B-LEVEL-OF-CARE-CD
PIC X(00003).
15 W1C51691-C-LI-UB92-RATE-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C51691-C-NN-CVRD-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C51691-C-LI-FUT-1-CD
PIC X(00003).
15 W1C51691-C-LI-FUT-2-CD
PIC X(00003).
15 W1C51691-C-LI-FUT-1-IND
PIC X(00001).
15 W1C51691-C-LI-FUT-2-IND
PIC X(00001).
15 W1C51691-C-LI-FUT-1-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C51691-C-LI-FUT-2-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C51691-C-LI-COST-CNTR-CD
PIC X(00005).
15 W1C51691-C-LI-ATT-1ST-CD
PIC X(00002).
15 W1C51691-C-LI-ATT-2ND-CD
PIC X(00002).
15 W1C51691-C-LI-ATT-3RD-CD
PIC X(00002).
15 W1C51691-C-LI-FUT-3-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C51691-C-LI-FUT-4-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C51691-C-LI-NDC-UNT-CD
PIC X(00002).
15 W1C51691-C-LI-NDC-UNT-NUM
PIC S9(00007)V9(00002) COMP-3.
05 W1C51691-C-LI-DRUG-GRP-PHYS.
10 W1C51691-C-LI-DRUG-VW
OCCURS 0 TO 0014 TIMES
DEPENDING ON W1C51691-C-LI-DRUG-REC-NUM
INDEXED BY W1C51691-C-LI-DRUG-VW-X .
15 W1C51691-C-LI-NUM
PIC S9(00003) COMP.
15 W1C51691-R-DRUG-GCN-SEQ-NUM
PIC S9(00007) COMP-3.
15 W1C51691-R-DRG-THR-CHAR3-CD
PIC X(00003).
15 W1C51691-C-DRUG-GEN-PRD-CD
PIC X(00001).
15 W1C51691-C-DRUG-GEN-CD-NUM
PIC X(00005).
15 W1C51691-C-DRUG-MAINT-IND
PIC X(00001).
15 W1C51691-C-DRUG-ROUTE-CD
PIC X(00001).
15 W1C51691-C-BSE-AMT-SRC-CD
PIC X(00002).
15 W1C51691-R-DRUG-DEA-CD
PIC X(00001).
15 W1C51691-C-LI-SUB-QTY-AMT
PIC S9(00008)V9(00003) COMP-3.
15 W1C51691-C-LI-PD-QTY-AMT
PIC S9(00008)V9(00003) COMP-3.
15 W1C51691-C-LI-ALLOW-ING-AMT
PIC S9(00009)V9(00002) COMP-3.
05 W1C51691-C-LI-CAS-PHRM-GRP.
10 W1C51691-C-CAS-VW
OCCURS 0 TO 0240 TIMES
DEPENDING ON W1C51691-C-LI-CAS-NUM
INDEXED BY W1C51691-C-CAS-VW-X .
15 W1C51691-C-LI-NUM
PIC S9(00003) COMP.
15 W1C51691-C-CAS-PYR-ID
PIC X(00015).
15 W1C51691-C-CAS-PROC-CD
PIC X(00008).
15 W1C51691-C-CAS-GRP-CD
PIC X(00002).
15 W1C51691-C-CAS-RSN-CD
PIC X(00005).
15 W1C51691-C-CAS-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C51691-C-CAS-UNT-NUM
PIC S9(00009) COMP.
05 W1C51691-C-LI-BSE-CHG-PHRM-PHY.
10 W1C51691-C-LI-BSE-CHG-VW
OCCURS 0 TO 0112 TIMES
DEPENDING ON W1C51691-C-LI-BSE-CHG-NUM
INDEXED BY W1C51691-C-LI-BSE-CHG-VW-X .
15 W1C51691-C-LI-NUM
PIC S9(00003) COMP.
15 W1C51691-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C51691-C-BSE-CHNG-RSN-CD
PIC X(00002).
15 W1C51691-C-BSE-AMT-CHG-AMT
PIC S9(00009)V9(00002) COMP-3.
05 W1C51691-C-LI-EXC-GRP-PHYS.
10 W1C51691-C-LI-EXC-VW
OCCURS 0 TO 0210 TIMES
DEPENDING ON W1C51691-C-LI-EXC-NUM
INDEXED BY W1C51691-C-LI-EXC-VW-X .
15 W1C51691-C-LI-NUM
PIC S9(00003) COMP.
15 W1C51691-R-CLM-EXC-CD
PIC X(00004).
15 W1C51691-C-LI-EXC-CLRK-ID
PIC X(00007).
15 W1C51691-C-EXC-STAT-CD
PIC X(00001).
15 W1C51691-R-EXC-FORCE-APP-CD
PIC X(00001).
15 W1C51691-R-FORCE-DENY-CD
PIC X(00001).
05 W1C51691-C-LI-AUX-GRP-PHYS.
10 W1C51691-C-LI-AUX-VW
OCCURS 0 TO 0014 TIMES
DEPENDING ON W1C51691-C-LI-AUX-NUM
INDEXED BY W1C51691-C-LI-AUX-VW-X .
15 W1C51691-C-LI-NUM
PIC S9(00003) COMP.
15 W1C51691-C-ATT-1ST-CNTL-NUM
PIC X(00015).
15 W1C51691-C-ATT-1ST-XMIT-CD
PIC X(00002).
15 W1C51691-C-ATT-1ST-RECD-IND
PIC X(00001).
15 W1C51691-C-ATT-2ND-CNTL-NUM
PIC X(00015).
15 W1C51691-C-ATT-2ND-XMIT-CD
PIC X(00002).
15 W1C51691-C-ATT-2ND-RECD-IND
PIC X(00001).
15 W1C51691-C-ATT-3RD-CNTL-NUM
PIC X(00015).
15 W1C51691-C-ATT-3RD-XMIT-CD
PIC X(00002).
15 W1C51691-C-ATT-3RD-RECD-IND
PIC X(00001).
*Layout used if the claim is Pharmacy - Line Level
*
01 W1C85701-C-HDR-PHRM-VW.
05 W1C85701-C-SORT-GRP.
10 W1C85701-C-SORT-DAT
PIC X(00030).
10 W1C85701-C-LI-REC-STRT-NUM
PIC 9(00004) COMP.
05 W1C85701-C-COUNTERS-VW.
10 W1C85701-C-CNT-COE-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-COND-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-OCC-CD-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-OCC-SPN-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-VALU-CD-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-ICD-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-DIAG-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-COB-NUM
PIC S9(00004) COMP.
10 W1C85701-C-HDR-CAS-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-LOCN-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-OVRD-EOB-NUM
PIC S9(00004) COMP.
10 W1C85701-C-HDR-OVRD-EOB-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-OVRD-EXC-NUM
PIC S9(00004) COMP.
10 W1C85701-C-HDR-OVRD-EXC-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-RLTD-HST-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-LI-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-LI-MCARE-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-LI-COB-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-LI-CAS-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-BSE-CHG-NUM
PIC S9(00004) COMP.
10 W1C85701-C-HDR-BSE-CHG-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-EXC-NUM
PIC S9(00004) COMP.
10 W1C85701-C-HDR-EXC-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-LI-TPL-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-LI-CAP-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-LI-DRUG-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-UNUSED-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-AUX-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CNT-LI-AUX-NUM
PIC S9(00004) COMP.
05 W1C85701-C-HDR-TB.
10 W1C85701-C-TCN-NUM PIC S9(00017) COMP-3.
10 W1C85701-C-XCN-NUM PIC X(00031).
10 W1C85701-C-HDR-ID-CD
PIC X(00002).
10 W1C85701-C-HDR-EMC-CD
PIC X(00001).
10 W1C85701-C-HDR-SUBMITTER-ID
PIC X(00016).
10 W1C85701-C-CNTL-ORGN-CD
PIC X(00001).
10 W1C85701-C-HDR-STAT-CD
PIC X(00001).
10 W1C85701-C-HDR-TXN-TY-CD
PIC X(00001).
10 W1C85701-C-HDR-TY-CD
PIC X(00001).
10 W1C85701-C-BAT-MED-SRC-CD
PIC X(00001).
10 W1C85701-C-BAT-JLN-DT-NUM
PIC X(00005).
10 W1C85701-C-BT-IMGD-CNTL-NUM
PIC X(00002).
10 W1C85701-C-BAT-NUM PIC X(00003).
10 W1C85701-C-BAT-DOC-TY-CD
PIC X(00001).
10 W1C85701-C-BAT-PYMT-TY-CD
PIC X(00001).
10 W1C85701-C-BAT-TY-CD
PIC X(00001).
10 W1C85701-C-HDR-DOC-NUM
PIC X(00006).
10 W1C85701-C-NSF-X12N-CD
PIC X(00001).
10 W1C85701-C-MCARE-STAT-CD
PIC X(00001).
10 W1C85701-C-CLNT-MCARE-CD
PIC X(00001).
10 W1C85701-B-SYS-ID PIC S9(00009) COMP.
10 W1C85701-B-FST-NAM PIC X(00015).
10 W1C85701-B-LAST-NAM
PIC X(00021).
10 W1C85701-B-MI-NAM PIC X(00001).
10 W1C85701-B-ALT-ID PIC X(00014).
10 W1C85701-B-CURR-ID PIC X(00014).
10 W1C85701-B-RACE-CD PIC X(00001).
10 W1C85701-B-GENDER-CD
PIC X(00001).
10 W1C85701-B-MAJ-PROG-CD
PIC X(00001).
10 W1C85701-T-MSQ-TY-CD
PIC X(00001).
10 W1C85701-A-ID PIC X(00011).
10 W1C85701-C-BLNG-PROV-ID
PIC X(00008).
10 W1C85701-C-BLNG-NPI-ID
PIC X(00010).
10 W1C85701-C-BLNG-TXNMY-CD
PIC X(00010).
10 W1C85701-C-BLNG-PROV-ZIP-CD
PIC X(00009).
10 W1C85701-C-BLNG-PROV-TY-CD
PIC X(00003).
10 W1C85701-C-BLNG-SPECL-CD
PIC X(00003).
10 W1C85701-C-BLNG-NTRPRS-ID
PIC X(00008).
10 W1C85701-C-PROV-SIGN-IND
PIC X(00001).
10 W1C85701-C-ATTACH-1ST-CD
PIC X(00002).
10 W1C85701-C-ATTACH-2ND-CD
PIC X(00002).
10 W1C85701-C-ATTACH-3RD-CD
PIC X(00002).
10 W1C85701-C-ATTACH-4TH-CD
PIC X(00002).
10 W1C85701-C-ATTACH-5TH-CD
PIC X(00002).
10 W1C85701-C-HDR-RMK-IND
PIC X(00001).
10 W1C85701-C-HDR-PAT-ACCT-NUM
PIC X(00020).
10 W1C85701-C-MED-REC-NUM
PIC X(00024).
10 W1C85701-C-ELIG-TWO-PASS-CD
PIC X(00001).
10 W1C85701-C-CREDIT-CD
PIC X(00001).
10 W1C85701-C-OTHR-INSR-IND
PIC X(00001).
10 W1C85701-P-LOCN-CD PIC X(00001).
10 W1C85701-P-PROFIT-IND
PIC X(00001).
10 W1C85701-P-TAX-DISCT-IND
PIC X(00001).
10 W1C85701-P-PROF-TECH-IND
PIC X(00001).
10 W1C85701-P-IHS-IND PIC X(00001).
10 W1C85701-P-PSY-SOC-IND
PIC X(00001).
10 W1C85701-C-COST-AVOID-IND
PIC X(00001).
10 W1C85701-C-PRIOR-AUTH-IND
PIC X(00001).
10 W1C85701-C-DAILY-RPT-IND
PIC X(00001).
10 W1C85701-C-HDR-RA-NUM
PIC S9(00009) COMP.
10 W1C85701-C-EXC-LOCN-CD
PIC X(00003).
10 W1C85701-C-EXC-LOCN-ID
PIC X(00007).
10 W1C85701-C-SUSP-LOCN-EXC-CD
PIC X(00004).
10 W1C85701-C-OVRRD-EXC-LOC-CD
PIC X(00003).
10 W1C85701-C-COST-CENTER-CD
PIC X(00005).
10 W1C85701-C-FAM-PLN-CC-CD
PIC X(00005).
10 W1C85701-C-RLTD-FCN-NUM
PIC X(00015).
10 W1C85701-F-RSN-CD PIC X(00003).
10 W1C85701-C-CYCL-NUM
PIC S9(00002) COMP.
10 W1C85701-C-HDR-CLNT-AGE
PIC S9(00003) COMP.
10 W1C85701-C-TOT-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-CALC-TOT-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-TOT-TPL-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-TOT-TPL-DIR-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-HD-TPL-COPAY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-TOT-NET-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-TOT-REIMB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-TOT-COPAY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-REIMB-STAT-CD
PIC X(00001).
10 W1C85701-C-PREV-REIMB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-PREV-REIMB-CD
PIC X(00001).
10 W1C85701-C-PAT-LIAB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-B-DOB-DT PIC X(00010).
10 W1C85701-C-SUBM-CLNT-DOB-DT
PIC X(00010).
10 W1C85701-C-HDR-ENTRD-DT
PIC X(00010).
10 W1C85701-C-HDR-ADJUD-DT
PIC X(00010).
10 W1C85701-C-HDR-ADJUD-TM
PIC X(00008).
10 W1C85701-C-HDR-ITERM-ADJ-DT
PIC X(00010).
10 W1C85701-C-BILLED-DT
PIC X(00010).
10 W1C85701-C-EXC-LOCN-DT
PIC X(00010).
10 W1C85701-C-HDR-BATCH-DT
PIC X(00010).
10 W1C85701-C-HDR-SVC-FST-DT
PIC X(00010).
10 W1C85701-C-HDR-SVC-LST-DT
PIC X(00010).
10 W1C85701-C-HDR-LST-CYCL-DT
PIC X(00010).
10 W1C85701-C-HDR-PD-DT
PIC X(00010).
10 W1C85701-C-HDR-ORIG-PD-DT
PIC X(00010).
10 W1C85701-C-HDR-SUSP-DT
PIC X(00010).
10 W1C85701-C-HDR-HX-DT
PIC X(00010).
10 W1C85701-C-HDR-CLIA-NUM
PIC X(00010).
10 W1C85701-C-HDR-DENT-OCCP-DT
PIC X(00010).
10 W1C85701-C-HDR-DENT-AUTO-DT
PIC X(00010).
10 W1C85701-C-HDR-DENT-OTHR-DT
PIC X(00010).
10 W1C85701-C-REF-PROV-ID
PIC X(00008).
10 W1C85701-C-REF-NPI-ID
PIC X(00010).
10 W1C85701-C-OCCUP-RLTD-IND
PIC X(00001).
10 W1C85701-C-AUTO-RLTD-IND
PIC X(00001).
10 W1C85701-C-OTHR-RLTD-IND
PIC X(00001).
10 W1C85701-C-ILLNESS-DT
PIC X(00010).
10 W1C85701-C-ADMIT-DT
PIC X(00010).
10 W1C85701-C-DISCH-DT
PIC X(00010).
10 W1C85701-R-DRG-CD PIC X(00005).
10 W1C85701-C-OTHR-PROV-ID
PIC X(00008).
10 W1C85701-C-OTHR-PROV-NPI-ID
PIC X(00010).
10 W1C85701-C-OPR-PROV-ID
PIC X(00008).
10 W1C85701-C-OPR-NPI-ID
PIC X(00010).
10 W1C85701-C-ATNDG-PROV-ID
PIC X(00008).
10 W1C85701-C-ATNDG-NPI-ID
PIC X(00010).
10 W1C85701-C-ATNDG-TXNMY-CD
PIC X(00010).
10 W1C85701-C-LTC-PROV-ID
PIC X(00008).
10 W1C85701-C-PAT-STAT-CD
PIC X(00002).
10 W1C85701-C-ADM-SRC-CD
PIC X(00001).
10 W1C85701-C-TY-OF-ADM-CD
PIC X(00001).
10 W1C85701-C-TY-OF-BLL-PFX-CD
PIC X(00001).
10 W1C85701-C-TY-OF-BLL-1-2-CD
PIC X(00002).
10 W1C85701-C-TY-OF-BILL-3-CD
PIC X(00001).
10 W1C85701-C-COS-CD PIC X(00002).
10 W1C85701-C-UB92-A-DIAG-CD
PIC X(00010).
10 W1C85701-C-UB92-ADM-HR-CD
PIC X(00002).
10 W1C85701-C-UB92-DISCH-HR-CD
PIC X(00002).
10 W1C85701-C-BSE-AMT-SRC-CD
PIC X(00002).
10 W1C85701-C-PRCNG-PROCESS-CD
PIC X(00002).
10 W1C85701-C-UB92-ABORT-IND
PIC X(00001).
10 W1C85701-C-HDR-FAM-PLNG-IND
PIC X(00001).
10 W1C85701-C-UB92-STERIL-IND
PIC X(00001).
10 W1C85701-C-UB92-HYSTER-IND
PIC X(00001).
10 W1C85701-C-HDR-BSE-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-CALC-ALLOW-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-HDR-ALLOW-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-NCVRD-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-CVRD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C85701-C-NCVRD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C85701-C-OUTLIER-DAYS-NUM
PIC S9(00004) COMP.
10 W1C85701-C-CALC-DAYS-NUM
PIC S9(00004) COMP.
10 W1C85701-C-DRG-PD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C85701-B-GUARANTEE-NUM
PIC X(00012).
10 W1C85701-C-ORIG-PAPER-IND
PIC X(00001).
10 W1C85701-C-CREATION-DT
PIC X(00010).
10 W1C85701-C-SVC-FACI-NPI-ID
PIC X(00010).
10 W1C85701-R-CD-REL-WT-AMT
PIC S9(00004)V9(00005) COMP-3.
10 W1C85701-C-BLNG-TAX-ID
PIC X(00009).
10 W1C85701-C-BLNG-SSN-NUM
PIC X(00009).
10 W1C85701-C-FUT-PROV-ID
PIC X(00008).
10 W1C85701-C-MC-PROV-ID
PIC X(00008).
10 W1C85701-H-PLN-NUM PIC X(00004).
10 W1C85701-H-PLN-TY-CD
PIC X(00001).
10 W1C85701-H-PLN-BEG-DT
PIC X(00010).
10 W1C85701-C-HDR-FUT-1-CD
PIC X(00003).
10 W1C85701-C-HDR-FUT-2-CD
PIC X(00003).
10 W1C85701-B-PARENT-IND
PIC X(00001).
10 W1C85701-C-HDR-AUD-IND
PIC X(00001).
10 W1C85701-C-HDR-FUT-1-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-HDR-FUT-2-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-EPSDT-CERT1-CD
PIC X(00003).
10 W1C85701-C-EPSDT-CERT2-CD
PIC X(00003).
10 W1C85701-C-ANES-REL-PROC-CD
PIC X(00007).
10 W1C85701-R-ICD-VER-CD
PIC X(00002).
10 W1C85701-C-HDR-FUT-1-IND
PIC X(00001).
10 W1C85701-C-HDR-FUT-2-IND
PIC X(00001).
10 W1C85701-G-AUD-USER-ID
PIC X(00007).
10 W1C85701-G-AUD-DT PIC X(00010).
10 W1C85701-G-AUD-TM PIC X(00008).
05 W1C85701-C-HDR-PARAM-ERR-VW.
10 W1C85701-C-ERR-PARAM-CD
PIC X(00004).
10 W1C85701-C-ERR-PROG-ID
PIC X(00008).
10 W1C85701-C-ERR-MSG-DAT
PIC X(00010).
05 W1C85701-C-HDR-ADJ-VD-VW.
10 W1C85701-C-KEYED-REPLCD-NUM
PIC S9(00017) COMP-3.
10 W1C85701-C-HDR-ADJ-RSN-CD
PIC X(00003).
10 W1C85701-C-REPLCD-TCN-NUM
PIC S9(00017) COMP-3.
10 W1C85701-C-HDR-ADJ-STAT-CD
PIC X(00001).
10 W1C85701-C-REPLCMT-TCN-NUM
PIC S9(00017) COMP-3.
10 W1C85701-F-FCN-DT PIC X(00010).
10 W1C85701-F-FCN-MED-CD
PIC X(00001).
10 W1C85701-F-FCN-NUM PIC S9(00003) COMP.
10 W1C85701-C-ADJ-ORIG-TCN-NUM
PIC S9(00017) COMP-3.
10 W1C85701-C-ADJ-SEQ-NUM
PIC S9(00002) COMP.
05 W1C85701-C-HDR-COE-GRP.
10 W1C85701-C-HDR-COE-VW
OCCURS 0 TO 0004 TIMES
DEPENDING ON W1C85701-C-CNT-COE-NUM
INDEXED BY W1C85701-C-HDR-COE-VW-X .
15 W1C85701-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C85701-B-COE-CD
PIC X(00003).
15 W1C85701-B-FED-MTCH-CD
PIC X(00001).
15 W1C85701-B-FED-CAT-CD
PIC X(00001).
15 W1C85701-B-GEO-CNTY-CD
PIC X(00002).
15 W1C85701-B-ADMIN-CNTY-CD
PIC X(00002).
15 W1C85701-B-MONEY-CD
PIC X(00001).
05 W1C85701-C-HDR-WARRANT-VW.
10 W1C85701-C-HDR-RA-NUM
PIC S9(00009) COMP.
10 W1C85701-C-HDR-WARR-NUM
PIC X(00011).
10 W1C85701-C-HDR-WARR-MED-CD
PIC X(00001).
10 W1C85701-C-HDR-WARR-AMT
PIC S9(00013)V9(00002) COMP-3.
10 W1C85701-C-HDR-WARR-DT
PIC X(00010).
10 W1C85701-C-EFT-TRC-ID
PIC X(00015).
05 W1C85701-C-HDR-RLTD-HIST-GRP-P.
10 W1C85701-C-HDR-RLTD-HIST-VW
OCCURS 0 TO 0025 TIMES
DEPENDING ON W1C85701-C-CNT-RLTD-HST-NUM
INDEXED BY W1C85701-C-HDR-RLTD-HIST-VW-X .
15 W1C85701-C-LI-NUM
PIC S9(00003) COMP.
15 W1C85701-C-RLTD-LI-TCN-NUM
PIC S9(00017) COMP-3.
15 W1C85701-C-RLTD-LI-NUM
PIC S9(00003) COMP.
15 W1C85702-R-CLM-EXC-CD
PIC X(00004).
15 W1C85702-C-HDR-PD-DT
PIC X(00010).
15 W1C85702-C-EXC-STAT-CD
PIC X(00001).
15 W1C85702-C-HDR-TY-CD
PIC X(00001).
15 W1C85701-C-SYS-REPLCD-IND
PIC X(00001).
05 W1C85701-C-HDR-DRUG-VW.
10 W1C85701-C-NABP-PROV-ID
PIC X(00011).
10 W1C85701-C-PRESCR-PROV-ID
PIC X(00009).
10 W1C85701-C-DAW-CD PIC X(00001).
10 W1C85701-C-DRUG-RX-OVRRD-CD
PIC X(00002).
10 W1C85701-C-ELIG-OVRRD-IND
PIC X(00001).
10 W1C85701-C-MGMT-OVRRD-IND
PIC X(00001).
10 W1C85701-C-UNIT-DOSE-CD
PIC X(00001).
10 W1C85701-C-DRUG-CMPND-CD
PIC X(00001).
10 W1C85701-C-HDR-DRUG-CERT-CD
PIC X(00001).
10 W1C85701-C-HDR-DRUG-XREF-CD
PIC X(00015).
10 W1C85701-C-HDR-DRUG-RX-NUM
PIC S9(00012) COMP-3.
10 W1C85701-C-RX-REFLL-NUM
PIC S9(00002) COMP-3.
10 W1C85701-C-DRUG-PRESCR-DT
PIC X(00010).
10 W1C85701-C-DRUG-SUB-QTY-AMT
PIC S9(00008)V9(00003) COMP-3.
10 W1C85701-C-DRUG-PD-QTY-AMT
PIC S9(00008)V9(00003) COMP-3.
10 W1C85701-C-PAT-LOCN-CD
PIC S9(00004) COMP.
10 W1C85701-C-PA-TY-CD
PIC S9(00004) COMP.
10 W1C85701-C-DISP-STAT-CD
PIC X(00001).
10 W1C85701-C-MCARE-RX-IND
PIC X(00001).
10 W1C85701-C-RT-OF-ADMIN-CD
PIC S9(00004) COMP.
10 W1C85701-C-DSG-FM-DESC-CD
PIC X(00002).
10 W1C85701-C-DISP-UNT-FM-CD
PIC X(00001).
10 W1C85701-C-ASSOC-RX-SVC-NUM
PIC S9(00012) COMP-3.
10 W1C85701-C-ASSOC-RX-SVC-DT
PIC X(00010).
10 W1C85701-C-INT-DISP-QTY-AMT
PIC S9(00008)V9(00003) COMP-3.
10 W1C85701-C-INT-DISP-DAY-NUM
PIC S9(00004) COMP.
10 W1C85701-C-ORG-DRUG-CD
PIC X(00011).
10 W1C85701-C-ORG-PRSC-QTY-AMT
PIC S9(00008)V9(00003) COMP-3.
10 W1C85701-C-QTY-PRESCR-AMT
PIC S9(00008)V9(00003) COMP-3.
10 W1C85701-C-NUM-REFILLS-AMT
PIC S9(00002) COMP-3.
10 W1C85701-C-SUB-DAY-SPLY-AMT
PIC S9(00003) COMP-3.
10 W1C85701-C-PD-DAYS-SPLY-AMT
PIC S9(00003) COMP-3.
10 W1C85701-C-DRUG-FILLED-DT
PIC X(00010).
10 W1C85701-C-ALLW-INGRED-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-DISP-FEE-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-DRUG-GROUP-ID
PIC X(00008).
10 W1C85701-C-DRUG-CLIENT-ID
PIC X(00006).
10 W1C85701-C-DRUG-VERSN-NUM
PIC X(00002).
10 W1C85701-C-DRUG-EXTRACT-DT
PIC X(00010).
10 W1C85701-C-DRUG-PROV-NUM
PIC S9(00009) COMP-3.
10 W1C85701-C-DRUG-DEA-NUM
PIC X(00009).
10 W1C85701-C-DRUG-CVRG-CD
PIC X(00001).
10 W1C85701-C-DRUG-PLAN-ID
PIC X(00003).
10 W1C85701-C-DRUG-COB-IND
PIC X(00001).
10 W1C85701-C-PHYS-DEA-ID
PIC X(00009).
10 W1C85701-C-PRSC-LIC-NUM
PIC X(00009).
10 W1C85701-C-DRUG-IFACE-TY-CD
PIC X(00001).
10 W1C85701-C-IFACE-CLM-ID
PIC X(00014).
10 W1C85701-C-IFACE-CLM-CR-CD
PIC X(00014).
10 W1C85701-C-FCN-NUM PIC S9(00009) COMP-3.
10 W1C85701-C-PROV-ON-REVW-IND
PIC X(00001).
10 W1C85701-C-DRUG-COB-CHS-IND
PIC X(00001).
10 W1C85701-C-DRUG-OTH-INS-IND
PIC X(00001).
10 W1C85701-C-DRUG-TPL-IND
PIC X(00001).
10 W1C85701-C-PRESCR-NPI-ID
PIC X(00010).
10 W1C85701-C-RX-ORGN-CD
PIC S9(00004) COMP.
05 W1C85701-C-HDR-ENCTR-VW.
10 W1C85701-C-MCO-TCN-DAT
PIC X(00020).
10 W1C85701-C-SUB-CAP-CD
PIC X(00001).
10 W1C85701-C-MC-ENCTR-PD-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-MC-ENCTR-PD-DT
PIC X(00010).
10 W1C85701-C-MC-ENCTR-RECD-DT
PIC X(00010).
05 W1C85701-C-HDR-MCARE-VW.
10 W1C85701-C-MCARE-PROV-ID
PIC X(00013).
10 W1C85701-C-MCARE-CLM-NUM
PIC X(00026).
10 W1C85701-C-HD-MCARE-CARR-ID
PIC X(00006).
10 W1C85701-C-MCARE-HIC-ID
PIC X(00019).
10 W1C85701-C-HD-MCARE-EOMB-DT
PIC X(00010).
10 W1C85701-C-HDR-MCAR-STAT-CD
PIC X(00001).
10 W1C85701-C-MCARE-ALLOW-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-MCARE-DED-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-MCARE-COINS-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-MCARE-PSY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-MCARE-O-PR-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-MCARE-PD-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-HDR-MCAR-DED-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-HDR-MCAR-COI-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-HDR-MCAR-PSY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C85701-C-HD-MCAR-O-PR-AMT
PIC S9(00009)V9(00002) COMP-3.
05 W1C85701-C-HDR-BSE-CHG-GRP.
10 W1C85701-C-HDR-BSE-CHG-VW
OCCURS 0 TO 0008 TIMES
DEPENDING ON W1C85701-C-HDR-BSE-CHG-NUM
INDEXED BY W1C85701-C-HDR-BSE-CHG-VW-X .
15 W1C85701-C-LI-NUM
PIC S9(00003) COMP.
15 W1C85701-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C85701-C-BSE-CHNG-RSN-CD
PIC X(00002).
15 W1C85701-C-BSE-AMT-CHG-AMT
PIC S9(00009)V9(00002) COMP-3.
05 W1C85701-C-HDR-COB-GRP.
10 W1C85701-C-HDR-COB-VW
OCCURS 0 TO 0005 TIMES
DEPENDING ON W1C85701-C-CNT-COB-NUM
INDEXED BY W1C85701-C-HDR-COB-VW-X .
15 W1C85701-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C85701-C-COB-PYR-ID
PIC X(00015).
15 W1C85701-C-COB-PYR-NAM
PIC X(00035).
15 W1C85701-C-COB-PYR-SEQ-CD
PIC X(00001).
15 W1C85701-C-COB-PLCY-REL-CD
PIC X(00002).
15 W1C85701-C-COB-PLCY-NUM
PIC X(00009).
15 W1C85701-C-COB-GRP-PLN-NAM
PIC X(00030).
15 W1C85701-C-COB-FLN-IND-CD
PIC X(00002).
15 W1C85701-C-COB-PYR-PYMT-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C85701-C-COB-ADJUD-DT
PIC X(00010).
15 W1C85701-C-COB-CLM-NUM
PIC X(00026).
15 W1C85701-C-CERT-SSN-HIC-ID
PIC X(00019).
15 W1C85701-C-UB92-EST-DUE-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C85701-C-UB92-PYR-AUTH-CD
PIC X(00018).
15 W1C85701-C-COB-NN-CVRD-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C85701-C-HDR-RMK-CD
PIC X(00005).
15 W1C85701-C-COB-DRG-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C85701-C-COB-DSP-SHR-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C85701-C-COB-CAP-IME-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C85701-C-COB-REIMB-PCT
PIC S9(00003)V9(00002) COMP-3.
15 W1C85701-C-COB-HCPCS-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C85701-C-COB-ESRD-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C85701-C-COB-NONP-PC-AMT
PIC S9(00009)V9(00002) COMP-3.
05 W1C85701-C-HDR-CAS-PHRM-GRP.
10 W1C85701-C-CAS-VW
OCCURS 0 TO 0006 TIMES
DEPENDING ON W1C85701-C-HDR-CAS-NUM
INDEXED BY W1C85701-C-CAS-VW-X .
15 W1C85701-C-LI-NUM
PIC S9(00003) COMP.
15 W1C85701-C-CAS-PYR-ID
PIC X(00015).
15 W1C85701-C-CAS-PROC-CD
PIC X(00008).
15 W1C85701-C-CAS-GRP-CD
PIC X(00002).
15 W1C85701-C-CAS-RSN-CD
PIC X(00005).
15 W1C85701-C-CAS-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C85701-C-CAS-UNT-NUM
PIC S9(00009) COMP.
05 W1C85701-C-LI-TPL-BLNG-GRP.
10 W1C85701-C-LI-TPL-BLNG-VW
OCCURS 0 TO 0006 TIMES
DEPENDING ON W1C85701-C-CNT-LI-TPL-NUM
INDEXED BY W1C85701-C-LI-TPL-BLNG-VW-X .
15 W1C85701-C-LI-NUM
PIC S9(00003) COMP.
15 W1C85701-T-PLCY-NUM
PIC X(00020).
15 W1C85701-T-PLCY-SEQ-NUM
PIC S9(00003) COMP.
15 W1C85701-T-PLCY-RESRC-CD
PIC X(00002).
15 W1C85701-T-CARR-ID
PIC X(00006).
15 W1C85701-T-CVRG-PLCY-CD
PIC X(00002).
05 W1C85701-C-HDR-EXC-GRP.
10 W1C85701-C-HDR-EXC-VW
OCCURS 0 TO 0025 TIMES
DEPENDING ON W1C85701-C-HDR-EXC-NUM
INDEXED BY W1C85701-C-HDR-EXC-VW-X .
15 W1C85701-C-LI-NUM
PIC S9(00003) COMP.
15 W1C85701-R-CLM-EXC-CD
PIC X(00004).
15 W1C85701-C-EXC-CLRK-ID
PIC X(00007).
15 W1C85701-C-EXC-STAT-CD
PIC X(00001).
15 W1C85701-R-EXC-FORCE-APP-CD
PIC X(00001).
15 W1C85701-R-FORCE-DENY-CD
PIC X(00001).
05 W1C85701-C-HDR-AUX-VW.
10 W1C85701-C-ATT-1ST-CNTL-NUM
PIC X(00015).
10 W1C85701-C-ATT-1ST-XMIT-CD
PIC X(00002).
10 W1C85701-C-ATT-1ST-RECD-IND
PIC X(00001).
10 W1C85701-C-ATT-2ND-CNTL-NUM
PIC X(00015).
10 W1C85701-C-ATT-2ND-XMIT-CD
PIC X(00002).
10 W1C85701-C-ATT-2ND-RECD-IND
PIC X(00001).
10 W1C85701-C-ATT-3RD-CNTL-NUM
PIC X(00015).
10 W1C85701-C-ATT-3RD-XMIT-CD
PIC X(00002).
10 W1C85701-C-ATT-3RD-RECD-IND
PIC X(00001).
10 W1C85701-C-ATT-4TH-CNTL-NUM
PIC X(00015).
10 W1C85701-C-ATT-4TH-XMIT-CD
PIC X(00002).
10 W1C85701-C-ATT-4TH-RECD-IND
PIC X(00001).
10 W1C85701-C-ATT-5TH-CNTL-NUM
PIC X(00015).
10 W1C85701-C-ATT-5TH-XMIT-CD
PIC X(00002).
10 W1C85701-C-ATT-5TH-RECD-IND
PIC X(00001).
10 W1C85701-C-AMBL-PU-LINE1-AD
PIC X(00030).
10 W1C85701-C-AMBL-PU-LINE2-AD
PIC X(00030).
10 W1C85701-C-AMBL-PU-CITY-NAM
PIC X(00020).
10 W1C85701-C-AMBL-PU-ST-CD
PIC X(00002).
10 W1C85701-C-AMBL-PU-ZIP5-CD
PIC X(00005).
10 W1C85701-C-AMBL-PU-ZIP4-CD
PIC X(00004).
10 W1C85701-C-AMBL-DO-LINE1-AD
PIC X(00030).
10 W1C85701-C-AMBL-DO-LINE2-AD
PIC X(00030).
10 W1C85701-C-AMBL-DO-CITY-NAM
PIC X(00020).
10 W1C85701-C-AMBL-DO-ST-CD
PIC X(00002).
10 W1C85701-C-AMBL-DO-ZIP5-CD
PIC X(00005).
10 W1C85701-C-AMBL-DO-ZIP4-CD
PIC X(00004).
*Layout used if the claim is Institutional - Header Level
* *
01 W1C04511-C-HDR-INST-REC.
05 W1C04511-C-SORT-GRP.
10 W1C04511-C-SORT-DAT
PIC X(00030).
10 W1C04511-C-LI-REC-STRT-NUM
PIC 9(00004) COMP.
05 W1C04511-C-COUNTERS-VW.
10 W1C04511-C-CNT-COE-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-COND-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-OCC-CD-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-OCC-SPN-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-VALU-CD-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-ICD-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-DIAG-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-COB-NUM
PIC S9(00004) COMP.
10 W1C04511-C-HDR-CAS-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-LOCN-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-OVRD-EOB-NUM
PIC S9(00004) COMP.
10 W1C04511-C-HDR-OVRD-EOB-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-OVRD-EXC-NUM
PIC S9(00004) COMP.
10 W1C04511-C-HDR-OVRD-EXC-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-RLTD-HST-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-LI-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-LI-MCARE-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-LI-COB-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-LI-CAS-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-BSE-CHG-NUM
PIC S9(00004) COMP.
10 W1C04511-C-HDR-BSE-CHG-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-EXC-NUM
PIC S9(00004) COMP.
10 W1C04511-C-HDR-EXC-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-LI-TPL-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-LI-CAP-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-LI-DRUG-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-UNUSED-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-AUX-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CNT-LI-AUX-NUM
PIC S9(00004) COMP.
05 W1C04511-C-HDR-TB.
10 W1C04511-C-TCN-NUM PIC S9(00017) COMP-3.
10 W1C04511-C-XCN-NUM PIC X(00031).
10 W1C04511-C-HDR-ID-CD
PIC X(00002).
10 W1C04511-C-HDR-EMC-CD
PIC X(00001).
10 W1C04511-C-HDR-SUBMITTER-ID
PIC X(00016).
10 W1C04511-C-CNTL-ORGN-CD
PIC X(00001).
10 W1C04511-C-HDR-STAT-CD
PIC X(00001).
10 W1C04511-C-HDR-TXN-TY-CD
PIC X(00001).
10 W1C04511-C-HDR-TY-CD
PIC X(00001).
10 W1C04511-C-BAT-MED-SRC-CD
PIC X(00001).
10 W1C04511-C-BAT-JLN-DT-NUM
PIC X(00005).
10 W1C04511-C-BT-IMGD-CNTL-NUM
PIC X(00002).
10 W1C04511-C-BAT-NUM PIC X(00003).
10 W1C04511-C-BAT-DOC-TY-CD
PIC X(00001).
10 W1C04511-C-BAT-PYMT-TY-CD
PIC X(00001).
10 W1C04511-C-BAT-TY-CD
PIC X(00001).
10 W1C04511-C-HDR-DOC-NUM
PIC X(00006).
10 W1C04511-C-NSF-X12N-CD
PIC X(00001).
10 W1C04511-C-MCARE-STAT-CD
PIC X(00001).
10 W1C04511-C-CLNT-MCARE-CD
PIC X(00001).
10 W1C04511-B-SYS-ID PIC S9(00009) COMP.
10 W1C04511-B-FST-NAM PIC X(00015).
10 W1C04511-B-LAST-NAM
PIC X(00021).
10 W1C04511-B-MI-NAM PIC X(00001).
10 W1C04511-B-ALT-ID PIC X(00014).
10 W1C04511-B-CURR-ID PIC X(00014).
10 W1C04511-B-RACE-CD PIC X(00001).
10 W1C04511-B-GENDER-CD
PIC X(00001).
10 W1C04511-B-MAJ-PROG-CD
PIC X(00001).
10 W1C04511-T-MSQ-TY-CD
PIC X(00001).
10 W1C04511-A-ID PIC X(00011).
10 W1C04511-C-BLNG-PROV-ID
PIC X(00008).
10 W1C04511-C-BLNG-NPI-ID
PIC X(00010).
10 W1C04511-C-BLNG-TXNMY-CD
PIC X(00010).
10 W1C04511-C-BLNG-PROV-ZIP-CD
PIC X(00009).
10 W1C04511-C-BLNG-PROV-TY-CD
PIC X(00003).
10 W1C04511-C-BLNG-SPECL-CD
PIC X(00003).
10 W1C04511-C-BLNG-NTRPRS-ID
PIC X(00008).
10 W1C04511-C-PROV-SIGN-IND
PIC X(00001).
10 W1C04511-C-ATTACH-1ST-CD
PIC X(00002).
10 W1C04511-C-ATTACH-2ND-CD
PIC X(00002).
10 W1C04511-C-ATTACH-3RD-CD
PIC X(00002).
10 W1C04511-C-ATTACH-4TH-CD
PIC X(00002).
10 W1C04511-C-ATTACH-5TH-CD
PIC X(00002).
10 W1C04511-C-HDR-RMK-IND
PIC X(00001).
10 W1C04511-C-HDR-PAT-ACCT-NUM
PIC X(00020).
10 W1C04511-C-MED-REC-NUM
PIC X(00024).
10 W1C04511-C-ELIG-TWO-PASS-CD
PIC X(00001).
10 W1C04511-C-CREDIT-CD
PIC X(00001).
10 W1C04511-C-OTHR-INSR-IND
PIC X(00001).
10 W1C04511-P-LOCN-CD PIC X(00001).
10 W1C04511-P-PROFIT-IND
PIC X(00001).
10 W1C04511-P-TAX-DISCT-IND
PIC X(00001).
10 W1C04511-P-PROF-TECH-IND
PIC X(00001).
10 W1C04511-P-IHS-IND PIC X(00001).
10 W1C04511-P-PSY-SOC-IND
PIC X(00001).
10 W1C04511-C-COST-AVOID-IND
PIC X(00001).
10 W1C04511-C-PRIOR-AUTH-IND
PIC X(00001).
10 W1C04511-C-DAILY-RPT-IND
PIC X(00001).
10 W1C04511-C-HDR-RA-NUM
PIC S9(00009) COMP.
10 W1C04511-C-EXC-LOCN-CD
PIC X(00003).
10 W1C04511-C-EXC-LOCN-ID
PIC X(00007).
10 W1C04511-C-SUSP-LOCN-EXC-CD
PIC X(00004).
10 W1C04511-C-OVRRD-EXC-LOC-CD
PIC X(00003).
10 W1C04511-C-COST-CENTER-CD
PIC X(00005).
10 W1C04511-C-FAM-PLN-CC-CD
PIC X(00005).
10 W1C04511-C-RLTD-FCN-NUM
PIC X(00015).
10 W1C04511-F-RSN-CD PIC X(00003).
10 W1C04511-C-CYCL-NUM
PIC S9(00002) COMP.
10 W1C04511-C-HDR-CLNT-AGE
PIC S9(00003) COMP.
10 W1C04511-C-TOT-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-CALC-TOT-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-TOT-TPL-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-TOT-TPL-DIR-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-HD-TPL-COPAY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-TOT-NET-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-TOT-REIMB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-TOT-COPAY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-REIMB-STAT-CD
PIC X(00001).
10 W1C04511-C-PREV-REIMB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-PREV-REIMB-CD
PIC X(00001).
10 W1C04511-C-PAT-LIAB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-B-DOB-DT PIC X(00010).
10 W1C04511-C-SUBM-CLNT-DOB-DT
PIC X(00010).
10 W1C04511-C-HDR-ENTRD-DT
PIC X(00010).
10 W1C04511-C-HDR-ADJUD-DT
PIC X(00010).
10 W1C04511-C-HDR-ADJUD-TM
PIC X(00008).
10 W1C04511-C-HDR-ITERM-ADJ-DT
PIC X(00010).
10 W1C04511-C-BILLED-DT
PIC X(00010).
10 W1C04511-C-EXC-LOCN-DT
PIC X(00010).
10 W1C04511-C-HDR-BATCH-DT
PIC X(00010).
10 W1C04511-C-HDR-SVC-FST-DT
PIC X(00010).
10 W1C04511-C-HDR-SVC-LST-DT
PIC X(00010).
10 W1C04511-C-HDR-LST-CYCL-DT
PIC X(00010).
10 W1C04511-C-HDR-PD-DT
PIC X(00010).
10 W1C04511-C-HDR-ORIG-PD-DT
PIC X(00010).
10 W1C04511-C-HDR-SUSP-DT
PIC X(00010).
10 W1C04511-C-HDR-HX-DT
PIC X(00010).
10 W1C04511-C-HDR-CLIA-NUM
PIC X(00010).
10 W1C04511-C-HDR-DENT-OCCP-DT
PIC X(00010).
10 W1C04511-C-HDR-DENT-AUTO-DT
PIC X(00010).
10 W1C04511-C-HDR-DENT-OTHR-DT
PIC X(00010).
10 W1C04511-C-REF-PROV-ID
PIC X(00008).
10 W1C04511-C-REF-NPI-ID
PIC X(00010).
10 W1C04511-C-OCCUP-RLTD-IND
PIC X(00001).
10 W1C04511-C-AUTO-RLTD-IND
PIC X(00001).
10 W1C04511-C-OTHR-RLTD-IND
PIC X(00001).
10 W1C04511-C-ILLNESS-DT
PIC X(00010).
10 W1C04511-C-ADMIT-DT
PIC X(00010).
10 W1C04511-C-DISCH-DT
PIC X(00010).
10 W1C04511-R-DRG-CD PIC X(00005).
10 W1C04511-C-OTHR-PROV-ID
PIC X(00008).
10 W1C04511-C-OTHR-PROV-NPI-ID
PIC X(00010).
10 W1C04511-C-OPR-PROV-ID
PIC X(00008).
10 W1C04511-C-OPR-NPI-ID
PIC X(00010).
10 W1C04511-C-ATNDG-PROV-ID
PIC X(00008).
10 W1C04511-C-ATNDG-NPI-ID
PIC X(00010).
10 W1C04511-C-ATNDG-TXNMY-CD
PIC X(00010).
10 W1C04511-C-LTC-PROV-ID
PIC X(00008).
10 W1C04511-C-PAT-STAT-CD
PIC X(00002).
10 W1C04511-C-ADM-SRC-CD
PIC X(00001).
10 W1C04511-C-TY-OF-ADM-CD
PIC X(00001).
10 W1C04511-C-TY-OF-BLL-PFX-CD
PIC X(00001).
10 W1C04511-C-TY-OF-BLL-1-2-CD
PIC X(00002).
10 W1C04511-C-TY-OF-BILL-3-CD
PIC X(00001).
10 W1C04511-C-COS-CD PIC X(00002).
10 W1C04511-C-UB92-A-DIAG-CD
PIC X(00010).
10 W1C04511-C-UB92-ADM-HR-CD
PIC X(00002).
10 W1C04511-C-UB92-DISCH-HR-CD
PIC X(00002).
10 W1C04511-C-BSE-AMT-SRC-CD
PIC X(00002).
10 W1C04511-C-PRCNG-PROCESS-CD
PIC X(00002).
10 W1C04511-C-UB92-ABORT-IND
PIC X(00001).
10 W1C04511-C-HDR-FAM-PLNG-IND
PIC X(00001).
10 W1C04511-C-UB92-STERIL-IND
PIC X(00001).
10 W1C04511-C-UB92-HYSTER-IND
PIC X(00001).
10 W1C04511-C-HDR-BSE-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-CALC-ALLOW-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-HDR-ALLOW-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-NCVRD-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-CVRD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C04511-C-NCVRD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C04511-C-OUTLIER-DAYS-NUM
PIC S9(00004) COMP.
10 W1C04511-C-CALC-DAYS-NUM
PIC S9(00004) COMP.
10 W1C04511-C-DRG-PD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C04511-B-GUARANTEE-NUM
PIC X(00012).
10 W1C04511-C-ORIG-PAPER-IND
PIC X(00001).
10 W1C04511-C-CREATION-DT
PIC X(00010).
10 W1C04511-C-SVC-FACI-NPI-ID
PIC X(00010).
10 W1C04511-R-CD-REL-WT-AMT
PIC S9(00004)V9(00005) COMP-3.
10 W1C04511-C-BLNG-TAX-ID
PIC X(00009).
10 W1C04511-C-BLNG-SSN-NUM
PIC X(00009).
10 W1C04511-C-FUT-PROV-ID
PIC X(00008).
10 W1C04511-C-MC-PROV-ID
PIC X(00008).
10 W1C04511-H-PLN-NUM PIC X(00004).
10 W1C04511-H-PLN-TY-CD
PIC X(00001).
10 W1C04511-H-PLN-BEG-DT
PIC X(00010).
10 W1C04511-C-HDR-FUT-1-CD
PIC X(00003).
10 W1C04511-C-HDR-FUT-2-CD
PIC X(00003).
10 W1C04511-B-PARENT-IND
PIC X(00001).
10 W1C04511-C-HDR-AUD-IND
PIC X(00001).
10 W1C04511-C-HDR-FUT-1-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-HDR-FUT-2-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-EPSDT-CERT1-CD
PIC X(00003).
10 W1C04511-C-EPSDT-CERT2-CD
PIC X(00003).
10 W1C04511-C-ANES-REL-PROC-CD
PIC X(00007).
10 W1C04511-R-ICD-VER-CD
PIC X(00002).
10 W1C04511-C-HDR-FUT-1-IND
PIC X(00001).
10 W1C04511-C-HDR-FUT-2-IND
PIC X(00001).
10 W1C04511-G-AUD-USER-ID
PIC X(00007).
10 W1C04511-G-AUD-DT PIC X(00010).
10 W1C04511-G-AUD-TM PIC X(00008).
05 W1C04511-C-HDR-PARAM-ERR-VW.
10 W1C04511-C-ERR-PARAM-CD
PIC X(00004).
10 W1C04511-C-ERR-PROG-ID
PIC X(00008).
10 W1C04511-C-ERR-MSG-DAT
PIC X(00010).
05 W1C04511-C-HDR-ADJ-VD-VW.
10 W1C04511-C-KEYED-REPLCD-NUM
PIC S9(00017) COMP-3.
10 W1C04511-C-HDR-ADJ-RSN-CD
PIC X(00003).
10 W1C04511-C-REPLCD-TCN-NUM
PIC S9(00017) COMP-3.
10 W1C04511-C-HDR-ADJ-STAT-CD
PIC X(00001).
10 W1C04511-C-REPLCMT-TCN-NUM
PIC S9(00017) COMP-3.
10 W1C04511-F-FCN-DT PIC X(00010).
10 W1C04511-F-FCN-MED-CD
PIC X(00001).
10 W1C04511-F-FCN-NUM PIC S9(00003) COMP.
10 W1C04511-C-ADJ-ORIG-TCN-NUM
PIC S9(00017) COMP-3.
10 W1C04511-C-ADJ-SEQ-NUM
PIC S9(00002) COMP.
05 W1C04511-C-HDR-COE-GRP.
10 W1C04511-C-HDR-COE-VW
OCCURS 0 TO 0004 TIMES
DEPENDING ON W1C04511-C-CNT-COE-NUM
INDEXED BY W1C04511-C-HDR-COE-VW-X .
15 W1C04511-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C04511-B-COE-CD
PIC X(00003).
15 W1C04511-B-FED-MTCH-CD
PIC X(00001).
15 W1C04511-B-FED-CAT-CD
PIC X(00001).
15 W1C04511-B-GEO-CNTY-CD
PIC X(00002).
15 W1C04511-B-ADMIN-CNTY-CD
PIC X(00002).
15 W1C04511-B-MONEY-CD
PIC X(00001).
05 W1C04511-C-HDR-ENCTR-VW.
10 W1C04511-C-MCO-TCN-DAT
PIC X(00020).
10 W1C04511-C-SUB-CAP-CD
PIC X(00001).
10 W1C04511-C-MC-ENCTR-PD-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-MC-ENCTR-PD-DT
PIC X(00010).
10 W1C04511-C-MC-ENCTR-RECD-DT
PIC X(00010).
05 W1C04511-C-HDR-COND-CD-GRP.
10 W1C04511-C-HDR-COND-CD-VW
OCCURS 0 TO 0010 TIMES
DEPENDING ON W1C04511-C-CNT-COND-NUM
INDEXED BY W1C04511-C-HDR-COND-CD-VW-X .
15 W1C04511-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C04511-C-COND-CD
PIC X(00002).
05 W1C04511-C-HDR-OCC-CD-GRP.
10 W1C04511-C-HDR-OCC-CD-VW
OCCURS 0 TO 0008 TIMES
DEPENDING ON W1C04511-C-CNT-OCC-CD-NUM
INDEXED BY W1C04511-C-HDR-OCC-CD-VW-X .
15 W1C04511-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C04511-C-OCC-CD
PIC X(00002).
15 W1C04511-C-UB92-OCC-CD-DT
PIC X(00010).
05 W1C04511-C-HDR-OCC-SPN-GRP.
10 W1C04511-C-HDR-OCC-SPN-VW
OCCURS 0 TO 0002 TIMES
DEPENDING ON W1C04511-C-CNT-OCC-SPN-NUM
INDEXED BY W1C04511-C-HDR-OCC-SPN-VW-X .
15 W1C04511-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C04511-C-OCC-SPN-CD
PIC X(00002).
15 W1C04511-C-OCC-SPN-FR-DT
PIC X(00010).
15 W1C04511-C-OCC-SPN-THRU-DT
PIC X(00010).
05 W1C04511-C-HDR-VALU-CD-GRP.
10 W1C04511-C-HDR-VALU-CD-VW
OCCURS 0 TO 0012 TIMES
DEPENDING ON W1C04511-C-CNT-VALU-CD-NUM
INDEXED BY W1C04511-C-HDR-VALU-CD-VW-X .
15 W1C04511-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C04511-C-VALU-CD
PIC X(00002).
15 W1C04511-C-UB92-VALU-CD-AMT
PIC S9(00009)V9(00002) COMP-3.
05 W1C04511-C-HDR-ICD-GRP.
10 W1C04511-C-HDR-ICD-VW
OCCURS 0 TO 0024 TIMES
DEPENDING ON W1C04511-C-CNT-ICD-NUM
INDEXED BY W1C04511-C-HDR-ICD-VW-X .
15 W1C04511-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C04511-R-ICD9-CD
PIC X(00007).
15 W1C04511-C-HDR-UB92-ICD9-DT
PIC X(00010).
05 W1C04511-C-HDR-DIAG-INST-GRP.
10 W1C04511-C-HDR-DIAG-VW
OCCURS 0 TO 0025 TIMES
DEPENDING ON W1C04511-C-CNT-DIAG-NUM
INDEXED BY W1C04511-C-HDR-DIAG-VW-X .
15 W1C04511-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C04511-R-DIAG-CD
PIC X(00010).
15 W1C04511-C-POA-IND
PIC X(00001).
05 W1C04511-C-HDR-MCARE-VW.
10 W1C04511-C-MCARE-PROV-ID
PIC X(00013).
10 W1C04511-C-MCARE-CLM-NUM
PIC X(00026).
10 W1C04511-C-HD-MCARE-CARR-ID
PIC X(00006).
10 W1C04511-C-MCARE-HIC-ID
PIC X(00019).
10 W1C04511-C-HD-MCARE-EOMB-DT
PIC X(00010).
10 W1C04511-C-HDR-MCAR-STAT-CD
PIC X(00001).
10 W1C04511-C-MCARE-ALLOW-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-MCARE-DED-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-MCARE-COINS-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-MCARE-PSY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-MCARE-O-PR-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-MCARE-PD-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-HDR-MCAR-DED-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-HDR-MCAR-COI-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-HDR-MCAR-PSY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C04511-C-HD-MCAR-O-PR-AMT
PIC S9(00009)V9(00002) COMP-3.
05 W1C04511-C-HDR-COB-GRP.
10 W1C04511-C-HDR-COB-VW
OCCURS 0 TO 0005 TIMES
DEPENDING ON W1C04511-C-CNT-COB-NUM
INDEXED BY W1C04511-C-HDR-COB-VW-X .
15 W1C04511-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C04511-C-COB-PYR-ID
PIC X(00015).
15 W1C04511-C-COB-PYR-NAM
PIC X(00035).
15 W1C04511-C-COB-PYR-SEQ-CD
PIC X(00001).
15 W1C04511-C-COB-PLCY-REL-CD
PIC X(00002).
15 W1C04511-C-COB-PLCY-NUM
PIC X(00009).
15 W1C04511-C-COB-GRP-PLN-NAM
PIC X(00030).
15 W1C04511-C-COB-FLN-IND-CD
PIC X(00002).
15 W1C04511-C-COB-PYR-PYMT-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C04511-C-COB-ADJUD-DT
PIC X(00010).
15 W1C04511-C-COB-CLM-NUM
PIC X(00026).
15 W1C04511-C-CERT-SSN-HIC-ID
PIC X(00019).
15 W1C04511-C-UB92-EST-DUE-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C04511-C-UB92-PYR-AUTH-CD
PIC X(00018).
15 W1C04511-C-COB-NN-CVRD-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C04511-C-HDR-RMK-CD
PIC X(00005).
15 W1C04511-C-COB-DRG-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C04511-C-COB-DSP-SHR-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C04511-C-COB-CAP-IME-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C04511-C-COB-REIMB-PCT
PIC S9(00003)V9(00002) COMP-3.
15 W1C04511-C-COB-HCPCS-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C04511-C-COB-ESRD-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C04511-C-COB-NONP-PC-AMT
PIC S9(00009)V9(00002) COMP-3.
05 W1C04511-C-HDR-CAS-GRP.
10 W1C04511-C-CAS-VW
OCCURS 0 TO 0026 TIMES
DEPENDING ON W1C04511-C-HDR-CAS-NUM
INDEXED BY W1C04511-C-CAS-VW-X .
15 W1C04511-C-LI-NUM
PIC S9(00003) COMP.
15 W1C04511-C-CAS-PYR-ID
PIC X(00015).
15 W1C04511-C-CAS-PROC-CD
PIC X(00008).
15 W1C04511-C-CAS-GRP-CD
PIC X(00002).
15 W1C04511-C-CAS-RSN-CD
PIC X(00005).
15 W1C04511-C-CAS-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C04511-C-CAS-UNT-NUM
PIC S9(00009) COMP.
05 W1C04511-C-LI-TPL-BLNG-GRP.
10 W1C04511-C-LI-TPL-BLNG-VW
OCCURS 0 TO 0006 TIMES
DEPENDING ON W1C04511-C-CNT-LI-TPL-NUM
INDEXED BY W1C04511-C-LI-TPL-BLNG-VW-X .
15 W1C04511-C-LI-NUM
PIC S9(00003) COMP.
15 W1C04511-T-PLCY-NUM
PIC X(00020).
15 W1C04511-T-PLCY-SEQ-NUM
PIC S9(00003) COMP.
15 W1C04511-T-PLCY-RESRC-CD
PIC X(00002).
15 W1C04511-T-CARR-ID
PIC X(00006).
15 W1C04511-T-CVRG-PLCY-CD
PIC X(00002).
05 W1C04511-C-HDR-PREV-LOCN-GRP.
10 W1C04511-C-HDR-PREV-LOCN-VW
OCCURS 0 TO 0010 TIMES
DEPENDING ON W1C04511-C-CNT-LOCN-NUM
INDEXED BY W1C04511-C-HDR-PREV-LOCN-VW-X .
15 W1C04511-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C04512-C-EXC-LOCN-CD
PIC X(00003).
15 W1C04512-C-EXC-LOCN-ID
PIC X(00007).
15 W1C04512-C-SUSP-LOCN-EXC-CD
PIC X(00004).
15 W1C04512-C-EXC-LOCN-DT
PIC X(00010).
05 W1C04511-C-HDR-WARRANT-VW.
10 W1C04511-C-HDR-RA-NUM
PIC S9(00009) COMP.
10 W1C04511-C-HDR-WARR-NUM
PIC X(00011).
10 W1C04511-C-HDR-WARR-MED-CD
PIC X(00001).
10 W1C04511-C-HDR-WARR-AMT
PIC S9(00013)V9(00002) COMP-3.
10 W1C04511-C-HDR-WARR-DT
PIC X(00010).
10 W1C04511-C-EFT-TRC-ID
PIC X(00015).
05 W1C04511-C-HDR-OVRRD-EOB-I-GRP.
10 W1C04511-C-HDR-OVRRD-EOB-VW
OCCURS 0 TO 0100 TIMES
DEPENDING ON W1C04511-C-HDR-OVRD-EOB-NUM
INDEXED BY W1C04511-C-HDR-OVRRD-EOB-VW-X .
15 W1C04511-C-LI-NUM
PIC S9(00003) COMP.
15 W1C04511-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C04511-C-OVRRD-EOB-CD
PIC X(00004).
15 W1C04511-C-OVRRD-EOB-ID
PIC X(00007).
05 W1C04511-C-HDR-OVRRD-EXC-I-GRP.
10 W1C04511-C-HDR-OVRRD-EXC-VW
OCCURS 0 TO 0100 TIMES
DEPENDING ON W1C04511-C-HDR-OVRD-EXC-NUM
INDEXED BY W1C04511-C-HDR-OVRRD-EXC-VW-X .
15 W1C04511-C-LI-NUM
PIC S9(00003) COMP.
15 W1C04511-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C04511-C-OVRRD-EXC-CD
PIC X(00004).
15 W1C04511-C-OVRRD-EXC-ID
PIC X(00007).
05 W1C04511-C-HDR-RLTD-HIST-GRP.
10 W1C04511-C-HDR-RLTD-HIST-VW
OCCURS 0 TO 0100 TIMES
DEPENDING ON W1C04511-C-CNT-RLTD-HST-NUM
INDEXED BY W1C04511-C-HDR-RLTD-HIST-VW-X .
15 W1C04511-C-LI-NUM
PIC S9(00003) COMP.
15 W1C04511-C-RLTD-LI-TCN-NUM
PIC S9(00017) COMP-3.
15 W1C04511-C-RLTD-LI-NUM
PIC S9(00003) COMP.
15 W1C04512-R-CLM-EXC-CD
PIC X(00004).
15 W1C04512-C-HDR-PD-DT
PIC X(00010).
15 W1C04512-C-EXC-STAT-CD
PIC X(00001).
15 W1C04512-C-HDR-TY-CD
PIC X(00001).
15 W1C04511-C-SYS-REPLCD-IND
PIC X(00001).
05 W1C04511-C-HDR-BSE-CHG-GRP.
10 W1C04511-C-HDR-BSE-CHG-VW
OCCURS 0 TO 0008 TIMES
DEPENDING ON W1C04511-C-HDR-BSE-CHG-NUM
INDEXED BY W1C04511-C-HDR-BSE-CHG-VW-X .
15 W1C04511-C-LI-NUM
PIC S9(00003) COMP.
15 W1C04511-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C04511-C-BSE-CHNG-RSN-CD
PIC X(00002).
15 W1C04511-C-BSE-AMT-CHG-AMT
PIC S9(00009)V9(00002) COMP-3.
05 W1C04511-C-HDR-EXC-GRP.
10 W1C04511-C-HDR-EXC-VW
OCCURS 0 TO 0025 TIMES
DEPENDING ON W1C04511-C-HDR-EXC-NUM
INDEXED BY W1C04511-C-HDR-EXC-VW-X .
15 W1C04511-C-LI-NUM
PIC S9(00003) COMP.
15 W1C04511-R-CLM-EXC-CD
PIC X(00004).
15 W1C04511-C-EXC-CLRK-ID
PIC X(00007).
15 W1C04511-C-EXC-STAT-CD
PIC X(00001).
15 W1C04511-R-EXC-FORCE-APP-CD
PIC X(00001).
15 W1C04511-R-FORCE-DENY-CD
PIC X(00001).
05 W1C04511-C-HDR-AUX-VW.
10 W1C04511-C-ATT-1ST-CNTL-NUM
PIC X(00015).
10 W1C04511-C-ATT-1ST-XMIT-CD
PIC X(00002).
10 W1C04511-C-ATT-1ST-RECD-IND
PIC X(00001).
10 W1C04511-C-ATT-2ND-CNTL-NUM
PIC X(00015).
10 W1C04511-C-ATT-2ND-XMIT-CD
PIC X(00002).
10 W1C04511-C-ATT-2ND-RECD-IND
PIC X(00001).
10 W1C04511-C-ATT-3RD-CNTL-NUM
PIC X(00015).
10 W1C04511-C-ATT-3RD-XMIT-CD
PIC X(00002).
10 W1C04511-C-ATT-3RD-RECD-IND
PIC X(00001).
10 W1C04511-C-ATT-4TH-CNTL-NUM
PIC X(00015).
10 W1C04511-C-ATT-4TH-XMIT-CD
PIC X(00002).
10 W1C04511-C-ATT-4TH-RECD-IND
PIC X(00001).
10 W1C04511-C-ATT-5TH-CNTL-NUM
PIC X(00015).
10 W1C04511-C-ATT-5TH-XMIT-CD
PIC X(00002).
10 W1C04511-C-ATT-5TH-RECD-IND
PIC X(00001).
10 W1C04511-C-AMBL-PU-LINE1-AD
PIC X(00030).
10 W1C04511-C-AMBL-PU-LINE2-AD
PIC X(00030).
10 W1C04511-C-AMBL-PU-CITY-NAM
PIC X(00020).
10 W1C04511-C-AMBL-PU-ST-CD
PIC X(00002).
10 W1C04511-C-AMBL-PU-ZIP5-CD
PIC X(00005).
10 W1C04511-C-AMBL-PU-ZIP4-CD
PIC X(00004).
10 W1C04511-C-AMBL-DO-LINE1-AD
PIC X(00030).
10 W1C04511-C-AMBL-DO-LINE2-AD
PIC X(00030).
10 W1C04511-C-AMBL-DO-CITY-NAM
PIC X(00020).
10 W1C04511-C-AMBL-DO-ST-CD
PIC X(00002).
10 W1C04511-C-AMBL-DO-ZIP5-CD
PIC X(00005).
10 W1C04511-C-AMBL-DO-ZIP4-CD
PIC X(00004).
*Layout used if the claim is Institutional - Line Level
* *
01 W1C30111-C-LI-INST-COMMON-VW.
05 W1C30111-C-SORT-GRP.
10 W1C30111-C-SORT-DAT
PIC X(00030).
10 W1C30111-C-LI-REC-STRT-NUM
PIC 9(00004) COMP.
05 W1C30111-C-COUNTERS-VW.
10 W1C30111-C-CNT-COE-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-COND-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-OCC-CD-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-OCC-SPN-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-VALU-CD-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-ICD-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-DIAG-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-COB-NUM
PIC S9(00004) COMP.
10 W1C30111-C-HDR-CAS-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-LOCN-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-OVRD-EOB-NUM
PIC S9(00004) COMP.
10 W1C30111-C-HDR-OVRD-EOB-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-OVRD-EXC-NUM
PIC S9(00004) COMP.
10 W1C30111-C-HDR-OVRD-EXC-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-RLTD-HST-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-LI-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-LI-MCARE-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-LI-COB-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-LI-CAS-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-BSE-CHG-NUM
PIC S9(00004) COMP.
10 W1C30111-C-HDR-BSE-CHG-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-EXC-NUM
PIC S9(00004) COMP.
10 W1C30111-C-HDR-EXC-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-LI-TPL-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-LI-CAP-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-LI-DRUG-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-UNUSED-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-AUX-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CNT-LI-AUX-NUM
PIC S9(00004) COMP.
05 W1C30111-C-HDR-TB.
10 W1C30111-C-TCN-NUM PIC S9(00017) COMP-3.
10 W1C30111-C-XCN-NUM PIC X(00031).
10 W1C30111-C-HDR-ID-CD
PIC X(00002).
10 W1C30111-C-HDR-EMC-CD
PIC X(00001).
10 W1C30111-C-HDR-SUBMITTER-ID
PIC X(00016).
10 W1C30111-C-CNTL-ORGN-CD
PIC X(00001).
10 W1C30111-C-HDR-STAT-CD
PIC X(00001).
10 W1C30111-C-HDR-TXN-TY-CD
PIC X(00001).
10 W1C30111-C-HDR-TY-CD
PIC X(00001).
10 W1C30111-C-BAT-MED-SRC-CD
PIC X(00001).
10 W1C30111-C-BAT-JLN-DT-NUM
PIC X(00005).
10 W1C30111-C-BT-IMGD-CNTL-NUM
PIC X(00002).
10 W1C30111-C-BAT-NUM PIC X(00003).
10 W1C30111-C-BAT-DOC-TY-CD
PIC X(00001).
10 W1C30111-C-BAT-PYMT-TY-CD
PIC X(00001).
10 W1C30111-C-BAT-TY-CD
PIC X(00001).
10 W1C30111-C-HDR-DOC-NUM
PIC X(00006).
10 W1C30111-C-NSF-X12N-CD
PIC X(00001).
10 W1C30111-C-MCARE-STAT-CD
PIC X(00001).
10 W1C30111-C-CLNT-MCARE-CD
PIC X(00001).
10 W1C30111-B-SYS-ID PIC S9(00009) COMP.
10 W1C30111-B-FST-NAM PIC X(00015).
10 W1C30111-B-LAST-NAM
PIC X(00021).
10 W1C30111-B-MI-NAM PIC X(00001).
10 W1C30111-B-ALT-ID PIC X(00014).
10 W1C30111-B-CURR-ID PIC X(00014).
10 W1C30111-B-RACE-CD PIC X(00001).
10 W1C30111-B-GENDER-CD
PIC X(00001).
10 W1C30111-B-MAJ-PROG-CD
PIC X(00001).
10 W1C30111-T-MSQ-TY-CD
PIC X(00001).
10 W1C30111-A-ID PIC X(00011).
10 W1C30111-C-BLNG-PROV-ID
PIC X(00008).
10 W1C30111-C-BLNG-NPI-ID
PIC X(00010).
10 W1C30111-C-BLNG-TXNMY-CD
PIC X(00010).
10 W1C30111-C-BLNG-PROV-ZIP-CD
PIC X(00009).
10 W1C30111-C-BLNG-PROV-TY-CD
PIC X(00003).
10 W1C30111-C-BLNG-SPECL-CD
PIC X(00003).
10 W1C30111-C-BLNG-NTRPRS-ID
PIC X(00008).
10 W1C30111-C-PROV-SIGN-IND
PIC X(00001).
10 W1C30111-C-ATTACH-1ST-CD
PIC X(00002).
10 W1C30111-C-ATTACH-2ND-CD
PIC X(00002).
10 W1C30111-C-ATTACH-3RD-CD
PIC X(00002).
10 W1C30111-C-ATTACH-4TH-CD
PIC X(00002).
10 W1C30111-C-ATTACH-5TH-CD
PIC X(00002).
10 W1C30111-C-HDR-RMK-IND
PIC X(00001).
10 W1C30111-C-HDR-PAT-ACCT-NUM
PIC X(00020).
10 W1C30111-C-MED-REC-NUM
PIC X(00024).
10 W1C30111-C-ELIG-TWO-PASS-CD
PIC X(00001).
10 W1C30111-C-CREDIT-CD
PIC X(00001).
10 W1C30111-C-OTHR-INSR-IND
PIC X(00001).
10 W1C30111-P-LOCN-CD PIC X(00001).
10 W1C30111-P-PROFIT-IND
PIC X(00001).
10 W1C30111-P-TAX-DISCT-IND
PIC X(00001).
10 W1C30111-P-PROF-TECH-IND
PIC X(00001).
10 W1C30111-P-IHS-IND PIC X(00001).
10 W1C30111-P-PSY-SOC-IND
PIC X(00001).
10 W1C30111-C-COST-AVOID-IND
PIC X(00001).
10 W1C30111-C-PRIOR-AUTH-IND
PIC X(00001).
10 W1C30111-C-DAILY-RPT-IND
PIC X(00001).
10 W1C30111-C-HDR-RA-NUM
PIC S9(00009) COMP.
10 W1C30111-C-EXC-LOCN-CD
PIC X(00003).
10 W1C30111-C-EXC-LOCN-ID
PIC X(00007).
10 W1C30111-C-SUSP-LOCN-EXC-CD
PIC X(00004).
10 W1C30111-C-OVRRD-EXC-LOC-CD
PIC X(00003).
10 W1C30111-C-COST-CENTER-CD
PIC X(00005).
10 W1C30111-C-FAM-PLN-CC-CD
PIC X(00005).
10 W1C30111-C-RLTD-FCN-NUM
PIC X(00015).
10 W1C30111-F-RSN-CD PIC X(00003).
10 W1C30111-C-CYCL-NUM
PIC S9(00002) COMP.
10 W1C30111-C-HDR-CLNT-AGE
PIC S9(00003) COMP.
10 W1C30111-C-TOT-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C30111-C-CALC-TOT-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C30111-C-TOT-TPL-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C30111-C-TOT-TPL-DIR-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C30111-C-HD-TPL-COPAY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C30111-C-TOT-NET-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C30111-C-TOT-REIMB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C30111-C-TOT-COPAY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C30111-C-REIMB-STAT-CD
PIC X(00001).
10 W1C30111-C-PREV-REIMB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C30111-C-PREV-REIMB-CD
PIC X(00001).
10 W1C30111-C-PAT-LIAB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C30111-B-DOB-DT PIC X(00010).
10 W1C30111-C-SUBM-CLNT-DOB-DT
PIC X(00010).
10 W1C30111-C-HDR-ENTRD-DT
PIC X(00010).
10 W1C30111-C-HDR-ADJUD-DT
PIC X(00010).
10 W1C30111-C-HDR-ADJUD-TM
PIC X(00008).
10 W1C30111-C-HDR-ITERM-ADJ-DT
PIC X(00010).
10 W1C30111-C-BILLED-DT
PIC X(00010).
10 W1C30111-C-EXC-LOCN-DT
PIC X(00010).
10 W1C30111-C-HDR-BATCH-DT
PIC X(00010).
10 W1C30111-C-HDR-SVC-FST-DT
PIC X(00010).
10 W1C30111-C-HDR-SVC-LST-DT
PIC X(00010).
10 W1C30111-C-HDR-LST-CYCL-DT
PIC X(00010).
10 W1C30111-C-HDR-PD-DT
PIC X(00010).
10 W1C30111-C-HDR-ORIG-PD-DT
PIC X(00010).
10 W1C30111-C-HDR-SUSP-DT
PIC X(00010).
10 W1C30111-C-HDR-HX-DT
PIC X(00010).
10 W1C30111-C-HDR-CLIA-NUM
PIC X(00010).
10 W1C30111-C-HDR-DENT-OCCP-DT
PIC X(00010).
10 W1C30111-C-HDR-DENT-AUTO-DT
PIC X(00010).
10 W1C30111-C-HDR-DENT-OTHR-DT
PIC X(00010).
10 W1C30111-C-REF-PROV-ID
PIC X(00008).
10 W1C30111-C-REF-NPI-ID
PIC X(00010).
10 W1C30111-C-OCCUP-RLTD-IND
PIC X(00001).
10 W1C30111-C-AUTO-RLTD-IND
PIC X(00001).
10 W1C30111-C-OTHR-RLTD-IND
PIC X(00001).
10 W1C30111-C-ILLNESS-DT
PIC X(00010).
10 W1C30111-C-ADMIT-DT
PIC X(00010).
10 W1C30111-C-DISCH-DT
PIC X(00010).
10 W1C30111-R-DRG-CD PIC X(00005).
10 W1C30111-C-OTHR-PROV-ID
PIC X(00008).
10 W1C30111-C-OTHR-PROV-NPI-ID
PIC X(00010).
10 W1C30111-C-OPR-PROV-ID
PIC X(00008).
10 W1C30111-C-OPR-NPI-ID
PIC X(00010).
10 W1C30111-C-ATNDG-PROV-ID
PIC X(00008).
10 W1C30111-C-ATNDG-NPI-ID
PIC X(00010).
10 W1C30111-C-ATNDG-TXNMY-CD
PIC X(00010).
10 W1C30111-C-LTC-PROV-ID
PIC X(00008).
10 W1C30111-C-PAT-STAT-CD
PIC X(00002).
10 W1C30111-C-ADM-SRC-CD
PIC X(00001).
10 W1C30111-C-TY-OF-ADM-CD
PIC X(00001).
10 W1C30111-C-TY-OF-BLL-PFX-CD
PIC X(00001).
10 W1C30111-C-TY-OF-BLL-1-2-CD
PIC X(00002).
10 W1C30111-C-TY-OF-BILL-3-CD
PIC X(00001).
10 W1C30111-C-COS-CD PIC X(00002).
10 W1C30111-C-UB92-A-DIAG-CD
PIC X(00010).
10 W1C30111-C-UB92-ADM-HR-CD
PIC X(00002).
10 W1C30111-C-UB92-DISCH-HR-CD
PIC X(00002).
10 W1C30111-C-BSE-AMT-SRC-CD
PIC X(00002).
10 W1C30111-C-PRCNG-PROCESS-CD
PIC X(00002).
10 W1C30111-C-UB92-ABORT-IND
PIC X(00001).
10 W1C30111-C-HDR-FAM-PLNG-IND
PIC X(00001).
10 W1C30111-C-UB92-STERIL-IND
PIC X(00001).
10 W1C30111-C-UB92-HYSTER-IND
PIC X(00001).
10 W1C30111-C-HDR-BSE-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C30111-C-CALC-ALLOW-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C30111-C-HDR-ALLOW-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C30111-C-NCVRD-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C30111-C-CVRD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C30111-C-NCVRD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C30111-C-OUTLIER-DAYS-NUM
PIC S9(00004) COMP.
10 W1C30111-C-CALC-DAYS-NUM
PIC S9(00004) COMP.
10 W1C30111-C-DRG-PD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C30111-B-GUARANTEE-NUM
PIC X(00012).
10 W1C30111-C-ORIG-PAPER-IND
PIC X(00001).
10 W1C30111-C-CREATION-DT
PIC X(00010).
10 W1C30111-C-SVC-FACI-NPI-ID
PIC X(00010).
10 W1C30111-R-CD-REL-WT-AMT
PIC S9(00004)V9(00005) COMP-3.
10 W1C30111-C-BLNG-TAX-ID
PIC X(00009).
10 W1C30111-C-BLNG-SSN-NUM
PIC X(00009).
10 W1C30111-C-FUT-PROV-ID
PIC X(00008).
10 W1C30111-C-MC-PROV-ID
PIC X(00008).
10 W1C30111-H-PLN-NUM PIC X(00004).
10 W1C30111-H-PLN-TY-CD
PIC X(00001).
10 W1C30111-H-PLN-BEG-DT
PIC X(00010).
10 W1C30111-C-HDR-FUT-1-CD
PIC X(00003).
10 W1C30111-C-HDR-FUT-2-CD
PIC X(00003).
10 W1C30111-B-PARENT-IND
PIC X(00001).
10 W1C30111-C-HDR-AUD-IND
PIC X(00001).
10 W1C30111-C-HDR-FUT-1-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C30111-C-HDR-FUT-2-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C30111-C-EPSDT-CERT1-CD
PIC X(00003).
10 W1C30111-C-EPSDT-CERT2-CD
PIC X(00003).
10 W1C30111-C-ANES-REL-PROC-CD
PIC X(00007).
10 W1C30111-R-ICD-VER-CD
PIC X(00002).
10 W1C30111-C-HDR-FUT-1-IND
PIC X(00001).
10 W1C30111-C-HDR-FUT-2-IND
PIC X(00001).
10 W1C30111-G-AUD-USER-ID
PIC X(00007).
10 W1C30111-G-AUD-DT PIC X(00010).
10 W1C30111-G-AUD-TM PIC X(00008).
05 W1C30111-C-LI-CNT-GRP.
10 W1C30111-C-LI-REC-NUM
PIC S9(00004) COMP.
10 W1C30111-C-LI-CAP-NUM
PIC S9(00004) COMP.
10 W1C30111-C-LI-REC-MCARE-NUM
PIC S9(00004) COMP.
10 W1C30111-C-LI-COB-NUM
PIC S9(00004) COMP.
10 W1C30111-C-LI-CAS-NUM
PIC S9(00004) COMP.
10 W1C30111-C-LI-BSE-CHG-NUM
PIC S9(00004) COMP.
10 W1C30111-C-LI-EXC-NUM
PIC S9(00004) COMP.
10 W1C30111-C-LI-OVRD-EOB-NUM
PIC S9(00004) COMP.
10 W1C30111-C-LI-OVRD-EXC-NUM
PIC S9(00004) COMP.
10 W1C30111-C-LI-AUX-NUM
PIC S9(00004) COMP.
05 W1C30111-C-LI-INST-GRP-PHYS.
10 W1C30111-C-LI-VW
OCCURS 0 TO 0014 TIMES
DEPENDING ON W1C30111-C-LI-REC-NUM
INDEXED BY W1C30111-C-LI-VW-X .
15 W1C30111-C-LI-NUM
PIC S9(00003) COMP.
15 W1C30111-R-PROC-CD
PIC X(00007).
15 W1C30111-C-PROC-MOD-1ST-CD
PIC X(00002).
15 W1C30111-C-PROC-MOD-2ND-CD
PIC X(00002).
15 W1C30111-C-PROC-MOD-3RD-CD
PIC X(00002).
15 W1C30111-C-PROC-MOD-4TH-CD
PIC X(00002).
15 W1C30111-R-PL-OF-SVC-CD
PIC X(00002).
15 W1C30111-R-SVC-AREA-CD
PIC X(00001).
15 W1C30111-C-SVC-COMPONENT-CD
PIC X(00001).
15 W1C30111-A-LI-NUM
PIC S9(00003) COMP.
15 W1C30111-C-PRIOR-AUTH-IND
PIC X(00001).
15 W1C30111-C-LI-AUTH-ID
PIC X(00011).
15 W1C30111-C-LI-CLIA-NUM
PIC X(00010).
15 W1C30111-C-BSE-AMT-SRC-CD
PIC X(00002).
15 W1C30111-C-PRCNG-PROCESS-CD
PIC X(00002).
15 W1C30111-C-COS-CD
PIC X(00002).
15 W1C30111-C-REIMB-STAT-CD
PIC X(00001).
15 W1C30111-C-COST-AVOID-IND
PIC X(00001).
15 W1C30111-C-ONCE-IN-LFTM-IND
PIC X(00001).
15 W1C30111-C-LI-DUPL-CHK-IND
PIC X(00001).
15 W1C30111-C-ALLOW-UNTS-IND
PIC X(00001).
15 W1C30111-C-LI-ABORT-IND
PIC X(00001).
15 W1C30111-C-LI-STERIL-IND
PIC X(00001).
15 W1C30111-C-LI-FAM-PLNG-IND
PIC X(00001).
15 W1C30111-C-LI-HYSTER-IND
PIC X(00001).
15 W1C30111-C-MULTI-SURG-IND
PIC X(00001).
15 W1C30111-C-LI-FST-DOS-DT
PIC X(00010).
15 W1C30111-C-LI-LAST-DOS-DT
PIC X(00010).
15 W1C30111-C-MC-ENCTR-PD-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-LI-TPL-COPAY-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-LI-SUBM-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-LI-BSE-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-LI-CLC-ALLW-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-LI-ALLW-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-LI-REIMB-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-LI-UNT-MSR-CD
PIC X(00002).
15 W1C30111-C-LI-UNT-MSR-NUM
PIC S9(00007)V9(00002) COMP-3.
15 W1C30111-C-LI-SUBM-UNT-NUM
PIC S9(00007)V9(00002) COMP-3.
15 W1C30111-C-LI-ALLOW-UNT-NUM
PIC S9(00007)V9(00002) COMP-3.
15 W1C30111-C-LI-REIMB-UNT-NUM
PIC S9(00007)V9(00002) COMP-3.
15 W1C30111-C-LI-FLLWP-LMT-DT
PIC X(00010).
15 W1C30111-R-DRUG-CD
PIC X(00011).
15 W1C30111-C-DIAG-1ST-RLTD-CD
PIC X(00001).
15 W1C30111-C-DIAG-2ND-RLTD-CD
PIC X(00001).
15 W1C30111-C-DIAG-3RD-RLTD-CD
PIC X(00001).
15 W1C30111-C-DIAG-4TH-RLTD-CD
PIC X(00001).
15 W1C30111-C-DIAG-5TH-RLTD-CD
PIC X(00001).
15 W1C30111-C-DIAG-6TH-RLTD-CD
PIC X(00001).
15 W1C30111-C-DIAG-7TH-RLTD-CD
PIC X(00001).
15 W1C30111-C-DIAG-8TH-RLTD-CD
PIC X(00001).
15 W1C30111-R-PROC-ORAL-CAV-CD
PIC X(00002).
15 W1C30111-R-PROC-TOOTH-CD
PIC X(00002).
15 W1C30111-C-DENT-1ST-SURF-CD
PIC X(00001).
15 W1C30111-C-DENT-2ND-SURF-CD
PIC X(00001).
15 W1C30111-C-DENT-3RD-SURF-CD
PIC X(00001).
15 W1C30111-C-DENT-4TH-SURF-CD
PIC X(00001).
15 W1C30111-C-DENT-5TH-SURF-CD
PIC X(00001).
15 W1C30111-C-RNDR-PROV-ID
PIC X(00008).
15 W1C30111-C-RNDR-NPI-ID
PIC X(00010).
15 W1C30111-C-RNDR-TXNMY-CD
PIC X(00010).
15 W1C30111-C-RNDR-NTRPRS-ID
PIC X(00008).
15 W1C30111-C-DSTN-PROV-ID
PIC X(00008).
15 W1C30111-P-TY-CD
PIC X(00003).
15 W1C30111-P-SPECL-CD
PIC X(00003).
15 W1C30111-C-SUBM-FAM-PLN-IND
PIC X(00001).
15 W1C30111-C-SUBM-EPSDT-IND
PIC X(00001).
15 W1C30111-R-REV-CD
PIC X(00007).
15 W1C30111-R-REV-TY-CD
PIC X(00001).
15 W1C30111-B-LEVEL-OF-CARE-CD
PIC X(00003).
15 W1C30111-C-LI-UB92-RATE-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-NN-CVRD-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-LI-FUT-1-CD
PIC X(00003).
15 W1C30111-C-LI-FUT-2-CD
PIC X(00003).
15 W1C30111-C-LI-FUT-1-IND
PIC X(00001).
15 W1C30111-C-LI-FUT-2-IND
PIC X(00001).
15 W1C30111-C-LI-FUT-1-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-LI-FUT-2-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-LI-COST-CNTR-CD
PIC X(00005).
15 W1C30111-C-LI-ATT-1ST-CD
PIC X(00002).
15 W1C30111-C-LI-ATT-2ND-CD
PIC X(00002).
15 W1C30111-C-LI-ATT-3RD-CD
PIC X(00002).
15 W1C30111-C-LI-FUT-3-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-LI-FUT-4-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-LI-NDC-UNT-CD
PIC X(00002).
15 W1C30111-C-LI-NDC-UNT-NUM
PIC S9(00007)V9(00002) COMP-3.
05 W1C30111-C-LI-MCARE-INST-GRP-P.
10 W1C30111-C-LI-MCARE-VW
OCCURS 0 TO 0014 TIMES
DEPENDING ON W1C30111-C-LI-REC-MCARE-NUM
INDEXED BY W1C30111-C-LI-MCARE-VW-X .
15 W1C30111-C-LI-NUM
PIC S9(00003) COMP.
15 W1C30111-C-LI-MCARE-COI-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-LI-MCARE-DED-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-LI-MCARE-PD-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-LI-MCAR-ALLW-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-LI-MCARE-STAT-CD
PIC X(00001).
15 W1C30111-C-LI-MCAR-O-PR-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-LI-MCARE-PSY-AMT
PIC S9(00009)V9(00002) COMP-3.
05 W1C30111-C-LI-COB-INST-GRP-PHY.
10 W1C30111-C-LI-COB-VW
OCCURS 0 TO 0070 TIMES
DEPENDING ON W1C30111-C-LI-COB-NUM
INDEXED BY W1C30111-C-LI-COB-VW-X .
15 W1C30111-C-LI-NUM
PIC S9(00003) COMP.
15 W1C30111-C-COB-LI-PYR-ID
PIC X(00015).
15 W1C30111-C-COB-PD-PROC-CD
PIC X(00008).
15 W1C30111-C-LI-PYR-PYMT-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-COB-LI-ADJUD-DT
PIC X(00010).
15 W1C30111-C-COB-REFER-LI-NUM
PIC S9(00003) COMP.
05 W1C30111-C-LI-CAS-INST-GRP-PHY.
10 W1C30111-C-CAS-VW
OCCURS 0 TO 0280 TIMES
DEPENDING ON W1C30111-C-LI-CAS-NUM
INDEXED BY W1C30111-C-CAS-VW-X .
15 W1C30111-C-LI-NUM
PIC S9(00003) COMP.
15 W1C30111-C-CAS-PYR-ID
PIC X(00015).
15 W1C30111-C-CAS-PROC-CD
PIC X(00008).
15 W1C30111-C-CAS-GRP-CD
PIC X(00002).
15 W1C30111-C-CAS-RSN-CD
PIC X(00005).
15 W1C30111-C-CAS-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C30111-C-CAS-UNT-NUM
PIC S9(00009) COMP.
05 W1C30111-C-LI-BSE-CHG-INST-PHY.
10 W1C30111-C-LI-BSE-CHG-VW
OCCURS 0 TO 0112 TIMES
DEPENDING ON W1C30111-C-LI-BSE-CHG-NUM
INDEXED BY W1C30111-C-LI-BSE-CHG-VW-X .
15 W1C30111-C-LI-NUM
PIC S9(00003) COMP.
15 W1C30111-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C30111-C-BSE-CHNG-RSN-CD
PIC X(00002).
15 W1C30111-C-BSE-AMT-CHG-AMT
PIC S9(00009)V9(00002) COMP-3.
05 W1C30111-C-LI-EXC-GRP-PHYS.
10 W1C30111-C-LI-EXC-VW
OCCURS 0 TO 0210 TIMES
DEPENDING ON W1C30111-C-LI-EXC-NUM
INDEXED BY W1C30111-C-LI-EXC-VW-X .
15 W1C30111-C-LI-NUM
PIC S9(00003) COMP.
15 W1C30111-R-CLM-EXC-CD
PIC X(00004).
15 W1C30111-C-LI-EXC-CLRK-ID
PIC X(00007).
15 W1C30111-C-EXC-STAT-CD
PIC X(00001).
15 W1C30111-R-EXC-FORCE-APP-CD
PIC X(00001).
15 W1C30111-R-FORCE-DENY-CD
PIC X(00001).
05 W1C30111-C-LI-OVRRD-EOB-I-GRP.
10 W1C30111-C-LI-OVRRD-EOB-VW
OCCURS 0 TO 0099 TIMES
DEPENDING ON W1C30111-C-LI-OVRD-EOB-NUM
INDEXED BY W1C30111-C-LI-OVRRD-EOB-VW-X .
15 W1C30111-C-LI-NUM
PIC S9(00003) COMP.
15 W1C30111-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C30111-C-OVRRD-EOB-CD
PIC X(00004).
15 W1C30111-C-OVRRD-EOB-ID
PIC X(00007).
05 W1C30111-C-LI-OVRRD-EXC-I-GRP.
10 W1C30111-C-LI-OVRRD-EXC-VW
OCCURS 0 TO 0099 TIMES
DEPENDING ON W1C30111-C-LI-OVRD-EXC-NUM
INDEXED BY W1C30111-C-LI-OVRRD-EXC-VW-X .
15 W1C30111-C-LI-NUM
PIC S9(00003) COMP.
15 W1C30111-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C30111-C-OVRRD-EXC-CD
PIC X(00004).
15 W1C30111-C-OVRRD-EXC-ID
PIC X(00007).
05 W1C30111-C-LI-AUX-GRP-PHYS.
10 W1C30111-C-LI-AUX-VW
OCCURS 0 TO 0014 TIMES
DEPENDING ON W1C30111-C-LI-AUX-NUM
INDEXED BY W1C30111-C-LI-AUX-VW-X .
15 W1C30111-C-LI-NUM
PIC S9(00003) COMP.
15 W1C30111-C-ATT-1ST-CNTL-NUM
PIC X(00015).
15 W1C30111-C-ATT-1ST-XMIT-CD
PIC X(00002).
15 W1C30111-C-ATT-1ST-RECD-IND
PIC X(00001).
15 W1C30111-C-ATT-2ND-CNTL-NUM
PIC X(00015).
15 W1C30111-C-ATT-2ND-XMIT-CD
PIC X(00002).
15 W1C30111-C-ATT-2ND-RECD-IND
PIC X(00001).
15 W1C30111-C-ATT-3RD-CNTL-NUM
PIC X(00015).
15 W1C30111-C-ATT-3RD-XMIT-CD
PIC X(00002).
15 W1C30111-C-ATT-3RD-RECD-IND
PIC X(00001).
*Layout used if the claim is Medical - Header Level
* *
01 W1C01751-C-HDR-MED-REC.
05 W1C01751-C-SORT-GRP.
10 W1C01751-C-SORT-DAT
PIC X(00030).
10 W1C01751-C-LI-REC-STRT-NUM
PIC 9(00004) COMP.
05 W1C01751-C-COUNTERS-VW.
10 W1C01751-C-CNT-COE-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-COND-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-OCC-CD-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-OCC-SPN-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-VALU-CD-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-ICD-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-DIAG-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-COB-NUM
PIC S9(00004) COMP.
10 W1C01751-C-HDR-CAS-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-LOCN-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-OVRD-EOB-NUM
PIC S9(00004) COMP.
10 W1C01751-C-HDR-OVRD-EOB-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-OVRD-EXC-NUM
PIC S9(00004) COMP.
10 W1C01751-C-HDR-OVRD-EXC-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-RLTD-HST-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-LI-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-LI-MCARE-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-LI-COB-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-LI-CAS-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-BSE-CHG-NUM
PIC S9(00004) COMP.
10 W1C01751-C-HDR-BSE-CHG-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-EXC-NUM
PIC S9(00004) COMP.
10 W1C01751-C-HDR-EXC-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-LI-TPL-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-LI-CAP-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-LI-DRUG-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-UNUSED-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-AUX-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CNT-LI-AUX-NUM
PIC S9(00004) COMP.
05 W1C01751-C-HDR-TB.
10 W1C01751-C-TCN-NUM PIC S9(00017) COMP-3.
10 W1C01751-C-XCN-NUM PIC X(00031).
10 W1C01751-C-HDR-ID-CD
PIC X(00002).
10 W1C01751-C-HDR-EMC-CD
PIC X(00001).
10 W1C01751-C-HDR-SUBMITTER-ID
PIC X(00016).
10 W1C01751-C-CNTL-ORGN-CD
PIC X(00001).
10 W1C01751-C-HDR-STAT-CD
PIC X(00001).
10 W1C01751-C-HDR-TXN-TY-CD
PIC X(00001).
10 W1C01751-C-HDR-TY-CD
PIC X(00001).
10 W1C01751-C-BAT-MED-SRC-CD
PIC X(00001).
10 W1C01751-C-BAT-JLN-DT-NUM
PIC X(00005).
10 W1C01751-C-BT-IMGD-CNTL-NUM
PIC X(00002).
10 W1C01751-C-BAT-NUM PIC X(00003).
10 W1C01751-C-BAT-DOC-TY-CD
PIC X(00001).
10 W1C01751-C-BAT-PYMT-TY-CD
PIC X(00001).
10 W1C01751-C-BAT-TY-CD
PIC X(00001).
10 W1C01751-C-HDR-DOC-NUM
PIC X(00006).
10 W1C01751-C-NSF-X12N-CD
PIC X(00001).
10 W1C01751-C-MCARE-STAT-CD
PIC X(00001).
10 W1C01751-C-CLNT-MCARE-CD
PIC X(00001).
10 W1C01751-B-SYS-ID PIC S9(00009) COMP.
10 W1C01751-B-FST-NAM PIC X(00015).
10 W1C01751-B-LAST-NAM
PIC X(00021).
10 W1C01751-B-MI-NAM PIC X(00001).
10 W1C01751-B-ALT-ID PIC X(00014).
10 W1C01751-B-CURR-ID PIC X(00014).
10 W1C01751-B-RACE-CD PIC X(00001).
10 W1C01751-B-GENDER-CD
PIC X(00001).
10 W1C01751-B-MAJ-PROG-CD
PIC X(00001).
10 W1C01751-T-MSQ-TY-CD
PIC X(00001).
10 W1C01751-A-ID PIC X(00011).
10 W1C01751-C-BLNG-PROV-ID
PIC X(00008).
10 W1C01751-C-BLNG-NPI-ID
PIC X(00010).
10 W1C01751-C-BLNG-TXNMY-CD
PIC X(00010).
10 W1C01751-C-BLNG-PROV-ZIP-CD
PIC X(00009).
10 W1C01751-C-BLNG-PROV-TY-CD
PIC X(00003).
10 W1C01751-C-BLNG-SPECL-CD
PIC X(00003).
10 W1C01751-C-BLNG-NTRPRS-ID
PIC X(00008).
10 W1C01751-C-PROV-SIGN-IND
PIC X(00001).
10 W1C01751-C-ATTACH-1ST-CD
PIC X(00002).
10 W1C01751-C-ATTACH-2ND-CD
PIC X(00002).
10 W1C01751-C-ATTACH-3RD-CD
PIC X(00002).
10 W1C01751-C-ATTACH-4TH-CD
PIC X(00002).
10 W1C01751-C-ATTACH-5TH-CD
PIC X(00002).
10 W1C01751-C-HDR-RMK-IND
PIC X(00001).
10 W1C01751-C-HDR-PAT-ACCT-NUM
PIC X(00020).
10 W1C01751-C-MED-REC-NUM
PIC X(00024).
10 W1C01751-C-ELIG-TWO-PASS-CD
PIC X(00001).
10 W1C01751-C-CREDIT-CD
PIC X(00001).
10 W1C01751-C-OTHR-INSR-IND
PIC X(00001).
10 W1C01751-P-LOCN-CD PIC X(00001).
10 W1C01751-P-PROFIT-IND
PIC X(00001).
10 W1C01751-P-TAX-DISCT-IND
PIC X(00001).
10 W1C01751-P-PROF-TECH-IND
PIC X(00001).
10 W1C01751-P-IHS-IND PIC X(00001).
10 W1C01751-P-PSY-SOC-IND
PIC X(00001).
10 W1C01751-C-COST-AVOID-IND
PIC X(00001).
10 W1C01751-C-PRIOR-AUTH-IND
PIC X(00001).
10 W1C01751-C-DAILY-RPT-IND
PIC X(00001).
10 W1C01751-C-HDR-RA-NUM
PIC S9(00009) COMP.
10 W1C01751-C-EXC-LOCN-CD
PIC X(00003).
10 W1C01751-C-EXC-LOCN-ID
PIC X(00007).
10 W1C01751-C-SUSP-LOCN-EXC-CD
PIC X(00004).
10 W1C01751-C-OVRRD-EXC-LOC-CD
PIC X(00003).
10 W1C01751-C-COST-CENTER-CD
PIC X(00005).
10 W1C01751-C-FAM-PLN-CC-CD
PIC X(00005).
10 W1C01751-C-RLTD-FCN-NUM
PIC X(00015).
10 W1C01751-F-RSN-CD PIC X(00003).
10 W1C01751-C-CYCL-NUM
PIC S9(00002) COMP.
10 W1C01751-C-HDR-CLNT-AGE
PIC S9(00003) COMP.
10 W1C01751-C-TOT-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-CALC-TOT-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-TOT-TPL-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-TOT-TPL-DIR-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-HD-TPL-COPAY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-TOT-NET-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-TOT-REIMB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-TOT-COPAY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-REIMB-STAT-CD
PIC X(00001).
10 W1C01751-C-PREV-REIMB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-PREV-REIMB-CD
PIC X(00001).
10 W1C01751-C-PAT-LIAB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-B-DOB-DT PIC X(00010).
10 W1C01751-C-SUBM-CLNT-DOB-DT
PIC X(00010).
10 W1C01751-C-HDR-ENTRD-DT
PIC X(00010).
10 W1C01751-C-HDR-ADJUD-DT
PIC X(00010).
10 W1C01751-C-HDR-ADJUD-TM
PIC X(00008).
10 W1C01751-C-HDR-ITERM-ADJ-DT
PIC X(00010).
10 W1C01751-C-BILLED-DT
PIC X(00010).
10 W1C01751-C-EXC-LOCN-DT
PIC X(00010).
10 W1C01751-C-HDR-BATCH-DT
PIC X(00010).
10 W1C01751-C-HDR-SVC-FST-DT
PIC X(00010).
10 W1C01751-C-HDR-SVC-LST-DT
PIC X(00010).
10 W1C01751-C-HDR-LST-CYCL-DT
PIC X(00010).
10 W1C01751-C-HDR-PD-DT
PIC X(00010).
10 W1C01751-C-HDR-ORIG-PD-DT
PIC X(00010).
10 W1C01751-C-HDR-SUSP-DT
PIC X(00010).
10 W1C01751-C-HDR-HX-DT
PIC X(00010).
10 W1C01751-C-HDR-CLIA-NUM
PIC X(00010).
10 W1C01751-C-HDR-DENT-OCCP-DT
PIC X(00010).
10 W1C01751-C-HDR-DENT-AUTO-DT
PIC X(00010).
10 W1C01751-C-HDR-DENT-OTHR-DT
PIC X(00010).
10 W1C01751-C-REF-PROV-ID
PIC X(00008).
10 W1C01751-C-REF-NPI-ID
PIC X(00010).
10 W1C01751-C-OCCUP-RLTD-IND
PIC X(00001).
10 W1C01751-C-AUTO-RLTD-IND
PIC X(00001).
10 W1C01751-C-OTHR-RLTD-IND
PIC X(00001).
10 W1C01751-C-ILLNESS-DT
PIC X(00010).
10 W1C01751-C-ADMIT-DT
PIC X(00010).
10 W1C01751-C-DISCH-DT
PIC X(00010).
10 W1C01751-R-DRG-CD PIC X(00005).
10 W1C01751-C-OTHR-PROV-ID
PIC X(00008).
10 W1C01751-C-OTHR-PROV-NPI-ID
PIC X(00010).
10 W1C01751-C-OPR-PROV-ID
PIC X(00008).
10 W1C01751-C-OPR-NPI-ID
PIC X(00010).
10 W1C01751-C-ATNDG-PROV-ID
PIC X(00008).
10 W1C01751-C-ATNDG-NPI-ID
PIC X(00010).
10 W1C01751-C-ATNDG-TXNMY-CD
PIC X(00010).
10 W1C01751-C-LTC-PROV-ID
PIC X(00008).
10 W1C01751-C-PAT-STAT-CD
PIC X(00002).
10 W1C01751-C-ADM-SRC-CD
PIC X(00001).
10 W1C01751-C-TY-OF-ADM-CD
PIC X(00001).
10 W1C01751-C-TY-OF-BLL-PFX-CD
PIC X(00001).
10 W1C01751-C-TY-OF-BLL-1-2-CD
PIC X(00002).
10 W1C01751-C-TY-OF-BILL-3-CD
PIC X(00001).
10 W1C01751-C-COS-CD PIC X(00002).
10 W1C01751-C-UB92-A-DIAG-CD
PIC X(00010).
10 W1C01751-C-UB92-ADM-HR-CD
PIC X(00002).
10 W1C01751-C-UB92-DISCH-HR-CD
PIC X(00002).
10 W1C01751-C-BSE-AMT-SRC-CD
PIC X(00002).
10 W1C01751-C-PRCNG-PROCESS-CD
PIC X(00002).
10 W1C01751-C-UB92-ABORT-IND
PIC X(00001).
10 W1C01751-C-HDR-FAM-PLNG-IND
PIC X(00001).
10 W1C01751-C-UB92-STERIL-IND
PIC X(00001).
10 W1C01751-C-UB92-HYSTER-IND
PIC X(00001).
10 W1C01751-C-HDR-BSE-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-CALC-ALLOW-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-HDR-ALLOW-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-NCVRD-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-CVRD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C01751-C-NCVRD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C01751-C-OUTLIER-DAYS-NUM
PIC S9(00004) COMP.
10 W1C01751-C-CALC-DAYS-NUM
PIC S9(00004) COMP.
10 W1C01751-C-DRG-PD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C01751-B-GUARANTEE-NUM
PIC X(00012).
10 W1C01751-C-ORIG-PAPER-IND
PIC X(00001).
10 W1C01751-C-CREATION-DT
PIC X(00010).
10 W1C01751-C-SVC-FACI-NPI-ID
PIC X(00010).
10 W1C01751-R-CD-REL-WT-AMT
PIC S9(00004)V9(00005) COMP-3.
10 W1C01751-C-BLNG-TAX-ID
PIC X(00009).
10 W1C01751-C-BLNG-SSN-NUM
PIC X(00009).
10 W1C01751-C-FUT-PROV-ID
PIC X(00008).
10 W1C01751-C-MC-PROV-ID
PIC X(00008).
10 W1C01751-H-PLN-NUM PIC X(00004).
10 W1C01751-H-PLN-TY-CD
PIC X(00001).
10 W1C01751-H-PLN-BEG-DT
PIC X(00010).
10 W1C01751-C-HDR-FUT-1-CD
PIC X(00003).
10 W1C01751-C-HDR-FUT-2-CD
PIC X(00003).
10 W1C01751-B-PARENT-IND
PIC X(00001).
10 W1C01751-C-HDR-AUD-IND
PIC X(00001).
10 W1C01751-C-HDR-FUT-1-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-HDR-FUT-2-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-EPSDT-CERT1-CD
PIC X(00003).
10 W1C01751-C-EPSDT-CERT2-CD
PIC X(00003).
10 W1C01751-C-ANES-REL-PROC-CD
PIC X(00007).
10 W1C01751-R-ICD-VER-CD
PIC X(00002).
10 W1C01751-C-HDR-FUT-1-IND
PIC X(00001).
10 W1C01751-C-HDR-FUT-2-IND
PIC X(00001).
10 W1C01751-G-AUD-USER-ID
PIC X(00007).
10 W1C01751-G-AUD-DT PIC X(00010).
10 W1C01751-G-AUD-TM PIC X(00008).
05 W1C01751-C-HDR-PARAM-ERR-VW.
10 W1C01751-C-ERR-PARAM-CD
PIC X(00004).
10 W1C01751-C-ERR-PROG-ID
PIC X(00008).
10 W1C01751-C-ERR-MSG-DAT
PIC X(00010).
05 W1C01751-C-HDR-ADJ-VD-VW.
10 W1C01751-C-KEYED-REPLCD-NUM
PIC S9(00017) COMP-3.
10 W1C01751-C-HDR-ADJ-RSN-CD
PIC X(00003).
10 W1C01751-C-REPLCD-TCN-NUM
PIC S9(00017) COMP-3.
10 W1C01751-C-HDR-ADJ-STAT-CD
PIC X(00001).
10 W1C01751-C-REPLCMT-TCN-NUM
PIC S9(00017) COMP-3.
10 W1C01751-F-FCN-DT PIC X(00010).
10 W1C01751-F-FCN-MED-CD
PIC X(00001).
10 W1C01751-F-FCN-NUM PIC S9(00003) COMP.
10 W1C01751-C-ADJ-ORIG-TCN-NUM
PIC S9(00017) COMP-3.
10 W1C01751-C-ADJ-SEQ-NUM
PIC S9(00002) COMP.
05 W1C01751-C-HDR-COE-GRP.
10 W1C01751-C-HDR-COE-VW
OCCURS 0 TO 0004 TIMES
DEPENDING ON W1C01751-C-CNT-COE-NUM
INDEXED BY W1C01751-C-HDR-COE-VW-X .
15 W1C01751-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C01751-B-COE-CD
PIC X(00003).
15 W1C01751-B-FED-MTCH-CD
PIC X(00001).
15 W1C01751-B-FED-CAT-CD
PIC X(00001).
15 W1C01751-B-GEO-CNTY-CD
PIC X(00002).
15 W1C01751-B-ADMIN-CNTY-CD
PIC X(00002).
15 W1C01751-B-MONEY-CD
PIC X(00001).
05 W1C01751-C-HDR-ENCTR-VW.
10 W1C01751-C-MCO-TCN-DAT
PIC X(00020).
10 W1C01751-C-SUB-CAP-CD
PIC X(00001).
10 W1C01751-C-MC-ENCTR-PD-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-MC-ENCTR-PD-DT
PIC X(00010).
10 W1C01751-C-MC-ENCTR-RECD-DT
PIC X(00010).
05 W1C01751-C-HDR-DIAG-MED-GRP.
10 W1C01751-C-HDR-DIAG-VW
OCCURS 0 TO 0008 TIMES
DEPENDING ON W1C01751-C-CNT-DIAG-NUM
INDEXED BY W1C01751-C-HDR-DIAG-VW-X .
15 W1C01751-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C01751-R-DIAG-CD
PIC X(00010).
15 W1C01751-C-POA-IND
PIC X(00001).
05 W1C01751-C-HDR-MCARE-VW.
10 W1C01751-C-MCARE-PROV-ID
PIC X(00013).
10 W1C01751-C-MCARE-CLM-NUM
PIC X(00026).
10 W1C01751-C-HD-MCARE-CARR-ID
PIC X(00006).
10 W1C01751-C-MCARE-HIC-ID
PIC X(00019).
10 W1C01751-C-HD-MCARE-EOMB-DT
PIC X(00010).
10 W1C01751-C-HDR-MCAR-STAT-CD
PIC X(00001).
10 W1C01751-C-MCARE-ALLOW-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-MCARE-DED-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-MCARE-COINS-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-MCARE-PSY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-MCARE-O-PR-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-MCARE-PD-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-HDR-MCAR-DED-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-HDR-MCAR-COI-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-HDR-MCAR-PSY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C01751-C-HD-MCAR-O-PR-AMT
PIC S9(00009)V9(00002) COMP-3.
05 W1C01751-C-HDR-COB-GRP.
10 W1C01751-C-HDR-COB-VW
OCCURS 0 TO 0005 TIMES
DEPENDING ON W1C01751-C-CNT-COB-NUM
INDEXED BY W1C01751-C-HDR-COB-VW-X .
15 W1C01751-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C01751-C-COB-PYR-ID
PIC X(00015).
15 W1C01751-C-COB-PYR-NAM
PIC X(00035).
15 W1C01751-C-COB-PYR-SEQ-CD
PIC X(00001).
15 W1C01751-C-COB-PLCY-REL-CD
PIC X(00002).
15 W1C01751-C-COB-PLCY-NUM
PIC X(00009).
15 W1C01751-C-COB-GRP-PLN-NAM
PIC X(00030).
15 W1C01751-C-COB-FLN-IND-CD
PIC X(00002).
15 W1C01751-C-COB-PYR-PYMT-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C01751-C-COB-ADJUD-DT
PIC X(00010).
15 W1C01751-C-COB-CLM-NUM
PIC X(00026).
15 W1C01751-C-CERT-SSN-HIC-ID
PIC X(00019).
15 W1C01751-C-UB92-EST-DUE-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C01751-C-UB92-PYR-AUTH-CD
PIC X(00018).
15 W1C01751-C-COB-NN-CVRD-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C01751-C-HDR-RMK-CD
PIC X(00005).
15 W1C01751-C-COB-DRG-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C01751-C-COB-DSP-SHR-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C01751-C-COB-CAP-IME-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C01751-C-COB-REIMB-PCT
PIC S9(00003)V9(00002) COMP-3.
15 W1C01751-C-COB-HCPCS-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C01751-C-COB-ESRD-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C01751-C-COB-NONP-PC-AMT
PIC S9(00009)V9(00002) COMP-3.
05 W1C01751-C-HDR-CAS-GRP.
10 W1C01751-C-CAS-VW
OCCURS 0 TO 0026 TIMES
DEPENDING ON W1C01751-C-HDR-CAS-NUM
INDEXED BY W1C01751-C-CAS-VW-X .
15 W1C01751-C-LI-NUM
PIC S9(00003) COMP.
15 W1C01751-C-CAS-PYR-ID
PIC X(00015).
15 W1C01751-C-CAS-PROC-CD
PIC X(00008).
15 W1C01751-C-CAS-GRP-CD
PIC X(00002).
15 W1C01751-C-CAS-RSN-CD
PIC X(00005).
15 W1C01751-C-CAS-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C01751-C-CAS-UNT-NUM
PIC S9(00009) COMP.
05 W1C01751-C-LI-TPL-BLNG-GRP.
10 W1C01751-C-LI-TPL-BLNG-VW
OCCURS 0 TO 0006 TIMES
DEPENDING ON W1C01751-C-CNT-LI-TPL-NUM
INDEXED BY W1C01751-C-LI-TPL-BLNG-VW-X .
15 W1C01751-C-LI-NUM
PIC S9(00003) COMP.
15 W1C01751-T-PLCY-NUM
PIC X(00020).
15 W1C01751-T-PLCY-SEQ-NUM
PIC S9(00003) COMP.
15 W1C01751-T-PLCY-RESRC-CD
PIC X(00002).
15 W1C01751-T-CARR-ID
PIC X(00006).
15 W1C01751-T-CVRG-PLCY-CD
PIC X(00002).
05 W1C01751-C-HDR-PREV-LOCN-GRP.
10 W1C01751-C-HDR-PREV-LOCN-VW
OCCURS 0 TO 0010 TIMES
DEPENDING ON W1C01751-C-CNT-LOCN-NUM
INDEXED BY W1C01751-C-HDR-PREV-LOCN-VW-X .
15 W1C01751-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C01752-C-EXC-LOCN-CD
PIC X(00003).
15 W1C01752-C-EXC-LOCN-ID
PIC X(00007).
15 W1C01752-C-SUSP-LOCN-EXC-CD
PIC X(00004).
15 W1C01752-C-EXC-LOCN-DT
PIC X(00010).
05 W1C01751-C-HDR-WARRANT-VW.
10 W1C01751-C-HDR-RA-NUM
PIC S9(00009) COMP.
10 W1C01751-C-HDR-WARR-NUM
PIC X(00011).
10 W1C01751-C-HDR-WARR-MED-CD
PIC X(00001).
10 W1C01751-C-HDR-WARR-AMT
PIC S9(00013)V9(00002) COMP-3.
10 W1C01751-C-HDR-WARR-DT
PIC X(00010).
10 W1C01751-C-EFT-TRC-ID
PIC X(00015).
05 W1C01751-C-HDR-OVRRD-EOB-M-GRP.
10 W1C01751-C-HDR-OVRRD-EOB-VW
OCCURS 0 TO 0020 TIMES
DEPENDING ON W1C01751-C-HDR-OVRD-EOB-NUM
INDEXED BY W1C01751-C-HDR-OVRRD-EOB-VW-X .
15 W1C01751-C-LI-NUM
PIC S9(00003) COMP.
15 W1C01751-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C01751-C-OVRRD-EOB-CD
PIC X(00004).
15 W1C01751-C-OVRRD-EOB-ID
PIC X(00007).
05 W1C01751-C-HDR-OVRRD-EXC-M-GRP.
10 W1C01751-C-HDR-OVRRD-EXC-VW
OCCURS 0 TO 0020 TIMES
DEPENDING ON W1C01751-C-HDR-OVRD-EXC-NUM
INDEXED BY W1C01751-C-HDR-OVRRD-EXC-VW-X .
15 W1C01751-C-LI-NUM
PIC S9(00003) COMP.
15 W1C01751-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C01751-C-OVRRD-EXC-CD
PIC X(00004).
15 W1C01751-C-OVRRD-EXC-ID
PIC X(00007).
05 W1C01751-C-HDR-RLTD-HIST-GRP.
10 W1C01751-C-HDR-RLTD-HIST-VW
OCCURS 0 TO 0100 TIMES
DEPENDING ON W1C01751-C-CNT-RLTD-HST-NUM
INDEXED BY W1C01751-C-HDR-RLTD-HIST-VW-X .
15 W1C01751-C-LI-NUM
PIC S9(00003) COMP.
15 W1C01751-C-RLTD-LI-TCN-NUM
PIC S9(00017) COMP-3.
15 W1C01751-C-RLTD-LI-NUM
PIC S9(00003) COMP.
15 W1C01752-R-CLM-EXC-CD
PIC X(00004).
15 W1C01752-C-HDR-PD-DT
PIC X(00010).
15 W1C01752-C-EXC-STAT-CD
PIC X(00001).
15 W1C01752-C-HDR-TY-CD
PIC X(00001).
15 W1C01751-C-SYS-REPLCD-IND
PIC X(00001).
05 W1C01751-C-HDR-BSE-CHG-GRP.
10 W1C01751-C-HDR-BSE-CHG-VW
OCCURS 0 TO 0008 TIMES
DEPENDING ON W1C01751-C-HDR-BSE-CHG-NUM
INDEXED BY W1C01751-C-HDR-BSE-CHG-VW-X .
15 W1C01751-C-LI-NUM
PIC S9(00003) COMP.
15 W1C01751-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C01751-C-BSE-CHNG-RSN-CD
PIC X(00002).
15 W1C01751-C-BSE-AMT-CHG-AMT
PIC S9(00009)V9(00002) COMP-3.
05 W1C01751-C-HDR-EXC-GRP.
10 W1C01751-C-HDR-EXC-VW
OCCURS 0 TO 0025 TIMES
DEPENDING ON W1C01751-C-HDR-EXC-NUM
INDEXED BY W1C01751-C-HDR-EXC-VW-X .
15 W1C01751-C-LI-NUM
PIC S9(00003) COMP.
15 W1C01751-R-CLM-EXC-CD
PIC X(00004).
15 W1C01751-C-EXC-CLRK-ID
PIC X(00007).
15 W1C01751-C-EXC-STAT-CD
PIC X(00001).
15 W1C01751-R-EXC-FORCE-APP-CD
PIC X(00001).
15 W1C01751-R-FORCE-DENY-CD
PIC X(00001).
05 W1C01751-C-HDR-AUX-VW.
10 W1C01751-C-ATT-1ST-CNTL-NUM
PIC X(00015).
10 W1C01751-C-ATT-1ST-XMIT-CD
PIC X(00002).
10 W1C01751-C-ATT-1ST-RECD-IND
PIC X(00001).
10 W1C01751-C-ATT-2ND-CNTL-NUM
PIC X(00015).
10 W1C01751-C-ATT-2ND-XMIT-CD
PIC X(00002).
10 W1C01751-C-ATT-2ND-RECD-IND
PIC X(00001).
10 W1C01751-C-ATT-3RD-CNTL-NUM
PIC X(00015).
10 W1C01751-C-ATT-3RD-XMIT-CD
PIC X(00002).
10 W1C01751-C-ATT-3RD-RECD-IND
PIC X(00001).
10 W1C01751-C-ATT-4TH-CNTL-NUM
PIC X(00015).
10 W1C01751-C-ATT-4TH-XMIT-CD
PIC X(00002).
10 W1C01751-C-ATT-4TH-RECD-IND
PIC X(00001).
10 W1C01751-C-ATT-5TH-CNTL-NUM
PIC X(00015).
10 W1C01751-C-ATT-5TH-XMIT-CD
PIC X(00002).
10 W1C01751-C-ATT-5TH-RECD-IND
PIC X(00001).
10 W1C01751-C-AMBL-PU-LINE1-AD
PIC X(00030).
10 W1C01751-C-AMBL-PU-LINE2-AD
PIC X(00030).
10 W1C01751-C-AMBL-PU-CITY-NAM
PIC X(00020).
10 W1C01751-C-AMBL-PU-ST-CD
PIC X(00002).
10 W1C01751-C-AMBL-PU-ZIP5-CD
PIC X(00005).
10 W1C01751-C-AMBL-PU-ZIP4-CD
PIC X(00004).
10 W1C01751-C-AMBL-DO-LINE1-AD
PIC X(00030).
10 W1C01751-C-AMBL-DO-LINE2-AD
PIC X(00030).
10 W1C01751-C-AMBL-DO-CITY-NAM
PIC X(00020).
10 W1C01751-C-AMBL-DO-ST-CD
PIC X(00002).
10 W1C01751-C-AMBL-DO-ZIP5-CD
PIC X(00005).
10 W1C01751-C-AMBL-DO-ZIP4-CD
PIC X(00004).
*Layout used if the claim is Medical - Line Level
* *
01 W1C48141-C-LI-MED-COMMON-VW.
05 W1C48141-C-SORT-GRP.
10 W1C48141-C-SORT-DAT
PIC X(00030).
10 W1C48141-C-LI-REC-STRT-NUM
PIC 9(00004) COMP.
05 W1C48141-C-COUNTERS-VW.
10 W1C48141-C-CNT-COE-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-COND-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-OCC-CD-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-OCC-SPN-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-VALU-CD-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-ICD-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-DIAG-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-COB-NUM
PIC S9(00004) COMP.
10 W1C48141-C-HDR-CAS-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-LOCN-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-OVRD-EOB-NUM
PIC S9(00004) COMP.
10 W1C48141-C-HDR-OVRD-EOB-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-OVRD-EXC-NUM
PIC S9(00004) COMP.
10 W1C48141-C-HDR-OVRD-EXC-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-RLTD-HST-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-LI-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-LI-MCARE-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-LI-COB-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-LI-CAS-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-BSE-CHG-NUM
PIC S9(00004) COMP.
10 W1C48141-C-HDR-BSE-CHG-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-EXC-NUM
PIC S9(00004) COMP.
10 W1C48141-C-HDR-EXC-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-LI-TPL-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-LI-CAP-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-LI-DRUG-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-UNUSED-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-AUX-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CNT-LI-AUX-NUM
PIC S9(00004) COMP.
05 W1C48141-C-HDR-TB.
10 W1C48141-C-TCN-NUM PIC S9(00017) COMP-3.
10 W1C48141-C-XCN-NUM PIC X(00031).
10 W1C48141-C-HDR-ID-CD
PIC X(00002).
10 W1C48141-C-HDR-EMC-CD
PIC X(00001).
10 W1C48141-C-HDR-SUBMITTER-ID
PIC X(00016).
10 W1C48141-C-CNTL-ORGN-CD
PIC X(00001).
10 W1C48141-C-HDR-STAT-CD
PIC X(00001).
10 W1C48141-C-HDR-TXN-TY-CD
PIC X(00001).
10 W1C48141-C-HDR-TY-CD
PIC X(00001).
10 W1C48141-C-BAT-MED-SRC-CD
PIC X(00001).
10 W1C48141-C-BAT-JLN-DT-NUM
PIC X(00005).
10 W1C48141-C-BT-IMGD-CNTL-NUM
PIC X(00002).
10 W1C48141-C-BAT-NUM PIC X(00003).
10 W1C48141-C-BAT-DOC-TY-CD
PIC X(00001).
10 W1C48141-C-BAT-PYMT-TY-CD
PIC X(00001).
10 W1C48141-C-BAT-TY-CD
PIC X(00001).
10 W1C48141-C-HDR-DOC-NUM
PIC X(00006).
10 W1C48141-C-NSF-X12N-CD
PIC X(00001).
10 W1C48141-C-MCARE-STAT-CD
PIC X(00001).
10 W1C48141-C-CLNT-MCARE-CD
PIC X(00001).
10 W1C48141-B-SYS-ID PIC S9(00009) COMP.
10 W1C48141-B-FST-NAM PIC X(00015).
10 W1C48141-B-LAST-NAM
PIC X(00021).
10 W1C48141-B-MI-NAM PIC X(00001).
10 W1C48141-B-ALT-ID PIC X(00014).
10 W1C48141-B-CURR-ID PIC X(00014).
10 W1C48141-B-RACE-CD PIC X(00001).
10 W1C48141-B-GENDER-CD
PIC X(00001).
10 W1C48141-B-MAJ-PROG-CD
PIC X(00001).
10 W1C48141-T-MSQ-TY-CD
PIC X(00001).
10 W1C48141-A-ID PIC X(00011).
10 W1C48141-C-BLNG-PROV-ID
PIC X(00008).
10 W1C48141-C-BLNG-NPI-ID
PIC X(00010).
10 W1C48141-C-BLNG-TXNMY-CD
PIC X(00010).
10 W1C48141-C-BLNG-PROV-ZIP-CD
PIC X(00009).
10 W1C48141-C-BLNG-PROV-TY-CD
PIC X(00003).
10 W1C48141-C-BLNG-SPECL-CD
PIC X(00003).
10 W1C48141-C-BLNG-NTRPRS-ID
PIC X(00008).
10 W1C48141-C-PROV-SIGN-IND
PIC X(00001).
10 W1C48141-C-ATTACH-1ST-CD
PIC X(00002).
10 W1C48141-C-ATTACH-2ND-CD
PIC X(00002).
10 W1C48141-C-ATTACH-3RD-CD
PIC X(00002).
10 W1C48141-C-ATTACH-4TH-CD
PIC X(00002).
10 W1C48141-C-ATTACH-5TH-CD
PIC X(00002).
10 W1C48141-C-HDR-RMK-IND
PIC X(00001).
10 W1C48141-C-HDR-PAT-ACCT-NUM
PIC X(00020).
10 W1C48141-C-MED-REC-NUM
PIC X(00024).
10 W1C48141-C-ELIG-TWO-PASS-CD
PIC X(00001).
10 W1C48141-C-CREDIT-CD
PIC X(00001).
10 W1C48141-C-OTHR-INSR-IND
PIC X(00001).
10 W1C48141-P-LOCN-CD PIC X(00001).
10 W1C48141-P-PROFIT-IND
PIC X(00001).
10 W1C48141-P-TAX-DISCT-IND
PIC X(00001).
10 W1C48141-P-PROF-TECH-IND
PIC X(00001).
10 W1C48141-P-IHS-IND PIC X(00001).
10 W1C48141-P-PSY-SOC-IND
PIC X(00001).
10 W1C48141-C-COST-AVOID-IND
PIC X(00001).
10 W1C48141-C-PRIOR-AUTH-IND
PIC X(00001).
10 W1C48141-C-DAILY-RPT-IND
PIC X(00001).
10 W1C48141-C-HDR-RA-NUM
PIC S9(00009) COMP.
10 W1C48141-C-EXC-LOCN-CD
PIC X(00003).
10 W1C48141-C-EXC-LOCN-ID
PIC X(00007).
10 W1C48141-C-SUSP-LOCN-EXC-CD
PIC X(00004).
10 W1C48141-C-OVRRD-EXC-LOC-CD
PIC X(00003).
10 W1C48141-C-COST-CENTER-CD
PIC X(00005).
10 W1C48141-C-FAM-PLN-CC-CD
PIC X(00005).
10 W1C48141-C-RLTD-FCN-NUM
PIC X(00015).
10 W1C48141-F-RSN-CD PIC X(00003).
10 W1C48141-C-CYCL-NUM
PIC S9(00002) COMP.
10 W1C48141-C-HDR-CLNT-AGE
PIC S9(00003) COMP.
10 W1C48141-C-TOT-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C48141-C-CALC-TOT-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C48141-C-TOT-TPL-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C48141-C-TOT-TPL-DIR-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C48141-C-HD-TPL-COPAY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C48141-C-TOT-NET-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C48141-C-TOT-REIMB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C48141-C-TOT-COPAY-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C48141-C-REIMB-STAT-CD
PIC X(00001).
10 W1C48141-C-PREV-REIMB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C48141-C-PREV-REIMB-CD
PIC X(00001).
10 W1C48141-C-PAT-LIAB-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C48141-B-DOB-DT PIC X(00010).
10 W1C48141-C-SUBM-CLNT-DOB-DT
PIC X(00010).
10 W1C48141-C-HDR-ENTRD-DT
PIC X(00010).
10 W1C48141-C-HDR-ADJUD-DT
PIC X(00010).
10 W1C48141-C-HDR-ADJUD-TM
PIC X(00008).
10 W1C48141-C-HDR-ITERM-ADJ-DT
PIC X(00010).
10 W1C48141-C-BILLED-DT
PIC X(00010).
10 W1C48141-C-EXC-LOCN-DT
PIC X(00010).
10 W1C48141-C-HDR-BATCH-DT
PIC X(00010).
10 W1C48141-C-HDR-SVC-FST-DT
PIC X(00010).
10 W1C48141-C-HDR-SVC-LST-DT
PIC X(00010).
10 W1C48141-C-HDR-LST-CYCL-DT
PIC X(00010).
10 W1C48141-C-HDR-PD-DT
PIC X(00010).
10 W1C48141-C-HDR-ORIG-PD-DT
PIC X(00010).
10 W1C48141-C-HDR-SUSP-DT
PIC X(00010).
10 W1C48141-C-HDR-HX-DT
PIC X(00010).
10 W1C48141-C-HDR-CLIA-NUM
PIC X(00010).
10 W1C48141-C-HDR-DENT-OCCP-DT
PIC X(00010).
10 W1C48141-C-HDR-DENT-AUTO-DT
PIC X(00010).
10 W1C48141-C-HDR-DENT-OTHR-DT
PIC X(00010).
10 W1C48141-C-REF-PROV-ID
PIC X(00008).
10 W1C48141-C-REF-NPI-ID
PIC X(00010).
10 W1C48141-C-OCCUP-RLTD-IND
PIC X(00001).
10 W1C48141-C-AUTO-RLTD-IND
PIC X(00001).
10 W1C48141-C-OTHR-RLTD-IND
PIC X(00001).
10 W1C48141-C-ILLNESS-DT
PIC X(00010).
10 W1C48141-C-ADMIT-DT
PIC X(00010).
10 W1C48141-C-DISCH-DT
PIC X(00010).
10 W1C48141-R-DRG-CD PIC X(00005).
10 W1C48141-C-OTHR-PROV-ID
PIC X(00008).
10 W1C48141-C-OTHR-PROV-NPI-ID
PIC X(00010).
10 W1C48141-C-OPR-PROV-ID
PIC X(00008).
10 W1C48141-C-OPR-NPI-ID
PIC X(00010).
10 W1C48141-C-ATNDG-PROV-ID
PIC X(00008).
10 W1C48141-C-ATNDG-NPI-ID
PIC X(00010).
10 W1C48141-C-ATNDG-TXNMY-CD
PIC X(00010).
10 W1C48141-C-LTC-PROV-ID
PIC X(00008).
10 W1C48141-C-PAT-STAT-CD
PIC X(00002).
10 W1C48141-C-ADM-SRC-CD
PIC X(00001).
10 W1C48141-C-TY-OF-ADM-CD
PIC X(00001).
10 W1C48141-C-TY-OF-BLL-PFX-CD
PIC X(00001).
10 W1C48141-C-TY-OF-BLL-1-2-CD
PIC X(00002).
10 W1C48141-C-TY-OF-BILL-3-CD
PIC X(00001).
10 W1C48141-C-COS-CD PIC X(00002).
10 W1C48141-C-UB92-A-DIAG-CD
PIC X(00010).
10 W1C48141-C-UB92-ADM-HR-CD
PIC X(00002).
10 W1C48141-C-UB92-DISCH-HR-CD
PIC X(00002).
10 W1C48141-C-BSE-AMT-SRC-CD
PIC X(00002).
10 W1C48141-C-PRCNG-PROCESS-CD
PIC X(00002).
10 W1C48141-C-UB92-ABORT-IND
PIC X(00001).
10 W1C48141-C-HDR-FAM-PLNG-IND
PIC X(00001).
10 W1C48141-C-UB92-STERIL-IND
PIC X(00001).
10 W1C48141-C-UB92-HYSTER-IND
PIC X(00001).
10 W1C48141-C-HDR-BSE-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C48141-C-CALC-ALLOW-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C48141-C-HDR-ALLOW-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C48141-C-NCVRD-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C48141-C-CVRD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C48141-C-NCVRD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C48141-C-OUTLIER-DAYS-NUM
PIC S9(00004) COMP.
10 W1C48141-C-CALC-DAYS-NUM
PIC S9(00004) COMP.
10 W1C48141-C-DRG-PD-DAYS-NUM
PIC S9(00004) COMP.
10 W1C48141-B-GUARANTEE-NUM
PIC X(00012).
10 W1C48141-C-ORIG-PAPER-IND
PIC X(00001).
10 W1C48141-C-CREATION-DT
PIC X(00010).
10 W1C48141-C-SVC-FACI-NPI-ID
PIC X(00010).
10 W1C48141-R-CD-REL-WT-AMT
PIC S9(00004)V9(00005) COMP-3.
10 W1C48141-C-BLNG-TAX-ID
PIC X(00009).
10 W1C48141-C-BLNG-SSN-NUM
PIC X(00009).
10 W1C48141-C-FUT-PROV-ID
PIC X(00008).
10 W1C48141-C-MC-PROV-ID
PIC X(00008).
10 W1C48141-H-PLN-NUM PIC X(00004).
10 W1C48141-H-PLN-TY-CD
PIC X(00001).
10 W1C48141-H-PLN-BEG-DT
PIC X(00010).
10 W1C48141-C-HDR-FUT-1-CD
PIC X(00003).
10 W1C48141-C-HDR-FUT-2-CD
PIC X(00003).
10 W1C48141-B-PARENT-IND
PIC X(00001).
10 W1C48141-C-HDR-AUD-IND
PIC X(00001).
10 W1C48141-C-HDR-FUT-1-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C48141-C-HDR-FUT-2-AMT
PIC S9(00009)V9(00002) COMP-3.
10 W1C48141-C-EPSDT-CERT1-CD
PIC X(00003).
10 W1C48141-C-EPSDT-CERT2-CD
PIC X(00003).
10 W1C48141-C-ANES-REL-PROC-CD
PIC X(00007).
10 W1C48141-R-ICD-VER-CD
PIC X(00002).
10 W1C48141-C-HDR-FUT-1-IND
PIC X(00001).
10 W1C48141-C-HDR-FUT-2-IND
PIC X(00001).
10 W1C48141-G-AUD-USER-ID
PIC X(00007).
10 W1C48141-G-AUD-DT PIC X(00010).
10 W1C48141-G-AUD-TM PIC X(00008).
05 W1C48141-C-LI-CNT-GRP.
10 W1C48141-C-LI-REC-NUM
PIC S9(00004) COMP.
10 W1C48141-C-LI-CAP-NUM
PIC S9(00004) COMP.
10 W1C48141-C-LI-REC-MCARE-NUM
PIC S9(00004) COMP.
10 W1C48141-C-LI-COB-NUM
PIC S9(00004) COMP.
10 W1C48141-C-LI-CAS-NUM
PIC S9(00004) COMP.
10 W1C48141-C-LI-BSE-CHG-NUM
PIC S9(00004) COMP.
10 W1C48141-C-LI-EXC-NUM
PIC S9(00004) COMP.
10 W1C48141-C-LI-OVRD-EOB-NUM
PIC S9(00004) COMP.
10 W1C48141-C-LI-OVRD-EXC-NUM
PIC S9(00004) COMP.
10 W1C48141-C-LI-AUX-NUM
PIC S9(00004) COMP.
05 W1C48141-C-LI-MED-GRP-PHYS.
10 W1C48141-C-LI-VW
OCCURS 0 TO 0014 TIMES
DEPENDING ON W1C48141-C-LI-REC-NUM
INDEXED BY W1C48141-C-LI-VW-X .
15 W1C48141-C-LI-NUM
PIC S9(00003) COMP.
15 W1C48141-R-PROC-CD
PIC X(00007).
15 W1C48141-C-PROC-MOD-1ST-CD
PIC X(00002).
15 W1C48141-C-PROC-MOD-2ND-CD
PIC X(00002).
15 W1C48141-C-PROC-MOD-3RD-CD
PIC X(00002).
15 W1C48141-C-PROC-MOD-4TH-CD
PIC X(00002).
15 W1C48141-R-PL-OF-SVC-CD
PIC X(00002).
15 W1C48141-R-SVC-AREA-CD
PIC X(00001).
15 W1C48141-C-SVC-COMPONENT-CD
PIC X(00001).
15 W1C48141-A-LI-NUM
PIC S9(00003) COMP.
15 W1C48141-C-PRIOR-AUTH-IND
PIC X(00001).
15 W1C48141-C-LI-AUTH-ID
PIC X(00011).
15 W1C48141-C-LI-CLIA-NUM
PIC X(00010).
15 W1C48141-C-BSE-AMT-SRC-CD
PIC X(00002).
15 W1C48141-C-PRCNG-PROCESS-CD
PIC X(00002).
15 W1C48141-C-COS-CD
PIC X(00002).
15 W1C48141-C-REIMB-STAT-CD
PIC X(00001).
15 W1C48141-C-COST-AVOID-IND
PIC X(00001).
15 W1C48141-C-ONCE-IN-LFTM-IND
PIC X(00001).
15 W1C48141-C-LI-DUPL-CHK-IND
PIC X(00001).
15 W1C48141-C-ALLOW-UNTS-IND
PIC X(00001).
15 W1C48141-C-LI-ABORT-IND
PIC X(00001).
15 W1C48141-C-LI-STERIL-IND
PIC X(00001).
15 W1C48141-C-LI-FAM-PLNG-IND
PIC X(00001).
15 W1C48141-C-LI-HYSTER-IND
PIC X(00001).
15 W1C48141-C-MULTI-SURG-IND
PIC X(00001).
15 W1C48141-C-LI-FST-DOS-DT
PIC X(00010).
15 W1C48141-C-LI-LAST-DOS-DT
PIC X(00010).
15 W1C48141-C-MC-ENCTR-PD-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-LI-TPL-COPAY-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-LI-SUBM-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-LI-BSE-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-LI-CLC-ALLW-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-LI-ALLW-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-LI-REIMB-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-LI-UNT-MSR-CD
PIC X(00002).
15 W1C48141-C-LI-UNT-MSR-NUM
PIC S9(00007)V9(00002) COMP-3.
15 W1C48141-C-LI-SUBM-UNT-NUM
PIC S9(00007)V9(00002) COMP-3.
15 W1C48141-C-LI-ALLOW-UNT-NUM
PIC S9(00007)V9(00002) COMP-3.
15 W1C48141-C-LI-REIMB-UNT-NUM
PIC S9(00007)V9(00002) COMP-3.
15 W1C48141-C-LI-FLLWP-LMT-DT
PIC X(00010).
15 W1C48141-R-DRUG-CD
PIC X(00011).
15 W1C48141-C-DIAG-1ST-RLTD-CD
PIC X(00001).
15 W1C48141-C-DIAG-2ND-RLTD-CD
PIC X(00001).
15 W1C48141-C-DIAG-3RD-RLTD-CD
PIC X(00001).
15 W1C48141-C-DIAG-4TH-RLTD-CD
PIC X(00001).
15 W1C48141-C-DIAG-5TH-RLTD-CD
PIC X(00001).
15 W1C48141-C-DIAG-6TH-RLTD-CD
PIC X(00001).
15 W1C48141-C-DIAG-7TH-RLTD-CD
PIC X(00001).
15 W1C48141-C-DIAG-8TH-RLTD-CD
PIC X(00001).
15 W1C48141-R-PROC-ORAL-CAV-CD
PIC X(00002).
15 W1C48141-R-PROC-TOOTH-CD
PIC X(00002).
15 W1C48141-C-DENT-1ST-SURF-CD
PIC X(00001).
15 W1C48141-C-DENT-2ND-SURF-CD
PIC X(00001).
15 W1C48141-C-DENT-3RD-SURF-CD
PIC X(00001).
15 W1C48141-C-DENT-4TH-SURF-CD
PIC X(00001).
15 W1C48141-C-DENT-5TH-SURF-CD
PIC X(00001).
15 W1C48141-C-RNDR-PROV-ID
PIC X(00008).
15 W1C48141-C-RNDR-NPI-ID
PIC X(00010).
15 W1C48141-C-RNDR-TXNMY-CD
PIC X(00010).
15 W1C48141-C-RNDR-NTRPRS-ID
PIC X(00008).
15 W1C48141-C-DSTN-PROV-ID
PIC X(00008).
15 W1C48141-P-TY-CD
PIC X(00003).
15 W1C48141-P-SPECL-CD
PIC X(00003).
15 W1C48141-C-SUBM-FAM-PLN-IND
PIC X(00001).
15 W1C48141-C-SUBM-EPSDT-IND
PIC X(00001).
15 W1C48141-R-REV-CD
PIC X(00007).
15 W1C48141-R-REV-TY-CD
PIC X(00001).
15 W1C48141-B-LEVEL-OF-CARE-CD
PIC X(00003).
15 W1C48141-C-LI-UB92-RATE-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-NN-CVRD-CHRG-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-LI-FUT-1-CD
PIC X(00003).
15 W1C48141-C-LI-FUT-2-CD
PIC X(00003).
15 W1C48141-C-LI-FUT-1-IND
PIC X(00001).
15 W1C48141-C-LI-FUT-2-IND
PIC X(00001).
15 W1C48141-C-LI-FUT-1-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-LI-FUT-2-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-LI-COST-CNTR-CD
PIC X(00005).
15 W1C48141-C-LI-ATT-1ST-CD
PIC X(00002).
15 W1C48141-C-LI-ATT-2ND-CD
PIC X(00002).
15 W1C48141-C-LI-ATT-3RD-CD
PIC X(00002).
15 W1C48141-C-LI-FUT-3-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-LI-FUT-4-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-LI-NDC-UNT-CD
PIC X(00002).
15 W1C48141-C-LI-NDC-UNT-NUM
PIC S9(00007)V9(00002) COMP-3.
05 W1C48141-C-LI-CAP-GRP-PHYS.
10 W1C48141-C-LI-CAP-VW
OCCURS 0 TO 0014 TIMES
DEPENDING ON W1C48141-C-LI-CAP-NUM
INDEXED BY W1C48141-C-LI-CAP-VW-X .
15 W1C48141-C-LI-NUM
PIC S9(00003) COMP.
15 W1C48141-H-COHRT-NUM
PIC X(00003).
15 W1C48141-H-SVC-AREA-CD
PIC X(00001).
15 W1C48141-H-PLN-RATE-BEG-DT
PIC X(00010).
05 W1C48141-C-LI-MCARE-MED-GRP-PH.
10 W1C48141-C-LI-MCARE-VW
OCCURS 0 TO 0014 TIMES
DEPENDING ON W1C48141-C-LI-REC-MCARE-NUM
INDEXED BY W1C48141-C-LI-MCARE-VW-X .
15 W1C48141-C-LI-NUM
PIC S9(00003) COMP.
15 W1C48141-C-LI-MCARE-COI-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-LI-MCARE-DED-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-LI-MCARE-PD-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-LI-MCAR-ALLW-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-LI-MCARE-STAT-CD
PIC X(00001).
15 W1C48141-C-LI-MCAR-O-PR-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-LI-MCARE-PSY-AMT
PIC S9(00009)V9(00002) COMP-3.
05 W1C48141-C-LI-COB-MED-GRP-PHYS.
10 W1C48141-C-LI-COB-VW
OCCURS 0 TO 0070 TIMES
DEPENDING ON W1C48141-C-LI-COB-NUM
INDEXED BY W1C48141-C-LI-COB-VW-X .
15 W1C48141-C-LI-NUM
PIC S9(00003) COMP.
15 W1C48141-C-COB-LI-PYR-ID
PIC X(00015).
15 W1C48141-C-COB-PD-PROC-CD
PIC X(00008).
15 W1C48141-C-LI-PYR-PYMT-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-COB-LI-ADJUD-DT
PIC X(00010).
15 W1C48141-C-COB-REFER-LI-NUM
PIC S9(00003) COMP.
05 W1C48141-C-LI-CAS-MED-GRP-PHYS.
10 W1C48141-C-CAS-VW
OCCURS 0 TO 0280 TIMES
DEPENDING ON W1C48141-C-LI-CAS-NUM
INDEXED BY W1C48141-C-CAS-VW-X .
15 W1C48141-C-LI-NUM
PIC S9(00003) COMP.
15 W1C48141-C-CAS-PYR-ID
PIC X(00015).
15 W1C48141-C-CAS-PROC-CD
PIC X(00008).
15 W1C48141-C-CAS-GRP-CD
PIC X(00002).
15 W1C48141-C-CAS-RSN-CD
PIC X(00005).
15 W1C48141-C-CAS-AMT
PIC S9(00009)V9(00002) COMP-3.
15 W1C48141-C-CAS-UNT-NUM
PIC S9(00009) COMP.
05 W1C48141-C-LI-BSE-CHG-MED-GR-P.
10 W1C48141-C-LI-BSE-CHG-VW
OCCURS 0 TO 0112 TIMES
DEPENDING ON W1C48141-C-LI-BSE-CHG-NUM
INDEXED BY W1C48141-C-LI-BSE-CHG-VW-X .
15 W1C48141-C-LI-NUM
PIC S9(00003) COMP.
15 W1C48141-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C48141-C-BSE-CHNG-RSN-CD
PIC X(00002).
15 W1C48141-C-BSE-AMT-CHG-AMT
PIC S9(00009)V9(00002) COMP-3.
05 W1C48141-C-LI-EXC-GRP-PHYS.
10 W1C48141-C-LI-EXC-VW
OCCURS 0 TO 0210 TIMES
DEPENDING ON W1C48141-C-LI-EXC-NUM
INDEXED BY W1C48141-C-LI-EXC-VW-X .
15 W1C48141-C-LI-NUM
PIC S9(00003) COMP.
15 W1C48141-R-CLM-EXC-CD
PIC X(00004).
15 W1C48141-C-LI-EXC-CLRK-ID
PIC X(00007).
15 W1C48141-C-EXC-STAT-CD
PIC X(00001).
15 W1C48141-R-EXC-FORCE-APP-CD
PIC X(00001).
15 W1C48141-R-FORCE-DENY-CD
PIC X(00001).
05 W1C48141-C-LI-OVRRD-EOB-M-GRP.
10 W1C48141-C-LI-OVRRD-EOB-VW
OCCURS 0 TO 0020 TIMES
DEPENDING ON W1C48141-C-LI-OVRD-EOB-NUM
INDEXED BY W1C48141-C-LI-OVRRD-EOB-VW-X .
15 W1C48141-C-LI-NUM
PIC S9(00003) COMP.
15 W1C48141-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C48141-C-OVRRD-EOB-CD
PIC X(00004).
15 W1C48141-C-OVRRD-EOB-ID
PIC X(00007).
05 W1C48141-C-LI-OVRRD-EXC-M-GRP.
10 W1C48141-C-LI-OVRRD-EXC-VW
OCCURS 0 TO 0020 TIMES
DEPENDING ON W1C48141-C-LI-OVRD-EXC-NUM
INDEXED BY W1C48141-C-LI-OVRRD-EXC-VW-X .
15 W1C48141-C-LI-NUM
PIC S9(00003) COMP.
15 W1C48141-C-SEQ-NUM
PIC S9(00002) COMP.
15 W1C48141-C-OVRRD-EXC-CD
PIC X(00004).
15 W1C48141-C-OVRRD-EXC-ID
PIC X(00007).
05 W1C48141-C-LI-AUX-GRP-PHYS.
10 W1C48141-C-LI-AUX-VW
OCCURS 0 TO 0014 TIMES
DEPENDING ON W1C48141-C-LI-AUX-NUM
INDEXED BY W1C48141-C-LI-AUX-VW-X .
15 W1C48141-C-LI-NUM
PIC S9(00003) COMP.
15 W1C48141-C-ATT-1ST-CNTL-NUM
PIC X(00015).
15 W1C48141-C-ATT-1ST-XMIT-CD
PIC X(00002).
15 W1C48141-C-ATT-1ST-RECD-IND
PIC X(00001).
15 W1C48141-C-ATT-2ND-CNTL-NUM
PIC X(00015).
15 W1C48141-C-ATT-2ND-XMIT-CD
PIC X(00002).
15 W1C48141-C-ATT-2ND-RECD-IND
PIC X(00001).
15 W1C48141-C-ATT-3RD-CNTL-NUM
PIC X(00015).
15 W1C48141-C-ATT-3RD-XMIT-CD
PIC X(00002).
15 W1C48141-C-ATT-3RD-RECD-IND
PIC X(00001).
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE
HMS ENCOUNTER CLAIMS INTERFACE
|Description: |
|This interface consists of a copy of the flat file of monthly encounter claims, both paid and denied, which is sent to HMS (Maximus). The layouts are the Omnicaid internal flat file layouts. A |
|control totals file is produced containing a table identifier, date produced, and a record count. |
|NEWM.PROD.C4502SC.&MTHYR, where MTH is a three character abbreviation for the month, and YR is a two digit number for the year, eg NEWM.PROD.C4502SC.APR07. This file is created during the |
|monthly reporting process. Contains a record for each encounter claim adjudicated during the prior month. |
|Target Files: |
|HMS encounter claims file. |
|Reports: |
|N/A |
|Remarks: |
|Detailed output file layouts and specifications are not included for this interface since it is a simple copy of the Omnicaid monthly encounter claims file. The record layouts are the same as the|
|FFS claims layout defined above. |
|A example follows of the control totals file for the Encounter claims: |
|ENCTRCLM 2016-03-09 003619998 |
NEW MEXICO OMNICAID MMIS PROVIDER SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE LAYOUT
WELLS FARGO PAYMENT INTERFACE
|Description: |
|An interface file containing Provider EFT payment information will be created weekly for submission to Wells Fargo for processing. The weekly Payment Update Process (Job NMCW4560) will create a |
|file of the Providers and amounts that will be paid using EFT, then program NMMC4592 reads that file to create the Wells Fargo Payment file. |
|Source Tables: |
|(G_PARAM_DTL_TB) |
| |
|Target Files: |
|Wells Fargo EFT Payment File |
|Reports: |
|N/A |
|Remarks: |
|N/A |
NEW MEXICO MMIS PROVIDER SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE LAYOUT
WELLS FARGO PAYMENT INTERFACE
Record Layout:
*
*** FILE HEADER RECORD
*
01 WK-300-FILE-HDR-REC
05 WK-300-RECORD-TYPE PIC X(01)
05 WK-300-PRIORITY-CODE PIC X(02)
05 WK-300-IMM-DESTINATION PIC X(10)
05 WK-300-ORIGIN-NUM PIC X(10)
05 WK-300-CREAT-DT PIC X(06)
05 WK-300-CREAT-TM PIC X(04)
05 WK-300-FILE-ID PIC X(01)
05 WK-300-REC-SIZ PIC X(03)
05 WK-300-BLCK-FACTOR PIC X(02)
05 WK-300-FORMAT-CD PIC X(01)
05 WK-300-DESTINATION PIC X(23)
05 WK-300-COMPANY-NAM PIC X(23)
05 WK-300-REF-COD PIC X(08)
NEW MEXICO MMIS PROVIDER SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE LAYOUT
WELLS FARGO PAYMENT INTERFACE
*
*** WELLS FARGO SECURITY RECORD
*
01 WK-299-SECURITY-REC.
05 FILLER PIC X(22)
05 FILLER PIC X(16)
05 FILLER PIC X(56)
*
*** COMPANY HEADER RECORD
*
01 WK-310-COMPANY-HDR-REC
05 WK-310-RECORD-TYPE PIC X(01)
05 WK-310-SRV-CLASS-CD PIC X(03)
05 WK-310-COMPANY-NAME PIC X(16)
05 WK-310-COMPANY-DISC-DATA PIC X(20)
05 WK-310-COMPANY-ID PIC X(10)
05 WK-310-STAND-ENTR-CLASS-CD PIC X(03)
05 WK-310-COMPANY-ENTRY-DESC PIC X(10)
05 WK-310-COMPANY-DESC-DT PIC X(06)
05 WK-310-EFF-ENTRY-DT PIC X(06)
05 WK-310-SETTLEMENT-DT PIC X(03)
05 WK-310-ORIGIN-ST-CD PIC X(01)
05 WK-310-ORIGIN-DFI-ID PIC X(08)
05 WK-310-BAT-NUM PIC 9(07)
*
*** ENTRY DETAIL RECORD
*
01 WK-320-ENTRY-DTL-REC.
05 WK-320-RECORD-TYPE PIC X(01)
05 WK-320-TRANS-CD PIC X(02)
05 WK-320-ROUTING-NUM PIC 9(08)
05 WK-320-ROUTING-CHK-DIGIT PIC 9(01)
05 WK-320-DFI-ACCOUNT-NUM PIC X(17)
05 WK-320-AMOUNT PIC 9(08)V9(02)
05 WK-320-PAYEE-ID PIC X(15)
05 WK-320-PAYEE-NAME PIC X(22)
05 WK-320-BOA-DRAFT-IND PIC X(02)
05 WK-320-ADDENDA-REC-IND PIC X(01)
05 WK-320-TRACE-NUM PIC X(15)
*
*** ENTRY RE-ASSOCIATION RECORD
*
01 WK-325-COMPANY-REASSOC-REC.
05 WK-325-RECORD-TYPE PIC X(01) VALUE '7'.
05 WK-325-ADDENDA-TYPE-CD PIC X(02) VALUE '05'.
05 WK-325-TRN PIC X(03) VALUE 'TRN'.
05 WK-325-TRACE-TY-CD PIC X(01) VALUE '1'.
05 WK-325-EFT-TRACE-NUM PIC X(15).
05 WK-325-COMPANY-ID PIC X(10) VALUE '1856000560'.
05 WK-325-REF-ID-RA-NUM PIC X(10).
05 FILLER PIC X(41) VALUE SPACES.
05 WK-325-ADDENDA-SEQ-NUM PIC 9(04) VALUE 0.
05 WK-325-DETAIL-SEQ-NUM PIC 9(07) VALUE 0.
*
NEW MEXICO MMIS PROVIDER SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE LAYOUT
WELLS FARGO PAYMENT INTERFACE
*
*** COMPANY TRAILER RECORD
*
01 WK-330-COMPANY-TRAIL-REC.
05 WK-330-RECORD-TYPE PIC X(01)
05 WK-330-SRV-CLASS-CD PIC X(03)
05 WK-330-ENTRY-REC-COUNT PIC 9(06)
05 WK-330-ENTRY-HASH PIC 9(10)
05 WK-330-TOTAL-DEB-BAT-AMT PIC 9(10)V9(02)
05 WK-330-TOTAL-CRE-BAT-AMT PIC 9(10)V9(02)
05 WK-330-COMPANY-ID PIC X(10)
05 WK-330-FILLER PIC X(25)
05 WK-330-ORIGIN-DFI-ID PIC X(08)
05 WK-330-BAT-NUM PIC 9(07)
*
*** FILE CONTROL RECORD
*
01 WK-340-FILE-CTRL-REC.
05 WK-340-RECORD-TYPE PIC X(01)
05 WK-340-BAT-CNT PIC 9(06)
05 WK-340-BLCK-CNT PIC 9(06)
05 WK-340-ENTRY-CNT PIC 9(08)
05 WK-340-ENTRY-HASH PIC 9(10)
05 WK-340-TOT-DEB-BAT-AMT PIC 9(10)V9(02)
05 WK-340-TOT-CRE-BAT-AMT PIC 9(10)V9(02)
05 WK-340-FILLER PIC X(39)
NEW MEXICO MMIS PROVIDER SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE LAYOUT
WELLS FARGO PAYMENT INTERFACE
|Source |Source |Target | | | |Note |
|Table |Column |Field |Req |Def |Specifications |Ref |
| | | | | | | |
|N/A |N/A |WK-300-RECORD-TYPE |A |N/A |Value will be “1” | |
|N/A |N/A |WK-300-PRIORITY-CODE |A |N/A |Value will be “01” | |
|N/A |N/A |WK-300-IMM-DESTINATION |A |N/A |Value will be “091000019” | |
|N/A |N/A |WK-300-ORIGIN-NUM |A |N/A |Value will be “8560005601” | |
|N/A |N/A |WK-300-CREAT-DT |A |N/A |Run Date in YYMMDD format | |
|N/A |N/A |WK-300-CREAT-TM |A |N/A |Run Time in HHMM Format | |
|N/A |N/A |WK-300-FILE-ID |A |N/A |Value will be “A” | |
|N/A |N/A |WK-300-REC-SIZ |A |N/A |Value will be “094” | |
|N/A |N/A |WK-300-BLCK-FACTOR |A |N/A |Value will be “10” | |
|N/A |N/A |WK-300-FORMAT-CD |A |N/A |Value will be “1” | |
|N/A |N/A |WK-300-DESTINATION |A |N/A |Value will be “WELLS FARGO” | |
|N/A |N/A |WK-300-COMPANY-NAM |A |N/A |Value will be “NM HSD-MEDICAID ACH PYT” | |
|N/A |N/A |WK-300-REF-COD |A |N/A |Value will be “WKLYPYMT” | |
| | | | | | | |
|N/A |N/A |WK-310-RECORD-TYPE |A |N/A |Value will be “5” | |
|N/A |N/A |WK-310-SRV-CLASS-CD |A |N/A |Value will be “220” | |
|N/A |N/A |WK-310-COMPANY-NAME |A |N/A |Value will be “NM HSD-MCAID ACH” | |
|N/A |N/A |WK-310-COMPANY-DISC-DATA |N |N/A |Value will be spaces | |
|N/A |N/A |WK-310-COMPANY-ID |A |N/A |Value will be “8560005601” | |
|N/A |N/A |WK-310-STAND-ENTR-CLASS-CD |A |N/A |Value will be “CCD” | |
|N/A |N/A |WK-310-COMPANY-ENTRY-DESC |A |N/A |Value will be “HCCLAIMPMT” | |
|N/A |N/A |WK-310-EFF-ENTRY-DT |A |N/A |Run Date in YYMMDD format | |
|G_PARAM_DTL_TB |G_PARAM_VALUE_DT |WK-310-SETTLEMENT-DT |N |N/A |This is the date (in YYMMDD format) the EFT payments will |1 |
| | | | | |be released by WF | |
|N/A |N/A |WK-310-ORIGIN-ST-CD |A |N/A |Value will be “1” | |
|N/A |N/A |WK-310-ORIGIN-DFI-ID |A |N/A |Value will be “09100001” | |
|N/A |N/A |WK-310-BAT-NUM |A |N/A |Value will be 1 | |
| | | | | | | |
|N/A |N/A |WK-320-RECORD-TYPE |A |N/A |Value will be “6” | |
|Payment File |WFC81250-EFT-ACCT-TY |WK-320-TRANS-CD |A |N/A |If this is a Checking Account (P_ACCT_TY_CD = “C”), value | |
| | | | | |is “22”. If this is a Savings Account (P_ACCT_TY_CD = | |
| | | | | |“S”), value is “32”. If neither one, program aborts. | |
|Payment File |WFC81250-EFT-ROUT-NUM (1:8) |WK-320-ROUTING-NUM |A |N/A |First eight (8) digits of the Routing Number passed from | |
| | | | | |Payment file | |
|Payment File |WFC81250-EFT-ROUT-NUM (9:1) |WK-320-ROUTING-CHK-DIGIT |A |N/A |Last (ninth) digit of the Routing Number passed from | |
| | | | | |Payment file | |
|Payment File |WFC81250-EFT-ACCT-NUM |WK-320-DFI-ACCOUNT-NUM |A |N/A |Provider Account Number from Payment file | |
|Payment File |WFC81250-EFT-AMT |WK-320-AMOUNT |A |N/A |EFT Amount from Payment file | |
|Payment File |WFC81250-EFT-PAYEE-NUM |WK-320-PAYEE-ID |A |N/A |Provider ID Number from Payment file | |
|Payment File |WFC81250-EFT-PAYEE-NAME |WK-320-PAYEE-NAME |A |N/A |Provider Business Name from Payment file | |
|N/A |N/A |WK-320-BOA-DRAFT-IND |N |N/A |Value will be spaces | |
|N/A |N/A |WK-320-ADDENDA-REC-IND |A |N/A |Value will be “1”. | |
|Payment File |WFC81250-EFT-TRACE-ID |WK-320-TRACE-NUM |A |N/A |EFT Trace Number from Payment file | |
| | | | | | | |
|N/A |N/A |WK-325-RECORD-TYPE |A |N/A |Value will be “7” | |
|N/A |N/A |WK-325-ADDENDA-TYPE-CD |A |N/A |Value will be “05”. | |
|N/A |N/A |WK-325-TRN |A |N/A |Value will be “TRN” | |
|N/A |N/A |WK-325-TRACE-TY-CD |A |N/A |Value will be “1” | |
|Payment File |WFC81250-EFT-TRACE-ID |WK-325-EFT-TRACE-NUM |A |N/A |EFT Trace Number from Payment file | |
|N/A |N/A |WK-325-COMPANY-ID |A |N/A |Value will be '1856000560' | |
|Payment File |WFC81250-EFT-RA-NUM |WK-325-REF-ID-RA-NUM |A |N/A |EFT RA Number from Payment file | |
|N/A | |WK-325-ADDENDA-SEQ-NUM |A |N/A |Value 0 increments +1 for ever entry | |
|N/A |WFC81250-EFT-TRACE-ID |WK-325-DETAIL-SEQ-NUM |A |N/A |The last 7 digits from the EFT Trace ID | |
| | | | | | | |
|N/A |N/A |WK-330-RECORD-TYPE |A |N/A |Value will be “8” | |
|N/A |N/A |WK-330-SRV-CLASS-CD |A |N/A |Value will be “220” | |
|N/A |program generated |WK-330-ENTRY-REC-COUNT |A |N/A |Total number of Detail (Type = “6”) records | |
|N/A |program generated |WK-330-ENTRY-HASH |A |N/A |This is the ten (10) low-order digits of the sum of all the| |
| | | | | |Routing Numbers (excluding the Check Digit) in this file | |
|N/A |N/A |WK-330-TOTAL-DEB-BAT-AMT |A |N/A |Value will be 0 | |
|Payment File |WFC81250-EFT-AMT |WK-330-TOTAL-CRE-BAT-AMT |A |N/A |This is the sum of all EFT Amounts from the Detail records | |
|N/A |N/A |WK-330-COMPANY-ID |A |N/A |Value will be “8560005601” | |
|N/A |N/A |WK-330-FILLER |N |N/A |Value will be spaces | |
|N/A |N/A |WK-330-ORIGIN-DFI-ID |A |N/A |Value will be “09100001” | |
|N/A |N/A |WK-330-BAT-NUM |A |N/A |Value will be 1 | |
| | | | | | | |
|N/A |N/A |WK-340-RECORD-TYPE |A |N/A |Value will be “9” | |
|N/A |N/A |WK-340-BAT-CNT |A |N/A |Value will be 1 | |
|N/A |program generated |WK-340-BLCK-CNT |A |N/A |This is the total number of record blocks in the file. The| |
| | | | | |program calculates this number as the total number of | |
| | | | | |records in the file (including Block Filler records) | |
| | | | | |divided by ten (10). | |
|N/A |program generated |WK-340-ENTRY-CNT |A |N/A |Total number of Detail (Type = “6”) records | |
|N/A |program generated |WK-340-ENTRY-HASH |A |N/A |This is the ten (10) low-order digits of the sum of all the| |
| | | | | |Routing Numbers (excluding the Check Digit) in this file | |
|N/A |N/A |WK-340-TOT-DEB-BAT-AMT |A |N/A |Value will be 0 | |
|Payment File |WFC81250-EFT-AMT |WK-340-TOT-CRE-BAT-AMT |A |N/A |This is the sum of all EFT Amounts from the Detail records | |
|N/A |N/A |WK-340-FILLER |N |N/A |Value will be spaces | |
Notes:
1. NMMC4592 searches the System Parameter table with SubSys Code = “C” and Param Number = “4806” to find the row that encompasses the Payment Date passed in the EFT Payment file. The Param Value Date for that row is then reformatted and moved to WK-310-SETTLEMENT-DT.
2. WF requires that all files be in multiples of ten (10) records. The program adds enough “pad” records to make that happen.
LEGEND: For Req: A = Always For Std Edits: D = Date Edit V = Valid Value Edit C = Conditionally N = Numeric Edits S = System Generated
N = Never
NEW MEXICO OMNICAID MMIS PROVIDER SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE LAYOUT
WELLS FARGO REJECTS INTERFACE
|Description: |
|Wells fargo performs high-level edits of any Prenote or Payment file they receive and responds with an Rejects file within ninety minutes of input file receipt. The Rejects file indicates that |
|the Prenote or Payment file was accepted, plus lists any errors that were encountered on the detail lines. |
|Source Files: |
|WF Rejects Acknowledgement file |
| |
|Target Tables: |
|Provider EFT Account Table (P_EFT_ACCT_TB) |
|Reports: |
|RC105 – Wells Fargo Returns Report |
|Remarks: |
|N/A |
NEW MEXICO MMIS PROVIDER SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE LAYOUT
WELLS FARGO REJECTS INTERFACE
Record Layout:
01 WK-600-INPUT-FILE-STAT-RCD
05 WK-600-RECORD-ID-CODE PIC X(01)
05 FILLER PIC X(22)
05 WK-600-BOA-TRANS-DATE
10 WK-600-T-DATE-YY PIC X(02)
10 WK-600-T-DATE-MM PIC X(02)
10 WK-600-T-DATE-DD PIC X(02)
05 WK-600-BOA-TRANS-TIME
10 WK-600-T-TIME-HH PIC X(02)
10 WK-600-T-TIME-MM PIC X(02)
05 FILLER PIC X(46)
05 WK-600-FILE-STATUS PIC X(04)
05 WK-600-FILE-REJECT-CD PIC X(04)
05 FILLER PIC X(07)
*
NEW MEXICO MMIS PROVIDER SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE LAYOUT
WELLS FARGO REJECTS INTERFACE
Record Layout:
01 WK-620-REJECT-DETAIL-RCD
REDEFINES WK-600-INPUT-FILE-STAT-RCD
05 WK-620-RECORD-ID-CODE PIC X(01)
05 WK-620-TRAN-CODE PIC 9(02)
05 WK-620-ROUTING-TRANS-NUM
10 WK-620-ROUTING-NUM PIC X(08)
10 WK-620-CHECK-DIGIT PIC X(01)
05 WK-620-DFI-ACCOUNT-NUM PIC X(17)
05 WK-620-AMOUNT PIC 9(08)V9(02)
05 WK-620-PAYEE-ID PIC X(15)
05 FILLER PIC X(25)
05 WK-620-RCD-STATUS PIC X(04)
05 WK-620-DTL-REJECT-CD PIC X(04)
05 FILLER PIC X(07)
MEXICO MMIS PROVIDER SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE LAYOUT
WELLS FARGO REJECTS INTERFACE
|Source |Target |Target |Std | | | |Note |
|Field |Table |Column |Edit |Req |Def |Specifications |Ref |
| | | | | | |No other edits are performed on the 1 record | |
| | | | | | | | |
|WK620-RECORD-ID-CODE |N/A |N/A |N/A |A |N/A |Value must be “6” | |
|WK-620-PAYEE-ID |N/A |N/A |N/A |A |N/A |Moved to RC105 report; also used to determine which | |
| | | | | | |occurrence of the P_EFT_ACCT_TB will be updated | |
|WK-620-DFI-ACCOUNT-NUM |N/A |N/A |N/A |A |N/A |Moved to RC105 report | |
|WK-620-ROUTING-TRANS-NUM |N/A |N/A |N/A |A |N/A |Moved to RC105 report | |
|WK-620-TRAN-CODE |N/A |N/A |N/A |A |N/A |Moved to RC105 report | |
|WK-620-DTL-REJECT-CD |N/A |N/A |N/A |A |N/A |Moved to RC105 report | |
LEGEND: For Req: A = Always For Std Edits: D = Date Edit V = Valid Value Edit C = Conditionally N = Numeric Edits S = System Generated
N = Never
NEW MEXICO OMNICAID MMIS PROVIDER SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE LAYOUT
WELLS FARGO RETURNS AND NOTIFICATION OF CHANGE INTERFACE
|Description: |
|Wells fargo performs high-level edits of any Prenote or Payment file they receive and responds with an Acknowledgement file within thirty minutes of input file receipt. The Acknowledgement file |
|indicates that the Prenote or Payment file was accepted, plus lists any errors that were encountered on the detail lines. |
|Source Files: |
|WF Acknowledgement file |
| |
|Target Tables: |
|Provider EFT Account Table (P_EFT_ACCT_TB) |
|Reports: |
|RC105 – Wells fargo Returns Report |
|Remarks: |
|N/A |
NEW MEXICO MMIS PROVIDER SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE LAYOUT
WELLS FARGO RETURNS AND NOTIFICATION OF CHANGE INTERFACE
Record Layout:
*** RETURNS AND NOC FILE
*** . HEADER RECORD
*
01 WK-700-RETURN-FILE-RCD-1
05 WK-700-RCD-TYPE-CODE PIC X(01)
05 WK-700-PRIORITY-CODE PIC X(02)
05 WK-700-IMM-ORIGIN PIC X(10)
05 WK-700-IMM-DESTINATION PIC X(10)
05 WK-700-FILE-CREATION-DATE PIC X(06)
05 WK-700-FILE-CREATION-TIME PIC X(04)
05 FILLER PIC X(61)
*
01 WK-710-RETURN-FILE-RCD-5
05 WK-710-RCD-TYPE-CODE PIC X(01)
05 FILLER PIC X(52)
05 WK-710-FILE-TYPE PIC X(10)
05 FILLER PIC X(31)
NEW MEXICO MMIS PROVIDER SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE LAYOUT
WELLS FARGO RETURNS AND NOTIFICATION OF CHANGE INTERFACE
Record Layout:
01 WK-720-RETURN-FILE-RCD-6
05 WK-720-RCD-TYPE-CODE PIC X(01)
05 WK-720-TRAN-CODE PIC X(02)
05 WK-720-ROUTING-NUM PIC X(09)
05 WK-720-ACCOUNT-NUM PIC X(17)
05 WK-720-AMOUNT PIC 9(08)V9(02)
05 WK-720-PAYEE-ID PIC X(15)
05 FILLER PIC X(24)
05 WK-720-ADDENDA-FLAG PIC X(01)
05 FILLER PIC X(15)
01 WK-730-RETURN-FILE-RCD-7
05 WK-730-RCD-TYPE-CODE PIC X(01)
05 FILLER PIC X(02)
05 WK-730-REASON-CODE PIC X(03)
05 WK-730-TRACE-NUMBER PIC X(15)
05 WK-730-DATE-OF-DEATH PIC X(06)
05 FILLER PIC X(08)
05 WK-730-DESCRIPTION PIC X(44)
05 FILLER PIC X(15)
01 WK-740-RETURN-FILE-RCD-9
05 WK-740-RCD-TYPE-CODE PIC X(01)
05 WK-740-BATCH-COUNT PIC 9(06)
05 FILLER PIC X(87)
NEW MEXICO MMIS PROVIDER SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE LAYOUT
WELLS FARGO RETURNS AND NOTIFICATION OF CHANGE INTERFACE
|Source |Target |Target |Std | | | |Note |
|Field |Table |Column |Edit |Req |Def |Specifications |Ref |
|WK-740-BATCH-COUNT |N/A |N/A |N/A |A |N/A |If equal to zeroes, no errors were received | |
| | | | | | |No other edits are performed on the 9 record | |
| | | | | | | | |
|WK-700-RCD-TYPE-CODE |N/A |N/A |N/A |A |N/A |Value must be “1” | |
|WK-700-FILE-CREATION-DATE, | | | | | |Used to create Date & Time fields on the RC105 report | |
|WK-700-FILE-CREATION-TIME | | | | | | | |
| | | | | | |No other edits are performed on the 1 record | |
| | | | | | | | |
|WK-720-PAYEE-ID |N/A |N/A |N/A |A |N/A |Moved to RC105 report; also used to determine which | |
| | | | | | |occurrence of the P_EFT_ACCT_TB will be updated | |
|WK-720-ACCOUNT-NUM |N/A |N/A |N/A |A |N/A |Moved to RC105 report | |
|WK-720-ROUTING-NUM |N/A |N/A |N/A |A |N/A |Moved to RC105 report | |
|WK-720-TRAN-CODE |N/A |N/A |N/A |A |N/A |Moved to RC105 report | |
|WK-720-AMOUNT |
|Source File: |File Description: |
|Payorder Check Record File |Created during payment process. Contains a record for each warrant produced. |
|Target Files: |File Description: |
|Laser Check Print Interface file to operations |Detail transaction for each warrant produced by the MMIS in the payment cycle. |
|Reports: |
|RC059 - Check Register Summary Report |
|Remarks: |
|Program NMMC4590 |
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE LAYOUT
OUTPUT FILE
LASER CHECK PRINTING INTERFACE
01 WP-100-WARR-PRINT-FILE.
05 WP-100-PAY-CHK-PAYEE-NUM PIC X(09).
05 WP-100-PAY-CHK-PAYEE-NAME PIC X(45).
05 WP-100-PAY-CHK-ADDR1 PIC X(45).
05 WP-100-PAY-CHK-ADDR2 PIC X(45).
05 WP-100-PAY-CHK-CITY-STATE.
10 WP-100-PAY-CHK-CITY PIC X(20).
10 WP-100-PAY-CHK-STATE PIC X(02).
05 WP-100-PAY-CHK-ZIP PIC X(05).
05 WP-100-PAY-CHK-CHECK-DATE.
10 WP-100-PAY-CHK-CHECK-YY PIC X(02).
10 WP-100-PAY-CHK-CHECK-MM PIC X(02).
10 WP-100-PAY-CHK-CHECK-DD PIC X(02).
05 WP-100-PAY-CHK-CHECK-NUM PIC X(08).
05 WP-100-PAY-CHK-CHECK-AMT PIC 9(8)V99.
05 WP-100-PAY-CHK-RA-NO PIC 9(07).
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
LASER CHECK PRINTING INTERFACE
DETAIL RECORD
|Source Table |Source Field |Target Field | Req | | |Note |
| | | | |Def |Specifications |Ref |
|N/A |PAY-CHK-PAYEE-NAME |WP-100-PAY-CHK-PAYEE-NAME |N/A |N/A |Provider Name | |
|N/A |PAY-CHK-ADDR1 |WP-100-PAY-CHK-ADDR1 |N/A |N/A |Provider Address | |
|N/A |PAY-CHK-ADDR2 |WP-100-PAY-CHK-ADDR2 |N/A |N/A |Provider Address | |
|N/A |PAY-CHK-CITY |WP-100-PAY-CHK-CITY |N/A |N/A |Provider City | |
|N/A |PAY-CHK-STATE |WP-100-PAY-CHK-STATE |N/A |N/A |Provider State | |
|N/A |PAY-CHK-ZIP |WP-100-PAY-CHK-ZIP |N/A |N/A |Provider Zip | |
|N/A |PAY-CHK-DATE |WP-100-PAY-CHK-CHECK-DATE |N/A |N/A |Date Check Issued | |
|N/A |PAY-CHK-CHECK-NUM |WP-100-PAY-CHK-CHECK-NUM |N/A |N/A |Check Number | |
|N/A |PAY-CHK-CHECK-AMT |WP-100-PAY-CHK-CHECK-AMT |N/A |N/A |Amount of Check | |
|N/A |PAY-CHK-RA-NO |WP-100-PAY-CHK-RA-NO |N/A |N/A |RA # associated with check | |
________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
MMIS WARRANT STATE TREASURY INTERFACE
BALANCE RECORD
|Source Table |Source Field |Target Field | Req | | |Note |
| | | | |Def |Specifications |Ref |
|N/A |N/A |WARRANT-BAL-NUM |N/A |N/A |9999999 | |
|N/A |N/A |WARRANT-BAL-SOURCE |N/A |N/A |Value of “P” | |
|N/A |N/A |WARRANT-BAL-COUNT |N/A |N/A |Total count of warrants produced, not including | |
| | | | | |PAY-CHK-REC-TYPE = “S” (spoiled) | |
________________________________________________________________________________________________________________________________
LEGEND: For Req: A = Always
C = Conditionally
N = Never
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE SPECIFICATION
OUTPUT FILE
X835 ELECTRONIC REMITTANCE ADVICE INTERFACE
|Description: |
|This interface reads the payment file created during payment processing and creates the X835 Electronic Remittance Advice IRL file transmitted to EDI to send to the providers requesting X835s.|
| |
|Source File: |File Description: |
|Adjudicated Claims Payment File |Created during payment process. Contains a group of records for each claim paid or denied. |
|Target Files: |File Description: |
|X835 claims IRL file sent to EDI |IRL (Internal Record Layout) X835 file produced by the MMIS in the payment cycle. |
|Reports: |
|RC052 - X835 Electronic Remittance Advice Processing Report |
|Process Summaries |
|Remarks: |
|1. MCO providers, Capitation claims, and history only claims are eliminated from the C4568SA input file before the X835 process is run. |
|2. See the X835 EDI Crosswalk for a full explanation of each field. The crosswalk is located in the 11d-5exhb Exhibit section of system documentation. The field ‘Target Segment’ is provided in|
|the Interface Layout table below to assist in matching the fields on this table with the fields on the X835 crosswalk. |
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE LAYOUT
OUTPUT FILE
X835 ELECTRONIC REMITTANCE ADVICE INTERFACE
****************************************************************
* 835 - ISA INTERCHANGE
****************************************************************
*
01 X835-FILE-HEADER.
*
05 X835-HDR-SORT-KEY.
10 X835-HDR-FILE-ID
VALUE SPACES
PIC X(15).
10 X835-HDR-ROUTING-ID
VALUE SPACES
PIC X(15).
10 X835-HDR-DOCUMENT-SEQ-NUM
VALUE ZEROES
PIC 9(09).
10 X835-HDR-FILE-REC-SEQ-NUM
VALUE ZEROES
PIC 9(10).
*
05 X835-HDR-TX-CD
VALUE 'HDR'
PIC X(03).
*
* LOOP (NONE), SEGMENT ISA (INTERCHANGE)
*
05 X835-FILE-HEADER-SEG.
10 X835-FILE-VER-RELEASE-CD
PIC X(12).
10 X835-FILE-VER-NAME
PIC X(04).
10 X835-FILE-ISA-SENDER
PIC X(15).
10 X835-FILE-ISA-RECEIVER
PIC X(15).
10 X835-FILE-GS-SENDER
PIC X(15).
10 X835-FILE-GS-RECEIVER
PIC X(15).
********************************************************
* 835-TRANSACTION SET HEADER
********************************************************
*
01 X835-TX-HEADER.
*
05 X835-000-SORT-KEY.
10 X835-000-FILE-ID
VALUE SPACES
PIC X(15).
10 X835-000-ROUTING-ID
VALUE SPACES
PIC X(15).
10 X835-000-DOCUMENT-SEQ-NUM
VALUE ZEROES
PIC 9(09).
10 X835-000-FILE-REC-SEQ-NUM
VALUE ZEROES
PIC 9(10).
*
05 X835-000-TX-CD
VALUE '000'
PIC X(03).
*
* LOOP (NONE), SEGMENT ST (TRANSACTION HEADER)
*
05 X835-TX-HEADER-SEG.
10 X835-TX-ID
VALUE '835'
PIC X(03).
10 X835-TX-CTL-NUM
PIC X(09).
*
* LOOP (NONE), SEGMENT BPR (FINANCIAL INFO)
*
05 X835-BPR-SEG.
10 X835-TX-TRANS-HANDLING-CD
PIC X(02).
10 X835-TX-REIMB-AMT
PIC S9(16)V99.
10 X835-TX-CREDIT-DEBIT-CD
PIC X(01).
10 X835-TX-PMT-METHOD-CD
PIC X(03).
10 X835-TX-PMT-FORMAT-CD
PIC X(10).
10 X835-TX-SENDER-DFI-ID-QL
PIC X(02).
10 X835-TX-SENDER-DFI-ID
PIC X(12).
10 X835-TX-SENDER-ACCT-QL
PIC X(03).
10 X835-TX-SENDER-ACCT
PIC X(35).
10 X835-TX-SENDER-ID
PIC X(10).
10 X835-TX-SENDER-SUPL-CD
PIC X(09).
10 X835-TX-RCV-DFI-ID-QL
PIC X(02).
10 X835-TX-RCV-DFI-ID
PIC X(12).
10 X835-TX-RCV-ACCT-QL
PIC X(03).
10 X835-TX-RCV-ACCT
PIC X(35).
10 X835-TX-CHECK-EFT-DT
PIC X(08).
*
* LOOP (NONE), SEGMENT TRN (REASSOCIATION TRACE NUMBER)
*
05 X835-REASSOC-TRACE-SEG.
10 X835-TX-TRACE-TYP-CD
PIC X(02).
10 X835-TX-CHECK-EFT-TRACE-NUM
PIC X(50).
10 X835-TX-PYR-ID
PIC X(10).
10 X835-TX-PYR-SUPL-CD
PIC X(50).
*
* LOOP (NONE), SEGMENT CUR (FOREIGN CURRENCY INFO)
*
05 X835-CURRENCY-SEG.
10 X835-TX-CURRENCY-ENTY-CD
PIC X(03).
10 X835-TX-CURRENCY-CD
PIC X(03).
*
* LOOP (NONE), SEGMENT REF (RECEVIER ID)
*
05 X835-RCV-ID-SEG.
10 X835-TX-RCV-ID-CD
PIC X(03).
10 X835-TX-RCV-ID
PIC X(50).
*
* LOOP (NONE), SEGMENT REF (VERSION ID)
*
05 X835-VER-ID-SEG.
10 X835-TX-VER-ID-CD
PIC X(03).
10 X835-TX-VER-ID
PIC X(50).
*
* LOOP (NONE), SEGMENT DTM (PRODUCTION DATE)
*
05 X835-PROD-DT-SEG.
10 X835-TX-PROD-DT-CD
PIC X(03).
10 X835-TX-PROD-DT
PIC X(08).
*
****************************************************************
* 835 - PAYER IDENTIFICATION LOOP
****************************************************************
*
01 X835-PYR-ID.
*
05 X835-010-SORT-KEY.
10 X835-010-FILE-ID
VALUE SPACES
PIC X(15).
10 X835-010-ROUTING-ID
VALUE SPACES
PIC X(15).
10 X835-010-DOCUMENT-SEQ-NUM
VALUE ZEROES
PIC 9(09).
10 X835-010-FILE-REC-SEQ-NUM
VALUE ZEROES
PIC 9(10).
*
05 X835-010-TX-CD
VALUE '010'
PIC X(03).
05 X835-REC-TYP-010-CTR.
10 X835-PYR-SEC-ID-SEG-CTR
PIC 9(02).
10 X835-PYR-COMM-CTR
PIC 9(02).
*
* LOOP 1000A, SEGMENT N1 (PAYER NAME)
*
05 X835-PYR-NAME-SEG.
10 X835-PYR-ENTY-CD
PIC X(03).
10 X835-PYR-NM
PIC X(60).
10 X835-PYR-PLAN-ID-QL
PIC X(02).
10 X835-PYR-ID-CD
PIC X(80).
*
* LOOP 1000A, SEGMENT N3 (PAYER ADDRESS)
*
05 X835-PYR-ADDR-SEG.
10 X835-PYR-ADDR-1
PIC X(55).
10 X835-PYR-ADDR-2
PIC X(55).
*
* LOOP 1000A, SEGMENT N4 (PAYER CITY, STATE)
*
05 X835-PYR-CITY-ST-SEG.
10 X835-PYR-CITY
PIC X(30).
10 X835-PYR-ST
PIC X(02).
10 X835-PYR-ZIP
PIC X(15).
10 X835-PYR-CNTRY
PIC X(03).
10 X835-PYR-CNTRY-SUB
PIC X(03).
*
* LOOP 1000A, SEGMENT REF (ADDITIONAL PAYER IDS)
*
05 X835-PYR-SEC-ID-SEG
OCCURS 0 TO 4 TIMES DEPENDING ON
X835-PYR-SEC-ID-SEG-CTR.
*
10 X835-PYR-SEC-ID-CD
PIC X(03).
10 X835-PYR-SEC-ID
PIC X(50).
*
* LOOP 1000A, SEGMENT PER (PAYER CONTACT)
*
05 X835-PYR-CONTACT-INFO-SEG.
10 X835-PYR-CONTACT-CD
PIC X(02).
10 X835-PYR-CONTACT-NM
PIC X(60).
10 X835-PYR-COMM
OCCURS 0 TO 3 TIMES
DEPENDING ON X835-PYR-COMM-CTR.
15 X835-PYR-COMM-QL
PIC X(02).
15 X835-PYR-COMM-NUM
PIC X(256).
*
05 X835-PYR-WEB-INFO-SEG.
10 X835-PYR-WEB-CD
PIC X(02).
10 X835-PYR-WEB-COMM.
15 X835-PYR-WEB-COMM-QL
PIC X(02).
15 X835-PYR-WEB-COMM-NUM
PIC X(256).
*
****************************************************************
* 835 - PAYER-TECHNICIAL-CONTACT-INFORMATION
****************************************************************
*
01 X835-TECH-CONTACT-INFO.
*
05 X835-011-SORT-KEY.
10 X835-011-FILE-ID
VALUE SPACES
PIC X(15).
10 X835-011-ROUTING-ID
VALUE SPACES
PIC X(15).
10 X835-011-DOCUMENT-SEQ-NUM
VALUE ZEROES
PIC 9(09).
10 X835-011-FILE-REC-SEQ-NUM
VALUE ZEROES
PIC 9(10).
*
05 X835-011-TX-CD
VALUE '011'
PIC X(03).
05 X835-REC-TYP-011-CTR.
10 X835-PYR-TECH-CTR
PIC 9(02).
*
* LOOP 1000A, SEGMENT PER (PAYER TECHNICAL CONTACT INFORMATION)
*
05 X835-PYR-TECH-CONTACT-INFO-SEG.
10 X835-PYR-TECH-CONTACT-CD
PIC X(02).
10 X835-PYR-TECH-CONTACT-NM
PIC X(60).
10 X835-PYR-TECH-COMM
OCCURS 0 TO 3 TIMES
DEPENDING ON X835-PYR-TECH-CTR.
15 X835-PYR-TECH-COMM-QL
PIC X(02).
15 X835-PYR-TECH-COMM-NUM
PIC X(256).
*
****************************************************************
* 835 -PAYEE-IDENTIFICATION
****************************************************************
*
01 X835-PAYEE-ID.
*
05 X835-020-SORT-KEY.
10 X835-020-FILE-ID
VALUE SPACES
PIC X(15).
10 X835-020-ROUTING-ID
VALUE SPACES
PIC X(15).
10 X835-020-DOCUMENT-SEQ-NUM
VALUE ZEROES
PIC 9(09).
10 X835-020-FILE-REC-SEQ-NUM
VALUE ZEROES
PIC 9(10).
*
05 X835-020-TX-CD
VALUE '020'
PIC X(03).
*
* LOOP 1000B, SEGMENT N1 (PAYEE NAME)
*
05 X835-PAYEE-ID-SEG.
10 X835-PAYEE-ENTY-CD
PIC X(03).
10 X835-PAYEE-NM
PIC X(60).
10 X835-PAYEE-ID-QL
PIC X(02).
10 X835-PAYEE-PLAN-ID
PIC X(80).
*
* LOOP 1000B, SEGMENT N3 (PAYEE ADDRESS)
*
05 X835-PAYEE-ADDR-SEG.
10 X835-PAYEE-ADDR-1
PIC X(55).
10 X835-PAYEE-ADDR-2
PIC X(55).
*
* LOOP 1000B, SEGMENT N4 (PAYEE CITY, STATE)
*
05 X835-PAYEE-CITY-ST-SEG.
10 X835-PAYEE-CITY
PIC X(30).
10 X835-PAYEE-ST
PIC X(02).
10 X835-PAYEE-ZIP
PIC X(15).
10 X835-PAYEE-CNTRY
PIC X(03).
10 X835-PAYEE-CNTRY-SUB
PIC X(03).
*
* LOOP 1000B, SEGMENT RDM (REMIT DELIVERY METHOD)
*
05 X835-REMIT-DELIVERY-SEG.
10 X835-PAYEE-REMIT-RPT-TRANS-CD
PIC X(02).
10 X835-PAYEE-REMIT-RPT-GOTO-NM
PIC X(60).
10 X835-PAYEE-REMIT-RPT-COMM-NUM
PIC X(256).
*
*************************************************************
* 835 - PAYEE-ADDITIONAL-IDENTIFICATION
*************************************************************
*
01 X835-PAYEE-ADDL-ID.
*
05 X835-021-SORT-KEY.
10 X835-021-FILE-ID
VALUE SPACES
PIC X(15).
10 X835-021-ROUTING-ID
VALUE SPACES
PIC X(15).
10 X835-021-DOCUMENT-SEQ-NUM
VALUE ZEROES
PIC 9(09).
10 X835-021-FILE-REC-SEQ-NUM
VALUE ZEROES
PIC 9(10).
*
05 X835-021-TX-CD
VALUE '021'
PIC X(03).
*
* LOOP 1000B SEGMENT REF (ADDITIONAL PAYEE ID)
*
05 X835-ADDNL-PAYEE-ID-SEG.
10 X835-PAYEE-SEC-ID-CD
PIC X(03).
10 X835-PAYEE-SEC-ID
PIC X(50).
*
****************************************************************
* 835-HEADER-NUMBER *
****************************************************************
*
01 X835-PROV-SUM.
*
05 X835-030-SORT-KEY.
10 X835-030-FILE-ID
VALUE SPACES
PIC X(15).
10 X835-030-ROUTING-ID
VALUE SPACES
PIC X(15).
10 X835-030-DOCUMENT-SEQ-NUM
VALUE ZEROES
PIC 9(09).
10 X835-030-FILE-REC-SEQ-NUM
VALUE ZEROES
PIC 9(10).
*
05 X835-030-TX-CD
VALUE '030'
PIC X(03).
*
* LOOP 2000, SEGMENT LX (HEADER NUMBER)
*
05 X835-PROV-SUM-SEG.
10 X835-HN-PROV-LX-NUM
PIC 9(06).
*
* LOOP 2000, SEGMENT TS3 (PROV SUMMARY INFO)
*
05 X835-PROV-SUM-INFO-SEG.
10 X835-HN-SUM-PROV-ID
PIC X(50).
10 X835-HN-SUM-TYP-FAC
PIC X(02).
10 X835-HN-SUM-FISCAL-YR-END-DT
PIC X(08).
10 X835-HN-SUM-NUM-OF-CLM
PIC 9(15).
10 X835-HN-SUM-TOT-CHRGS
PIC S9(16)V99.
10 X835-HN-SUM-TOT-MSP-PYR-AMT
PIC S9(16)V99.
10 X835-HN-SUM-TOT-NON-LAB-AMT
PIC S9(16)V99.
10 X835-HN-TOT-HCPCS-CHRG
PIC S9(16)V99.
10 X835-HN-TOT-HCPCS-REIMB
PIC S9(16)V99.
10 X835-HN-TOT-PROF-COMP-AMT
PIC S9(16)V99.
10 X835-HN-TOT-MSP-PAT-LIAB-MET
PIC S9(16)V99.
10 X835-HN-TOT-PAT-REIMB
PIC S9(16)V99.
10 X835-HN-TOT-PIP-CLM-CNT
PIC 9(15).
10 X835-HN-TOT-PIP-ADJ-AMT
PIC S9(16)V99.
*
* LOOP 2000, SEGMENT TS2 (PROV SUPPLEMENTAL SUMMARY INFO)
*
05 X835-PROV-SUPL-SEG.
10 X835-HN-TOT-DRG-AMT
PIC S9(16)V99.
10 X835-HN-TOT-FED-SPECIFIC
PIC S9(16)V99.
10 X835-HN-TOT-HOSP-SPECIFIC
PIC S9(16)V99.
10 X835-HN-TOT-DISPROP-SHARE
PIC S9(16)V99.
10 X835-HN-TOT-CAP-AMT
PIC S9(16)V99.
10 X835-HN-TOT-INDIR-MED-EDUC
PIC S9(16)V99.
10 X835-HN-TOT-OL-DAYS
PIC S9(15).
10 X835-HN-TOT-DAY-OL-AMT
PIC S9(16)V99.
10 X835-HN-TOT-COST-OL-AMT
PIC S9(16)V99.
10 X835-HN-AVG-DRG-LOS
PIC S9(15).
10 X835-HN-TOT-DISCHARGE-CNT
PIC S9(15).
10 X835-HN-TOT-COST-RPT-DAYS
PIC S9(15).
10 X835-HN-TOT-COV-DAYS
PIC S9(15).
10 X835-HN-TOT-NON-COV-DAYS
PIC S9(15).
10 X835-HN-TOT-MSP-PASS-THRU
PIC S9(16)V99.
10 X835-HN-AVG-DRG-WEIGHT
PIC S9(10V9(5).
10 X835-HN-TOT-PPS-CAP-FSP
PIC S9(16)V99.
10 X835-HN-TOT-PPS-CAP-HSP
PIC S9(16)V99.
10 X835-HN-TOT-PPS-DSH
PIC S9(16)V99.
/
****************************************************************
* 835-CLAIM-PAYMENT-INFORMATION *
****************************************************************
*
01 X835-CLP-PMT-INFO.
*
05 X835-040-SORT-KEY.
10 X835-040-FILE-ID
VALUE SPACES
PIC X(15).
10 X835-040-ROUTING-ID
VALUE SPACES
PIC X(15).
10 X835-040-DOCUMENT-SEQ-NUM
VALUE ZEROES
PIC 9(09).
10 X835-040-FILE-REC-SEQ-NUM
VALUE ZEROES
PIC 9(10).
*
05 X835-040-TX-CD
VALUE '040'
PIC X(03).
05 X835-CL-REC-TYP-040-CTR.
10 X835-CLP-OTH-CL-ID-CTR
PIC 9(02).
10 X835-CLP-REND-PROV-CTR
PIC 9(02).
10 X835-CLP-DT-CTR
PIC 9(02).
10 X835-CLP-COMM-CTR1
PIC 9(02).
10 X835-CLP-COMM-CTR2
PIC 9(02).
10 X835-CLP-SUPL-INFO-CTR
PIC 9(02).
10 X835-CLP-SUPL-INFO-QTY-CTR
PIC 9(02).
*
* LOOP 2100, SEGMENT CLP (CLAIM PAYMENT INFORMATION)
*
*
05 X835-CLP-SEG.
10 X835-CLP-PAT-CTL-NUM
PIC X(38).
10 X835-CLP-CL-STATUS-CD
PIC X(02).
10 X835-CLP-TOT-CL-CHRG-AMT
PIC S9(16)V99.
10 X835-CLP-CL-REIMB-AMT
PIC S9(16)V99.
10 X835-CLP-PAT-RESP-AMT
PIC S9(16)V99.
10 X835-CLP-CL-FILING-IND-CD
PIC X(02).
10 X835-CLP-PYR-CL-CTL-NUM
PIC X(50).
10 X835-CLP-FAC-TYP
PIC X(02).
10 X835-CLP-CL-FREQ-TYP-CD
PIC X(01).
10 X835-CLP-DRG-CD
PIC X(04).
10 X835-CLP-DRG-WEIGHT
PIC 9(10V9(5)).
10 X835-CLP-DISCHRG-FRACTION
PIC 9(5)V9(5).
*
* LOOP 2100, SEGMENT NM1 (PATIENT NAME)
*
05 X835-CL-PAT-NM-SEG.
10 X835-CLP-PAT-ENTY-CD
PIC X(03).
10 X835-CLP-PAT-ENTY-TYP
PIC X(01).
10 X835-CLP-PAT-NM-LST
PIC X(60).
10 X835-CLP-PAT-NM-FST
PIC X(35).
10 X835-CLP-PAT-NM-MID
PIC X(25).
10 X835-CLP-PAT-NM-SFX
PIC X(10).
10 X835-CLP-PAT-ID-QL
PIC X(02).
10 X835-CLP-PAT-ID
PIC X(80).
*
*** NOTE: THE INSURED IS ANOTHER NAME FOR SUBSCRIBER
* LOOP 2100, SEGMENT NM1 (INSURED NAME)
*
05 X835-CL-INSURED-NM-SEG.
10 X835-CLP-INSURED-ENTY-CD
PIC X(03).
10 X835-CLP-INSURED-ENTY-TYP
PIC X(01).
10 X835-CLP-INSURED-NM-LST
PIC X(60).
10 X835-CLP-INSURED-NM-FST
PIC X(35).
10 X835-CLP-INSURED-NM-MID
PIC X(25).
10 X835-CLP-INSURED-NM-SFX
PIC X(10).
10 X835-CLP-INSURED-ID-QL
PIC X(02).
10 X835-CLP-INSURED-ID
PIC X(80).
*
* LOOP 2100, SEGMENT NM1 (CORRCTED PATIENT/INSURED NAME)
*
05 X835-CL-CORR-PERSON-NM-SEG.
10 X835-CLP-CORR-PERSON-ENTY-CD
PIC X(03).
10 X835-CLP-CORR-PERSON-ENTY-TYP
PIC X(01).
10 X835-CLP-CORR-PERSON-NM-LST
PIC X(60).
10 X835-CLP-CORR-PERSON-NM-FST
PIC X(35).
10 X835-CLP-CORR-PERSON-NM-MID
PIC X(25).
10 X835-CLP-CORR-PERSON-NM-SFX
PIC X(10).
10 X835-CLP-CORR-PERSON-ID-QL
PIC X(02).
10 X835-CLP-CORR-PERSON-ID
PIC X(80).
*
* LOOP 2100, SEGMENT NM1 (SERVICE PROVIDER NAME)
*
05 X835-CLP-SVC-PROV-NM-SEG.
10 X835-CLP-SVC-PROV-ENTY-CD
PIC X(03).
10 X835-CLP-SVC-PROV-ENTY-TYP
PIC X(01).
10 X835-CLP-SVC-PROV-NM-LST
PIC X(60).
10 X835-CLP-SVC-PROV-NM-FST
PIC X(35).
10 X835-CLP-SVC-PROV-NM-MID
PIC X(25).
10 X835-CLP-SVC-PROV-NM-SFX
PIC X(10).
10 X835-CLP-SVC-PROV-ID-QL
PIC X(02).
10 X835-CLP-SVC-PROV-ID
PIC X(80).
*
* LOOP 2100, SEGMENT NM1 (CROSSOVER CARRIER NAME)
*
05 X835-CLP-XO-CARRIER-NM-SEG.
10 X835-CLP-XO-CARRIER-ENTY-CD
PIC X(03).
10 X835-CLP-XO-CARRIER-ENTY-TYP
PIC X(01).
10 X835-CLP-XO-CARRIER-NM
PIC X(60).
10 X835-CLP-XO-CARRIER-ID-QL
PIC X(02).
10 X835-CLP-XO-CARRIER-ID
PIC X(80).
*
* LOOP 2100, SEGMENT NM1 (CORRECTED PRIORITY PAYER NAME)
*
05 X835-CLP-CORR-PYR-SEG.
10 X835-CLP-CORR-PYR-ENTY-CD
PIC X(03).
10 X835-CLP-CORR-PYR-ENTY-TYP
PIC X(01).
10 X835-CLP-CORR-PYR-NM
PIC X(60).
10 X835-CLP-CORR-PYR-ID-QL
PIC X(02).
10 X835-CLP-CORR-PYR-ID
PIC X(80).
*
* LOOP 2100, SEGMENT NM1 (OTHER SUBSCRIBER NAME)
*
05 X835-OTH-SUBS-INFORMATION-SEG.
10 X835-CLP-OTH-SUBS-ENTY-CD
PIC X(03).
10 X835-CLP-OTH-SUBS-ENTY-TYP
PIC X(01).
10 X835-CLP-OTH-SUBS-NM-LST
PIC X(60).
10 X835-CLP-OTH-SUBS-NM-FST
PIC X(35).
10 X835-CLP-OTH-SUBS-NM-MID
PIC X(25).
10 X835-CLP-OTH-SUBS-NM-SFX
PIC X(10).
10 X835-CLP-OTH-SUBS-ID-QL
PIC X(02).
10 X835-CLP-OTH-SUBS-ID
PIC X(80).
*
* LOOP 2100, SEGMENT MIA (INPATIENT ADJUDICATION INFO)
*
05 X835-CLP-MIA-ADJUD-SEG.
10 X835-CLP-MIA-COV-DAYS-VISITS
PIC S9(15).
10 X835-CLP-MIA-PPS-OL-AMT
PIC S9(16)V99.
10 X835-CLP-MIA-PYSC-DAYS
PIC S9(15).
10 X835-CLP-MIA-CL-DRG-AMT
PIC S9(16)V99.
10 X835-CLP-MIA-REMARK-CD
PIC X(50).
10 X835-CLP-MIA-CL-DISPROP-SHARE
PIC S9(16)V99.
10 X835-CLP-MIA-CL-MSP-PASSTHRU
PIC S9(16)V99.
10 X835-CLP-MIA-CL-PPS-CAP
PIC S9(16)V99.
10 X835-CLP-MIA-PPS-CAP-FSP-DRG
PIC S9(16)V99.
10 X835-CLP-MIA-PPS-CAP-HSP-DRG
PIC S9(16)V99.
10 X835-CLP-MIA-PPS-CAP-DSH-DRG
PIC S9(16)V99.
10 X835-CLP-MIA-OLD-CAP-AMT
PIC S9(16)V99.
10 X835-CLP-MIA-PPS-CAP-IME-AMT
PIC S9(16)V99.
10 X835-CLP-MIA-PPS-OPER-HOSP-DRG
PIC S9(16)V99.
10 X835-CLP-MIA-COST-RPT-DAYS
PIC S9(15).
10 X835-CLP-MIA-PPS-OPER-FED-DRG
PIC S9(16)V99.
10 X835-CLP-MIA-CL-PPS-CAP-OL-AMT
PIC S9(16)V99.
10 X835-CLP-MIA-CL-INDIR-TEACH
PIC S9(16)V99.
10 X835-CLP-MIA-NONPAY-PROF-COMP
PIC S9(16)V99.
10 X835-CLP-MIA-PPS-CAP-EXEP-AMT
PIC S9(16)V99.
10 X835-CLP-MIA-ADDL-REMARK
OCCURS 4 TIMES
PIC X(50).
*
* LOOP 2100, SEGMENT MOA (OUTPATIENT ADJUDICATION INFO)
*
05 X835-CLP-MOA-ADJUD-SEG.
10 X835-CLP-MOA-REIMB-RATE
PIC S9(5)V9(5).
10 X835-CLP-MOA-CL-HCPCS-PMT
PIC S9(16)V99.
10 X835-CLP-MOA-REMARK-CD
OCCURS 5 TIMES
PIC X(50).
10 X835-CLP-MOA-CL-ESRD-PMT
PIC S9(16)V99.
10 X835-CLP-MOA-NONPAY-PROF-COMP
PIC S9(16)V99.
*
* LOOP 2100, SEGMENT REF (OTHER CLAIM RELATED IDENTIFICATION)
*
05 X835-CLP-OTH-CL-ID-SEG
OCCURS 0 TO 5 TIMES
DEPENDING ON X835-CLP-OTH-CL-ID-CTR.
10 X835-CLP-OTH-CL-ID-CD
PIC X(03).
10 X835-CLP-OTH-CL-ID
PIC X(50).
*
* LOOP 2100, SEGMENT REF (RENDERING PROVIDER IDENTIFICATION)
*
05 X835-CLP-REND-PROV-SEG
OCCURS 0 TO 10 TIMES
DEPENDING ON X835-CLP-REND-PROV-CTR.
10 X835-CLP-REND-ID-QL
PIC X(03).
10 X835-CLP-REND-ID
PIC X(50).
*
* LOOP 2100, SEGMENT DTM (CLAIM DATE)
*
05 X835-CLP-DT-SEG
OCCURS 0 TO 2 TIMES
DEPENDING ON X835-CLP-DT-CTR.
10 X835-CLP-DT-CD
PIC X(03).
10 X835-CLP-DT
PIC X(08).
*
* LOOP 2100, SEGMENT DTM (COVERAGE EXPIRE DATE)
*
05 X835-CLP-CVRG-EXPIRE-DT-SEG.
10 X835-CLP-CVRG-EXPIRE-DT-QL
PIC X(03).
10 X835-CLP-CVRG-EXPIRE-DT
PIC X(08).
*
* LOOP 2100, SEGMENT DTM (CLAIM RECEIVED DATE)
*
05 X835-CLP-CL-RCVD-DT-SEG.
10 X835-CLP-CL-RCVD-DT-QL
PIC X(03).
10 X835-CLP-CL-RCVD-DT
PIC X(08).
*
* LOOP 2100, SEGMENT PER (CLAIM CONTACT INFORMATION)
*
05 X835-CLP-CL-CONTACT1-INFO-SEG.
10 X835-CLP-CONTACT-CD1
PIC X(02).
10 X835-CLP-CL-CONTACT-NM1
PIC X(60).
10 X835-CLP-COMM1
OCCURS 0 TO 3 TIMES
DEPENDING ON X835-CLP-COMM-CTR1.
*
15 X835-CLP-COMM-NUM-QL1
PIC X(02).
15 X835-CLP-COMM-NUM1
PIC X(256).
*
05 X835-CLP-CL-CONTACT2-INFO-SEG.
10 X835-CLP-CONTACT-CD2
PIC X(02).
10 X835-CLP-CL-CONTACT-NM2
PIC X(60).
10 X835-CLP-COMM2
OCCURS 0 TO 3 TIMES
DEPENDING ON X835-CLP-COMM-CTR2.
15 X835-CLP-COMM-NUM-QL2
PIC X(02).
15 X835-CLP-COMM-NUM2
PIC X(256).
*
* LOOP 2100, SEGMENT AMT (CL SUPPLEMENTAL AMT)
*
05 X835-CLP-SUPL-INFO-SEG
OCCURS 0 TO 13 TIMES
DEPENDING ON X835-CLP-SUPL-INFO-CTR.
10 X835-CLP-SUPL-AMT-QL
PIC X(03).
10 X835-CLP-SUPL-AMT
PIC S9(16)V99.
*
* LOOP 2100, SEGMENT QTY (CLAIM SUPPLEMENTAL INFORMATION
* QUANITY)
*
05 X835-CLP-SUPL-INFO-QTY-SEG
OCCURS 0 TO 14 TIMES
DEPENDING ON X835-CLP-SUPL-INFO-QTY-CTR.
10 X835-CLP-SUPP-QTY-CD
PIC X(02).
10 X835-CLP-SUPP-QTY
PIC S9(10)V9(5).
*
* LOOP N/A, SEGMENT N/A (ACS EDI GATEWAY TRACE NUMBER)
*
05 X835-ACS-EDI-TRACE-NUM
PIC X(31).
****************************************************************
* 835-CLAIMS-ADJUSTMENT *
****************************************************************
*
01 X835-CLM-CAS.
*
05 X835-041-SORT-KEY.
10 X835-041-FILE-ID
VALUE SPACES
PIC X(15).
10 X835-041-ROUTING-ID
VALUE SPACES
PIC X(15).
10 X835-041-DOCUMENT-SEQ-NUM
VALUE ZEROES
PIC 9(09).
10 X835-041-FILE-REC-SEQ-NUM
VALUE ZEROES
PIC 9(10).
*
05 X835-041-TX-CD
VALUE '041'
PIC X(03).
05 X835-REC-TYP-041-CTR.
10 X835-CL-ADJ-CTR
PIC 9(02).
*
* LOOP 2100, SEGMENT CAS (CLAIM ADJUSTMENT)
*
05 X835-CL-ADJ-GROUP-SEG.
10 X835-CL-ADJ-GROUP
PIC X(02).
10 X835-CL-ADJ-DATA
OCCURS 1 TO 6 TIMES
DEPENDING ON X835-CL-ADJ-CTR.
15 X835-CL-ADJ-REASON
PIC X(05).
15 X835-CL-ADJ-AMT
PIC S9(16)V99.
15 X835-CL-ADJ-QTY
PIC S9(10)V9(5).
*
****************************************************************
* 835-SERVICE-PAYMENT-INFORMATION *
****************************************************************
*
01 X835-SVC-PMT-INFO.
*
05 X835-050-SORT-KEY.
10 X835-050-FILE-ID
VALUE SPACES
PIC X(15).
10 X835-050-ROUTING-ID
VALUE SPACES
PIC X(15).
10 X835-050-DOCUMENT-SEQ-NUM
VALUE ZEROES
PIC 9(09).
10 X835-050-FILE-REC-SEQ-NUM
VALUE ZEROES
PIC 9(10).
*
05 X835-050-TX-CD
VALUE '050'
PIC X(03).
05 X835-REC-TYP-050-CTR.
10 X835-SVC-ID-CTR
PIC 9(02).
10 X835-SVC-REND-PROV-CTR
PIC 9(02).
10 X835-HEALTHCARE-POLICY-CTR
PIC 9(02).
10 X835-SVC-SUPL-INFO-CTR
PIC 9(02).
10 X835-SVC-SUPL-QTY-CTR
PIC 9(02).
*
* LOOP 2110, SEGMENT SVC (SERVICE PAYMENT INFORMATION)
*
05 X835-SVC-PMT-SEG.
10 X835-SVC-PROC-CD-QL
PIC X(02).
10 X835-SVC-PROC-CD
PIC X(48).
10 X835-SVC-MOD
OCCURS 4 TIMES
PIC X(02).
10 X835-SVC-PROC-DESC
PIC X(80).
10 X835-SVC-LI-CHRG-AMT
PIC S9(16)V99.
10 X835-SVC-LI-REIMB-AMT
PIC S9(16)V99.
10 X835-SVC-REVENUE-CD
PIC X(48).
10 X835-SVC-UNITS-OF-SVC
PIC S9(10)V9(5).
10 X835-SVC-SUBS-PROC-CD-QL
PIC X(02).
10 X835-SVC-SUBS-PROC-CD
PIC X(48).
10 X835-SVC-SUBS-MOD
OCCURS 4 TIMES
PIC X(02).
10 X835-SVC-SUBS-PROC-DESC
PIC X(80).
10 X835-SVC-SUBS-UNITS-OF-SVC
PIC S9(10)V9(5).
*
* LOOP 2110, SEGMENT DTM (SERVICE DATE)
*
05 X835-SVC-DT-SEG
OCCURS 2 TIMES.
10 X835-SVC-DT-CD
PIC X(03).
10 X835-SVC-DT
PIC X(08).
*
* LOOP 2110, SEGMENT REF (SERVICE IDENTIFICATION)
*
05 X835-SVC-ID-SEG
OCCURS 0 TO 8 TIMES
DEPENDING ON X835-SVC-ID-CTR.
10 X835-SVC-ID-CD
PIC X(03).
10 X835-SVC-ID
PIC X(50).
*
* LOOP 2110, SEGMENT REF (LINE ITEM CONTROL NUMBER)
*
05 X835-SVC-LI-CTL-SEG.
10 X835-SVC-LI-CTL-NUM-QL
PIC X(03).
10 X835-SVC-LI-CTL-NUM
PIC X(50).
*
* LOOP 2110, SEGMENT REF (SERVICE RENDERING PROVIDER ID)
*
05 X835-SVC-REND-PROV-SEG
OCCURS 0 TO 10 TIMES
DEPENDING ON X835-SVC-REND-PROV-CTR.
10 X835-SVC-REND-ID-CD
PIC X(03).
10 X835-SVC-REND-ID
PIC X(50).
*
* LOOP 2110, SEGMENT REF (HEALTHCARE POLICY IDENTIFICATION)
*
05 X835-SVC-HEALTHCARE-POLICY-SEG
OCCURS 0 TO 5 TIMES
DEPENDING ON X835-HEALTHCARE-POLICY-CTR.
10 X835-SVC-HEALTHCARE-POLICY-QL
PIC X(03).
10 X835-SVC-HEALTHCARE-POLICY-ID
PIC X(50).
*
* LOOP 2110, SEGMENT AMT (SERVICE SUPPLEMENTAL AMOUNT)
*
05 X835-SVC-SUPL-INFO-SEG
OCCURS 0 TO 9 TIMES
DEPENDING ON X835-SVC-SUPL-INFO-CTR.
10 X835-SVC-SUPL-AMT-CD
PIC X(03).
10 X835-SVC-SUPL-AMT
PIC S9(16)V99.
*
* LOOP 2110, SEGMENT QTY (SERVICE SUPPLEMENTAL QUANITY)
*
05 X835-SVC-SUPL-QTY-SEG
OCCURS 0 TO 6 TIMES
DEPENDING ON X835-SVC-SUPL-QTY-CTR.
10 X835-SVC-SUPL-QTY-CD
PIC X(02).
10 X835-SVC-SUPL-QTY
PIC S9(10)V9(5).
*
****************************************************************
* X835-SERVICE-ADJUSTMENT (MAX 99) *
****************************************************************
*
01 X835-SVC-CAS.
*
05 X835-051-SORT-KEY.
10 X835-051-FILE-ID
VALUE SPACES
PIC X(15).
10 X835-051-ROUTING-ID
VALUE SPACES
PIC X(15).
10 X835-051-DOCUMENT-SEQ-NUM
VALUE ZEROES
PIC 9(09).
10 X835-051-FILE-REC-SEQ-NUM
VALUE ZEROES
PIC 9(10).
*
05 X835-051-TX-CD
VALUE '051'
PIC X(03).
*
05 X835-REC-TYP-051-CTR.
10 X835-SVC-ADJ-CTR
PIC 9(02).
*
* LOOP 2110, SEGMENT CAS (SERVICE ADJUSTMENT)
*
05 X835-SVC-CAS-SEG.
10 X835-SVC-ADJ-GROUP
PIC X(02).
10 X835-SVC-ADJ-DATA
OCCURS 1 TO 6 TIMES
DEPENDING ON X835-SVC-ADJ-CTR.
15 X835-SVC-ADJ-REASON-CD
PIC X(05).
15 X835-SVC-ADJ-AMT
PIC S9(16)V99.
15 X835-SVC-ADJ-QTY
PIC S9(10)V9(5).
***************************************************************
* X835-SERVICE-HEALTH-CARE-REMARK-CODES *
***************************************************************
*
01 X835-SVC-REMARKS.
*
05 X835-052-SORT-KEY.
10 X835-052-FILE-ID
VALUE SPACES
PIC X(15).
10 X835-052-ROUTING-ID
VALUE SPACES
PIC X(15).
10 X835-052-DOCUMENT-SEQ-NUM
VALUE ZEROES
PIC 9(09).
10 X835-052-FILE-REC-SEQ-NUM
VALUE ZEROES
PIC 9(10).
*
05 X835-052-TX-CD
VALUE '052'
PIC X(03).
*
* LOOP 2110, SEGMENT LQ (HEALTH CARE REMARK CODES)
*
05 X835-SVC-REMARKS-SEG.
10 X835-SVC-REMARK-CD-QL
PIC X(03).
10 X835-SVC-REMARK-CD
PIC X(30).
/
*
****************************************************************
* 835 - PROVIDER-LEVEL-ADJUSTMENT *
****************************************************************
*
01 X835-PROV-ADJ.
*
05 X835-060-SORT-KEY.
10 X835-060-FILE-ID
VALUE SPACES
PIC X(15).
10 X835-060-ROUTING-ID
VALUE SPACES
PIC X(15).
10 X835-060-DOCUMENT-SEQ-NUM
VALUE ZEROES
PIC 9(09).
10 X835-060-FILE-REC-SEQ-NUM
VALUE ZEROES
PIC 9(10).
*
05 X835-060-TX-CD
VALUE '060'
PIC X(03).
*
05 X835-REC-TYP-060-CTR.
10 X835-PROV-ADJ-REASON-CTR
PIC 9(02).
*
* LOOP (NONE), SEGMENT PLB (PROV ADJUSTMENT)
*
05 X835-PROV-ADJ-SEG.
10 X835-PLB-PROV-ID
PIC X(50).
10 X835-PROV-FISCAL-YR-END
PIC X(08).
10 X835-PROV-ADJ-RSN-TB
OCCURS 0 TO 6 TIMES DEPENDING ON
X835-PROV-ADJ-REASON-CTR.
15 X835-PROV-ADJ-REASON-CD
PIC X(02).
15 X835-GROSS-ADJ-TCN
PIC X(50).
15 X835-GROSS-ADJ-AMT
PIC S9(11)V99.
/
****************************************************************
* 835 - TRANSACTION-SET-TRAILER *
****************************************************************
*
01 X835-TX-TRAILER.
*
05 X835-999-SORT-KEY.
10 X835-999-FILE-ID
VALUE SPACES
PIC X(15).
10 X835-999-ROUTING-ID
VALUE SPACES
PIC X(15).
10 X835-999-DOCUMENT-SEQ-NUM
VALUE ZEROES
PIC 9(09).
10 X835-999-FILE-REC-SEQ-NUM
VALUE ZEROES
PIC 9(10).
*
05 X835-999-TX-CD
VALUE '999'
PIC X(03).
*
* LOOP (NONE), SEGMENT SE (TRANSACTION TRAILER)
*
05 X835-TX-TRAILER-SEG.
10 X835-TX-NUM-OF-SEG
PIC 9(10).
10 X835-TX-CTL-NUM-TLR
PIC X(09).
****************************************************************
* 835 - IEA INTERCHANGE *
****************************************************************
*
01 X835-FILE-TRAILER.
*
05 X835-TRL-SORT-KEY.
10 X835-TRL-FILE-ID
VALUE SPACES
PIC X(15).
10 X835-TRL-ROUTING-ID
VALUE SPACES
PIC X(15).
10 X835-TRL-DOCUMENT-SEQ-NUM
VALUE ZEROES
PIC 9(09).
10 X835-TRL-FILE-REC-SEQ-NUM
VALUE ZEROES
PIC 9(10).
*
05 X835-TRL-TX-CD
VALUE 'TRL'
PIC X(03).
*
* LOOP (NONE), SEGMENT IEA (INTERCHANGE)
*
05 X835-FILE-TRAILER-SEG.
10 X835-FILE-TRAILER-NUM-OF-RECS
PIC 9(10).
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE EXHIBIT
OUTPUT FILE
X835 ELECTRONIC REMITTANCE ADVICE INTERFACE
DETAIL RECORD
|Source Table |Source Field |Target Segment |Target Field |Req | | |Note |
| | | | | |Def |Specifications |Ref |
|N/A | |All |X835-ROUTING-ID | |N/A | |1 |
|N/A | |All |X835-DOCUMENT-SEQ-NUM |A |N/A |Starts with 000000001 and increments by 1 for each|1 |
| | | | | | |batch in the input file. The batch is identified | |
| | | | | | |by the first 23 characters of the XCN number. Used| |
| | | | | | |for sorting the output file that will be sent to | |
| | | | | | |EDI. | |
|N/A | |All |X835-FILE-REC-SEQ-NUM |A |N/A |Starts with 0000000001 and increments by 1 for |1 |
| | | | | | |each segment written. Used for sorting the output | |
| | | | | | |file that will be sent to EDI. | |
|N/A |N/A |All |X835-TX-CD |A |N/A |Segment identifier. |1 |
| | | | | | |HDR..........X835-FILE-HEADER | |
| | | | | | |000............X835-TX-HEADER | |
| | | | | | |010............X835-PYR-ID | |
| | | | | | |011............X835-TECH-CONTACT-INFO | |
| | | | | | |020............X835-PAYEE-ID | |
| | | | | | |021............X835-PAYEE-ADDL-ID | |
| | | | | | |030............X835-PROV-SUM | |
| | | | | | |040............X835-CLP-PMT-INFO | |
| | | | | | |041............X835-CLM-CAS | |
| | | | | | |050............X835-SVC-PMT-INFO | |
| | | | | | |051............X835-SVC-CAS | |
| | | | | | |052............X835-SVC-REMARKS | |
| | | | | | |060............X835-PROV-ADJ | |
| | | | | | |999............X835-TX-TRAILER | |
| | | | | | |TRL............X835-FILE-TRAILER | |
| | |HDR |X835-FILE-VER-RELEASE-CD |A |N/A |005010X221A1 | |
| | |HDR |X835-FILE-VER-NAME |A |N/A |X835 | |
| | |HDR |X835-FILE-ISA-SENDER |A |N/A |77048 | |
| |C-HDR-SUBMITTER-ID |HDR |X835-FILE-ISA-RECEIVER | |N/A |Trading Partner ID from TPMS and X837. The ID that| |
| | | | | | |will go in this field is from the first claim | |
| | | | | | |record read in, but will not be used by EDI when | |
| | | | | | |sending the X835 transaction to the receiver. | |
| | |HDR |X835-FILE-GS-SENDER |A |N/A |77048 | |
| |C-HDR-SUBMITTER-ID |HDR |X835-FILE-GS-RECEIVER | |N/A |Trading Partner ID from TPMS and X837. The ID that| |
| | | | | | |will go in this field is from the first claim | |
| | | | | | |record read in, but will not be used by EDI when | |
| | | | | | |sending the X835 transaction to the receiver. | |
| | |000 |X835-TX-ID |A | |EDI transaction id - ‘835’ | |
| | |000 |X835-TX-CTL-NUM | |spaces |Initialized to spaces. EDI will populate. | |
| | |000 |X835-TX-TRANS-HANDLING-CD |A |N/A |Transaction Handling Code. Set to “I” if the | |
| | | | | | |warrant amount is greater than zero. Set to “H” if| |
| | | | | | |the warrant amount is equal to zeros. | |
| |C-HDR-WARR-AMT |000 |X835-TX-REIMB-AMT |A |N/A |Warrant/EFT Amount | |
| | |000 |X835-TX-CREDIT-DEBIT-CD |A |N/A |Credit or Debit Flag Code - always set to “C”. | |
| | |000 |X835-TX-PMT-METHOD-CD |A |N/A |Payment Method Code. If the TX-TRANS-HANDLING-CD | |
| | | | | | |is set to “I” and C-EFT-TRC-ID > spaces, use ‘ACH’| |
| | | | | | |otherwise “CHK” is moved to this field. If the | |
| | | | | | |reimbursement amount is = 0, “NON” is used in | |
| | | | | | |this field. | |
| | |000 |X835-TX-PMT-FORMAT-CD |N |spaces |If X835-TX-PMT-METHOD-CD = ‘ACH’, this field will | |
| | | | | | |be set to ‘CCP’. | |
| | |000 |X835-TX-SENDER-DFI-ID-QL |N |spaces | If X835-TX-PMT-METHOD-CD = ‘ACH’, this field will| |
| | | | | | |be set to ‘01’. | |
| | |000 |X835-TX-SENDER-DFI-ID |N |spaces | Sender's DFI ID if BPR04 = 'ACH'. This is the | |
| | | | | | |Routing Transit Number of Sender's Financial | |
| | | | | | |Institution and will be set to '999999999999'. | |
| | |000 |X835-TX-SENDER-ACCT-QL |N |spaces | Sender's account number qualifier. Will be equal | |
| | | | | | |to 'DA' if BPR04 = 'ACH'. | |
| | |000 |X835-TX-SENDER-ACCT |N |spaces | Sender's account number. Will be a dummy account | |
| | | | | | |number if BPR04 = 'ACH'. Will be set to | |
| | | | | | |'99999999999999999' | |
| | |000 |X835-TX-SENDER-ID |N |spaces | Sender's company ID. | |
| | |000 |X835-TX-SENDER-SUPL-CD |N |spaces | RA Number (equal to TRN04) | |
| | |000 |X835-TX-RCV-DFI-ID-QL |N |spaces | Provider's DFI ID qualifer. Will be equal to '01'| |
| | | | | | |if BPR04 = 'ACH'. | |
| | |000 |X835-TX-RCV-DFI-ID |N |spaces | Provider's DFI ID. Will be a dummy number if | |
| | | | | | |BPR04 = 'ACH'. This is the Routing Transit Number | |
| | | | | | |of Provider's Financial Institution and will be | |
| | | | | | |set to '888888888888'. | |
| | |000 |X835-TX-RCV-ACCT-QL |N |spaces | Provider's account number qualifier. Will be | |
| | | | | | |equal to 'DA' if BPR04 = 'ACH'. | |
| | |000 |X835-TX-RCV-ACCT |N |spaces | Provider's account number. Will be a dummy | |
| | | | | | |account number if BPR04 = 'ACH'. | |
| | | | | | |Will be set to '88888888888888888' | |
| |C-HDR-WARR-DT |000 |X835-TX-CHECK-EFT-DT |A | |If payment is by EFT, parm 4806(EFT Payment | |
| | | | | | |Release Date) will be used, otherwise this field | |
| | | | | | |will contain the warrant date. Format CCYYMMDD. | |
| | |000 |X835-TX-TRACE-TYP-CD |A | |Trace Type Code -Set to “1”. | |
| |C-HDR-WARR-NUM or C-EFT-TRC-ID |000 |X835-TX-CHECK-EFT-TRACE-NUM |A | |Check or EFT Trace Number | |
| | |000 |X835-TX-PYR-ID |A | |Payer Identifier - Set to “1856000565”. | |
| | |000 |X835-TX-PYR-SUPL-CD |A |N/A |Remittance advice number | |
| | |000 |X835-TX-CURRENCY-ENTY-CD |A |spaces |Not sent since currency will always be in US | |
| | | | | | |dollars | |
| | |000 |X835-TX-CURRENCY-CD |A |spaces |Not sent since currency will always be in US | |
| | | | | | |dollars | |
| | |000 |X835-TX-RCV-ID-CD |A |N/A |Receiver ID Qualifier - Set to “EV” | |
| |W1C41521-C-BLNG-NPI-ID |000 |X835-TX-RCV-ID |A |N/A |Receiver Identifier. Will be equal to either the | |
| | | | | | |Billing Provider NPI ID, Federal Tax ID or SSN. | |
| | |000 |X835-TX-VER-ID-CD |N |spaces |Not sent | |
| | |000 |X835-TX-VER-ID |N |spaces |Not sent | |
| | |000 |X835-TX-PROD-DT-CD |A |N/A |Date Time Qualifier - Set to “405” | |
| | |000 |X835-TX-PROD-DT |A |N/A |Current date | |
| | |010 |X835-PYR-SEC-ID-SEG-CTR |A |N/A |Counter. Calculated. | |
| | |010 |X835-PYR-COMM-CTR |A |N/A |Counter. Calculated. | |
| | |010 |X835-PYR-ENTY-CD |A |N/A |Entity Identifier Code - Set to “PR” | |
| | |010 |X835-PYR-NM |A |N/A |Payer Name - Set to 'NM MEDICAID' | |
| | |010 |X835-PYR-PLAN-ID-QL |A |N/A |ID Code Qualifier - “XV” | |
| | |010 |X835-PYR-ID-CD |A |N/A |Payer Identifier - Set to '1856000565' | |
| | |010 |X835-PYR-ADDR-1 |A |N/A |Payer Address. Set to | |
| | | | | | |P.O. BOX 27478 | |
| | |010 |X835-PYR-ADDR-2 |N |spaces |Not sent | |
| | |010 |X835-PYR-CITY |A |N/A |Payer City - Set to “ALBUQUERQUE” | |
| | |010 |X835-PYR-ST |A |N/A |Payer State - Set to “NM” | |
| | |010 |X835-PYR-ZIP |A |N/A |Payer zip code - Set to “871257478” | |
| | |010 |X835-PYR-CNTRY |N |spaces |Not sent | |
| | |010 |X835-PYR-CNTRY-SUB |N |spaces |Not sent | |
| | |010 |X835-PYR-SEC-ID-CD |N |spaces |Not sent | |
| | |010 |X835-PYR-SEC-ID |N |spaces |Not sent | |
| | |010 |X835-PYR-CONTACT-CD |A |N/A |Contact Function Code - Set to “CX” | |
| | |010 |X835-PYR-CONTACT-NM |A |N/A |Payer Contact Name - Set to “NM HIPAA HELP DESK” | |
| | |010 |X835-PYR-COMM-QL |A |N/A |Communication # Qualifier - Set to “TE’ | |
| | |010 |X835-PYR-COMM-NUM |A |N/A |Communication Number - Set to | |
| | | | | | |“5052460710” - 1ST occurrence | |
| | | | | | |“8002997304” - 2nd occurrence | |
| | |010 |X835-PYR-WEB-CD |N |Spaces |Segment not sent per the state | |
| | |010 |X835-PYR-WEB-COMM-QL |N |Spaces |Segment not sent per the state | |
| | |010 |X835-PYR-WEB-COMM-NUM |N |spaces |Segment not sent per the state | |
| | |011 |X835-PYR-TECH-CTR |A |N/A |Counter. Calculated. | |
| | |011 |X835-PYR-TECH-CONTACT-CD |A |N/A |Payer Technical Contact Code - Set to “BL” | |
| | |011 |X835-PYR-TECH-CONTACT-NM |A |N/A |Payer Technical Contact Name - Set to “NM HIPAA | |
| | | | | | |HELP DESK” | |
| | |011 |X835-PYR-TECH-COMM-QL |A |N/A |Communication # Qualifier - Set to “TE’ for 1st | |
| | | | | | |and 2nd occurrence. Set to “EM” for 3rd | |
| | | | | | |occurrence. | |
| | |011 |X835-PYR-TECH-COMM-NUM |A |N/A |Communication Number - Set to | |
| | | | | | |“5052460710” - 1ST occurrence | |
| | | | | | |“8002997304” - 2nd occurrence | |
| | | | | | |HIPAAHELPDESK@ACS- - 3rd occurrence | |
| | |020 |X835-PAYEE-ENTY-CD |A |N/A |Payee entity code - Set to “PE” | |
|P_PROV_TB |P-NAM |020 |X835-PAYEE-NM |A |N/A |Provider Name | |
| | |020 |X835-PAYEE-ID-QL |A |N/A |If NPI > spaces, set to ‘XX’, else set to “FI” if| |
| | | | | | |either Federal Tax ID or SSN is present. | |
| | |020 |X835-PAYEE-PLAN-ID |A |N/A |NPI or Federal Tax ID or SSN | |
|P_ADDR_TB |P_LINE1_AD |020 |X835-PAYEE-ADDR-1 |A |N/A |Provider Address 1 | |
|P_ADDR_TB |P_LINE2_AD |020 |X835-PAYEE-ADDR-2 |A |N/A |Provider Address 2 | |
|P_ADDR_TB |P_CITY_NAM |020 |X835-PAYEE-CITY |A |N/A |Provider city | |
|P_ADDR_TB |P_ST_CD |020 |X835-PAYEE-ST |A |N/A |Provider state | |
|P_ADDR_TB |P_ZIP5_CD + P_ZIP4_CD |020 |X835-PAYEE-ZIP |A |N/A |Provider zip code | |
| | |020 |X835-PAYEE-CNTRY |N |spaces |Not sent | |
| | |020 |X835-PAYEE-CNTRY-SUB |N |spaces |Not sent | |
| | |020 |X835-PAYEE-REMIT-RPT-TRANS-CD |N |spaces |Not sent | |
| | |020 |X835-PAYEE-REMIT-RPT-GOTO-NM |N |spaces |Not sent | |
| | |020 |X835-PAYEE-REMIT-RPT-COMM-NUM |N |spaces |Not sent | |
| | |021 |X835-PAYEE-SEC-ID-CD |A |N/A |Payee secondary id - Set to “PQ” for Billing | |
| | | | | | |Provider ID or ‘TJ’ for Federal Tax ID | |
| |W1C41521-C-BLNG-PROV-ID |021 |X835-PAYEE-SEC-ID |A |N/A |Billing Provider ID or Federal Tax ID. | |
| | |030 |X835-HN-PROV-LX-NUM |A |N/A |Calculated. Starts at 0 and increments by 1 for | |
| | | | | | |each claim. | |
| |W1C41521-C-BLNG-NPI-ID or |030 |X835-HN-SUM-PROV-ID |A |spaces |Provider NPI ID or Federal Tax ID or SSN |4 |
| |W1C41521-C-FED-TAX-ID or | | | | | | |
| |W1C41521-C-BLNG-SSN-NUM | | | | | | |
| |W1C41521-C-TY-OF-BLL-1-2-CD |030 |X835-HN-SUM-TYP-FAC |A |spaces |Facility Type Code. |4 |
| | | | | | |The C-TY-OF-BLL-1-2-CD is checked to see if it is| |
| | | | | | |the same for all claims in the RA. If all of the | |
| | | | | | |claims are the same, the C-TY-OF-BLL-1-2-CD is | |
| | | | | | |moved to the X835 record, otherwise the default | |
| | | | | | |code of “11” is moved to the X835. | |
|P-PROV-TB |P-FSCL-END-MO-NUM |030 |X835-HN-SUM-FISCAL-YR-END-DT |A |spaces |Fiscal year end date for the billing provider. If |4 |
| | | | | | |P-FSCL-END-MO-NUM = spaces, this field is set to | |
| | | | | | |12/31 of the current year, otherwise we check to | |
| | | | | | |see if the current month is >= P-FSCL-END-MO-NUM. | |
| | | | | | |If it’s greater, we add 1 month to the | |
| | | | | | |P-FSCL-END-MO-NUM and set the year to current year| |
| | | | | | |+ 1, otherwise we use P-FSCL-END-MO-NUM and set | |
| | | | | | |the year to the current year. The day is always | |
| | | | | | |set to the derived month’s ending day. | |
| | |030 |X835-HN-SUM-NUM-OF-CLM |A |zeros |Calculated. Starts at 0 and increments by 1 for |4 |
| | | | | | |each claim in the RA. | |
| |W1C41521-C-TOT-CHRG-AMT |030 |X835-HN-SUM-TOT-CHRGS |A |N/A |Total charges for all claims. Calculated. |4 |
| | |030 |X835-HN-SUM-TOT-MSP-PYR-AMT |N |zeros |Not sent | |
| | |030 |X835-HN-SUM-TOT-NON-LAB-AMT |N |zeros |Not sent | |
| | |030 |X835-HN-TOT-HCPCS-CHRG |N |zeros |Not sent | |
| | |030 |X835-HN-TOT-HCPCS-REIMB |N |zeros |Not sent | |
| | |030 |X835-HN-TOT-PROF-COMP-AMT |N |zeros |Not sent | |
| | |030 |X835-HN-TOT-MSP-PAT-LIAB-MET |N |zeros |Not sent | |
| | |030 |X835-HN-TOT-PAT-REIMB |N |zeros |Not sent | |
| | |030 |X835-HN-TOT-PIP-CLM-CNT |N |zeros |Not sent | |
| | |030 |X835-HN-TOT-PIP-ADJ-AMT |N |zeros |Not sent | |
|W1C41521-C-HDR-COB-VW |W1C41521-C-COB-DRG-AMT |030 |X835-HN-TOT-DRG-AMT |C |zeros |Only sent for Medicare Part A claims |4 |
| | |030 |X835-HN-TOT-FED-SPECIFIC |N |zeros |Not sent | |
| | |030 |X835-HN-TOT-HOSP-SPECIFIC |N |zeros |Not sent | |
|W1C41521-C-HDR-COB-VW |W1C41521-C-COB-DSP-SHR-AMT |030 |X835-HN-TOT-DISPROP-SHARE |C |zeros |Only sent for Medicare Part A claims |4 |
| | |030 |X835-HN-TOT-CAP-AMT |N |zeros |Not sent | |
|W1C41521-C-HDR-COB-VW |W1C41521-C-COB-CAP-IME-AMT |030 |X835-HN-TOT-INDIR-MED-EDUC |C |zeros |Only sent for Medicare Part A claims |4 |
| | |030 |X835-HN-TOT-OL-DAYS |N |zeros |Not sent | |
| | |030 |X835-HN-TOT-DAY-OL-AMT |N |zeros |Not sent | |
| | |030 |X835-HN-TOT-COST-OL-AMT |N |zeros |Not sent | |
| | |030 |X835-HN-AVG-DRG-LOS |N |zeros |Not sent | |
| | |030 |X835-HN-TOT-DISCHARGE-CNT |N |zeros |Not sent | |
| | |030 |X835-HN-TOT-COST-RPT-DAYS |N |zeros |Not sent | |
| | |030 |X835-HN-TOT-COV-DAYS |N |zeros |Not sent | |
| | |030 |X835-HN-TOT-NON-COV-DAYS |N |zeros |Not sent | |
| | |030 |X835-HN-TOT-MSP-PASS-THRU |N |zeros |Not sent | |
| | |030 |X835-HN-AVG-DRG-WEIGHT |N |zeros |Not sent | |
| | |030 |X835-HN-TOT-PPS-CAP-FSP |N |zeros |Not sent | |
| | |030 |X835-HN-TOT-PPS-CAP-HSP |N |zeros |Not sent | |
| | |030 |X835-HN-TOT-PPS-DSH |N |zeros |Not sent | |
| | |040 |X835-CLP-OTH-CL-ID-CTR |A |Zeros |Claim Other client ID counter. Calculated | |
| | |040 |X835-CLP-REND-PROV-CTR |A |Zeros |Rendering Provider counter. Set to 1 if | |
| | | | | | |C-RNDR-NPI-ID is present, otherwise defaults to 0.| |
| | |040 |X835-CLP-DT-CTR |A |Zeros |Claim date counter. Calculated. Will be equal to 2| |
| | | | | | |since we will always have a beginning service date| |
| | | | | | |and ending service date. | |
| | |040 |X835-CLP-COMM-CTR1 |A |Zeros |Claim communication counter 1. This segment is | |
| | | | | | |not sent, so the counter will always be equal to | |
| | | | | | |0. | |
| | |040 |X835-CLP-COMM-CTR2 |A |Zeros |Claim communication counter 2. This segment is | |
| | | | | | |not sent, so the counter will always be equal to | |
| | | | | | |0. | |
| | |040 |X835-CLP-SUPL-INFO-CTR | |Zeros |Claim Supplemental info counter. This segment is | |
| | | | | | |not sent, so the counter will always be equal to | |
| | | | | | |0. | |
| | |040 |X835-CLP-SUPL-INFO-QTY-CTR |A |Zeros |Claim Supplemental info quantity counter. This | |
| | | | | | |segment is not sent, so the counter will always be| |
| | | | | | |equal to 0. | |
| |C-HDR-PAT-ACCT-NUM or |040 |X835-CLP-PAT-CTL-NUM |A |spaces |Claim patient account number or Pharmacy | |
| |C-HDR-DRUG-RX-NUM if Pharmacy | | | | |prescription number (if Pharmacy claim). | |
| |C-HDR-STAT-CD |040 |X835-CLP-CL-STATUS-CD |A |spaces |Claim status code | |
| |C-TOT-CHRG-AMT |040 |X835-CLP-TOT-CL-CHRG-AMT |A |Zeros |Total claim charge amount | |
| |C-TOT-REIMB-AMT |040 |X835-CLP-CL-REIMB-AMT |A |Zeros |Total claim reimbursement amount | |
| |W1C41521-C-PAT-LIAB-AMT + |040 |X835-CLP-PAT-RESP-AMT |C |Zeros |Patient responsibility amount | |
| |W1C41521-C-TOT-COPAY-AMT | | | | | | |
| |W1C41521-C-HDR-TY-CD |040 |X835-CLP-CL-FILING-IND-CD |A |spaces |Claim filing indicator code. If | |
| | | | | | |W1C41521-C-HDR-TY-CD = “A”, set to “MA” , else | |
| | | | | | |if W1C41521-C-HDR-TY-CD = “B” or “C”, | |
| | | | | | |set to “MB” else set to “MC” . | |
| |C-TCN-NUM |040 |X835-CLP-PYR-CL-CTL-NUM |A |spaces |Payer claim control number | |
| |C-TY-OF-BLL-1-2-CD |040 |X835-CLP-FAC-TYP |A |spaces |Facility Type Code | |
| |C-TY-OF-BILL-3-CD |040 |X835-CLP-CL-FREQ-TYP-CD |A |spaces |Claim Frequency Code | |
| |R-DRG-CD |040 |X835-CLP-DRG-CD |C |spaces |DRG Code, if present | |
| |R-CD-REL-WT-AMT * 100000 |040 |X835-CLP-DRG-WEIGHT |C |zeros |DRG Weight | |
| | |040 |X835-CLP-DISCHRG-FRACTION |C |zeros |Discharge Fraction. Set to zeros. | |
| | |040 |X835-CLP-PAT-ENTY-CD |A |spaces |Entity Identifier Code - Set to “QC” | |
| | |040 |X835-CLP-PAT-ENTY-TYP |A |spaces |Entity Type Qualifier - Set to ‘1’ | |
| |W1C41521-B-LAST-NAM |040 |X835-CLP-PAT-NM-LST |A |spaces |Patient Last Name | |
| |W1C41521-B-FST-NAM |040 |X835-CLP-PAT-NM-FST |A |spaces |Patient First Name | |
| |W1C41521-B-MI-NAM |040 |X835-CLP-PAT-NM-MID |A |spaces |Patient Middle Name | |
| | |040 |X835-CLP-PAT-NM-SFX |N |spaces |Not sent | |
| |W1C41521-B-MAJ-PROG-CD |040 |X835-CLP-PAT-ID-QL | |spaces |ID Code Qualifier: | |
| | | | | | |Always set to “MI”, | |
| |W1C41521-B-ALT-ID |040 |X835-CLP-PAT-ID |A |spaces |Patient Identifier | |
| | |040 |X835-CLP-INSURED-ENTY-CD |N |spaces |Not sent since insured is same as patient | |
| | |040 |X835-CLP- INSURED -ENTY-TYP |N |spaces |Not sent since insured is same as patient | |
| | |040 |X835-CLP- INSURED -NM-LST |N |spaces |Not sent since insured is same as patient | |
| | |040 |X835-CLP- INSURED -NM-FST |N |spaces |Not sent since insured is same as patient | |
| | |040 |X835-CLP- INSURED -NM-MID |N |spaces |Not sent since insured is same as patient | |
| | |040 |X835-CLP- INSURED -NM-SFX |N |spaces |Not sent since insured is same as patient | |
| | |040 |X835-CLP- INSURED -ID-QL |N |spaces |Not sent since insured is same as patient | |
| | |040 |X835-CLP- INSURED -ID |N |spaces |Not sent since insured is same as patient | |
| | |040 |X835-CLP-CORR-PERSON-ENTY-CD |N |spaces |Not sent since corrected person is same as patient| |
| | |040 |X835-CLP- CORR-PERSON -ENTY-TYP |N |spaces |Not sent since corrected person is same as patient| |
| | |040 |X835-CLP- CORR-PERSON -NM-LST |N |spaces |Not sent since corrected person is same as patient| |
| | |040 |X835-CLP- CORR-PERSON -NM-FST |N |spaces |Not sent since corrected person is same as patient| |
| | |040 |X835-CLP- CORR-PERSON -NM-MID |N |spaces |Not sent since corrected person is same as patient| |
| | |040 |X835-CLP- CORR-PERSON -NM-SFX |N |spaces |Not sent | |
| | |040 |X835-CLP- CORR-PERSON -ID-QL |N |spaces |Not sent since corrected person is same as patient| |
| | |040 |X835-CLP- CORR-PERSON -ID |N |spaces |Not sent since corrected person is same as patient| |
| | |040 |X835-CLP-SVC-PROV-ENTY-CD |N |spaces |Not sent | |
| | |040 |X835-CLP- SVC-PROV -ENTY-TYP |N |spaces |Not sent | |
| | |040 |X835-CLP- SVC-PROV -NM-LST |N |spaces |Not sent | |
| | |040 |X835-CLP- SVC-PROV -NM-FST |N |spaces |Not sent | |
| | |040 |X835-CLP- SVC-PROV -NM-MID |N |spaces |Not sent | |
| | |040 |X835-CLP- SVC-PROV -NM-SFX |N |spaces |Not sent | |
| | |040 |X835-CLP- SVC-PROV -ID-QL |N |spaces |Not sent | |
| | |040 |X835-CLP- SVC-PROV -ID |N |spaces |Not sent | |
| | |040 |X835-CLP-XO-CARRIER-ENTY-CD |N |spaces |Not sent | |
| | |040 |X835-CLP-XO-CARRIER-ENTY-TYP |N |spaces |Not sent | |
| | |040 |X835-CLP-XO-CARRIER-NM |N |spaces |Not sent | |
| | |040 |X835-CLP-XO-CARRIER-ID-QL |N |spaces |Not sent | |
| | |040 |X835-CLP-XO-CARRIER-ID |N |spaces |Not sent | |
| | |040 |X835-CLP-CORR-PYR-ENTY-CD |C |spaces |Entity Identifier Code - Set to “PR” | |
| | |040 |X835-CLP- CORR-PYR -ENTY-TYP |C |spaces |Entity Type Qualifier - Set to “2” | |
| |T-CARR-NAM |040 |X835-CLP- CORR-PYR -NM |C |spaces |Corrected Priority Payer Name | |
| | |040 |X835-CLP- CORR-PYR -ID-QL |C |spaces |ID Code Qualifier. Set to “PI” | |
| |T-CARR-ID |040 |X835-CLP- CORR-PYR -ID |C |spaces |Corrected Priority Payer ID | |
| | |040 |X835-CLP-OTH-SUBS-ENTY-CD |C |spaces |Entity ID Code - Set to “GB” | |
| | |040 |X835-CLP OTH-SUBS -ENTY-TYP |C |spaces |Entity Type Qualifier - Set to “1” | |
| |T-PLCYHLD-LST-NAM |040 |X835-CLP- OTH-SUBS -NM-LST |C |spaces |Last Name/Org Name | |
| |T-PLCYHLD-FST-NAM |040 |X835-CLP- OTH-SUBS -NM-FST |C |spaces |First Name | |
| |T-PLCYHLD-MI-NAM |040 |X835-CLP- OTH-SUBS -NM-MID |C |spaces |Middle Name | |
| | |040 |X835-CLP- OTH-SUBS -NM-SFX |N |spaces |Not sent | |
| | |040 |X835-CLP OTH-SUBS -ID-QL |C |spaces |ID Code Qualifier - Set to “MI” | |
| |T-PLCYHLD-B-ALT-ID or |040 |X835-CLP OTH-SUBS -ID |C |spaces |ID Code | |
| |T-PLCYHLD-SSN-NUM or spaces | | | | | | |
| |W1C41521-C-CVRD-DAYS-NUM |040 |X835-CLP-MIA-COV-DAYS-VISITS |C |zeros | |2 |
| | |040 |X835-CLP-MIA-PPS-OL-AMT |N |zeros |Not sent |2 |
| | |040 |X835-CLP-MIA-PYSC-DAYS |N |zeros |Not sent |2 |
| |W1C41521-C-COB-DRG-AMT |040 |X835-CLP-MIA-CL-DRG-AMT |C |zeros |DRG amount |2 |
| |W1C41521-C-HDR-RMK-CD |040 |X835-CLP-MIA-REMARK-CD |C |zeros |Claim payment remark code from C-HDR-COB-TB remark|2 |
| | | | | | |code field. | |
| |W1C41521-C-COB-DSP-SHR-AMT |040 |X835-CLP-MIA-CL-DISPROP-SHARE |C |zeros |Claim DSH amount |2 |
| | |040 |X835-CLP-MIA-CL-MSP-PASSTHRU |N |zeros |Not sent |2 |
| | |040 |X835-CLP-MIA-CL-PPS-CAP |N |zeros |Not sent |2 |
| | |040 |X835-CLP-MIA-PPS-CAP-FSP-DRG |N |zeros |Not sent |2 |
| | |040 |X835-CLP-MIA-PPS-CAP-HSP-DRG |N |zeros |Not sent |2 |
| | |040 |X835-CLP-MIA-PPS-CAP-DSH-DRG |N |zeros |Not sent |2 |
| | |040 |X835-CLP-MIA-OLD-CAP-AMT |N |zeros |Not sent |2 |
| | |040 |X835-CLP-MIA-PPS-CAP-IME-AMT |N |zeros |Not sent |2 |
| | |040 |X835-CLP-MIA-PPS-OPER-HOSP-DRG |N |zeros |Not sent |2 |
| | |040 |X835-CLP-MIA-COST-RPT-DAYS |N |zeros |Not sent |2 |
| | |040 |X835-CLP-MIA-PPS-OPER-FED-DRG |N |zeros |Not sent |2 |
| | |040 |X835-CLP-MIA-CL-PPS-CAP-OL-AMT |N |zeros |Not sent |2 |
| | |040 |X835-CLP-MIA-CL-INDIR-TEACH |N |zeros |Not sent |2 |
| | |040 |X835-CLP-MIA-NONPAY-PROF-COMP |N |zeros |Not sent |2 |
| | |040 |X835-CLP-MIA-PPS-CAP-EXEP-AMT |N |zeros |Not sent |2 |
| |R-CLM-EXC-CD |040 |X835-CLP-MIA-ADDL-REMARK |C |zeros |Additional remark codes from R_TXT_RA_EOB_TB |2 |
| | | | | | |fields. The EOB code is used to select the | |
| | | | | | |matching R-CMS-RMK*-CD fields. | |
| |C-COB-REIMB-PCT |040 |X835-CLP-MOA-REIMB-RATE |C |zeros | |3,5 |
| |C-COB-HCPCS-AMT |040 |X835-CLP-MOA-CL-HCPCS-PMT |C |zeros | |3 |
| |C-HDR-RMK-CD |040 |X835-CLP-MOA-REMARK-CD |C |spaces | |3 |
| |C-COB-ESRD-AMT |040 |X835-CLP-MOA-CL-ESRD-PMT |C |zeros | |3 |
| |C-COB-NONP-PC-AMT |040 |X835-CLP-MOA-NONPAY-PROF-COMP |C |zeros | |3 |
| | |040 |X835-CLP-OTH-CL-ID-CD |C |spaces |A maximum of 5 occurrences for this field. | |
| | | | | | |1) If W1C41521-A-ID > spaces, set to “G1” and add | |
| | | | | | |1 to X835-CLP-OTH-CL-ID-CTR. | |
| | | | | | |2) If W1C41521-C-MED-REC-NUM > spaces, set to | |
| | | | | | |“EA” and add 1 to X835-CLP-OTH-CL-ID-CTR. | |
| | | | | | |3) If T-PLCY-GRP-ID > spaces, set to “6P” and add | |
| | | | | | |1 to X835-CLP-OTH-CL-ID-CTR. | |
| | |040 |X835-CLP-OTH-CL-ID |C |spaces |W1C41521-A-ID or W1C41521-C-MED-REC-NUM or | |
| | | | | | |T-PLCY-GRP-ID can be entered in this field. | |
| | |040 |X835-CLP-REND-ID-QL |C |spaces |Only the first occurrence is used for this field. | |
| | | | | | |If W1C41521-C-RNDR-NPI-ID > spaces, set to “HPI”. | |
| |C-RNDR-NPI-ID or |040 |X835-CLP-REND-ID |C |spaces |Rendering provider NPI ID or provider ID. | |
| |C-RNDR-PROV-ID | | | | | | |
| | |040 |X835-CLP-DT-CD |A |spaces |There are 2 occurrences for this field. The first | |
| | | | | | |occurrence will contain “232” for beginning | |
| | | | | | |service date. The second occurrence will contain | |
| | | | | | |“233” for the ending service date. | |
| |C-HDR-SVC-FST-DT or |040 |X835-CLP-DT |A |spaces |If CLP-DT-CD = “232”, this field will be the | |
| |C-HDR-SVC-LST-DT | | | | |beginning service date. If CLP-DT-CD = “233”, this| |
| | | | | | |field will contain the ending service date. | |
| | |040 |X835-CLP-CVRG-EXPIRE-DT-QL |C |spaces |Coverage Expiration Date qualifier - Set to “036” | |
| |B-COE-SPN-END-DT |040 |X835-CLP-CVRG-EXPIRE-DT |C |spaces |Coverage Expiration date | |
| | |040 |X835-CLP-CL-RCVD-DT-QL |A |spaces |Claim receive date qualifier - Set to “050” | |
| |C-HDR-ENTRD-DT |040 |X835-CLP-CL-RCVD-DT |A |spaces |Date claim was entered into the system | |
| | |040 |X835-CLP-CONTACT-CD1 |N |spaces |Not sent | |
| | |040 |X835-CLP-CL-CONTACT-NM1 |N |spaces |Not sent | |
| | |040 |X835-CLP-COMM-NUM-QL1 |N |spaces |Not sent | |
| | |040 |X835-CLP-COMM-NUM1 |N |spaces |Not sent | |
| | |040 |X835-CLP-CONTACT-CD2 |N |spaces |Not sent | |
| | |040 |X835-CLP-CL-CONTACT-NM2 |N |spaces |Not sent | |
| | |040 |X835-CLP-COMM-NUM-QL2 |N |spaces |Not sent | |
| | |040 |X835-CLP-COMM-NUM2 |N |spaces |Not sent | |
| | |040 |X835-CLP-SUPL-AMT-QL |N |spaces |Not sent | |
| | |040 |X835-CLP-SUPL-AMT |N |zeros |Not sent | |
| | |040 |X835-CLP-SUPP-QTY-CD |N |spaces |Not sent | |
| | |040 |X835-CLP-SUPP-QTY |N |zeros |Not sent | |
| |C-XCN-NUM |040 |X835-ACS-EDI-TRACE-NUM |A |spaces |EDI trace number. Only sent on 5010 claims. | |
| |C-HDR-CAS-NUM |041 |X835-CL-ADJ-CTR |A |zeros |Number of CAS segments. Set to C-HDR-CAS-NUM | |
| |C-CAS-GRP-CD |041 |X835-CL-ADJ-GROUP |C |spaces |Claim adjustment group code | |
| |C-CAS-RSN-CD |041 |X835-CL-ADJ-REASON |C |spaces |Claim adjustment reason | |
| |C-CAS-AMT |041 |X835-CL-ADJ-AMT |C |zeros |Claim adjustment amount not equal to zeros. | |
| |C-CAS-UNT-NUM |041 |X835-CL-ADJ-QTY |C |zeros |Claims adjustment quantity | |
| | |050 |X835-SVC-ID-CTR |A |zeros |Set to 1. | |
| | |050 |X835-SVC-REND-PROV-CTR |A |zeros |Set to 1 if the C-RNDR-PROV-ID > spaces. | |
| | |050 |X835-HEALTHCARE-POLICY-CTR |A |zeros |Not sent. | |
| | |050 |X835-SVC-SUPL-INFO-CTR |A |zeros |Not sent | |
| | |050 |X835-SVC-SUPL-QTY-CTR |A |zeros |Not sent | |
| | |050 |X835-SVC-PROC-CD-QL |C |spaces |If R-PROC-CD > spaces, this field is set to “HC” | |
| | | | | | |Else if R-REV-CD > spaces, this field is set to | |
| | | | | | |“NU”. | |
| |R-PROC-CD or R-REV-CD |050 |X835-SVC-PROC-CD |C |spaces |Procedure code (all claims) or | |
| | | | | | |revenue code ( Institutional claims only if the | |
| | | | | | |claim does not have a procedure code) | |
| |C-PROC-MOD-1ST-CD thru |050 |X835-SVC-MOD |C |spaces |If R-PROC-CD > spaces, the procedure modifiers are| |
| |C-PROC-MOD-4TH-CD | | | | |moved to this field. Up to 4 occurrences can be | |
| | | | | | |used. | |
| |R-PROC-SHORT-DESC |050 |X835-SVC-PROC-DESC |N |spaces |Not sent | |
| |C-LI-SUBM-CHRG-AMT |050 |X835-SVC-LI-CHRG-AMT |A |zeros |Line Item Charge Amount | |
| |C-LI-REIMB-AMT |050 |X835-SVC-LI-REIMB-AMT |A |zeros |Line Item Provider Payment | |
| |R-REV-CD |050 |X835-SVC-REVENUE-CD |C |spaces |N/UBC Revenue Code. If the Institutional claim | |
| | | | | | |has both a procedure code and revenue code, then | |
| | | | | | |the revenue code will go in this field. | |
| |C-LI-ALLOW-UNT-NUM |050 |X835-SVC-UNITS-OF-SVC |A |zeros |Paid units of service | |
| | |050 |X835-SVC-SUBS-PROC-CD-QL |C |spaces |If R-DRUG-CD > spaces, this field is set to “N4”. | |
| |W1C41541-R-DRUG-CD |050 |X835-SVC-SUBS-PROC-CD |C |spaces |Drug code | |
| | |050 |X835-SVC-SUBS-MOD |N |spaces |Not sent | |
| | |050 |X835-SVC-SUBS-PROC-DESC |N |spaces |Not sent | |
| |C-LI-SUBM-UNT-NUM |050 |X835-SVC-SUBS-UNITS-OF-SVC |C |zeros |Submitted units of service. Not sent if the | |
| | | | | | |submitted units of service are equal to | |
| | | | | | |X835-SVC-UNITS-OF-SVC | |
| | |050 |X835-SVC-DT-CD |N |spaces |If the first service date equals the last service | |
| | | | | | |date, this field is set to ‘472’for the first | |
| | | | | | |occurrence and spaces for the second occurrence. | |
| | | | | | |If the dates are not equal, the first occurrence | |
| | | | | | |is set to ‘151’ for the first service date and the| |
| | | | | | |second occurrence is set to ‘152’.for the last | |
| | | | | | |service date. | |
| |C-LI-FST-DOS-DT |050 |X835-SVC-DT |N |spaces | | |
| |C-LI-LAST-DOS-DT | | | | | | |
| | |050 |X835-SVC-ID-CD |A |spaces |Service ID code. Set to “”LU” | |
| |C-BLNG-PROV-ID |050 |X835-SVC-ID |A |spaces |Billing provider ID | |
| | |050 |X835-SVC-LI-CTL-NUM-QL |A |spaces |Service line control number qualifier. Set to “6R”| |
| |C-LI-NUM |050 |X835-SVC-LI-CTL-NUM |A |spaces | This field will contain the line control number | |
| | | | | | |from the X837 transaction, or the claim line | |
| | | | | | |number if the control number is not available. | |
| | |050 |X835-SVC-REND-ID-CD |C |spaces |Service rendering id code. Set to “1D” if | |
| | | | | | |C-RNDR-NPI-ID or C-RNDR-PROV-ID is > spaces. | |
| |C-RNDR-NPI-ID or |050 |X835-SVC-REND-ID |C |spaces |Rendering provider id. | |
| |C-RNDR-PROV-ID | | | | | | |
| | |050 |X835-SVC-HEALTHCARE-POLICY-QL |N |spaces |Not sent | |
| | |050 |X835-SVC-HEALTHCARE-POLICY-ID |N |spaces |Not sent | |
| | |050 |X835-SVC-SUPL-AMT-CD |N |spaces |Not sent | |
| | |050 |X835-SVC-SUPL-AMT |N |zeros |Not sent | |
| | |050 |X835-SVC-SUPL-QTY-CD |N |spaces |Not sent | |
| | |050 |X835-SVC-SUPL-QTY |N |zeros |Not sent | |
| |C-CNT-LI-CAS-NUM |051 |X835-SVC-ADJ-CTR |C |zeros |Calculated using C-CNT-LI-CAS-NUM | |
| |C-CAS-GRP-CD |051 |X835-SVC-ADJ-GROUP |C |spaces |Service adjustment group code. | |
| |C-CAS-RSN-CD |051 |X835-SVC-ADJ-REASON-CD |C |spaces |Service adjustment reason code | |
| |C-CAS-AMT |051 |X835-SVC-ADJ-AMT |C |zeros |Service adjustment monetary amount not equal to | |
| | | | | | |zeros. | |
| |C-CAS-UNT-NUM |051 |X835-SVC-ADJ-QTY |C |zeros |Service adjustment quantity | |
| | |052 |X835-SVC-REMARK-CD-QL |C |spaces |Service remark code qualifier. If remark code is a| |
| | | | | | |reject code, set to “RX”, else set to “HE”. | |
| |R-CMS-RMK-CD |052 |X835-SVC-REMARK-CD |C |spaces |Line service remark code | |
| | |060 |X835-PROV-ADJ-REASON-CTR |C |zeros |Provider adjustment reason counter. Calculated. | |
| |C-BLNG-NPI-ID or C-BLNG-TAX-ID |060 |X835-PLB-PROV-ID |C |spaces |Adjustment claims only. | |
| |or C-BLNG-SSN-NUM | | | | | | |
| | |060 |X835-PROV-FISCAL-YR-END |C |spaces |Fiscal year end date for the billing provider. If | |
| | | | | | |P-FSCL-END-MO-NUM = spaces, this field is set to | |
| | | | | | |12/31 of the current year, otherwise we check to | |
| | | | | | |see if the current month is >= P-FSCL-END-MO-NUM. | |
| | | | | | |If it’s greater, we add 1 month to the | |
| | | | | | |P-FSCL-END-MO-NUM and set the year to current year| |
| | | | | | |+ 1, otherwise we use P-FSCL-END-MO-NUM and set | |
| | | | | | |the year to the current year. The day is always | |
| | | | | | |set to the derived month’s ending day. | |
| |F-RSN-CD |060 |X835-PROV-ADJ-REASON-CD |C |spaces |Financial claims only. Provider adjustment reason.|7 |
| |C-RLTD-FCN-NUM |060 |X835-GROSS-ADJ-TCN |C |spaces |Financial claims only. Financial Control Number or| |
| |or C-TCN-NUM | | | | |TCN Number | |
| |C-TOT-REIMB-AMT |060 |X835-GROSS-ADJ-AMT |C |zeros |Financial claims only. Adjustment amount not equal|6 |
| | | | | | |to zeros. | |
| | |999 |X835-TX-NUM-OF-SEG |A |zeros |Calculated. Total number of segments for the | |
| | | | | | |submitter. | |
| | |999 |X835-TX-CTL-NUM-TLR |A |spaces |Calculated. | |
| | |TRL |X835-FILE-TRAILER-NUM-OF-RECS |A |zeros |Calculated. Total number of segments for the X835 | |
| | | | | | |file. | |
LEGEND: For Req: A = Always
C = Conditionally
N = Never
NOTES:
1. The first 4 fields are the key sort fields for the file. The 5th field, TX-CD, is used to identify each segment of the IRL. All of these fields occur once per segment .
2. Only used for Medicare Part A, Inpatient, Hospice, and Long-Term Care.
3. Only used for Medicare Part B claims and Medicare UB Part B claims.
4. Only used for Medicare Part A Crossover claims.
5. IF (W1C41521-C-HDR-TY-CD = WV-C1031-C-MCARE-A-XOVER
OR W1C41521-C-HDR-TY-CD = WV-C1031-C-HOSPICE
OR W1C41521-C-HDR-TY-CD = WV-C1031-C-INPATIENT
OR W1C41521-C-HDR-TY-CD = WV-C1031-C-LTC
OR W1C41521-C-HDR-ID-CD = WV-G0145-C-CREDADJREC) , skip this segment.
6. Adjustment amount is multiplied by -1 before moving it to the segment.
7. F-RSN-CD crosswalk:
|Financial Reason Code |Valid Value from WVF9884C |835 ADJ RSN CODE |
|073 - Recpt Disposition Refund |WV-F9884-C-DISP-REFUND |B2 |
|074- Refund TPL Medicare |WV-F9884-C-REFUND-TPL-MEDICAR |B2 |
|075- Refund TPL Casualty |WV-F9884-C-REFUND-TPL-CASUALT |B2 |
|076- Refund TPL Insurance |WV-F9884-C-REFUND-TPL-INSURAN |B2 |
|077- Refund SUR Overpay and Abuse |WV-F9884-C-REFUND-SUR-OV-ABUS |B2 |
|078- Refund Aud Overpay and Abuse |WV-F9884-C-REFUND-AUD-OV-ABUS |B2 |
|079- Refund Prov Self Audit Abuse |WV-F9884-C-REFUND-SLF-AUD-ABU |B2 |
|089- Refund SUR Fraud/Aud Fraud |WV-F9884-C-REFUND-SUR-AUD-FRD |B2 |
|090- Refund OIG False Clm/Stl/Jdg |WV-F9884-C-REFUND-OIG-STL-JG |B2 |
|091- Refund DPNA |WV-F9884-C-REFUND-DPNA |B2 |
|092- Refund CMS MIC Overpayment |WV-F9884-C-REFUND-CMS-MIC-OVP |B2 |
|095- Refund HHS/OIG |WV-F9884-C-REFUND-HHS-OIG |B2 |
|096- Refund External Audit |WV-F9884-C-REFUND-EXT-AUDIT |B2 |
|155- Refund HIT |WV-F9884-C-REFUND-HIT |B2 |
|159- Refund RAC |WV-F9884-C-REFUND-RAC |B2 |
|007 - Receivable Audit Fraud |WV-F9884-C-RECV-AUDIT-FRAUD |FB |
|008 - Receivable Audit Abuse |WV-F9884-C-RECV-AUDIT-ABUSE |FB |
|009 - Receivable SUR Overpayment |WV-F9884-C-RECV-SUR-OVER-PMT |FB |
|011 - Receivable Settlemnt/Judgmnt |WV-F9884-C-RECV-STLMNT-JUDGMN |FB |
|012 - Receivable Audit Overpayment |WV-F9884-C-RECV-AUDIT-OVR-PMT |FB |
|013 - Receivable SUR Fraud |WV-F9884-C-RECV-SUR-FRAUD |FB |
|014 - Receivable SUR Abuse |WV-F9884-C-RECV-SUR-ABUSE |FB |
|060 - Receivable CMS MIC Overpaymnt |WV-F9884-C-RECV-CMS-MIC-OVPMT |FB |
|061 - Receivable DPNA |WV-F9884-C-RECV-DPNA |FB |
|062 - Recv HHS/OIG |WV-F9884-C-RECV-HHS-OIG |FB |
|063 - Recv OIG Comp False Claim Ac |WV-F9884-C-RECV-OIG-FALSE-CLM |FB |
|066 - Recv Prov Self-Audit Abuse |WV-F9884-C-RECV-SELF-AUDIT |FB |
|080 - Receivable Claim Fiscal Agent |WV-F9884-C-RECV-CLAIM-FA |FB |
|081 - Receivable Claim HSD |WV-F9884-C-RECV-CLAIM-HSD |FB |
|082 - Receivable RAC |WV-F9884-C-RECV-RAC |FB |
|083 - Receivable HWT Claim Overpaymnt |WV-F9884-C-RECV-OVERPAY-HWT |FB |
|123 - Recv External Audit |WV-F9884-C-RECV-EXT-AUDIT |FB |
|005 - Hospital GME Payment |WV-F9884-C-HOSP-GME-PYMNT |GO |
|002 - Payout Gross Level Adjustment |WV-F9884-C-PAYOUT-GLA |LS |
|003 - Payout of HIPP Payment |WV-F9884-C-PAYOUT-HIPP-PYMNT |LS |
|004 - Hospital DSH Payment |WV-F9884-C-HOSP-DSH-PYMNT |LS |
|006 - Hospital IME Payment |WV-F9884-C-HOSP-IME-PYMNT |LS |
|017 - Upper Limit Payment |WV-F9884-C-UPPER-LIMIT-PMT |LS |
|093 Reverse Recoupment |WV-F9884-C-PAYOUT-REV-RECOUP |LS |
|102 - WrapAround Payment |WV-F9884-C-WRAP-AROUND-PYMNT |LS |
|103 - Sole Community Provider Payment |WV-F9884-C-SOLE-COMM-PROV-PMT |LS |
|104 - Nurse Aid Training |WV-F9884-C-NURSE-AID-TRNG |LS |
|105- Criminal Background Checks |WV-F9884-C-CRIMINAL-BKGRD-CHK |LS |
|113 - RAC Payout |WV-F9884-C-RAC-PAYOUT |LS |
|131 - HIT Payout |WV-F9884-C-HIT-PAYOUT |LS |
|019 - Warrant Replacement System |WV-F9884-C-WARRANT-REPL-SYS |CS |
|016 - Advance Payment System |WV-F9884-C-ADVANCED-PYMT-SYS |PI |
|001 - Payout Cost Settlement |WV-F9884-C-PAYOUT-COST-STTLMN |PL |
|086 – Claim Recoup of a Receivable |WV-F9884-C-CLAIM-RECOUPMENT |WO |
|Other Financial Reason Codes Default Value |N/A |CS |
NEW MEXICO OMNICAID MMIS CLAIMS SUBSYSTEM
INTERFACE LAYOUT
OUTPUT FILE
X820 PREMIUM PAYMENT INTERFACE
|Description: |
|This interface reads the payment file created during payment processing and creates the X820 Electronic Premium Payment Advice IRL file transmitted to EDI to send to the providers requesting |
|X820s. |
|Source File: |File Description: |
|Adjudicated Claims Payment File |Created during payment process. Contains a group of records for each claim paid or denied. |
|Target Files: |File Description: |
|X820 claims IRL file sent to EDI |IRL (Internal Record Layout) X820 file produced by the MMIS in the payment cycle. |
|Reports: |
|RC114 - X820 Electronic Premium Payment Processing Report |
|Process Summaries |
|Remarks: |
|1. Only MCO providers, Capitation claims, and financial transactions are included from the C4568SA input file before the X820 process is run. |
|2. See the X820 EDI Crosswalk for a full explanation of each field. The crosswalk is located in the 11d-5exhb Exhibit section of system documentation. The field ‘Target Segment’ is provided in|
|the Interface Layout table below to assist in matching the fields on this table with the fields on the X820 crosswalk. |
000100**************************************************************** 00000200
000200* PREMIUM PAYMENT EDI INTERFACE * 00000300
000300* COPYBOOK X820V01 * 00000400
000400* * 00000500
000500* * 00000600
000600* THE PREMIUM PAYMENT EDI INTERFACE COPYBOOK HAS THE SAME * 00000700
000700* DATA CONTENT AS THE 820 PREMIUM PAYMENT TRANSACTION. * 00000800
000800* * 00000900
000900* THE PAYMENT EDI INTERFACE COPYBOOK CONTAINS THE * 00001000
001000* FOLLOWING RECORDS. * 00001100
001100* * 00001200
001200* * 00001300
001300* RECORD DESCRIPTION * 00001400
001400* ----------------------- ------------------------------ * 00001500
001500* * 00001600
001600* X820-FILE-HEADER FILE LEVER HADER CONTAINS ISA *
001600* LEVEL FILE VERSION *
001700* RELEASE CODE AND NAME AND *
001800* SENDER/RECEIVERS ID'S *
002000* *
002100* X820-TX-HEADER CONTAINS ALL TRANSACTION * 00001700
002200* HEADER SEGMENTS EXCEPT FOR THE * 00001800
002200* REF SEGMENT * 00001800
002300* * 00001900
002100* X820-TX-PREM-RECEIVER CONTAINS REF SEGMENT FROM * 00001700
002300* HEADER * 00001900
002300* * 00001900
002100* X820-PREMIUM-RECV-NAME CONTAINS LOOP 1000A SEGMENTS * 00001700
002300* * 00001900
002100* X820-PAYER-NAME CONTAINS LOOP 1000B SGMENTS * 00001700
002100* EXCEPT THE PER SEGMENT * 00001700
002300* * 00001900
002100* X820-PAYER-CONTACT CONTAINS PER SEGMENT FROM LOOP * 00001700
002100* 1000B * 00001700
002300* * 00001900
002100* X820-INTER-BANK CONTAINS LOOP 1000C SEGMENTS * 00001700
002100* EXCEPT THE PER SEGMENT * 00001700
002300* * 00001900
002100* X820-INTER-BANK-CONTACT CONTAINS PER SEGMENT FROM LOOP * 00001700
002100* 1000C * 00001700
002300* * 00001900
002400* X820-ORG-SUM-REMIT CONTAINS LOOP 2000A SEGMENTS * 00002000
002800* * 00002400
002400* X820-ORG-SUM-REMIT-ADJ CONTAINS LOOP 2200A SEGMENTS * 00002000
002800* * 00002400
002800* X820-ORG-SUMMARY-REMIT-DETAIL CONTAINS LOOP 2300A SEGMENTS * 00002400
002400* EXCEPT THE REF SEGMENT * 00002000
002800* * 00002400
002800* X820-ORG-SUMMARY-REMIT-REF CONTAINS REF SEGMENT OF LOOP * 00002400
002400* 2300A * 00002000
002800* * 00002400
002800* X820-ORG-DETAIL CONTAINS LOOP 2310A, 2312A AND * 00002400
002400* 2315A SEGMENTS * 00002000
002800* * 00002400
002800* X820-ORG-ADJUD CONTAINS LOOP 2320A SEGMENTS * 00002400
002800* * 00002400
002800* X820-INDIV-REMIT-SEG CONTAINS LOOP 2000B SEGMENTS * 00002400
002800* * 00002400
002800* X820-INDIV-NAME-SEG CONTAINS LOOP 2100B SEGMENTS * 00002400
002800* * 00002400
002800* X820-IND-PREM-ADJ CONTAINS LOOP 2200B SEGMENTS * 00002400
002800* * 00002400
002800* X820-IND-REMIT-DET CONTAINS LOOP 2300B SEGMENTS * 00002400
002800* EXCEPT FOR THE REF SEGMENT * 00002400
002800* * 00002400
002800* X820-IND-REMIT-REFERENCE-INFO CONTAINS SEGMENT REF FROM * 00002400
002800* LOOP 2300B * 00002400
002800* * 00002400
002800* X820-IND-PREM-ADJ-CURR-PYMT CONTAINS LOOP 2320B SEGMENTS * 00002400
002800* * 00002400
003900* X820-TX-TRAILER CONTAINS THE TRANSACTION * 00003500
004100* TRAILER SEGMENT * 00003700
004200* *
010100* X820-FILE-TRAILER FILE LEVEL TRAILER *
010200* CONTAINS RECORD COUNT FOR IRL *
004500* * 00003800
004700**************************************************************** 00000200
005200* * 00004500
005300* X820-TX-CD TO IDENTIFY EACH TYPE OF RECORD *
005400* HDR............X820-FILE-HEADER *
005500* 000............X820-TX-HEADER *
005500* 001............X820-TX-PREM-RECEIVER *
005600* 010............X820-PREMIUM-RECV-NAME *
005700* 020............X820-PAYER-NAME *
005700* 021............X820-PAYER-CONTACT NOT SENT *
005800* 030............X820-INTER-BANK NOT SENT *
005800* 031............X820-INTER-BANK-CONTACT NOT SENT *
005900* 040............X820-ORG-SUM-REMIT NOT SENT *
005910* 041............X820-ORG-SUM-REMIT-ADJ NOT SENT *
005920* 042............X820-ORG-SUMMARY-REMIT-DETAIL NOT SENT *
005930* 043............X820-ORG-SUMMARY-REMIT-REF NOT SENT *
005930* 044............X820-ORG-DETAIL NOT SENT *
005940* 045............X820-ORG-ADJUD NOT SENT *
005950* 050............X820-INDIV-REMIT-SEG *
005960* 051............X820-INDIV-NAME-SEG *
005970* 052............X820-IND-PREM-ADJ *
005980* 053............X820-IND-REMIT-DET *
005990* 054............X820-IND-REMIT-REFERENCE-INFO *
005990* 055............X820-IND-PREM-ADJ-CURR-PYMT *
006000* 999............X820-TX-TRAILER *
006100* TRL............X820-FILE-TRAILER *
006300* * 00008400
006400****************************************************************
006500* *
006600* 820 - SORT KEY *
006700* *
006800* SORT KEY: *
006900* FILE-ID = XXXXXXXXXXXXXXX FILE ID *
007000* ROUTING-ID = XXXXXXXXXXXXXXX ROUTING ID *
007100* DOC-SEQ-NUM = XXXXXXXXX DOCUMENT INDEX *
007200* FILE-REC-SEQ-NUM = 9999999999 FILE RECORD INDEX *
007300* WILL BE GENERATED *
007400* SEQUENTIALLY. *
007500* *
007600****************************************************************
007700* CHANGE LOG *
007800* *
007900* *
008000* ID DESCRIPTION PERSON DATE *
008100* -------- -------------------------- -------- -------- *
008200* CHG001 CREATE GENERIC COPYBOOK EDI 04-01-10 *
008300* *
008400* *
008500****************************************************************
008600* 820 - ISA INTERCHANGE
* contains HDR segment
008700****************************************************************
008800*
008900 01 X820-FILE-HEADER.
009000*
009100 05 X820-SORT-KEY.
009200 10 X820-FILE-ID
009300 VALUE SPACES
009400 PIC X(15).
009500 10 X820-ROUTING-ID
009600 VALUE SPACES
009700 PIC X(15).
009800 10 X820-DOCUMENT-SEQ-NUM
009900 VALUE ZEROES
010000 PIC 9(09).
010100 10 X820-TX-CD-SEQ-NUM
010200 VALUE ZEROES
010300 PIC 9(10).
010400*
010500 05 X820-TX-CD
010600 VALUE 'HDR'
010700 PIC X(03). 'HDR'
010800*
010900* LOOP (NONE), SEGMENT ISA (INTERCHANGE)
011000*
011100 05 X820-FILE-HEADER-SEG.
011200 10 X820-FILE-VER-RELEASE-CD
011300 PIC X(12). '005010X218'
011400 10 X820-FILE-VER-NAME
011500 PIC X(04). '0820'
011600 10 X820-FILE-ISA-SENDER
011700 PIC X(15). '77048'
011800 10 X820-FILE-ISA-RECEIVER
011900 PIC X(15).
012000 10 X820-FILE-GS-SENDER
012100 PIC X(15). '77048'
012200 10 X820-FILE-GS-RECEIVER
012300 PIC X(15).
012400
012500****************************************************************
012600* 820 TRANSACTION HEADER RECORD (NO LOOP) *
Contains ST, BPR, TRN,CUR,DTM segments
012700****************************************************************
012800*
012900 01 X820-TX-HEADER.
012910*
012950 05 X820-SORT-KEY.
012960 10 X820-FILE-ID
012970 VALUE SPACES
012980 PIC X(15).
012990 10 X820-ROUTING-ID
012991 VALUE SPACES
012992 PIC X(15).
012993 10 X820-DOCUMENT-SEQ-NUM
012994 VALUE ZEROES
012995 PIC 9(09).
012996 10 X820-TX-CD-SEQ-NUM
012997 VALUE ZEROES
012998 PIC 9(10).
012999
013000 05 X820-TX-CD
013001 VALUE '000'
013002 PIC X(03). '000'
013003*
014400* LOOP (NONE), SEGMENT ST (TRANSACTION HEADER)
014500*
014600 05 X820-TX-HEADER-SEG.
014700*
014800 10 X820-TX-ID
014900 VALUE '820'
015000 PIC X(03). '820'
015100 10 X820-TX-CTL-NUM
015200 PIC X(09). Starts at 1 and incremented by 1 for each ST-999 group
015300 10 X820-TX-COPYBOOK-NM
015400 PIC X(35). '005010X218'
015500*
015600* LOOP (NONE), SEGMENT BPR (FINANCIAL INFO)
015700*
015800 05 X820-TX-FINANCIAL-INFO-SEG.
015900*
016000 10 X820-TX-HANDLING-CD BPR01
016100 PIC X(02). ‘I’
016200 10 X820-TX-TOTAL-PREMIUM-AMT BPR02
016300 PIC S9(16)V99. C-HDR-WARR-AMT = 042 + 053 TOTALS
016400 10 X820-TX-DEBIT-CREDIT-FLAG BPR03
016500 PIC X(01). ‘C’
016600 10 X820-TX-PMT-METHOD-CD BPR04
016700 PIC X(03). ‘NON’
016800 10 X820-TX-PMT-FORMAT-CD
016900 PIC X(10). NOT SENT
017000 10 X820-TX-SENDER-DFI-QL
017100 PIC X(02). NOT SENT
017200 10 X820-TX-SENDER-DFI-ID
017300 PIC X(12). NOT SENT
017400 10 X820-TX-SENDER-ACCT-QL
017500 PIC X(03). NOT SENT
017600 10 X820-TX-SENDER-ACCT
017700 PIC X(35). NOT SENT
017800 10 X820-TX-SENDER-ID BPR10
017900 PIC X(10). WK-000-SENDER-ID
018000 10 X820-TX-SENDER-SUPL-CD BPR11
018100 PIC X(09). C-HDR-RA-NUM (matches TRN04 field)
018200 10 X820-TX-RCV-DFI-QL
018300 PIC X(02). NOT SENT
018400 10 X820-TX-RCV-DFI-ID
018500 PIC X(12). NOT SENT
018600 10 X820-TX-RCV-ACCT-QL
018700 PIC X(03). NOT SENT
018800 10 X820-TX-RCV-ACCT
018900 PIC X(35). NOT SENT
019000 10 X820-TX-CHECK-EFT-DT BPR16 format CCYYMMDD
019100 PIC X(08). C-HDR-PD-DT
019200*
019300* LOOP (NONE), SEGMENT TRN (REASSOCIATION TRACE NUM)
019400*
019500 05 X820-TX-REASSOCIATION-SEG.
019600*
019700 10 X820-TX-CHECK-EFT-TRACE-TYP TRN01
019800 PIC X(02). ‘3’
019900 10 X820-TX-CHECK-EFT-TRACE-NUM TRN02
020000 PIC X(50). C-EFT-TRC-ID OR C-HDR-WARR-NUM
020100 10 X820-TX-PYR-TAX-ID TRN03
020200 PIC X(10).
020300 10 X820-TX-PYR-SUPL-CD TRN04
020400 PIC X(50). C-HDR-RA-NUM (matches BPR11 field)
020500*
020600* LOOP (NONE), SEGMENT CUR (FOREIGN CURRENCY INFO) not sent
020700*
020800 05 X820-TX-CURRENCY-SEG.
020900*
021000 10 X820-TX-CURRENCY-ENTY-CD
021100 PIC X(03).
021200 10 X820-TX-CURRENCY-CD
021300 PIC X(03).
022300*
022400* LOOP (NONE), SEGMENT DTM (PROCESS DATE)
022500*
022600 05 X820-TX-PROCESS-DATE-SEG.
022700*
022800 10 X820-TX-PROCESS-CD DTM01
022900 PIC X(03). ‘009’
023000 10 X820-TX-PROCESS-DT DTM02
023100 PIC X(08). C-HDR-PD-DT
023200*
023300* LOOP (NONE), SEGMENT DTM (DELIVERY DATE) NOT SENT
023400*
023500 05 X820-TX-DELIVERY-DATE-SEG.
023600*
023700 10 X820-TX-DELIVERY-CD DTM01
023800 PIC X(03). Not sent since payment is not being sent
023900 10 X820-TX-DELIVERY-DT DTM02
024000 PIC X(08). Not sent since payment is not being sent
024100*
024200* LOOP (NONE), SEGMENT DTM (COVERAGE PERIOD)
024300*
024400 05 X820-TX-COVERAGE-PERIOD-SEG.
024500*
024600 10 X820-TX-CVRG-CD DTM01
024700 PIC X(03). ‘582’
024800 10 X820-TX-CVRG-PERIOD-CD DTM05
024900 PIC X(03). ‘RD8’
025000 10 X820-TX-CVRG-DT DTM06
025100 PIC X(35). C-HDR-SVC-FST-DT and C-HDR-SVC-LST-DT
025200*
025300* LOOP (NONE), SEGMENT DTM (CREATION DATE)
025400*
025500 05 X820-TX-CREATION-PERIOD-SEG.
025600*
025700 10 X820-TX-CREATION-CD
025800 PIC X(03). ‘097’
025900 10 X820-TX-CREATION-DT
026000 PIC X(08). C-HDR-ADJUD-DT CCYYMMDD
*
012500****************************************************************
012600* 820 PREMIUM RECEIVERS IDENTIFICATION KEY MAX >1 *
REF segment
012700****************************************************************
012800*
012900 01 X820-TX-PREM-RECEIVER.
012910*
012950 05 X820-SORT-KEY.
012960 10 X820-FILE-ID
012970 VALUE SPACES
012980 PIC X(15).
012990 10 X820-ROUTING-ID
012991 VALUE SPACES
012992 PIC X(15).
012993 10 X820-DOCUMENT-SEQ-NUM
012994 VALUE ZEROES
012995 PIC 9(09).
012996 10 X820-TX-CD-SEQ-NUM
012997 VALUE ZEROES
012998 PIC 9(10).
012999
013000 05 X820-TX-CD
013001 VALUE '001'
013002 PIC X(03).
021400*
021500* LOOP (NONE), SEGMENT REF (PREMIUM RECEIVERS IDENTIFICATION
021500* KEY)
021600*
021700 05 X820-TX-RCV-ID-SEG.
021900 10 X820-TX-RCV-QL REF01 PIC X(03). ????? 14
022100 10 X820-TX-RCV-ID REF02 PIC X(50). ?????? NPI ID, Tax id or SSN
026200****************************************************************
026300* *
026400* 820 PREMIUM RECEIVERS NAME *
026500* segments N1 thru N4 and RDM *
026600****************************************************************
026700*
027100 01 X820-PREMIUM-RECV-NAME.
027110*
027210 05 X820-SORT-KEY.
027220 10 X820-FILE-ID
027230 VALUE SPACES
027240 PIC X(15).
027250 10 X820-ROUTING-ID
027260 VALUE SPACES
027270 PIC X(15).
027280 10 X820-DOCUMENT-SEQ-NUM
027290 VALUE ZEROES
027291 PIC 9(09).
027292 10 X820-FILE-REC-SEQ-NUM
027293 VALUE ZEROES
027294 PIC 9(10).
027295
027296 05 X820-TX-CD
027297 VALUE '010'
027298 PIC X(03).
027299*
027300* LOOP 1000A, SEGMENT N1 (PREMIUM RECEIVER'S NAME)
027400*
028500 05 X820-RCV-NAME-SEG.
028700 10 X820-RCV-ENTY-CD N101
028800 PIC X(03). ‘PE’
028900 10 X820-RCV-NM N102
029000 PIC X(60). P-NAM
029100 10 X820-RCV-QL N103
029200 PIC X(02). XV or FI
029300 10 X820-RCV-ID N104
029400 PIC X(80). C-BLNG-NPI-ID or C-BLNG-TAX-ID or C-BLNG-SSN-NUM
029500*
029600* LOOP 1000A, SEGMENT N2 (PREMIUM RECEIVER ADDITIONAL NAME)
029700*
029800 05 X820-RCV-OTHER-NAME-SEG.
030000 10 X820-RCV-SEC-NM
030100 PIC X(60). Not sent since P-NAM is X(45).
030200*
030300* LOOP 1000A, SEGMENT N3 (PREMIUM RECEIVER'S ADDRESS)
030400*
030500 05 X820-RCV-ADDRESS-SEG.
030700 10 X820-RCV-ADDR-1 Use P-ADR-TY-CD = “L” for location
030800 PIC X(55). P-ADDR-TB. P-LINE1-AD
030900 10 X820-RCV-ADDR-2
031000 PIC X(55). P-ADDR-TB. P-LINE2-AD
031100*
031200* LOOP 1000A, SEGMENT N4 (PREMIUM RECEIVER'S CITY, STATE)
031300*
031400 05 X820-RCV-CITY-STATE-SEG.
031600 10 X820-RCV-CITY
031700 PIC X(30). P-ADDR-TB.P-CITY-NAM
031800 10 X820-RCV-ST
031900 PIC X(02). P-ADDR-TB. P-ST-CD
032000 10 X820-RCV-ZIP
032100 PIC X(15). P-ADDR-TB.P-ZIP4-CD + P-ZIP5-CD
032200 10 X820-RCV-CNTRY
032300 PIC X(03). NOT SENT
032400 10 X820-RCV-CNTRY-SUB
032500 PIC X(03). NOT SENT
032600*
032700* LOOP 1000A, SEGMENT RDM (PREMIUM RECEIVER REMIT DELIVERY)
032800*
032900 05 X820-RCV-REMIT-DELIVERY-SEG.
033100 10 X820-RCV-RPT-XMIT-CD
033200 PIC X(02). NOT SENT
033300 10 X820-RCV-REMIT-NM
033400 PIC X(60). NOT SENT
033500 10 X820-RCV-COMM-NUM
033600 PIC X(256). NOT SENT
*
033700****************************************************************
033800* *
033900* 820 PREMIUM PAYERS'S NAME *
034000* *
034100****************************************************************
034200*
034600 01 X820-PREMIUM-PAYER-NAME.
034700*
034710 05 X820-SORT-KEY.
034720 10 X820-FILE-ID
034730 VALUE SPACES
034740 PIC X(15).
034750 10 X820-ROUTING-ID
034760 VALUE SPACES
034770 PIC X(15).
034780 10 X820-DOCUMENT-SEQ-NUM
034790 VALUE ZEROES
034791 PIC 9(09).
027292 10 X820-FILE-REC-SEQ-NUM
034793 VALUE ZEROES
034794 PIC 9(10).
036301*
034796 05 X820-TX-CD
034797 VALUE '020'
034798 PIC X(03).
036301*
036310* LOOP 1000B, SEGMENT N1 (PREMIUM PAYER'S NAME)
036320*
036400 05 X820-PAYER-NAME.
036600 10 X820-PYR-ENTY-CD N101
036700 PIC X(03). ‘PR’
036800 10 X820-PYR-NM N102
036900 PIC X(60). WK-000-PYR-NM
037000 10 X820-PYR-QL N103
037100 PIC X(02). NOT SENT
037200 10 X820-PYR-ID N104
037300 PIC X(80). NOT SENT
037400*
037500* LOOP 1000B, SEGMENT N2 (PREMIUM PAYER ADDITIONAL NAME)
037600*
037700 05 X820-PAYER-OTHER-NAME-SEG.
037800*
037900 10 X820-PYR-SEC-NM N201
038000 PIC X(60). NOT SENT
038100*
038200* LOOP 1000B, SEGMENT N3 (PREMIUM PAYER'S ADDRESS)
038300*
038400 05 X820-PAYER-ADDRESS-SEG.
038500*
038600 10 X820-PYR-ADDR-1
038700 PIC X(55). SEE X835
038800 10 X820-PYR-ADDR-2
038900 PIC X(55). SEE X835
039000*
039100* LOOP 1000B, SEGMENT N4 (PREMIUM PAYER'S CITY, STATE)
039200*
039300 05 X820-PAYER-CITY-STATE-SEG.
039400*
039500 10 X820-PYR-CITY
039600 PIC X(30). SEE X835
039700 10 X820-PYR-ST
039800 PIC X(02). SEE X835
039900 10 X820-PYR-ZIP
040000 PIC X(15). SEE X835
040100 10 X820-PYR-CNTRY
040200 PIC X(03). NOT SENT
040300 10 X820-PYR-CNTRY-SUB-CD
040400 PIC X(03). NOT SENT
*
0
33700****************************************************************
033800* *
033900* PREMIMUM PAYERS'S ADMINISTRATIVE CONTACT MAX >1 *
034000* NOT SENT *
034100****************************************************************
034200*
034600 01 X820-PAYER-CONTACT.
034700*
034710 05 X820-SORT-KEY.
034720 10 X820-FILE-ID
034730 VALUE SPACES
034740 PIC X(15).
034750 10 X820-ROUTING-ID
034760 VALUE SPACES
034770 PIC X(15).
034780 10 X820-DOCUMENT-SEQ-NUM
034790 VALUE ZEROES
034791 PIC 9(09).
027292 10 X820-FILE-REC-SEQ-NUM
034793 VALUE ZEROES
034794 PIC 9(10).
034795
034796 05 X820-TX-CD
034797 VALUE '021'
034798 PIC X(03).
036000*
036100 05 X820-REC-TYP-021-CNTR.
036200 10 X820-PYR-COMM-CTR
036300 PIC 9(03). NOT SENT
036000*
040600* LOOP 1000B, SEGMENT PER (PREMIUM PAYER'S CONTACT)
040700*
040800 05 X820-PAYER-CONTACT-SEG.
041000 10 X820-PYR-CONTACT-CD
041100 PIC X(02). NOT SENT
041200 10 X820-PYR-CONTACT-NM
041300 PIC X(60). NOT SENT
041400 10 X820-PYR-COMM
041500 OCCURS 0 TO 3 TIMES
041600 DEPENDING ON X820-PYR-COMM-CTR.
041700 15 X820-PYR-COMM
041800 PIC X(02). NOT SENT
041900 15 X820-PYR-COMM-NUM
042000 PIC X(256). NOT SENT
*
042100****************************************************************
042200* INTERMEDIARY BANK INFORMATION NOT SENT *
042300****************************************************************
042400*
042500 01 X820-INTERMEDIARY-BANK.
042400*
042700 05 X820-SORT-KEY.
042800 10 X820-FILE-ID
042900 VALUE SPACES
043000 PIC X(15).
043100 10 X820-ROUTING-ID
043200 VALUE SPACES
043300 PIC X(15).
043400 10 X820-DOCUMENT-SEQ-NUM
043500 VALUE ZEROES
043600 PIC 9(09).
027292 10 X820-FILE-REC-SEQ-NUM
043800 VALUE ZEROES
043810 PIC 9(10).
043820
043830 05 X820-TX-CD
043840 VALUE '030'
043850 PIC X(03). NOT SENT
044300*
044400* LOOP 1000C, SEGMENT N1 (INTERMEDIARY BANK INFO)
044500*
044600 05 X820-INTER-BANK-INFO.
044700*
044800 10 X820-BANK-CD
044900 PIC X(03). NOT SENT
045000 10 X820-BANK-NM
045100 PIC X(60). NOT SENT
045200 10 X820-BANK-CD-QL
045300 PIC X(02). NOT SENT
045400 10 X820-BANK-ID-CD
045500 PIC X(80). NOT SENT
045600*
045700* LOOP 1000C, SEGMENT N2 (INTER BANK ADDITIONAL NAME)
045800*
045900 05 X820-INTER-BANK-SEC-INFO-SEG.
046000*
046100 10 X820-BANK-SEC-NM
046200 PIC X(60). NOT SENT
046300*
046400* LOOP 1000C, SEGMENT N3 (INTERMEDIARY BANK ADDRESS)
046500*
046600 05 X820-INTER-BANK-ADDRESS-SEG.
046700*
046800 10 X820-BANK-ADDR-1
046900 PIC X(55). NOT SENT
047000 10 X820-BANK-ADDR-2
047100 PIC X(55). NOT SENT
047200*
047300* LOOP 1000C, SEGMENT N4 (INTER BANK CITY, STATE, ZIP)
047400*
047500 05 X820-INTER-BANK-CTY-ST-ZIP-SEG.
047600*
047700 10 X820-BANK-CITY
047800 PIC X(30). NOT SENT
047900 10 X820-BANK-ST
048000 PIC X(02). NOT SENT
048100 10 X820-BANK-ZIP
048200 PIC X(15). NOT SENT
048300 10 X820-BANK-CNTRY-CD
048400 PIC X(03). NOT SENT
048500 10 X820-BANK-CNTRY-SUB-CD
048600 PIC X(03). NOT SENT
*
042100****************************************************************
042200* INTERMEDIARY BANK'S ADMINISTRATIVE CONTACT MAX >1 *
NOT SENT
042300****************************************************************
042400*
042500 01 X820-INTER-BANK-CONTACT.
042400*
042700 05 X820-SORT-KEY.
042800 10 X820-FILE-ID
042900 VALUE SPACES
043000 PIC X(15).
043100 10 X820-ROUTING-ID
043200 VALUE SPACES
043300 PIC X(15).
043400 10 X820-DOCUMENT-SEQ-NUM
043500 VALUE ZEROES
043600 PIC 9(09).
027292 10 X820-FILE-REC-SEQ-NUM
043800 VALUE ZEROES
043810 PIC 9(10).
043820
043830 05 X820-TX-CD
043840 VALUE '031'
043850 PIC X(03). NOT SENT
043900*
044000 05 X820-REC-TYP-031-CNTR.
044100 10 X820-BANK-ADMIN-CTR
044200 PIC 9(03). NOT SENT
048700*
048800* LOOP 1000C, SEGMENT PER (INTER BANK ADMIN CONTACT)
048900*
049000 05 X820-INTER-BANK-ADMIN-SEG.
049200 10 X820-BANK-ADMIN-CD
049300 PIC X(02). NOT SENT
049400 10 X820-BANK-ADMIN-NM
049500 PIC X(60). NOT SENT
049600 10 X820-BANK-ADMIN-COMM
043900 OCCURS 0 TO 3 TIMES
044000 DEPENDING ON X820-BANK-ADMIN-CTR.
049800 15 X820-BANK-ADMIN-COMM-QL
049900 PIC X(02). NOT SENT
050000 15 X820-BANK-ADMIN-COMM-NUM
050100 PIC X(256). NOT SENT
050200*
050300****************************************************************
050400* 820 ORGANIZATION SUMMARY REMITTANCE *
ENT segment - LEAVE FOR LATER USAGE
050500****************************************************************
050700*
050600 01 X820-ORG-SUM-REMIT.
050700*
050810 05 X820-SORT-KEY.
050820 10 X820-FILE-ID
050830 VALUE SPACES
050840 PIC X(15).
050850 10 X820-ROUTING-ID
050860 VALUE SPACES
050870 PIC X(15).
050880 10 X820-DOCUMENT-SEQ-NUM
050890 VALUE ZEROES
050891 PIC 9(09).
027292 10 X820-FILE-REC-SEQ-NUM
050893 VALUE ZEROES
050894 PIC 9(10).
050895
050896 05 X820-TX-CD
050897 VALUE '040'
050898 PIC X(03).
052000*
052100* LOOP 2000A, SEGMENT ENT (ORGANIZATION SUMMARY REMITTANCE)
052200*
052300 05 X820-ORG-ID-SEG.
052400*
052500 10 X820-ORG-ASSIGN-NUM
052600 PIC 9(06).
052700 10 X820-ORG-OR-INDIV-IND
052800 PIC X(03). ‘2L’.
052900 10 X820-ORG-OR-INDIV-QL
053000 PIC X(02).
053100 10 X820-ORG-OR-INDIV-ID
053200 PIC X(80).
053300*
053400****************************************************************
053500* 820 ORGANIZATION SUMMARY REMITTANCE LEVEL *
053600* ADJUSTMENT FOR PREVIOUS PAYMENT *
LEAVE FOR LATER USAGE
053700****************************************************************
053300*
053800 01 X820-ORG-SUM-REMIT-ADJ.
053900*
053910 05 X820-SORT-KEY.
053920 10 X820-FILE-ID
053930 VALUE SPACES
053940 PIC X(15).
053950 10 X820-ROUTING-ID
053960 VALUE SPACES
053970 PIC X(15).
053980 10 X820-DOCUMENT-SEQ-NUM
053990 VALUE ZEROES
053991 PIC 9(09).
027292 10 X820-FILE-REC-SEQ-NUM
053993 VALUE ZEROES
053994 PIC 9(10).
053995
053996 05 X820-TX-CD
053997 VALUE '041'
053998 PIC X(03).
055200*
055300* LOOP 2200A, SEGMENT ADX (ORGANIZATION SUMMARY REMITTANCE
055400* LEVEL ADJUSTMENT FOR PREVIOUS
055500* PAYMENT)
055600*
055700 05 X820-ORG-REMIT-ADJ-PAY-SEG.
055800*
055900 10 X820-ORG-REMIT-ADJ-AMT
056000 S9(16)V99. C-TOT-REIMB-AMT
056100 10 X820-ORG-REMIT-ADJ-REASON-CD
056200 PIC X(02). W1C41521-C-HDR-ADJ-RSN-CD : this field is X(3) for claims
056300*
056400****************************************************************
056500* 820 ORGANIZATION SUMMARY REMITTANCE DETAIL *
LEAVE FOR LATER USAGE
056600****************************************************************
056700*
056800 01 X820-ORG-SUMMARY-REMIT-DETAIL.
056900*
057010 05 X820-SORT-KEY.
057020 10 X820-FILE-ID
057030 VALUE SPACES
057040 PIC X(15).
057050 10 X820-ROUTING-ID
057060 VALUE SPACES
057070 PIC X(15).
057080 10 X820-DOCUMENT-SEQ-NUM
057090 VALUE ZEROES
057091 PIC 9(09).
027292 10 X820-FILE-REC-SEQ-NUM
057093 VALUE ZEROES
057094 PIC 9(10).
057095
057096 05 X820-TX-CD
057097 VALUE '042'
057098 PIC X(03).
058200*
058300* LOOP 2300A, SEGMENT RMR (ORG SUMMARY REMIT DETAIL)
058400*
058500 05 X820-ORG-SUM-REMIT-DETAIL-SEG.
058700 10 X820-ORG-CNTRC-QL
058800 PIC X(03). ‘11’
058900 10 X820-ORG-CNTRC-NUM
059000 PIC X(50). C-HDR-RA-NUM
059100 10 X820-ORG-PMT-ACTION-CD
059200 PIC X(02). ‘PI’
059300 10 X820-ORG-PMT-AMT
059400 PIC S9(16)V99. C-HDR-WARR-AMT
059500 10 X820-ORG-BILL-AMT
059600 PIC S9(16)V99. C-TOT-REIMB-AMT
060600*
060700* LOOP 2300A, SEGMENT DTM (ORGANIZATION COVERAGE PERIOD)
060800*
060900 05 X820-ORG-COVERAGE-SEG.
061100 10 X820-ORG-SUM-DT-QL
061200 PIC X(03).
061300 10 X820-ORG-SUM-DT
061400 PIC X(08).
061500 10 X820-ORG-SUM-DT-PERIOD-QL
061600 PIC X(03).
061700 10 X820-ORG-SUM-DT-PERIOD
061800 PIC X(35).
056300*
056400****************************************************************
056500* 820 ORGANIZATION SUMMARY REMITTANCE DETAIL / REF INFO MAX >1 *
LEAVE FOR LATER USAGE
056600****************************************************************
056700*
056800 01 X820-ORG-SUMMARY-REMIT-REF.
056900*
057010 05 X820-SORT-KEY.
057020 10 X820-FILE-ID
057030 VALUE SPACES
057040 PIC X(15).
057050 10 X820-ROUTING-ID
057060 VALUE SPACES
057070 PIC X(15).
057080 10 X820-DOCUMENT-SEQ-NUM
057090 VALUE ZEROES
057091 PIC 9(09).
027292 10 X820-FILE-REC-SEQ-NUM
057093 VALUE ZEROES
057094 PIC 9(10).
057095
057096 05 X820-TX-CD
057097 VALUE '043'
057098 PIC X(03).
059700*
059800* LOOP 2300A, SEGMENT REF (REFERENCE INFORMATION)
059900*
060000 05 X820-ORG-REFERENCE-INFO-SEG.
060200 10 X820-ORG-SUM-REF-QL
060300 PIC X(03).
060400 10 X820-ORG-SUM-REF-ID
060500 PIC X(50).
061900*
062000****************************************************************
062100* 820 ORGANIZATION DETAIL RECORD *
062200******LOOP 2310A, SEGMENT IT1 (SUMMARY LINE ITEM) *
062300******LOOP 2312A, SEGMENT SAC (SERVICE, PROMO, ALLOWANCE, CHR *
062400******LOOP 2315A, SEGMENT SLN (MEMBER COUNT) *
LEAVE FOR LATER USAGE
062500****************************************************************
061900*
062600 01 X820-ORG-DETAIL.
062700*
062810 05 X820-SORT-KEY.
062820 10 X820-FILE-ID
062830 VALUE SPACES
062840 PIC X(15).
062850 10 X820-ROUTING-ID
062860 VALUE SPACES
062870 PIC X(15).
062880 10 X820-DOCUMENT-SEQ-NUM
062890 VALUE ZEROES
062891 PIC 9(09).
027292 10 X820-FILE-REC-SEQ-NUM
062893 VALUE ZEROES
062894 PIC 9(10).
062895
062896 05 X820-TX-CD
062897 VALUE '044'
062898 PIC X(03).
063900*
064000 05 X820-REC-TYP-044-CNTR.
064100 10 X820-SVC-PROMO-ALLOW-CTR
064200 PIC 9(03).
064300 10 X820-ORG-SUM-MEMBER-CNTS-CTR
064400 PIC 9(03).
064500*
064600* LOOP 2310A, SEGMENT IT1 (ORG SUMMARY LINE ITEM)
064700*
064800 05 X820-ORG-LI-BASELINE-SEG.
065000 10 X820-ORG-LI-BASELINE
065100 PIC X(20).
065200*
064600* LOOP 2312A, SEGMENT SAC (SERVICE, PROMOTION, ALLOWANCE OR
064600* CHARGE INFORMATION)
065400*
065500 05 X820-ORG-SVC-PROMO-ALLOW-CHRG
065600 OCCURS 0 TO 4 TIMES
065700 DEPENDING ON X820-SVC-PROMO-ALLOW-CTR.
065900 10 X820-ORG-SVC-CHRG-IND
066000 PIC X(01).
066100 10 X820-ORG-SVC-CHRG-CD
066200 PIC X(04).
066300 10 X820-ORG-SVC-CHRG-AMT
066400 PIC X(15). ................
................
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