*** Effective Date: 5/13/2025
*** Master ***
"1151","Electronic 837 (Baseline) 04/02/25","UB92        ","Y"
*** Option ***
"1","0","1151","LOC_1","10","4"," ","0","","N","1000.15 NM1*41 Submitter Information (NA)","Invisible Value for NM1*41 and NM1*85","Y",""
"2","0","1151","LOC_2","0","4"," ","30","","N","Miscellaneous Information","Enter 30 Character Constant or choose to Bypass"," ",""
"3","0","1151","LOC_3","12","1","F","0","","N","2300.52 REF*EA Patient Claim Reference Number","Select for Loop 2300 REF*EA Claim Reference"," ",""
"3","1","1151","LOC_3B","16","4"," ","0",""," ","Patient MedRec (View)",""," ",""
"4","0","1151","LOC_4","62","0","Y","3","32S","N","2300.05 CLM*05 Type Of Bill","Enter 3 Character Type-of-Bill Code:      => Use the Help Button Above for Instructions <="," ",""
"5","0","1151","LOC_5","17","4"," ","0","","N","Federal Tax ID (NA)",""," ",""
"6","0","1151","LOC_6","22","1"," ","0","","N","2300.30 DTP*434 Claim Covered Period","Select for Loop 2300 DTP*434 Claim Covered Period","Y",""
"7","0","1151","LOC_7","0","4"," ","0","","N","Cov D. (NA)",""," ",""
"8","0","1151","LOC_8A","0","4"," ","0",""," ","Patient ID (View)","","Y",""
"8","1","1151","LOC_8B","30","4"," ","0",""," ","Patient Name (View)","","Y",""
"9","0","1151","LOC_9","55","4"," ","0",""," ","Patient Address (View)","","Y",""
"10","0","1151","LOC_10","32","4"," ","0",""," ","Birth (View)",""," ",""
"11","0","1151","LOC_11","33","4"," ","0","","N","Sex (View)",""," ",""
"12","0","1151","LOC_12","30","4"," ","0","","N","Patient Name (NA)",""," ",""
"13","0","1151","LOC_13","31","4"," ","0","","N","Patient Address (NA)",""," ",""
"14","0","1151","LOC_14","32","4","Y","0","","N","Patient Birthday (NA)",""," ",""
"15","0","1151","LOC_15","33","4"," ","0","","N","Patient Sex (NA)",""," ",""
"16","0","1151","LOC_16","34","4"," ","0","","N","Patient Marital Status (NA)",""," ",""
"17","0","1151","LOC_17","35","1"," ","0","","N","2300.33 DTP*435 Admission Date","Select for Loop 2300 DTP*435 Admission Date"," ",""
"19","0","1151","LOC_19","0","4"," ","1","","N","Admission Code (NA)",""," ",""
"19","1","1151","LOC_19A","1","2","F","1","9"," ","2300.41 CL1*01 Institutional Claim Code","Select for Loop 2300 CL1 01 Claim code (Note: CL*01-02-03 are Institutional Only)"," ",""
"20","0","1151","LOC_20","1","2","Y","1","1","N","2300.42 CL1*02 Admission Source Code (1 Char Max)","Select for Loop 2300 CL1 02 Admit Source"," ",""
"21","0","1151","LOC_21","0","1","Y","0",""," ","2300.28 DTP*096 Discharge Hour","Select for Loop 2300 DTP*096 Discharge Hour","N",""
"22","0","1151","LOC_22","40","2","Y","2","","N","2300.43 CL1*03 Patient Status","Select for Loop 2300 CL1 03 Patient Status (Note: Default is 30-Active/01-Disch)"," ",""
"22","1","1151","LOC_22A","0","2"," ","60",""," ","2300.47 PWK Claim Supplemental Paperwork","Example: Enter [OZ*FX***AC*DCN120] if faxing claim supporting document DCN120"," ",""
"23","0","1151","LOC_23","13","4"," ","0","","N","Medical Record Number (NA)",""," ",""
"24","0","1151","LOC_24","0","2"," ","2","","N","2300.70 HI*BG Condition Code 1","Select for Loop 2300 HI*BG 02 Cond Code 1"," ",""
"25","0","1151","LOC_25","0","2"," ","2","","N","2300.71 HI*BG Condition Code 2","Select for Loop 2300 HI*BG 02 Cond Code 2"," ",""
"30","0","1151","LOC_30","0","2"," ","2","","N","2300.72 HI*BG Condition Code 7","Select for Loop 2300 HI*BG 02 Code Code 7"," ",""
"32","0","1151","LOC_32","0","2"," ","2","","N","2300.73 HI*BH Occurrence Code/Date A","Select for Loop 2300 HI*BH Occurrence A","N",""
"33","0","1151","LOC_33","0","2"," ","2",""," ","2300.74 HI*BH Occurrence Code/Date B","Select for Loop 2300 HI*BH Occurrence B"," ",""
"34","0","1151","LOC_34","0","2"," ","2",""," ","2300.75 HI*BH Occurrence Code/Date C","Select for Loop 2300 HI*BH Occurrence C"," ",""
"35","0","1151","LOC_35","0","2"," ","2",""," ","2300.78 HI*BI Occurrence Date Span ","Select for Loop 2300 HI*BI Occurrence Date Span","Y",""
"36","0","1151","LOC_36","0","4"," ","0","","N","Occurrence Code/Span (NA)",""," ",""
"37","0","1151","LOC_37","0","4"," ","0","","N","Untitled (NA)",""," ",""
"38","0","1151","LOC_38","55","4"," ","0","","N","Responsible Party (NA)","","Y",""
"39","0","1151","LOC_39","63","2"," ","2","","N","2300.65 HI*BE Value Code Amount A","Select for Loop 2300 HI*BE Value Code A"," ",""
"40","0","1151","LOC_40","0","2"," ","2","","N","2300.66 HI*BE Value Code Amount B","Select for Loop 2300 HI*BE Value Code B"," ",""
"41","0","1151","LOC_41","0","2"," ","2","","N","2300.67 HI*BE Value Code Amount C ","Select for Loop 2300 HI*BE Value Code C"," ",""
"42","0","1151","LOC_42_ITEMIZATION","501","5"," ","0","  1X XV  2X XV  3X XV  4X XV  5X XV  6X XV  7X XV  8X XS","N","2390.15 Charge Itemizations","Select for Loop 2400 Modality/Visit/Charge Options","Y",""
"42","1","1151","LOC_42_SORTING","1004","4","F","0","","Y","2390.14 Charge Sorting Options","Select for Loop 2400 Sort Order (Not Visible)"," ",""
"42","2","1151","LOC_42_SUMMARY","1006","4"," ","0","","Y","2390.13 Summary Line Options","Select for Loop 2400 Summary Line Options (Not Visible)"," ",""
"42","3","1151","LOC_42_ITEM_CONSOLIDATION","1011","1","Y","0","","Y","2390.12 Charge Itemized Consolidation Options","Select for Loop 2400 Charge Consolidation Option"," ",""
"42","4","1151","LOC_42_TOTAL_LINES","1015","1","Y","0","","Y","2290.10 Claim Loop Options","Select for Loop 2300 Claim Loop Options"," ",""
"42","5","1151","LOC_42_OPTIONS","0","4","F","0","","Y","Revenue Code","Select Appropriate Option"," ",""
"42","6","1151","LOC_42_REV_CODES","0","4","F","0","","Y","Revenue Code Selection","Mark Desired Modalities","Y",""
"42","7","1151","LOC_42_DATA","500","4"," ","0","","N","Data Retireval (not Visible to end user)","","Y",""
"43","0","1151","LOC_43","0","4","F","0","","Y","Revenue Descriptions","Select Appropriate Format"," ",""
"44","0","1151","LOC_44","1027","1","Y","0","","Y","2400.02 SV1*01/SV2*02 HCPCS/Rate Code","Select for Loop 2400 SV2*02 (Inst) or SV1*01 (Prof) Hcpcs/Rate Value"," ",""
"44","1","1151","LOC_44A","0","1"," ","0",""," ","2400.04 SV1*01-7/SV2*02-7 Description","Select for Loop 2400 SV2*02-7 (Inst) or SV1*01-7 (Prof) Description"," ",""
"44","2","1151","LOC_44B","74","1","Y","0",""," ","2400.05 SV2*04 Unit of Measure","Select for Loop 2400 SV2*04 (Inst only) Unit of Measure (UN is default)"," ",""
"45","0","1151","LOC_45","1029","1","Y","0","","Y","2400.30 DTP*472 Service Date Options","Select for Loop 2400 DTP*472 Service Date Value"," ",""
"45","5","1151","LOC_45C","0","1","N","0",""," ","2400.35 REF*6R Line Item Control #","Select for Loop 2400 REF*6R Line Item Control Number"," ",""
"45","6","1151","LOC_45D","0","4"," ","0",""," ","2410.04 LIN*02/03 Drug Identification","Select for Loop 2410 LIN*02 Qualifier(N4) and LIN*03 NDC Code (NOT VISIBLE)"," ",""
"45","7","1151","LOC_45E","0","4"," ","0",""," ","2410.05 CTP*04/05 Drug Quantity","Select for Loop 2410 CTP*04 Quantity and CTP*05 Unit of Measure (NOT VISIBLE)"," ",""
"45","8","1151","LOC_45F","0","2"," ","3",""," ","2400.38 NTE Line Item Note","Select for Loop 2400 NTE Line Item Note (Enter Qualifier in Constant Value if not ADD)"," ",""
"46","0","1151","LOC_46","0","4","Y","0","","Y","2390.16 Charge Service Units","Select Unit Format for Each Applicable Modality","Y",""
"47","0","1151","LOC_47","1030","1","Y","0","","Y","2400.03 SV1*02/SV2*03 Charge Amount","Select for Loop 2400 SV2*03 (Inst) or SV1*02 (Prof) Charge Amount"," ",""
"47","1","1151","LOC_47A","0","1","Y","0",""," ","2390.17 Credit All Charges","Put minus signs before all charge and unit amounts to allow for credit billing"," ",""
"47","2","1151","LOC_47B","0","1","F","0",""," ","2390.18 Charge Gross When Rounding Hours","Compute gross amount based on rounded hours (only rounded hour modalities)"," ",""
"47","3","1151","LOC_47C","0","1","N","0","","Y","2400.06 SV2*06 Unit Rate","Select for Loop 2400 SV2*06 (Inst) Unit Rate Amount"," ",""
"47","4","1151","LOC_47D","0","1","N","0",""," ","2390.19 Always Include Zero Net Charges","Include zero net charges in every case."," ",""
"47","5","1151","LOC_47E","0","2"," ","4",""," ","2390.20 Maximum Service-Lines or Claims","Select the maximum service lines per claim or maximum claims (bypass default is NO Maximum)"," ",""
"47","6","1151","LOC_47F","0","1"," ","0","","N","2390.21 Top Revenue Line Options","Top Revenue charge line options (Note: PPS defaults to Revenue 0023 w/Qty1 HIPPS line)"," ",""
"47","7","1151","LOC_47G","0","2"," ","2",""," ","2390.22 Override Units Option","Enter number of units to substitute for the [1/x Units] billing units option.  Default is 8."," ",""
"47","8","1151","LOC_47H","","2","N","12",""," ","2390.23 Professional Service Rate Line","Enter the Procedure Code and Optional Modifier (only 1 per claim will be exported) "," ",""
"48","0","1151","LOC_48","1034","1","F","0","","Y","2400.07 SV2*07 Non Covered Charges","Select for Loop 2400 SV2*07 (institutional only) Non-covered Charges","F",""
"49","0","1151","LOC_49","0","1"," ","0",""," ","2420.20 NM1*XX Charge Specific Provider","Select for Loop 2420A NM1*XX  Charge Specific Provider","Y",""
"49","1","1151","LOC_49A","0","1","N","0",""," ","2430.10 SVD Service Line Adjudication","Select for Loop 2430 SVD adjudiction information"," ",""
"49","2","1151","LOC_49B","0","2"," ","15",""," ","2420.22 REF*G2 Charge Specific Secondary Provider","Select for Loop 2420A REF*G2 (professional only) Charge Secondary Provider"," ",""
"49","3","1151","LOC_49C","0","2"," ","15",""," ","2420.21 PRV*PE Rendering Provider Specialty","Select for Loop 2420A PRV*PE (professional only) Charge Rendering Provider Specialty"," ",""
"50","0","1151","LOC_50","66","2"," ","12","","N","1000.20 NM1*40 03 Receiver Name","Used in Loops 1000B NM1*40*03 (Receiver); 2000B SBR*04 (Subscriber); 2010B NM1*PR*04 (Payor)","Y",""
"50","1","1151","LOC_50A","0","2","Y","2",""," ","2010.30 SBR*09 Subscriber Payor Qualifier","Select for Loop 2000B SBR*09; MA=Medicare; MC=Medicaid; BL=Blue Cross; CI=Commercial","Y",""
"50","2","1151","LOC_50B","0","2"," ","20",""," ","2010.27 SBR*03 Subscriber Payor Group","Select for Loop 2000B SBR*03 Subscriber Payor Group"," ",""
"50","3","1151","LOC_50C","66","1"," ","0",""," ","2010.28 SBR*04 Subscriber Payor Name","Select for Loop 2000B SBR*04 Subscriber Payor Name"," ",""
"51","0","1151","LOC_51","17","2"," ","20","","N","2010.12 REF*02 Billing Provider Secondary ID","Select for 2010AA REF*02 Provider Secondary ID (Note: 5010 defaults to FedTaxID)","Y",""
"51","1","1151","LOC_51A","0","0","Y","2",""," ","2010.10 REF*01 Billing Provider Secondary ID Qualifier (5010 defaults to EI)","Select for 2010AA REF*01; 1A=BC; 1B=BS; 1C=Care; 1D=Caid; G2=Commercial; **=Bypass"," ",""
"51","2","1151","LOC_51B","0","2","Y","20",""," ","2010.80 NM1*PR Subscriber Payor ID","Select for Loop 2010BB NM1*PR*09 (If different from Receiver ID)"," ",""
"51","3","1151","LOC_51C","0","2"," ","0",""," ","2010.85 N3/N4 Subscriber Payor Address","Select for Loop 2010BB N3/N4 Address for NM1*PR","Y",""
"51","4","1151","LOC_51D","0","2"," ","20",""," ","2010.90 REF*G2/LU Billing Provider Secondary ID","Select for Loop 2010BB REF*G2/LU Billing Provider Secondary ID"," ",""
"51","5","1151","LOC_51E","0","1"," ","0",""," ","2010.92 REF*G2/LU Billing Provider Secondary Qualifier","Select for Loop 2010BB REF*G2/LU Billing Provider Secondary Qualifier (Default is G2)"," ",""
"52","0","1151","LOC_52","74","1","Y","0","","N","2300.09 CLM*09 Release Information","Select for Loop 2300 CLM*09 Release Info (Default is Y)","F",""
"52","1","1151","LOC_52A","0","1","Y","0",""," ","2300.07 CLM*07 Accept Assignment","Select for Loop 2300 CLM*07 Accept Assignment (Default is A)"," ",""
"52","2","1151","LOC_52B","0","2","Y","1",""," ","2300.10 CLM*10 Patient Signature Source","Select for Loop 2300 CLM*10 Signature Source (Default is Blank)"," ",""
"52","3","1151","LOC_52C","0","1","Y","0",""," ","2300.06 CLM*06 Provider Signature Indicator","Select for Loop 2300 CLM*06 Signature Indicator (Y/N) (Default is Blank)"," ",""
"52","4","1151","LOC_52D","0","1","N","0",""," ","2300.11 CLM*11 Related Causes (Prof Only)","Select for Loop 2300 CLM*11 Related Causes (Professional Only)","Y",""
"52","5","1151","LOC_52E","2","1","Y","0",""," ","2300.01 CLM*01 Claim Submitter ID","Select for Loop 2300 CLM*01 Claim Submitter ID (Default is short Format)"," ",""
"53","0","1151","LOC_53","0","1"," ","0","","N","2300.18 CLM*18 Assignment of Benefits","Select for Loop 2300 CLM*18 Assignment of Benefit","F",""
"54","0","1151","LOC_54","0","1"," ","0","","N","2300.38 AMT*F5 Patient Prior Payments","Select for Loop 2300  AMT*F5 02 Prior Paid","Y",""
"54","1","1151","LOC_54A","0","1","Y","0",""," ","2320.30 COB Coordination of Benefit Loop (Secondary Ins)","Payor and Amount for Secondary COB Loop 2320 SBR/CAS/AMT/DMG/OI"," ",""
"54","2","1151","LOC_54B","0","1","Y","0",""," ","2320.32 COB Insurance Sequence","Default is COB insurance is secondary to the Billed insurance"," ",""
"54","3","1151","LOC_54C","72","2","Y","20",""," ","2330.10 COB NM1*PR Insurance Payor ID","Default NM1*PR is Insurance Submitter Number"," ",""
"54","4","1151","LOC_54D","0","2","Y","15",""," ","2320.34 COB CAS*01/02 Claim Adjustment Group/Reason","Default CAS 01/02 value is PR*1","Y",""
"54","5","1151","LOC_54E","0","2","N","2",""," ","2320.35 COB AMT*01 Prior Payment Type","Default AMT*01 is D=Prior Paid;  A8=Non-Covered;  EAF=Remaining-Responsibility","Y",""
"54","6","1151","LOC_54F","0","1","Y","0",""," ","2330.20 COB DTP*03 Claim Adjudication Date","Default DTP*03 is Prior Payment Date","Y",""
"54","7","1151","LOC_54G","0","2","Y","10",""," ","2320.37 COB AMT*EAF Remaining Responsibility","Default AMT*EAF is Total Claim Amount from Claim line"," ",""
"54","8","1151","LOC_54H","0","2","Y","2",""," ","2320.33 COB SBR*09 Claim Indicator","Default Claim Indicator is (MA, CI, etc) based on other insurance payor type"," ",""
"54","21","1151","LOC_54P","0","1","Y","0",""," ","2340.30 COB Coordination of Benefit Loop (Tertiary Ins)","Payor/Amount for Tertiary COB Loops 2320 SBR/CAS/AMT/DMG/OI - 2320.30 Must be Active"," ",""
"55","0","1151","LOC_55","0","1"," ","0","","N","2300.37 AMT*F3 Estimated Amount Due","Select for Loop 2300 AMT*F3 02 Estimated Amt","Y",""
"56","0","1151","LOC_56","67","2","N","15","","N","2010.09 NM1*85 Billing Provider NPI","Select for Loop 2010A NM1*85*09  Billing Provider NPI"," ",""
"56","1","1151","LOC_56A","0","2","N","15",""," ","2000.20 PRV*BI Billing Provider Specialty","Select for Loop 2000A PRV*BI*03  (Note: Bypass Defaults to System File Taxonomy)"," ",""
"56","2","1151","LOC_56B","10","1","Y","0",""," ","2010.05 NM1*85 Billing Provider Name/Address","Loop 2010A Billing Provider Name/Address (If choosing patient unit you must bill one unit only!)","Y",""
"58","0","1151","LOC_58","30","1","Y","0","","N","2010.34 NM1*IL Subscriber Name/Address","Choosing Guarantor Info will create Patient 2000C Loop if Relation is NOT Self","Y",""
"59","0","1151","LOC_59","54","4"," ","0","","N","Guarantor (Current Ins) (NA)","","Y",""
"60","0","1151","LOC_60","88","2"," ","20","","N","2010.40 NM1*IL*09 Subscriber Contract or ID ","Select for Loop 2010B and 2330A NM1*IL*09 Subscriber Contract ID","Y",""
"61","0","1151","LOC_61","117","4"," ","0","","N","Insurance Name Address (UB04-NA)","","Y",""
"62","0","1151","LOC_62","0","4"," ","0","","N","Insurance Group Number (NA)","","Y",""
"63","0","1151","LOC_63","95","2"," ","20","","N","2300.50 REF*G1 Treatment Authorization Codes","Select for Loop 2300 REF*G1 02 Treament Authorization","Y",""
"63","1","1151","LOC_63A","0","2"," ","25",""," ","2300.53 REF*F8 Original Reference Code","Select for Loop 2300 REF*F8 02 Original Reference"," ",""
"63","2","1151","LOC_63B","0","1"," ","0",""," ","2300.54 REF*9F Claim Referral Code","Select for Loop 2300 REF*9F 02 Referral Code"," ",""
"63","3","1151","LOC_63C","0","2"," ","20",""," ","2300.56 REF*X4 CLIA Number","Select for Loop 2300 REF*X4 02 Clinical Lab Improvement Amendment Number"," ",""
"63","4","1151","LOC_63D","0","1","Y","0",""," ","2300.51 REF*G1 Treatment Authorization Edit","Default will NOT create a claim with missing Authorization if requested"," ",""
"63","5","1151","LOC_63E","0","1"," ","0",""," ","2300.58 CRC*75 Homebound Indicator","Use when Lab work required for homebound patient (Professional Only)"," ",""
"64","0","1151","LOC_64","0","4"," ","0","","N","ESC Codes (NA)","","Y",""
"65","0","1151","LOC_65","0","4"," ","0","","N","Employer Name (NA)","","Y",""
"66","0","1151","LOC_66","0","4"," ","0","","N","Employer Location (NA)","","Y",""
"67","0","1151","LOC_67","96","2"," ","7","","N","2300.60 HI*BK/BF Diagnosis Codes","Select for Loop 2300 HI*BK and HI*BF Diagnosis","Y",""
"67","1","1151","LOC_67A","0","2"," ","7",""," ","2300.62 HI*PR Reason for Visit","Select for Loop 2300 HI*PR Reason for Visit","Y",""
"76","0","1151","LOC_76","0","2"," ","7","","N","2300.61 HI*BJ Admission Diagnosis","Select for Loop 2300 HI*BJ Diagnosis","F",""
"77","0","1151","LOC_77","0","4"," ","0","","N","E - Code (NA)",""," ",""
"79","0","1151","LOC_79","0","4"," ","1","","N","P.C Code (NA)",""," ",""
"80","0","1151","LOC_80","0","4"," ","0","","N","Principal Procdure (NA)",""," ",""
"81","0","1151","LOC_81","0","4"," ","0","","N","Other Procedure (NA)","","Y",""
"82","0","1151","LOC_82","105","1"," ","0","","N","2310.20 NM1*71 Attending Physician/Facility Info","Loop 2310A NM1*71 (Inst) / NM1*DN (Prof)  Attending/Referring Physician or NM1*77 Facility Info","Y",""
"82","1","1151","LOC_82A","0","1"," ","0",""," ","2310.21 NM1*71*09 Attending Physician/Institution ID","Loop 2310A NM1*71*09 Attending Physician ID  Note: If Not Selected, Default Will Be Used","Y",""
"82","2","1151","LOC_82B","0","1"," ","0",""," ","2310.22 PRV*AT Attending Provider Specialty","Loop 2310A PRV*AT Attending Provider Specialty (Optional)"," ",""
"83","0","1151","LOC_83","0","1","Y","60","","N","2310.23 REF*02 Attending/Referring Physician/Institution Secondary ID","Loop 2310A REF*02 (Note: REF*01 will be 1G; 0B or 1D if Professional)"," ",""
"83","1","1151","LOC_83A","0","2"," ","2",""," ","2310.26 NM1*XX Rendering Provider/Facility Info/Referring Physician","Loop 2310D/E/F NM1*82/77/DN Rendering Provider/Facility Name/Referring Physican","Y",""
"83","2","1151","LOC_83B","1","0"," ","2",""," ","2310.27 REF*01 Rendering/Facility/Referring ID Qualifier","Loop 2310D/E/F REF*01 Qualifier (0B=License#, 1G=UPIN, G2=Commercial#, LU=Location#)"," ",""
"83","3","1151","LOC_83C","0","1"," ","0",""," ","2310.28 REF*02 Rendering/Facility/Referring Provider ID","Loop 2310D/E/F REF*02 Rendering/Facility/Referring Provider ID","Y",""
"84","0","1151","LOC_84","0","7"," ","80","","N","2300.59 NTE*ADD Comments","Select for Loop 2300 NTE*ADD Comments (Max 80 Char)","Y",""
"85","0","1151","LOC_85","120","4"," ","0","","N","Provider Representative (NA)","","N",""
"86","0","1151","LOC_86","0","1"," ","0","","N","2311.10 NM1*XX Additional Facility/Referring Physican Info","Loop 2310E/F NM1*77/DN Facility Info/Referring Physician (Optional only)","Y",""
"100","0","1151","UNIT_FORMAT","0","4"," ","0","","N","Format - Units","Select Format For Units"," ",""
"101","0","1151","MONEY_FORMAT","0","4"," ","0","","N","Format - Money","Select Format for Dollar Values"," ",""
"102","0","1151","ZIP_FORMAT","0","1","Y","0",""," ","9000.40 Format - Zip Code","Select Format for Zip Codes"," ",""
"103","0","1151","PPS_ACTIVE","1497","1","Y","0","","Y","9000.30 Bill Processing Type","Select Appropriate Value "," ",""
"104","0","1151","CLEAR_HOUSE","0","1","N","0","","Y","9000.15 Clearing House","Select Appropriate Value"," ",""
"105","0","1151","CLAIM_FORMAT","207","1","N","0","","Y","9000.20 Claim Format","Select Appropriate Value "," ",""
"105","1","1151","CLAIM_VERSION","212","4"," ","0",""," ","9000.25 Claim Version ","Select X12 5010 (since 1/1/2011)  Note: 4010 is no longer supported"," ",""
"107","0","1151","INS_PATBD","165","1"," ","0","","N","9000.50 Include Pat-Ins-Bill Data","Select to include all patient-insurance bill data items","Y",""
"150","0","1151","SEL_INS","74","4"," ","250",""," ","9000.90 Selected Insurances","Selected Insurances Option"," ",""
"200","0","1151","SNDRID","1","2","Y","15","","N","0100.06 ISA*06 Interchange Sender ID","Select for Interchange Control Header (ICH) ISA*06 Sender ID "," ",""
"201","0","1151","RCVRID","1","0"," ","15","","N","0100.08 ISA*08 Interchange Receiver ID","Select for (ICH) ISA*08 Receiver ID "," ",""
"201","1","1151","RCVRQUAL","1","0"," ","2",""," ","0100.07 ISA*07 Interchange Receiver Qualifier","Select for (ICH) ISA*07 Qualifier if not 28(Medicare) or ZZ(Other)"," ",""
"201","2","1151","RCVRACK","0","1","Y","0",""," ","0100.14 ISA*14 Interchange Acknowlegement","Select for (ICH) ISA*14 Acknowlegement Code (0 is default)"," ",""
"201","4","1151","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","1151","APPRID","1","0"," ","15",""," ","0200.03 GS*03 Application Receiver ID","Select for (FGH)  GS*03 Receiver ID if not ISA*08 Reciever ID"," ",""
"201","6","1151","SUBID","1","0"," ","15",""," ","1000.10 NM1*41 Submitter ID","Select for Loop 1000A NM1*41 Submitter ID if not (ISA*06 Sender ID)"," ",""
"201","7","1151","SUBNAME","1","2"," ","30",""," ","1000.12 NM1*41 Submitter Name","Select for Loop 1000A NM1*41 Submitter Name if not Agency Name (default)","Y",""
"201","8","1151","ISAREP","1","0","N","1",""," ","0100.11 ISA*11 Repetition Seperator","Select for ISA*11 Seperator if not (^)"," ",""
"202","0","1151","SERIAL","202","4"," ","0","","N","Submission Serial Number (NA)",""," ",""
"203","0","1151","RCVID","1","2"," ","15",""," ","1000.39 NM1*40 09 Insurance Receiver ID","Select for Loop 1000B NM1*40 09 (Receiver ID Override)"," ",""
"204","0","1151","RCVNAME","1","0"," ","25",""," ","1000.33 NM1*40 03 Insurance Receiver Name","Select for Loop 1000B NM1*40 03 (Receiver Name Override)","Y",""
"205","0","1151","CRLF","205","1","Y","0",""," ","9000.10 Output file format type","Select Appropriate Value "," ",""
"206","0","1151","DELAYID","0","2"," ","2",""," ","2300.20 CLM*20 Claim Delay Code ","Select for Loop 2300 CLM 20 Claim Delay"," ",""
"207","0","1151","PROVAID","0","2"," ","15",""," ","2010.22 REF*02 Provider Tertiary ID","Select for Loop 2010AA REF*02 Provider Tertiary ID "," ",""
"207","1","1151","PROVAQUAL","0","0","Y","2",""," ","2010.20 REF*01 Provider Tertiary Qualifier ","Select for Loop 2010AA REF*01 Qualifier; G5=Site #; LU=Location; "," ",""
"207","2","1151","PROVPAY2","0","2"," ","60",""," ","2010.24 NM1*87 Provider Pay-To Address","Select for Loop 2010AB Pay-To Address (Optional)","Y",""
*** Choice ***
"1","0","1151","11","1","Provider Information From Patient Unit"
"1","0","1151","10","2","Provider Information From Control File"
"2","0","1151","1","1","Enter Constant Value"
"3","0","1151","12","1","Patient Number"
"3","0","1151","13","2","Patient Medical Record Number"
"3","1","1151","16","1","Patient Medical Record Number And Bill Date"
"5","0","1151","18","1","Federal Tax ID Plus 3 Digit Suffix"
"5","0","1151","19","2","Federal Tax ID From Unit Master"
"5","0","1151","17","3","Federal Tax ID"
"6","0","1151","22","1","System Bill From And To Dates (Use for PPS)"
"6","0","1151","21","2","Patient Admit/Discharge and Bill Dates"
"6","0","1151","24","3","Insurance Effective and Bill Dates (N/A)"
"6","0","1151","20","4","Charge First and Last Visit Dates"
"6","0","1151","123","5","Charge First and Last Visit or Disch Dates Within Visit Month"
"7","0","1151","25","1","Charge Visit Totals Based On Summary Codes"
"8","1","1151","30","1","Patient Name"
"9","0","1151","55","1","Patient Name And Address"
"10","0","1151","32","1","Patient Birthday"
"11","0","1151","33","1","Patient Sex"
"12","0","1151","30","1","Patient Name"
"13","0","1151","31","1","Patient Address"
"14","0","1151","32","1","Patient Birthday"
"15","0","1151","33","1","Patient Sex"
"16","0","1151","34","1","Patient Marital Status"
"17","0","1151","112","1","Patient Admit Date w/No Time"
"17","0","1151","35","2","Patient Admit Date"
"17","0","1151","52","3","Insurance Effective Date"
"17","0","1151","20","4","Charge First Visit Date"
"17","0","1151","51","5","Patient Certification From Date"
"19","0","1151","1","1","Enter 1 Character Constant"
"19","1","1151","1","1","Constant Value (Entered)"
"20","0","1151","37","1","Patient Admission Source Code"
"20","0","1151","1","2","Constant Value (Entered)"
"21","0","1151","0","1","Bypass this Data Element"
"21","0","1151","76","2","Constant 0000"
"22","0","1151","40","1","Status Codes 30-Active 01-Discharged (Default)"
"22","0","1151","42","2","Default w/Discharge Reason Status Code Override "
"22","0","1151","41","3","Default w/Disposition Status Code Override  (Non-PPS only)"
"22","0","1151","47","4","Default w/Discharge Reason Status Override and Bill To-Date (Non-PPS only)"
"22","0","1151","1","5","Constant Value (Entered)"
"22","1","1151","74","1","Constant [OZ*FX***AC*] + CLM*01"
"22","1","1151","76","2","Constant [OB*FX***AC*] + REF*EA"
"22","1","1151","1","3","Constant Value (Entered)"
"23","0","1151","14","1","Patient Number And Medical Record Number"
"23","0","1151","15","2","Patient Number And Bill Date"
"23","0","1151","12","3","Patient Number"
"23","0","1151","13","4","Patient Medical Record Number"
"23","0","1151","16","5","Medical Record Number And Bill Date"
"24","0","1151","29","1","Insurance Claim Number"
"24","0","1151","42","2","Discharge Reason Status Codes (52, H2 only)"
"24","0","1151","1","3","Constant Value (Entered)"
"25","0","1151","1","1","Constant Value (Entered)"
"30","0","1151","1","1","Constant Value (Entered)"
"32","0","1151","49","1","Patient Discharge Date (Alive/Not Transferred)"
"32","0","1151","48","2","Patient Discharge Date"
"32","0","1151","46","3","Patient Diagnosis Primary Onset Date"
"32","0","1151","51","4","Patient Certification From Date"
"32","0","1151","35","5","Patient Admit Date"
"32","0","1151","50","6","First Billable Visit or Assess Date for this Cert (PPS)"
"33","0","1151","48","1","Patient Discharge Date"
"33","0","1151","46","2","Patient Diagnosis Primary Onset Date"
"33","0","1151","116","3","Patient Death Date"
"33","0","1151","51","4","Patient Certification From Date"
"33","0","1151","35","5","Patient Admit Date"
"34","0","1151","48","1","Patient Discharge Date"
"34","0","1151","46","2","Patient Diagnosis Primary Onset Date"
"34","0","1151","51","3","Patient Certification From Date"
"34","0","1151","35","4","Patient Admit Date"
"35","0","1151","1040","1","Statement Covered Dates"
"35","0","1151","163","2","Untimely Hospice NOE Dates"
"35","0","1151","114","3","Charge Visit Occurence Dates (Special Billing Only)"
"36","0","1151","52","1","Insurance Effective Stop/Start Dates"
"36","0","1151","53","2","Institution From/To Dates"
"36","0","1151","20","3","Charge First and Last Visit Dates"
"38","0","1151","55","1","Patient Name And Address"
"38","0","1151","56","2","Institution Transfered To (Hospice)"
"38","0","1151","54","3","Guarantor Name And Address"
"39","0","1151","1018","1","Charge Revenue Code (+24) (Note: this causes claim breaks by Rev-Code)"
"39","0","1151","64","2","MSA/CBSA/Rate Code (+61 or 24) With Trailing Zeros"
"39","0","1151","63","3","MSA/CBSA/Rate Code (+61 or 24)  (PPS default)"
"40","0","1151","63","1","Patient MSA/CBSA Code (+G8 for 655/656 Revenue Codes)"
"40","0","1151","77","2","Insurance Co-Pay Amount (Current Insurance)"
"40","0","1151","76","3","Constant 0.00"
"40","0","1151","60","4","Patient FIPS County ID"
"40","0","1151","58","5","Patient FIPS County ID No Leading Zero"
"41","0","1151","60","1","Patient FIPS County ID"
"41","0","1151","58","2","Patient FIPS County ID No Leading Zero"
"41","0","1151","77","3","Insurance Co-Pay Amount (Current Insurance)"
"41","0","1151","80","4","Charge Total Gross Amount"
"41","0","1151","119","5","Charge Service/Covered Days (First to Last Visit)"
"42","1","1151","1004","1","Sort by Revenue Code"
"42","1","1151","1003","2","Sort by Modality Sequence"
"42","1","1151","1005","3","Sort by Date/Modality Sequence"
"42","2","1151","1009","1","Print Summary Line With Totals For All Modalities"
"42","2","1151","1007","2","Print Summary Line For All Modalities"
"42","2","1151","1008","3","Print Only Summary Line For Non-Itemized Codes"
"42","2","1151","1010","4","Print Only Summary Line (With Totals) For Non-Itemized Codes"
"42","2","1151","1006","5","Bypass Printing"
"42","3","1151","1013","1","Revenue Code/Date Consolidation"
"42","3","1151","1057","2","Revenue Code Consolidation"
"42","3","1151","1045","3","Hospice LOC wQCodes (use for Medicare)"
"42","3","1151","1041","4","Hospice LOC No-QCodes"
"42","3","1151","1066","5","Hospice LOC wQCodes Charge Summarized"
"42","3","1151","1058","6","Hospice Detailed LOC wQCodes "
"42","3","1151","1064","7","Hospice Detailed LOC No-QCodes "
"42","3","1151","1011","8","Each Charge"
"42","3","1151","1069","9","Revenue Code/Date/Employee Consolidation"
"42","4","1151","1013","1","One Claim for Each Revenue Code (2390.12 must be Rev/Date or Rev/Code Consolidation)"
"42","4","1151","1011","2","One Claim for Each Charge"
"42","4","1151","1015","3","One Claim for All Charges"
"42","4","1151","1047","4","One Claim for Each Prior Authorization Rev/Date Order"
"42","4","1151","1065","5","One Claim for Each Prior Authorization Date Order"
"42","5","1151","1018","1","Charge Revenue Code"
"42","5","1151","1020","2","Charge Description"
"42","5","1151","1019","3","Charge Code"
"44","0","1151","1006","1","Printing (Bypass)"
"44","0","1151","1035","2","Charge Revenue Other Code"
"44","0","1151","1054","3","Charge Foreign Code"
"44","0","1151","1027","4","Charge CPT Code Number"
"44","0","1151","1068","5","Charge Revenue CPT + Other Code"
"44","1","1151","1021","1","Charge Revenue Description"
"44","1","1151","1020","2","Charge Description"
"44","1","1151","1037","3","Charge Start/Stop Times"
"44","2","1151","74","1","Constant (UN) - Units"
"44","2","1151","85","2","Constant (DA) - Days"
"45","0","1151","1023","1","Charge From and To Service Dates (Summarized Modalites Only)"
"45","0","1151","1029","2","Charge Service Date"
"45","0","1151","94","3","Treatment Authorization Dates (Summarized Modalities Only)"
"45","5","1151","82","1","Line Item Control Number "
"45","5","1151","1049","2","Charge Start-Time + Employee Medicaid No"
"45","6","1151","1054","1","NDC Code from Charge Foreign Code"
"45","7","1151","1054","1","Drug Qty and UM from Charge Foreign Code"
"45","8","1151","1037","1","Charge Start/Stop Times"
"47","0","1151","1031","1","Charge Net Amount (Selected Charges)"
"47","0","1151","1030","2","Charge Gross Amount (Selected Charges)"
"47","1","1151","0","1","Bypass this Data Element"
"47","1","1151","74","2","Credit All Charges"
"47","2","1151","1030","1","Compute Gross Amount Based on Rounded Hours"
"47","3","1151","1028","1","Charge Unit Price"
"47","4","1151","1031","1","Include Zero Net Charges"
"47","5","1151","1","1","Maximum Service LInes Per Claim (1-999)"
"47","5","1151","76","2","Maximum Claims (1-5000)"
"47","6","1151","76","1","Revenue 0023 Charge Line for PPS w/HIPPS and Qty 0"
"47","6","1151","74","2","Revenue 0023 Charge Line for NON-PPS w/HIPPS and Qty 1"
"47","6","1151","118","3","Revenue 0023 Charge Line for PPS or Non-PPS w/HIPPS; Qty 1; and 1 Cent Charge "
"47","6","1151","75","4","Revenue 0022 Charge Line for Room+Board w/Acuity (RUG score)"
"47","7","1151","1","1","Constant Value (Entered)"
"47","8","1151","1021","1","Service Rate Line will Follow the First Charge Line"
"48","0","1151","1034","1","Charge Amount (Non-Covered for Selected Modalities)"
"48","0","1151","1033","2","Charge Amount (Only if Revenue Other Code is N/C)"
"49","0","1151","1043","1","Charge Employee Taxonomy"
"49","0","1151","1050","2","Charge Employee Specialty"
"49","0","1151","1049","3","Charge Employee Medicaid No"
"49","0","1151","1048","4","Charge Employee FedTaxID"
"49","0","1151","11","5","Unit Provider Information Based on Patient"
"49","0","1151","10","6","Provider Information From Control File"
"49","0","1151","105","7","Physician Info (Order Doctor)"
"49","0","1151","56","8","Patient Institution"
"49","1","1151","153","1","Pat-Ins Bill Data Occurrence 1 Date"
"49","2","1151","1","1","Constant Value (Entered)"
"49","2","1151","74","2","Use Provider ID Chosen From NM1*XX above and output constant value for NM1*82"
"49","3","1151","1","1","Constant Value (Entered)"
"50","0","1151","65","1","Insurance Name (Current->Primary Options Override) "
"50","0","1151","66","2","Insurance Name (Current Insurance)"
"50","0","1151","1","3","Constant Value (Entered)"
"50","1","1151","0","1","Use Default Based on Insurance Payor Type"
"50","1","1151","1","2","Constant Value (Entered)"
"50","2","1151","44","1","Insurance Group Code"
"50","2","1151","1","2","Constant Value (Entered)"
"50","3","1151","66","1","Payor Name (Same as 1000.20 NM1*40 Value)"
"50","3","1151","44","2","Payor Group (Note: 2010.27 Should be Set to Bypass)"
"51","0","1151","68","1","System Medicare Provider Number"
"51","0","1151","69","2","System Medicaid Provider Number"
"51","0","1151","17","3","System Federal Tax ID"
"51","0","1151","70","4","System Blue Cross Provider Number"
"51","0","1151","71","5","Insurance Provider Number"
"51","0","1151","11","6","Unit Provider Number Based on Patient"
"51","0","1151","19","7","Unit Federal Tax ID Based on Patient"
"51","0","1151","1","8","Constant Value (Entered)"
"51","2","1151","71","1","Insurance Provider Number"
"51","2","1151","1","2","Constant Value (Entered)"
"51","2","1151","0","3","Bypass this Data Element (Use Receiver ID)"
"51","2","1151","72","4","Insurance Submitter Number"
"51","3","1151","11","1","Name/Address of First Patient Unit in Submission"
"51","3","1151","117","2","Insurance Name and Address (Current Insurance)"
"51","4","1151","1","1","Constant Value (Entered)"
"51","5","1151","74","1","Constant (LU) "
"52","0","1151","74","1","Constant (Y)"
"52","0","1151","118","2","Constant (N)"
"52","1","1151","0","1","Constant (A) - Assigned"
"52","1","1151","74","2","Constant (B) - Part B Claims only"
"52","1","1151","118","3","Constant (C) - Not Assigned"
"52","2","1151","0","1","Bypass this Data Element"
"52","2","1151","1","2","Constant Value (Entered)"
"52","3","1151","0","1","Bypass this Data Element"
"52","3","1151","74","2","Constant (Y)"
"52","3","1151","1","3","Constant (N)"
"52","4","1151","162","1","Pat-Ins Bill Data Accident Info"
"52","5","1151","3","1","Bill ID/Patient ID With Leading Zeros (Long Format)"
"52","5","1151","2","2","Bill ID - Patient ID (Short Format)"
"52","5","1151","4","3","Bill ID/Patient ID w/Leading Zeros + Auth-Seq (Multi-Auths per Claim)"
"53","0","1151","74","1","Constant (Y)"
"53","0","1151","118","2","Constant (N)"
"54","0","1151","77","1","Insurance Co-Pay Amount (Current Insurance)"
"54","0","1151","76","2","Constant 0.00"
"54","1","1151","0","1","Bypass COB Coordination of Benefit Loops"
"54","1","1151","156","2","Patient Bill Data Value1 Amount "
"54","1","1151","78","3","Payment Amount from First Other Insurance"
"54","1","1151","77","4","Co-Pay Amount from Billed Insurance"
"54","1","1151","59","5","Payment Amount is Constant Zero"
"54","2","1151","0","1","Billed insurance is primary (COB insurance is secondary) (Default)"
"54","2","1151","1044","2","Billed insurance is secondary (COB insurance is primary)"
"54","2","1151","1059","3","Billed insurance is tertiary (2340.30 must NOT be set to bypass)"
"54","3","1151","72","1","Insurance Submitter Number (Default)"
"54","3","1151","71","2","Insurance Provider Number"
"54","3","1151","1","3","Constant Value (Entered)"
"54","4","1151","0","1","Set Value to PR*1 (Default)"
"54","4","1151","160","2","Patient-Insurance Bill Data Adjustment Reason(s)"
"54","4","1151","118","3","Bypass CAS Segment Entirely"
"54","4","1151","1","4","Constant Value (Entered)"
"54","5","1151","1","1","Constant Value (Entered)"
"54","6","1151","0","1","Set to Prior Payment Date (Default)"
"54","6","1151","153","2","Patient-Insurance Bill Data Occurrence1 Date"
"54","6","1151","52","3","Insurance Start Date"
"54","6","1151","118","4","Bypass this Segment Entirely"
"54","6","1151","20","5","Charge Last Visit Date"
"54","7","1151","0","1","Set to Total Claim Amount (Default)"
"54","7","1151","1","2","Constant Value (Entered)"
"54","7","1151","157","3","Patient Bill Data Value2 Amount from Billed Insurance"
"54","8","1151","0","1","(MA, CI, etc) based on Other Insurance Payor Type (Default)"
"54","8","1151","74","2","Same as Default Except Payor Type 2 Gets Value (16) "
"54","8","1151","1","3","Constant Value (Entered)"
"54","21","1151","0","1","Bypass Tertiary COB Coordination of Benefit Loop (Default)"
"54","21","1151","78","2","No CAS and AMT*A8 Total Not Covered"
"54","21","1151","59","3","Payment Amount is Constant Zero"
"55","0","1151","77","1","Insurance Co-Pay Amount (Current Insurance)"
"55","0","1151","76","2","Constant 0.00"
"55","0","1151","158","3","Pat-Ins Bill Data Value3"
"56","0","1151","67","1","System NPI Number"
"56","0","1151","17","2","System Federal Tax ID"
"56","0","1151","1","3","Constant Value (Entered)"
"56","0","1151","11","4","Unit Provider Number Based on First Patient in X12 File"
"56","0","1151","1302","5","Unit NPI Number Based on First Patient in X12 File"
"56","1","1151","1","1","Constant Value (Entered)"
"56","2","1151","10","1","Provider Information From System Control File"
"56","2","1151","11","2","Provider Information Based on First Patient Unit"
"56","2","1151","1305","3","Provider Information Based on First Patient Unit w/Alias Name"
"58","0","1151","30","1","Patient Info"
"58","0","1151","84","2","Guarantor Info"
"58","0","1151","1325","3","Guarantor Name (No Address/Phone)"
"59","0","1151","54","1","Guarantor Name And Address"
"60","0","1151","88","1","Insurance Contract (Current Insurance)"
"60","0","1151","124","2","Insurance Contract (Secondary Insurance)"
"60","0","1151","44","3","Insurance Group Code"
"60","0","1151","29","4","Insurance Claim Number"
"60","0","1151","1","5","Constant Value (Entered)"
"63","0","1151","93","1","Auth-No for Care-Type (Authorized-By) "
"63","0","1151","95","2","Auth-No (Use for PPS Claimkey)"
"63","0","1151","91","3","Auth-No (Non-PPS Auth or PPS-UTN)"
"63","0","1151","159","4","Pat-Ins Bill Data BillNote1"
"63","0","1151","29","5","Insurance Claim Number"
"63","0","1151","1","6","Constant Value (Entered)"
"63","0","1151","89","7","Treatment Authorization Notes"
"63","1","1151","95","1","Treatment Authorization Codes"
"63","1","1151","44","2","Insurance Group Code"
"63","1","1151","29","3","Insurance Claim Number"
"63","1","1151","82","4","Claim Reference Number (DCN#)"
"63","1","1151","1","5","Constant Value (Entered)"
"63","2","1151","44","1","Insurance Group Code"
"63","2","1151","88","2","Insurance Contract (Current Insurance)"
"63","2","1151","29","3","Insurance Claim Number"
"63","2","1151","90","4","Treatment Auth Codes NO Claimkey"
"63","3","1151","1","1","Constant Value (Entered)"
"63","4","1151","0","1","Error (No Claim) When Treatment Authorization Missing (Default)"
"63","4","1151","74","2","Claim Created Even if Treatment Authorization Missing"
"63","5","1151","74","1","Include CRC*75 Indicator "
"65","0","1151","97","1","Employer Name"
"66","0","1151","98","1","Employer Address"
"67","0","1151","99","1","Patient Diagnosis Codes"
"67","0","1151","96","2","Order Diagnosis Codes (PPS Default)"
"67","0","1151","1","3","Constant Value (Entered)"
"67","1","1151","99","1","Patient Primary Diagnosis Code"
"67","1","1151","96","2","Treatment Plan Primary Diagnosis Code"
"67","1","1151","1","3","Constant Value (Entered)"
"76","0","1151","99","1","Primary Diagnosis"
"76","0","1151","1","2","Constant Value (Entered)"
"77","0","1151","101","1","First E-Diagnosis"
"79","0","1151","1","1","Enter A One Digit Constant"
"80","0","1151","102","1","Principal Procedure Code And Date"
"81","0","1151","102","1","Other Procedure Codes And Dates"
"82","0","1151","105","1","Physician Info (Order Doctor) - Use for PPS"
"82","0","1151","113","2","Physician Info (Non-Order/Seq1 Doctor) "
"82","0","1151","56","3","Institution (First for this admit)"
"82","1","1151","109","1","Physician NPI"
"82","1","1151","56","2","Institution (First for this admit) Provider ID"
"82","2","1151","103","1","Physician Taxonomy"
"83","0","1151","110","1","Physician UPIN"
"83","0","1151","103","2","Physician Taxonomy"
"83","0","1151","104","3","Physician License"
"83","0","1151","56","4","Institution (First for admit)"
"83","0","1151","0","5","Bypass this Data Element"
"83","1","1151","1038","1","Charge Employee w/ID based on 2420A NM1*82 "
"83","1","1151","10","2","Agency Name/Address w/NPI  (77)"
"83","1","1151","110","3","Physician (Referring/Seq1)  Allow Duplicates"
"83","1","1151","113","4","Physician (Referring/Non-Order)  Use for PPS"
"83","1","1151","105","5","Physician (Order Doctor) w/NPI"
"83","1","1151","107","6","Physician (Clinic Specialty) w/NPI"
"83","1","1151","55","7","Patient Name/Address (no ID)"
"83","1","1151","57","8","Institution (Last for Bill Period) w/NPI  (77)"
"83","1","1151","56","9","Institution (First for admit) w/Provider ID  (77)"
"83","1","1151","1302","10","Unit Name w/NPI Number Based on Unit"
"83","3","1151","103","1","Physician Taxonomy"
"83","3","1151","104","2","Physician License"
"83","3","1151","44","3","Insurance Group Code"
"83","3","1151","57","4","Institution Name and Prov# (First for admit)"
"83","3","1151","1043","5","Charge Employee Taxonomy"
"84","0","1151","45","1","Patient Discharge Reason and Date"
"84","0","1151","44","2","Insurance Group Code"
"84","0","1151","88","3","Insurance Contract (Current Insurance)"
"84","0","1151","29","4","Insurance Claim Number"
"84","0","1151","57","5","Institution Name and Prov# (First for admit)"
"84","0","1151","118","6","Constant (NOT COVERED)"
"84","0","1151","1","7","Constant Value (Entered)"
"85","0","1151","120","1","System Agency Representative Name"
"86","0","1151","113","1","Physician (Referring/Seq1)  "
"86","0","1151","57","2","Institution (Last for Bill Period) w/NPI "
"86","0","1151","55","3","Patient Name And Address"
"100","0","1151","3","1","Format Units With Leading Zeros"
"100","0","1151","2","2","Format Units With Leading Spaces"
"101","0","1151","6","1","Format Dollar Values Without Decimal Point Or Space"
"101","0","1151","4","2"," Format Dollar Values with Decimal Space"
"101","0","1151","5","3","Format Dollar Values With Decimal Point"
"102","0","1151","1039","1","Format full 9 digit zip"
"102","0","1151","1042","2","Format full 9 digit zip no dash"
"103","0","1151","1496","1","Process Type: PPS Secondary"
"103","0","1151","1500","2","Process Type: PPS"
"103","0","1151","1497","3","Process Type: Non-PPS"
"103","0","1151","1494","4","Process Type: Homecare Notice"
"103","0","1151","1495","5","Process Type: Hospice Notice"
"104","0","1151","1055","1","Use RevConnect/Ability Clearing House"
"104","0","1151","1056","2","Use Waystar/Zirmed Clearing House"
"105","0","1151","207","1","Institutional claim format"
"105","0","1151","208","2","Professional claim format"
"105","1","1151","211","1","EBill X12 version 4010 (no longer supported)"
"105","1","1151","212","2","EBill X12 version 5010"
"107","0","1151","165","1","Include All Patient-Insurance Bill Data Items"
"150","0","1151","74","1","Store and Auto Select Insurances"
"200","0","1151","1303","1","Unit Medicare ID Based on Patient Unit"
"200","0","1151","1304","2","Unit Medicaid ID Based on Patient Unit"
"200","0","1151","19","3","Unit Federal Tax ID Based on Patient Unit"
"200","0","1151","72","4","Insurance Submitter Number"
"200","0","1151","1","5","Constant Value (Entered)"
"201","2","1151","0","1","Default (0)"
"201","2","1151","74","2","Constant (1)"
"201","7","1151","11","1","Unit Name Based on First Patient in X12 File"
"201","7","1151","1","2","Constant Value (Entered)"
"201","7","1151","1305","3","Unit Alias Name Based on First Patient Unit"
"203","0","1151","72","1","Insurance Submitter Number"
"203","0","1151","1","2","Constant Value (Entered)"
"205","0","1151","205","1","EBill create output file WITH CR/LF"
"205","0","1151","206","2","EBill create output file WITHOUT CR/LF"
"206","0","1151","1","1","Constant Value (Entered)"
"207","0","1151","1","1","Constant Value (Entered)"
"207","2","1151","11","1","Provider Information Based on Patient Unit"
"207","2","1151","10","2","Provider Information From System Control File"
"207","2","1151","1","3","Constant Value (Must Be: Street, City, St, Zip)"
