*** Effective Date: 01/30/2023
*** Master ***
"1220","Electronic Eligibility 01/30/23","Eligibility ","Y"
*** Option ***
"1","0","1220","LOC_1","10","4"," ","0","","N","zz1000.15 NM1*41 Submitter Information (NA)","Invisible for Loop 1000A NM1*41 and NM1*85","Y",""
"2","0","1220","LOC_2","0","4"," ","30","","N","Miscellaneous Information","Enter 30 Character Constant or choose to Bypass"," ",""
"3","0","1220","LOC_3","12","4","F","0","","N","2300.40 REF*EA Patient Claim Reference Number","Select Value for Loop 2300 REF*EA "," ",""
"5","0","1220","LOC_5","17","4"," ","0",""," ","Federal Tax ID",""," ",""
"12","0","1220","LOC_12","30","1","N","0","","N","2100.40 NM1*IL Subscriber Name","Select for Loop 2100C NM1*IL*03 (Last Name) and 04 (First Name)"," ",""
"13","0","1220","LOC_13","31","4"," ","0","","N","Patient Address (NA)",""," ",""
"14","0","1220","LOC_14","32","1","N","0","","N","2100.60 DMG Subscriber Birthday","Select for Loop 2100C DMG*02"," ",""
"15","0","1220","LOC_15","33","1"," ","0","","N","Patient Sex",""," ",""
"16","0","1220","LOC_16","0","4"," ","0","","N","Patient Marital Status (NA)",""," ",""
"17","0","1220","LOC_17","0","4"," ","0","","N","2300.20 DTP*435 Admission Date","Select Value for Loop 2300 DTP*435"," ",""
"23","0","1220","LOC_23","0","4"," ","0","","N","Medical Record Number (NA)",""," ",""
"38","0","1220","LOC_38","55","4"," ","0","","N","Responsible Party (NA)","","Y",""
"45","0","1220","LOC_45","1023","1","N","0","","N","2100.70 DTP*472 Subscriber Date Options","Select Loop 2100C DTP*472 Value"," ",""
"50","0","1220","LOC_50","1","2","Y","12","CMS","N","2010.20 NM1*PR*03 Information Source Name","Select for Loop 2010A NM1*PR*03 Information Source Name","Y",""
"50","1","1220","LOC_50A","0","0","N","2","PI"," ","2010.25 NM1*PR*08 Information Source ID Qualifier","Select for Loop 2010A NM1*PR*08 Info Source Qualifier (FI=Fiscal Intermed; 46=ElecTrans#) "," ",""
"51","2","1220","LOC_51B","1","2","Y","20","CMS"," ","2010.30 NM1*PR*09 Information Source ID","Select for Loop 2010B NM1*PR*09 Info Source ID"," ",""
"51","3","1220","LOC_51C","0","4","N","0",""," ","2010.52 N3/N4 Info Source Address","Select for Loop 2010B N3/N4 following NM1*PR","Y",""
"56","0","1220","LOC_56","67","2","Y","15","","N","2100.09 NM1*1P Receiver ID (Agency ID) ","Select for Loop 2010A NM1*IP*09 Information Receiver ID (Note: Receiver name is agency name)"," ",""
"56","2","1220","LOC_56B","0","0","N","2","XX"," ","2100.08 NM1*1P Receiver Qualifier","Select for Loop 2010A NM1*IP*08 Info Receiver Qualifier (SV=Provider No; XX=NPI)"," ",""
"58","0","1220","LOC_58","30","4"," ","0","","N","Insured Name (NA)","","Y",""
"59","0","1220","LOC_59","0","4"," ","0","","N","Patient Relationship (NA)","","Y",""
"60","0","1220","LOC_60","88","2","N","20","","N","2100.50 NM1*IL Subscriber Contract or ID ","Select for Loop 2100C NM1*IL*09","Y",""
"61","0","1220","LOC_61","0","4"," ","0","","N","Insurance Group Name (NA)","","Y",""
"62","0","1220","LOC_62","0","4"," ","0","","N","Insurance Group Number (NA)","","Y",""
"100","0","1220","UNIT_FORMAT","0","4"," ","0","","N","9000.54 Format - Units","Select Format For Units"," ",""
"101","0","1220","MONEY_FORMAT","0","4"," ","0","","N","9000.52 Format - Money","Select Format for Dollar Values"," ",""
"102","0","1220","ZIP_FORMAT","0","4"," ","0",""," ","9000.50 Format - Zip Code","Select Format for Zip Codes"," ",""
"103","0","1220","PPS_ACTIVE","1500","1","Y","0","","Y","9000.32 Bill Processing Type","Select Appropriate Value "," ",""
"105","0","1220","CLAIM_FORMAT","207","4","Y","0","","Y","9000.30 X12 Format",""," ",""
"105","1","1220","CLAIM_VERSION","212","1","Y","0",""," ","9000.25 X12 Version",""," ",""
"150","0","1220","SEL_INS","0","1"," ","250",""," ","9000.90 Selected Insurances",""," ",""
"200","0","1220","SNDRID","73","0"," ","15","Your Submitter ID","N","0100.06 ISA*06 Interchange Sender ID","Select for Interchange Control Header (ICH) ISA*06 Sender ID"," ",""
"201","0","1220","RCVRID","1","0"," ","15","CMS","N","0100.08 ISA*08 Interchange Receiver ID","Select for (ICH) ISA*08 Receiver ID"," ",""
"201","1","1220","RCVRQUAL","1","0"," ","2","ZZ"," ","0100.07 ISA*07 Interchange Receiver Qualifier","Select for (ICH) ISA*07 Qualifier if not 28(Medicare) or ZZ(Other)"," ",""
"201","2","1220","RCVRACK","0","1","Y","0",""," ","0100.14 ISA*14 Interchange Acknowlegement","Select for (ICH) ISA*14 Acknowledgement Code (0 is default)"," ",""
"201","4","1220","APPSID","1","0"," ","15",""," ","0200.02 GS*02 Application Sender ID","Select for Functional Group Header (FGH)  GS*02 Sender ID if not ISA*06 Sender ID"," ",""
"201","5","1220","APPRID","1","0"," ","15",""," ","0200.03 GS*03 Application Receiver ID","Select for (FGH)  GS*03 Receiver ID if not ISA*07 Receiver ID"," ",""
"201","6","1220","SUBID","1","4","N","15",""," ","zz1000.10 NM1*41 Submitter ID","Select for Loop 1000A NM1*41 if not ISA*06 Sender ID"," ",""
"202","0","1220","SERIAL","202","4"," ","0","","N","9000.20 Submission Serial Number (NA)",""," ",""
"203","0","1220","RCVID","1","4"," ","15",""," ","z1000.39 NM1*40 09 Information Receiver ID (Override)","Select for Loop 1000B NM1*40*09 (Receiver ID Override)"," ",""
"204","0","1220","RCVNAME","1","4"," ","25",""," ","z1000.33 NM1*40 03 Receiver Name (Override)","Select for Loop 1000B NM1*40*03 (Receiver Name Override)"," ",""
"205","0","1220","CRLF","205","1","Y","0",""," ","9000.10 Output file format type",""," ",""
*** Choice ***
"1","0","1220","11","1","Provider Information From Patient Unit"
"1","0","1220","10","2","Provider Information From Control File"
"2","0","1220","1","1","Enter Constant Value"
"3","0","1220","12","1","Patient Number"
"3","0","1220","13","2","Patient Medical Record Number"
"5","0","1220","17","1","System Federal Tax ID"
"12","0","1220","30","1","Patient Name"
"13","0","1220","31","1","Patient Address"
"14","0","1220","32","1","Patient Birthday"
"15","0","1220","33","1","Patient Sex"
"16","0","1220","34","1","Patient Marital Status"
"17","0","1220","35","1","Patient Admit Date"
"23","0","1220","14","1","Patient Number And Medical Record Number"
"23","0","1220","15","2","Patient Number And Bill Date"
"23","0","1220","12","3","Patient Number"
"23","0","1220","13","4","Patient Medical Record Number"
"23","0","1220","16","5","Medical Record Number And Bill Date"
"38","0","1220","55","1","Patient Name And Address"
"38","0","1220","56","2","Institution Transfered To (Hospice)"
"38","0","1220","54","3","Guarantor Name And Address"
"45","0","1220","36","1","Patient Referral Date"
"45","0","1220","51","2","Patient Certification From Date"
"45","0","1220","35","3","Patient Admit Date"
"45","0","1220","1","4","Subscriber Date (Entered)"
"45","0","1220","0","5","Bypass this Data Element"
"45","0","1220","1023","6","From and To Dates Selected"
"50","0","1220","66","1","Insurance Name (Current Insurance)"
"50","0","1220","1","2","Constant Value (Entered)"
"51","2","1220","71","1","Insurance Provider Number"
"51","2","1220","1","2","Constant Value (Entered)"
"51","3","1220","117","1","Insurance Name and Address (Current Insurance)"
"51","3","1220","11","2","Name/Address of First Patient Unit in Submission"
"56","0","1220","67","1","System NPI Number"
"56","0","1220","1","2","Constant Value (Entered)"
"58","0","1220","85","1","Set To 'PATIENT' (Primary Only)"
"58","0","1220","30","2","Patient Name"
"58","0","1220","83","3","Guarantor Name (Primary Only)"
"58","0","1220","84","4","Guarantor Name"
"59","0","1220","86","1","Guarantor Relation From Master File"
"60","0","1220","88","1","Insurance Contract (Current Insurance)"
"60","0","1220","1","2","Constant Value (Entered)"
"100","0","1220","3","1","Format Units With Leading Zeros"
"100","0","1220","2","2","Format Units With Leading Spaces"
"101","0","1220","6","1","Format Dollar Values Without Decimal Point Or Space"
"101","0","1220","4","2"," Format Dollar Values with Decimal Space"
"101","0","1220","5","3","Format Dollar Values With Decimal Point"
"102","0","1220","1039","1","Format full 9 digit zip"
"102","0","1220","1042","2","Format full 9 digit zip no dash"
"103","0","1220","1500","1","Process Type: PPS"
"103","0","1220","1497","2","Process Type: Non-PPS"
"103","0","1220","1499","3","Process Type: Medicaid"
"103","0","1220","1498","4","Process Type: Commercial"
"103","0","1220","1496","5","Process Type: PPS Secondary"
"105","0","1220","207","1","Institutional claim format"
"105","0","1220","208","2","Professional claim format"
"105","1","1220","211","1","X12 version 4010"
"105","1","1220","212","2","X12 version 5010"
"150","0","1220","74","1","Store and Auto Select Insurances"
"200","0","1220","1","1","Constant Value (Entered)"
"200","0","1220","73","2","Medicare Submitter Number"
"201","2","1220","0","1","Default (0)"
"201","2","1220","74","2","Constant (1)"
"203","0","1220","72","1","Insurance Submitter Number"
"203","0","1220","1","2","Constant Value (Entered)"
"205","0","1220","205","1","EBill create output file WITH CR/LF"
"205","0","1220","206","2","EBill create output file WITHOUT CR/LF"
