CARIN Blue Button Implementation Guide CI Build

CARIN Blue Button, CARIN Alliance - CI build for vesion 0.1.36-DRAFT). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

Data Element Index

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Map ID CARIN CPCDS Data Element Name CARIN CPCDS Description CARIN BB2.0 FHIR Profile Date Harmonized FHIR Resource L0 FHIR Resource L1 Element FHIR Resource L2 Element FHIR Element Description
or L3 | L4
FHIR
REF
1 Member id Unique identifier for a member Coverage Coverage beneficiary--> Plan beneficiary Reference(Patient)
1 Member id Unique identifier for a member EOB Inpatient Facility ExplanationOfBenefit[1] patient--> The recipient of the products and services Reference(Patient)
1 Member id Unique identifier for a member EOB Outpatient Facility ExplanationOfBenefit patient--> The recipient of the products and services Reference(Patient)
1 Member id Unique identifier for a member EOB Professional | Non-Physician ExplanationOfBenefit patient--> The recipient of the products and services Reference(Patient)
1 Member id Unique identifier for a member EOB Pharmacy ExplanationOfBenefit patient--> The recipient of the products and services Reference(Patient)
2 Payer Identifier Issuer of the Policy Coverage Coverage payor--> Issuer of the policy Reference(Organization)
2 Claim payer Identifier Code of the primary payer responsible for the claim EOB Inpatient Facility 7/2/2019 ExplanationOfBenefit insurance Insurance information Reference(Coverage)
2 Claim payer Identifier Code of the primary payer responsible for the claim EOB Outpatient Facility 7/2/2019 ExplanationOfBenefit insurance Insurance information Reference(Coverage)
2 Claim payer Identifier Code of the primary payer responsible for the claim EOB Professional | Non-Physician 7/2/2019 ExplanationOfBenefit insurance Insurance information Reference(Coverage)
2 Claim payer Identifier Code of the primary payer responsible for the claim EOB Pharmacy 7/2/2019 ExplanationOfBenefit insurance Insurance information Reference(Coverage)
3 Coverage type Identifies if the coverage is PPO, HMO, POS, etc. Coverage Coverage type Coverage Type and Self-Pay Codes (Preferred)
6 Diagnosis code - ICD-9 admitting ICD-9-CM code describing the condition chiefly responsible for a patient's admission to a facility. It may be different from the principal diagnosis, which is the diagnosis assigned after evaluation. (UB04 Form Locator 69). Decimals will be included. EOB Inpatient Facility 7/19/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
6 Diagnosis code - ICD-9 admitting ICD-9-CM code describing the condition chiefly responsible for a patient's admission to a facility. It may be different from the principal diagnosis, which is the diagnosis assigned after evaluation. (UB04 Form Locator 69). Decimals will be included. EOB Outpatient Facility 7/19/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
7 Diagnosis code - ICD-9 principal The member's principal condition treated during this service. (UB04 Form Locator 67). This may or may not be different from the admitting diagnosis. Decimals will be included. EOB Inpatient Facility 7/19/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
7 Diagnosis code - ICD-9 principal The member's principal condition treated during this service. (UB04 Form Locator 67). This may or may not be different from the admitting diagnosis. Decimals will be included. EOB Outpatient Facility 7/19/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
7 Diagnosis code - ICD-9 principal The member's principal condition treated during this service. EOB Professional | Non-Physician 7/19/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
8 Diagnosis code - ICD-9 secondary Additional diagnosis identified for this member. Decimals will be included. EOB Inpatient Facility 7/19/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
8 Diagnosis code - ICD-9 secondary Additional diagnosis identified for this member. Decimals will be included. EOB Outpatient Facility 7/19/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
8 Diagnosis code - ICD-9 secondary Additional diagnosis identified for this member. Decimals will be included. EOB Professional | Non-Physician 7/19/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
9 Procedure Code - ICD-9 PCS principal Principal medical procedure a patient received during inpatient stay. Current coding methods include: International Classification of Diseases Surgical Procedures (ICD-9). Information located on UB04 (Form Locator 74). EOB Inpatient Facility 7/19/2019 ExplanationOfBenefit procedure Specific clinical procedure
10 Procedure Date - ICD-9 principal Date of Procedure. Information located on UB04 (Form Locator 74). EOB Inpatient Facility 7/19/2019 ExplanationOfBenefit procedure When the procedure was performed
11 Procedure Code - ICD-10 PCS secondary Additional surgical procedure surgical (ICD-9) administered during inpatient stay. EOB Inpatient Facility 7/19/2019 ExplanationOfBenefit procedure Specific clinical procedure
12 Procedure Date - ICD-9 secondary Date of Procedure. (UB04 Form Locator 74). EOB Inpatient Facility 7/19/2019 ExplanationOfBenefit procedure When the procedure was performed
13 Claim source inpatient admission code The source of admission identifies the place where the patient was identified as needing admission to a facility. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). EOB Inpatient Facility 6/28/2019 ExplanationOfBenefit supportingInfo code Type of information
13 Claim source inpatient admission code The source of admission identifies the place where the patient was identified as needing admission to a facility. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). EOB Outpatient Facility 6/28/2019 ExplanationOfBenefit supportingInfo code Type of information
14 Claim inpatient admission type code Priority of the inpatient admission. Information located on (UB04 Form Locator 14). For example, an admission type of elective indicates that the patient's condition permitted time for medical services to be scheduled. EOB Inpatient Facility 6/28/2019 ExplanationOfBenefit supportingInfo code Type of information
14 Claim inpatient admission type code Priority of the inpatient admission. Information located on (UB04 Form Locator 14). For example, an admission type of elective indicates that the patient's condition permitted time for medical services to be scheduled. EOB Outpatient Facility 6/28/2019 ExplanationOfBenefit supportingInfo code Type of information
15 Claim sub type High-level categorization of the claim. Removed from scope Removed from scope ExplanationOfBenefit subtype More granular claim type
15 Claim sub type High-level categorization of the claim. Removed from scope Removed from scope ExplanationOfBenefit subtype More granular claim type
15 Claim sub type High-level categorization of the claim. Removed from scope Removed from scope ExplanationOfBenefit subtype More granular claim type
15 Claim sub type High-level categorization of the claim. Removed from scope Removed from scope ExplanationOfBenefit subtype More granular claim type
16 Claim type Specifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.). EOB Inpatient Facility 7/1/2019 ExplanationOfBenefit type Category or discipline
16 Claim type Specifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.). EOB Outpatient Facility 7/1/2019 ExplanationOfBenefit type Category or discipline
16 Claim type Specifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.). EOB Professional | Non-Physician 7/1/2019 ExplanationOfBenefit type Category or discipline
16 Claim type Specifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.). EOB Pharmacy 7/1/2019 ExplanationOfBenefit type Category or discipline
18 Member admission date Identifies the date the patient was admitted for facility care EOB Inpatient Facility 6/28/2019 ExplanationOfBenefit billablePeriod period.start
period.end
Relevant time frame for the claim
18 Member admission date Identifies the date the patient was admitted for facility care EOB Outpatient Facility 6/28/2019 ExplanationOfBenefit billablePeriod period.start
period.end
Relevant time frame for the claim
19 Member discharge date
Date patient was discharged from a facility. EOB Inpatient Facility 6/28/2019 ExplanationOfBenefit billablePeriod period.start
period.end
Relevant time frame for the claim
19 Member discharge date
Date patient was discharged from a facility. EOB Outpatient Facility 6/28/2019 ExplanationOfBenefit billablePeriod period.start
period.end
Relevant time frame for the claim
20 Claim total submitted amount
Amount submitted by the provider for reimbursement of health care services. This amount includes non-covered services. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line submitted amount Amount submitted by the provider for reimbursement of health care services. This amount includes non-covered services. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Claim total submitted amount
Amount submitted by the provider for reimbursement of health care services. This amount includes non-covered services. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line submitted amount Amount submitted by the provider for reimbursement of health care services. This amount includes non-covered services. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line submitted amount Amount submitted by the provider for reimbursement of health care services. This amount includes non-covered services. EOB Professional | Non-Physician 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line submitted amount Represents the Usual & Customary Charge Amount or the Average Wholesale Price (AWP) for the Quantity Dispensed plus the Dispensing Fee Paid. EOB Pharmacy 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Claim total allowed amount
The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. Allowed mount should not include any COB adjustment. That is, the Allowed amount on a claim should be the same when the Plan is primary or secondary. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line allowed amount The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. Allowed mount should not include any COB adjustment. That is, the Allowed amount on a claim should be the same when the Plan is primary or secondary. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Claim total allowed amount
The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. Allowed mount should not include any COB adjustment. That is, the Allowed amount on a claim should be the same when the Plan is primary or secondary. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line allowed amount The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. Allowed mount should not include any COB adjustment. That is, the Allowed amount on a claim should be the same when the Plan is primary or secondary. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line allowed amount The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. Allowed mount should not include any COB adjustment. That is, the Allowed amount on a claim should be the same when the Plan is primary or secondary. EOB Professional | Non-Physician 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line allowed amount The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. Allowed mount should not include any COB adjustment. That is, the Allowed amount on a claim should be the same when the Plan is primary or secondary. EOB Pharmacy 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Member paid deductible

The portion of this service that the member
must pay which is applied to the total period
deductible. Deductibles are usually
applied over a specific time period, such as
per calendar year, per benefit period,
EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line patient deductible
The portion of this service that the member
must pay which is applied to the total period
deductible. Deductibles are usually
applied over a specific time period, such as
per calendar year, per benefit period,
EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Member paid deductible

The portion of this service that the member
must pay which is applied to the total period
deductible. Deductibles are usually
applied over a specific time period, such as
per calendar year, per benefit period,
EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line patient deductible
The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line patient deductible
The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. EOB Professional | Non-Physician 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line patient deductible
The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. EOB Pharmacy 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Co-insurance liability amount


The amount the insured individual pays, as a set percentage of the cost of covered medical services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line coinsurance amount

The amount the insured individual pays, as a set percentage of the cost of covered medical services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Co-insurance liability amount


The amount the insured individual pays, as a set percentage of the cost of covered medical services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line coinsurance amount

The amount the insured individual pays, as a set percentage of the cost of covered medical services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line coinsurance amount

The amount the insured individual pays, as a set percentage of the cost of covered medical services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%. EOB Professional | Non-Physician 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line coinsurance amount

Amount to be collected from a patient that is included in the Patient Pay Amount that is due to a per prescription copay or coinsurance. EOB Pharmacy 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Copay amount



Amount an insured individual pays directly to a provider at the time the services or supplies are rendered. Usually, a copay will be a fixed amount per service, such as $15.00 per office visit. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line copay amount


Amount an insured individual pays directly to a provider at the time the services or supplies are rendered. Usually, a copay will be a fixed amount per service, such as $15.00 per office visit. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Copay amount



Amount an insured individual pays directly to a provider at the time the services or supplies are rendered. Usually, a copay will be a fixed amount per service, such as $15.00 per office visit. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line copay amount


Amount an insured individual pays directly to a provider at the time the services or supplies are rendered. Usually, a copay will be a fixed amount per service, such as $15.00 per office visit. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line copay amount


Amount an insured individual pays directly to a provider at the time the services or supplies are rendered. Usually, a copay will be a fixed amount per service, such as $15.00 per office visit. EOB Professional | Non-Physician 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line copay amount


Amount to be collected from a patient that is included in the Patient Pay Amount that is due to a per prescription copay or coinsurance. EOB Pharmacy 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Claim disallowed amount





The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line disallowed charged amount




The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Claim disallowed amount





The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line disallowed charged amount




The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line disallowed charged amount




The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract. EOB Professional | Non-Physician 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line disallowed charged amount




Non-Covered Amount represents the NCPDP financial response field Amount Exceeding Periodic Benefit Maximum. EOB Pharmacy 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Claim primary payer paid amount The reduction in the payment amount to reflect the carrier as a secondary payor. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line primary payer paid amount The reduction in the payment amount to reflect the carrier as a secondary payor. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Claim primary payer paid amount The reduction in the payment amount to reflect the carrier as a secondary payor. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line primary payer paid amount The reduction in the payment amount to reflect the carrier as a secondary payor. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line primary payer paid amount The reduction in the payment amount to reflect the carrier as a secondary payor. EOB Professional | Non-Physician 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line primary payer paid amount The reduction in the payment amount to reflect the carrier as a secondary payor. EOB Pharmacy 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Claim payment amount
The amount sent to the payee from the health plan. This amount is to include withhold amounts (the portion of the claim that is deducted and withheld by the Plan from the provider's payment) and exclude any member cost sharing. It should include the total of member and provider payments. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line payment amount
The amount sent to the payee from the health plan. This amount is to include withhold amounts (the portion of the claim that is deducted and withheld by the Plan from the provider's payment) and exclude any member cost sharing. It should include the total of member and provider payments. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Claim payment amount
The amount sent to the payee from the health plan. This amount is to include withhold amounts (the portion of the claim that is deducted and withheld by the Plan from the provider's payment) and exclude any member cost sharing. It should include the total of member and provider payments. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line payment amount
The amount sent to the payee from the health plan. This amount is to include withhold amounts (the portion of the claim that is deducted and withheld by the Plan from the provider's payment) and exclude any member cost sharing. It should include the total of member and provider payments. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line payment amount
The amount sent to the payee from the health plan. This amount is to include withhold amounts (the portion of the claim that is deducted and withheld by the Plan from the provider's payment) and exclude any member cost sharing. It should include the total of member and provider payments. EOB Professional | Non-Physician 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line payment amount
The amount sent to the payee from the health plan. This amount is to include withhold amounts (the portion of the claim that is deducted and withheld by the Plan from the provider's payment) and exclude any member cost sharing. It should include the total of member and provider payments. EOB Pharmacy 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Amount paid by patient The amount paid by the member at the point of service. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line amount paid by patient The amount paid by the member at the point of service. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Amount paid by patient The amount paid by the member at the point of service. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line amount paid by patient The amount paid by the member at the point of service. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line amount paid by patient The amount paid by the member at the point of service. EOB Professional | Non-Physician 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line amount paid by patient Amount that is calculated by the processor and returned to the pharmacy as the total amount to be paid by the patient to the pharmacy; the patients total cost share, including copayments, amounts applied to deductible, over maximum amounts, penalties, etc EOB Pharmacy 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Claim amount paid to provider
The amount paid to the provider. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line amount paid to provider
The amount paid to the provider. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Claim amount paid to provider
The amount paid to the provider. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line amount paid to provider
The amount paid to the provider. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line amount paid to provider
The amount paid to the provider. EOB Professional | Non-Physician 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line amount paid to provider
The amount paid to the provider. EOB Pharmacy 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Member reimbursement The amount paid to the member. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line member reimbursement The amount paid to the member. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Member reimbursement The amount paid to the member. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line member reimbursement The amount paid to the member. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line member reimbursement The amount paid to the member. EOB Professional | Non-Physician 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line member reimbursement The amount paid to the member. EOB Pharmacy 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Member liability The amount of the member's liability. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line member liability The amount of the member's liability. EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Member liability The amount of the member's liability. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit adjudication amount Monetary amount
20 Line member liability The amount of the member's liability. EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line member liability The amount of the member's liability. EOB Professional | Non-Physician 7/26/2019 ExplanationOfBenefit item adjudication amount
20 Line member liability The amount of the member's liability. EOB Pharmacy 7/26/2019 ExplanationOfBenefit item adjudication amount
21 Diagnosis code - ICD-10 admitting ICD-10-CM code describing the condition chiefly responsible for a patient's admission to a facility. It may be different from the principal diagnosis, which is the diagnosis assigned after evaluation. Decimals will be included. EOB Inpatient Facility 7/19/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
21 Diagnosis code - ICD-10 admitting ICD-10-CM code describing the condition chiefly responsible for a patient's admission to a facility. It may be different from the principal diagnosis, which is the diagnosis assigned after evaluation. Decimals will be included. EOB Outpatient Facility 7/19/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
22 Diagnosis code - ICD-10 principal The member's principal condition treated during this service. This may or may not be different from the admitting diagnosis. Decimals will be included. EOB Inpatient Facility 7/19/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
22 Diagnosis code - ICD-10 principal The member's principal condition treated during this service. This may or may not be different from the admitting diagnosis. Decimals will be included. EOB Outpatient Facility 7/19/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
22 Diagnosis code - ICD-10 header principal The member's principal condition treated on the claim (837P Data Element HI01 or CMS 1500 Item 21A). Decimals will be included. EOB Professional | Non-Physician 7/19/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
22 Diagnosis code - ICD-10 principal The member's principal condition treated during this service. This may or may not be different from the admitting diagnosis. Decimals will be included. EOB Professional | Non-Physician 7/19/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
23 Diagnosis code - ICD-10 secondary Additional diagnosis identified for this member. Decimals will be included. EOB Inpatient Facility 7/19/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
23 Diagnosis code - ICD-10 secondary Additional diagnosis identified for this member. Decimals will be included. EOB Outpatient Facility 7/19/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
23 Diagnosis code - ICD-10 header secondary Additional diagnosis identified for this member (837P Data Element HI02 or CMS 1500 Item 21B). Decimals will be included. EOB Professional | Non-Physician 7/19/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
23 Diagnosis code - ICD-10 secondary Additional diagnosis identified for this member. Decimals will be included. EOB Professional | Non-Physician 7/19/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
24 Procedure Code - ICD-10 PCS primary Principal medical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10). EOB Inpatient Facility 7/19/2019 ExplanationOfBenefit procedure Specific clinical procedure
25 Procedure Date - ICD-10 primary Date of Procedure - Principal EOB Inpatient Facility 7/19/2019 ExplanationOfBenefit procedure When the procedure was performed
26 Procedure Code - ICD-10 PCS secondary Additional surgical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10). EOB Inpatient Facility 7/19/2019 ExplanationOfBenefit procedure Specific clinical procedure
27 Procedure Date - ICD-10 secondary Date of Procedure - Secondary EOB Inpatient Facility 7/19/2019 ExplanationOfBenefit procedure When the procedure was performed
28 Present on admission Used to capture whether a diagnosis was present at time of a patient's admission. This is used to group diagnoses into the proper DRG for all claims involving inpatient admissions to general acute care facilities. EOB Inpatient Facility 7/19/2019 ExplanationOfBenefit diagnosis onAdmission Present on admission
29 Present on admission Used to capture whether a diagnosis was present at time of a patient's admission. This is used to group diagnoses into the proper DRG for all claims involving inpatient admissions to general acute care facilities. EOB Inpatient Facility 7/19/2019 ExplanationOfBenefit diagnosis onAdmission Present on admission
30 Is E code This is any valid ICD-10 Diagnosis code in the range V00.* through Y99.*. EOB Inpatient Facility 7/24/2019 ExplanationOfBenefit diagnosis ICD-10 Codes (Example)
30 Is E code This is any valid ICD-10 Diagnosis code in the range V00.* through Y99.*. EOB Outpatient Facility 7/24/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
31 Patient reason for visit This is the reason given by the patient for visiting the doctor or practitioner. It is not the doctor's or practitioner's diagnosis. Patient Reason for Visit Codes can be any ICD-10diagnosis and may or may not be a repeat of an ICD-10 Principal or Secondary diagnosis field. EOB Inpatient Facility 7/24/2019 ExplanationOfBenefit diagnosis ICD-10 Codes (Example)
31 Patient reason for visit This is the reason given by the patient for visiting the doctor or practitioner. It is not the doctor's or practitioner's diagnosis. Patient Reason for Visit Codes can be any ICD-10diagnosis and may or may not be a repeat of an ICD-10 Principal or Secondary diagnosis field. EOB Outpatient Facility 7/24/2019 ExplanationOfBenefit diagnosis Nature of illness or problem
32 Claim diagnosis related group (DRG) Version of the AP-DRG codes assigned for inpatient facility claims. EOB Inpatient Facility 6/28/2019 ExplanationOfBenefit supportingInfo code Classification of the supplied information
33 Claim diagnosis related group (DRG) DRG codes assigned EOB Inpatient Facility 6/28/2019 ExplanationOfBenefit supportingInfo code Classification of the supplied information
34 Type of service High level classification of services into logical groupings EOB Inpatient Facility 7/24/2019 ExplanationOfBenefit supportingInfo code Type of information
34 Type of service High level classification of services into logical groupings EOB Outpatient Facility 7/24/2019 ExplanationOfBenefit item category Benefit classification
34 Type of service High level classification of services into logical groupings EOB Professional | Non-Physician 7/24/2019 ExplanationOfBenefit item category Benefit classification
34 Type of service High level classification of services into logical groupings EOB Pharmacy 7/24/2019 ExplanationOfBenefit item category category
35 Claim unique identifier Claim identifier for a claim. EOB Inpatient Facility 7/1/2019 ExplanationOfBenefit identifier Business Identifier for the resource
35 Claim unique identifier Claim identifier for a claim. EOB Outpatient Facility 7/1/2019 ExplanationOfBenefit identifier Business Identifier for the resource
35 Claim unique identifier Claim identifier for a claim. EOB Professional | Non-Physician 7/1/2019 ExplanationOfBenefit identifier Business Identifier for the resource
35 RX service reference number
Assigned by the pharmacy at the time the prescription is filled
EOB Pharmacy 7/1/2019 ExplanationOfBenefit identifier Business Identifier for the resource
36 Line number Line identification number that represents the number assigned in a source system for identification and processing. EOB Inpatient Facility 7/23/2019 ExplanationOfBenefit item sequence Item instance identifier
36 Line number Line identification number that represents the number assigned in a source system for identification and processing. EOB Outpatient Facility 7/23/2019 ExplanationOfBenefit item sequence Item instance identifier
36 Line number Line identification number that represents the number assigned in a source system for identification and processing. EOB Professional | Non-Physician 7/23/2019 ExplanationOfBenefit item sequence Item instance identifier
36 Line number Line identification number that represents the number assigned in a source system for identification and processing. EOB Pharmacy 7/23/2019 ExplanationOfBenefit item sequence Item instance identifier
38 National drug code National Drug Code (NDC) EOB Pharmacy 7/17/2019 ExplanationOfBenefit item productOrService Billing, service, product, or drug code
39 Quantity dispensed Quantity dispensed for the drug EOB Pharmacy ExplanationOfBenefit item quantity Count of products or services
40 Procedure Code - CPT / HCPCS Medical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII). EOB Outpatient Facility 7/19/2019 ExplanationOfBenefit item productOrService Billing, service, product, or drug code
40 Procedure Code - CPT / HCPCS Medical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII). EOB Professional | Non-Physician 7/19/2019 ExplanationOfBenefit item productOrService Billing, service, product, or drug code
41 Procedure Code Modifier - CPT / HCPCS Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. EOB Outpatient Facility 7/19/2019 ExplanationOfBenefit item modifier Product or service billing modifiers
41 Procedure Code Modifier - CPT / HCPCS Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. EOB Professional | Non-Physician 7/19/2019 ExplanationOfBenefit item modifier Product or service billing modifiers
42 Number of units The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. EOB Inpatient Facility ExplanationOfBenefit item quantity Count of products or services
42 Number of units The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. EOB Outpatient Facility ExplanationOfBenefit item quantity Count of products or services
42 Number of units The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. EOB Professional | Non-Physician ExplanationOfBenefit item quantity Count of products or services
46 Place of service code Code indicating the location, such as inpatient, outpatient facility, office, or home health agency, where this service was performed. EOB Inpatient Facility ExplanationOfBenefit supportingInfo code Type of information
46 Place of service code Code indicating the location, such as inpatient, outpatient facility, office, or home health agency, where this service was performed. EOB Outpatient Facility ExplanationOfBenefit supportingInfo code Type of information
46 Place of service code Code indicating the location, such as inpatient, outpatient facility, office, or home health agency, where this service was performed. EOB Professional | Non-Physician ExplanationOfBenefit item location Place of service or where product was supplied
70 Date of birth Date of birth of the member Coverage Coverage beneficiary--> Plan beneficiary Reference(Patient)
71 Gender code Gender of the member Coverage Coverage beneficiary--> Plan beneficiary Reference(Patient)
72 Relationship to subscriber Relationship of the member to the person insured (subscriber). Coverage Coverage relationship Beneficiary relationship to the subscriber
74 Start date Date that the contract became effective Coverage Coverage period Coverage start and end dates
75 End date Date that the contract was terminated or coverage changed Coverage Coverage period Coverage start and end dates
77 Days supply Number of days supply of medication dispensed by the pharmacy EOB Pharmacy 7/17/2019 ExplanationOfBenefit supportingInfo value Quantity
78 Compound code The code indicating whether or not the prescription is a compound EOB Pharmacy 7/17/2019 ExplanationOfBenefit item productOrService Billing, service, product, or drug code
79 DAW product selection code Prescriber's instruction regarding substitution of generic equivalents or order to dispense the specific prescribed medication
EOB Pharmacy 7/17/2019 ExplanationOfBenefit supportingInfo code CodeableConcept
80 Removed from scope Removed from scope Removed from scope Removed from scope ExplanationOfBenefit supportingInfo code CodeableConcept
85 Removed from scope Removed from scope Removed from scope Removed from scope          
86 Revenue center code Code used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed EOB Inpatient Facility ExplanationOfBenefit item revenue Revenue or cost center code
86 Revenue center code Code used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed EOB Outpatient Facility ExplanationOfBenefit item revenue Revenue or cost center code
88 Claim received date The date the claim for payment was received EOB Inpatient Facility 7/1/2019 ExplanationOfBenefit supportingInfo timing timing | date
88 Claim received date The date the claim for payment was received EOB Outpatient Facility 7/1/2019 ExplanationOfBenefit supportingInfo timing timing | date
88 Claim received date The date the claim for payment was received EOB Professional | Non-Physician 7/1/2019 ExplanationOfBenefit supportingInfo timing timing | date
88 Claim received date The date the claim for payment was received EOB Pharmacy 7/1/2019 ExplanationOfBenefit supportingInfo timing timing | date
90 Service (from) date Date on which services began. UB04
(Form Locator 45).
EOB Outpatient Facility 6/28/2019 ExplanationOfBenefit item serviced Date or dates of service or product delivery
90 Service (from) date Identifies date the prescription was filled or
professional service rendered
EOB Pharmacy 6/28/2019 ExplanationOfBenefit item serviced Date or dates of service or product delivery
91 Claim payment status code Indicates whether the line was paid or denied. EOB Inpatient Facility 7/1/2019 ExplanationOfBenefit payment type Partial or complete payment
91 Claim payment status code Indicates whether the line was paid or denied. EOB Outpatient Facility 7/1/2019 ExplanationOfBenefit payment type Partial or complete payment
91 Claim payment status code Indicates whether the line was paid or denied. EOB Professional | Non-Physician 7/1/2019 ExplanationOfBenefit payment type Partial or complete payment
91 Claim payment status code Indicates whether the line was paid or denied. EOB Pharmacy 7/1/2019 ExplanationOfBenefit payment type Partial or complete payment
92 Claim Payment Denial Code Reason codes used to interpret the Non-Covered Amount EOB Inpatient Facility 7/1/2019 ExplanationOfBenefit payment adjustmentReason Explanation for the variance
92 Claim Payment Denial Code Reason codes used to interpret the Non-Covered Amount EOB Inpatient Facility 7/8/2019 ExplanationOfBenefit item adjudication Explanation of adjudication outcome
92 Claim Payment Denial Code Reason codes used to interpret the Non-Covered Amount EOB Outpatient Facility 7/8/2019 ExplanationOfBenefit payment adjustmentReason Explanation for the variance
92 Claim Payment Denial Code Reason codes used to interpret the Non-Covered Amount EOB Outpatient Facility 7/8/2019 ExplanationOfBenefit item adjudication Explanation of adjudication outcome
92 Claim Payment Denial Code Reason codes used to interpret the Non-Covered Amount EOB Professional | Non-Physician 7/8/2019 ExplanationOfBenefit item adjudication Explanation of adjudication outcome
92 Claim Payment Denial Code Reason codes used to interpret the Non-Covered Amount EOB Pharmacy 7/8/2019 ExplanationOfBenefit item adjudication Explanation of adjudication outcome
93 Claim attending provider NPI The National Provider Identifier assigned to the Attending Physician for the admission EOB Inpatient Facility 7/2/2019 ExplanationOfBenefit careTeam provider--> Practitioner or organization Reference(Practitioner | PractitionerRole | Organization)
94 Claim billing provider NPI The National Provider Identifier assigned to the Billing Provider. EOB Inpatient Facility 7/8/2019 ExplanationOfBenefit provider--> Party responsible for the claim Reference(Organization)
94 Claim billing provider NPI The National Provider Identifier assigned to the Billing Provider. EOB Outpatient Facility 7/8/2019 ExplanationOfBenefit provider--> Party responsible for the claim Reference(Organization)
94 Claim billing provider NPI The National Provider Identifier assigned to the Billing Provider. EOB Professional | Non-Physician 7/8/2019 ExplanationOfBenefit provider--> Party responsible for the claim Reference(Organization)
94 Claim billing provider NPI The National Provider Identifier assigned to the Billing Provider. EOB Pharmacy 7/8/2019 ExplanationOfBenefit provider--> Party responsible for the claim Reference(Organization)
95 Claim performing physician NPI The National Provider Identifier assigned to the Rendering Provider. This is the lowest level of provider available (for example, if both individual and group are available, then the individual should be provided). EOB Inpatient Facility 7/2/2019 ExplanationOfBenefit careTeam provider--> Practitioner or organization Reference(Practitioner | PractitionerRole | Organization)
95 Claim performing physician NPI The National Provider Identifier assigned to the Rendering Provider. This is the lowest level of provider available (for example, if both individual and group are available, then the individual should be provided). EOB Outpatient Facility 7/2/2019 ExplanationOfBenefit careTeam provider--> Practitioner or organization Reference(Practitioner | PractitionerRole | Organization)
95 Claim performing physician NPI The National Provider Identifier assigned to the Rendering Provider. This is the lowest level of provider available (for example, if both individual and group are available, then the individual should be provided). EOB Professional | Non-Physician 7/2/2019 ExplanationOfBenefit careTeam provider--> Practitioner or organization Reference(Practitioner | PractitionerRole | Organization)
96 Claim PCP NPI The identifier assigned to the PCP Provider. EOB Inpatient Facility 7/2/2019 ExplanationOfBenefit careTeam provider--> Practitioner or organization Reference(Practitioner | PractitionerRole | Organization)
96 Claim PCP NPI The identifier assigned to the PCP Provider. EOB Outpatient Facility 7/2/2019 ExplanationOfBenefit careTeam provider--> Practitioner or organization Reference(Practitioner | PractitionerRole | Organization)
96 Claim PCP NPI The identifier assigned to the PCP Provider. EOB Professional | Non-Physician 7/2/2019 ExplanationOfBenefit careTeam provider--> Practitioner or organization Reference(Practitioner | PractitionerRole | Organization)
95 Claim PCP NPI The identifier assigned to the PCP Provider. EOB Pharmacy 7/2/2019 ExplanationOfBenefit careTeam provider--> Practitioner or organization Reference(Practitioner | PractitionerRole | Organization)
97 Claim site of service NPI The NPI of the facility where the services were rendered. EOB Professional | Non-Physician 7/8/2019 ExplanationOfBenefit facility--> Servicing Facility Reference(Location)
99 Claim Referring Physician NPI The NPI of the referring physician. EOB Inpatient Facility 7/2/2019 ExplanationOfBenefit careTeam provider--> Practitioner or organization Reference(Practitioner | PractitionerRole | Organization)
99 Claim Referring Physician NPI The NPI of the referring physician. EOB Outpatient Facility 7/2/2019 ExplanationOfBenefit careTeam provider--> Practitioner or organization Reference(Practitioner | PractitionerRole | Organization)
99 Claim Referring Physician NPI The NPI of the referring physician. EOB Professional | Non-Physician 7/2/2019 ExplanationOfBenefit careTeam provider--> Practitioner or organization Reference(Practitioner | PractitionerRole | Organization)
101 Claim billing provider network status Indicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. EOB Inpatient Facility 7/8/2019 ExplanationOfBenefit supportingInfo code Type of information
101 Claim billing provider network status Indicates that the Rendering Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. EOB Outpatient Facility 7/8/2019 ExplanationOfBenefit supportingInfo code Type of information
101 Claim billing provider network status Indicates that the Rendering Provider has a
contract with the Plan (regardless of the
network) that is effective on the date of
service or admission.
EOB Professional | Non-Physician 7/8/2019 ExplanationOfBenefit supportingInfo code Type of information
101 Claim billing provider network status Indicates that the Rendering Provider has a
contract with the Plan (regardless of the
network) that is effective on the date of
service or admission.
EOB Pharmacy 7/8/2019 ExplanationOfBenefit supportingInfo code Type of information
101 Claim performing physician network status Indicates that the Rendering Provider has a
contract with the Plan (regardless of the
network) that is effective on the date of
service or admission.
EOB Professional | Non-Physician 7/8/2019 ExplanationOfBenefit supportingInfo code Type of information
101 Claim attending provider network status Indicates the network status of the attending physician EOB Inpatient Facility 7/8/2019 ExplanationOfBenefit supportingInfo code Type of information
101 Claim Referring Physican Network Status Indicates the network status of the referring physician EOB Inpatient Facility 7/8/2019 ExplanationOfBenefit supportingInfo code Type of information
101 Claim Referring Physican Network Status Indicates the network status of the referring physician EOB Outpatient Facility 7/8/2019 ExplanationOfBenefit supportingInfo code Type of information
101 Claim Referring Physican Network Status Indicates the network status of the referring physician EOB Professional | Non-Physician 7/8/2019 ExplanationOfBenefit supportingInfo code Type of information
101 Claim site of service network status
Indicates the network status of the site of service EOB Professional | Non-Physician 7/8/2019 ExplanationOfBenefit supportingInfo code Type of information
107 Claim paid date The date the claim was paid. EOB Inpatient Facility 7/1/2019 ExplanationOfBenefit payment date Expected date of payment
107 Claim paid date The date the claim was paid. EOB Outpatient Facility 7/1/2019 ExplanationOfBenefit payment date Expected date of payment
107 Claim paid date The date the claim was paid. EOB Professional | Non-Physician 7/1/2019 ExplanationOfBenefit payment date Expected date of payment
107 Claim paid date The date the claim was paid. EOB Pharmacy 7/1/2019 ExplanationOfBenefit payment date Expected date of payment
109 Patient account number Provider submitted information that can be included on the claim EOB Inpatient Facility 7/1/2019 ExplanationOfBenefit patient--> The recipient of the products and services identifier
109 Patient account number Provider submitted information that can be included on the claim EOB Outpatient Facility 7/1/2019 ExplanationOfBenefit patient--> The recipient of the products and services identifier
109 Patient account number Provider submitted information that can be included on the claim EOB Professional | Non-Physician 7/1/2019 ExplanationOfBenefit patient--> The recipient of the products and services identifier
110 Medical record number Provider submitted information that can be included on the claim EOB Inpatient Facility 7/1/2019 ExplanationOfBenefit patient--> The recipient of the products and services identifier
110 Medical record number Provider submitted information that can be included on the claim EOB Outpatient Facility 7/1/2019 ExplanationOfBenefit patient--> The recipient of the products and services identifier
110 Medical record number Provider submitted information that can be included on the claim EOB Professional | Non-Physician 7/1/2019 ExplanationOfBenefit patient--> The recipient of the products and services identifier
111 Claim adjusted from identifier Prior claim number EOB Inpatient Facility 6/28/2019 ExplanationOfBenefit related Prior or corollary claims
111 Claim adjusted from identifier Prior claim number EOB Outpatient Facility 6/28/2019 ExplanationOfBenefit related Prior or corollary claims
111 Claim adjusted from identifier Prior claim number EOB Professional | Non-Physician 6/28/2019 ExplanationOfBenefit related Prior or corollary claims
111 Claim adjusted from identifier Prior claim number EOB Pharmacy 6/28/2019 ExplanationOfBenefit related Prior or corollary claims
112 Claim adjusted to identifier Replaced or Merged claim number EOB Inpatient Facility 6/28/2019 ExplanationOfBenefit related Prior or corollary claims
112 Claim adjusted to identifier Replaced or Merged claim number EOB Outpatient Facility 6/28/2019 ExplanationOfBenefit related Prior or corollary claims
112 Claim adjusted to identifier Replaced or Merged claim number EOB Professional | Non-Physician 6/28/2019 ExplanationOfBenefit related Prior or corollary claims
112 Claim adjusted to identifier Replaced or Merged claim number EOB Pharmacy 6/28/2019 ExplanationOfBenefit related Prior or corollary claims
113 Claim diagnosis related group (DRG) Name of the DRG grouper assigned EOB Inpatient Facility 6/28/2019 ExplanationOfBenefit supportingInfo code Classification of the supplied information
114 Claim bill facility type code UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of facility. EOB Inpatient Facility 6/28/2019 ExplanationOfBenefit supportingInfo code Type of information
114 Claim bill facility type code UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of facility. EOB Outpatient Facility 6/28/2019 ExplanationOfBenefit supportingInfo code Type of information
115 Claim service classification type code UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The second digit classifies the type of care (service classification) being billed. EOB Inpatient Facility 6/28/2019 ExplanationOfBenefit supportingInfo code Type of information
115 Claim service classification type code UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The second digit classifies the type of care (service classification) being billed. EOB Outpatient Facility 6/28/2019 ExplanationOfBenefit supportingInfo code Type of information
116 Claim frequency code UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. EOB Inpatient Facility 6/28/2019 ExplanationOfBenefit supportingInfo code Type of information
116 Claim frequency code UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. EOB Outpatient Facility 6/28/2019 ExplanationOfBenefit supportingInfo code Type of information
117 Patient discharge status code Patients status as of the discharge date for a facility stay. Information located on UB04 (Form Locator 17). EOB Inpatient Facility 6/28/2019 ExplanationOfBenefit supportingInfo code Type of information
117 Patient discharge status code Patients status as of the discharge date for a facility stay. Information located on UB04 (Form Locator 17). EOB Outpatient Facility 6/28/2019 ExplanationOfBenefit supportingInfo code Type of information
118 Service (from) date Date on which services began. Located on
CMS 1500 (Form Locator 24A)
EOB Professional | Non-Physician 6/28/2019 ExplanationOfBenefit item servicedPeriod Relevant time frame for the line
119 Service to date Date on which services ended. Located on
CMS 1500 (Form Locator 24A)
EOB Professional | Non-Physician 6/28/2019 ExplanationOfBenefit item servicedPeriod Relevant time frame for the line
120 Claim payee type code Identifies recipient of benefits payable; i.e., provider or subscriber
EOB Inpatient Facility 7/2/2019 ExplanationOfBenefit payee type Category of recipient
120 Claim payee type code Identifies recipient of benefits payable; i.e., provider or subscriber
EOB Outpatient Facility 7/2/2019 ExplanationOfBenefit payee type Category of recipient
120 Claim payee type code Identifies recipient of benefits payable; i.e., provider or subscriber
EOB Professional | Non-Physician 7/2/2019 ExplanationOfBenefit payee type Category of recipient
120 Claim payee type code Identifies recipient of benefits payable; i.e., provider or subscriber
EOB Pharmacy 7/2/2019 ExplanationOfBenefit payee type Category of recipient
121 Claim payee Recipient reference
EOB Inpatient Facility 7/2/2019 ExplanationOfBenefit payee party--> Recipient reference Reference(PractitionerRole | Patient)
121 Claim payee Recipient reference
EOB Outpatient Facility 7/2/2019 ExplanationOfBenefit payee party--> Recipient reference Reference(PractitionerRole | Patient)
121 Claim payee Recipient reference
EOB Professional | Non-Physician 7/2/2019 ExplanationOfBenefit payee party--> Recipient reference Reference(PractitionerRole | Patient)
121 Claim payee Recipient reference
EOB Pharmacy 7/2/2019 ExplanationOfBenefit payee party--> Recipient reference Reference(PractitionerRole | Patient)
122 Claim prescribing physician NPI The identifier from NCPDP field # 411-DB (Prescriber ID) that identifies the National Provider Identifier (NPI) of the provider who prescribed the pharmaceutical. EOB Pharmacy 7/8/2019 ExplanationOfBenefit careTeam provider--> Practitioner or organization Reference(Practitioner | PractitionerRole | Organization)
123 Claim prescriber Network Status Indicates the network status of the prescribing physician EOB Pharmacy          
124 Date of death Date of death of the member Coverage Coverage[2] beneficiary-->   Plan beneficiary Reference(Patient)
125 County The county for the member's primary address Coverage Coverage[3] beneficiary-->   Plan beneficiary Reference(Patient)
126 State The state for the member's primary address Coverage Coverage[4] beneficiary-->   Plan beneficiary Reference(Patient)
127 Country The country for the member's primary address Coverage Coverage[5] beneficiary-->   Plan beneficiary Reference(Patient)
128 Race Code The race of the member Coverage Coverage[6] beneficiary-->   Plan beneficiary Reference(Patient)
129 Ethnicity The ethnicity of the member Coverage Coverage[7] beneficiary-->   Plan beneficiary Reference(Patient)
130 Patient Name The name of the patient Coverage Coverage[8] beneficiary-->   Plan beneficiary Reference(Patient)
131 ZIP Code This represents the member's 5 digit zip code Coverage Coverage[9] beneficiary-->   Plan beneficiary Reference(Patient)
132 Subscriber id Identifies the subscriber identification Coverage Coverage[10] beneficiary-->   Plan beneficiary Reference(Patient)
133 Coverage status Identfies the member's coverage status Coverage Coverage[11] beneficiary-->   Plan beneficiary Reference(Patient)
134 Group id Employer account identifier Coverage Coverage[12] beneficiary-->   Plan beneficiary Reference(Patient)
135 Group name Name of the Employer Account Coverage Coverage[13] beneficiary-->   Plan beneficiary Reference(Patient)
137 Refill number The number fill of the current dispensed supply (0, 1, 2, etc.)
EOB Pharmacy 7/17/2019 ExplanationOfBenefit supportingInfo value Quantity
140 Claim processing status code
EOB Inpatient Facility 7/1/2019 ExplanationOfBenefit status active | cancelled | draft | entered-in-error
140 Claim processing status code
EOB Outpatient Facility 7/1/2019 ExplanationOfBenefit status active | cancelled | draft | entered-in-error
140 Claim processing status code
EOB Professional | Non-Physician 7/1/2019 ExplanationOfBenefit status active | cancelled | draft | entered-in-error
140 Claim processing status code
EOB Pharmacy 7/1/2019 ExplanationOfBenefit status active | cancelled | draft | entered-in-error
141 Claim primary payer identifier Identifies the primary payer. For use only on secondary claims. EOB Inpatient Facility 7/1/2019 ExplanationOfBenefit insurance Insurance information Reference(Coverage)
141 Claim primary payer identifier Identifies the primary payer. For use only on secondary claims. EOB Outpatient Facility 7/1/2019 ExplanationOfBenefit insurance Insurance information Reference(Coverage)
141 Claim primary payer identifier Identifies the primary payer. For use only on secondary claims. EOB Professional | Non-Physician 7/1/2019 ExplanationOfBenefit insurance Insurance information Reference(Coverage)
141 Claim primary payer identifier Identifies the primary payer. For use only on secondary claims. EOB Pharmacy 7/1/2019 ExplanationOfBenefit insurance Insurance information Reference(Coverage)
142 Line benefit payment status Indicates the in network or out of network payment status of the claim. EOB Inpatient Facility 7/8/2019 ExplanationOfBenefit adjudication category Type of adjudication information
142 Line benefit payment status Indicates the in network or out of network payment status of the claim. EOB Outpatient Facility 7/8/2019 ExplanationOfBenefit adjudication category Type of adjudication information
142 Line benefit payment status Indicates the in network or out of network payment status of the claim. EOB Professional | Non-Physician 7/8/2019 ExplanationOfBenefit item adjudication CodeableConcept
142 Line benefit payment status Indicates the in network or out of network payment status of the claim. EOB Pharmacy 7/8/2019 ExplanationOfBenefit item adjudication CodeableConcept
143 Prescription origin code Whether the prescription was transmitted as an electronic prescription, by phone, by fax, or as a written paper copy
EOB Pharmacy 7/17/2019 ExplanationOfBenefit supportingInfo code CodeableConcept
144 Plan reported brand-generic code Whether the plan adjudicated the claim as a brand or generic drug
EOB Pharmacy 7/17/2019 ExplanationOfBenefit supportingInfo code CodeableConcept
145 Diagnosis Code Description A plain text representation of the diagnosis EOB Inpatient Facility 7/19/2019 ExplanationOfBenefit diagnosis diagnosis CodeableConcept
145 Diagnosis Code Description A plain text representation of the diagnosis EOB Outpatient Facility 7/19/2019 ExplanationOfBenefit diagnosis diagnosis CodeableConcept
145 Diagnosis Code Description A plain text representation of the diagnosis EOB Professional | Non-Physician 7/19/2019 ExplanationOfBenefit diagnosis diagnosis CodeableConcept
146 ICD Procedure Code Description A plain text representation of the ICD procedure EOB Inpatient Facility 7/19/2019 ExplanationOfBenefit diagnosis diagnosis CodeableConcept
147 CPT / HCPCS Procedure Code Description A plain text representation of the CPT / HCPCS procedure EOB Outpatient Facility 7/19/2019 ExplanationOfBenefit item productOrService Billing, service, product, or drug code
147 CPT / HCPCS Procedure Code Description A plain text representation of the CPT / HCPCS procedure EOB Professional | Non-Physician 7/19/2019 ExplanationOfBenefit item productOrService Billing, service, product, or drug code
148 Total Amount Total amount for each category (i.e., submitted, allowed, etc.) EOB Inpatient Facility 7/26/2019 ExplanationOfBenefit total amount Financial total for the category
148 Total Amount Total amount for each category (i.e., submitted, allowed, etc.) EOB Outpatient Facility 7/26/2019 ExplanationOfBenefit total amount Financial total for the category
148 Total Amount Total amount for each category (i.e., submitted, allowed, etc.) EOB Professional | Non-Physician 7/26/2019 ExplanationOfBenefit total amount Financial total for the category
148 Total Amount Total amount for each category (i.e., submitted, allowed, etc.) EOB Pharmacy 7/26/2019 ExplanationOfBenefit total amount Financial total for the category
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