DATA_ELEMENT_FILE DATA_ELEMENT_NAME DATA_ELEMENT_DESCRIPTIONP_SPECL_T AUD_TM USER UPDATE TIME STAMPP_SPECL_T AUD_USER_ID USER UPDATE IDP_SPECL_T DW_BEG_DT DW BEGIN DATEP_SPECL_T LAST_UPDATE_DT RECORD UPDATE DATEP_SPECL_T LIC_BRD_NUM LICENSE BOARD NUMBERP_SPECL_T LIC_CERT_NUM LICENSE CERTIFICATION NUMBERP_SPECL_T PROV_SYS_ID PROVIDER IDP_SPECL_T SPECL_BEG_DT SPECIALITY BEGIN DATEP_SPECL_T SPECL_CD SPECIALITY CODEP_SPECL_T SPECL_END_DT SPECIALITY END DATEP_SPECL_T ST_CD STATE CODE

Data Extract is an automated monthy extract of Provider and Claims information submitted via Secure FTP as

s Pipe (|) delimited text file(s)

DATA_ELEMENT_FILE DATA_ELEMENT_NAME DATA_ELEMENT_DESCRIPTIONP_ADDR_TAX_DSS_T ADDR1 ADDRESS 1P_ADDR_TAX_DSS_T ADDR2 ADDRESS 2P_ADDR_TAX_DSS_T ADDR_TY_CD ADDRESS TYPE CODEP_ADDR_TAX_DSS_T CITY_NAM CITYP_ADDR_TAX_DSS_T CNTY_CD COUNTY CODEP_ADDR_TAX_DSS_T CONTCT_EMAIL_ADDR CONTACT EMAIL ADDRESSP_ADDR_TAX_DSS_T CONTCT_FAX_NUM CONTACT FAX NUMBERP_ADDR_TAX_DSS_T CONTCT_NAM CONTACT NAMEP_ADDR_TAX_DSS_T CONTCT_PHON_NUM CONTACT PHONE NUMVERP_ADDR_TAX_DSS_T DW_BEG_DT LOAD DATEP_ADDR_TAX_DSS_T FAX_NUM FAX NUMBERP_ADDR_TAX_DSS_T FED_ID_IND FEDERAL ID INDICATORP_ADDR_TAX_DSS_T FED_TAX_ID FEDERAL TAX IDP_ADDR_TAX_DSS_T FST_NAM PROVIDER FIRST NAMEP_ADDR_TAX_DSS_T LAST_NAM PROVIDER LAST NAMEP_ADDR_TAX_DSS_T LAST_UPDATE_DT RECORD UPDATE DATEP_ADDR_TAX_DSS_T MI_NAM PROVIDER MIDDLE INITIALP_ADDR_TAX_DSS_T NAM_ORG_IND PROVIDER ORGANIZATIONAL INDICATORP_ADDR_TAX_DSS_T PHON_NUM PHONE NUMBERP_ADDR_TAX_DSS_T PROV_NAM PROVIDER NAMEP_ADDR_TAX_DSS_T PROV_SYS_ID PROVIDER SYSTEM IDP_ADDR_TAX_DSS_T SFX_NAM PROVIDER NAME SUFFIXP_ADDR_TAX_DSS_T SSN_NUM SOCIAL SECURITY NUMBERP_ADDR_TAX_DSS_T ST_CD STATE CODEP_ADDR_TAX_DSS_T TAX_BEG_DT TAX ID BEGIN DATEP_ADDR_TAX_DSS_T TAX_END_DT TAX ID END DATEP_ADDR_TAX_DSS_T TAX_KEY_ID TAX IDP_ADDR_TAX_DSS_T ZIP4_CD ZIP CODE - 4P_ADDR_TAX_DSS_T ZIP5_CD ZIP CODE - 5

DATA_ELEMENT_FILE DATA_ELEMENT_NAMEP_PROV_T ADD_DTP_PROV_T APPL_COMPLETE_DTP_PROV_T APPL_DTP_PROV_T APPL_NUMP_PROV_T APPL_STAT_CDP_PROV_T ATYP_INDP_PROV_T AUD_TMP_PROV_T AUD_USER_IDP_PROV_T BKUP_WHOLD_INDP_PROV_T BLLTN_COPY_NUMP_PROV_T BLLTN_MEDM_CDP_PROV_T BLNG_CDP_PROV_T CANCEL_APPL_INDP_PROV_T COST_STTLMT_DTP_PROV_T DBA_FST_NAMP_PROV_T DBA_LAST_NAMP_PROV_T DBA_MI_NAMP_PROV_T DBA_NAMP_PROV_T DBA_ORG_INDP_PROV_T DBA_SFX_NAMP_PROV_T DEA_NUMP_PROV_T DEFER_COMP_INDP_PROV_T DUPL_OVRRD_INDP_PROV_T DW_BEG_DTP_PROV_T EMC_PSWD_DATP_PROV_T ENROLL_ACTION_CDP_PROV_T EPSDT_INFO_INDP_PROV_T EPSDT_ONLY_INDP_PROV_T FACI_BEG_DTP_PROV_T FACI_END_DTP_PROV_T FACI_FY_MO_NUMP_PROV_T FACI_TY_CDP_PROV_T FED_VAC_CHLD_INDP_PROV_T FST_NAMP_PROV_T GROSS_TAX_NUMP_PROV_T HOUR_OPER_TXP_PROV_T IHS_INDP_PROV_T INDIV_GRP_CDP_PROV_T LAST_NAMP_PROV_T LAST_UPDATE_DTP_PROV_T LOCN_CDP_PROV_T MCAID_FY_MO_NUMP_PROV_T MCARE_FY_MO_NUMP_PROV_T MCARE_INDP_PROV_T MI_NAMP_PROV_T MULTI_LOCN_IND

P_PROV_T NABP_NUMP_PROV_T NAM_ORG_INDP_PROV_T NF_CLS_CDP_PROV_T NPI_NUMP_PROV_T NTRPRS_IDP_PROV_T ORIG_PROV_IDP_PROV_T OWNER_TY_CDP_PROV_T PHRM_CLS_CDP_PROV_T PRACT_TY_CDP_PROV_T PROFIT_INDP_PROV_T PROF_TECH_INDP_PROV_T PROV_IDP_PROV_T PROV_NAMP_PROV_T PROV_SYS_IDP_PROV_T RA_MEDM_CDP_PROV_T RA_PRT_SUSP_CDP_PROV_T RA_SORT_SEQ_CDP_PROV_T REC_TY_CDP_PROV_T REVER_DTP_PROV_T REVER_RECD_DTP_PROV_T REVER_RECD_INDP_PROV_T SFX_NAMP_PROV_T SOLE_COMM_INDP_PROV_T SORT_NAMP_PROV_T SSN_NUMP_PROV_T STATE_MATCH_INDP_PROV_T SVC_LOC_CDP_PROV_T TAX_DISCT_INDP_PROV_T TPL_AUDIT_DTP_PROV_T TPL_AUDIT_TY_CDP_PROV_T UPIN_NUMP_PROV_T VFC_INFO_INDP_PROV_T W9_SIGNED_DTP_PROV_T WEB_PART_IND

DATA_ELEMENT_DESCRIPTIONRECORD ADD DATEAPPLICATION COMPLETE DATEAPPLICATION DATEAPPLICATION NUMBERAPPLICATION STATUS CODEAFFLICATION TYPE INDICATORUSER TIME STAMPUSER IDPROVIDERS CURRENT W9 OR TAX WITHHOLDING STATUSBULLETIN COPY NUMVERBULLETIN MEDIA CODEBILLING CODECANCEL APPLICATION INDICATORCOST SETTLEMENT DATEDBA FIRST NAMEDBA LAST NAMEDBA MIDDLE INITIALDBA NAMEDBA ORGANIZATION INDICATORDBA SUFFIX NAMEDEA NUMBERDEFERRED COMPENSATION INDICATORDUPLICATE OVERRIDE INDICATORLOAD BEGIN DATEPROVIDERS EMC PASSWORDENROLLMENT ACTION CODEEPSDT INFORMATION INDICATOREPSDT ONLY INDICATORFACILITY BEGIN DATEFACILITY END DATEFACILITY FISCAL YR/MOFACILITY TYPE CODEFEDERAL VACCINE CHILD INDICATORFIRST NAMEGROSS TAX NUMBERHOURS OF OPERATIONINDIAN HEALTH SERVICE INDICATORGROUP CODELAST NAMERECORD LAST UPDATE DATELOCATION CODEMEDICAID PROVIDER FISCAL YR/MO NUMBERERAL YEAR MON NUMPROVIDER MCARE FISCAL YR/MO NUMBERMEDICARE INDICATORMIDDLE INITIALMULTIPLE LOCATION INDICATOR

NATIONAL ASSOCIATION OF BOARDS OF PHARMACY NUMBERORGANIZATION INDICATORNURSING FACILITY CLASSIFICATION CODENPI NUMBERPROVIDER ENTERPRISE IDORIGINAL PROVIDER IDOWNERSHIP TYPE CODEPHARMACY CLASSIFICATION CODEPRACTICE TYPE CODEPROFIT INDICATORPROFESSIONAL TECHNICAL INDICATORPROVIDER IDPROVIDER NAMEPROVIDER SYSTEM IDRA MEDIA CODERA SUSPENSION CODERA SORT SEQUENCE CODERECORD TYPE CODEREVERIFY DATEREVERIFY RECORD DATEREVERIFY RECORD INDICATORSUFFIX NAMECOMMUNITY INDICATORPROVIDER SORT NAMESOCIAL SECURITY NUMBERSTATE MATCH INDICATORSERVICE LOCATION CODETAX DISCOUNT INDICATORTPL AUDIT DATETPL AUDIT TYPE CODEUPIN NUMBERVFC INFORMATION INDICATORW9 SIGNED DATEWEB INDICATOR

DATA_ELEMENT_FILE DATA_ELEMENT_NAMEP_ENROL_STAT_T AUD_TSP_ENROL_STAT_T AUD_USER_IDP_ENROL_STAT_T BRND_DISCT_PCTP_ENROL_STAT_T DISP_FEE_AMTP_ENROL_STAT_T DW_BEG_DTP_ENROL_STAT_T ENROL_STAT_TY_CDP_ENROL_STAT_T GENR_DISCT_PCTP_ENROL_STAT_T LAST_UPDATE_DTP_ENROL_STAT_T PROV_SYS_IDP_ENROL_STAT_T PROV_TY_CDP_ENROL_STAT_T STAT_EFF_DTP_ENROL_STAT_T STAT_END_DT

DATA_ELEMENT_DESCRIPTIONUSER UPDATE TIME STAMPUSER IDBRAND DISCOUNT PERCENTDISPENSING FEELOAD DATEPROVIDER ENROLLMENT STATUS CODEGENERIC DISCOUNT PERCENTRECORD UPDATE DATEPROVIDER SYSTEM IDPROVIDER TYPE CODEPROVIDER BEGIN DATEPROVIDER END DATE

DATA_ELEMENT_FILE DATA_ELEMENT_NAME DATA_ELEMENT_DESCRIPTIONP_LIC_CERT_T AUD_DT USER UPDATE IDP_LIC_CERT_T AUD_TM USER UPDATE TIME STAMPP_LIC_CERT_T AUD_USER_ID USER IDP_LIC_CERT_T DW_BEG_DT DW BEGIN DATEP_LIC_CERT_T LIC_BRD_NUM LICENSE BOARD NUMBERP_LIC_CERT_T LIC_CERT_CD LICENSE CERTIFICATION CODEP_LIC_CERT_T LIC_CERT_NUM LICENSE CERTIFICATION NUMBERP_LIC_CERT_T LIC_EFF_DT LICENSE BEGIN DATEP_LIC_CERT_T LIC_EXPIR_DT LICENSE EXPIRATION DATEP_LIC_CERT_T LIC_PERMIT_ID LICENSE PERMIT IDP_LIC_CERT_T LIC_RSTRCT_CD LICENSE RESTRICTION CODEP_LIC_CERT_T LIC_VRFY_IND LICENSE VERIFICATION INDICATORP_LIC_CERT_T PROV_SYS_ID PROVIDER SYSTEM IDP_LIC_CERT_T ST_CD STATE CODE

DATA_ELEMENT_FILE DATA_ELEMENT_NAME DATA_ELEMENT_DESCRIPTIONP_NUM_BED_T AUD_DT USER UPDATE IDP_NUM_BED_T AUD_TM USER UPDATE TIME STAMPP_NUM_BED_T AUD_USER_ID USER IDP_NUM_BED_T DUAL_BED_NUM DUAL BED NUMBERP_NUM_BED_T DW_BEG_DT DW BEGIN DATEP_NUM_BED_T FACI_ADMIN_NAM FACILITY ADMINSTRATOR NAMEP_NUM_BED_T IP_BED_NUM INPATIENT BED NUMBERP_NUM_BED_T MCAID_BED_NUM MEDICAID BED NUMBERP_NUM_BED_T MO_OF_CERT_NUM PROVIDER MONTHS OF CERTIFICATIONP_NUM_BED_T PROV_SYS_ID PROVIDER SYSTEM IDP_NUM_BED_T PTRF_BED_NUM PTRF BED NUMBER

DATA_ELEMENT_FILE DATA_ELEMENT_NAMEHEADER ADDR1 HEADER ADDR2 HEADER ADJUST_STAT_CD HEADER ADMIN_CNTY_CD HEADER ADMIT_DT HEADER ATNDG_PROV_ID HEADER ATNDG_PROV_TY_CD HEADER BAT_DOC_TY_CD HEADER BAT_JLN_DT_NUM HEADER BAT_MED_SRC_CD HEADER BAT_NUM HEADER BAT_PYMT_TY_CD HEADER BAT_TY_CD HEADER BEN_ALT_ID HEADER BEN_CURR_ID HEADER BEN_SYS_ID HEADER BILLED_DT HEADER BLNG_NPI_NUM HEADER BLNG_PROV_ID HEADER BLNG_PROV_TY_CD HEADER BLNG_QLFR_CD HEADER BLNG_QLFR_DAT HEADER BLNG_SPECL_CD HEADER BLNG_TAXON_CD HEADER CALC_TOT_AMT HEADER CITY_NAM HEADER CLM_FREQ_CD HEADER CNTL_ORGN_CD HEADER COE_CD HEADER COE_SPN_BEG_DT HEADER COE_SPN_END_DT HEADER COPAY_EXCLSN_CD HEADER COST_AVOID_IND HEADER COS_CD HEADER CREDIT_CD HEADER CR_BAL_AMT HEADER CVRD_DAYS_NUM HEADER CYCL_NUM HEADER DELAY_RSN_CD HEADER DISCH_DT HEADER DOB_DT HEADER EDI_TRACK_NUM HEADER ERR_MSG_DAT HEADER ERR_PARAM_CD HEADER ERR_PROG_ID HEADER EXC_CD1

HEADER EXC_CD1 HEADER EXC_CD10 HEADER EXC_CD10 HEADER EXC_CD2 HEADER EXC_CD2 HEADER EXC_CD3 HEADER EXC_CD3 HEADER EXC_CD4 HEADER EXC_CD4 HEADER EXC_CD5 HEADER EXC_CD5 HEADER EXC_CD6 HEADER EXC_CD6 HEADER EXC_CD7 HEADER EXC_CD7 HEADER EXC_CD8 HEADER EXC_CD8 HEADER EXC_CD9 HEADER EXC_CD9 HEADER EXC_LOCN_CDHEADER EXC_LOCN_DT HEADER EXC_LOCN_ID HEADER FCN_NUM HEADER FED_CAT_CD HEADER FED_MTCH_CD HEADER FED_TAX_ID HEADER FIN_PYE_PYR_CD HEADER FIN_RSN_CD HEADER FST_NAM HEADER FST_NAM HEADER GENDER_CD HEADER GEO_CNTY_CD HEADER GEO_RGN_CD HEADER HDR_ADJUD_DT HEADER HDR_ADJ_RSN_CD HEADER HDR_ALLOW_AMT HEADER HDR_BATCH_DT HEADER HDR_CHK_NUM HEADER HDR_CLNT_AGE HEADER HDR_DOC_NUM HEADER HDR_EMC_CD HEADER HDR_ENTRD_DT HEADER HDR_HX_DT HEADER HDR_ID_CD HEADER HDR_ITERM_ADJ_DT HEADER HDR_LST_CYCL_DT HEADER HDR_ORIG_PD_DT

HEADER HDR_PAT_ACCT_NUM HEADER HDR_PD_DTHEADER HDR_RA_NUM HEADER HDR_STAT_CD HEADER HDR_SUBMITTER_ID HEADER HDR_SUSP_DT HEADER HDR_SVC_FST_DTHEADER HDR_SVC_LST_DTHEADER HDR_TXN_TY_CD HEADER HDR_TY_CDHEADER ILL_SVRTY_NUM HEADER INDIV_REL_CD HEADER INST_TY_CD HEADER LAST_NAM HEADER LAST_NAM HEADER LCKN_PROV_ID HEADER LCKN_TY_CD HEADER LOS_DISCH_ADMIT HEADER LOS_DISCH_SURG HEADER LOS_FST_DOS_ADMIT HEADER LOS_LST_DOS_ADMIT HEADER LOS_LST_DOS_FST_DOS HEADER LOS_SURG_ADMIT HEADER MAJ_PROG_CD HEADER MCARE_ALLOW_AMT HEADER MCARE_T_ALLW_AMT HEADER MCO_TCN_DAT HEADER MC_ENCTR_PD_AMT HEADER MC_PROV_ID HEADER MED_REC_NUM HEADER MI_NAM HEADER MI_NAM HEADER MONEY_CD HEADER OCN_TCN_NUM HEADER ORIG_MED_SRC_CD HEADER OTHR_INSR_IND HEADER OVRRD_EXC_LOC_CD HEADER PAT_PD_AMT HEADER PAT_RESP_AMT HEADER PAT_STAT_CD HEADER PA_ID HEADER PA_TY_CD HEADER PHON_NUM HEADER PLN_BEG_DT HEADER PLN_NUM HEADER PLN_TY_CD HEADER POS_B_SYS_ID

HEADER PREV_REIMB_AMT HEADER PREV_REIMB_CD HEADER PRIN_DIAG_CD HEADER PRIN_POA_IND HEADER PRIN_POA_IND HEADER PRIOR_AUTH_IND HEADER PROFIT_IND HEADER PROF_TECH_IND HEADER PROV_LOCN_CD HEADER PYTO_NPI_NUM HEADER PYTO_PROV_ID HEADER PYTO_PROV_NAM HEADER PYTO_QLFR_CD HEADER PYTO_QLFR_DAT HEADER RACE_CD HEADER RECD_DT HEADER REF_NPI_NUM HEADER REF_NUM HEADER REF_PROV_ID HEADER REF_QLFR_CD HEADER REF_QLFR_DAT HEADER REIMB_STAT_CD HEADER REPLCD_TCN_NUM HEADER SL_CUTBACK_AMTHEADER SORT_NAM HEADER SPECL_PROG_CD HEADER SSN_NUM HEADER ST_CD HEADER SUBM_CLNT_DOB_DT HEADER SUBM_CLNT_DOD_DT HEADER SUBM_COPAY_EX_CD HEADER SUB_CAP_CD HEADER SUSP_BAL_AMT HEADER SUSP_LOCN_EXC_CD HEADER TCN_NUMHEADER TCN_TY_CD HEADER TOT_ASSESS_AMT HEADER TOT_CHRG_AMT HEADER TOT_COPAY_AMT HEADER TOT_NET_CHRG_AMT HEADER TOT_PAT_LIAB_AMT HEADER TOT_REIMB_AMT HEADER TOT_TPL_AMT HEADER TPL_MSQ_TY_CD HEADER TY_OF_BILL_3_CD HEADER TY_OF_BLL_1_2_CD HEADER XOVER_TY_CD

HEADER XOVER_TY_CD HEADER ZIP5_CD

DATA_ELEMENT_DESCRIPTIONADDRESS 1ADDRESS 2ADJUSTMENT STAT CODEADMIT COUNTY CODEADMIT DATEATTENDING PROVIDER IDATTENDING PROVIDER TYPE CODEBATCH DOC TYPE CODEBATCH JULIAN DATE NUMBERBATCH MEDIA SOURCE CODEBATCH NUMBERBATCH PAYMENT TYPE CODEBATCH TYPE CODEBENEFICIARY ALT IDBENEFICIARY CURRENT IDPARTICIPANT SYSTEM IDBILLED DATEBILLING NPI BILLING PROVIDER IDBILLING PROVIDER TYPE CODEBILLING QUALIFIER CODEBILLING QUALIFIER DATEBILLING SPECIALTY CODEBILLING TAXONOMY CODETOTAL CALCULATED AMOUNTCITYCLAIM FREQUENCY CODECONTROL ORIGINAL CODECATEGORY OF ELIGIBILITY CODECATEGORY OF ELIGIBILITY SPAN BEGIN DATECATEGORY OF ELIGIBILITY SPAN END DATECOPAY EXCLUSION CODECOST AVOID INDICATORCATEGORY OF SERVICE CODECREDIT CODECREDIT BALANCE AMOUNTNUMBER OF COVERED DAYSCYCLE NUMBERDELAY REASON CODEDISCHARGE DATEDATE OF BIRTHEDI TRACK NUMBERERROR MESSAGE DATEERR PARAMETER CODEERR PROGRAM IDEXCEPTION CODE

EXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION LOCKIN CODEEXCEPTION LOCKIN DATEEXCEPTION LOCKIN IDFINANTIAL CONTROL NUMBERFEDERAL CATEGORY CODEFEDERAL MATCH CODEFEDERAL TAX IDFINANTIAL PAYEE PAYER CODEFINANCIAL REASON CODEFIRST NAMEFIRST NAMEGENDER CODEGEOGRAPHIC COUNTY CODEGEOGRAPHIC REGION CODEHEADER ADJUSTMENT DATEHEADER ADJUSTMENT REASON CODEHEADER ALLOWED AMOUNTHEADER BATCH DATEHEADER CHECK NUMBERHEADER CLIENT AGEHEADER DOCUMENT NUMBEREMC CODEHEADER ENTERED DATEHEADER HX DATEHEADER ID CODEHEADER INTERIM ADJUSTMENT DATEHEADER LAST CYCLE DATEHEADER ORIGINAL PAID DATE

PATIENT ACCOUNT NUMBERPAID DATEHEADER REMITTANCE ADVICE NUMBERHEADER STAT CODEHEADER SUBMITTER IDHEADER SUSPENDED DATEHEADER FIRST SERVICE DATEHEADER LAST SERVICE DATEHEADER TAXONOMY TYPE CODEHEADER TYPE CODEILLNESS SEVERITY NUMBERINDIVIDUAL RELATIONSHIP CODEINSTITURION TYPE CODELAST NAMELAST NAMELOCKIN PROVIDER IDLOCKIN TYPE CODELOS DISCHARGE AMOUNTLOS DISCHARGE SURGICALLOS FIRST DATE OF SERVICE ADMISSIONLOS LAST DATE OF SERVICE ADMISSIONLOS LAST DATE OF SERVICE - LOS FIRST DATE OF SERVICE LOS SURGICAL ADMISSIONMAJOR PROGRAM CODEMEDICARE ALLOWED AMOUNTMEDICARE THIRD PARTY ALLLOWED AMOUNTMCO TCN DATEMANAGED CARE ENCOUNTER PAID AMOUNTMEDICARE PROVIDER IDMEDICAID RECORD NUMBERMIDDLE NAMEMIDDLE NAMEMONEY CODETCN-TRANSACTION CONTROL NUMBERORIGINAL MEDICAID SOURCE CODEOTHER INSURANCE INDICATOROVERRIDE EXCEPTION LOCKIN CODEPATIENT PAID AMOUNTPATIENT RESPONSIBLE AMOUNTPATIENT STAT CODEPRIOR AUTHORIZATION IDPRIOR AUTHORIZATION TYPE CODEPHONE NUMBERPLAN BEGIN DATEPLAN NUMBERPLAN TYPE CODEPOINT OF SALE PARTICIPANT SYSTEM ID

PREVIOUS REIMBURSEMENT AMOUNTPREVIOUS REIMBURSEMENT CODEPRINCIPLE DIAGNOSIS CODEPRINCIPLE POA INDICATORPRINCIPLE POA INDICATORPRIOR AUTHORIZATION INDICATORPROFIT INDICATORPROFESSIONAL TECH INDICATORPROVIDER LOCATION CODEPAY TO NPI NUMBERPAY TO PROVIDER IDPAY TO PROVIDER NAMEPAY TO QUALIFIER CODEPAY TO QUALIFIER DATERACE CODERECORD DATEREFERRING NPI NUMBERREFERENCE NUMBERREFERRING PROVIDER IDREFERRING QUALIFIER CODEREFERRING QUALIFIER DATEREIMBURSEMENT STAT CODETCN-TRANSACTION CONTROL NUMBERSERVICE LIMIT CUTBACK AMTSORT NAMESPECIAL PROGNOSIS CODESOCIAL SECURITY NUMBERSTATE CODESUBMITTED CLIENT DATE OF BIRTHSUBMITTED CLIENT DATE OF DEATHSUBMITTED COPAY EXCEPTION CODESUB CAP CODESUSPENDED BALANCE AMOUNTEXCEPTION CODETCN-TRANSACTION CONTROL NUMBERTCN TYPE CODETOTAL ASSESS AMOUNTTOTAL CHARGE AMOUNTTOTAL COPAY AMOUNTTOTAL NET CHARGE AMOUNTTOTAL PATIENT LIABILITY AMOUNTTOTAL REIMBURSEMENT AMOUNTTOTAL TPL AMOUNTTHIRD PARTY MSQ TYPE CODETYPE OF BILL CODE 3TYPE OF BILL CODE 1,CROSSOVER TYPE CODE

CROSSOVER TYPE CODEZIP CODE

DATA_ELEMENT_FILE DATA_ELEMENT_NAMELINE ALLOW_UNTS_IND LINE ASSESS_AMT LINE ATNDG_NPI_NUM LINE ATNDG_PROV_ID LINE ATNDG_QLFR_CD LINE ATNDG_QLFR_DAT LINE BEN_SYS_ID LINE BSE_AMT_SRC_CD LINE CHK_LI_NUM LINE CHK_RSLT_CD LINE CHK_STAT_CD LINE COHRT_NUM LINE COPAY_EXCLSN_CD LINE COST_AVOID_IND LINE COS_CD LINE EXC_CD1 LINE EXC_CD10 LINE EXC_CD2 LINE EXC_CD3 LINE EXC_CD4 LINE EXC_CD5 LINE EXC_CD6 LINE EXC_CD7 LINE EXC_CD8 LINE EXC_CD9 LINE FATAL_ERR_IND LINE HDR_PD_DTLINE LCKN_PROV_ID LINE LCKN_TY_CD LINE LI_ABORT_IND LINE LI_ALLOW_UNT_NUM LINE LI_ALLW_CHRG_AMT LINE LI_BSE_AMT LINE LI_CLC_ALLW_AMT LINE LI_CLIA_NUM LINE LI_CNTL_NUM LINE LI_COPAY_AMT LINE LI_DUPL_CHK_IND LINE LI_FAM_PLNG_IND LINE LI_FLLWP_LMT_DT LINE LI_FST_DOS_DT LINE LI_HYSTER_IND LINE LI_LAST_DOS_DT LINE LI_MCARE_COI_AMT LINE LI_MCARE_DED_AMT

LINE LI_MCARE_PD_AMT LINE LI_MCAR_ALLW_AMT LINE LI_NUMLINE LI_REIMB_AMT LINE LI_REIMB_UNT_NUM LINE LI_STERIL_IND LINE LI_SUBM_CHRG_AMT LINE LI_SUBM_UNT_NUM LINE LI_UB92_RATE_AMT LINE LVL_OF_CARE_CD LINE MC_ENCTR_PD_AMT LINE MULTI_SURG_IND LINE NN_CVRD_CHRG_AMT LINE PAT_LIAB_AMT LINE PAT_PD_AMT LINE PA_ID LINE PA_LI_NUM LINE PA_TY_CD LINE PHM_CD LINE PLN_RATE_BEG_DT LINE PL_OF_SVC_CD LINE POS_B_SYS_ID LINE PRCNG_PROCESS_CD LINE PRIOR_AUTH_IND LINE PROC_CD LINE PROC_MOD_1ST_CD LINE PROC_MOD_2ND_CD LINE PROC_MOD_3RD_CD LINE PROC_MOD_4TH_CD LINE PROC_QLFR_CD LINE REF_NPI_NUM LINE REF_NUM LINE REF_PROV_ID LINE REF_QLFR_CD LINE REF_QLFR_DAT LINE REIMB_STAT_CD LINE RETENTION_CD LINE REV_CDLINE REV_TY_CD LINE RLTD_DIAG_CD1 LINE RLTD_DIAG_CD2 LINE RLTD_DIAG_CD3 LINE RLTD_DIAG_CD4 LINE RNDR_NPI_NUM LINE RNDR_PROV_ID LINE RNDR_PROV_TY_CD LINE RNDR_QLFR_CD

LINE RNDR_SPECL_CD LINE RNDR_TAXON_CD LINE RX_BASIS_COST_CD LINE RX_BSE_AMT_SRC_CD LINE RX_CTBCK_CD LINE RX_CTBCK_RSN_CD LINE RX_DISCT_RATE_AMT LINE RX_DRG_THR_CHAR3_CD LINE RX_DRUG_CD LINE RX_DRUG_DEA_CD LINE RX_DRUG_GCN_SEQ_NUM LINE RX_DRUG_GEN_CD_NUM LINE RX_DRUG_GEN_PRD_CD LINE RX_DRUG_MAINT_IND LINE RX_DRUG_NAM LINE RX_DRUG_ROUTE_CD LINE RX_INGRED_DISCT_PCT LINE RX_LI_ING_ALLOW_AMT LINE RX_LI_PD_QTY_AMT LINE RX_PROD_SVC_ID LINE RX_PROD_SVC_ID_CD LINE RX_PRS_ALT_ID_TY_CD LINE RX_SPH_ALT_ID_TY_CD LINE RX_SUBM_ING_CST_AMT LINE RX_SUBM_ING_QTY_AMT LINE SL_CUTBACK_AMT LINE SVC_AREA_CD LINE SVC_AREA_CD LINE SVC_COMPONENT_CD LINE TCN_NUMLINE TOS_CD LINE TPL_AMT

DATA_ELEMENT_DESCRIPTIONALLOWED UNITS INDICATORASSESSMENT AMOUNTATTENDING NPI NUMBERATTENDING PROVIDER NUMBERATTENDING MEDICARE CODEATTENDING MEDICARE DATEPARTICIPANT SYSTEM IDBASE SOURCE AMOUNT CODECHECK LINE NUMBERCHECK RESULT CODECHECK STATUS CODECOHORT NUMBERCOPAY EXCLUSION CODECOST AVODIANCE INDICATORCATEGORY OF SERVICE CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEEXCEPTION CODEFATAL ERROR INDICATORPAID DATELOCKIN PROVIDER IDLOCKIN PROVIDER TYPE CODELINE ABORTIION INDICATORLINE ALLOWED UNITSLINE ALLOWED CHARGE AMOUNTLINE BASE AMOUNTLINE CALCULATED ALLOWED AMOUNTLINE CLIA NUMBERLINE CONTROL NUMBERLINE COPAY AMOUNTLINE DUPLICATE CHECK INDICATORLINE FAMILY PLANNING INDICATORLINE FLLWP LIMIT DATELINE FIRST DATE OF SERVICELINE HYSTERECTOMY INDICATORLINE LAST DATE OF SERVICELINE MEDICARE COINSURANCE AMOUNTLINE MEDICARE DEDUCTIBLE AMOUNT

LINE MEDICARE PAID AMOUNTLINE MEDICARE ALLOWED AMOUNTTCN LINE NUMBERLINE REIMBURSEMENT AMOUNTLINE REIMBURSEMENT UNITLINE STERILIZATION INDICATORLINE SUBMITTED CHARGE AMOUNTLINE SUBMITTED UNITSLINE UB92 RATELEVEL OF CARE CODEMANAGED CARE ENCOUNTER PAID AMOUNTMULTIPLE SURGERIES INDICATORNON-COVERED CHARGE AMOUNTPATIENT LIABILITY AMOUNTPATIENT PAID AMOUNTPRIOR AUTHORIZATION INDICATORPRIOR AUTHORIZATION LINE NUMBERPRIOR AUTHORIZATION TYPE CODEPHM CODEPLAN RATE BEGIN DATEPLACE OF SERVICEPOINT OF SALE PARTICIPANT SYSTEM IDPRICING PROCESS CODEPRIOR AUTHORIZATION INDICATORPROCEDURE CODEPROCEDURE CODE MODIFIER 1PROCEDURE CODE MODIFIER 2PROCEDURE CODE MODIFIER 3PROCEDURE CODE MODIFIER 4MEDICARE PROCEDURE CODEREFERRING NPI NUMBERREFERENCE NUMBERREFERRING PROVIDER IDREFERRING QUALIFIER CODEREFERRING QUALIFIER DATEREIMBURSEMENT STATUS CODERETENTION CODEREVENUE CODEREVENUE TYPE CODERELATED DIAGNOSIS CODERELATED DIAGNOSIS CODERELATED DIAGNOSIS CODERELATED DIAGNOSIS CODERENDERING NPI NUMBERRENDERING PROVIDER IDRENDERING PROVIDER TYPE CODERENDERING QUALIFIER CODE

RENDERING SPECIAL CODERENDERING TAXONOMY CODEDRUG BASIS COST CODEBASE AMOUNT SOURCE CODEDRUG CUTBACK CODEDRUG CUTBACK REASON CODEDRUG DISCOUNT RATE AMOUNTDRUG THREE CHARACTER CODEDRUG CODEDRUG DEA CODESEQUENCE NUMBERGENERIC DRUG CODE NUMBERGENERIC DRUG PRODUCT CODEDRUG MAINTENENCE INDICATORDRUG NAMEDRUG ROUTE CODEDRUG INGREDIENT DISCOUNT PERCENTAGEDRUG LINE ALLOW AMOUNTDRUG LINE PAID QUANTITY AMOUNTPRODUCT SERVICE IDPRODUCT SERVICE ID CODEPRES ALTERNATE ID TYPE CODESPH ALTERNATE ID CODEDRUG SUBMITTING COST AMOUNTDRUG SUBMITTING QUANTITY AMOUNTCUTBACK AMOUNTSERVICE AREA CODESERVICE AREA CODESERVICE COMPONENT CODETCN-TRANSACTION CONTROL NUMBERTYPE OF SERVICE CODETPL AMOUNT

DATA_ELEMENT_FILE DATA_ELEMENT_NAMEUB92 ADMIT_DIAG_CD UB92 ADMIT_HR_NUM UB92 ADM_SRC_CD UB92 ATNDG_NPI_NUM UB92 ATNDG_QLFR_CD UB92 ATNDG_QLFR_DAT UB92 BEN_SYS_ID UB92 BSE_AMT_SRC_CD UB92 CALC_ALLOW_AMTUB92 CALC_DAYS_NUM UB92 COINS_DAY_NUM UB92 DISCH_HR_NUM UB92 DRG_ALOS_NUMUB92 DRG_CD UB92 DRG_PD_DAYS_NUM UB92 HDR_BSE_AMTUB92 HDR_DRG_MDC_CD UB92 HDR_FAM_PLNG_IND UB92 HDR_PD_DTUB92 LTC_PROV_ID UB92 MED_REC_NUM UB92 NCVRD_CHRG_AMTUB92 NCVRD_DAYS_NUM UB92 OTHR_1_NPI_NUM UB92 OTHR_1_QLFR_CD UB92 OTHR_1_QLFR_DAT UB92 OTHR_2_NPI_NUM UB92 OTHR_2_QLFR_CD UB92 OTHR_2_QLFR_DAT UB92 OTHR_PROV_1_ID UB92 OTHR_PROV_2_ID UB92 OUTLIER_DAYS_NUM UB92 PRCNG_PROCESS_CD UB92 PREG_IND UB92 PRIN_ICD9_CD UB92 PRIN_ICD9_DT UB92 PROGNOSIS_CD UB92 TCN_NUMUB92 TOT_DENY_AMTUB92 TY_OF_ADM_CD UB92 UB92_ABORT_IND UB92 UB92_HYSTER_IND UB92 UB92_STERIL_IND

DATA_ELEMENT_DESCRIPTIONADMIT DIAGNOSIS CODEADMIT HOUR NUMBERADMIT SOURCE CODEATTENDING NPI NUMBERATTENDING QUALIFIER CODEATTENDING QUALIFIER DATEPARTICIPANT SYSTEM IDBASE AMOUNT SOURCE CODECALCULATED ALLOWED AMOUNTCALCULATED NUMBER OF DAYSCOINSURANCE NUMBER OF DAYSDISHCHARGE HOURDRUG ALOS NUMBERDRG CODEDRG NUMBER OF PAID DAYSHEADER BASE AMOUNTDRUG MDC CODEHEADER FAMILY PLANNING INDICATORPAID DATELTC PROVIDER IDMEDICAID RECORD NUMBERNON-COVERED CHARGE AMOUNTNON-COVERED NUMBER OF DAYSOTHER NPI NUMBEROTHER QUALIFIER CODEOTHER QUALIFIER DATEOTHER NPI NUMBER OTHER QUALIFIER CODEOTHER QUALIFIER DATEOTHER PROVIDER IDOTHER PROVIDER IDOUTLIER NUMBER OF DAYSPRICING PROCESS CODEPREGNANCY INDICATORPRINCIPLE ICD9 CODEPRINCIPLE ICD9 DATEPROGNOSIS CODETCN-TRANSACTION CONTROL NUMBERTOTAL DENIED AMOUNTTYPE OF ADMIT CODEABORTION INDICATORHYSTERECTOMYSTERLIZATION INDICATOR

DATA_ELEMENT_FILE DATA_ELEMENT_NAMEXOVR BEN_SYS_ID XOVR CLNT_MCARE_CD XOVR C_CNTRCT_OBLIG_AMTXOVR HDR_PD_DT XOVR HD_MCARE_EOMB_DT XOVR MCARE_ASGN_CD XOVR MCARE_BLOOD_AMT XOVR MCARE_COINS_AMT XOVR MCARE_DED_AMT XOVR MCARE_PD_AMT XOVR MCARE_STAT_CD XOVR MCARE_T_BLOD_AMT XOVR MCARE_T_COIN_AMT XOVR MCARE_T_DED_AMT XOVR MCARE_T_PD_AMT XOVR NCVRD_CHRG_AMT XOVR NCVRD_DAYS_NUM XOVR TCN_NUM

DATA_ELEMENT_DESCRIPTIONPARTICIPANT SYSTEM IDCLIENT MEDICARE CODECONTRACT OBLIGATION AMOUNTHEADER PAID DATEMEDICARE EXPLANATION OF BENEFITS DATEMEDICARE ASSIGNMENT CODEMEDICARE BLOOD AMOUNTMEDICARE COINSURANCE AMOUNTMEDICARE DEDUCTABLE AMOUNTMEDICARE PAID AMOUNTMEDICARE STATUS CODEMEDICARE TOTAL BLOOD AMOUNTMEDICARE TOTAL COINSURANCE AMOUNTMEDICARE TOTAL DEDUCTION AMOUNTMEDICARE TOTAL PAID AMOUNTNON-COVERED CHARGE AMOUNTNUMBER OF NON-COVERED DAYSTCN-TRANSACTION CONTROL NUMBER

DATA_ELEMENT_FILE DATA_ELEMENT_NAMEDIAG BEN_SYS_ID DIAG DIAG_CD DIAG HDR_PD_DTDIAG POA_IND DIAG POS_B_SYS_ID DIAG SEQ_NUM DIAG TCN_NUMDIAG TCN_NUM

DATA_ELEMENT_DESCRIPTIONPARTICIPANT SYSTEM IDDIAGNOSIS CODEPAID DATEPRESENT ON ADMISSION INDICATORPOINT OF SALE PARTICIPANT SYSTEM IDSEQUENCE NUMBERTCN-TRANSACTION CONTROL NUMBERTCN-TRANSACTION CONTROL NUMBER

DATA_ELEMENT_FILE DATA_ELEMENT_NAME DATA_ELEMENT_DESCRIPTIONICD BEN_SYS_ID PARTICIPANT SYSTEM IDICD HDR_PD_DT PAID DATEICD HDR_UB92_ICD9_DT UB92 ICD9 DATEICD ICD9_CD ICD CODEICD SEQ_NUM SEQUENCE NUMBERICD TCN_NUM TCN-TRANSACTION CONTROL NUMBER

DATA_ELEMENT_FILE DATA_ELEMENT_NAMEOCC_CD BEN_SYS_IDOCC_CD HDR_PD_DTOCC_CD OCC_CD OCC_CD SEQ_NUM OCC_CD TCN_NUMOCC_CD UB92_OCC_CD_DT

DATA_ELEMENT_DESCRIPTIONPARTICIPANT SYSTEM IDPAID DATEOCCURANCE CODESEQUENCE NUMBERTCN-TRANSACTION CONTROL NUMBERDATE E OF OCCURANCE CODE

DATA_ELEMENT_FILE DATA_ELEMENT_NAMEOCC_SPN_CD BEN_SYS_IDOCC_SPN_CD HDR_PD_DTOCC_SPN_CD OCC_SPN_CD OCC_SPN_CD OCC_SPN_FROM_DTOCC_SPN_CD OCC_SPN_THRU_DTOCC_SPN_CD SEQ_NUM OCC_SPN_CD TCN_NUM

DATA_ELEMENT_DESCRIPTIONPARTICIPANT SYSTEM IDPAID DATEOCCURANCE SPAN CODEOCCURENCE SPAN FROM DATEOCCURENCE SPAN THRU DATESEQUENCE NUMBERTCN-TRANSACTION CONTROL NUMBER