*** Effective Date: 2/19/2024
*** Master ***
"1002","UB-04 (Baseline) 05/08/23","UB04        ","N"
*** Option ***
"1","0","1002","LOC_1","10","1"," ","0","","N","Box 1 - Provider Information","Select Appropriate Data Source","Y",""
"2","0","1002","LOC_2","0","7"," ","250","","N","Box 2 - Pay To Information","Enter Constant or choose to Bypass"," ",""
"3","0","1002","LOC_3","15","1","F","0","","N","Box 3a - Patient Control Number",""," ",""
"3","1","1002","LOC_3B","13","1"," ","0",""," ","Box 3b - Patient Med-Rec-#",""," ",""
"4","0","1002","LOC_4","62","0","Y","3","33S","N","Box 4 - Type Of Bill","Positions 1 and 2 are constants. Position 3 can be a constant (S) or (I). (S) will print (1-4) based on claim period and admit/discharge range. (I) will print (1-4) based on claim period and insurance from to dates."," ",""
"4","1","1002","LOC_4A","0","1","F","0",""," ","Box 4 - Leading Zero","Optional Type of Bill Leading Zero"," ",""
"5","0","1002","LOC_5","17","1"," ","0","","N","Box 5 - Federal Tax ID",""," ",""
"6","0","1002","LOC_6","22","1"," ","0","","N","Box 6 - Covered Dates","Note: PPS Billing will Override any selection made below","Y",""
"7","0","1002","LOC_7","0","1"," ","0","","N","Box 7 - Optional",""," ",""
"8","0","1002","LOC_8A","0","1"," ","0",""," ","Box 8a - Patient ID","","Y",""
"8","1","1002","LOC_8B","30","1","Y","0",""," ","Box 8b - Patient Name","","Y",""
"9","0","1002","LOC_9","55","1","Y","0",""," ","Box 9a-e - Patient Address","","Y",""
"10","0","1002","LOC_10","32","1","Y","0",""," ","Box 10 - Patient Birthday",""," ",""
"11","0","1002","LOC_11","33","1"," ","0",""," ","Box 11 - Patient Sex",""," ",""
"12","0","1002","LOC_12","35","1"," ","0","","N","Box 12 - Admission Date",""," ",""
"13","0","1002","LOC_13","0","2"," ","2","","N","Box 13 - Admission Hour",""," ",""
"14","0","1002","LOC_14","0","2","F","2","","N","Box 14 - Admission Type",""," ",""
"15","0","1002","LOC_15","37","2"," ","1","","N","Box 15 - Admission Source",""," ",""
"16","0","1002","LOC_16","0","2"," ","2","","N","Box 16 - Discharge Hour",""," ",""
"17","0","1002","LOC_17","41","1"," ","0","","N","Box 17 - Discharge Status",""," ",""
"18","0","1002","LOC_18","0","2"," ","2",""," ","Box 18 - Condition Code",""," ",""
"19","0","1002","LOC_19","0","2"," ","2","","N","Box 19 - Condition Code",""," ",""
"20","0","1002","LOC_20","0","2"," ","2","","N","Box 20 - Condition Code",""," ",""
"22","0","1002","LOC_22","0","4"," ","2","","N","Box 22 - Condition Code",""," ",""
"23","0","1002","LOC_23","0","4"," ","2","","N","Box 23 - Condition Code",""," ",""
"24","0","1002","LOC_24","0","4"," ","2","","N","Box 24 - Condition Code ",""," ",""
"25","0","1002","LOC_25","0","4"," ","2","","N","Box 25 - Condition Code ",""," ",""
"30","0","1002","LOC_30","0","2"," ","12","","N","Box 30 - Optional Field",""," ",""
"31","0","1002","LOC_31","0","2"," ","2",""," ","Box 31 - Occurence Code/Date",""," ",""
"32","0","1002","LOC_32","0","2"," ","2","","N","Box 32 - Occurrence Code/Date",""," ",""
"33","0","1002","LOC_33","0","2"," ","2",""," ","Box 33 - Occurrence Code/Date",""," ",""
"34","0","1002","LOC_34","0","2"," ","2",""," ","Box 34 - Occurrence Code/Date",""," ",""
"35","0","1002","LOC_35","0","2"," ","2",""," ","Box 35 - Occurrence Code/Date Span","","Y",""
"36","0","1002","LOC_36","0","2"," ","2","","N","Box 36 - Occurrence Code Date/Span","","Y",""
"37","0","1002","LOC_37","0","2"," ","6","","N","Box 37 - Untitled Box",""," ",""
"38","0","1002","LOC_38","55","1"," ","0","","N","Box 38 - Responsible Party Name and Address","","Y",""
"39","0","1002","LOC_39","64","2"," ","2","","N","Box 39a - Value Code Amount",""," ",""
"40","0","1002","LOC_40","0","2"," ","2","","N","Box 40a - Value Code Amount",""," ",""
"41","0","1002","LOC_41","0","2"," ","2","","N","Box 41a - Value Code Amount",""," ",""
"42","0","1002","LOC_42_ITEMIZATION","501","5"," ","0","  1X XV  2X RV  3X XV  4X XV  5X XV  6X XV  7X XV  8X XS","N","Box 42 - 48 - Itemizations","Select Modalities and Visits or Charges","Y",""
"42","1","1002","LOC_42_SORTING","1004","1","Y","0","","Y","Box 42 - 48 - Charge Sorting Options","Select Sort Order"," ",""
"42","2","1002","LOC_42_SUMMARY","1007","1"," ","0","","Y","Box 42 - 48 - Summary Line Options","Select Summary Line Option"," ",""
"42","3","1002","LOC_42_ITEM_CONSOLIDATION","1011","1","Y","0","","Y","Box 42 - 48 - Itemized Consolidation","Select Consolidation Option - Note: Use similar charge sorting option"," ",""
"42","4","1002","LOC_42_TOTAL_LINES","1014","1","Y","0","","Y","Box 42 - 48 - Total Line Options","Select Total Line Option"," ",""
"42","5","1002","LOC_42_OPTIONS","0","4","F","0","","Y","Box 42 - Revenue Code","Select Appropriate Option"," ",""
"42","6","1002","LOC_42_REV_CODES","0","4","F","0","","Y","Box 42 - Revenue Code Selection","Mark Desired Modalities","Y",""
"42","7","1002","LOC_42_DATA","500","4"," ","0","","N","Locator 42 Data Retireval (not Visible to end user)","","Y",""
"42","8","1002","LOC_42_CREATE","0","1"," ","0",""," ","Box 42 - 48 - Total Line Creation Date",""," ",""
"42","9","1002","LOC_42_REV_001","0","1"," ","0",""," ","Box 42 - 48 - Total Line Revenue Code ",""," ",""
"42","10","1002","LOC_42_FIRST","0","1"," ","0",""," ","Box 42 - 48 - First Line Option","","Y",""
"43","0","1002","LOC_43","1021","1","Y","0","","Y","Box 43 - Revenue Descriptions","Note: PPS always prints charge description"," ",""
"44","0","1002","LOC_44","1027","1","F","0","","Y","Box 44 - HCPCS/RATES","Select Appropriate Format"," ",""
"45","0","1002","LOC_45","1029","1","Y","0","","Y","Box 45 - Service Date Options","Select Appropriate Format"," ",""
"46","0","1002","LOC_46","0","4","Y","0","","Y","Box 46 - Service Units","Select Unit Format for Each Applicable Modality","Y",""
"46","1","1002","LOC_46A","0","2"," ","2",""," ","Box 46 - Override Units Option","Enter number of units to substitute for [1/x Units] billing units option.  Default is 8"," ",""
"47","0","1002","LOC_47","1030","1","Y","0","","Y","Box 47 - Total Charges","Select Appropriate Format"," ",""
"48","0","1002","LOC_48","0","1","N","0","","Y","Box 48 - Non Covered Charges","Select Appropriate Format","N",""
"50","0","1002","LOC_50","66","1"," ","0","","N","Box 50 - Payer","","Y",""
"51","0","1002","LOC_51","68","1"," ","0","","N","Box 51 - Health Plan ID","","Y",""
"52","0","1002","LOC_52","0","1"," ","0","","N","Box 52 - Release Information","","Y",""
"53","0","1002","LOC_53","0","1"," ","0","","N","Box 53 - Assignment of Benefits","","Y",""
"54","0","1002","LOC_54","0","1"," ","0","","N","Box 54 - Prior Payments","","Y",""
"55","0","1002","LOC_55","0","1"," ","0","","N","Box 55 - Estimated Amount Due","","Y",""
"56","0","1002","LOC_56","67","2"," ","15","","N","Box 56 - NPI",""," ",""
"57","0","1002","LOC_57","0","1"," ","0",""," ","Box 57 - Other Provider ID","","Y",""
"57","1","1002","LOC_57B","0","1"," ","0",""," ","Box 57b - Other Provider ID (Line b)","","Y",""
"58","0","1002","LOC_58","30","1"," ","0","","N","Box 58 - Insured Name","","Y",""
"59","0","1002","LOC_59","0","1"," ","0","","N","Box 59 - Patient Relationship","","Y",""
"60","0","1002","LOC_60","88","1"," ","0","","N","Box 60 - Cert.-SSN-HIC-ID NO","","Y",""
"61","0","1002","LOC_61","0","1"," ","0","","N","Box 61 - Insurance Group Name","","Y",""
"62","0","1002","LOC_62","0","1"," ","0","","N","Box 62 - Insurance Group Number","","Y",""
"63","0","1002","LOC_63","0","1"," ","0","","N","Box 63 - Treatment Authorization Codes","","Y",""
"64","0","1002","LOC_64","0","2"," ","20","","N","Box 64 - Document Control Number","","Y",""
"65","0","1002","LOC_65","0","2"," ","25","","N","Box 65 - Employer Name","","Y",""
"66","0","1002","LOC_66","74","1","Y","0","","N","Box 66 - Diagnosis Version","Note: Pre-printed red-forms need to bypass this box; otherwise it is selected for you.","N",""
"67","0","1002","LOC_67","99","1"," ","0","","N","Box 67a-q Diagnosis Codes","","Y",""
"69","0","1002","LOC_69","0","1"," ","0",""," ","Box 69 - Admit Diagnosis",""," ",""
"70","0","1002","LOC_70","0","1"," ","0",""," ","Box 70 - Patient Reason Dx",""," ",""
"71","0","1002","LOC_71","0","4"," ","0",""," ","Box 71 - PPS Code",""," ",""
"72","0","1002","LOC_72","0","1"," ","0",""," ","Box 72 - External Injury Diagnosis",""," ",""
"74","0","1002","LOC_74","0","4"," ","0",""," ","Box 74 - Procedure Code/Date",""," ",""
"76","0","1002","LOC_76","109","1"," ","0","","N","Box 76 - Attending Physician","","Y",""
"76","1","1002","LOC_76A","0","2"," ","2",""," ","Box 76 - Attending Physician Other ID","Choose Other ID Type and Enter Optional Qualifier if NOT NPI"," ",""
"77","0","1002","LOC_77","0","1"," ","0","","N","Box 77 - Operating Physician","","Y",""
"78","0","1002","LOC_78","0","2"," ","2",""," ","Box 78 - Other","Choose Other ID Type and Enter Optional Provider Qualifier","Y",""
"79","0","1002","LOC_79","0","4"," ","0","","N","Box 79 - Other ",""," ",""
"80","0","1002","LOC_80","0","2"," ","250","","N","Box 80 - Remarks","","Y",""
"81","0","1002","LOC_81","0","2"," ","80","","N","Box 81 - Qualifier/Code/Value","","Y",""
"100","0","1002","UNIT_FORMAT","0","4"," ","0","","N","Format - Units","Select Format For Units"," ",""
"101","0","1002","MONEY_FORMAT","0","4"," ","0","","N","Format - Money","Select Format for Dollar Values"," ",""
"102","0","1002","ZIP_FORMAT","0","1","Y","0",""," ","Format - Zip Code","Select Format for Zip Codes"," ",""
"103","0","1002","PPS_ACTIVE","1500","1","Y","0","","Y","Process Type",""," ",""
"150","0","1002","SEL_INS","0","1"," ","250",""," ","Selected Insurances",""," ",""
*** Choice ***
"1","0","1002","11","1","Provider Information From Patient Unit"
"1","0","1002","10","2","Provider Information From Control File"
"2","0","1002","1","1","Enter Constant Value"
"3","0","1002","14","1","Patient Number And Medical Record Number"
"3","0","1002","15","2","Patient Number And Bill Date"
"3","0","1002","12","3","Patient Number"
"3","0","1002","16","4","Medical Record Number And Bill Date"
"3","0","1002","13","5","Patient Medical Record Number"
"3","0","1002","23","6","Patient # and Bill Date as Invoice No"
"3","0","1002","74","7","Bill Master ID as Invoice No"
"3","0","1002","76","8","Bill Master ID - Patient ID (Electronic CLM*01)"
"3","1","1002","13","1","Patient Medical Record Number"
"3","1","1002","16","2","Patient Medical Record Number And Bill Date"
"3","1","1002","12","3","Patient Number"
"3","1","1002","15","4","Patient Number And Bill Date"
"3","1","1002","14","5","Patient Number And Medical Record Number"
"4","1","1002","76","1","Constant 0"
"5","0","1002","18","1","Federal Tax ID Plus 3 Digit Suffix"
"5","0","1002","19","2","Federal Tax ID From Unit Master"
"5","0","1002","17","3","Federal Tax ID"
"6","0","1002","22","1","System Bill From And To Dates"
"6","0","1002","21","2","Patient Admit/Discharge and Bill Dates"
"6","0","1002","24","3","Insurance Effective and Bill Dates (N/A)"
"6","0","1002","20","4","Charge First and Last Visit Dates"
"6","0","1002","123","5","Charge First and Last Visit or Disch Within Visit Month"
"7","0","1002","25","1","Charge Visit Total"
"8","0","1002","12","1","Patient Number"
"8","0","1002","55","2","Patient Last Name"
"8","0","1002","13","3","Patient Medical Record Number"
"8","0","1002","88","4","Insurance Contract (Current Insurance)"
"8","1","1002","30","1","Patient Name (Last, First)"
"8","1","1002","55","2","Patient First Name"
"9","0","1002","55","1","Patient Address"
"10","0","1002","32","1","Patient Birthday"
"11","0","1002","33","1","Patient Sex"
"12","0","1002","35","1","Patient Admit Date"
"12","0","1002","52","2","Insurance Effective Date"
"12","0","1002","51","3","Patient Certification From Date"
"13","0","1002","1","1","Constant Value (Entered)"
"14","0","1002","1","1","Constant Value (Entered)"
"15","0","1002","37","1","Patient Admission Source Code"
"15","0","1002","1","2","Constant Value (Entered)"
"16","0","1002","1","1","Constant Value (Entered)"
"17","0","1002","41","1","Status Codes 30-Active 01-Discharged W/Disposition Override"
"17","0","1002","40","2","Status Codes 30-Active 01-Discharged"
"17","0","1002","42","3","Discharge Reason Status Code (Non-PPS)/Actual-End Override (PPS)"
"17","0","1002","47","4","Discharge Reason Status Code Using To Date (Non-PPS)"
"18","0","1002","1","1","Constant Value (Entered)"
"18","0","1002","150","2","Pat-Ins Bill Data Condition1"
"19","0","1002","1","1","Constant Value (Entered)"
"19","0","1002","151","2","Pat-Ins Bill Data Condition2"
"20","0","1002","1","1","Constant Value (Entered)"
"20","0","1002","152","2","Pat-Ins Bill Data Condition3"
"22","0","1002","1","1","Constant Value (Entered)"
"23","0","1002","1","1","Constant Value (Entered)"
"24","0","1002","1","1","Constant Value (Entered)"
"25","0","1002","1","1","Constant Value (Entered)"
"30","0","1002","1","1","Constant Value (Entered)"
"31","0","1002","48","1","Patient Discharge Date"
"31","0","1002","46","2","Patient Diagnosis Primary Onset Date"
"31","0","1002","35","3","Patient Admit Date"
"31","0","1002","50","4","First Billable Visit Date or Assess Date for this Cert (Based on PPS Type)"
"31","0","1002","153","5","Pat-Ins Bill Data Occurrence1"
"32","0","1002","154","1","Pat-Ins Bill Data Occurrence2"
"32","0","1002","48","2","Patient Discharge Date"
"32","0","1002","46","3","Patient Diagnosis Primary Onset Date"
"32","0","1002","35","4","Patient Admit Date"
"32","0","1002","50","5","First Billable Visit Date or Assess Date for this Cert (Based on PPS Type)"
"32","0","1002","116","6","Patient Death Date"
"33","0","1002","155","1","Pat-Ins Bill Data Occurrence3"
"33","0","1002","48","2","Patient Discharge Date"
"33","0","1002","46","3","Patient Diagnosis Primary Onset Date"
"33","0","1002","51","4","Patient Certification From Date"
"33","0","1002","35","5","Patient Admit Date"
"33","0","1002","50","6","First Billable Visit Date or Assess Date for this Cert (Based on PPS Type)"
"33","0","1002","116","7","Patient Death Date"
"34","0","1002","48","1","Patient Discharge Date"
"34","0","1002","46","2","Patient Diagnosis Primary Onset Date"
"34","0","1002","35","3","Patient Admit Date"
"34","0","1002","50","4","First Billable Visit Date or Assess Date for this Cert (Based on PPS Type)"
"34","0","1002","51","5","Patient Certification From Date"
"35","0","1002","24","1","Insurance Effective and Bill Dates"
"35","0","1002","20","2","Charge First and Last Visit Dates"
"35","0","1002","163","3","Untimely Hospice NOE Info"
"36","0","1002","24","1","Insurance Effective and Bill Dates"
"36","0","1002","20","2","Charge First and Last Visit Dates"
"37","0","1002","1","1","Constant Value (Entered)"
"38","0","1002","55","1","Patient Name And Address"
"38","0","1002","54","2","Guarantor Name And Address"
"38","0","1002","117","3","Insurance Name and Address (Current Insurance)"
"39","0","1002","64","1","MSA Code or Rate Code based on PPS Type W/Trailing '00'"
"39","0","1002","63","2","MSA Code or Rate Code based on PPS Type"
"39","0","1002","77","3","Insurance Co-Pay Amount (Current Insurance)"
"39","0","1002","156","4","Pat-Ins Bill Data Value1 (Code/Amount)"
"40","0","1002","157","1","Pat-Ins Bill Data Value2 (Code/Amount)"
"40","0","1002","77","2","Insurance Co-Pay Amount (Current Insurance)"
"40","0","1002","60","3","Patient FIPS County ID"
"41","0","1002","64","1","Patient MSA Code With Trailing '00'"
"41","0","1002","63","2","Patient MSA Code"
"41","0","1002","158","3","Pat-Ins Bill Data Value3 (Code/Amount)"
"42","1","1002","1004","1","Sort by Revenue-Code/Chg-Date/Chg-Code (default)"
"42","1","1002","1005","2","Sort by Chg-Date/Revenue-Code/Chg-Code"
"42","2","1002","1009","1","Print Summary Line With Totals For All Modalities"
"42","2","1002","1007","2","Print Summary Line For All Modalities"
"42","3","1002","1013","1","Print Revenue Code/Date Consolidation"
"42","3","1002","1045","2","Print Hospice Summarized LOC (Medicare)"
"42","3","1002","1058","3","Print Hospice Detailed LOC (non-Medicare)"
"42","3","1002","1011","4","Print Each Charge"
"42","3","1002","1064","5","Print Hospice Detailed LOC No-QCodes (non-Medicare)"
"42","3","1002","1041","6","Print Hospice LOC Detail No-QCodes"
"42","4","1002","1014","1","Print Total On Last Line After All Charges"
"42","4","1002","1016","2","Print Last Line Total Each Multi Page Bill"
"42","8","1002","121","1","System Billing Date"
"42","8","1002","122","2","System Todays Date"
"42","9","1002","76","1","Constant 0001"
"42","10","1002","1060","1","Hospice 0022 Revenue Code and RUG Score  (Room&Board)"
"42","10","1002","56","2","Hospice Institution Name and First Visit Date (Room&Board)"
"42","10","1002","74","3","Force 0023 Revenue Code and HIPPS for Non-PPS (Qty 1)"
"42","10","1002","118","4","Force 0023 Revenue Code and HIPPS for PPS/Non-PPS (Qty 1 plus 1 Cent)"
"43","0","1002","1021","1","Charge Description"
"43","0","1002","1022","2","Charge Rev-Description (Summary or Non-PPS Detail lines only)"
"44","0","1002","1028","1","Charge Unit Price"
"44","0","1002","1027","2","Charge CPT Code Number"
"44","0","1002","1035","3","Charge Revenue Other Code"
"45","0","1002","1029","1","Print Each Service Date"
"45","0","1002","1006","2","Bypass Printing"
"46","1","1002","1","1","Constant Value (Entered)"
"47","0","1002","1031","1","Charge Net Amount (Selected Charges)"
"47","0","1002","1030","2","Charge Gross Amount (Selected Charges)"
"48","0","1002","1033","1","Charge (Non-Covered if revenue other code is N/C)"
"48","0","1002","1034","2","Charge (Non-Covered for Selected Modalities)"
"50","0","1002","66","1","Insurance Name (Current Insurance)"
"50","0","1002","65","2","Insurance Names (All)"
"51","0","1002","68","1","System Medicare Provider Number"
"51","0","1002","69","2","System Medicaid Provider Number"
"51","0","1002","70","3","System Blue Cross Provider Number"
"51","0","1002","71","4","Insurance Provider Number"
"51","0","1002","11","5","Unit Provider Number Based on Patient (Payer Line A only)"
"52","0","1002","74","1","Constant (Y)"
"53","0","1002","74","1","Constant (Y)"
"54","0","1002","77","1","Insurance Co-Pay Amount (Current Insurance)"
"54","0","1002","83","2","Insurance Paid Amount (Current Insurance)"
"54","0","1002","76","3","Constant 0.00"
"55","0","1002","77","1","Insurance Co-Pay Amount (Current Insurance)"
"55","0","1002","79","2","Charge Total Net Amount"
"55","0","1002","80","3","Charge Total Gross Amount"
"55","0","1002","81","4","Charge Gross Amount Less Co-Pay Amount"
"55","0","1002","87","5","Charge Gross Amount Less Paid Amt This Bill"
"56","0","1002","67","1","System NPI Number"
"56","0","1002","68","2","System Medicare Provider Number"
"56","0","1002","69","3","System Medicaid Provider Number"
"56","0","1002","1302","4","Unit NPI Number Based on Patient"
"56","0","1002","11","5","Unit Provider Number Based on Patient"
"56","0","1002","1","6","Constant Value (Entered)"
"57","0","1002","11","1","Unit Provider Number Based on Patient Unit"
"57","0","1002","1302","2","Unit NPI Number Based on Patient Unit"
"57","0","1002","19","3","Unit Federal Tax ID Based on Patient"
"57","0","1002","68","4","System Medicare Provider Number"
"57","0","1002","69","5","System Medicaid Provider Number"
"57","0","1002","71","6","Insurance Provider Number"
"57","0","1002","1304","7","Unit Medicaid ID Based on Patient Unit"
"57","1","1002","1301","1","Unit Taxonomy Code Based on Patient Unit"
"58","0","1002","30","1","Patient Name"
"58","0","1002","84","2","Guarantor Name (Current Insurance)"
"59","0","1002","86","1","Guarantor Relation From Master File"
"60","0","1002","29","1","Insurance Claim Number"
"60","0","1002","88","2","Insurance Contract"
"60","0","1002","44","3","Insurance Group Code"
"61","0","1002","44","1","Insurance Group Code"
"61","0","1002","29","2","Insurance Claim Number"
"62","0","1002","29","1","Insurance Claim Number"
"62","0","1002","44","2","Insurance Group Code"
"62","0","1002","88","3","Insurance Contract"
"63","0","1002","92","1","Treatment Authorization w/Matching ID"
"63","0","1002","93","2","Treatment Authorization For Modality"
"63","0","1002","95","3","Treatment Authorization (Use for PPS)"
"63","0","1002","29","4","Insurance Claim Number"
"63","0","1002","91","5","Treatment Auth PPS Claimkey And Codes"
"64","0","1002","1","1","Constant Value (Entered)"
"65","0","1002","1","1","Constant Value (Entered)"
"65","0","1002","161","2","Pat-Ins Bill Data Employer"
"66","0","1002","74","1","Constant (0 or 9) based on Diagnosis Type"
"66","0","1002","76","2","Bypass this Option"
"67","0","1002","96","1","Treatment Plan Diagnosis Codes"
"67","0","1002","99","2","Patient Diagnosis Codes"
"69","0","1002","28","1","Patient Diagnosis Code (Primary)"
"70","0","1002","28","1","Patient Diagnosis Code (Primary)"
"72","0","1002","101","1","Patient First E-Diagnosis"
"72","0","1002","98","2","Treatment Plan First E-Diagnosis"
"76","0","1002","109","1","Physician NPI and Name"
"76","1","1002","110","1","Physician UPIN"
"76","1","1002","103","2","Physician Taxonomy"
"76","1","1002","104","3","Physician License"
"77","0","1002","109","1","Physician NPI and Name"
"77","0","1002","107","2","Physician (Clinic Specialty) Name/Address"
"77","0","1002","56","3","Institution Name and Prov# (First for admit)"
"77","0","1002","111","4","Physician NPI Only"
"78","0","1002","109","1","Physician NPI and Name (Ordering)"
"78","0","1002","113","2","Physician NPI and Name (Referring/Seq1)"
"78","0","1002","107","3","Physician NPI and Name (Clinic Specialty) "
"78","0","1002","44","4","Insurance Group Code"
"78","0","1002","56","5","Institution Name and Prov# (First for Admit)"
"78","0","1002","57","6","Institution Name and NPI "
"79","0","1002","44","1","Insurance Group Code"
"80","0","1002","159","1","Pat-Ins Bill Data BillNote1"
"80","0","1002","117","2","Insurance Name and Address (Current Insurance)"
"80","0","1002","56","3","Institution Name and Address (Current Insurance)"
"80","0","1002","1","4","Constant Value (Entered)"
"80","0","1002","45","5","Patient Discharge Reason and Date"
"81","0","1002","1","1","Constant Value (Entered)"
"100","0","1002","3","1","Format Units With Leading Zeros"
"100","0","1002","2","2","Format Units With Leading Spaces"
"101","0","1002","6","1","Format Dollar Values Without Decimal Point Or Space"
"101","0","1002","4","2","Format Dollar Values with Decimal Space"
"101","0","1002","5","3","Format Dollar Values With Decimal Point"
"102","0","1002","1039","1","Format full 9 digit zip codes"
"102","0","1002","1042","2","Format full 9 digit zip no dash"
"103","0","1002","1496","1","Process Type: PPS Secondary"
"103","0","1002","1500","2","Process Type: PPS"
"103","0","1002","1497","3","Process Type: Non-PPS"
"103","0","1002","1495","4","Process Type: Hospice NOE/NOTR"
"103","0","1002","1494","5","Process Type: Homecare Notice"
"150","0","1002","74","1","Store and Auto Select Insurances"
