{ "name": "Patient EOB Model", "mnemonic": "PAT_EOB_V1", "description": "This model is for patient claims data and is based on CPCDS", "version": 1, "modelTypeName": "Standard base", "baseModel": null, "rootEntityName": "patient", "rootEntityMnemonic": "PATIENT", "dataClasses": [ { "name": "Member", "mnemonic": "MEMB", "description": null, "shortName": "Member", "fieldName": "member", "isInherited": false, "sequence": 1, "cardinality": { "name": "One", "mnemonic": "ONE" }, "attributes": [ { "name": "Member data class", "mnemonic": "MEMB", "shortName": "Member", "fieldName": "member", "description": null, "sequence": 1, "autoGenerated": true, "isInherited": false, "attributeType": { "name": "Data Class", "mnemonic": "CLS" } }, { "name": "Member element", "mnemonic": "MEMB_ELEMENT", "shortName": "Member", "fieldName": "memberElement", "description": null, "sequence": 2, "autoGenerated": true, "isInherited": false, "attributeType": { "name": "Element", "mnemonic": "ELM" } }, { "name": "Member ID", "mnemonic": "MEMB_ID", "shortName": "Member ID", "fieldName": "memberId", "description": "Identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided.", "sequence": 3, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Unique Member ID", "mnemonic": "MEMB_UNIQUEID", "shortName": "Unique Member ID", "fieldName": "uniqueMemberId", "description": "Unique identifier for a member assigned by the Payer. ", "sequence": 4, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Member Identifier Type", "mnemonic": "MEMB_IDTYPE", "shortName": "Member Identifier Type", "fieldName": "memberIdentifierType", "description": "Identifies the type of identifier payers and providers assign to patients", "sequence": 5, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Date of Birth", "mnemonic": "MEMB_DOB", "shortName": "Date of Birth", "fieldName": "dateOfBirth", "description": "Date of birth of the member.", "sequence": 6, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Date of Death", "mnemonic": "MEMB_DOD", "shortName": "Date of Death", "fieldName": "dateOfDeath", "description": "Date of death of the member.", "sequence": 7, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Deceased Flag", "mnemonic": "MEMB_DECEASED", "shortName": "Deceased Flag", "fieldName": "deceasedFlag", "description": "Flag indicating if the member is deceased", "sequence": 8, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Birth Sex", "mnemonic": "MEMB_BIRTHSEX", "shortName": "Birth Sex", "fieldName": "birthSex", "description": "The gender of the member at birth.", "sequence": 9, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Race Code", "mnemonic": "MEMB_RACE", "shortName": "Race Code", "fieldName": "raceCode", "description": "The race of the member.", "sequence": 10, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Ethnicity", "mnemonic": "MEMB_ETHNICITY", "shortName": "Ethnicity", "fieldName": "ethnicity", "description": "The ethnicity of the member.", "sequence": 11, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "City", "mnemonic": "MEMB_CITY", "shortName": "City", "fieldName": "city", "description": "The city for the member's primary address", "sequence": 12, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "County", "mnemonic": "MEMB_COUNTY", "shortName": "County", "fieldName": "county", "description": "125\tCounty\tThe county for the member's primary address.", "sequence": 13, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "State", "mnemonic": "MEMB_STATE", "shortName": "State", "fieldName": "state", "description": "The state for the member's primary address.", "sequence": 14, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Country", "mnemonic": "MEMB_COUNTRY", "shortName": "Country", "fieldName": "country", "description": "The country for the member's primary address.", "sequence": 15, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Postal Code", "mnemonic": "MEMB_POSTCODE", "shortName": "Postal Code", "fieldName": "postalCode", "description": "This represents the member's 5 digit zip code. ", "sequence": 16, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Address start date", "mnemonic": "MEMB_ADDRSTARTDATE", "shortName": "Address start date", "fieldName": "addressStartDate", "description": "Member address start date", "sequence": 17, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Address end date", "mnemonic": "MEMB_ADDRENDDATE", "shortName": "Address end date", "fieldName": "addressEndDate", "description": "member address end date", "sequence": 18, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "telecom system", "mnemonic": "MEMB_TELECOM_SYSTEM", "shortName": "member telecom system", "fieldName": "telecomSystem", "description": "Telecommunications form for contact point.", "sequence": 19, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Telecom Use", "mnemonic": "MEMB_TELECOM_USE", "shortName": "telecom use", "fieldName": "telecomUse", "description": "Purpose of this contact point - home, mobile, work, etc", "sequence": 20, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Street address", "mnemonic": "MEMB_ADDRESS", "shortName": "Street address", "fieldName": "streetAddress", "description": "Street name, number, direction & P.O. Box etc.", "sequence": 21, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Primary language", "mnemonic": "MEMB_PRIM_LANG", "shortName": "primary language", "fieldName": "primaryLanguage", "description": "A language which may be used to communicate with the patient about his or her health", "sequence": 22, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } } ], "roles": [] }, { "name": "Coverage", "mnemonic": "COVER", "description": null, "shortName": "Coverage", "fieldName": "coverage", "isInherited": false, "sequence": 2, "cardinality": { "name": "One to Many", "mnemonic": "ONE_TO_MANY" }, "attributes": [ { "name": "Coverage data class", "mnemonic": "COVER", "shortName": "Coverage", "fieldName": "coverage", "description": "A collection representing a patient's insurance coverage and benefit information.", "sequence": 1, "autoGenerated": true, "isInherited": false, "attributeType": { "name": "Data Class", "mnemonic": "CLS" } }, { "name": "Coverage element", "mnemonic": "COVER_ELEMENT", "shortName": "Coverage", "fieldName": "coverageElement", "description": "A single Coverage element of the Coverage Data Class.", "sequence": 2, "autoGenerated": true, "isInherited": false, "attributeType": { "name": "Element", "mnemonic": "ELM" } }, { "name": "Subscriber ID", "mnemonic": "COVER_SUBID", "shortName": "Subscriber ID", "fieldName": "subscriberId", "description": "The identifier assigned by the Payer on the subscriber's ID card.", "sequence": 3, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Coverage Type", "mnemonic": "COVER_TYPE", "shortName": "Coverage Type", "fieldName": "coverageType", "description": "Identifies if the coverage is PPO, HMO, POS, etc. ", "sequence": 4, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Coverage Status", "mnemonic": "COVER_STATUS", "shortName": "Coverage Status", "fieldName": "coverageStatus", "description": "Identifies the status of the coverage information (default: active).", "sequence": 5, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Start Date", "mnemonic": "COVER_STARTDATE", "shortName": "Start Date", "fieldName": "startDate", "description": "Date that the contract became effective.", "sequence": 6, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "End Date", "mnemonic": "COVER_ENDDATE", "shortName": "End Date", "fieldName": "endDate", "description": "Date that the contract was terminated or coverage changed", "sequence": 7, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Group ID", "mnemonic": "COVER_GROUPID", "shortName": "Group ID", "fieldName": "groupId", "description": "Employer account identifier.", "sequence": 8, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Group Name", "mnemonic": "COVER_GROUPNAME", "shortName": "Group Name", "fieldName": "groupName", "description": "Name of the Employer Account.", "sequence": 9, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Plan Identifier", "mnemonic": "COVER_PLANID", "shortName": "Plan Identifier", "fieldName": "planIdentifier", "description": "Business concept used by a health plan to describe its benefit offerings.", "sequence": 10, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Plan Name", "mnemonic": "COVER_PLANNAME", "shortName": "Plan Name", "fieldName": "planName", "description": "Name of the health plan benefit offering assigned to the Plan Identifier.", "sequence": 11, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Payer Identifier", "mnemonic": "COVER_PAYERID", "shortName": "Payer Identifier", "fieldName": "payerIdentifier", "description": "Issuer of the Policy", "sequence": 12, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Other Payer Name", "mnemonic": "COVER_OTHERPAYER", "shortName": "Other Payer Name", "fieldName": "otherPayerName", "description": "Identifies another payer who applied benefits for the service on another claim", "sequence": 13, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Relationship to Subscriber", "mnemonic": "COVER_RELATION", "shortName": "Relationship to Subscriber", "fieldName": "relationshipToSubscriber", "description": "Relationship of the member to the person insured (subscriber).", "sequence": 14, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Claim payer Name", "mnemonic": "COVER_PAYERNAME", "shortName": "Claim payer Name", "fieldName": "claimPayerName", "description": "Name of the payer responsible for the claim", "sequence": 15, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } } ], "roles": [] }, { "name": "Medical Claim", "mnemonic": "CLAIM", "description": null, "shortName": "ClaimMedicalClass", "fieldName": "medicalClaim", "isInherited": false, "sequence": 3, "cardinality": { "name": "One to Many", "mnemonic": "ONE_TO_MANY" }, "attributes": [ { "name": "Medical Claim data class", "mnemonic": "CLAIM", "shortName": "ClaimMedicalClass", "fieldName": "medicalClaim", "description": null, "sequence": 1, "autoGenerated": true, "isInherited": false, "attributeType": { "name": "Data Class", "mnemonic": "CLS" } }, { "name": "Medical Claim element", "mnemonic": "CLAIM_ELEMENT", "shortName": "ClaimMedicalClass", "fieldName": "medicalClaim", "description": null, "sequence": 2, "autoGenerated": true, "isInherited": false, "attributeType": { "name": "Element", "mnemonic": "ELM" } }, { "name": "Claim DRG Version", "mnemonic": "CLAIM_DRG_VERSION", "shortName": "Claim DRG Version", "fieldName": "claimDrgVersion", "description": "32 - Version of the DRG codes assigned for inpatient facility claims.\r\n33- Claim diagnosis related group (DRG) code value\r\n113 - Name of the DRG grouper assigned; i.e., MS-DRG, AP-DRG or APR-DRG\r\n", "sequence": 3, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Claim DRG Code", "mnemonic": "CLAIM_DRG_CODE", "shortName": "DRG code", "fieldName": "claimDrgCode", "description": null, "sequence": 4, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Claim Service Start Date", "mnemonic": "CLAIM_START_DATE", "shortName": "Claim start date", "fieldName": "claimStartDate", "description": "90 - Date on which services began. UB04 (Form Locator 45).\r\n118 - Date on which services began. Located on CMS 1500 (Form Locator 24A)\r\n", "sequence": 5, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Statement Thru Date", "mnemonic": "CLAIM_STATEMENT_THRU_DATE", "shortName": "Statement Thru Date", "fieldName": "statementThruDate", "description": "On Institutional claims, the last day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers Thru Date’) On Professional and Non-Clinician claims, the latest of any of the line-item level dates.\r\n", "sequence": 6, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Procedure Code Type", "mnemonic": "CLAIM_PROCEDURE_CODE_TYPE", "shortName": "Procedure Code Type", "fieldName": "procedureCodeType", "description": "Indicates if the inpatient institutional procedure (ICD-PCS) is the principal procedure or another procedure", "sequence": 7, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Adjudication Date", "mnemonic": "CLAIM_ADJUDICATION_DATE", "shortName": "Adjudication Date", "fieldName": "adjudicationDate", "description": "Date the claim was adjudicated", "sequence": 8, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Member Discharge Date", "mnemonic": "CLAIM_DISCHARGE_DATE", "shortName": "Discharge Date", "fieldName": "dischargedate", "description": "Date the beneficiary was discharged from the facility, or died. Matches the Statement Thru Date. When there is a discharge date, the Patient Discharge Status Code indicates the final disposition of the patient after discharge.", "sequence": 9, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Claim Primary Payer Identifier", "mnemonic": "CLAIM_PRIMARY_PAYER_IDENTIFIER", "shortName": "Primary Payer Identifier", "fieldName": "primaryPayerIdentifier", "description": "Identifies the primary payer. For use only on secondary claims.", "sequence": 10, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Claim Sub Type", "mnemonic": "CLAIM_SUB_TYPE", "shortName": "Claim Sub Type", "fieldName": "claimSubType", "description": "High-level categorization of the claim. ", "sequence": 11, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Patient Discharge Status Code", "mnemonic": "CLAIM_PATIENT_DISCHARGE_STATUS_CODE", "shortName": "Patient Discharge Status Code", "fieldName": "patientDischargeStatusCode", "description": "Patient’s status as of the discharge date for a facility stay. Information located on UB04 (Form Locator 17).", "sequence": 12, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Claim Payer Identifier", "mnemonic": "CLAIM_PAYER_IDENTIFIER", "shortName": "Claim Payer Identifier", "fieldName": "claimPayerIdentifier", "description": " The identifier assigned to the Operating Surgeon.", "sequence": 13, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Medical Record Number", "mnemonic": "CLAIM_MEDICAL_RECORD_NUMBER", "shortName": "Medical Record Number", "fieldName": "medicalRecordNumber", "description": "Provider submitted information that can be included on the claim.", "sequence": 14, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Claim Identifier Type", "mnemonic": "CLAIM_IDENTIFIER_TYPE", "shortName": "Claim Identifier Type", "fieldName": "claimIdentifierType", "description": "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber.", "sequence": 15, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Claim Processing Status Code", "mnemonic": "CLAIM_PROCESSING_STATUS_CODE", "shortName": "Processing Status Code", "fieldName": "processingStatusCode", "description": "Claim processing status code", "sequence": 16, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Claim Bill Facility Type Code", "mnemonic": "CLAIM_BILL_FACILITY_TYPE_CODE", "shortName": "Bill Facility Type Code", "fieldName": "billFacilityTypeCode", "description": "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.", "sequence": 17, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Claim Adjusted from Identifier", "mnemonic": "CLAIM_ADJUSTED_FROM_CLAIM_ID", "shortName": "Claim Adjusted from Identifier", "fieldName": "claimAdjustedfromIdentifier", "description": "If the current claim represents a claim that has been adjusted and was given a prior claim number, this field represents the prior claim number", "sequence": 18, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Claim Adjusted to Identifier", "mnemonic": "CLAIM_ADJUSTED_TO_CLAIM_ID", "shortName": "Claim Adjusted to Identifier", "fieldName": "claimAdjustedtoIdentifier", "description": "If the current claim has been adjusted; i.e., replaced by or merged to another claim number, this data element represents that new number. ", "sequence": 19, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Claim Adjusted Relationship ", "mnemonic": "CLAIM_ADJUSTED_REL", "shortName": "claim adjusted relationship ", "fieldName": "claimAdjustedRelationship", "description": "The nature of the claim adjustment", "sequence": 20, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Claim Received Date", "mnemonic": "CLAIM_RECEIVED_DATE", "shortName": "Claim Received Date", "fieldName": "claimReceivedDate", "description": "The date the claim was received by the payer.", "sequence": 21, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Claim Payment Status Code", "mnemonic": "CLAIM_PAYMENT_STATUS_CODE", "shortName": "Payment Status Code", "fieldName": "claimPaymentStatusCode", "description": "Indicates whether the claim was paid or denied.", "sequence": 22, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Claim Paid Date", "mnemonic": "CLAIM_PAID_DATE", "shortName": "Claim Paid Date", "fieldName": "claimPaidDate", "description": "The date the claim was paid.", "sequence": 23, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Claim Discount Amount", "mnemonic": "CLAIM_DISCAMT", "shortName": "Claim Discount Amount", "fieldName": "claimDiscountAmount", "description": "The amount of the discount.", "sequence": 24, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Claim Service Classification Type Code", "mnemonic": "CLAIM_SERVICE_CLASSIFICATION_TYPE_CODE", "shortName": "Service Classification Type Code", "fieldName": "serviceClassificationTypeCode", "description": "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.", "sequence": 25, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Patient Account Number", "mnemonic": "CLAIM_PATIENT_ACCOUNT_NUMBER", "shortName": "Patient Account Number", "fieldName": "patientAccountNumber", "description": "Provider submitted information that can be included on the claim.", "sequence": 26, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Claim Payee Type Code", "mnemonic": "CLAIM_PAYEE_TYPE_CODE", "shortName": "Claim Payee Type Code", "fieldName": "claimPayeeTypeCode", "description": "Identifies the type of recipient of the adjudication amount; i.e., provider, subscriber, beneficiary or another recipient", "sequence": 27, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Claim Inpatient Source Admission Code", "mnemonic": "CLAIM_INPATIENT_SOURCE_ADMIN_CODE", "shortName": "Inpatient Source admin Code", "fieldName": "inpatientSourceAdmissionCode", "description": "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).", "sequence": 28, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Member Admission Date", "mnemonic": "CLAIM_MEMBER_ADMISSION_DATE", "shortName": "Admission Date", "fieldName": "admissionDate", "description": "The date corresponding with admission of the beneficiary to a facility and the onset of services. May precede the Statement From Date if this claim is for a beneficiary who has been continuously under care.", "sequence": 29, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Claim Payment Denial Code", "mnemonic": "CLAIM_PAYMENT_DENIAL_CODE", "shortName": "Payment Denial Code", "fieldName": "paymentDenialCode", "description": "Reason codes used to interpret the Non-Covered Amount that are provided to the Provider", "sequence": 30, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Claim Service End Date", "mnemonic": "CLAIM_END_DATE", "shortName": "Claim End Date", "fieldName": "claimServiceEndDate", "description": "119\tClaim Service End Date\tDate on which services ended. Located on CMS 1500 (Form Locator 24A)", "sequence": 31, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Claim Type Code", "mnemonic": "CLAIM_TYPE_CODE", "shortName": "Claim Type Code", "fieldName": "claimTypeCode", "description": "Specifies the type of claim. (e.g., inpatient institutional, outpatient institutional, physician, etc.).", "sequence": 32, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Payer Claim Unique Identifier", "mnemonic": "CLAIM_UNIQUE_ID", "shortName": "Claim Unique Identifier", "fieldName": "payerClaimUniqueIdentifier", "description": "35\tPayer Claim Unique Identifier\tIdentifier assigned by a payer for a claim received from a provider or subscriber. It is not the same identifier as that assigned by a provider. ", "sequence": 33, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Adjudication Amount Type", "mnemonic": "CLAIM_ADJUDICATION_AMOUNT_TYPE", "shortName": "Adjudication Amount Type", "fieldName": "adjudicationAmountType", "description": "Describes the various amount fields used when payers receive and adjudicate a claim", "sequence": 34, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Claim Inpatient Admission Type Code", "mnemonic": "CLAIM_INPATIENT_ADMIN_TYPE_CODE", "shortName": "Inpatient Admin Type Code", "fieldName": "inpatientAdmissionTypeCode", "description": "Priority of the 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.", "sequence": 35, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Claim Frequency Code", "mnemonic": "CLAIM_FREQUENCY_CODE", "shortName": "Frequency Code", "fieldName": "frequencyCode", "description": "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.", "sequence": 36, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Claim Payee ", "mnemonic": "CLAIM_PAYEE", "shortName": "Claim Payee ", "fieldName": "claimPayee", "description": "Recipient reference.", "sequence": 37, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Total Amount", "mnemonic": "CLAIM_TOTAL_AMOUNT", "shortName": "Total Amount", "fieldName": "totalAmount", "description": "Total amount for each category (i.e., submitted, eligible, etc.)", "sequence": 38, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Statement From Date", "mnemonic": "CLAIM_STATEMENT_FROM_DATE", "shortName": "Statement From Date", "fieldName": "statementFromDate", "description": "On Institutional claims, the first day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers From Date’). On Professional and Non-Clinician claims, Earliest of any of the line-item level dates. It is almost always the same as Claim Service End Date except for DME claims - where some services are billed in advance.", "sequence": 39, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "claim total submitted amount", "mnemonic": "CLAIM_TOTSUBAMT", "shortName": "total submitted amount", "fieldName": "claimTotalSubmittedAmount", "description": "Amount submitted by the provider for reimbursement of health care services. This amount includes non-covered services.", "sequence": 40, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "claim total allowed amount", "mnemonic": "CLAIM_TOTALLOWAMT", "shortName": "total allowed amount", "fieldName": "claimTotalAllowedAmount", "description": "The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for non-contracted providers. Allowed amount 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.", "sequence": 41, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Amount Paid by Patient", "mnemonic": "CLAIM_PATPAIDAMT", "shortName": "Amount Paid by Patient", "fieldName": "amountPaidByPatient", "description": "The amount paid by the member at the point of service.", "sequence": 42, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Claim Amount Paid to Provider", "mnemonic": "CLAIM_PROVAMT", "shortName": "Claim Amount Paid to Provider", "fieldName": "claimAmountPaidToProvider", "description": "The amount paid to the provider.", "sequence": 43, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Member Reimbursement", "mnemonic": "CLAIM_MEMBREIMBAMT", "shortName": "Member Reimbursement", "fieldName": "memberReimbursement", "description": "The amount paid to the member.", "sequence": 44, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Claim Payment Amount", "mnemonic": "CLAIM_PAYAMT", "shortName": "Claim Payment Amount", "fieldName": "claimPaymentAmount", "description": "The amount sent to the payee from the health plan. This amount is to exclude any member cost sharing. It should include the total of member and provider payments.", "sequence": 45, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Claim Non-covered Amount", "mnemonic": "CLAIM_NONCOVAMT", "shortName": "Claim Non-covered Amount", "fieldName": "claimNonCoveredAmount", "description": "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.", "sequence": 46, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Member Paid Deductible", "mnemonic": "CLAIM_DEDUCTAMT", "shortName": "Member Paid Deductible", "fieldName": "memberPaidDeductible", "description": "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.", "sequence": 47, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Co-insurance Liability Amount", "mnemonic": "CLAIM_COINSLIABAMT", "shortName": "Co-insurance Liability Amount", "fieldName": "coInsuranceLiabilityAmount", "description": "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%.", "sequence": 48, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Copay Amount", "mnemonic": "CLAIM_COPAYAMT", "shortName": "Copay Amount", "fieldName": "copayAmount", "description": "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.", "sequence": 49, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Member Liability", "mnemonic": "CLAIM_MEMBLIABAMT", "shortName": "Member Liability", "fieldName": "memberLiability", "description": "The amount of the member's liability.", "sequence": 50, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Claim Other Payer Paid Amount", "mnemonic": "CLAIM_OTHERPAYERAMT", "shortName": "Claim Other Payer Paid Amount", "fieldName": "claimOtherPayerPaidAmount", "description": "The reduction in the payment amount to reflect the current carrier as a secondary, teritary, etc, payer. May be multiple occurrences if the current carrier is a teritary, etc. carrier.", "sequence": 51, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Claim Use", "mnemonic": "CLAIM_USE", "shortName": "Claim Use", "fieldName": "claimUse", "description": "A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.", "sequence": 52, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Claim Last Update Date", "mnemonic": "CLAIM_LAST_UPDATE_DATE", "shortName": "last update date", "fieldName": "claimLastUpdateDate", "description": null, "sequence": 53, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } } ], "roles": [] }, { "name": "Claim Line", "mnemonic": "LINE", "description": null, "shortName": "Claim Line", "fieldName": "claimServiceLine", "isInherited": false, "sequence": 4, "cardinality": { "name": "One to Many", "mnemonic": "ONE_TO_MANY" }, "attributes": [ { "name": "Claim Line data class", "mnemonic": "LINE", "shortName": "Claim Line", "fieldName": "claimServiceLine", "description": null, "sequence": 1, "autoGenerated": true, "isInherited": false, "attributeType": { "name": "Data Class", "mnemonic": "CLS" } }, { "name": "Claim Line element", "mnemonic": "LINE_ELEMENT", "shortName": "Claim Line", "fieldName": "claimServiceLineElement", "description": null, "sequence": 2, "autoGenerated": true, "isInherited": false, "attributeType": { "name": "Element", "mnemonic": "ELM" } }, { "name": "Service Date", "mnemonic": "LINE_SERVICE_DATE", "shortName": "Service Date", "fieldName": "serviceDate", "description": "90 - Date on which services began. UB04 (Form Locator 45).\r\n\r\n118 - Date on which services began. Located on CMS 1500 (Form Locator 24A)\r\n", "sequence": 3, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Line Number", "mnemonic": "LINE_NUMBER", "shortName": "Line Number", "fieldName": "lineNumber", "description": "Line identification number that represents the number assigned in a source system for identification and processing.", "sequence": 4, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Service to Date", "mnemonic": "LINE_SERVICE_TO_DATE", "shortName": "Service to Date", "fieldName": "serviceToDate", "description": "Date on which services ended. Located on CMS 1500 (Form Locator 24A)", "sequence": 5, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Type of Service", "mnemonic": "LINE_TYPE_OF_SERVICE", "shortName": "Type of Service", "fieldName": "typeOfService", "description": "High level classification of services into logical grouping.", "sequence": 6, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Place of Service Code", "mnemonic": "LINE_PLACE_OF_SERVICE", "shortName": "Place of Service Code", "fieldName": "placeOfServiceCode", "description": "Code indicating the location, such as inpatient, outpatient facility, office, or home health agency, where this service was performed.", "sequence": 7, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Revenue Center Code", "mnemonic": "LINE_REVENUE_CENTER_CODE", "shortName": "Revenue Center Code", "fieldName": "revenueCenterCode", "description": "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.", "sequence": 8, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Allowed Number of Units", "mnemonic": "LINE_ALLOWED_UNITS", "shortName": "Allowed Number of Units", "fieldName": "allowedNumberOfUnits", "description": "The quantity of units, times, days, visits, services, or treatments allowed for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider.", "sequence": 9, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "National Drug Code", "mnemonic": "LINE_NDC", "shortName": "National Drug Code", "fieldName": "nationalDrugCode", "description": "National Drug Code (NDC), or if the prescription is a compound, the value 'Compound'", "sequence": 10, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Compound Code", "mnemonic": "LINE_COMPOUND_CODE", "shortName": "Compound Code", "fieldName": "compoundCode", "description": "The code indicating whether or not the prescription is a compound. NCPDP field # 406-D6", "sequence": 11, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Quantity Dispensed", "mnemonic": "LINE_QTY_DISP", "shortName": "Quantity Dispensed", "fieldName": "quantityDispensed", "description": "Quantity dispensed for the drug.", "sequence": 12, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Quantity Qualifier Code", "mnemonic": "LINE_QTY_UOM", "shortName": "Quantity Qualifier Code", "fieldName": "quantityQualifierCode", "description": "The unit of measurement for the drug. (gram, ml, etc.).", "sequence": 13, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Benefit Payment Status", "mnemonic": "LINE_BENEFIT_PAYMENT_STATUS", "shortName": "Benefit Payment Status", "fieldName": "benefitPaymentStatus", "description": "Indicates the in network or out of network payment status of the claim.", "sequence": 14, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Line Payment Denial Code", "mnemonic": "LINE_PAYMENT_DENIAL_CODE", "shortName": "Line Payment Denial Code", "fieldName": "linePaymentDenialCode", "description": "Reason codes used to interpret the Non-Covered Amount that are provided to the Provider", "sequence": 15, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Payment member explanation", "mnemonic": "LINE_PAYMENT_MEMBER_EXP", "shortName": "Payment member explanation", "fieldName": "paymentMemberExplanation", "description": "Payment explanation to a member on an EOB", "sequence": 16, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Line Noncovered Amount", "mnemonic": "LINE_NONCOVERED_AMT", "shortName": "Line Noncovered Amount", "fieldName": "lineNoncoveredAmount", "description": "Medical: 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.\r\n\r\nPharmacy: Non-Covered Amount represents the NCPDP financial response field Amount Exceeding Periodic Benefit Maximum.\r\n", "sequence": 17, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Line Member Reimbursement", "mnemonic": "LINE_MEMBER_REIMB", "shortName": "Line Member Reimbursement", "fieldName": "lineMemberReimbursement", "description": "The amount paid to the member.", "sequence": 18, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Line Payment Amount", "mnemonic": "LINE_PAYMENT_AMT", "shortName": "Line Payment Amount", "fieldName": "linePaymentAmount", "description": "The amount sent to the payee from the health plan. This amount is to exclude any member cost sharing. It should include the total of member and provider payments.", "sequence": 19, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Line Discount Amount", "mnemonic": "LINE_DISC_AMT", "shortName": "Line Discount Amount", "fieldName": "lineDiscountAmount", "description": "The amount of the discount.", "sequence": 20, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Line Amount Paid by Patient", "mnemonic": "LINE_PAT_PAID_AMT", "shortName": "Line Amount Paid by Patient", "fieldName": "lineAmountPaidByPatient", "description": "Medical: The amount paid by the member at the point of service.\r\n\r\nPharmacy: 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 patient’s total cost share, including copayments, amounts applied to deductible, over maximum amounts, penalties, etc\r\n", "sequence": 21, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Drug Cost", "mnemonic": "LINE_DRUG_COST", "shortName": "Drug Cost", "fieldName": "drugCost", "description": "Price paid for the drug excluding mfr discounts. It is the sum of the following components:ingredient cost, dispensing fee, sales tax, and vaccine administration fee.", "sequence": 22, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Line Allowed Amount", "mnemonic": "LINE_ALLOWED_AMT", "shortName": "Line Allowed Amount", "fieldName": "lineAllowedAmount", "description": "The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. Allowed amount 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.", "sequence": 23, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Line Amount Paid to Provider", "mnemonic": "LINE_PROV_PAID_AMT", "shortName": "Line Amount Paid to Provider", "fieldName": "lineAmountPaidToProvider", "description": "The amount paid to the provider.", "sequence": 24, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Line Patient Deductible", "mnemonic": "LINE_PAT_DEDUCTIBLE", "shortName": "Line Patient Deductible", "fieldName": "linePatientDeductible", "description": "The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers.", "sequence": 25, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Line Other Payer Paid Amount", "mnemonic": "LINE_OTHER_PAYER_PAID_AMT", "shortName": "Line Other Payer Paid Amount", "fieldName": "lineOtherPayerPaidAmount", "description": "The reduction in the payment amount to reflect the current carrier as a secondary, tertiary, etc, payer. May be multiple occurrences if the current carrier is a tertiary, etc. carrier.", "sequence": 26, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Line Coinsurance Amount", "mnemonic": "LINE_COINSUR_AMT", "shortName": "Line Coinsurance Amount", "fieldName": "lineCoinsuranceAmount", "description": "Medical: 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%.\r\nPharmacy: 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.\r\n", "sequence": 27, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Line Submitted Amount", "mnemonic": "LINE_SUBMITTED_AMT", "shortName": "Line Submitted Amount", "fieldName": "lineSubmittedAmount", "description": "Amount submitted by the provider for reimbursement of health care services. This amount includes non-covered services.", "sequence": 28, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Line Member Liability Amount", "mnemonic": "LINE_MEMBER_LIABILITY_AMT", "shortName": "Line Member Liability", "fieldName": "lineMemberLiabilityAmount", "description": "The amount of the member's liability.", "sequence": 29, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Line Copay Amount", "mnemonic": "LINE_COPAY_AMT", "shortName": "Line Copay Amount", "fieldName": "lineCopayAmount", "description": "Medical: 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.\r\nPharmacy: 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.\r\n", "sequence": 30, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Line Procedure Code", "mnemonic": "LINE_PROCEDURE_CODE", "shortName": "line procedure code", "fieldName": "lineProcedureCode", "description": "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). Health Insurance Prospective Payment System (HIPPS) rate codes represent specific sets of patient characteristics (or case-mix groups) health insurers use to make payment determinations under several prospective payment systems", "sequence": 31, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Line Procedure Code Modifier", "mnemonic": "LINE_PROCEDURE_CODE_MOD", "shortName": "line procedure code modifier", "fieldName": "lineProcedureCodeModifier", "description": "Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service.\r\n", "sequence": 32, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } } ], "roles": [] }, { "name": "Claim Diagnosis", "mnemonic": "DIAG", "description": null, "shortName": "Claim Diagnosis", "fieldName": "claimDiagnosis", "isInherited": false, "sequence": 5, "cardinality": { "name": "One to Many", "mnemonic": "ONE_TO_MANY" }, "attributes": [ { "name": "Claim Diagnosis data class", "mnemonic": "DIAG", "shortName": "Claim Diagnosis", "fieldName": "claimDiagnosis", "description": "A collection representing the diagnoses associated with a claim, including admitting, principal, and secondary diagnoses.", "sequence": 1, "autoGenerated": true, "isInherited": false, "attributeType": { "name": "Data Class", "mnemonic": "CLS" } }, { "name": "Claim Diagnosis element", "mnemonic": "DIAG_ELEMENT", "shortName": "Claim Diagnosis", "fieldName": "claimDiagnosisElement", "description": "A single Diagnosis element of the Claim Diagnosis Data Class.", "sequence": 2, "autoGenerated": true, "isInherited": false, "attributeType": { "name": "Element", "mnemonic": "ELM" } }, { "name": "Diagnosis Code", "mnemonic": "DIAG_DIAGNOSIS", "shortName": "Diagnosis Code", "fieldName": "diagnosisCode", "description": "21- 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.\r\n\r\n22 - The member's principal condition treated during this service. This may or may not be different from the admitting diagnosis. Decimals will be included.\r\n\r\n23 - Additional diagnosis identified for this member. Decimals will be included.\r\n", "sequence": 3, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "E code Indicator", "mnemonic": "DIAG_E_CODE_IND", "shortName": "Is E code", "fieldName": "eCodeIndicator", "description": "This is any valid ICD-10 Diagnosis code in the range V00.* through Y99.*", "sequence": 4, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Present on Admission Indicator", "mnemonic": "DIAG_PRESENT_ON_ADM_IND", "shortName": "Present on Admission", "fieldName": "presentOnAdmissionIndicator", "description": "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.", "sequence": 5, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Diagnosis Type", "mnemonic": "DIAG_DIAG_TYPE", "shortName": "Diagnosis Type", "fieldName": "diagnosisType", "description": "\r\nIndicates if the diagnosis is admitting, principal, other, an external cause of injury or secondary", "sequence": 6, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } } ], "roles": [] }, { "name": "Claim Procedure", "mnemonic": "PROC", "description": null, "shortName": "Claim Procedure", "fieldName": "claimProcedure", "isInherited": false, "sequence": 6, "cardinality": { "name": "One to Many", "mnemonic": "ONE_TO_MANY" }, "attributes": [ { "name": "Claim Procedure data class", "mnemonic": "PROC", "shortName": "Claim Procedure", "fieldName": "claimProcedure", "description": null, "sequence": 1, "autoGenerated": true, "isInherited": false, "attributeType": { "name": "Data Class", "mnemonic": "CLS" } }, { "name": "Claim Procedure element", "mnemonic": "PROC_ELEMENT", "shortName": "Claim Procedure", "fieldName": "claimProcedureElement", "description": null, "sequence": 2, "autoGenerated": true, "isInherited": false, "attributeType": { "name": "Element", "mnemonic": "ELM" } }, { "name": "Procedure Claim Line", "mnemonic": "PROC_CLAIMLINE", "shortName": "Procedure Line", "fieldName": "procedureClaimLine", "description": "The reference back to a particular claim line where 0 or null is the header", "sequence": 3, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Procedure Code", "mnemonic": "PROC_PROCEDURE", "shortName": "Procedure Code", "fieldName": "procedureCode", "description": "24 –Principal medical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10).\r\n26 – Additional surgical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10).\r\n40 - Medical procedure Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII). \r\n", "sequence": 4, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Procedure Date", "mnemonic": "PROC_PERF_DATE", "shortName": "Procedure Date", "fieldName": "procedureDate", "description": "24- Principal medical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10).\r\n\r\n26 - Additional surgical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10).\r\n", "sequence": 5, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Procedure Type", "mnemonic": "PROC_PROC_TYPE", "shortName": "Procedure Type", "fieldName": "procedureType", "description": "Indicates whether procedure is 'principal' or 'other'", "sequence": 6, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Modifier Code -1", "mnemonic": "PROC_MOD_CODE_1", "shortName": "Modifier Code -1", "fieldName": "modifierCode1", "description": "Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service.", "sequence": 7, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Modifier Code -2", "mnemonic": "PROC_MOD_CODE_2", "shortName": "Modifier Code -2", "fieldName": "modifierCode2", "description": "Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service.", "sequence": 8, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Modifier Code -3", "mnemonic": "PROC_MOD_CODE_3", "shortName": "Modifier Code -3", "fieldName": "modifierCode3", "description": "Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service.", "sequence": 9, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Modifier Code -4", "mnemonic": "PROC_MOD_CODE_4", "shortName": "Modifier Code -4", "fieldName": "modifierCode4", "description": "Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service.", "sequence": 10, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } } ], "roles": [] }, { "name": "Pharmacy Claim", "mnemonic": "PHARMCLAIM", "description": null, "shortName": "Pharmacy Claim", "fieldName": "pharmacyClaim", "isInherited": false, "sequence": 7, "cardinality": { "name": "One to Many", "mnemonic": "ONE_TO_MANY" }, "attributes": [ { "name": "Pharmacy Claim data class", "mnemonic": "PHARMCLAIM", "shortName": "Pharmacy Claim", "fieldName": "pharmacyClaim", "description": null, "sequence": 1, "autoGenerated": true, "isInherited": false, "attributeType": { "name": "Data Class", "mnemonic": "CLS" } }, { "name": "Pharmacy Claim element", "mnemonic": "PHARMCLAIM_ELEMENT", "shortName": "Pharmacy Claim", "fieldName": "pharmacyClaimElement", "description": null, "sequence": 2, "autoGenerated": true, "isInherited": false, "attributeType": { "name": "Element", "mnemonic": "ELM" } }, { "name": "Days Supply", "mnemonic": "PHARMCLAIM_DAYS_SUPPLY", "shortName": "Days Supply", "fieldName": "daysSupply", "description": "Number of days supply of medication dispensed by the pharmacy.", "sequence": 3, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "RX Service Reference Number", "mnemonic": "PHARMCLAIM_RX_SERV_REF_NO", "shortName": "RX Service Ref No", "fieldName": "rxServiceReferenceNumber", "description": "Identifier assigned by a payer for a claim received from a provider or subscriber. It is not the same identifier as that assigned by a provider. This identifier assigned by the payer becomes the payer's EOB identifier.", "sequence": 4, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "DAW Code", "mnemonic": "PHARMCLAIM_DAW_CODE", "shortName": "DAW Code", "fieldName": "dawCode", "description": "Prescriber's instruction regarding substitution of generic equivalents or order to dispense the specific prescribed medication.", "sequence": 5, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Refill Number", "mnemonic": "PHARMCLAIM_REFILL_NO", "shortName": "Refill Number", "fieldName": "refillNumber", "description": "The number fill of the current dispensed supply (0, 1, 2, etc.).", "sequence": 6, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Prescription Origin Code", "mnemonic": "PHARMCLAIM_PRESC_ORIGIN", "shortName": "Presc Origin Code", "fieldName": "prescriptionOriginCode", "description": "Whether the prescription was transmitted as an electronic prescription, by phone, by fax, or as a written paper copy", "sequence": 7, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Plan Reported Brand-Generic Code", "mnemonic": "PHARMCLAIM_PLAN_BRAND_GEN_IND", "shortName": "Plan Brand-Generic Code", "fieldName": "planReportedBrandGenericCode", "description": "Whether the plan adjudicated the claim as a brand or generic drug.", "sequence": 8, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Total Amount", "mnemonic": "PHARMCLAIM_TOTAL_AMT", "shortName": "Total Amount", "fieldName": "totalAmount", "description": "Total amount for each category (i.e., submitted, eligible, etc.)", "sequence": 9, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Claim Identifier Amount", "mnemonic": "PHARMCLAIM_CLAIM_ID_AMT", "shortName": "Claim Identifier Amount", "fieldName": "claimIdentifierAmount", "description": "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber.", "sequence": 10, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Adjudication Amount Type", "mnemonic": "PHARMCLAIM_ADJ_AMT_TYPE", "shortName": "Adj Amount Type", "fieldName": "adjudicationAmountType", "description": "Describes the various amount fields used when payers receive and adjudicate a claim", "sequence": 11, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } } ], "roles": [] }, { "name": "Dental Claim", "mnemonic": "DENTCLAIM", "description": null, "shortName": "Dental Claim", "fieldName": "dentalClaim", "isInherited": false, "sequence": 8, "cardinality": { "name": "One to Many", "mnemonic": "ONE_TO_MANY" }, "attributes": [ { "name": "Dental Claim data class", "mnemonic": "DENTCLAIM", "shortName": "Dental Claim", "fieldName": "dentalClaim", "description": "A collection representing a dental claim submitted to a payer for dental services rendered to a patient.", "sequence": 1, "autoGenerated": true, "isInherited": false, "attributeType": { "name": "Data Class", "mnemonic": "CLS" } }, { "name": "Dental Claim element", "mnemonic": "DENTCLAIM_ELEMENT", "shortName": "Dental Claim", "fieldName": "dentalClaimElement", "description": "A single Dental Claim element of the Dental Claim Data Class.", "sequence": 2, "autoGenerated": true, "isInherited": false, "attributeType": { "name": "Element", "mnemonic": "ELM" } }, { "name": "Procedure Code", "mnemonic": "DENTCLAIM_PROCEDURE", "shortName": "Procedure Code ", "fieldName": "procedureCode", "description": "Dental procedure that a patient received from a health care provider. Current coding methods for reporting dental services are based on Current Dental Terminology, commonly known as CDT published by the American Dental Association (ADA).", "sequence": 3, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Procedure Modifier Code ", "mnemonic": "DENTCLAIM_PROC_MOD_CODE", "shortName": "Procedure Modifier Code ", "fieldName": "procedureModifierCode", "description": "Modifier(s) for the dental procedure represented on this line. Identifies special circumstances related to the performance of the service.", "sequence": 4, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Tooth Number - First Occurrence", "mnemonic": "DENTCLAIM_TOOTH_NO_1ST_OCC", "shortName": "Tooth No - First Occ", "fieldName": "toothNumberFirstOccurrence", "description": "Indicates the tooth notation i.e. the unique number or letter designated to the teeth, of the first occurrence. The values are based on the American Dental Association (ADA)'s Universal Numbering System/National Tooth Designation system for tooth numbers. (01 - 32 for permanent teeth; A – T for deciduous teeth). (01 - 32 for permanent teeth; A – T for deciduous teeth).", "sequence": 5, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Tooth Surface", "mnemonic": "DENTCLAIM_TOOTH_SURFACE", "shortName": "Tooth Surface", "fieldName": "toothSurface", "description": "Indicates the specific areas of the teeth. This is based on the ADA's Universal standard mandated under HIPAA 837D.", "sequence": 6, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Missing Tooth Number - First Occurrence", "mnemonic": "DENTCLAIM_MISSING_TOOTH_NO_1ST_OCC", "shortName": "Missing Tooth Number - First Occurrence", "fieldName": "missingToothNumberFirstOccurrence", "description": "Indicates the first occurrence of the missing tooth number. The values are based on the American Dental Association (ADA)'s Universal Numbering System/National Tooth Designation system for tooth numbers. (01 - 32 for permanent teeth; A – T for deciduous teeth). (01 - 32 for permanent teeth; A – T for deciduous teeth).", "sequence": 7, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Orthodontics Treatment Indicator", "mnemonic": "DENTCLAIM_ORTHO_IND", "shortName": "Orthodontics Treatment Indicator", "fieldName": "orthodonticsTreatmentIndicator", "description": "Indicates if the treatment is for orthodontics", "sequence": 8, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Orthodontics Appliance Application Date", "mnemonic": "DENTCLAIM_ORTHO_APP_DATE", "shortName": "Orthodontics Appliance Application Date", "fieldName": "orthodonticsApplianceApplicationDate", "description": "Date that the orthodontic appliances were placed.", "sequence": 9, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Total Number of Months for Orthodontia", "mnemonic": "DENTCLAIM_TOTAL_MO_ORTHO", "shortName": "Total Number of Months for Orthodontia", "fieldName": "totalNumberOfMonthsForOrthodontia", "description": "Number of months the orthodontia will remain in place.", "sequence": 10, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Prosthesis Replacement Indicator", "mnemonic": "DENTCLAIM_PROSTH_REP_IND", "shortName": "Prosthesis Replacement Indicator", "fieldName": "prosthesisReplacementIndicator", "description": "Indicate whether the services billed are for an oral prosthesis such as bridges, dentures, etc.", "sequence": 11, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Date of Prior Prosthesis Placement", "mnemonic": "DENTCLAIM_PRIOR_PROSTH_DATE", "shortName": "Date of Prior Prosthesis Placement", "fieldName": "dateOfPriorProsthesisPlacement", "description": "Identify the date when the prior prosthesis was placed. ", "sequence": 12, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Tooth Number - After First Occurrence", "mnemonic": "DENTCLAIM_TOOTH_NO_AFTER_1ST_OCC", "shortName": "Tooth Number - After First Occurrence", "fieldName": "toothNumberAfterFirstOccurrence", "description": "Indicates the tooth notation i.e. the unique number or letter designated to the teeth, for those after the first occurrence. The values are based on the American Dental Association (ADA)'s Universal Numbering System/National Tooth Designation system for tooth numbers. (01 - 32 for permanent teeth; A – T for deciduous teeth). (01 - 32 for permanent teeth; A – T for deciduous teeth).", "sequence": 13, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Missing Tooth Number - After First Occurrence", "mnemonic": "DENTCLAIM_MISSING_TOOTH_NO_AFTER_1ST_OCC", "shortName": "Missing Tooth Number - After First Occurrence", "fieldName": "missingToothNumberAfterFirstOccurrence", "description": "Indicates the missing tooth number after the first occurrence. The values are based on the American Dental Association (ADA)'s Universal Numbering System/National Tooth Designation system for tooth numbers. (01 - 32 for permanent teeth; A – T for deciduous teeth). (01 - 32 for permanent teeth; A – T for deciduous teeth).", "sequence": 14, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } } ], "roles": [] }, { "name": "Provider", "mnemonic": "PROV", "description": null, "shortName": "Provider", "fieldName": "provider", "isInherited": false, "sequence": 9, "cardinality": { "name": "One to Many", "mnemonic": "ONE_TO_MANY" }, "attributes": [ { "name": "Provider data class", "mnemonic": "PROV", "shortName": "Provider", "fieldName": "provider", "description": null, "sequence": 1, "autoGenerated": true, "isInherited": false, "attributeType": { "name": "Data Class", "mnemonic": "CLS" } }, { "name": "Provider element", "mnemonic": "PROV_ELEMENT", "shortName": "Provider", "fieldName": "providerElement", "description": null, "sequence": 2, "autoGenerated": true, "isInherited": false, "attributeType": { "name": "Element", "mnemonic": "ELM" } }, { "name": "Provider NPI", "mnemonic": "PROV_NPI", "shortName": "Provider NPI", "fieldName": "providerNpi", "description": "The National Provider Identifier assigned to the Provider.", "sequence": 3, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Provider Contracting Status", "mnemonic": "PROV_PROV_CONTRACT_STATUS", "shortName": "Provider Contracting Status", "fieldName": "providerContractingStatus", "description": "Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission.", "sequence": 4, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Site of Service Network Status", "mnemonic": "PROV_SITE_OF_SERV_NET_STATUS", "shortName": "Site of Service Network Status", "fieldName": "siteOfServiceNetworkStatus", "description": "Indicates the network status of the site of service.", "sequence": 5, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Care Team Role", "mnemonic": "PROV_CARE_TEAM_ROLE", "shortName": "Care Team Role", "fieldName": "careTeamRole", "description": "The functional role of a provider on a claim. ", "sequence": 6, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Provider Name", "mnemonic": "PROV_NAME", "shortName": "Provider Name", "fieldName": "providerName", "description": "The name of the Attending Physician for the admission", "sequence": 7, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Provider Address", "mnemonic": "PROV_ADDR", "shortName": "Provider Address", "fieldName": "providerAddress", "description": "The address of the facility where the service occurred.", "sequence": 8, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Simple Attribute", "mnemonic": "ATR" } }, { "name": "Provider Payer Specific Identifier", "mnemonic": "PROV_PAYER_SPEC_ID", "shortName": "Provider Payer Specific Identifier", "fieldName": "providerPayerSpecificIdentifier", "description": "Identifies the type of identifiers for practitioners", "sequence": 9, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } }, { "name": "Provider Type", "mnemonic": "PROV_TYPE", "shortName": "Provider Type", "fieldName": "providerType", "description": "Type of provider: Billing, Attending , Referring , Performing , Prescribing , Service Facility , PCP , Supervising , Operating ", "sequence": 10, "autoGenerated": false, "isInherited": false, "attributeType": { "name": "Codeable Concept", "mnemonic": "CC" } } ], "roles": [] } ] }