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Sub-Field: 9002313.0201

Package: Pharmacy Point of Sale

ABSP CLAIMS(#9002313.02)-->9002313.0201

Sub-Field: 9002313.0201


Information

Parent File Name Number Package
ABSP CLAIMS(#9002313.02) Medication(s) 9002313.0201 Pharmacy Point of Sale

Details

Field # Name Loc Type Details
.01 Medication Order 0;1 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>999999999)!(X<1)!(X?.E1"."1N.N) X
  • LAST EDITED:  JUN 07, 1995
  • HELP-PROMPT:  Type a Number between 1 and 999999999, 0 Decimal Digits
  • CROSS-REFERENCE:  9002313.0201^B
    1)= S ^ABSPC(DA(1),400,"B",$E(X,1,30),DA)=""
    2)= K ^ABSPC(DA(1),400,"B",$E(X,1,30),DA)
.02 VCPT IEN 0;2 POINTER ** TO AN UNDEFINED FILE **

  • LAST EDITED:  MAY 22, 1995
.03 Medication Number 0;3 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>999999999)!(X<1)!(X?.E1"."1N.N) X
  • LAST EDITED:  JUN 07, 1995
  • HELP-PROMPT:  Type a Number between 1 and 999999999, 0 Decimal Digits
  • CROSS-REFERENCE:  9002313.0201^AC
    1)= S ^ABSPC(DA(1),400,"AC",$E(X,1,30),DA)=""
    2)= K ^ABSPC(DA(1),400,"AC",$E(X,1,30),DA)
.04 Medication Name 0;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
  • LAST EDITED:  JUN 08, 1995
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
308 Other Coverage Code 300;8 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  JUL 31, 2002
  • HELP-PROMPT:  Answer must be 2 characters in length.
315 Employer Name 310;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<30) X
  • LAST EDITED:  JUL 31, 2002
  • HELP-PROMPT:  Answer must be 30 characters in length.
316 Employer Street Address 310;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<30) X
  • LAST EDITED:  JUL 31, 2002
  • HELP-PROMPT:  Answer must be 30 characters in length.
317 Employer City Address 310;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>20!($L(X)<20) X
  • LAST EDITED:  JUL 31, 2002
  • HELP-PROMPT:  Answer must be 20 characters in length.
318 Employer State/Prov Address 310;8 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  JUL 31, 2002
  • HELP-PROMPT:  Answer must be 2 characters in length.
319 Employer Zip/Postal Zone 310;9 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>15!($L(X)<15) X
  • LAST EDITED:  JUL 31, 2002
  • HELP-PROMPT:  Answer must be 15 characters in length.
320 Employer Phone Number 310;10 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>10!($L(X)<10) X
  • LAST EDITED:  JUL 31, 2002
  • HELP-PROMPT:  Answer must be 10 characters in length.
321 Employer Contact Name 320;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<30) X
  • LAST EDITED:  JUL 31, 2002
  • HELP-PROMPT:  Answer must be 30 characters in length.
327 Carrier ID 320;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>10!($L(X)<10) X
  • LAST EDITED:  JUL 31, 2002
  • HELP-PROMPT:  Answer must be 10 characters in length.
330 Alternate ID 320;10 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>20!($L(X)<20) X
  • LAST EDITED:  JUL 31, 2002
  • HELP-PROMPT:  Answer must be 20 characters in length.
337 COB/Other Payments Cnt 330;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>1!($L(X)<1) X
  • LAST EDITED:  JUL 31, 2002
  • HELP-PROMPT:  Answer must be 1 character in length.
337.01 COB/Other Payments 337;0 Multiple #9002313.0401 9002313.0401
343 Dispensing Status 340;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>1!($L(X)<1) X
  • LAST EDITED:  JUL 31, 2002
  • HELP-PROMPT:  Answer must be 1 character in length.
344 Qty Intended to be Dispensed 340;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>10!($L(X)<10) X
  • LAST EDITED:  JUL 31, 2002
  • HELP-PROMPT:  Answer must be 10 characters in length.
345 Days Supply Intd Dispensed 340;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<3) X
  • LAST EDITED:  JUL 31, 2002
  • HELP-PROMPT:  Answer must be 3 characters in length.
354 Subm Clarif Code Count 350;4 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>19)!(X<1)!(X?.E1"."1.N) X
  • LAST EDITED:  OCT 04, 2011
  • HELP-PROMPT:  Type a number between 1 and 19, 0 Decimal Digits
367 Prescriber State/Prov 360;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>4!($L(X)<2) X
  • LAST EDITED:  SEP 09, 2011
  • HELP-PROMPT:  Answer must be 2-4 characters in length.
401 Date of Service 400;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<8) X
  • OUTPUT TRANSFORM:  S Y=$$FM2EXT^ABSPOSU1(Y-17000000)
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 8 characters in length.
402 Prescription/Service Ref Num 400;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>7!($L(X)<1) X
  • LAST EDITED:  JUL 24, 2002
  • HELP-PROMPT:  Answer must be 1-7 characters in length.
403 Fill Number 400;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • OUTPUT TRANSFORM:  S:$E(Y,1,1)'["D" Y=+Y
  • LAST EDITED:  AUG 05, 2002
  • HELP-PROMPT:  Answer must be 2 characters in length.
404 Metric Quantity 400;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>5!($L(X)<5) X
  • OUTPUT TRANSFORM:  S Y=+Y
  • LAST EDITED:  DEC 23, 1997
  • HELP-PROMPT:  Answer must be 5 characters in length.
405 Days Supply 400;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<3) X
  • OUTPUT TRANSFORM:  S:$E(Y,1,1)'["D" Y=+Y
  • LAST EDITED:  AUG 05, 2002
  • HELP-PROMPT:  Answer must be 3 characters in length.
406 Compound Code 400;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>1!($L(X)<1) X
  • LAST EDITED:  APR 10, 1995
  • HELP-PROMPT:  Answer must be 1 character in length.
407 Product/Service ID 400;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>19!($L(X)<11) X
  • OUTPUT TRANSFORM:  Q:$E(Y,1,1)["D" S Y=$E(Y,1,5)_"-"_$E(Y,6,9)_"-"_$E(Y,10,11)
  • LAST EDITED:  AUG 05, 2002
  • HELP-PROMPT:  Answer must be 11-19 characters in length.
408 Dispense as Wrtn/Prd Sel Cd 400;8 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>1!($L(X)<1) X
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 1 character in length.
409 Ingredient Cost Submitted 400;9 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<6) X
  • OUTPUT TRANSFORM:  ;S Y="$"_$J($$DFF2EXT^ABSPECFM(Y),7,2)
  • LAST EDITED:  AUG 05, 2002
  • HELP-PROMPT:  Answer must be 6-8 characters in length.
410 Sales Tax 400;10 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>6!($L(X)<6) X
  • OUTPUT TRANSFORM:  S Y="$"_$J($$DFF2EXT^ABSPECFM($E(Y,3,$L(Y))),7,2)
  • LAST EDITED:  JUN 21, 1995
  • HELP-PROMPT:  Answer must be 6 characters in length.
411 Prescriber ID 400;11 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>15!($L(X)<10) X
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 10-15 characters in length.
412 Dispensing Fee Submitted 400;12 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<6) X
  • OUTPUT TRANSFORM:  ;S Y="$"_$J($$DFF2EXT^ABSPECFM($E(Y,3,$L(Y))),7,2)
  • LAST EDITED:  AUG 05, 2002
  • HELP-PROMPT:  Answer must be 6-8 characters in length.
414 Date Prescription Written 400;14 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<8) X
  • LAST EDITED:  APR 10, 1995
  • HELP-PROMPT:  Answer must be 8 characters in length.
415 Number Refills Authorized 400;15 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  APR 10, 1995
  • HELP-PROMPT:  Answer must be 2 characters in length.
416 PA/MC Code & Number 400;16 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>12!($L(X)<12) X
  • LAST EDITED:  APR 10, 1995
  • HELP-PROMPT:  Answer must be 12 characters in length.
418 Level of Service 400;18 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  APR 10, 1995
  • HELP-PROMPT:  Answer must be 2 characters in length.
419 Prescription Origin Code 400;19 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>1!($L(X)<1) X
  • LAST EDITED:  APR 10, 1995
  • HELP-PROMPT:  Answer must be 1 character in length.
420 Submission Clarification Code 400;20 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 2 characters in length.
420.1 Subm Clarif Code 1 421;1 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>19)!(X<1)!(X?.E1"."1.N) X
  • LAST EDITED:  OCT 04, 2011
  • HELP-PROMPT:  Type a number between 1 and 19, 0 Decimal Digits
420.2 Subm Clarif Code 2 421;2 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>19)!(X<1)!(X?.E1"."1.N) X
  • LAST EDITED:  OCT 04, 2011
  • HELP-PROMPT:  Type a number between 1 and 19, 0 Decimal Digits
420.3 Subm Clarif Code 3 421;3 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>19)!(X<1)!(X?.E1"."1.N) X
  • LAST EDITED:  OCT 04, 2011
  • HELP-PROMPT:  Type a number between 1 and 19, 0 Decimal Digits
421 Primary Care Provider ID 400;21 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>15!($L(X)<10) X
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 10-15 characters in length.
422 Clinic ID Number 400;22 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>5!($L(X)<5) X
  • LAST EDITED:  APR 10, 1995
  • HELP-PROMPT:  Answer must be 5 characters in length.
423 Basis of Cost Determination 400;23 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  APR 10, 1995
  • HELP-PROMPT:  Answer must be 2 characters in length.
424 Diagnosis Code 400;24 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>15!($L(X)<6) X
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 6-15 characters in length.
425 Drug Type 420;25 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<3) X
  • LAST EDITED:  JAN 25, 2001
  • HELP-PROMPT:  Answer must be 3 characters in length.
426 Usual & Customary Charge 400;26 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<6) X
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 6-8 characters in length.
427 Prescriber Last Name 420;27 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>17!($L(X)<1) X
  • LAST EDITED:  JAN 25, 2001
  • HELP-PROMPT:  Answer must be 1-17 characters in length.
428 Postage Amt. Claimed 420;28 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>6!($L(X)<1) X
  • LAST EDITED:  JAN 25, 2001
  • HELP-PROMPT:  Answer must be 1-6 characters in length.
429 Unit Dose Indicator 400;29 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>1!($L(X)<1) X
  • LAST EDITED:  APR 10, 1995
  • HELP-PROMPT:  Answer must be 1 character in length.
430 Gross Amount Due 400;30 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<6) X
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 6-8 characters in length.
431 Other Payer Amount 430;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<6) X
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 6-8 characters in length.
432 Basis of Days Supply Det 420;32 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<1) X
  • LAST EDITED:  JAN 25, 2001
  • HELP-PROMPT:  Answer must be 1-3 characters in length.
433 Patient Paid Amount Submitted 430;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<6) X
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 6-8 characters in length.
434 Date of Injury 430;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>10!($L(X)<1) X
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 1-10 characters in length.
435 Claim/Ref ID Number 430;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<1) X
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 1-30 characters in length.
436 Product/Service ID Qualifier 430;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<1) X
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 1-3 characters in length.
437 Alternate Product Code 430;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>13!($L(X)<1) X
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 1-13 characters in length.
438 Incentive Amount Submitted 430;8 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<6) X
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 6-8 characters in length.
439 Reason for Service Code 430;9 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>4!($L(X)<4) X
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 4 characters in length.
440 Professional Service Code 430;10 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>4!($L(X)<4) X
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 4 characters in length.
441 Result of Service Code 440;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>4!($L(X)<4) X
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 4 characters in length.
442 Quantity Dispensed 440;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>10!($L(X)<8) X
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 8-10 characters in length.
443 Other Payer Date 440;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<8) X
  • LAST EDITED:  JUL 26, 2002
  • HELP-PROMPT:  Answer must be 8 characters in length.
444 Provider ID 440;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>15!($L(X)<15) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 15 characters in length.
445 Orig Pres Prod/Srv Cd 440;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>19!($L(X)<19) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 19 characters in length.
446 Originally Prescribed Quantity 440;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>10!($L(X)<10) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 10 characters in length.
447 Comp Ingred Component Cnt 440;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 2 characters in length.
447.01 Compound Repeating Fields 447;0 Multiple #9002313.0501 9002313.0501

  • LAST EDITED:  OCT 31, 2002
450 Compound Dosage Form Desc Cd 440;10 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 2 characters in length.
451 Compound Disp Unit Form Ind 450;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>1!($L(X)<1) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 1 character in length.
452 Compound Route of Admin 450;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 2 characters in length.
453 Orig Pres/Serv ID Qual 450;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 2 characters in length.
454 Scheduled Pres ID Number 450;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>12!($L(X)<12) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 12 characters in length.
455 Pres/Srv Ref Number Qual 450;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>1!($L(X)<1) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 1 character in length.
456 Assoc Pres/Srv Ref Number 450;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>7!($L(X)<7) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 7 characters in length.
457 Assoc Pres/Srv Date 450;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<8) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 8 characters in length.
458 Procedure Mod Code Cnt 450;8 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>1!($L(X)<1) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 1 character in length.
459 Procedure Modifier Code 459;0 Multiple #9002313.201459 9002313.201459
460 Quantity Prescribed 450;10 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>10!($L(X)<10) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 10 characters in length.
461 Prior Authorization Type Code 460;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 2 characters in length.
462 Prior Authorization Num Sub 460;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>11!($L(X)<11) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 11 characters in length.
463 Intermediary Auth Type ID 460;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 2 characters in length.
464 Intermediary Auth ID 460;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>11!($L(X)<11) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 11 characters in length.
465 Provider ID Qualifier 460;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 2 characters in length.
466 Prescriber ID Qualifier 460;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 2 characters in length.
467 Prescriber Location Code 460;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<3) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 3 characters in length.
468 Primary Care Prov ID Qual 460;8 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 2 characters in length.
469 Primary Care Prov Loc Cd 460;9 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<3) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 3 characters in length.
470 Primary Care Prov Last Name 460;10 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>15!($L(X)<15) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 15 characters in length.
471 Other Payer Reject Count 470;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 2 characters in length.
473.01 DUR/PPS Repeating Fields 473.01;0 Multiple #9002313.1001 9002313.1001
477 Professional Srv Fee Submitted 470;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<8) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 8 characters in length.
478 Other Amt Claimed Sub Cnt 470;8 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>1!($L(X)<1) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 1 character in length.
478.01 Pricing Repeating Section 478.01;0 Multiple #9002313.0601 9002313.0601
481 Flat Sales Tax Amt Sub 480;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<8) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 8 characters in length.
482 Percentage Sales Tax Amt Sub 480;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<8) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 8 characters in length.
483 Percentage Sales Tax Rate Sub 480;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>7!($L(X)<7) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 7 characters in length.
484 Percentage Sales Tax Basis Sub 480;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 2 characters in length.
485 Coupon Type 480;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 2 characters in length.
486 Coupon Number 480;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>15!($L(X)<15) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 15 characters in length.
487 Coupon Value Amount 480;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<8) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 8 characters in length.
491 Diagnosis Code Count 490;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>1!($L(X)<1) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 1 character in length.
491.01 Clinical Diagnosis Repeating 491.01;0 Multiple #9002313.0701 9002313.0701
493.01 Clinical Information Repeating 493.01;0 Multiple #9002313.0801 9002313.0801
498.01 Request Type 498;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>1!($L(X)<1) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 1 character in length.
498.02 Request Period Date-Begin 498;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<8) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 8 characters in length.
498.03 Request Period Date-End 498;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<8) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 8 characters in length.
498.04 Basis of Request 498;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 2 characters in length.
498.05 Authorized Rep First Name 498;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>12!($L(X)<1) X
  • LAST EDITED:  SEP 03, 2003
  • HELP-PROMPT:  Answer must be 1-12 characters in length.
498.06 Authorized Rep Last Name 498;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>15!($L(X)<1) X
  • LAST EDITED:  SEP 03, 2003
  • HELP-PROMPT:  Answer must be 1-15 characters in length.
498.07 Authorized Rep Street Address 498;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<1) X
  • LAST EDITED:  SEP 03, 2003
  • HELP-PROMPT:  Answer must be 1-30 characters in length.
498.08 Authorized Rep City Address 498;8 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>20!($L(X)<1) X
  • LAST EDITED:  SEP 03, 2003
  • HELP-PROMPT:  Answer must be 1-20 characters in length.
498.09 Authorized Rep State/Prov 498;9 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 2 characters in length.
498.11 Authorized Rep Zip/Postal Zone 498;11 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>15!($L(X)<1) X
  • LAST EDITED:  SEP 03, 2003
  • HELP-PROMPT:  Answer must be 1-15 characters in length.
498.12 Prescriber Phone Number 498;12 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>10!($L(X)<1) X
  • LAST EDITED:  SEP 03, 2003
  • HELP-PROMPT:  Answer must be 1-10 characters in length.
498.13 Prior Auth Supporting Doc 498.13;0 WORD-PROCESSING #9002313.0901
498.14 Prior Auth Number Assigned 498;14 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>11!($L(X)<1) X
  • LAST EDITED:  SEP 03, 2003
  • HELP-PROMPT:  Answer must be 1-11 characters in length.
503 Authorization Number 500;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>20!($L(X)<20) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 20 characters in length.
600 Unit of Measure 600;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<2) X
  • LAST EDITED:  JUL 30, 2002
  • HELP-PROMPT:  Answer must be 2 characters in length.
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