Loop | Loop Description | System-Related Information |
1000A | PER SUBMITTER EDI CONTACT INFORMATION 2 R | This information does not get submitted on the 5010. |
1000B | NM1 RECEIVER NAME 1 R |
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2000A | HL BILLING PROVIDER HIERARCHICAL LEVEL 1 R |
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2000A | PRV BILLING PROVIDER SPECIALTY INFORMATION 1 S |
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2000A | CUR FOREIGN CURRENCY INFORMATION 1 S |
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2010A | NM1 Billing Provider Name 1 R |
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2010AA | N3 BILLING PROVIDER ADDRESS 1 R |
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2010AA | N4 BILLING PROVIDER CITY/STATE/ZIP CODE 1 R |
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2010AA | REF BILLING PROVIDER TAX IDENTIFICATION 1 R |
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2010AA | REF BILLING PROVIDER UPIN/LICENSE INFORMATION 2 S |
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2010AA | PER BILLING PROVIDER CONTACT INFORMATION 2 S |
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2010AB | NM1 PAY-TO ADDRESS NAME 1 S |
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2010AB | N3 PAY-TO PROVIDER ADDRESS 1 R |
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2010AB | N4 PAY-TO PROVIDER CITY/STATE/ZIP CODE 1 R |
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2010AC | N3 PAY-TO PLAN ADDRESS 1 R |
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2010AC | N4 PAY-TO PLAN CITY/STATE/ZIP CODE 1 R |
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2010AC | REF PAY-TO PLAN SECONDARY IDENTIFICATION 1 S |
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2000B | HL SUBSCRIBER HIERARCHICAL LEVEL 1 R |
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2000B | SBR SUBSCRIBER INFORMATION 1 R |
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2000B | PAT PATIENT INFORMATION 1 S |
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2010BA | NM1 SUBSCRIBER NAME 1 R |
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2010BA | N3 SUBSCRIBER ADDRESS 1 S |
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2010BA | N4 SUBSCRIBER CITY/STATE/ZIP CODE 1 S |
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2010BA | DMG SUBSCRIBER DEMOGRAPHIC INFORMATION 1 S |
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2010BA | REF SUBSCRIBER SECONDARY IDENTIFICATION 1 S |
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2010BA | REF PROPERTY AND CASUALTY CLAIM NUMBER 1 S |
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2010BA | PER PROPERTY AND CASUALTY SUBSCRIBER CONTACT INFORMATION 1 S |
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2010BB | NM1 PAYER NAME 1 R |
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2010BB | N3 PAYER ADDRESS 1 S |
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2010BB | N4 PAYER CITY/STATE/ZIP CODE 1 R |
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2010BB | REF PAYER SECONDARY IDENTIFICATION 3 S |
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2000C | PAT PATIENT INFORMATION 1 R |
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2010CA | NM1 PATIENT NAME 1 R |
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2010CA | N3 Patient Address Line AN 1-55 R N301 |
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2010CA | N4 PATIENT CITY/STATE/ZIP CODE 1 R |
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2010CA | DMG PATIENT DEMOGRAPHIC INFORMATION 1 R |
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2010CA | REF PROPERTY AND CASUALTY CLAIM NUMBER 1 S |
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2010CA | PER PROPERTY AND CASUALTY PATIENT CONTACT INFORMATION S |
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2300 | CLM CLAIM INFORMATION 1 R |
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2300 | DTP DATE - ONSET OF CURRENT ILLNESS/SYMPTOM 1 S |
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2300 | DTP DATE - INITIAL TREATMENT 1 S |
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2300 | DTP DATE - DATE LAST SEEN 1 S |
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2300 | DTP DATE - ACUTE MANIFESTATION 1 S 2300 |
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2300 | DTP DATE - ACCIDENT 1 S 2300 |
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2300 | DTP DATE - LAST MENSTRUAL PERIOD 1 S |
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2300 | DTP DATE - LAST X-RAY 1 S |
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2300 | DTP DATE - HEARING AND VISION PRESCRIPTION DATE 1 S |
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2300 | DTP DATE - DISABILITY DATES 1 S |
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2300 | DTP DATE - LAST WORKED 1 S |
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2300 | DTP DATE - AUTHORIZED RETURN TO WORK 1 S |
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2300 | DTP DATE - ADMISSION 1 S |
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2300 | DTP DATE - DISCHARGE 1 S |
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2300 | DTP DATE - ASSUMED AND RELINQUISHED CARE DATES 2 S |
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2300 | DTP DATE - PROPERTY AND CASUALTY DATE OF FIRST CONTACT 1 S 2300 |
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2300 | DTP DATE - REPRICER RECEIVED DATE 1 S |
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2300 | PWK CLAIM SUPPLEMENTAL INFORMATION 10 S |
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2300 | CN1 CONTRACT INFORMATION 1 S |
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2300 | REF SERVICE AUTHORIZATION EXCEPTION CODE 1 S |
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2300 | REF MANDATORY MEDICARE (SECTION 4081) CROSSOVER NDICATOR 1 S |
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2300 | REF MAMMOGRAPHY CERTIFICATION NUMBER 1 S |
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2300 | REF REFERRAL NUMBER 1 S |
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2300 | REF REFERRAL NUMBER 1 S |
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2300 | REF PAYER CLAIM CONTROL NUMBER 1 S |
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2300 | REF CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) NUMBER 1 S |
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2300 | REF REPRICED CLAIM NUMBER 1 S |
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2300 | REF ADJUSTED REPRICED CLAIM NUMBER 1 S |
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2300 | REF INVESTIGATIONAL DEVICE EXEMPTION NUMBER 1 S |
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2300 | REF CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES 1 S |
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2300 | REF MEDICAL RECORD NUMBER 1 S |
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2300 | REF DEMONSTRATION PROJECT IDENTIFIER 1 S |
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2300 | REF CARE PLAN OVERSIGHT 1 S |
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2300 | K3 FILE INFORMATION 10 S |
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2300 | NTE CLAIM NOTE 1 S 2300 |
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2300 | CR1 AMBULANCE TRANSPORT INFORMATION 1 S |
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2300 | CR2 SPINAL MANIPULATION SERVICE INFORMATION 1 S |
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2300 | CRC AMBULANCE CERTIFICATION 3 S |
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2300 | CRC PATIENT CONDITION INFORMATION: VISION 3 S |
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2300 | CRC HOMEBOUND INDICATOR 1 S |
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2300 | CRC EPSDT REFERRAL 1 S |
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2300 | HI HEALTH CARE DIAGNOSIS CODE 1 R |
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2300 | HI ANESTHESIA RELATED PROCEDURE 1 S |
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2300 | HI CONDITION INFORMATION 2 S |
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2300 | HCP CLAIM PRICING/REPRICING INFORMATION 1 S |
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2310A | REF REFERRING PROVIDER SECONDARY IDENTIFICATION 3 S |
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2310B | NM1 RENDERING PROVIDER NAME 1 S |
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2310B | PRV RENDERING PROVIDER SPECIALTY INFORMATION 1 S |
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2310B | REF RENDERING PROVIDER SECONDARY IDENTIFICATION 4 S |
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2310C | NM1 SERVICE FACILITY LOCATION 1 S |
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2310C | REF SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION 3 S |
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2310C | PER SERVICE FACILITY CONTACT INFORMATION 1 R |
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2310D | NM1 SUPERVISING PROVIDER NAME 1 S |
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2310D | REF SUPERVISING PROVIDER SECONDARY IDENTIFIER 4 S |
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2310E | NM1 AMBULANCE PICK UP LOCATION 1 S |
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2310E | N3 AMBULANCE PICK UP LOCATION ADDRESS 1 R |
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2310E | N4 AMBULANCE PICK UP LOCATION CITY/STATE/ZIP 1 R |
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2310F | NM1 AMBULANCE DROP OFF LOCATION 1 |
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2310F | N3 AMBULANCE DROP OFF LOCATION ADDRESS 1 R |
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2310F | N4 AMBULANCE DROP OFF LOCATION CITY/STATE/ZIP 1 R |
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2320 | SBR OTHER SUBSCRIBER INFORMATION 1 S |
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2320 | CAS CLAIM LEVEL ADJUSTMENTS 5 S |
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2320 | AMT COB PAYER PAID AMOUNT 1 S |
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2320 | AMT COB TOTAL NONCOVERED AMOUNT 1 S |
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2320 | AMT REMAINING PATIENT LIABILITY 1 S |
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2320 | OI OTHER INSURANCE COVERAGE INFORMATION 1 R |
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2320 | MOA MEDICARE OUTPATIENT ADJUDICATION INFORMATION 1 S |
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2330A | NM1 OTHER SUBSCRIBER NAME |
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2330A | N3 OTHER SUBSCRIBER ADDRESS 1 S |
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2330A | N4 OTHER SUBSCRIBER CITY/STATE/ZIP CODE 1 R |
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2330A | REF OTHER SUBSCRIBER SECONDARY IDENTIFICATION 1 S |
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2330B | NM1 OTHER PAYER NAME 1 R |
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2330B | N3 OTHER PAYER ADDRESS 1 S |
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2330B | N4 OTHER PAYER CITY/STATE/ZIP CODE 1 R |
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2330B | DTP DATE - CLAIM CHECK OR REMITTANCE DATE 1 S |
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2330B | REF OTHER PAYER SECONDARY IDENTIFICATION 2 S |
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2330B | REF OTHER PAYER PRIOR AUTHORIZATION NUMBER 1 S |
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2330B | REF OTHER PAYER REFERRAL NUMBER 1 S |
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2330B | REF OTHER PAYER CLAIM ADJUSTMENT INDICATOR 1 S |
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2330B | REF OTHER PAYER CLAIM CONTROL NUMBER 1 S |
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2330C | NM1 OTHER PAYER REFERRING PROVIDER 1 S |
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2330C | REF OTHER PAYER REFERRING PROVIDER SECONDARY IDENTIFIER 3 R |
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2330D | NM1OT HER PAYERRENDERING PROVIDER 1 S |
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2330D | EF OTHER PAYER RENDERING PROVIDER SECONDARY IDENTIFIER 3 R |
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2330E | NM1 OTHER PAYER SERVICE FACILITY LOCATION 1 S |
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2330E | REF OTHER PAYER SERVICE FACILITY LOCATION SECONDARY IDENTIFIER 3 R |
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2330F | NM1 OTHER PAYER SUPERVISING PROVIDER 1 S |
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2330F | REF OTHER PAYER SUPERVISING PROVIDER SECONDARY IDENTIFICATION 3 R |
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2330G | NM1 OTHER PAYER BILLING PROVIDER 1 S |
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2330G | EF OTHER PAYER BILLING PROVIDER SECONDARY IDENTIFICATION 2 R |
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2400 | LX SERVICE LINE 1 R |
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2400 | SV1 PROFESSIONAL SERVICE 1 R |
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2400 | SV5 DURABLE MEDICAL EQUIPMENT SERVICE 1 S |
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2400 | PWK LINE SUPPLEMENTAL INFORMATION 10 S |
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2400 | PWK DURABLE MEDICAL EQUIPMENT CERTIFICATE OF MEDICAL NECESSITY INDICATOR 1 S |
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2400 | CR1 AMBULANCE TRANSPORT INFORMATION 1 S |
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2400 | CRC AMBULANCE CERTIFICATION 3 S |
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2400 | CRC HOSPICE EMPLOYEE INDICATOR 1 S |
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2400 | CRC CONDITION INDICATOR DURABLE MEDICAL EQUIPMENT 1 S |
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2400 | DTP DATE - SERVICE DATE 1 R |
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2400 | DTP DATE - PRESCRIPTION DATE 1 S |
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2400 | DTP DATE - CERTIFICATION REVISION/RECERTIFICATION DATE 1 S |
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2400 | DTP DATE - BEGIN THERAPY DATE 1 S |
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2400 | DTP DATE - LAST CERTIFICATION DATE 1 S |
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2400 | DTP DATE - DATE LAST SEEN 1 S |
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2400 | DTP DATE - TEST 2 S |
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2400 | DTP DATE - SHIPPED 1 S |
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2400 | DTP DATE - LAST X-RAY 1 S |
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2400 | DTP DATE - INITIAL TREATMENT 1 S |
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2400 | QTY AMBULANCE PATIENT COUNT 1 S |
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2400 | QTY OBSTETRIC ANESTHESIA ADDITIONAL UNITS 1 S |
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2400 | MEA TEST RESULTS 5 S |
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2400 | CN1 CONTRACT INFORMATION 1 S |
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2400 | REF REPRICED LINE ITEM REFERENCE NUMBER 1 S |
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2400 | REF ADJUSTED REPRICED LINE ITEM REFERENCE NUMBER 1 S |
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2400 | REF PRIOR AUTHORIZATION 5 S |
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2400 | REF LINE ITEM CONTROL NUMBER 1 S |
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2400 | REF MAMMOGRAPHY CERTIFICATION NUMBER 1 S |
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2400 | REF CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) IDENTIFICATION 1 S |
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2400 | REF REFERRING CLINICAL LABORATORY IMPROVEMENT IMENDMENT (CLIA) FACILITY IDENTIFICATION 1 S |
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2400 | REF IMMUNIZATION BATCH NUMBER 1 S |
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2400 | REF REFERRAL NUMBER 5 S |
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2400 | AMT SALES TAX AMOUNT 1 S |
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2400 | AMT POSTAGE CLAIMED AMOUNT 1 S |
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2400 | K3 FILE INFORMATION 10 S |
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2400 | NTE LINE NOTE 1 S |
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2400 | NTE THIRD PARTY ORGANIZATION NOTE 1 S |
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2400 | PS1 PURCHASED SERVICE INFORMATION 1 S |
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2400 | HCP LINE PRICING/REPRICING INFORMATION 1 S |
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2410 | LIN DRUG IDENTIFICATION 1 S |
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2410 | CTP DRUG PRICING 1 R |
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2410 | REF PRESCRIPTION OR COMPOUND DRUG ASSOCIATION NUMBER 1 S |
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2420A | NM1 RENDERING PROVIDER NAME 1 S |
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2420A | PRV RENDERING PROVIDER SPECIALTY INFORMATION 1 S |
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2420A | REF RENDERING PROVIDER SECONDARY IDENTIFICATION 20 S |
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2420B | NM1 PURCHASED SERVICE PROVIDER NAME 1 S | On the CPT code in CPT Library if you check "Outside Lab" you'll be able to enter a purchased service amount and specify the lab. If that amount is greater than 0.00 we will put the Billing Providers NPI in the 2420B loop |
2420B | REF PURCHASED SERVICE PROVIDER SECONDARY IDENTIFICATION 20 S |
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2420C | NM1 SERVICE FACILITY LOCATION NAME 1 S |
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2420C | N3 SERVICE FACILITY LOCATION ADDRESS 1 R |
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2420C | N4 SERVICE FACILITY LOCATION CITY/STATE/ZIP 1 R |
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2420C | REF SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION 3 S |
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2420D | NM1 SUPERVISING PROVIDER NAME 1 S |
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2420D | REF SUPERVISING PROVIDER SECONDARY IDENTIFICATION 20 S |
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2420E | NM1 ORDERING PROVIDER NAME 1 S |
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2420E | N3 ORDERING PROVIDER ADDRESS 1 S |
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2420E | N4 ORDERING PROVIDER CITY/STATE/ZIP CODE 1 R |
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2420E | REF ORDERING PROVIDER SECONDARY IDENTIFICATION 20 S |
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2420E | PER ORDERING PROVIDER CONTACT INFORMATION 1 S |
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2420F | NM1 REFERRING PROVIDER NAME 1 S |
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2420F | REF REFERRING PROVIDER SECONDARY IDENTIFICATION 20 S |
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2420G | NM1 AMBULANCE PICK UP LOCATION 1 S |
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2420G | N3 AMBULANCE PICK UP LOCATION ADDRESS 1 R |
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2420G | N3 AMBULANCE PICK UP LOCATION ADDRESS 1 R |
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2420G | N4 AMBULANCE PICK UP LOCATION CITY/STATE/ZIP 1 R |
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2420H | NM1 AMBULANCE DROP OFF LOCATION 1 S |
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2420H | N3 AMBULANCE DROP OFF LOCATION ADDRESS 1 R |
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2420H | N4/ AMBULANCE DROP OFF LOCATION CITY/STATE/ZIP 1 R |
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2430 | SVD LINE ADJUDICATION INFORMATION 1 S |
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2430 | CAS LINE ADJUSTMENT 5 S |
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2430 | DTP LINE CHECK OR REMITTANCE DATE 1 R |
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2430 | AMT REMAINING PATIENT LIABILITY 1 S |
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2440 | LQ FORM IDENTIFICATION CODE 1 S |
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2440 | FRM SUPPORTING DOCUMENTATION 99 S |
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2440 | FRM SUPPORTING DOCUMENTATION 99 S |
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| SE TRANSACTION SET TRAILER 1 R |
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| GE FUNCTION GROUP TRAILER 1 R |
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| IEA INTERCHANGE CONTROL TRAILER 1 R |
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