- ACHSEOBR ;IHS/SET/GTH - EOBR RECORD FORMATS ; [ 12/06/2002 10:36 AM ]
- ;;3.1;CONTRACT HEALTH MGMT SYSTEM;**5,22,23**;JUN 11, 2001;Build 43
- ;IHS/SET/GTH ACHS*3.1*5 12/06/2002 - New routine.
- ;
- ;;EXPLANATION OF BENEFITS RECORDS LAYOUTS
- ;; ( ALL RECORDS ARE 80 CHARACTERS )
- ;; Pieces of info identifying the claim, PO, CHECK, PATIENT
- ;; AUTHORIZING FACILITY, PROVIDER, ETC., ARE ON RECORD FORMATS A-E
- ;; FILLER ADDED AS NEEDED.
- ;;
- ;; DETAIL RECORDS ARE ON FORMAT F,G & J. POSSIBLE 999
- ;; LINES OF DETAIL PROCESSED UNDER A CLAIM CONTROL NUMBER (CCN).
- ;; IF A CLAIM HAS MORE THAN 999 LINES OF DETAIL, IT IS SPLIT USING
- ;; A "7" IN THE 6TH POSITION OF THE CCN WHERE A "0" NORMALLY
- ;; APPEARS. IT WOULD BE TRANSMITTED AS A SEPARATE EOBR. EACH
- ;; LINE HAS A NUMBER WHICH APPEARS ON FORMAT F FIELD 7. CLAIMS
- ;; ARE SPLIT FOR OTHER REASONS ALSO (MATERNITY CLAIMS WHERE THE
- ;; BILL INCLUDES CHARGES FOR MOM AND BABY, PROFESSIONAL FEES
- ;; BILLED ON A UB-82, BILLING CYCLE UB-82 WITH A PATIENT DISCHARGE
- ;; OF 30). THE MULTIPLE CLAIM INDICATOR IS NOT SENT ON THE EOBR.
- ;; HOWEVER, ANY CLAIM WITH A CCN THAT HAS A "7" IN THE SIXTH POSITION
- ;; IS A SPLIT CLAIM. THESE MAY NEED TO BE HANDLED IN SOME UNIQUE
- ;; WAY BY IHS TO POST THE PAYMENT TO THE CHS/MIS SYSTEM AND UPDATE
- ;; THE COMMITMENT REGISTER RECOGNIZING ANOTHER PAYMENT FOR THAT
- ;; PO NUMBER WILL BE FORTHCOMING.
- ;;
- ;; ANOTHER KEY ELEMENT MIGHT BE THE INTERIM/FINAL PAYMENT WHICH
- ;; APPEARS ON FORMAT C FIELD 13. THE FI'S SYSTEM IDENTIFIES THE
- ;; SPLIT CLAIMS AND SENDS THE EOBR AND PAYMENT DHR AS AN INTERIM
- ;; UNLESS IT IS THE LAST CLAIM PROCESSED WITH THAT PURCHASE ORDER
- ;; NUMBER WHICH BECOMES THE FINAL, AND CLOSES THE SHR424 OBLIGATION.
- ;; AN INTERIM DECREASES THE OBLIGATION AMOUNT BUT DOES NOT CLOSE IT.
- ;; EOBR AND DHR FOR BLANKET PO'S ARE REPORTED AS INTERIM PAYMENTS.
- ;;
- ;; A - HEADING
- ;; B - HEADING
- ;; C - HEADING
- ;; D - HEADING
- ;; E - HEADING
- ;; F - DETAIL
- ;; G - PROCEDURE CODES
- ;; H - SUMMARY
- ;; A - HEADING
- ;; NUM NAME PIC COMMENTS LOC
- ;; --- ------------------ ----- ----------------------- -----
- ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- ;; 02 SERVICE UNIT X(02) 03-04
- ;; 03 FACILITY NUMBER X(02) 05-06
- ;; 04 FISCAL YEAR X(02) 07-08
- ;; 05 CLAIM NUMBER 9(10) 2ND PART OF CONTROL NBR 09-18
- ;; 06 RECORD TYPE X(01) ALWAYS 'A' 19-19
- ;; 07 SEQUENCE NUMBER 9(03) ALWAYS 001 20-22
- ;; 08 CLAIM SEQUENCE CNT 9(09) A COUNT ON 2ND LINE OF 23-31
- ;; REPORT
- ;; 09 CHECK NUMBER 9(07) 32-38
- ;; 10 REMITTANCE NBR 9(07) 39-45
- ;; 11 PAID DATE X(08) FORMAT CCYYMMDD 46-53
- ;; 12 PURCHASE ORDER NBR X(12) FORMAT XX-XXX-XXXXX 54-65
- ;; 13 CERTIFICATE NBR X(07) 1ST PART OF CONTROL NBR 66-72
- ;; 14 FACILITY CODE X(06) 73-78
- ;; 15 DOCUMENTATION TYPE X(02) 79-80
- ;;
- ;; B - HEADING
- ;; NUM NAME PIC COMMENTS LOC
- ;; --- ------------------ ----- ----------------------- -----
- ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- ;; 02 SERVICE UNIT X(02) 03-04
- ;; 03 FACILITY NUMBER X(02) 05-06
- ;; 04 FISCAL YEAR X(02) 07-08
- ;; 05 CLAIM NUMBER 9(10) 09-18
- ;; 06 RECORD TYPE X(01) ALWAYS 'B' 19-19
- ;; 07 SEQUENCE NUMBER 9(03) ALWAYS 001 20-22
- ;; 08 PATIENT NAME X(30) 23-52
- ;; 09 HEALTH RECORD NBR X(07) 53-59
- ;; 10 AUTHORIZATION DATE X(08) FORMAT CCYYMMDD 60-67
- ;; 11 ACTUAL DAYS 9(02) INPATIENT DAYS 68-69
- ;; 12 DRG 9(03) 70-72
- ;;ACHS*3.1*22 FIXED SCC
- ;; 14 SERVICE CLASS CODE X(04) 73-76
- ;; 15 FILLER X(02) 77-80
- ;;***PRIOR TO PATCH ACHS*3.1*22
- ;; 13 DISCHARGE STATUS X(02) 73-74
- ;; 14 SERVICE CLASS CODE X(04) 75-78
- ;; 15 FILLER X(02) 79-80
- ;;
- ;; C - HEADING
- ;; NUM NAME PIC COMMENTS LOC
- ;; --- ------------------ ----- ----------------------- -----
- ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- ;; 02 SERVICE UNIT X(02) 03-04
- ;; 03 FACILITY NUMBER X(02) 05-06
- ;; 04 FISCAL YEAR X(02) 07-08
- ;; 05 CLAIM NUMBER 9(10) 09-18
- ;; 06 RECORD TYPE X(01) ALWAYS 'C' 19-19
- ;; 07 SEQUENCE NUMBER 9(03) 001 OR 002 20-22
- ;; For 001:
- ;; 08 COMMON ACCT NBR X(16) 23-38
- ;; 09 OBJECT CLASS CODE X(04) 39-42
- ;; 10 SERVICES BILLED X(01) A = PROF B = INPATIENT 43-43
- ;; C = OUTPAT D = DENTAL
- ;; 11 BLANKET INDICATOR X(01) Y = YES, ELSE NO 44-44
- ;; 12 CONTRACT NUMBER X(10) 45-54
- ;; 13 INTERIM/FINAL IND X(01) F = FINAL I = INTERIM 55-55
- ;; 16 VENDOR NUMBER X(13) PROVIDER ID - SUFFIX 56-68
- ;; FILLER 69-80
- ;; For 002:
- ;; 14 SERVICE START DATE X(08) FORMAT CCYYMMDD 23-30
- ;; 15 SERVICE END DATE X(08) FORMAT CCYYMMDD 31-38
- ;;
- ;; D - HEADING
- ;; NUM NAME PIC COMMENTS LOC
- ;; --- ------------------ ----- ----------------------- -----
- ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- ;; 02 SERVICE UNIT X(02) 03-04
- ;; 03 FACILITY NUMBER X(02) 05-06
- ;; 04 FISCAL YEAR X(02) 07-08
- ;; 05 CLAIM NUMBER 9(10) 09-18
- ;; 06 RECORD TYPE X(01) ALWAYS 'D' 19-19
- ;; 07 SEQUENCE NUMBER 9(03) ALWAYS 001 20-22
- ;; 08 VENDOR NAME X(30) 23-52
- ;; 09 BILLED BY PROVIDER S9(07)V99 FIELD WILL CONTAIN 53-61
- ;; ALL '*' IF IT IS NOT
- ;; APPLICABLE
- ;; 10 ALLOWABLE AMOUNT S9(07)V99 62-70
- ;; 11 PAID BY 3RD PARTY S9(07)V99 71-79
- ;; 12 FILLER X(01) 80-80
- ;;
- ;; E - HEADING
- ;; NUM NAME PIC COMMENTS LOC
- ;; --- ------------------ ----- ----------------------- -----
- ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- ;; 02 SERVICE UNIT X(02) 03-04
- ;; 03 FACILITY NUMBER X(02) 05-06
- ;; 04 FISCAL YEAR X(02) 07-08
- ;; 05 CLAIM NUMBER 9(10) 09-18
- ;; 06 RECORD TYPE X(01) ALWAYS 'E' 19-19
- ;; 07 SEQUENCE NUMBER 9(03) ALWAYS 001 20-22
- ;; 08 IHS COST S9(09)V99 23-31
- ;; 09 OBLIGATION IND X(01) 1=P.O. NBR, 2=SHR 424 32-32
- ;; 10 OBLIGATION AMOUNT S9(09)V99 FIELD WILL CONTAIN 33-41
- ;; ALL '*' IF IT IS NOT
- ;; APPLICABLE
- ;; 11 ADJUSTMENT AMOUNT S9(09)V99 FIELD WILL CONTAIN 42-50
- ;; ALL '*' IF IT IS NOT
- ;; APPLICABLE
- ;; 12 DIAGNOSIS CODE 1 X(06) 51-56 ;ACHS*3.1*23
- ;; 13 DIAGNOSIS CODE 2 X(06) 57-62 ;ACHS*3.1*23
- ;; 14 DIAGNOSIS CODE 3 X(06) 63-68 ;ACHS*3.1*23
- ;; 15 DIAGNOSIS CODE 4 X(06) 69-74 ;ACHS*3.1*23
- ;; 16 DIAGNOSIS CODE 5 X(06) 75-80 ;ACHS*3.1*23
- ;;
- ;; F - DETAIL
- ;; NUM NAME PIC COMMENTS LOC
- ;; --- ------------------ ----- ----------------------- -----
- ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- ;; 02 SERVICE UNIT X(02) 03-04
- ;; 03 FACILITY NUMBER X(02) 05-06
- ;; 04 FISCAL YEAR X(02) 07-08
- ;; 05 CLAIM NUMBER 9(10) 09-18
- ;; 06 RECORD TYPE X(01) ALWAYS 'F' 19-19
- ;; 07 SEQUENCE NUMBER 9(03) FROM 001 TO 999 20-22
- ;; 08 FROM DATE OF SVC X(08) FORMAT CCYYMMDD 23-30
- ;; 09 TO DATE OF SVC X(09) FORMAT CCYYMMDD 31-38
- ;; 10 PROCEDURE CODE X(05) 39-43
- ;; 11 UNITS BILLED 9(03) 44-46
- ;; 12 BILLED CHARGES S9(07)V99 47-55
- ;; 13 ALLOWABLE CHARGES S9(07)V99 56-64
- ;; 14 MESSAGE X(04) 65-68
- ;; 15 TOOTH NUMBER X(02) 69-70
- ;; 16 TOOTH SURFACE X(05) 71-75
- ;; 17 FILLER X(05) 76-80
- ;;
- ;; G - PROCEDURES
- ;; NUM NAME PIC COMMENTS LOC
- ;; --- ------------------ ----- ----------------------- -----
- ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- ;; 02 SERVICE UNIT X(02) 03-04
- ;; 03 FACILITY NUMBER X(02) 05-06
- ;; 04 FISCAL YEAR X(02) 07-08
- ;; 05 CLAIM NUMBER 9(10) 09-18
- ;; 06 RECORD TYPE X(01) ALWAYS 'G' 19-19
- ;; 07 SEQUENCE NUMBER 9(03) ALWAYS 001 20-22
- ;; 08 PROCEDURE CODE 1 9(07) 23-29 ;ACHS*3.1*23
- ;; 09 PROCEDURE CODE 2 9(07) 30-36 ;ACHS*3.1*23
- ;; 10 PROCEDURE CODE 3 9(07) 37-43 ;ACHS*3.1*23
- ;; 09 PROCEDURE CODE 4 9(07) 44-50 ;ACHS*3.1*23
- ;; 10 PROCEDURE CODE 5 9(07) 51-57 ;ACHS*3.1*23
- ;; 11 FILLER X(23) 58-80 ;ACHS*3.1*23
- ;;
- ;; I-INTEREST INFO FOR A GIVEN CLAIM
- ;; NUM NAME PIC COMMENTS LOC
- ;; --- ------------------ ----- ----------------------- -----
- ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- ;; 02 SERVICE UNIT X(02) 03-04
- ;; 03 FACILITY NUMBER X(02) 05-06
- ;; 04 FISCAL YEAR X(02) 07-08
- ;; 05 CLAIM NUMBER 9(10) 09-18
- ;; 06 RECORD TYPE X(01) ALWAYS 'I' 19-19
- ;; 07 SEQUENCE NUMBER 9(03) ALWAYS 001 20-22
- ;; 08 INTEREST CAN X(07) 23-29
- ;; 09 INTEREST OCC X(04) 30-33
- ;; 10 INTEREST RATE S9(05)V999 34-38
- ;; 11 DAYS ELIGIBLE 9(03) 39-41
- ;; 12 INTEREST PAID S9(09)V99 42-50
- ;; 13 ADD'L PENALTY PAID S9(06)V99 51-56
- ;; 14 TOT PD THIS CLAIM S9(10)V99 57-66
- ;; 15 FILLER X(14) 67-80
- ;;
- ;; H-SUMMARY
- ;; NUM NAME PIC COMMENTS LOC
- ;; --- ------------------ ----- ----------------------- -----
- ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- ;; 02 SERVICE UNIT X(02) 03-04
- ;; 03 FACILITY NUMBER X(02) 05-06
- ;; 04 FISCAL YEAR X(02) 07-08
- ;; 05 CLAIM NUMBER 9(10) 09-18
- ;; 06 RECORD TYPE X(01) ALWAYS 'H' 19-19
- ;; 07 SEQUENCE NUMBER 9(03) 001 OR 002 20-22
- ;; For 001:
- ;; 08 FACILITY CODE X(06) 23-28
- ;; FILLER X(12) 29-40
- ;; 11 TYPE 43 CLAIMS 9(05) 41-45
- ;; 12 TYPE 57 CLAIMS 9(05) 46-50
- ;; 13 TYPE 64 CLAIMS 9(05) 51-55
- ;; 14 TOTAL OF PAYMENTS S9(10)V99 56-65
- ;; 16 # OF OCC4319 PYMTS 9(05) 66-70
- ;; 15 TOT INT/LATE PEN S9(10)V99 71-80
- ;; For 002:
- ;; 09 PERIOD FROM DATE X(08) FORMAT CCYYMMDD 23-30
- ;; 10 PERIOD TO DATE X(08) FORMAT CCYYMMDD 31-38
- ;;
- ;; J-HEADING ;ACHS*3.1*23 ICD-10 REC
- ;; NUM NAME PIC COMMENTS LOC
- ;; --- ------------------ ----- ----------------------- -----
- ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- ;; 02 SERVICE UNIT X(02) 03-04
- ;; 03 FACILITY NUMBER X(02) 05-06
- ;; 04 FISCAL YEAR X(02) 07-08
- ;; 05 CLAIM NUMBER 9(10) 09-18
- ;; 06 RECORD TYPE X(01) ALWAYS 'J' 19-19
- ;; 07 SEQUENCE NUMBER 9(03) ALWAYS 001 20-22
- ;; 08 IHS COST S9(07)V99 23-31
- ;; 09 OBLIGATION IND X(01) 1=P.O. NBR, 2=SHR 424 32-32
- ;; 10 OBLIGATION AMOUNT S9(07)V99 FIELD WILL CONTAIN 33-41
- ;; ALL '*' IF IT IS NOT
- ;; APPLICABLE
- ;; 11 ADJUSTMENT AMOUNT S9(07)V99 FIELD WILL CONTAIN 42-50
- ;; ALL '*' IF IT IS NOT
- ;; APPLICABLE
- ;; 12 DIAGNOSIS CODE 1 X(08) 51-58
- ;; 13 DIAGNOSIS CODE 2 X(08) 59-66
- ;; 14 DIAGNOSIS CODE 3 X(08) 67-74
- ;; 15 FILLER X(06) 75-80
- ;;
- ACHSEOBR ;IHS/SET/GTH - EOBR RECORD FORMATS ; [ 12/06/2002 10:36 AM ]
- +1 ;;3.1;CONTRACT HEALTH MGMT SYSTEM;**5,22,23**;JUN 11, 2001;Build 43
- +2 ;IHS/SET/GTH ACHS*3.1*5 12/06/2002 - New routine.
- +3 ;
- +4 ;;EXPLANATION OF BENEFITS RECORDS LAYOUTS
- +5 ;; ( ALL RECORDS ARE 80 CHARACTERS )
- +6 ;; Pieces of info identifying the claim, PO, CHECK, PATIENT
- +7 ;; AUTHORIZING FACILITY, PROVIDER, ETC., ARE ON RECORD FORMATS A-E
- +8 ;; FILLER ADDED AS NEEDED.
- +9 ;;
- +10 ;; DETAIL RECORDS ARE ON FORMAT F,G & J. POSSIBLE 999
- +11 ;; LINES OF DETAIL PROCESSED UNDER A CLAIM CONTROL NUMBER (CCN).
- +12 ;; IF A CLAIM HAS MORE THAN 999 LINES OF DETAIL, IT IS SPLIT USING
- +13 ;; A "7" IN THE 6TH POSITION OF THE CCN WHERE A "0" NORMALLY
- +14 ;; APPEARS. IT WOULD BE TRANSMITTED AS A SEPARATE EOBR. EACH
- +15 ;; LINE HAS A NUMBER WHICH APPEARS ON FORMAT F FIELD 7. CLAIMS
- +16 ;; ARE SPLIT FOR OTHER REASONS ALSO (MATERNITY CLAIMS WHERE THE
- +17 ;; BILL INCLUDES CHARGES FOR MOM AND BABY, PROFESSIONAL FEES
- +18 ;; BILLED ON A UB-82, BILLING CYCLE UB-82 WITH A PATIENT DISCHARGE
- +19 ;; OF 30). THE MULTIPLE CLAIM INDICATOR IS NOT SENT ON THE EOBR.
- +20 ;; HOWEVER, ANY CLAIM WITH A CCN THAT HAS A "7" IN THE SIXTH POSITION
- +21 ;; IS A SPLIT CLAIM. THESE MAY NEED TO BE HANDLED IN SOME UNIQUE
- +22 ;; WAY BY IHS TO POST THE PAYMENT TO THE CHS/MIS SYSTEM AND UPDATE
- +23 ;; THE COMMITMENT REGISTER RECOGNIZING ANOTHER PAYMENT FOR THAT
- +24 ;; PO NUMBER WILL BE FORTHCOMING.
- +25 ;;
- +26 ;; ANOTHER KEY ELEMENT MIGHT BE THE INTERIM/FINAL PAYMENT WHICH
- +27 ;; APPEARS ON FORMAT C FIELD 13. THE FI'S SYSTEM IDENTIFIES THE
- +28 ;; SPLIT CLAIMS AND SENDS THE EOBR AND PAYMENT DHR AS AN INTERIM
- +29 ;; UNLESS IT IS THE LAST CLAIM PROCESSED WITH THAT PURCHASE ORDER
- +30 ;; NUMBER WHICH BECOMES THE FINAL, AND CLOSES THE SHR424 OBLIGATION.
- +31 ;; AN INTERIM DECREASES THE OBLIGATION AMOUNT BUT DOES NOT CLOSE IT.
- +32 ;; EOBR AND DHR FOR BLANKET PO'S ARE REPORTED AS INTERIM PAYMENTS.
- +33 ;;
- +34 ;; A - HEADING
- +35 ;; B - HEADING
- +36 ;; C - HEADING
- +37 ;; D - HEADING
- +38 ;; E - HEADING
- +39 ;; F - DETAIL
- +40 ;; G - PROCEDURE CODES
- +41 ;; H - SUMMARY
- +42 ;; A - HEADING
- +43 ;; NUM NAME PIC COMMENTS LOC
- +44 ;; --- ------------------ ----- ----------------------- -----
- +45 ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- +46 ;; 02 SERVICE UNIT X(02) 03-04
- +47 ;; 03 FACILITY NUMBER X(02) 05-06
- +48 ;; 04 FISCAL YEAR X(02) 07-08
- +49 ;; 05 CLAIM NUMBER 9(10) 2ND PART OF CONTROL NBR 09-18
- +50 ;; 06 RECORD TYPE X(01) ALWAYS 'A' 19-19
- +51 ;; 07 SEQUENCE NUMBER 9(03) ALWAYS 001 20-22
- +52 ;; 08 CLAIM SEQUENCE CNT 9(09) A COUNT ON 2ND LINE OF 23-31
- +53 ;; REPORT
- +54 ;; 09 CHECK NUMBER 9(07) 32-38
- +55 ;; 10 REMITTANCE NBR 9(07) 39-45
- +56 ;; 11 PAID DATE X(08) FORMAT CCYYMMDD 46-53
- +57 ;; 12 PURCHASE ORDER NBR X(12) FORMAT XX-XXX-XXXXX 54-65
- +58 ;; 13 CERTIFICATE NBR X(07) 1ST PART OF CONTROL NBR 66-72
- +59 ;; 14 FACILITY CODE X(06) 73-78
- +60 ;; 15 DOCUMENTATION TYPE X(02) 79-80
- +61 ;;
- +62 ;; B - HEADING
- +63 ;; NUM NAME PIC COMMENTS LOC
- +64 ;; --- ------------------ ----- ----------------------- -----
- +65 ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- +66 ;; 02 SERVICE UNIT X(02) 03-04
- +67 ;; 03 FACILITY NUMBER X(02) 05-06
- +68 ;; 04 FISCAL YEAR X(02) 07-08
- +69 ;; 05 CLAIM NUMBER 9(10) 09-18
- +70 ;; 06 RECORD TYPE X(01) ALWAYS 'B' 19-19
- +71 ;; 07 SEQUENCE NUMBER 9(03) ALWAYS 001 20-22
- +72 ;; 08 PATIENT NAME X(30) 23-52
- +73 ;; 09 HEALTH RECORD NBR X(07) 53-59
- +74 ;; 10 AUTHORIZATION DATE X(08) FORMAT CCYYMMDD 60-67
- +75 ;; 11 ACTUAL DAYS 9(02) INPATIENT DAYS 68-69
- +76 ;; 12 DRG 9(03) 70-72
- +77 ;;ACHS*3.1*22 FIXED SCC
- +78 ;; 14 SERVICE CLASS CODE X(04) 73-76
- +79 ;; 15 FILLER X(02) 77-80
- +80 ;;***PRIOR TO PATCH ACHS*3.1*22
- +81 ;; 13 DISCHARGE STATUS X(02) 73-74
- +82 ;; 14 SERVICE CLASS CODE X(04) 75-78
- +83 ;; 15 FILLER X(02) 79-80
- +84 ;;
- +85 ;; C - HEADING
- +86 ;; NUM NAME PIC COMMENTS LOC
- +87 ;; --- ------------------ ----- ----------------------- -----
- +88 ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- +89 ;; 02 SERVICE UNIT X(02) 03-04
- +90 ;; 03 FACILITY NUMBER X(02) 05-06
- +91 ;; 04 FISCAL YEAR X(02) 07-08
- +92 ;; 05 CLAIM NUMBER 9(10) 09-18
- +93 ;; 06 RECORD TYPE X(01) ALWAYS 'C' 19-19
- +94 ;; 07 SEQUENCE NUMBER 9(03) 001 OR 002 20-22
- +95 ;; For 001:
- +96 ;; 08 COMMON ACCT NBR X(16) 23-38
- +97 ;; 09 OBJECT CLASS CODE X(04) 39-42
- +98 ;; 10 SERVICES BILLED X(01) A = PROF B = INPATIENT 43-43
- +99 ;; C = OUTPAT D = DENTAL
- +100 ;; 11 BLANKET INDICATOR X(01) Y = YES, ELSE NO 44-44
- +101 ;; 12 CONTRACT NUMBER X(10) 45-54
- +102 ;; 13 INTERIM/FINAL IND X(01) F = FINAL I = INTERIM 55-55
- +103 ;; 16 VENDOR NUMBER X(13) PROVIDER ID - SUFFIX 56-68
- +104 ;; FILLER 69-80
- +105 ;; For 002:
- +106 ;; 14 SERVICE START DATE X(08) FORMAT CCYYMMDD 23-30
- +107 ;; 15 SERVICE END DATE X(08) FORMAT CCYYMMDD 31-38
- +108 ;;
- +109 ;; D - HEADING
- +110 ;; NUM NAME PIC COMMENTS LOC
- +111 ;; --- ------------------ ----- ----------------------- -----
- +112 ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- +113 ;; 02 SERVICE UNIT X(02) 03-04
- +114 ;; 03 FACILITY NUMBER X(02) 05-06
- +115 ;; 04 FISCAL YEAR X(02) 07-08
- +116 ;; 05 CLAIM NUMBER 9(10) 09-18
- +117 ;; 06 RECORD TYPE X(01) ALWAYS 'D' 19-19
- +118 ;; 07 SEQUENCE NUMBER 9(03) ALWAYS 001 20-22
- +119 ;; 08 VENDOR NAME X(30) 23-52
- +120 ;; 09 BILLED BY PROVIDER S9(07)V99 FIELD WILL CONTAIN 53-61
- +121 ;; ALL '*' IF IT IS NOT
- +122 ;; APPLICABLE
- +123 ;; 10 ALLOWABLE AMOUNT S9(07)V99 62-70
- +124 ;; 11 PAID BY 3RD PARTY S9(07)V99 71-79
- +125 ;; 12 FILLER X(01) 80-80
- +126 ;;
- +127 ;; E - HEADING
- +128 ;; NUM NAME PIC COMMENTS LOC
- +129 ;; --- ------------------ ----- ----------------------- -----
- +130 ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- +131 ;; 02 SERVICE UNIT X(02) 03-04
- +132 ;; 03 FACILITY NUMBER X(02) 05-06
- +133 ;; 04 FISCAL YEAR X(02) 07-08
- +134 ;; 05 CLAIM NUMBER 9(10) 09-18
- +135 ;; 06 RECORD TYPE X(01) ALWAYS 'E' 19-19
- +136 ;; 07 SEQUENCE NUMBER 9(03) ALWAYS 001 20-22
- +137 ;; 08 IHS COST S9(09)V99 23-31
- +138 ;; 09 OBLIGATION IND X(01) 1=P.O. NBR, 2=SHR 424 32-32
- +139 ;; 10 OBLIGATION AMOUNT S9(09)V99 FIELD WILL CONTAIN 33-41
- +140 ;; ALL '*' IF IT IS NOT
- +141 ;; APPLICABLE
- +142 ;; 11 ADJUSTMENT AMOUNT S9(09)V99 FIELD WILL CONTAIN 42-50
- +143 ;; ALL '*' IF IT IS NOT
- +144 ;; APPLICABLE
- +145 ;; 12 DIAGNOSIS CODE 1 X(06) 51-56 ;ACHS*3.1*23
- +146 ;; 13 DIAGNOSIS CODE 2 X(06) 57-62 ;ACHS*3.1*23
- +147 ;; 14 DIAGNOSIS CODE 3 X(06) 63-68 ;ACHS*3.1*23
- +148 ;; 15 DIAGNOSIS CODE 4 X(06) 69-74 ;ACHS*3.1*23
- +149 ;; 16 DIAGNOSIS CODE 5 X(06) 75-80 ;ACHS*3.1*23
- +150 ;;
- +151 ;; F - DETAIL
- +152 ;; NUM NAME PIC COMMENTS LOC
- +153 ;; --- ------------------ ----- ----------------------- -----
- +154 ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- +155 ;; 02 SERVICE UNIT X(02) 03-04
- +156 ;; 03 FACILITY NUMBER X(02) 05-06
- +157 ;; 04 FISCAL YEAR X(02) 07-08
- +158 ;; 05 CLAIM NUMBER 9(10) 09-18
- +159 ;; 06 RECORD TYPE X(01) ALWAYS 'F' 19-19
- +160 ;; 07 SEQUENCE NUMBER 9(03) FROM 001 TO 999 20-22
- +161 ;; 08 FROM DATE OF SVC X(08) FORMAT CCYYMMDD 23-30
- +162 ;; 09 TO DATE OF SVC X(09) FORMAT CCYYMMDD 31-38
- +163 ;; 10 PROCEDURE CODE X(05) 39-43
- +164 ;; 11 UNITS BILLED 9(03) 44-46
- +165 ;; 12 BILLED CHARGES S9(07)V99 47-55
- +166 ;; 13 ALLOWABLE CHARGES S9(07)V99 56-64
- +167 ;; 14 MESSAGE X(04) 65-68
- +168 ;; 15 TOOTH NUMBER X(02) 69-70
- +169 ;; 16 TOOTH SURFACE X(05) 71-75
- +170 ;; 17 FILLER X(05) 76-80
- +171 ;;
- +172 ;; G - PROCEDURES
- +173 ;; NUM NAME PIC COMMENTS LOC
- +174 ;; --- ------------------ ----- ----------------------- -----
- +175 ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- +176 ;; 02 SERVICE UNIT X(02) 03-04
- +177 ;; 03 FACILITY NUMBER X(02) 05-06
- +178 ;; 04 FISCAL YEAR X(02) 07-08
- +179 ;; 05 CLAIM NUMBER 9(10) 09-18
- +180 ;; 06 RECORD TYPE X(01) ALWAYS 'G' 19-19
- +181 ;; 07 SEQUENCE NUMBER 9(03) ALWAYS 001 20-22
- +182 ;; 08 PROCEDURE CODE 1 9(07) 23-29 ;ACHS*3.1*23
- +183 ;; 09 PROCEDURE CODE 2 9(07) 30-36 ;ACHS*3.1*23
- +184 ;; 10 PROCEDURE CODE 3 9(07) 37-43 ;ACHS*3.1*23
- +185 ;; 09 PROCEDURE CODE 4 9(07) 44-50 ;ACHS*3.1*23
- +186 ;; 10 PROCEDURE CODE 5 9(07) 51-57 ;ACHS*3.1*23
- +187 ;; 11 FILLER X(23) 58-80 ;ACHS*3.1*23
- +188 ;;
- +189 ;; I-INTEREST INFO FOR A GIVEN CLAIM
- +190 ;; NUM NAME PIC COMMENTS LOC
- +191 ;; --- ------------------ ----- ----------------------- -----
- +192 ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- +193 ;; 02 SERVICE UNIT X(02) 03-04
- +194 ;; 03 FACILITY NUMBER X(02) 05-06
- +195 ;; 04 FISCAL YEAR X(02) 07-08
- +196 ;; 05 CLAIM NUMBER 9(10) 09-18
- +197 ;; 06 RECORD TYPE X(01) ALWAYS 'I' 19-19
- +198 ;; 07 SEQUENCE NUMBER 9(03) ALWAYS 001 20-22
- +199 ;; 08 INTEREST CAN X(07) 23-29
- +200 ;; 09 INTEREST OCC X(04) 30-33
- +201 ;; 10 INTEREST RATE S9(05)V999 34-38
- +202 ;; 11 DAYS ELIGIBLE 9(03) 39-41
- +203 ;; 12 INTEREST PAID S9(09)V99 42-50
- +204 ;; 13 ADD'L PENALTY PAID S9(06)V99 51-56
- +205 ;; 14 TOT PD THIS CLAIM S9(10)V99 57-66
- +206 ;; 15 FILLER X(14) 67-80
- +207 ;;
- +208 ;; H-SUMMARY
- +209 ;; NUM NAME PIC COMMENTS LOC
- +210 ;; --- ------------------ ----- ----------------------- -----
- +211 ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- +212 ;; 02 SERVICE UNIT X(02) 03-04
- +213 ;; 03 FACILITY NUMBER X(02) 05-06
- +214 ;; 04 FISCAL YEAR X(02) 07-08
- +215 ;; 05 CLAIM NUMBER 9(10) 09-18
- +216 ;; 06 RECORD TYPE X(01) ALWAYS 'H' 19-19
- +217 ;; 07 SEQUENCE NUMBER 9(03) 001 OR 002 20-22
- +218 ;; For 001:
- +219 ;; 08 FACILITY CODE X(06) 23-28
- +220 ;; FILLER X(12) 29-40
- +221 ;; 11 TYPE 43 CLAIMS 9(05) 41-45
- +222 ;; 12 TYPE 57 CLAIMS 9(05) 46-50
- +223 ;; 13 TYPE 64 CLAIMS 9(05) 51-55
- +224 ;; 14 TOTAL OF PAYMENTS S9(10)V99 56-65
- +225 ;; 16 # OF OCC4319 PYMTS 9(05) 66-70
- +226 ;; 15 TOT INT/LATE PEN S9(10)V99 71-80
- +227 ;; For 002:
- +228 ;; 09 PERIOD FROM DATE X(08) FORMAT CCYYMMDD 23-30
- +229 ;; 10 PERIOD TO DATE X(08) FORMAT CCYYMMDD 31-38
- +230 ;;
- +231 ;; J-HEADING ;ACHS*3.1*23 ICD-10 REC
- +232 ;; NUM NAME PIC COMMENTS LOC
- +233 ;; --- ------------------ ----- ----------------------- -----
- +234 ;; 01 AREA OFFICE X(02) MUST BE A VALID AREA 01-02
- +235 ;; 02 SERVICE UNIT X(02) 03-04
- +236 ;; 03 FACILITY NUMBER X(02) 05-06
- +237 ;; 04 FISCAL YEAR X(02) 07-08
- +238 ;; 05 CLAIM NUMBER 9(10) 09-18
- +239 ;; 06 RECORD TYPE X(01) ALWAYS 'J' 19-19
- +240 ;; 07 SEQUENCE NUMBER 9(03) ALWAYS 001 20-22
- +241 ;; 08 IHS COST S9(07)V99 23-31
- +242 ;; 09 OBLIGATION IND X(01) 1=P.O. NBR, 2=SHR 424 32-32
- +243 ;; 10 OBLIGATION AMOUNT S9(07)V99 FIELD WILL CONTAIN 33-41
- +244 ;; ALL '*' IF IT IS NOT
- +245 ;; APPLICABLE
- +246 ;; 11 ADJUSTMENT AMOUNT S9(07)V99 FIELD WILL CONTAIN 42-50
- +247 ;; ALL '*' IF IT IS NOT
- +248 ;; APPLICABLE
- +249 ;; 12 DIAGNOSIS CODE 1 X(08) 51-58
- +250 ;; 13 DIAGNOSIS CODE 2 X(08) 59-66
- +251 ;; 14 DIAGNOSIS CODE 3 X(08) 67-74
- +252 ;; 15 FILLER X(06) 75-80
- +253 ;;
