NSF (National Standard Format)

NSF (National Standard Format)
NSF (National Standard Format) USER MANUAL
NSF OVERVIEW
This manual contains record layouts of the NSF, which is used to bill CMS-1500, Medical, and Dental claims.
The instructions for transmitting a file are as follows:
• Logon to www.emomed.com.
• Select "Send files" link.
• Populate the window with the file name.
• Submit the information.
A window appears either confirming successful receipt or notifying of non-receipt of the file.
If the receipt was successful, check for appropriate responses in the "Receive Provider files" area of the
www.emomed.com website. Claim confirmation and Functional Acknowledgement (997) files are generated
daily and remain on-line for more than 30 days.
If the receipt was not successful and the biller is unable to determine the reason for the non-receipt, contact the
Infocrossing Healthcare Services (IHS) Help Desk at (573) 635-3559.
If no claim confirmation file is available after 2 complete business days, contact the IHS Help Desk at (573) 6353559.
PROCESSING OVERVIEW
For Health Care Services/Dental Services using the National Standard Format (NSF)
Claims for one or more providers may be submitted on a file. These claims can be different types (health care
services or dental services). Electronic claim submissions should be made as frequently as possible to avoid
unnecessary delays in reimbursement.
The first record on each file must be a Record Type 'AA0'. This record contains file origination information
concerning the creation of specific information for all providers billing on the file. The information submitted on
this record is posted to the MO HealthNet Electronic Media Claims (EMC) reference file, assuring an accurate
contact address is always on file for future Service Bureau information.
FILE SPECIFICATIONS FOR HEALTH CARE/DENTAL (NSF)
The file name must be CLAIMS.ALI on diskettes or emomed.com, it may be any name you choose.
Record Type 'AA0' Processor Data must be the first record on each file.
Record Type 'ZA0' File Control must be the last record on each file.
For files with multiple providers, Record Type 'BA0' Provider Data and Record Type 'YA0' Provider Batch
Control are required for each different provider.
All records are 320 bytes long plus a 2 byte end of record marker
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1
All data in the records must be text format using IBM ASCII characters.
The end of record marker is a two byte field containing the value HEX OD OA (Carriage Return/Line Feed).
There are no field separators.
The end of file marker is a 1 byte HEX 1A.
This section of the manual contains National Standard Format (NSF) as accepted by CMS. It contains information
in order for you to send MO HealthNet CMS-1500 and Dental claims to Infocrossing Healthcare Services. If you
are beginning development for MO HealthNet, we strongly recommend you develop the NSF layout.
MEDICAL/CMS-1500/DENTAL OVERVIEW
What follows explains what fields/records are required for MO HealthNet claims. The Electronic Media Claims
NSF layout as published by CMS, version 003.00, giving you actual field lengths and positions.
CMS-1500 claims have a minimum of 5 records per claim. One CA0 record, one DA0 record, one EA0 record, 1 12 FA0 records, and one XA0 record. Dental claims have a minimum of 6 records per claim, one CA0 record, one
DA0 record, one EA0 record, 1 -13 FA0 records, 1 - 13 FD0 records and one XA0 record.
Required Records
AA0 File Header Record "Submitter Data"
BA0 Batch Header Record "Provider Data 1"
CA0 Claim Header Record "Patient Data"
DA0 Insurance Information "Payor Data 1"
EA0 Claim Record
FA0 Service Line Detail "Root Segment"
FD0 Service Line Detail "Dental Segment" (Dental Claims Only)
XA0 Claim Trailer Record "Record Summary"
YA0 Batch Trailer Record
ZA0 File Trailer Record
Record Layout Charts (for CMS-1500 and Dental)
Description of Headings
Field No.---------- Field Number
Field Name------- Field Name
Table Value------ Data element identifier for the Data Definition Table.
Default------------ A "YES" implies that the field is required for all claims.
A "NO" implies that the field is not always required or not required for all
MO HealthNet claims or the field is optional.
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"Not Used" implies that the field is NOT applicable to MO HealthNet billing and will not be
used if submitted.
CLAIM SUBMISSION RESTRICTIONS
Services or cases which require substantiating documentation or clarifying information cannot be billed via
electronic format and must be billed on paper claims. These may include:
*Sterilization consents
Abortions
*Hysterectomies
Medicare crossover claims—these claims should be submitted to Medicare via the customary procedure.
Emergency procedures performed which would otherwise require prior authorization.
Services for which special consideration is appropriate, e.g., complicated surgery requiring an operative report.
Services exceeding MO HealthNet benefits, thereby requiring the provider's statement of medical necessity.
Any procedures where the CPT-4 procedure coding system does not accurately identify the services being
rendered.
Other insurance resources present but no payment from other sources indicated. In such cases, justification for
nonpayment is required.
Services requiring denture certification, home health certification, or hearing aid certification.
*Second surgical opinion procedures
Eyeglass lenses
Complex consultations
Visits relating to a "grower" baby
*Oxygen and respiratory equipment justification
*Medical referral of restricted participants.
Any other claims which require special handling or attachments.
* May not be submitted in batch files, but may be submitted individually as attachments on emomed.com.
RECORD NAME: FILE HEADER RECORD TYPE AA0 "SUBMITTER DATA"
Required by MO HealthNet - Must be first record for NSF
Must be followed by BA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "AA0"
C-24
AA0
02
SUB ID
NSF (National Standard Format) User Manual
Not Used
3
03
RESERVED (AA0-03.0)
Not Used
04
SUBMISSION TYPE
Not Used
05
SUBMISSION NO
Not Used
06
SUB NAME
C-47
YES
07
SUB ADDR1
C-47
YES
08
SUB ADDR2
C-47
YES
09
SUB CITY
C-47
YES
10
SUB STATE
C-47
YES
11
SUB ZIP
C-47
YES
12
SUB REGION
C-47
NO
13
SUB CONTACT
C-47
NO
14
SUB PHONE
C-47
YES
15
CREATION DATE
Not Used
16
SUBMISSION TIME
Not Used
17
RECEIVER ID
Not Used
18
RECEIVER TYPE CODE
Not Used
19
VERSION CODE-NATIONAL
00300
20
VERSION CODE-LOCAL
Not Used
21
TEST/PROD IND
Not Used
22
PASSWORD
Not Used
23
RETRANSMISSION STATUS
Not Used
24
ORIGINAL SUB ID
Not Used
25
VENDOR APP CAT
Not Used
26
VENDOR SOFTWARE VER
Not Used
27
VENDOR SOFTWARE UPDTE
Not Used
28
COB FILE IND
Not Used
29
PROCESS FROM DATE
Not Used
30
PROCESS THRU DATE
Not Used
31
ACKNOWLEDGMENT REQUEST
Not Used
32
DATE OF RECEIPT
Not Used
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33
FILLER-NATIONAL
YES
RECORD TYPE: AA0
LEVEL: FILE
PURPOSE: The first record of any file submitted, it contains information pertinent to the submitter of the claim
file. A submitter could be a provider of medical services (e.g., physician, lab, clinic...) or a billing agency. The
information contained in this record will be the determining factor in whether or not the file will be allowed
system access.
REQUIREMENTS: A "AA0" record is required for every submission.
ORDER:
Preceding Record Type
Following Record Type
NONE
BA0
NOTES:
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "AA0"
3
X
01
03
02.0
SUB ID
16
X
04
19
03.0
RESERVED (AA0-03.0)
9
X
20
28
04.0
SUBMISSION TYPE
6
X
29
34
05.0
SUBMISSION NO
6
X
35
40
06.0
SUB NAME
33
X
41
73
07.0
SUB ADDR1
30
X
74
103
08.0
SUB ADDR2
30
X
104
133
09.0
SUB CITY
20
X
134
153
10.0
SUB STATE
2
X
154
155
11.0
SUB ZIP
9
X
156
164
12.0
SUB REGION
5
X
165
169
13.0
SUB CONTACT
33
X
170
202
14.0
SUB PHONE
10
X
203
212
15.0
CREATION DATE
8
X
213
220
16.0
SUBMISSION TIME
6
X
221
226
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17.0
RECEIVER ID
16
X
227
242
18.0
RECEIVER TYPE CODE
1
X
243
243
19.0
VERSION CODE-NATIONAL
5
N
244
248
20.0
VERSION CODE-LOCAL
5
N
249
253
21.0
TEST/PROD IND
4
X
254
257
22.0
PASSWORD
8
X
258
265
23.0
RETRANSMISSION STATUS
1
X
266
266
24.0
ORIGINAL SUB ID
16
X
267
282
25.0
VENDOR APP CAT
1
X
283
283
26.0
VENDOR SOFTWARE VER
5
X
284
288
27.0
VENDOR SOFTWARE UPDTE
2
X
289
290
28.0
COB FILE IND
1
X
291
291
29.0
PROCESS FROM DATE
8
X
292
299
30.0
PROCESS THRU DATE
8
X
300
307
31.0
ACKNOWLEDGMENT REQUEST
1
X
308
308
32.0
DATE OF RECEIPT
8
X
309
316
33.0
FILLER-NATIONAL
4
X
317
320
RECORD/FIELD: AA0-01.0
DATA ELEMENT: Record Identifier (RECORD ID "AA0")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: Field used to identify the "Submitter Data Record".
CODE VALUES: See the C-24 table for valid field values.
VALIDATION: Must be entered.
Must be "AA0".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: AA0-02.0
DATA ELEMENT: Submitter Identifier (SUB ID)
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FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(16)
LEFT
SPACES
04
19
DEFINITION: Identifies the submitter as defined by the receiver.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered.
Must be identical to the SUBMITTER ID entered in the File Trailer Record (ZA0-02.0).
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: N/A
REMARKS: May be a federally assigned Employer Identification Number (EIN). EIN is also referred to
as a Tax Identification Number (TIN) depending on the receiver's requirements.
RECORD/FIELD: AA0-03.0
DATA ELEMENT: Reserved (AA0-03.0)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(09)
LEFT
SPACES
20
28
DEFINITION: Unused reserved record space.
CODE VALUES: Not used by MO HealthNet.
VALIDATION:N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: AA0-04.0
DATA ELEMENT: Submission Type
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(06)
LEFT
SPACES
29
34
DEFINITION: Identifies the input medium or method used to transmit the data to the receiver.
CODE VALUES: Not used by MO HealthNet.
CODE VALUES:
ASYNC
BISYNC
SYNC
RJE
FAX
TAPE
ASY
BSY
NDM
RJE
FAX
TP
ASY003
BSY024
RJE024
TPCRTG
ASY012
BSY048
RJE048
TP0800
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ASY024
BSY096
RJE096
TP1600
ASY048
BSY192
RJE192
TP6250
ASY096
DISKETTE
SCANNER
CPU
DSK8SSDSK5SSDSK3SS
SCN
CPU
DSK8SDDSK5SDDSK3SD
SCNOCR
DSK8DDDSK5DDDSK3DD
SCNICR
DSK5HDDSK3HD
VALIDATION: At a minimum, must be a valid code from the above lists.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: AA0-05.0
DATA ELEMENT: Submission Number (SUBMISSION NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(06)
LEFT
SPACES
35
40
DEFINITION: The inventory file number of the tape reel or transmission assigned by the submitter's
system.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered.
The Submission Number must be unique for every new file submitted.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: AA0-06.0
DATA ELEMENT: Submitter Name (SUB NAME)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(33)
LEFT
SPACES
41
73
DEFINITION: The name of the submitter to which the receiver should direct inquiries regarding this file.
CODE VALUES: See the C-47 table for valid field values.
NSF (National Standard Format) User Manual
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VALIDATION: Must be entered if required by receiver.
See GENERAL INSTRUCTIONS for "Name 2" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: AA0-07.0, AA0-08.0, AA0-09.0, AA0-10.0, AA0-11.0
DATA ELEMENT:
Submitter Street Address 1
(SUB ADDR1)
Submitter Street Address 2
(SUB ADDR2)
Submitter City
(SUB CITY)
Submitter State
(SUB STATE)
Submitter Zip Code
(SUB ZIP)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(30)
LEFT
SPACES
74
103
08.0
X(30)
LEFT
SPACES
104
133
09.0
X(20)
LEFT
SPACES
134
153
10.0
X(02)
LEFT
SPACES
154
155
11.0
X(09)
LEFT
SPACES
156
164
DEFINITION: The mailing address of the submitter of the claim file.
CODE VALUES: See the C-47 table for valid field values.
VALIDATION: Must be entered if required by receiver.
See GENERAL INSTRUCTIONS for "Address" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: AA0-12.0
DATA ELEMENT: Submitter Region (SUB REGION)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(05)
LEFT
SPACES
165
169
DEFINITION:A receiver defined field that identifies the region submitting the claim. To be used for
future regional processing.
CODE VALUES: See the C-47 table for valid field values.
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VALIDATION: Must be entered if required by receiver.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: AA0-13.0
DATA ELEMENT: Submitter Contact (SUB CONTACT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
X(33)
LEFT
SPACES
170
202
DEFINITION: Identifies an individual responsible for issues that may arise concerning this submission.
CODE VALUES: See the C-47 table for valid field values.
VALIDATION: Must be entered if required by receiver.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: AA0-14.0
DATA ELEMENT: Submitter Telephone Number(SUB PHONE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
14.0
X(10)
LEFT
SPACES
203
212
DEFINITION: The telephone number of the SUBMITTER CONTACT (AA0-13.0).
CODE VALUES: See the C-47 table for valid field values.
VALIDATION: Must be entered if required by receiver.
See GENERAL INSTRUCTIONS for "Telephone" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: AA0-15.0
DATA ELEMENT: Creation Date
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
15.0
X(08)
LEFT
SPACES
213
220
DEFINITION: Identifies the date the submitter created the file.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered.
NSF (National Standard Format) User Manual
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Must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
Must not be later than the date the file is received.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: AA0-16.0
DATA ELEMENT: Submission Time
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
16.0
X(06)
LEFT
SPACES
221
226
DEFINITION: Identifies the time of day that the submitter created the file.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Format: HHMMSS (military time).
HH = hour
MM = minutes
SS = seconds
Must be entered if required by receiver.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: AA0-17.0
DATA ELEMENT: Receiver Identification (RECEIVER ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
17.0
X (16)
LEFT
SPACES
227
242
DEFINITION:A value assigned by the receiver/payor to identify the organization designated to ultimately
receive this file to prevent misrouting of claim data.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor / receiver.
Must be identical to the RECEIVER IDENTIFICATION value in the File Trailer Record (ZA0-04.0).
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: N/A
REMARKS: N/A
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RECORD/FIELD: AA0-18.0
DATA ELEMENT: Receiver Type Code
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
X(01)
LEFT
SPACES
243
243
DEFINITION:A code indicating the type of organization designated to receive this file.
CODE VALUES: Not used by MO HealthNet.
CODE VALUES:
A - Self Pay
B—Workers Compensation
C—Medicare
D—MO HealthNet
E—Other Federal Program
F—Insurance Company
G—Blue Shield
H—CHAMPUS
I—Other
J—Blue Cross
Z—Multiple Payor Organizations
VALIDATION: Must be entered if required by receiver. If entered, must be a valid code from the above
list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: AA0-19.0
DATA ELEMENT: Version Code-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
19.0
9(03)V99
RIGHT
ZEROS
244
248
DEFINITION:A code indicating the specification version being used. This is restricted to National use.
CODE VALUES: 00300
VALIDATION: Format: 999V99
Must be entered.
NSF (National Standard Format) User Manual
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Must be "00301".
FORM LOCATION: N/A
REMARKS: The first three (3) digits BEFORE the implied decimal will indicate changes in record
format or any new or deleted records. It is the VERSION of specifications.
The last two (2) digits AFTER the implied decimal will indicate changes in editing. It is the UPDATE
NUMBER of the specifications.
RECORD/FIELD: AA0-20.0
DATA ELEMENT: Version Code-Local
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
20.0
9(03)V99
RIGHT
ZEROS
249
253
DEFINITION:A code indicating the specification version being used. This is restricted to Local use.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by receiver. Format: 999V99
FORM LOCATION: N/A
REMARKS: Do not use for Medicare. Medicare does not allow local version of the NSF.
RECORD/FIELD: AA0-21.0
DATA ELEMENT: Test/Production Indicator (TEST/PROD IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
21.0
X(04)
LEFT
SPACES
254
257
DEFINITION:A code indicating whether the file is to be used for test or production purposes.
CODE VALUES: Not used by MO HealthNet.
TEST = file should be run through a test system.
PROD = file should be run through a production system.
VALIDATION: Must be entered if required by receiver. If entered, must be a valid code from the above
list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: AA0-22.0
DATA ELEMENT: Password
FIELD
COBOL PICTURE
NSF (National Standard Format) User Manual
JUSTIFY
INITIAL
FROM
THRU
13
22.0
X(08)
LEFT
SPACES
258
265
DEFINITION:A user-specific code designed to gain access to the receiver's network/application.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by receiver.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: AA0-23.0
DATA ELEMENT: Retransmission Status
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
23.0
X(01)
LEFT
SPACES
266
266
DEFINITION:A code indicating the type of transmission for this file.
CODE VALUES: Not used by MO HealthNet.
CODE VALUES:
0 - Normal Transmission
8 - Non-Chargeable Retransmission
9 - Chargeable Retransmission
VALIDATION: Must be entered if required by receiver. If entered, must be a valid code from the above
list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: AA0-24.0
DATA ELEMENT: Original Sub ID
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
24.0
X(16)
LEFT
SPACES
267
282
DEFINITION: Identifies the original submitter of claims in this file.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by receiver.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: N/A
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REMARKS: Limited to payor who requires identification of the original submitter when transferring
claims.
RECORD/FIELD: AA0-25.0
DATA ELEMENT: Vendor Application Category (VENDOR APP CAT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
25.0
X(01)
LEFT
SPACES
283
283
DEFINITION: The category that applies to the vendor who created this file.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by the payor.
FORM LOCATION: N/A
REMARKS: The application category can be used to identify the category the vendor's software (that
created this file) applies to. For example, Medicare Part B, Medicare Durable Medical Equipment
Regional Carrier, MO HEALTHNET, private and commercial side, etc.
Consult the Matrix/Usage document supplied by the payor/receiver for submission instructions.
RECORD/FIELD: AA0-26.0
DATA ELEMENT: Vendor Software Version (VENDOR SOFTWARE VER)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
26.0
X(05)
LEFT
SPACES
284
288
DEFINITION: The version of the software package that was used to create this file.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by the payor.
FORM LOCATION: N/A
REMARKS: Reporting the version of the software can assist in troubleshooting discrepancies between
what the biller sent and what the software vendor believes should be send when updates are made.
Consult the Matrix/Usage document supplied by the payor/receiver for submission instructions.
RECORD/FIELD: AA0-27.0
DATA ELEMENT: Vendor Software Update (VENDOR SOFTWARE UPDTE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
27.0
X(02)
LEFT
SPACES
289
290
DEFINITION: The update number of this version of software used to create this file.
NSF (National Standard Format) User Manual
15
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by the payor.
FORM LOCATION: N/A
REMARKS: This fields relates to any special "fixes" or updates to the version reported in field AA0-26.0.
Consult the Matrix/Usage document supplied by the payor/receiver for submission instructions.
RECORD/FIELD: AA0-28.0
DATA ELEMENT: Coordination of Benefits File Indicator (COB FILE IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
28.0
X(01)
LEFT
SPACES
29
291
DEFINITION: Identifies the NSF file submitted as an NSF
Coordination of Benefits file, exchanged between payors.
CODE VALUES: Not used by MO HealthNet.
CODE VALUES:
Y = This file is a NSF COB file
blank = this file is a NSF file
VALIDATION: Y must be entered if this file is to be exchanged between payors for COB purposes.
FORM LOCATION: N/A
REMARKS: Required for COB exchange.
RECORD/FIELD: AA0-29.0
DATA ELEMENT: PROCESS FROM DATE
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
29.0
X(08)
LEFT
SPACES
292
299
DEFINITION: The beginning date of the date range that this file covers.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: N/A
REMARKS: This is primarily for COB exchange. Required for COB exchange.
RECORD/FIELD: AA0-30.0
DATA ELEMENT: PROCESS THRU DATE
NSF (National Standard Format) User Manual
16
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
30.0
X(08)
LEFT
SPACES
300
307
DEFINITION: The end date of the date range that this file covers.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: N/A
REMARKS: This is primarily for COB exchange. Required for COB exchange
RECORD/FIELD: AA0-31.0
DATA ELEMENT: Acknowledgment Requested (ACKNOWLEDGMENT REQUEST)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
31.0
X(01)
LEFT
SPACES
308
308
DEFINITION: Indicates if sender of the transmission wants to receive a functional acknowledgment.
CODE VALUES: Not used by MO HealthNet.
CODE VALUES:
Y = Functional acknowledgment requested
N = No functional acknowledgment requested
VALIDATION: Must be a valid code.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: AA0-32.0
DATA ELEMENT: DATE OF RECEIPT
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
32.0
X(08)
LEFT
SPACES
309
316
DEFINITION: The date this file was received from the submitter.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: N/A
NSF (National Standard Format) User Manual
17
REMARKS: This is to be entered by the receiver of the file.
RECORD/FIELD: AA0-33.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
33.0
X(04)
LEFT
SPACES
317
320
DEFINITION: Unused record space reserved for National use.
CODE VALUES: N/A
VALIDATION:N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: BATCH HEADER RECORD TYPE BA0 "PROVIDER DATA 1"
Required by MO HealthNet
Must be followed by BA1 or CA0
Must follow either AA0 or YA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "BA0"
C-24
BA0
02
EMC PROV ID
03
BATCH TYPE
04
BATCH NO
Not Used
05
BATCH ID
Not Used
06
PROV TAX ID
Not Used
07
RESERVED (BA0-07.0)
Not Used
08
PROV TAX ID TYPE
Not Used
09
PROV MEDICARE NO
Not Used
10
PROV UPIN-USIN ID
Not Used
11
RESERVED (BA0-11.0)
Not Used
12
PROV MEDICAID ID
13
PROV CHAMPUS NO
NSF (National Standard Format) User Manual
Not Used
C-61
C-8
YES
YES
Not Used
18
14
PROV BLUE SHIELD NO
Not Used
15
PROV COMMERCIAL NO
Not Used
16
PROV NO 1
Not Used
17
PROV NO 2
Not Used
18
ORGANIZATION NAME
19
PROV LAST NAME
Not Used
20
PROV FIRST NAME
Not Used
21
PROV MI
Not Used
22
PROV SPECIALTY
Not Used
23
SPECIALTY LICENSE NO
Not Used
24
STATE LICENSE NO
Not Used
25
DENTIST LICENSE NO
Not Used
26
ANESTHESIA LICENSE NO
Not Used
27
PROV PARTICIPATE IND
Not Used
28
FILLER-NATIONAL
YES
C-33
YES
RECORD TYPE: BA0
LEVEL:BATCH
PURPOSE: To identify and provide information regarding the provider of services indicated in this batch.
REQUIREMENTS: This record is required. A "BA0" record is required for every submission.
ORDER:
Preceding Record Type
Following Record Type
AA0 or YA0
BA1 or CA0
NOTES: Only one BA0 record is allowed for each batch.
FIELD
NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "BA0"
3
X
01
03
02.0
EMC PROV ID
15
X
04
18
03.0
BATCH TYPE
3
X
19
21
04.0
BATCH NO
4
N
22
25
NSF (National Standard Format) User Manual
19
05.0
BATCH ID
6
X
26
31
06.0
PROV TAX ID
9
X
32
40
07.0
RESERVED (BA0-07.0)
6
X
41
46
08.0
PROV TAX ID TYPE
1
X
47
47
09.0
NATIONAL PROV ID
15
X
48
62
10.0
PROV UPIN-USIN ID
6
X
63
68
11.0
RESERVED (BA0-11.0)
6
X
69
74
12.0
PROV MEDICAID NO
15
X
75
89
13.0
PROV CHAMPUS NO
15
X
90
104
14.0
PROV BLUE SHIELD NO
15
X
105
119
15.0
PROV COMMERCIAL NO
15
X
120
134
16.0
PROV NO 1
15
X
135
149
17.0
PROV NO 2
15
X
150
164
18.0
ORGANIZATION NAME
33
X
165
197
19.0
PROV LAST NAME
20
X
198
217
20.0
PROV FIRST NAME
12
X
218
229
21.0
PROV MI
1
X
230
230
22.0
PROV SPECIALTY
3
X
231
233
23.0
SPECIALTY LICENSE NO
15
X
234
248
24.0
STATE LICENSE NO
15
X
249
263
25.0
DENTIST LICENSE NO
15
X
264
278
26.0
ANESTHESIA LICENSE NO
15
X
279
293
27.0
PROV PARTICIPATE IND
1
X
294
294
28.0
FILLER-NATIONAL
26
X
295
320
RECORD/FIELD: BA0-01.0
DATA ELEMENT: Record Type (RECORD ID 'BA0')
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: This field is used to identify the "PROVIDER DATA 1" record.
NSF (National Standard Format) User Manual
20
CODE VALUES: See the C-24 table for valid field values.
VALIDATION: Must be entered.
Must be BA0.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: BA0-02.0
DATA ELEMENT: EMC Provider Identifier (EMC PROV ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(15)
LEFT
SPACES
04
18
DEFINITION: The unique number assigned to the provider for EMC identification purposes by the
payor/receiver.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered. Must be identical to the "EMC Provider Identifier" in the corresponding
record
YA0 - 02.0.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: CMS-1500 Block 33
REMARKS: N/A
RECORD/FIELD: BA0-03.0
DATA ELEMENT: Batch Type
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(03)
LEFT
SPACES
19
21
DEFINITION: This field indicates the type of claims that are included within this batch.
CODE VALUES: See the C-61 table for valid field values.
VALIDATION: Must be entered if required by the receiver. If entered, must be a valid code from the
above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: BA0-04.0
DATA ELEMENT: Batch Number (BATCH NO)
NSF (National Standard Format) User Manual
21
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(04)
RIGHT
ZEROS
22
25
DEFINITION: This is a sequential number assigned by the submitter, to each batch of claims.
CODE VALUES: Not used by MO HealthNet.
Must be equal to 0001 through 9999.
VALIDATION: Must be entered.
Must be numeric.
First occurrence must be 0001.
Whenever the "EMC Provider Identifier", BA0 - 02.0, or "Type of Batch", BA0 - 03.0, changes from
those previously entered, the "Batch Number" must be reset to 01.
If the previous "EMC Provider Identifier", BA0 - 02.0 and "Type of Batch", BA0 - 03.0 are identical with
those currently being processed, the "Batch Number" must be one greater than the previous "Batch
Number".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: BA0-05.0
DATA ELEMENT: Batch Identification (BATCH ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(06)
LEFT
SPACES
26
31
DEFINITION: The identifier assigned by the submitter/provider to identify a batch within his own
system.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Optional at the submitter/provider discretion.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: N/A
REMARKS: Used to facilitate the communication between the receiver and submitter/provider,
concerning problem batches, as well as the reporting of claims with errors and accepted claims.
RECORD/FIELD: BA0-06.0
DATA ELEMENT: Provider Tax ID (PROV TAX ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(09)
LEFT
SPACES
32
40
NSF (National Standard Format) User Manual
22
DEFINITION: The federally assigned Tax identification number (T.I.N.) of the billing provider. This can
be either the Employer Identification Number (E.I.N.) or the Social Security Number (S.S.N.) of the
provider.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by carrier/receiver. The "Provider Tax ID" entered in BA0 06.0 must be identical to the "Provider Tax ID" entered in YA0 - 06.0.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: CMS-1500 Block 25
REMARKS: N/A
RECORD/FIELD: BA0-07.0
DATA ELEMENT: Reserved Field (BA0 07.0)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(06)
N/A
SPACES
41
46
DEFINITION: Unused reserved record space.
Reserved for Tax ID expansion.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: BA0-08.0
DATA ELEMENT: Provider Tax ID Type (PROV TAX ID TYPE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
08.0
X(01)
N/A
SPACE
47
47
DEFINITION: A code which identifies the type of Provider Tax ID entered in BA0 - 06.0.
CODE VALUES: Not used by MO HealthNet.
E = Employer Identification Number S = Social Security Number X = Corporate name, but Social
Security Number
VALIDATION: Must be entered if required by payor. If entered, must be a valid code from the above list.
If this field is equal to "E" or "X", then the "Provider Organization Name" (BA0 - 18.0) must not be blank
unless an individual provider (solo practioner) has a Tax ID/EIN "E" in which case, BA0-19.0 must not
NSF (National Standard Format) User Manual
23
be blank. If this field is equal to "S" then the "Provider Last Name" (BA0 - 19.0) and "Provider First
Name" (BA0 - 20.0) must not be blank.
FORM LOCATION: CMS-1500 Block 25
REMARKS: N/A
RECORD/FIELD: BA0-08.0
DATA ELEMENT: National Provider Identifier (NPI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
X(15)
LEFT
SPACES
48
62
DEFINITION: The National Provider Identifier assigned to the provider.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: If entered:
This field must contain the National Provider Identifier (NPI) for Medicare claims once the NPI is
implemented.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: CMS-1500 Block 33
REMARKS: If the NPI is not entered or entered incorrectly, all Medicare claims contained within the
batch may be rejected.
REQUIREMENTS: The NPI must be entered if the batch contains any claims that are to be processed by
a Medicare payor.
RECORD/FIELD: BA0-10.0
DATA ELEMENT: Provider "UPIN" - "USIN" ID (PROV UPIN-USIN ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
X(06)
LEFT
SPACES
63
68
DEFINITION: The number assigned to the provider by the National Registry for Medicare Identification
purposes.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Not applicable at this time.
FORM LOCATION: CMS-1500 Block 33
REMARKS: N/A
RECORD/FIELD: BA0-11.0
DATA ELEMENT: Reserved Field (BA0 11.0)
NSF (National Standard Format) User Manual
24
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
X(06)
LEFT
SPACES
69
74
DEFINITION: Unused reserved record space.
Reserved for UPIN expansion.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: BA0-12.0
DATA ELEMENT: Provider MO HealthNet Number (PROV MO HEALTHNET NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(15)
LEFT
SPACES
75
89
DEFINITION: The number assigned to the Provider by a MO HealthNet
State Agency for identification purposes.
CODE VALUES: See the C-8 table for valid field values.
VALIDATION: If entered:
This field must contain the MO HealthNet Provider Number as it appears on the Payor's Provider File.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: CMS-1500 Block 33
REMARKS: If the MO HealthNet Provider Number is not entered or entered incorrectly all MO
HealthNet claims contained within the batch may be rejected.
REQUIREMENTS: The MO HealthNet Provider Number must be entered if the batch contains any
claims that are to be processed by a MO HealthNet payor.
RECORD/FIELD: BA0-13.0
DATA ELEMENT: Provider Champus Number (PROV CHAMPUS NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
X(15)
LEFT
SPACES
90
104
DEFINITION: The number assigned to the Provider by the Champus payor for identification purposes.
CODE VALUES: Not used by MO HealthNet.
NSF (National Standard Format) User Manual
25
VALIDATION: If entered:
This field must contain the Champus Provider Number as it appears on the Payor's Provider
File.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: CMS-1500 Block 33
REMARKS: If the Champus Provider Number is not entered or entered incorrectly all Champus claims
contained within the batch may be rejected.
REQUIREMENTS: The Champus Provider Number must be entered if the batch contains any claims that
are to be processed by a Champus payor.
RECORD/FIELD: BA0-14.0
DATA ELEMENT: Provider Blue Shield Number (PROV BLUE SHIELD NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
14.0
X(15)
LEFT
SPACES
105
119
DEFINITION: The number assigned to the Provider by the Blue Shield payor for identification purposes.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: If entered:
This field must contain the Blue Shield number as it appears on the Payor's Provider File.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: CMS-1500 Block 33
REMARKS: If the Blue Shield Provider Number is not entered or entered incorrectly all Blue Shield
claims
contained within a batch may be rejected.
REQUIREMENTS: The Blue Shield Provider Number must be entered if the batch contains any claims
that are to be processed by a Blue Shield payor.
RECORD/FIELD: BA0-15.0
DATA ELEMENT: Provider Commercial Number (PROV COMMERCIAL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
15.0
X(15)
LEFT
SPACES
120
134
DEFINITION: The number assigned to the Provider by the Commercial payor for identification purposes.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: If entered:
NSF (National Standard Format) User Manual
26
This field must contain the Commercial Payor's Provider number as it appears on the Payor's
Provider File.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: CMS-1500 Block 25 & 33
REMARKS: If the Commercial Payor's Provider Number is not entered or entered incorrectly all
commercial
claims contained within a batch may be rejected.
REQUIREMENTS: The Commercial Carrier's Provider Number must be entered if the batch contains any
claims that are to be processed by a commercial payor.
RECORD/FIELD: BA0-16.0
DATA ELEMENT: Provider Other Number 1 (PROV NO 1)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
16.0
X(15)
LEFT
SPACES
135
149
DEFINITION: The number assigned to the provider by the receiver for other identification purposes.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered as required by receiver.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: N/A
REMARKS: Example: Specific number assigned for Workmen's Compensation, Health Maintenance
Organization
(HMO) or Additional Commercial Number.
RECORD/FIELD: BA0-17.0
DATA ELEMENT: Provider Other Number 2 (PROV NO 2)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
17.0
X(15)
LEFT
SPACES
150
164
DEFINITION: The number assigned to the provider by the receiver for other identification purposes.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered as required by the receiver.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: N/A
NSF (National Standard Format) User Manual
27
REMARKS: Example: Specific number assigned for Workmen's Compensation, Health Maintenance
Organization
(HMO) or Additional Commercial Number.
RECORD/FIELD: BA0-18.0
DATA ELEMENT: Provider Organization Name (ORGANIZATION NAME)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
X(33)
LEFT
SPACES
165
197
DEFINITION: The name of the group or organization submitting this batch of claims for payment.
CODE VALUES: See the C-33 table for valid field values.
VALIDATION: Must be entered if required by payor.
If entered:
This field should contain the Organization's (Group's) name as it appears on the Payor's File. See
GENERAL INSTRUCTIONS for "Name 2" entry. If BA0 - 08.0 equals "E" or "X" this field must not be
blank.
FORM LOCATION: CMS-1500 Block 33
REMARKS: N/A
RECORD/FIELD: BA0-19.0 BA0-20.0 BA0-21.0
DATA ELEMENT: Provider Last Name (PROV LAST NAME)
Provider First Name (PROV FIRST NAME)
Provider Middle Initial (PROV MI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
19.0
X(20)
LEFT
SPACES
198
217
20.0
X(12)
LEFT
SPACES
218
229
21.0
X(01)
LEFT
N/A
230
230
DEFINITION: The Last Name, First Name, and Middle initial of the individual provider submitting this
batch of claims for payment.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
If entered:
This field should contain the Individual Provider's last name, first name, and middle initial as it appears
on the Payor's File.
NSF (National Standard Format) User Manual
28
See GENERAL INSTRUCTIONS for "Name 1" entry.
If Record Type BA0 - 08.0 equals "S" these fields must not be blank.
FORM LOCATION: CMS-1500 Block 33
REMARKS: N/A
RECORD/FIELD: BA0-22.0
DATA ELEMENT: Provider Specialty (PROV SPECIALTY)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
22.0
X(03)
LEFT
SPACES
231
233
DEFINITION: A code indicating the primary specialty of the provider, as defined by the receiver.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by receiver.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: BA0-23.0
DATA ELEMENT: Specialty License Number (SPECIALTY LICENSE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
23.0
X(15)
LEFT
SPACES
234
248
DEFINITION: The Specialty License Number of the provider rendering services, as assigned by the
licensing board of that specialty.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by receiver.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: CMS-1500 Block 33
REMARKS: N/A
RECORD/FIELD: BA0-24.0
DATA ELEMENT: State License Number (STATE LICENSE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
24.0
X(15)
LEFT
SPACES
249
263
DEFINITION: The state license number of the provider.
NSF (National Standard Format) User Manual
29
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by receiver.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: CMS-1500 Block 33
REMARKS: N/A
RECORD/FIELD: BA0-25.0
DATA ELEMENT: Dentist License Number (DENTIST LICENSE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
25.0
X(15)
LEFT
SPACES
264
278
DEFINITION: The state license number of the dentist.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by receiver. See GENERAL INSTRUCTIONS for
"Identification
Number" entry.
FORM LOCATION: CMS-1500 Block 33
REMARKS: N/A
RECORD/FIELD: BA0-26.0
DATA ELEMENT: Anesthesia License Number (ANESTHESIA LICENSE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
26.0
X(15)
LEFT
SPACES
279
293
DEFINITION: The state license number of the anesthesiologist.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by receiver.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: CMS-1500 Block 33
REMARKS: N/A
RECORD/FIELD: BA0-27.0
DATA ELEMENT: Provider Participation Indicator (PROV PARTICIPATE IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
27.0
X(01)
LEFT
SPACES
294
294
NSF (National Standard Format) User Manual
30
DEFINITION: Indicates if the provider participates in the Medicare program.
CODE VALUES: Not used by MO HealthNet.
Y = Participating
N = Non-Participating
VALIDATION: If entered, must be a valid code from code list.
FORM LOCATION: N/A
REMARKS: This is required if this file is a COB NSF file.
RECORD/FIELD: BA0-28.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
28.0
X(26)
N/A
SPACES
295
320
DEFINITION: Unused reserved record space for National use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: BATCH HEADER RECORD TYPE BA1 "PROVIDER DATA 2"
Not Required by MO HealthNet
Must follow BA0
Must be followed by CA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "BA1"
C-24
BA1
02
EMC PROV ID
Not Used
03
BATCH TYPE
Not Used
04
BATCH NO
Not Used
05
BATCH ID
Not Used
06
PROV TYPE ORG
Not Used
07
PROV SVC ADDR1
Not Used
NSF (National Standard Format) User Manual
31
08
PROV SVC ADDR2
Not Used
09
PROV SVC CITY
Not Used
10
PROV SVC STATE
Not Used
11
PROV SVC ZIP
Not Used
12
PROV SVC PHONE
Not Used
13
PROV PAY TO ADDR1
Not Used
14
PROV PAY TO ADDR2
Not Used
15
PROV PAY TO CITY
Not Used
16
PROV PAY TO STATE
Not Used
17
PROV PAY TO ZIP
Not Used
18
PROV PAY TO PHONE
Not Used
19
FILLER-NATIONAL
YES
RECORD TYPE: BA1
LEVEL:BATCH
PURPOSE: Additional record to identify and provide information regarding the provider of services indicated in
this batch.
REQUIREMENTS: This record must be entered if required by the
payor.
ORDER:
Preceding Record Type
Following Record Type
BA0
CA0
NOTES: Only one BA1 record is allowed for each batch.
FIELD
NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "BA1"
3
X
01
03
02.0
EMC PROV ID
15
X
04
18
03.0
BATCH TYPE
3
X
19
21
04.0
BATCH NO
4
N
22
25
05.0
BATCH ID
6
X
26
31
NSF (National Standard Format) User Manual
32
06.0
PROV TYPE ORG
3
X
32
34
07.0
PROV SVC ADDR1
30
X
35
64
08.0
PROV SVC ADDR2
30
X
65
94
09.0
PROV SVC CITY
20
X
95
114
10.0
PROV SVC STATE
2
X
115
116
11.0
PROV SVC ZIP 9
9
X
117
125
12.0
PROV SVC PHONE
10
X
126
135
13.0
PROV PAY TO ADDR1
30
X
136
165
14.0
PROV PAY TO ADDR2
30
X
166
195
15.0
PROV PAY TO CITY
20
X
196
215
16.0
PROV PAY TO STATE
2
X
216
217
17.0
PROV PAY TO ZIP
9
X
218
226
18.0
PROV PAY TO PHONE
10
X
227
236
19.0
FILLER-NATIONAL
84
X
237
320
RECORD/FIELD: BA1-01.0
DATA ELEMENT: Record Type (RECORD ID 'BA1')
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: This field is used to identify the "PROVIDER DATA 2" record.
CODE VALUES: See the C-24 table for valid field values.
VALIDATION: Must be entered.
Must be BA1.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: BA1-02.0
DATA ELEMENT: EMC Provider Identifier (EMC PROV ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(15)
LEFT
SPACES
04
18
NSF (National Standard Format) User Manual
33
DEFINITION: The unique number assigned to the provider for EMC identification purposes.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered.
Must be identical to the "EMC Provider
Identifier" in the corresponding record YA0 - 02.0
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: CMS-1500 Block 33
REMARKS: N/A
RECORD/FIELD: BA1-03.0
DATA ELEMENT: Batch Type
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(03)
LEFT
SPACES
19
21
DEFINITION: This field indicates the type of claims that are included within this batch.
CODE VALUES: Not used by MO HealthNet.
100 - All Others
200 - Dental
VALIDATION: Must be entered if required by the receiver. If entered, must be a valid code from the
above list.
The "Batch Type" entered in BA1 - 03.0 must equal the "Batch Type" entered in YA0 - 03.0.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: BA1-04.0
DATA ELEMENT: Batch Number (BATCH NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
9(04)
RIGHT
ZEROS
22
25
DEFINITION: This is a sequential number assigned by the submitter, to each batch of claims.
CODE VALUES: Not used by MO HealthNet.
Must be equal to 0001 through 9999.
Must be numeric.
The "Batch Number" entered in BA1.04 must be identical to the "Batch Number" entered in BA0.04.
NSF (National Standard Format) User Manual
34
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: BA1-05.0
DATA ELEMENT: Batch Identification (BATCH ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(06)
LEFT
SPACES
26
31
DEFINITION: The identifier assigned by the submitter/provider to identify a batch within his own
system.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Optional at the submitter/provider discretion.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: N/A
REMARKS: Used to facilitate the communication between the receiver and submitter/provider,
concerning
problem batches, as well as the reporting of claims with errors and accepted claims.
RECORD/FIELD: BA1-06.0
DATA ELEMENT: Provider Type Organization(PROV TYPE ORG)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(03)
LEFT
SPACES
32
34
DEFINITION: The organizational structure of the billing provider of service.
CODE VALUES: Not used by MO HealthNet.
001 = Solo Practice
002 = Partnership
003 = PA (Professional Association)
004 = Clinic
005 = Single entity facility/hospital (all hospital provided under a single
provider number or corporate entity.
006 = Distinct part facility/hospital (a unit of a hospital or corporate entity
billing under a separate provider number) billing for professional service.
007 = Individual (corporation filing under an individual provider or tax
number (SSN) (common with suppliers)).
NSF (National Standard Format) User Manual
35
008 = Corporation.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: BA1-07.0 BA1-08.0 BA1-09.0 BA1-10.0 BA1-11.0
DATA ELEMENT:
Provider's Service Address 1 (PROV SVC ADDR1)
Provider's Service Address 2 (PROV SVC ADDR2)
Provider's Service City (PROV SVC CITY)
Provider's Service State (PROV SVC STATE)
Provider's Service Zip (PROV SVC ZIP)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(30)
LEFT
SPACES
35
64
08.0
X(30)
LEFT
SPACES
65
94
09.0
X(20)
LEFT
SPACES
95
114
10.0
X(02)
LEFT
SPACES
115
116
11.0
X(09)
LEFT
SPACES
117
125
DEFINITION: The current street address, city, state, and zip code of the Provider, designates where
services were rendered.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
See GENERAL INSTRUCTIONS for "Address" entry.
FORM LOCATION: CMS-1500 Block 33
REMARKS: N/A
RECORD/FIELD: BA1-12.0
DATA ELEMENT: Provider's Service Telephone Number (PROV SVC PHONE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(10)
LEFT
SPACES
126
135
NSF (National Standard Format) User Manual
36
DEFINITION: The telephone number, including area code at which the provider can be contacted (where
services were rendered).
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
See GENERAL INSTRUCTIONS for "Telephone" entry.
FORM LOCATION: CMS-1500 Block 33
REMARKS: N/A
RECORD/FIELD: BA1-13.0 BA1-14.0 BA1-15.0 BA1-16.0 BA1-17.0
DATA ELEMENT:
Provider's Pay - To Address 1 (PROV PAY TO
ADDR1)
Provider's Pay - To Address 2 (PROV PAY TO
ADDR2)
Provider's Pay - To City (PROV PAY TO CITY)
Provider's Pay - To State (PROV PAY TO STATE)
Provider's Pay - To Zip (PROV PAY TO ZIP)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
X(30)
LEFT
SPACES
136
165
14.0
X(30)
LEFT
SPACES
166
195
15.0
X(20)
LEFT
SPACES
196
215
16.0
X(02)
LEFT
SPACES
216
217
17.0
X(09)
LEFT
SPACES
218
226
DEFINITION: The current street mailing address, city, state, and zip code of the Provider, designates
where
payment is to be sent.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
See GENERAL INSTRUCTIONS for "Address" entry.
FORM LOCATION: CMS-1500 Block 33
REMARKS: N/A
RECORD/FIELD: BA1-18.0
DATA ELEMENT: Provider's Pay - To Telephone Number (PROV PAY TO PHONE)
NSF (National Standard Format) User Manual
37
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
X(10)
LEFT
SPACES
227
236
DEFINITION: The telephone number including area code at which the provider can be contacted,
designates where payment is to be sent.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
See GENERAL INSTRUCTIONS for "Telephone" entry.
FORM LOCATION: CMS-1500 Block 33
REMARKS: N/A
RECORD/FIELD: BA1-19.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
19.0
X(84)
LEFT
SPACES
237
320
DEFINITION: Unused reserved record space for National use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: CLAIM HEADER RECORD TYPE CA0 "PATIENT DATA"
Required by MO HealthNet
Must follow BA0 or BA1 or XA0
Must be followed by CB0 or DA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "CA0"
C-24
CA0
02
RESERVED (CA0-02.0)
03
PAT CONTROL NO
C-31
NO
04
PAT LAST NAME
C-2
YES
05
PAT FIRST NAME
C-2
YES
NSF (National Standard Format) User Manual
38
06
PAT MI
Not Used
07
PAT GENERATION
Not Used
08
PAT DATE OF BIRTH
Not Used
09
PAT SEX
Not Used
10
PAT TYPE OF RESIDENCE
Not Used
11
PAT ADDR1
Not Used
12
PAT ADDR2
Not Used
13
PAT CITY
Not Used
14
PAT STATE
Not Used
15
PAT ZIP
Not Used
16
PAT PHONE
Not Used
17
PAT MARITAL STATUS
Not Used
18
PAT STUDENT STATUS
Not Used
19
PAT EMPLOYMENT STATUS
Not Used
20
PAT DEATH IND
Not Used
21
PAT DATE OF DEATH
Not Used
22
OTHER INSURANCE IND
23
CLAIM EDITING IND
Not Used
24
TYPE OF CLAIM IND
Not Used
25
LEGAL REP IND
Not Used
26
ORIGIN CODE
Not Used
27
PAYOR CLM CONTROL NO
Not Used
28
PROVIDER NUMBER
Not Used
29
CLAIM ID NO
Not Used
30
FILLER-NATIONAL
YES
C-3
YES
RECORD TYPE: CA0
LEVEL: CLAIM
PURPOSE: To identify and provide information regarding the patient who received the services indicated in this
claim.
NSF (National Standard Format) User Manual
39
REQUIREMENTS: A CA0 record is required for every claim.
ORDER:
Preceding Record Type
Following Record Type
BA0, BA1 or XA0
CA1, CB0 or DA0
NOTES: Only one CA0 record is allowed for each claim.
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "CA0"
3
X
01
03
02.0
RESERVED (CA0-02.0)
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
PAT LAST NAME
20
X
23
42
05.0
PAT FIRST NAME
12
X
43
54
06.0
PAT MI
1
X
55
55
07.0
PAT GENERATION
3
X
56
58
08.0
PAT DATE OF BIRTH
8
X
59
66
09.0
PAT SEX
1
X
67
67
10.0
PAT TYPE OF RESIDENCE
1
X
68
68
11.0
PAT ADDR1
30
X
69
98
12.0
PAT ADDR2
30
X
99
128
13.0
PAT CITY
20
X
129
148
14.0
PAT STATE
2
X
149
150
15.0
PAT ZIP
9
X
151
159
16.0
PAT PHONE
10
X
160
169
17.0
PAT MARITAL STATUS
1
X
170
170
18.0
PAT STUDENT STATUS
1
X
171
171
19.0
PAT EMPLOYMENT STATUS
1
X
172
172
20.0
PAT DEATH IND
1
X
173
173
21.0
PAT DATE OF DEATH
8
X
174
181
22.0
OTHER INSURANCE IND
1
X
182
182
23.0
CLAIM EDITING IND
1
X
183
183
NSF (National Standard Format) User Manual
40
24.0
TYPE OF CLAIM IND
2
X
184
185
25.0
LEGAL REP IND
1
X
186
186
26.0
ORIGIN CODE
9
X
187
195
27.0
PAYOR CLM CONTROL NO
17
X
196
212
28.0
PROVIDER NUMBER
15
X
213
227
29.0
CLAIM ID NO
6
X
228
233
30.0
FILLER-NATIONAL
87
X
234
320
RECORD/FIELD: CA0-01.0
DATA ELEMENT: Record Identifier (RECORD ID "CA0")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: Code used to identify the "Patient Data" record.
CODE VALUES: See the C-24 table for valid field values.
VALIDATION: Must be entered.
Must be "CA0".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: CA0-02.0
DATA ELEMENT: RESERVED (CA0-02.0)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: Reserved record space.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: CA0-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
NSF (National Standard Format) User Manual
41
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: An identification assigned to the patient by the provider to identify the patient.
CODE VALUES: See the C-31 table for valid field values.
VALIDATION: See GENERAL INSTRUCTIONS for "Patient Control Number".
Must be entered.
FORM LOCATION: CMS-1500 Block 26
REMARKS: The patient control number is used by the EMC system to link all records for a claim. All
records between the record type CA0, up to and including the record type XA0, must have the same
patient control number.
Although up to seventeen characters are allowed, not all payors' systems will record and return seventeen
characters on remittance advices or other documents. Consult the Matrix/Usage document supplied by the
Payor/Receiver for additional information.
RECORD/FIELD: CA0-04.0, CA0-05.0, CA0-06.0
DATA ELEMENT:
Patient Last Name
(PAT LAST NAME)
Patient First Name
(PAT FIRST NAME)
Patient Middle Initial
(PAT MI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(20)
LEFT
SPACES
23
42
05.0
X(12)
LEFT
SPACES
43
54
06.0
X(01)
N/A
SPACES
55
55
DEFINITION: The name of the individual to whom the services were provided.
CODE VALUES: See the C-2 table for valid field values.
VALIDATION: See GENERAL INSTRUCTIONS for "Name 1" entry.
FORM LOCATION: CMS-1500 Block 2
REMARKS: N/A
RECORD/FIELD: CA0-07.0
DATA ELEMENT: Patient Generation (PAT GENERATION)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(03)
LEFT
SPACES
56
58
NSF (National Standard Format) User Manual
42
DEFINITION: The generation of the patient, such as I, II, III, Jr, Sr.
CODE VALUES: Not used by MO HealthNet.
I, II, III, IV, JR, SR
VALIDATION: Must be entered if required by payor. Must be a valid code from the above list.
FORM LOCATION: CMS-1500 Block 2
REMARKS: N/A
RECORD/FIELD: CA0-08.0
DATA ELEMENT: Patient Date of Birth (PAT DATE OF BIRTH)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
08.0
X(08)
LEFT
SPACES
59
66
DEFINITION: The date the patient was born.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
Must be less than or equal to the From Date of Service (FA0-05.0).
FORM LOCATION: CMS-1500 Block 3
REMARKS: N/A
RECORD/FIELD: CA0-09.0
DATA ELEMENT: Patient Sex Code (PAT SEX)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
X(01)
N/A
SPACE
67
67
DEFINITION: Code indicating the sex of the patient.
CODE VALUES: Not used by MO HealthNet.
M=MALE
F=FEMALE
VALIDATION: Must be entered.
Must be a valid code from the above list.
NSF (National Standard Format) User Manual
43
FORM LOCATION: CMS-1500 Block 3
REMARKS: N/A
RECORD/FIELD: CA0-10.0
DATA ELEMENT: Patient Type of Residence (PAT TYPE OF RESIDENCE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
X(01)
N/A
SPACE
68
68
DEFINITION: A code which indicates patient place of residence.
CODE VALUES: Not used by MO HealthNet.
S = Skilled Nursing Home
R = Residential Treatment Facility
P = Private Home
N=Nursing Home
VALIDATION: Must be entered if required by payor. If entered, must be a valid code from above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: CA0-11.0, CA0-12.0, CA0-13.0, CA0-14.0 CA0-15.0
DATA ELEMENT:
Patient Address 1
(PAT ADDR1)
Patient Address 2
(PAT ADDR2)
Patient City
(PAT CITY)
Patient State
(PAT STATE)
Patient Zip Code
(PAT ZIP)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
X(30)
LEFT
SPACES
69
98
12.0
X(30)
LEFT
SPACES
99
128
13.0
X(20)
LEFT
SPACES
129
148
14.0
X(02)
LEFT
SPACES
149
150
15.0
X(09)
LEFT
SPACES
151
159
DEFINITION: The mailing address of the patient.
CODE VALUES: Not used by MO HealthNet.
NSF (National Standard Format) User Manual
44
VALIDATION: See GENERAL INSTRUCTIONS for "Address" entry.
Must be entered if required by payor.
FORM LOCATION: CMS-1500 Block 5
REMARKS: N/A
RECORD/FIELD: CA0-16.0
DATA ELEMENT: Patient Telephone Number (PAT PHONE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
16.0
X(10)
LEFT
SPACES
160
169
DEFINITION: The telephone number. including area code, at which the patient may be contacted.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: See GENERAL INSTRUCTIONS for "Telephone" entry.
FORM LOCATION: CMS-1500 Block 5
REMARKS: N/A
RECORD/FIELD: CA0-17.0
DATA ELEMENT: Patient Marital Status (PAT MARITAL STATUS)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
17.0
X(01)
N/A
SPACE
170
170
DEFINITION: A code which indicates the marital status of the patient.
CODE VALUES: Not used by MO HealthNet.
S = Single
M = Married
D = Divorced
W=Widowed
X=Legally Separated
U=Unknown
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: CMS-1500 Block 8
REMARKS: N/A
NSF (National Standard Format) User Manual
45
RECORD/FIELD: CA0-18.0
DATA ELEMENT: Patient Student Status (PAT STUDENT STATUS)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
X(01)
N/A
SPACE
171
171
DEFINITION: A code which indicates the student status of the patient if 19 years of age or older, not
handicapped and not the insured.
CODE VALUES: Not used by MO HealthNet.
F = Full-time student
P = Part-time student
N = Not a student
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: CMS-1500 Block 8
REMARKS: N/A
RECORD/FIELD: CA0-19.0
DATA ELEMENT: Patient Employment Status (PAT EMPLOYMENT STATUS)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
19.0
X(01)
N/A
SPACE
172
172
DEFINITION: A code indicating employment status of the patient.
CODE VALUES: Not used by MO HealthNet.
1 = Employed full-time
2 = Employed part-time
3 = Not employed
4 = Self-employed
5 = Retired
6 = On active military duty
7 = Reserved for national assignment
8 = Reserved for national assignment
9 = Unknown
VALIDATION: Must be entered if required by payor.
NSF (National Standard Format) User Manual
46
If entered, must be a valid code from the above list.
FORM LOCATION: CMS-1500 Block 8
REMARKS: N/A
RECORD/FIELD: CA0-20.0
DATA ELEMENT: Patient Death Indicator (PAT DEATH IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
200
X(01)
N/A
SPACE
173
173
DEFINITION: A code which indicates the provider is billing services for a patient who is deceased.
CODE VALUES: Not used by MO HealthNet.
D = patient is deceased
N = patient is not deceased
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
If 'D', complete Date of Death (CA0-21.0).
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: CA0-21.0
DATA ELEMENT: Patient Date of Death (PAT DATE OF DEATH)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
21.0
X(08)
LEFT
SPACES
174
181
DEFINITION: Date patient was deceased.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
Should be present if Death Indicator (CA0-20.0) equals 'D'.
Date of service (FA0-05.0 and 06.0) must be equal to or less than date of death.
FORM LOCATION: N/A
REMARKS: N/A
NSF (National Standard Format) User Manual
47
RECORD/FIELD: CA0-22.0
DATA ELEMENT: Other Insurance Indicator (OTHER INSURANCE IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
22.0
X(01)
N/A
SPACE
182
182
DEFINITION: A code which indicates the patient has other insurance which may or may not be reflected
on this claim.
CODE VALUES: See the C-3 table for valid field values.
VALIDATION: Must be entered if required by payor/receiver.
If entered, must be a valid code from the above list.
FORM LOCATION: CMS-1500 Block 11d
REMARKS: 1. Patient has declared that he/she has other insurance which may pay a portion of this claim
and provided the necessary insurance information. (Not all insurance companies require the other
insurance fields to be completed.)
2. Patient has declared that he/she has other insurance which may pay a portion of this claim but did not
furnish the insurance information for this claim.
3. The provider has asked the patient if he/she has other insurance, and the patient has stated that they do
not.
RECORD/FIELD: CA0-23.0
DATA ELEMENT: Claim Editing Indicator (CLAIM EDITING IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
23.0
X(01)
N/A
SPACES
183
183
DEFINITION: A code assigned by the receiver to determine the adjudication program.
CODE VALUES: Not used by MO HealthNet.
A = Self Pay
B = Worker's Compensation
C = Medicare
D = MO HealthNet
E = Other Federal Program
F = Commercial Insurance Company
G = Blue Cross and Blue Shield
H = CHAMPUS
I = HMO
NSF (National Standard Format) User Manual
48
J = Federal Employees Program (FEP)
K = Central Certification
L = Self Administered Group
M = Medicare Claim Review
N = Medicare ADS Response
O = Indian Health Services
P = Blue Cross
Z = Other
VALIDATION: Must be entered if required by the receiver. If entered, must be a valid code from the
above list.
FORM LOCATION: CMS-1500 Block 1 and 11
REMARKS: If Receiver Type Code, AA0-18.0, equals "Z", some payors may require this field.
RECORD/FIELD: CA0-24.0
DATA ELEMENT: Type of Claim Indicator (TYPE OF CLAIM)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
24.0
X(02)
LEFT
SPACES
184
185
DEFINITION: A code which indicates the type of claim.
CODE VALUES: Not used by MO HealthNet.
A = Ambulance
B = Anesthesia
C = Chiropractic
D = Dental
E = Durable Medical Equipment
F = Medical
G = Occupational Therapy
H = Oxygen
J = Parenteral/Enteral
K = Podiatry
L = Physical Therapy
M = Speech/Language Therapy
N = Surgery
NSF (National Standard Format) User Manual
49
O = Other
P = EPSDT
Z = Multiple Types of Service
VALIDATION: Must be entered if required by payor. If entered, must be valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: CA0-25.0
DATA ELEMENT: Legal Representative Indicator (LEGAL REP IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
25.0
X(01)
N/A
SPACE
186
186
DEFINITION: A code which indicates that someone other than the patient is to receive the explanation
of benefits and/or the payment. (Person who is legally responsible for the patient.)
CODE VALUES: Not used by MO HealthNet.
Y = Yes, there is a responsible party.
N = No, there is not a responsible party.
VALIDATION: Must be entered if required by payor. If entered, must a valid code from the above list.
If 'Y', then the name and address of the responsible party (CB0-04.0 through 11.0) must be entered.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: CA0-26.0
DATA ELEMENT: Origin Code
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
26.0
X(09)
LEFT
SPACES
187
195
DEFINITION: A code to denote the geographic area where the service(s) being submitted on this claim
was/were performed.
CODE VALUES: Not used by MO HealthNet.
United Postal Service ZIP Code.
VALIDATION: Must be entered if required by the Payor/Receiver.
See GENERAL INSTRUCTIONS for "Address" entry.
FORM LOCATION: N/A
NSF (National Standard Format) User Manual
50
REMARKS: This code allows a Payor/Receiver to properly route claims to various claim adjudication
entities.
RECORD/FIELD: CA0-27.0
DATA ELEMENT: Payor Claim Control Number
(PAYOR CLM CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
27.0
X(17)
LEFT
SPACES
196
212
DEFINITION: A number assigned by the Payor/Receiver to identify the claim.
CODE VALUES: Not used by MO HealthNet.
Blanks / Spaces are only valid values.
VALIDATION: Must be blank / space filled.
FORM LOCATION: N/A
REMARKS: For Payor/Receiver usage only.
For assignment of an Internal / Document /Claim Control Number (ICN/DCN/CCN) that the
Payor/Receiver will pass to an adjudication system.
RECORD/FIELD: CA0-28.0
DATA ELEMENT: Provider Number (PROVIDER NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
28.0
X(15)
LEFT
SPACES
213
227
DEFINITION: The number assigned to the provider by the payor/receiver for identification purposes.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by Payor/Receiver.
If entered:
This field must contain the Provider Number as it appears on the Payor's/Receiver's file.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: CMS-1500 Block 33
REMARKS: The Payor/Receiver may elect to allow the Provider Number to be submitted in this Claim
Level record instead of at the Batch Level in the "BA0" record.
Consult the Matrix/Usage document supplied by the Payor/Receiver for additional information and
submission instructions.
RECORD/FIELD: CA0-29.0
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DATA ELEMENT: Claim Identification Number (CLAIM ID NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
29.0
X(06)
LEFT
SPACES
228
233
DEFINITION: Unique number of identification assigned to the claim by the sender.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by the Payor/Receiver.
FORM LOCATION: N/A
REMARKS: This number is not a portion of the MEDICAL RECORD NUMBER (EA1-11.0) or the
PATIENT ACCOUNT NUMBER (CA0-03.0).
This number is expected to be assigned by the sender's software system. One practice may be to assign a
sequential number. Consult the Matrix/Usage Guide supplied by the Payor/Receiver for additional
information.
RECORD/FIELD: CA0-30.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
30.0
X(87)
LEFT
SPACES
234
320
DEFINITION: Reserved record space for national use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: CLAIM HEADER RECORD TYPE CB0 "LEGAL
REPRESENTATIVE DATA"
Not Required by MO HealthNet
Must follow CA0
Must be followed by DA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "CB0"
C-24
CB0
02
RESERVED (CB0-02.0)
Not Used
03
PAT CONTROL NO
Not Used
NSF (National Standard Format) User Manual
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04
RESP PERSON LAST NAME
Not Used
05
RESP PERSON FIRST NAME
Not Used
06
RESP PERSON MI
Not Used
07
RESP PERSON ADDR1
Not Used
08
ESP PERSON ADDR2
Not Used
09
RESP PERSON CITY
Not Used
10
RESP PERSON STATE
Not Used
11
RESP PERSON ZIP
Not Used
12
RESP PERSON PHONE
Not Used
13
FILLER-NATIONAL
YES
RECORD TYPE: CB0
LEVEL: CLAIM
PURPOSE: To identify and provide information regarding the legal representative who is to receive the payment
and/or explanation of benefits on behalf of the patient.
REQUIREMENTS: This record is required only if the payor will recognize a legal representative for the patient.
ORDER:
Preceding Record Type
Following Record Type
CA0 or CA1
DA0
NOTES: Only one CB0 record is allowed for each claim.
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "CB0"
3
X
01
03
02.0
RESERVED (CB0-02.0)
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
RESP PERSON LAST NAME
20
X
23
42
05.0
RESP PERSON FIRST NAME
12
X
43
54
06.0
RESP PERSON MI
1
X
55
55
07.0
RESP PERSON ADDR1
30
X
56
85
08.0
RESP PERSON ADDR2
30
X
86
115
NSF (National Standard Format) User Manual
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09.0
RESP PERSON CITY
20
X
116
135
10.0
RESP PERSON STATE
2
X
136
137
11.0
RESP PERSON ZIP
9
X
138
146
12.0
RESP PERSON PHONE
10
X
147
156
13.0
FILLER – NATIONAL
164
X
157
320
RECORD/FIELD: CB0-01.0
DATA ELEMENT: Record Identifier (RECORD ID "CB0")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: Code used to identify the "Legal Representative Data" record.
CODE VALUES: See the C-24 table for valid field values.
VALIDATION: Must be entered if required by payor.
Must be "CB0".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: CB0-02.0
DATA ELEMENT: Reserved (CB0-02.0)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: Reserved record space.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: CB0-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
NSF (National Standard Format) User Manual
54
DEFINITION: An identification assigned to the patient by the provider to identify the patient.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: See GENERAL INSTRUCTIONS for "Patient Control Number".
Must be entered.
FORM LOCATION: CMS-1500 Block 26
REMARKS: The patient control number is used by the EMC system to link all records for a claim. All
records between the record type CA0, up to and including the record type XA0, must have the same
patient control number. Although up to seventeen characters are allowed, not all payors' systems will
record and return seventeen characters on remittance advices or other documents.
RECORD/FIELD: CB0-04.0 CB0-05.0, CB0-06.0
DATA ELEMENT: Responsible Person Last Name (RESP PERSON LAST NAME)
Responsible Person First Name (RESP PERSON FIRST NAME)
Responsible Person Middle Initial (RESP PERSON MI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(20)
LEFT
SPACES
23
42
05.0
X(12)
LEFT
SPACES
43
54
06.0
X(01)
N/A
SPACES
55
55
DEFINITION: The name of the responsible person who is to receive the explanation of benefits and/or
the payment on behalf of the patient.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: See GENERAL INSTRUCTIONS for "Name 1" entry.
Must be entered if required by payor.
Must be entered if Legal Representative Indicator
(CA0-25.0) equals 'Y'.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: CB0-07.0 CB0-08.0, CB0-09.0, CB0-10.0, CB0-11.0
DATA ELEMENT:
Responsible Person Address 1
(RESP PERSON ADDR1)
Responsible Person Address 2
(RESP PERSON ADDR2)
Responsible Person City
(RESP PERSON CITY)
Responsible Person State
(RESP PERSON STATE)
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Responsible Person Zip Code
(RESP PERSON ZIP)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(30)
LEFT
SPACES
56
85
08.0
X(30)
LEFT
SPACES
86
115
09.0
X(20)
LEFT
SPACES
116
135
10.0
X(02)
LEFT
SPACES
136
137
11.0
X(09)
LEFT
SPACES
138
146
DEFINITION: The mailing address of the responsible person.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: See GENERAL INSTRUCTIONS for "Address" entry.
Must be entered if required by payor.
Must be entered if Legal Representative Indicator
(CA0-25) equals 'Y'.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: CB0-12.0
DATA ELEMENT: Responsible Party Telephone Number (RESP PERSON PHONE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(10)
LEFT
SPACES
147
156
DEFINITION: The telephone number of the responsible party who is to receive the explanation of
benefits and/or the payment on behalf of the patient.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: See GENERAL INSTRUCTIONS for "Telephone" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: CB0-13.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
X(164)
LEFT
SPACES
157
320
NSF (National Standard Format) User Manual
56
DEFINITION: Reserved record space for national use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: INSURANCE INFORMATION RECORD TYPE DA0 "PAYOR
DATA 1"
Required for MO HealthNet processing
Must follow CA0 or CB0
Must be followed by DA1, DA2 or EA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "DA0"
C-24
DA0
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
Not Used
04
CLAIM FILING IND
Not Used
05
SOURCE OF PAY
06
INSURANCE TYPE CODE
Not Used
07
PAYOR ORGANIZATION ID
Not Used
08
PAYOR CLAIM OFFICE NO
Not Used
09
PAYOR NAME
10
GROUP NO
Not Used
11
GROUP NAME
Not Used
12
PPO/HMO IND
Not Used
13
PPO ID
Not Used
14
PRIOR AUTH NO
Not Used
15
ASSIGN OF BENEFITS
Not Used
16
PAT SIGNATURE SOURCE
Not Used
17
PAT REL TO INSURED
Not Used
NSF (National Standard Format) User Manual
C-27
C-53
NO
YES
57
18
INSURED ID NO
C-1
YES
19
INSURED LAST NAME
Not Used
20
INSURED FIRST NAME
Not Used
21
INSURED MI
Not Used
22
INSURED GENERATION
Not Used
23
INSURED SEX
Not Used
24
INSURED DATE OF BIRTH
Not Used
25
INSURED EMPL STATUS
Not Used
26
SUPPLEMENTAL INS IND
Not Used
27
INSURANCE LOCATION ID
Not Used
28
MEDICAID ID NO
Not Used
29
SUPPLEMENTAL PATIENT ID
Not Used
30
ASSIGN 4081 IND
Not Used
31
COB ROUTING IND
Not Used
32
FILLER-NATIONAL
YES
RECORD TYPE: DA0
LEVEL: CLAIM
PURPOSE: To identify the Payor(s) involved with and/or having liability for the resolution of this claim.
REQUIREMENTS: At least one DA0 record is required on every claim.
All known payors are to be identified by using this record.
ORDER:
Preceding Record Type
Following Record Type
CA0, CB0, DA0,DA0, DA1, DA2, DA3
DA1, DA2, or DA3or EA0
NOTES: When requesting payment from a secondary payor it is extremely important that the EOB/remittance
information be provided from the primary payor(s). This is of major importance in allowing the secondary claim
to be processed without having to request a hardcopy EOB.
Multiple DA0 records should be sequenced according to national and state coordination of benefits rules. The
primary payor should always be first regardless of whether or not payment is being requested in this transmission.
The order of the records should always be:
PRIMARY followed by SECONDARY insurance (if applicable), and then TERTIARY insurance (if applicable).
The CLAIM FILING INDICATOR (DA0-04.0) should be used to direct the claim to the appropriate payor(s).
NSF (National Standard Format) User Manual
58
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "DA0"
3
X
01
03
02.0
SEQUENCE NO2
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
CLAIM FILING IND
1
X
23
23
05.0
SOURCE OF PAY
1
X
24
24
06.0
INSURANCE TYPE CODE
2
X
25
26
07.0
PAYOR ORGANIZATION ID
5
X
27
31
08.0
PAYOR CLAIM OFFICE NO
4
X
32
35
07-08
Redefined as NATIONAL PAYER ID
9
X
09.0
PAYOR NAME
33
X
36
68
10.0
GROUP NO
20
X
69
88
11.0
GROUP NAME
33
X
89
121
12.0
PPO/HMO IND
1
X
122
122
13.0
PPO ID
15
X
123
137
14.0
PRIOR AUTH NO
15
X
138
152
15.0
ASSIGN OF BENEFITS
1
X
153
153
16.0
PAT SIGNATURE SOURCE
1
X
154
154
17.0
PAT REL TO INSURED
2
N
155
156
18.0
INSURED ID NO
25
X
157
181
19.0
INSURED LAST NAME
20
X
182
201
20.0
INSURED FIRST NAME
12
X
202
213
21.0
INSURED MI
1
X
214
214
22.0
INSURED GENERATION
3
X
215
217
23.0
INSURED SEX
1
X
218
218
24.0
INSURED DATE OF BIRTH
8
X
219
226
25.0
INSURED EMPL STATUS
1
X
227
227
26.0
SUPPLEMENTAL INS IND
1
X
228
228
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59
27.0
INSURANCE LOCATION ID
7
X
229
235
28.0
MEDICAID ID NO
25
X
236
260
29.0
SUPPLEMENTAL PATIENT ID
25
X
236
260
30.0
ASSIGN 4081 IND
1
X
286
286
31.0
COB ROUTING IND
1
X
287
287
32.0
FILLER-NATIONAL
33
X
288
320
RECORD/FIELD: DA0-01.0
DATA ELEMENT: Record Identifier (RECORD ID "DA0")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: Field used to identify the "INSURANCE INFORMATION"- "PAYOR DATA 1" record.
CODE VALUES: See the C-24 table for valid field values.
VALIDATION: A claim must have at least one "DA0" record and may have up to three.
Must be "DA0".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: DA0-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: A numeric value from 01 through 03 used to sequence the "DA0" records and to associate
"DA0" records with "DA1" and "DA2" records.
CODE VALUES: See the C-21 table for valid field values.
VALIDATION: Must be entered. Must be a valid code from the above list.
A claim must have at least one "DA0" record and may have up to three. All "Dan" records must be
grouped as "DA0", "DA1", "DA2" by sequence number.
The first (or only) record must be identified by a sequence number of '01'.
FORM LOCATION: N/A
NSF (National Standard Format) User Manual
60
REMARKS: Multiple DA0 records should be sequenced according to national and state coordination of
benefits rules. The primary payor should always be first regardless of whether or not payment is being
requested in this transmission.
The order of the records should always be PRIMARY followed by SECONDARY insurance (if
applicable) and then TERTIARY insurance (if applicable). The CLAIM FILING INDICATOR (DA004.0) should be used to direct the claim to the appropriate payor(s).
RECORD/FIELD: DA0-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: A unique identifier assigned by the provider to identify the patient.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered.
Must be identical to the "Patient Control Number" (CA0-03.0) of this claim.
See GENERAL INSTRUCTIONS for "Patient Account Number" entry.
FORM LOCATION: CMS-1500 Block 26
REMARKS: The Patient Account Number field is used to associate all of the records for a single claim.
RECORD/FIELD: DA0-04.0
DATA ELEMENT: Claim Filing Indicator(CLAIM FILING IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(01)
LEFT
SPACES
23
23
DEFINITION: A code indicating whether or not this record is being provided in order to obtain payment
from the indicated payor or for informational purposes only.
CODE VALUES: Not used by MO HealthNet.
P = Payment is being requested of this payor. "P" also indicates that a payment request is being made to
only one payor.
M = Payment is being requested of this payor. "M" also indicates that payment requests are being made to
more than one payor at the same time.
I = Payment is not being requested of this payor. Information is to be used for informational purposes
only. (To indicate information on a secondary payor.) VALIDATION: Must be entered.
Must be a valid code from the above list.
A claim must have one and only one "DA0" record with a "P" or at least two "DA0" records with "M's"
(may have up to 3 records with "M's").
NSF (National Standard Format) User Manual
61
A claim may have up to two "DA0" records with "I's" as long as the total number of records (P's, M's and
I's) do not exceed 3.
The claim may not have a mixture of "DA0" records with both "P's" and "M's".
FORM LOCATION: CMS-1500 Blocks 9, 11
REMARKS: The "M" code is not, repeat not, to be used to indicate crossover/piggyback situations such
as Medicare/MO HealthNet, Medicare/Medigap, Medicare/Blue Shield, Medicare/commercial, Blue
Shield/Champus etc. The "M" code is used to direct the claim to multiple payor's at the "same" time, not
one after another.
Crossover/piggyback situations are indicated by creating another "DA0" record secondary to the primary
insurance.
Example .... Medicare/MO HealthNet:
The first (primary) "DA0" record would have a
CLAIM FILING IND (DA0-04.0) of "P" and a SOURCE OF PAY (DA0-05.0) of "C". The second
(secondary) "DA0" record would have a CLAIM FILING IND (DA0-04.0) of "I" and a SOURCE OF
PAY (DA0-05.0) of "D". Depending upon the agreement the Medicare Carrier has with that particular
MO HealthNet intermediary the claim would be forwarded to the MO HealthNet intermediary upon
resolution of the claim by Medicare.
Example .... Medicare/Medigap:
The procedures are identical for Medigap processing except that the secondary payor is identified by not
only the SOURCE OF PAY - NATIONAL (DA0-05.0) of "F" (commercial), "G" (Blue Shield) or "Z"
(other), but by the INSURANCE TYPE CODE (DA0-06.0) of "MG" (Medigap).
RECORD/FIELD: DA0-05.0
DATA ELEMENT: Source of Payment (SOURCE OF PAY)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(01)
LEFT
SPACES
24
24
DEFINITION: A national code identifying the payment source for this claim for the indicated payor.
CODE VALUES: See the C-27 table for valid field values.
VALIDATION: Must be entered.
Must be a valid code from the above list.
FORM LOCATION: CMS-1500 Blocks 9, 11
REMARKS: When Medicare is identified as the primary source of payment (DA0-02.0 = 1, DA0-04.0 =
P, and DA0-05.0 = C) development for other insurance has been undertaken and it has been determined
that Medicare is the primary payer.
RECORD/FIELD: DA0-06.0
DATA ELEMENT: Insurance Type Code
NSF (National Standard Format) User Manual
62
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(02)
LEFT
SPACES
25
26
DEFINITION: Identifies the type of insurance (policy).
CODE VALUES: Not used by MO HealthNet.
MG = MEDIGAP POLICY - code requesting that the Medicare carrier forward this EOB to this payor.
Only allowed for SEQUENCE NO's (DA0-02.0) of "02" or "03". Only one allowed on a claim. Must
follow a "DA0" with a SOURCE OF PAY (DA0-05.0) of "C" (Medicare).
SP = SUPPLEMENTAL POLICY
IP = INDIVIDUAL POLICY
PP = PERSONAL PAYMENT (CASH - NO INSURANCE)
GP = GROUP POLICY
LT = LITIGATION
AP = AUTO INSURANCE POLICY
LD = LONG TERM POLICY
OT = OTHER
The following code must only be used if the SOURCE OF PAY (DA0-05.0) is "C" (Medicare): MP =
MEDICARE PRIMARY (MEDICARE SECONDARY REASON CODES)
12 = WORKING AGED BENEFICIARY/SPOUSE WITH EMPLOYER GROUP HEALTH PLAN
13 = ESRD BENEFICIARY IN THE 12 MONTH COORDINATION PERIOD WITH AN
EMPLOYER'S GROUP HEALTH PLAN
14 = NO FAULT INSURANCE INCLUDING AUTO/OTHER
15 = WORKER'S COMPENSATION
16 = PHS OR OTHER FEDERAL AGENCY
41 = BLACK LUNG
42 = VA
43 = DISABLED BENEFICIARY UNDER AGE 65 WITH LGHP
47 = ANY LIABILITY INSURANCE
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: CMS-1500 Blocks 9, 11
REMARKS: N/A
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63
RECORD/FIELD: DA0-07.0 DA0-08.0
DATA ELEMENT: Payor Organization Identification (PAYOR ORGANIZATION ID) Payor Claim Office
Number (PAYOR CLAIM OFFICE NO) Redefined as National Payer Identifier (PAYERID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(05)
LEFT
SPACES
27
31
08.0
X(04)
LEFT
SPACES
32
35
DEFINITION: The identification number for the payor.
The National PAYERID (DA0-07.0 and DA0-08.0) is to be entered for Medicare when implemented.
The PAYOR ORGANIZATION ID (DA0-07.0) will identify the insurance company or government
agency which has been identified as having some liability for payment on this claim.
The PAYOR CLAIM OFFICE NO (DA0-08.0) will identify the specific payor location responsible for
processing this claim.
CODE VALUES: Not used by MO HealthNet.
BLUE CROSS AND BLUE SHIELD - use either the NAIC (NATIONAL ASSOCIATION OF
INSURANCE COMMISSIONERS) assigned identifier or the BCBS plan number (00xxx) for the
organization id.
Use the "alpha prefix" from the subscriber's identification card as the claim office number.
COMMERCIAL INSURERS - use the NAIC assigned number (xxxxx) for the organization in and use the
claim office location off the insured's identification card for the claim office number.
MO HEALTHNET - use the MO HealthNet Division assigned number for the organization id and
"NONE" for the claim office number or "AIDxx" (xx = state code) for the organization id and "0001",
"0002" etc. for the claim office number. (Multiple codes will be necessary in states with more than one
MO HealthNet carrier.)
CHAMPUS - use the NAIC assigned number (xxxxx) for the organization id and the region / project code
for the claim office number.
Code Region/Project
SER SOUTHEAST REGION
MAR MID-ATLANTIC REGION
WTR WESTERN REGION
NTR NORTHERN REGION
SCR SOUTH CENTRAL REGION
CRI CALIFORNIA PROJECT
CMN CATCHMENT AREA MANAGEMENT PROJECT
(NAVY - CHARLESTON, SC)
CMF CATCHMENT AREA MANAGEMENT PROJECT
NSF (National Standard Format) User Manual
64
(AIRFORCE - __________, TX)
OTHERS - use the NAIC assigned number (xxxxx) or the value of "OTHER" for the organization id.
PERSONAL PAY - use "SELF " for the organization id.
VALIDATION: Must be a entered if required by Payor.
If entered, must be a valid code from the above list.
If "OTHER" is allowed by the Payor, the PAYOR NAME (DA0-09.0) MUST be completed.
FORM LOCATION: CMS-1500 Blocks 9, 11
REMARKS: N/A
RECORD/FIELD: DA0-09.0
DATA ELEMENT: Payor Name
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
X(33)
LEFT
SPACES
36
68
DEFINITION: The name of the payor organization.
CODE VALUES: See the C-53 table for valid field values.
VALIDATION: Must be entered if required by the receiver of the claim data file.
See GENERAL INSTRUCTIONS for "Name 2" (company name) entry.
Always required if "OTHER" is submitted as the PAYOR ORGANIZATION IDENTIFICATION (DA007.0).
FORM LOCATION: CMS-1500 Blocks 9, 11
REMARKS: N/A
RECORD/FIELD: DA0-10.0
DATA ELEMENT: Group Number (GROUP NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
X(20)
LEFT
SPACES
69
88
DEFINITION: The identification number assigned by the payor to the group or plan though which
insurance is provided.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
Must be completed when the primary source of payment (DA0-05.0) equals B, E, F, G, H, I, J, or Z and
Medicare secondary payment is being requested.
NSF (National Standard Format) User Manual
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If entered, must only contain 0-9, A-Z, forward slash (/), period (.), comma (,), hyphen (-), number sign
(#), ampersand (&) and blank ( ). No other characters are allowed.
Must NOT equal the PAYOR ID (DA0-07.0).
Must NOT equal the INSURED'S IDENTIFICATION NUMBER (DA0-18.0).
Must NOT contain all zeroes (0's) or a combination of all zeroes (0's) and spaces ( ).
Must NOT contain all nines (9's) or a combination of all nines (0's) and spaces ( ). EXCEPT for certain
commercial claims which allow "999999" (six nines followed by spaces).
Must NOT contain any of the following laterals:
"UNKNOWN", "123456789", "INDIVIDUAL", "NONE", "SELF", "N/A" OR "NOT APPLICABLE".
Must NOT equal the GROUP NAME (DA0-11.0).
FORM LOCATION: CMS-1500 Blocks 9a, 11
REMARKS: Some payors require this information for all claims others may only require it, if necessary,
for COB processing.
If available, it should be provided for all payors since it's presence may expedite the processing of the
claim.
This information is required for processing Medicare secondary claims.
RECORD/FIELD: DA0-11.0
DATA ELEMENT: Group Name
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
X(33)
LEFT
SPACES
89
121
DEFINITION: The name of the group or plan through which insurance is being provided.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
Must be completed when the primary source of payment (DA0-05.0) equals B, E, F, G, H, I, J, or Z and
Medicare secondary payment is being requested.
See GENERAL INSTRUCTIONS for "Name 2" (company name) entry.
Must NOT equal the PAYOR ID (DA0-07.0).
Must NOT equal the INSURED'S IDENTIFICATION NUMBER (DA0-18.0).
Must NOT contain all zeroes (0's) or a combination of all zeroes (0's) and spaces ( ).
Must NOT contain all nines (9's) or a combination of all nines (0's) and spaces ( ) EXCEPT for certain
commercial claims which allow "999999" (six nines followed by spaces).
Must NOT contain any of the following literals: "UNKNOWN", "123456789", "INDIVIDUAL",
"NONE", "SELF", "N/A" OR "NOT APPLICABLE".
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Must NOT equal the GROUP NUMBER (DA0-10.0).
FORM LOCATION: CMS-1500 Blocks 9d, 11
REMARKS: Some payors require this information for all claims others may only require it, if necessary,
for COB processing.
If available, it should be provided for all payors since it's presence may expedite the processing of the
claim.
This information is required for processing Medicare secondary claims.
RECORD/FIELD: DA0-12.0
DATA ELEMENT: Preferred Provider Organization Indicator/Health Maintenance Organization Indicator
(PPO/HMO IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(01)
LEFT
SPACES
122
122
DEFINITION: An indicator that the provider is submitting this claim to or has submitted this claim to the
indicated payor under a Special Processing Agreement.
CODE VALUES: Not used by MO HealthNet.
Y = Claim is to be processed under a PPO/HMO agreement.
I = Claim is to be processed under a CHAMPUS "Internal" Partnership agreement.
E = Claim is to be processed under a CHAMPUS "External" Partnership agreement.
N = Claim is not a PPO or HMO claim.
C = Claim is to be processed under a CHAMPUS "CAM Charleston" Partnership agreement.
G = Claim is to be processed as a CHAMPUS Army CAM Demonstration.
H = Claim is to be processed as a CHAMPUS Navy CAM Demonstration.
J = Claim is to be processed as a CHAMPUS Air Force CAM Demonstration.
O = Claim is to be processed under a CHAMPUS MCSP PPO agreement.
P = Claim is to be processed under a CHAMPUS MCSP Prime agreement.
T = Claim is to be processed under a CHAMPUS TRICARE MCSP Extra agreement.
U = Claim is to be processed under a CHAMPUS TRICARE MCSP HMO agreement.
X = Claim is to be processed as a CHAMPUS Cooperative Care Claim.
VALIDATION: Must be a valid code from the above list if required by the payor.
Must NOT be "Y" or "N" if the SOURCE OF PAY (DA0-05.0) contains an "H" (CHAMPUS).
Must NOT be "I", "E", "C", "G", "H", "J", "O", "P", "T", "U" or "X" unless the SOURCE OF PAY (DA005.0) is an "H".
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Must be "I", "E", "C", "G", "H", "J", "O", "P", "T", "U", or "X" if the SOURCE OF PAY (DA0-05.0) is
an "H" (CHAMPUS) and the PPO/HMO ID (DA0-13.0) is not blank.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: DA0-13.0
DATA ELEMENT: Preferred Provider Organization Identification (PPO ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
X(15)
LEFT
SPACES
123
137
DEFINITION: The identification number assigned to the preferred provider organization by the payor.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by the payor.
Must follow the GENERAL INSTRUCTIONS for "Identification Numbers".
Must be entered if the PPO/HMO IND (DA0-12.0) was I, E, C, G, H, J, O, P, T, U, or X. Must contain
the military treatment facility ID when filing CHAMPUS partnership claims.
FORM LOCATION: N/A
REMARKS: Some payors will require that the data be entered if the PPO/HMO IND (DA0-12.0) is NOT
"N" or SPACE.
RECORD/FIELD: DA0-14.0
DATA ELEMENT: Prior Authorization Number(PRIOR AUTH NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
14.0
X(15)
LEFT
SPACES
138
152
DEFINITION: A number, code or other indicator that the services provided on this claim have been
authorized by the payor.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by the payor and prior approval has been obtained from the
payor or his agent.
FORM LOCATION: CMS-1500 Block 23
REMARKS: N/A
RECORD/FIELD: DA0-15.0
DATA ELEMENT: Assignment of Benefits Indicator (ASSIGN OF BENEFITS)
FIELD
COBOL PICTURE
NSF (National Standard Format) User Manual
JUSTIFY
INITIAL
FROM
THRU
68
15.0
X(01)
LEFT
SPACES
153
153
DEFINITION: An indicator showing whether or not the provider has obtained a signed form authorizing
the payor to pay the provider.
CODE VALUES: Not used by MO HealthNet.
Y = Yes, benefits have been assigned to the provider and a signed form is on file in the provider's office.
N = No, benefits have not been assigned, insured did not authorize payment to provider.
O = Pay Other Organization/Legal (for NSF COB)
VALIDATION: Must be entered if required by the payor.
If entered, must be a valid code from the above.
FORM LOCATION: CMS-1500 Block 13
REMARKS: Please note that this is not the same as the provider accepting assignment; this is the
insured's authorization. Some payors (commercial) may make payment to the provider based upon this
indicator. Others such as Medicare and Blue Shield may use the PROVIDER ACCEPT ASSIGNMENT
INDICATOR (EA0-34.0).
Medicare requires that this indicator be "Y" prior to crossing claims to MEDIGAP payors.
An indicator of "Y" does not preclude the need for a signed RELEASE OF INFORMATION form (EA013.0).
RECORD/FIELD: DA0-16.0
DATA ELEMENT: Patient Signature Source (PAT SIGNATURE SOURCE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
16.0
X(01)
LEFT
SPACES
154
154
DEFINITION: An indicator on how the patient/subscriber authorization signatures, to permit releasing
medical information, were obtained and how they are being retained by the provider.
CODE VALUES: Not used by MO HealthNet.
C = Signed CMS-1500 claim form on file.
S = Signed signature authorization form for Block 12 on file.
M = Signed signature authorization form for Block 13 on file.
B = Signed signature authorization form or forms for both Block 12 and Block 13 are on file.
P = Signature generated by provider because the patient was not physically present for services.
VALIDATION: Must be entered if required by the payor.
If entered must be a valid code from the above list.
FORM LOCATION: CMS-1500 Blocks 12
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REMARKS: N/A
RECORD/FIELD: DA0-17.0
DATA ELEMENT: Patient Relationship To Insured (PAT REL TO INSURED)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
17.0
9(02)
RIGHT
ZEROS
155
156
DEFINITION: A code indicating the relationship of the patient to the insured.
CODE VALUES: Not used by MO HealthNet.
01 = Patient is Insured.
02 = Spouse
03 = Natural Child/Insured has Financial Responsibility (includes legally adopted child)
04 = Natural Child/insured does not have Financial Responsibility (includes legally adopted child)
05 = Step Child
06 = Foster Child
07 = Ward of the Court
08 = Employee
09 = Unknown - Patient's relationship to the insured is other than that indicated
10 = Handicapped Dependent
11 = Organ Donor
12 = Cadaver Donor
13 = Grandchild
14 = Niece/Nephew
VALIDATION: Must be numeric.
Must be a code from the above list.
FORM LOCATION: CMS-1500 Block 6
REMARKS: If code 09 is used an explanation should be entered in the remarks area (Record Type XA0
Field 22.0).
RECORD/FIELD: DA0-18.0
DATA ELEMENT: Insured Identification Number (INSURED ID NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
X(25)
LEFT
SPACES
157
181
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DEFINITION: Insured's unique identification number, assigned by the Third Party Payor.
CODE VALUES: See the C-1 table for valid field values.
VALIDATION: See GENERAL INSTRUCTIONS for identification number entry. Must not contain all
zeros or all nines (9's). May not contain any of the following literals:
"unknown", "individual", "self",
"1234567890" or "none"
FORM LOCATION: CMS-1500 Blocks 1a, 9a
REMARKS: Subscriber ID
Sponsor ID
HIC ID
SSN ID
Participant ID
Employee ID (Group self administered)
RECORD/FIELD: DA0-19.0 DA0-20.0 DA0-21.0
DATA ELEMENT:
Insured Last Name
(INSURED LAST NAME)
Insured First Name
(INSURED FIRST NAME)
Insured Middle Initial
(INSURED MI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
19.0
X(20)
LEFT
SPACES
182
201
20.0
X(12)
LEFT
SPACES
202
213
21.0
X(01)
LEFT
SPACES
214
214
DEFINITION: The last, first, middle name of the insured individual.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: See GENERAL INSTRUCTIONS for Name 1 (individual names) entry.
FORM LOCATION: CMS-1500 Blocks 4, 9
REMARKS: N/A
RECORD/FIELD: DA0-22.0
DATA ELEMENT: Insured Generation
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
22.0
X(03)
LEFT
SPACES
215
217
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71
DEFINITION: The generation of the patient, such as I,II, III, Jr, or Sr.
CODE VALUES: Not used by MO HealthNet.
I, II, III, IV, JR, SR
VALIDATION: If entered, must be one of the above codes.
FORM LOCATION: CMS-1500 Blocks 4, 9
REMARKS: N/A
RECORD/FIELD: DA0-23.0
DATA ELEMENT: Insured Sex
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
23.0
X(01)
LEFT
SPACES
218
218
DEFINITION: A code designating the insured's sex.
CODE VALUES: Not used by MO HealthNet.
M - Male
F - Female
U - Unknown
VALIDATION: Must be entered if required by payor (receiver).
If entered, must be a valid code from the above list.
FORM LOCATION: CMS-1500 Blocks 11a, 9b
REMARKS: N/A
RECORD/FIELD: DA0-24.0
DATA ELEMENT: Insured Date of Birth
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
24.0
X(08)
LEFT
SPACES
219
226
DEFINITION: The date of birth of the insured.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor (receiver).
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for Date entry.
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FORM LOCATION: CMS-1500 Blocks 9b, 11a
REMARKS: N/A
RECORD/FIELD: DA0-25.0
DATA ELEMENT: Insured Employment Status Code (INSURED EMPL STATUS)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
25.0
X(01)
LEFT
SPACES
227
227
DEFINITION: Code to indicate employment status of the insured individual.
CODE VALUES: Not used by MO HealthNet.
1 = Employed full-time
2 = Employed part-time
3 = Not employed
4 = Self-employed
5 = Retired
6 = On active military duty
7 = Reserved for national assignment
8 = Reserved for local assignment
9 = Unknown
VALIDATION: Must be entered if required by payor (receiver).
If entered, must be a valid code from the above list.
FORM LOCATION: CMS-1500 Blocks 11d, 9c
REMARKS: N/A
RECORD/FIELD: DA0-26.0
DATA ELEMENT: Supplemental Insurance Indicator (SUPPLEMENTAL INS IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
26.0
X(01)
LEFT
SPACES
228
228
DEFINITION: Indicates whether patient is carrying other insurance, is eligible for MO HealthNet or is
eligible for Medicare.
CODE VALUES: Not used by MO HealthNet.
I = Patient is Eligible for Medicare
M = MO HealthNet
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P = Primary Payer in MSP Situations
S = Supplemental/Medigap
W = MO HealthNet and MSP
X = MO HealthNet and Medigap
Y = MO HealthNet, MSP and Medigap
Z = MSP and Medigap
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: DA0-27.0
DATA ELEMENT: Insurance Location Identifier (INSURANCE LOCATION ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
27.0
X(7)
LEFT
SPACES
229
235
DEFINITION: A code to identify the location, Title XIX coverage, county of coverage, branch number,
HMO Satellite, plan contract number, etc.
CODE VALUES: Not used by MO HealthNet.
As developed by the payor or receiver.
VALIDATION: Must be entered if required by payor or receiver.
If entered, must be a valid code from the list maintained by the payor/receiver.
FORM LOCATION: N/A
REMARKS: Consult the Matrix/User Guide document supplied by the payor/receiver to determine usage
of this data element.
RECORD/FIELD: DA0-28.0
DATA ELEMENT: MO HealthNet Identification Number (MO HEALTHNET ID NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
28.0
X(25)
LEFT
SPACES
236
260
DEFINITION: Insured's unique MO HealthNet identification number.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: See GENERAL INSTRUCTIONS for identification number entry. Must not contain all
zeros or all nines (9's). May not contain any of the following literals:
NSF (National Standard Format) User Manual
74
"unknown", "individual", "self", "1234567890" or "none"
FORM LOCATION: CMS-1500, Block 10d
REMARKS: If Medicare patient is entitled to MO HealthNet (DA0-26.0 = "M") this field must be
entered.
RECORD/FIELD: DA0-29.0
DATA ELEMENT: Supplemental Patient Identification Number (SUPPLEMENTAL PAT ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
29.0
X(25)
LEFT
SPACES
261
285
DEFINITION: Supplemental ID on file with sender of the COB claim.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: If available, this is required for COB exchange.
RECORD/FIELD: DA0-30.0
DATA ELEMENT: Assignment for 4081 Claim
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
30.0
X(01)
LEFT
SPACES
286
286
DEFINITION: Beneficiary assignment for mandatory Medicare (Section 4081) Claim.
CODE VALUES: Not used by MO HealthNet.
1 = 4081
2 = Regular Crossover
VALIDATION: If entered must be valid code from code list.
FORM LOCATION: N/A
REMARKS: This is required for COB exchange.
RECORD/FIELD: DA0-31.0
DATA ELEMENT: Coordination of Benefits Routing Indicator (COB ROUTING IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
31.0
X(01)
LEFT
SPACES
287
287
DEFINITION: Identifies the type of coordination of benefits exchange.
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CODE VALUES: Not used by MO HealthNet.
1 = Regeneration
2 = Manual crossover transaction
3 = HMO
4 = Travelers (Railroad Beneficiaries)
VALIDATION: If entered must be valid code from code list.
FORM LOCATION: N/A
REMARKS: This is required for NSF COB exchange.
RECORD/FIELD: DA0-32.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
32.0
X(33)
LEFT
SPACES
288
320
DEFINITION: Unused record space reserved for national use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: INSURANCE INFORMATION RECORD TYPE DA1 "PAYOR
DATA 2"
Not Required by MO HealthNet
Must follow DA0
Must be followed by DA2 or EA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "DA1"
C-24
DA1
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
Not Used
04
PAYOR ADDR1
Not Used
05
PAYOR ADDR2
Not Used
06
PAYOR CITY
Not Used
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07
PAYOR STATE
Not Used
08
PAYOR ZIP
Not Used
09
DISALLOWED COST CONT
Not Used
10
DISALLOWED OTHER
Not Used
11
ALLOWED AMOUNT
Not Used
12
DEDUCTIBLE AMOUNT
Not Used
13
COINSURANCE AMOUNT
Not Used
14
PAYOR AMOUNT PAID
Not Used
15
ZERO PAY IND
Not Used
16
ADJUDICATION IND 1
Not Used
17
ADJUDICATION IND 2
Not Used
18
ADJUDICATION IND 3
Not Used
19
CHAMPUS SPNSR BRANCH
Not Used
20
CHAMPUS SPNSR GRADE
Not Used
21
CHAMPUS SPNSR STATUS
Not Used
22
INS CARD EFFECT DATE
Not Used
23
INS CARD TERM DATE
Not Used
24
BALANCE DUE
Not Used
25
EOMB DATE1
Not Used
26
EOMB DATE2
Not Used
27
EOMB DATE3
Not Used
28
EOMB DATE4
Not Used
29
CLAIM RECEIPT DATE
Not Used
30
AMT PAID TO BENE
Not Used
31
BENE CHECK/EFT TRACE NO
Not Used
32
BENE CHECK DATE
Not Used
33
AMT PAID TO PROV
Not Used
34
PROV CHECK/EFT TRACE NO
Not Used
35
PROV CHECK DATE
Not Used
36
INTEREST PAID
Not Used
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37
APPROVED AMT
Not Used
38
FILLER-NATIONAL
YES
RECORD TYPE: DA1
LEVEL:CLAIM
PURPOSE: To supply additional information for identifying the payor and/or to provide prior adjudication status
information from primary payors.
REQUIREMENTS: When filing 'secondary' claims a "DA1" record is required for every payor who has received
and/or processed the claim prior to this submission.
ORDER:
Preceding Record Type
Following Record Type
DA0
DA0, DA2 or EA0
NOTES: When requesting payment from a secondary payor it is extremely important that the EOB/remittance
information be provided from the primary payor(s). This is of major importance in allowing the secondary claim
to be processed without having to request a hardcopy EOB.
FIELD NO
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "DA1"
3
X
01
03
02.0
SEQUENCE NO
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
PAYOR ADDR1
30
X
23
52
05.0
PAYOR ADDR2
30
X
53
82
06.0
PAYOR CITY
20
X
83
102
07.0
PAYOR STATE
2
X
103
104
08.0
PAYOR ZIP
9
X
105
113
09.0
DISALLOWED COST CONT
7
N
114
120
10.0
DISALLOWED OTHER
7
N
121
127
11.0
ALLOWED AMOUNT
7
N
128
134
12.0
DEDUCTABLE AMOUNT
7
N
135
141
13.0
COINSURANCE AMOUNT
7
N
142
148
14.0
PAYOR AMOUNT PAID
7
N
149
155
15.0
ZERO PAY IND
1
X
156
156
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16.0
ADJUDICATION IND 1
2
X
157
158
17.0
ADJUDICATION IND 2
2
X
159
160
18.0
ADJUDICATION IND 3
2
X
161
162
19.0
CHAMPUS SPNSR BRANCH
1
X
163
163
20.0
CHAMPUS SPNSR GRADE
2
X
164
165
21.0
CHAMPUS SPNSR STATUS
1
X
166
166
22.0
INS CARD EFFECT DATE
8
X
167
174
23.0
INS CARD TERM DATE
8
X
175
182
24.0
BALANCE DUE
7
N
183
189
25.0
EOMB DATE1
8
X
190
197
26.0
EOMB DATE2
8
X
198
205
27.0
EOMB DATE3
8
X
206
213
28.0
EOMB DATE4
8
X
214
221
29.0
CLAIM RECEIPT DATE
8
X
222
229
30.0
AMT PAID TO BENE
9
N
230
238
31.0
BENE CHECK/EFT TRACE NO
15
X
239
253
32.0
BENE CHECK DATE
8
X
254
261
33.0
AMT PAID TO PROV
9
N
262
270
34.0
PROV CHECK/EFT TRACE NO
15
X
271
285
35.0
PROV CHECK DATE
8
X
286
293
36.0
INTEREST PAID
9
N
294
302
37.0
APPROVED AMT
9
N
303
311
38.0
CONTRACT AGREEMENT IND
1
X
312
312
39.0
FILLER-NATIONAL
8
X
313
320
RECORD/FIELD: DA1-01.0
DATA ELEMENT: Record Identifier (RECORD ID "DA1")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: Field used to identify the "INSURANCE INFORMATION" - "PAYOR DATA 2" record.
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CODE VALUES: See the C-24 table for valid field values.
VALIDATION: A claim may have up to three "DA1" records. Each must have a corresponding "DA0"
record.
Must be "DA1".
FORM LOCATION: N/A
REMARKS: Multiple "DA1" records must have corresponding "DA0" records. The records are 'matched'
by SEQUENCE NO (DA0-02.0 and DA1-02.0).
RECORD/FIELD: DA1-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: A numeric value from 01 through 03 used to sequence the "DA1" records and to associate
"DA1" records with "DA0" and "DA2" records.
CODE VALUES: See the C-21 table for valid field values.
VALIDATION: Must be entered.
Must be a valid code from the above list.
The value entered must match the SEQUENCE NUMBER (DA0-02.0) submitted in the preceding "DA0"
record.
FORM LOCATION: N/A
REMARKS: See sequencing instructions on page DA0.04.
RECORD/FIELD: DA1-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: A unique identifier assigned by the provider to identify the patient.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered.
Must be identical to the "Patient Control Number" (CA0-03.0) of this claim.
See GENERAL INSTRUCTIONS for "Patient Account Number" entry.
FORM LOCATION: CMS-1500 Block 26
REMARKS: The Patient Account Number field is used to associate all of the records for a single claim.
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ELECTRONIC MEDIA CLAIMS NATIONAL STANDARD FORMAT
RECORD/FIELD: DA1-04.0 DA1-05.0 DA1-06.0 DA1-07.0 DA1-08.0
DATA ELEMENT:
Payor Address Line 1
(PAYOR ADDR1)
Payor Address Line 2
(PAYOR ADDR2)
Payor City
(PAYOR CITY)
Payor State
(PAYOR STATE)
Payor Zip Code
(PAYOR ZIP CODE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(30)
LEFT
SPACES
23
52
05.0
X(30)
LEFT
SPACES
53
82
06.0
X(20)
LEFT
SPACES
83
102
07.0
X(02)
LEFT
SPACES
103
104
08.0
X(09)
LEFT
SPACES
105
113
DEFINITION: Payor's claim mailing address for this particular payor ID and claim office.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
If entered, see GENERAL INSTRUCTIONS for "address" entry.
FORM LOCATION: CMS-1500 Blocks 9, 11
REMARKS: N/A
RECORD/FIELD: DA1-09.0
DATA ELEMENT: Disallowed Cost Containment Amount (DISALLOWED COST CONT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
9(5)V99
RIGHT
ZEROS
114
120
DEFINITION: The amount disallowed by the payor due to the failure of either the provider or insured to
meet the cost containment provisions of the insurance contract, managed care contract or PPO contract
under which payment has been requested for this claim.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if applicable and the payor requires the information for the filing of
secondary claims EMC.
Must be a positive, unsigned numeric value.
NSF (National Standard Format) User Manual
81
FORM LOCATION: EOB (Explanation of Benefits) or remittance of primary payor.
REMARKS: Under some state (federal?) COB statues and regulations, secondary payors do not have any
liability for amounts disallowed by the primary payor because of the failure of the provider or insured to
fulfill a cost containment provision under the primary contract.
RECORD/FIELD: DA1-10.0
DATA ELEMENT: Disallowed Other Amount(DISALLOWED OTHER)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
9(5)V99
RIGHT
ZEROS
121
127
DEFINITION: The amount disallowed by the payor for reasons OTHER than the failure of the provider
or insured to meet the cost containment provisions of the insurance contract, managed care contract or
PPO contract under which payment has been requested for this claim.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if applicable and the payor requires the information for the filing of
secondary claims EMC.
Must be a positive, unsigned numeric value.
FORM LOCATION: EOB (Explanation of Benefits) or remittance of primary payor.
REMARKS: N/A
RECORD/FIELD: DA1-11.0
DATA ELEMENT: Allowed Amount
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
9(5)V99
RIGHT
ZEROS
128
134
DEFINITION: The maximum amount determined by the payor as being "allowable" under the provisions
of the contract prior to the determination of actual payment.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if applicable and the payor requires the information for the filing of
secondary claims EMC.
Must be a positive, unsigned numeric value.
FORM LOCATION: EOB (Explanation of Benefits) or remittance of primary payor.
REMARKS: This field may be used to report the total amount allowed on the claim for Medicare
Secondary Payor submission purposes.
Consult the Matrix/User Guide document supplied by the payor/receiver to determine usage of this data
element.
RECORD/FIELD: DA1-12.0
NSF (National Standard Format) User Manual
82
DATA ELEMENT: Deductible Amount
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
9(5)V99
RIGHT
ZEROS
135
141
DEFINITION: The amount deducted, by the payor, from the allowed amount in order to meet the contract
"deductible" provisions.
The amount applied toward the deductible by this payor.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if applicable and the payor requires the information for the filing of
secondary claims EMC.
Must be a positive, unsigned numeric value.
FORM LOCATION: EOB (Explanation of Benefits) or remittance of primary payor.
REMARKS: This field may be used to report the total amount of deductible on the claim for Medicare
Secondary Payor submission purposes.
Consult the Matrix/User Guide document supplied by the payor/receiver to determine usage of this data
element.
RECORD/FIELD: DA1-13.0
DATA ELEMENT: Coinsurance Amount
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
9(5)V99
RIGHT
ZEROS
142
148
DEFINITION: The amount deducted, by the payor, from the allowed amount in order to meet the
"coinsurance" provisions of the contract.
The amount applied toward the coinsurance by this payor.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if applicable and the payor requires the information for the filing of
secondary claims EMC.
Must be a positive, unsigned numeric value.
FORM LOCATION: EOB (Explanation of Benefits) or remittance of primary payor.
REMARKS: This field may be used to report the total amount of coinsurance on the claim for Medicare
Secondary Payor submission purposes.
Consult the Matrix/User Guide document supplied by the payor/receiver to determine usage of this data
element.
RECORD/FIELD: DA1-14.0
DATA ELEMENT: Payor Amount Paid
NSF (National Standard Format) User Manual
83
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
14.0
9(5)V99
RIGHT
ZEROS
149
155
DEFINITION: The amount paid by the payor on this claim.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if applicable and the payor requires the information for the filing of
secondary claims EMC.
Must be a positive, unsigned numeric value.
FORM LOCATION: EOB (Explanation of Benefits) or remittance of primary payor.
REMARKS: This field may be used to report the total amount paid on the claim for Medicare Secondary
Payor submission purposes.
Consult the Matrix/User Guide document supplied by the payor/receiver to determine usage of this data
element.
RECORD/FIELD: DA1-15.0
DATA ELEMENT: Zero Payment Indicator (ZERO PAY IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
15.0
X(01)
LEFT
SPACES
156
156
DEFINITION: An indicator showing:
1) that the claim has been filed to the payor,
2) that the payor has processed the claim and so informed the provider, and
3) that the PAYOR PAID AMOUNT (DA0-4.0) is the entire amount paid by the payor on this claim.
A payment of ZERO may be the result of the payor determining that they have no liability for the claim or
that the entire liability was applied to deductibles and coinsurance.
CODE VALUES: Not used by MO HealthNet.
Z = Zero payment.
N = Payment amount is greater than zero.
SPACE = Claim has not been filed or payment notification has not been received from this payor.
VALIDATION: Must be entered if applicable and the payor requires the information for the filing of
secondary claims EMC.
If entered, must be a valid code from the above list.
FORM LOCATION: EOB (Explanation of Benefits) or remittance of primary payor(s).
REMARKS: The purpose of this indicator is to allow payors to process secondary claims with zero
payments by the primary payor without having to obtain an EOB from the payor or insured.
NSF (National Standard Format) User Manual
84
The provider is certifying that he has filed the claim to the indicated payor, the payor has processed the
claim to completion, informed the provider of the results of that processing and that the amount shown in
PAYOR PAID AMOUNT (DA1-14.0) is the actual amount that the payor paid on the claim.
RECORD/FIELD: DA1-16.0 DA1-17.0 DA1-18.0
DATA ELEMENT: Adjudication Indicator 1 (ADJUDICATION IND 1)
Adjudication Indicator 2 (ADJUDICATION IND 2)
Adjudication Indicator 3 (ADJUDICATION IND 3)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
16.0
X(02)
LEFT
SPACES
157
158
17.0
X(02)
LEFT
SPACES
159
160
18.0
X(02)
LEFT
SPACES
161
162
DEFINITION: Codes indicating the reason(s) why the payor denied or reduced benefits on this claim.
Use all of the codes that apply, up to the maximum of three (3).
CODE VALUES: Not used by MO HealthNet.
01 = Benefits exhausted
02 = Non-covered benefits
03 = Insured coverage lapsed or did not exist
04 = Cost containment disallowed
05 = Entire amount applied to deductible
06 = Charges exceeded allowance
VALIDATION: Must be entered if applicable and the payor requires the information for the filing of
secondary claims EMC.
If entered, must be a valid code from the above list.
FORM LOCATION: EOB (Explanation of Benefits) or remittance of primary payor(s).
REMARKS: N/A
RECORD/FIELD: DA1-19.0
DATA ELEMENT: CHAMPUS Sponsor Branch (CHAMPUS SPNSR BRANCH)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
19.0
X(01)
LEFT
SPACES
163
163
DEFINITION: CHAMPUS sponsor's military branch of service obtained from the military identification
card
NSF (National Standard Format) User Manual
85
CODE VALUES: Not used by MO HealthNet.
1 = Army
2 = Air Force
3 = Marines
4 = Navy
5 = Coast Guard
6 = Public Health Service
7 = NOAA (National Oceanic & Atmospheric Adm.)
VALIDATION: If entered, must be a valid code from the above list.
Required if source of payment = H (Champus) and claim filing indicator is `P'.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: DA1-20.0
DATA ELEMENT: CHAMPUS Sponsor Grade (CHAMPUS SPNSR GRADE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
20.0
X(02)
LEFT
SPACES
614
165
DEFINITION: CHAMPUS sponsor's military grade obtained from the military identification card.
CODE VALUES: Not used by MO HealthNet.
See EXHIBIT 2 for valid values.
VALIDATION: If entered, must be a valid code from Exhibit 2. Required if source of payment = H
(Champus) and claim filing indicator is `P'.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: DA1-21.0
DATA ELEMENT: CHAMPUS Sponsor Status
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
21.0
X(01)
LEFT
SPACES
166
DEFINITION: CHAMPUS sponsor's military status obtained from the military identification card.
CODE VALUES: Not used by MO HealthNet.
1 = Active Military
NSF (National Standard Format) User Manual
86
2 = Retired Military
3 = Deceased
VALIDATION: If entered, must be a valid code from the above list.
Required if source of payment = H (Champus) and claim filing indicator is `P'.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: DA1-22.0
DATA ELEMENT: Insurance Card Effective Date (INS CARD EFFECT DATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
22.0
X(08)
LEFT
SPACES
167
174
DEFINITION: The effective date is obtained from the insurance identification card.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: See GENERAL INSTRUCTIONS for Date Entry.
Required if source of payment = H (CHAMPUS) and claim filing indicator is `P'.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: DA1-23.0
DATA ELEMENT: Insurance Card Termination Date (INS CARD TERM DATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
23.0
X(08)
LEFT
SPACES
175
182
FROM
THRU
DEFINITION: The effective date is obtained from the insurance identification card.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: See GENERAL INSTRUCTIONS for Date Entry.
Required if source of payment = H (Champus) and claim filing indicator is `P'.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: DA1-24.0
DATA ELEMENT: Balance Due
FIELD
COBOL PICTURE
NSF (National Standard Format) User Manual
JUSTIFY
INITIAL
87
24.0
9(5)V99
RIGHT
ZEROS
183
189
DEFINITION: Amount of total charges remaining if partial payment is made by the patient. If no balance
remains, show zeros.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
FORM LOCATION: CMS-1500 Block 30
REMARKS: N/A
RECORD/FIELD: DA1-25.0 DA1-26.0 DA1-27.0 DA1-28.0
DATA ELEMENT:
EOMB DATE1
EOMB DATE2
EOMB DATE3
EOMB DATE4
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
25.0
X(08)
LEFT
SPACES
190
197
26.0
X(08)
LEFT
SPACES
198
205
27.0
X(08)
LEFT
SPACES
206
213
28.0
X(08)
LEFT
SPACES
214
221
DEFINITION:
Date 1 = Date finalized in the system.
Date 2 = Date EOMB mailed.
Date 3 = Date of check/EFT transaction
Date 4 = "Other" Date
CODE VALUES: Not used by MO HealthNet.
Date 1 = Date finalized in the system.
Date 2 = Date EOMB mailed.
Date 3 = Date of check/EFT transaction
Date 4 = "Other" Date
VALIDATION: N/A
FORM LOCATION: N/A
NSF (National Standard Format) User Manual
88
REMARKS: Required for COB exchange.
RECORD/FIELD: DA1-29.0
DATA ELEMENT: CLAIM RECEIPT DATE
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
29.0
X(08)
LEFT
SPACES
222
229
DEFINITION: The Date the claim was received by the Payor.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: N/A
REMARKS: Required for Coordination of Benefits exchange.
RECORD/FIELD: DA1-30.0
DATA ELEMENT: BENE PAID AMT
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
30.0
s9(7)v99
RIGHT
ZEROS
230
238
DEFINITION: Total amount paid to the beneficiary.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: Used for Coordination of Benefits exchange.
RECORD/FIELD: DA1-31.0
DATA ELEMENT: BENE CHECK/EFT TRACE NO
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
31.0
X(15)
LEFT
SPACES
239
253
DEFINITION: The check number/EFT trace number.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: Used for Coordination of Benefits exchange.
NSF (National Standard Format) User Manual
89
RECORD/FIELD: DA1-32.0
DATA ELEMENT: BENE CHECK/EFT DATE
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
32.0
x(08)
LEFT
SPACES
254
261
DEFINITION: The date the Medicare check/EFT was issued to the beneficiary.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: N/A
REMARKS: Used for Coordination of Benefits exchange.
RECORD/FIELD: DA1-33.0
DATA ELEMENT: PROV PAID AMT
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
33.0
S9(7)v99
RIGHT
ZEROS
262
270
DEFINITION: Total amount paid to the provider.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: Used for Coordination of Benefits exchange.
RECORD/FIELD: DA1-34.0
DATA ELEMENT: PROV CHECK/EFT TRACE NO
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
34.0
X(15)
LEFT
SPACES
271
285
DEFINITION: The check number/EFT trace number.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: Used for Coordination of Benefits exchange.
RECORD/FIELD: DA1-35.0
DATA ELEMENT: PROV CHECK DATE
NSF (National Standard Format) User Manual
90
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
35.0
x(08)
LEFT
SPACES
286
293
DEFINITION: The date the Medicare check\EFT was issued to the provider.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: N/A
REMARKS: Used for Coordination of Benefits exchange.
RECORD/FIELD: DA1-36.0
DATA ELEMENT: INTEREST PAID
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
36.0
S9(7)v99
RIGHT
ZEROS
294
302
DEFINITION: The amount paid by the Payor for the interest due for the delay in processing of the claim
by Payor.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: Used for Coordination of Benefits exchange.
RECORD/FIELD: DA1-37.0
DATA ELEMENT: APPROVED AMT
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
37.0
S9(7)v99
RIGHT
ZEROS
303
311
FROM
THRU
DEFINITION: The amount approved for all services lines.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: Required for Coordination of Benefits exchange.
RECORD/FIELD: DA1-38.0
DATA ELEMENT: Contractual Agreement Indicator (CONTRACT AGREEMENT IND)
FIELD
COBOL PICTURE
NSF (National Standard Format) User Manual
JUSTIFY
INITIAL
91
38.0
X(01)
LEFT
SPACES
312
312
DEFINITION: Primary Payer has a contractual agreement with the provider that limits what the provider
may charge for a service.
CODE VALUES: Y = Yes, contractual agreement exists N = No , contractual agreement does not exist
VALIDATION: If entered, must be a valid code from above list.
FORM LOCATION: N/A
REMARKS: For Champus, If yes, the allowed amount (DA1-11.0) is required for double coverage
claims.
RECORD/FIELD: DA1-39.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
39.0
X(08)
LEFT
SPACES
313
320
DEFINITION: Unused record space reserved for national use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: INSURANCE INFORMATION RECORD TYPE DA2 "PAYOR
DATA 3"
Not Required by MO HealthNet
Must follow DA0 or DA1
Must be followed by EA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "DA2"
C-24
DA2
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
Not Used
04
INSURED ADDR1
Not Used
05
INSURED ADDR2
Not Used
06
INSURED CITY
Not Used
NSF (National Standard Format) User Manual
92
07
INSURED STATE
Not Used
08
INSURED ZIP
Not Used
09
INSURED PHONE
Not Used
10
INSURED RETIRE DATE
Not Used
11
INSURED SPOUSE RETIRE
Not Used
12
INSURED EMPLR NAME
Not Used
13
INSURED EMPLR ADDR1
Not Used
14
INSURED EMPLR ADDR2
Not Used
15
INSURED EMPLR CITY
Not Used
16
INSURED EMPLR STATE
Not Used
17
INSURED EMPLR ZIP
Not Used
18
EMPLOYEE ID NO
Not Used
19
FILLER-NATIONAL
YES
RECORD TYPE: DA2
LEVEL: CLAIM
PURPOSE: To identify the Insured(s) involved with and/or having liability for the resolution of this claim.
REQUIREMENTS: This record must be entered if required by payor.
ORDER:
Preceding Record Type
Following Record Type
DA0 or DA1
DA0 or EA0
NOTES: When requesting payment from a secondary payor it is extremely important that the EOB/remittance
information be provided from the primary payor(s).
This is of major importance in allowing the secondary claim to be processed without having to request a hardcopy
EOB.
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "DA2"
3
X
01
03
02.0
SEQUENCE NO
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
INSURED ADDR1
30
X
23
52
NSF (National Standard Format) User Manual
93
05.0
INSURED ADDR2
30
X
53
82
06.0
INSURED CITY
20
X
83
102
07.0
INSURED STATE
2
X
103
104
08.0
INSURED ZIP
9
X
105
113
09.0
INSURED PHONE
10
X
114
123
10.0
INSURED RETIRE DATE
8
X
124
131
11.0
INSURED SPOUSE RETIRE
8
X
132
139
12.0
INSURED EMPLR NAME
33
X
140
172
13.0
INSURED EMPLR ADDR1
30
X
173
202
14.0
INSURED EMPLR ADDR2
30
X
203
232
15.0
INSURED EMPLR CITY
20
X
233
252
16.0
INSURED EMPLR STATE
2
X
253
254
17.0
INSURED EMPLR ZIP
9
X
255
263
18.0
EMPLOYEE ID NO
12
X
264
275
19.0
FILLER-NATIONAL
45
X
276
320
RECORD/FIELD: DA2-01.0
DATA ELEMENT: Record Identifier (RECORD ID "DA2")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: Field used to identify the "INSURANCE INFORMATION" - "PAYOR DATA 3" record.
CODE VALUES: See the C-24 table for valid field values.
VALIDATION: Must be entered.
Must be "DA2".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: DA2-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
NSF (National Standard Format) User Manual
94
DEFINITION: A numeric value from 01 through 03 used to sequence the "DA2" records, and to associate
"DA2" records with "DA0" and "DA1" records.
CODE VALUES: See the C-21 table for valid field values.
VALIDATION: Must be entered.
Must be a valid code from the above list.
The value entered must match the SEQUENCE NUMBER (DA0-02.0) submitted in the preceding "DA0"
record.
FORM LOCATION: N/A
REMARKS: See sequencing instructions on page DA0.04.
RECORD/FIELD: DA2-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: A unique number assigned by the provider to identify the patient.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered.
Must be identical to the "Patient Control Number" (CA0-03.0) of this claim.
See GENERAL INSTRUCTIONS for "Patient Account Number" entry.
FORM LOCATION: CMS-1500 Block 26
REMARKS: The Patient Account Number field is used to associate all of the records for a single claim.
RECORD/FIELD: DA2-04.0 DA2-05.0 DA2-06.0 DA2-07.0 DA2-08.0
DATA ELEMENT:
Insured Address Line 1
(INSURED ADDR1)
Insured Address Line 2
(INSURED ADDR2)
Insured City
(INSURED CITY)
Insured State
(INSURED STATE)
Insured Zip
(INSURED ZIP)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(30)
LEFT
SPACES
23
52
05.0
X(30)
LEFT
SPACES
53
82
NSF (National Standard Format) User Manual
95
06.0
X(20)
LEFT
SPACES
83
102
07.0
X(02)
LEFT
SPACES
103
104
08.0
X(09)
LEFT
SPACES
105
113
DEFINITION: The current mailing address of the insured individual.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
See GENERAL INSTRUCTIONS for Address Entry.
FORM LOCATION: CMS-1500 Block 7
REMARKS: N/A
RECORD/FIELD: DA2-09.0
DATA ELEMENT: Insured Telephone Number (INSURED PHONE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
X(10)
LEFT
SPACES
114
123
DEFINITION: Telephone number, including area code, at which the insured individual can be contacted.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
See GENERAL INSTRUCTIONS for Telephone Entry.
FORM LOCATION: CMS-1500 Block 7
REMARKS: N/A
RECORD/FIELD: DA2-10.0
DATA ELEMENT: Insured Retirement Date (INSURED RETIRE DATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
X(08)
LEFT
SPACES
124
131
DEFINITION: The retirement date of the insured.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
See GENERAL INSTRUCTIONS for Date Entry.
FORM LOCATION: N/A
NSF (National Standard Format) User Manual
96
REMARKS: N/A
RECORD/FIELD: DA2-11.0
DATA ELEMENT: Insured Spouse Retirement Date (INSURED SPOUSE RETIRE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
X(08)
LEFT
SPACES
132
139
DEFINITION: The retirement date of the Insured's spouse.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor (receiver).
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for Date Entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: DA2-12.0
DATA ELEMENT: Insured Employer Name(INSURED EMPLR NAME)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(33)
LEFT
SPACES
140
172
DEFINITION: The name of the insured individual's employer.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
See GENERAL INSTRUCTIONS for "Name" ENTRY.
FORM LOCATION: CMS-1500 Blocks 11b, 9c
REMARKS: N/A
RECORD/FIELD: DA2-13.0 DA2-14.0 DA2-15.0 DA2-16.0 DA2-17.0
DATA ELEMENT:
Insured Employer Address Line 1
(INSURED EMPLR ADDR1)
Insured Employer Address Line 2
(INSURED EMPL ADDR2)
Insured Employer City
(INSURED EMPLR CITY)
Insured Employer State
(INSURED EMPLR STATE)
Insured Employer Zip
(INSURED EMPLR ZIP)
NSF (National Standard Format) User Manual
97
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
X(30)
LEFT
SPACES
173
202
14.0
X(30)
LEFT
SPACES
203
232
15.0
X(20)
LEFT
SPACES
233
252
16.0
X(02)
LEFT
SPACES
253
254
17.0
X(09)
LEFT
SPACES
255
263
DEFINITION: The current mailing address of the insured individual's employer.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: See GENERAL INSTRUCTIONS for Address Entry.
Must be entered if required by payor (receiver).
FORM LOCATION: CMS-1500 Blocks 9c, 11b
REMARKS: N/A
RECORD/FIELD: DA2-18.0
DATA ELEMENT: Employer Identification Number (EMPLOYER ID NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
X(12)
LEFT
SPACES
264
275
DEFINITION: The identification number assigned by the employer to the employee.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: See GENERAL INSTRUCTIONS for "Identification number" entry.
Must be entered if required by payor (receiver).
FORM LOCATION: CMS-1500 Blocks 9a, 11
REMARKS: N/A
RECORD/FIELD: DA2-19.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
19.0
X(45)
LEFT
SPACES
276
320
DEFINITION: Unused record space. Reserved for national use.
CODE VALUES: N/A
NSF (National Standard Format) User Manual
98
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: INSURANCE INFORMATION RECORD TYPE DA3 "PAYOR
DATA 4"
FIELD
NO
FIELD NAME
TABLE
VALUE
DEFAULT
01
RECORD ID "DA3"
C-24
DA3
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
Not Used
04
CLAIM REASON CODE1
Not Used
05
DOLLAR AMOUNT1
Not Used
06
CLAIM REASON CODE2
Not Used
07
DOLLAR AMOUNT2
Not Used
08
CLAIM REASON CODE3
Not Used
09
DOLLAR AMOUNT3
Not Used
10
CLAIM REASON CODE4
Not Used
11
DOLLAR AMOUNT4
Not Used
12
CLAIM REASON CODE5
Not Used
13
DOLLAR AMOUNT5
Not Used
14
CLAIM REASON CODE6
Not Used
15
DOLLAR AMOUNT6
Not Used
16
CLAIM REASON CODE7
Not Used
17
DOLLAR AMOUNT7
Not Used
18
CLAIM MESSAGE CODE1
Not Used
19
CLAIM MESSAGE CODE2
Not Used
20
CLAIM MESSAGE CODE3
Not Used
21
CLAIM MESSAGE CODE4
Not Used
22
CLAIM MESSAGE CODE5
Not Used
23
CLAIM DETAIL LINE COUNT
Not Used
24
CLAIM ADJUST IND
Not Used
NSF (National Standard Format) User Manual
99
25
PROV ADJUST AMT
Not Used
26
BENE ADJUST AMT
Not Used
27
ORIG APPROVE AMT
Not Used
28
ORIG PAID AMT
Not Used
29
ORIG PAYOR CLM CONTROL NO
Not Used
30
FILLER-NATIONAL
Not Used
RECORD TYPE: DA3
LEVEL:CLAIM
PURPOSE: To supply prior adjudication status information from primary payors.
REQUIREMENTS: This record must be entered if this is a Coordination of Benefits file and claim level
adjustments have been applied and/or claim level messages were reported.
ORDER:
Preceding Record Type
Following Record Type
DA1
DA0 or EA0
NOTES: When requesting payment from a secondary payor it is extremely important that the EOB/remittance
information be provided from the primary payor(s). This is of major importance in allowing the secondary claim
to be processed without having to request a hardcopy EOB.
FIELD NO
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "DA3"
3
X
01
03
02.0
SEQUENCE NO
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
CLAIM REASON CODE1
6
X
23
28
05.0
DOLLAR AMOUNT1
7
N
29
35
06.0
CLAIM REASON CODE2
6
X
36
41
07.0
DOLLAR AMOUNT2
7
N
42
48
08.0
CLAIM REASON CODE3
6
X
49
54
09.0
DOLLAR AMOUNT3
7
N
55
61
10.0
CLAIM REASON CODE4
6
X
62
67
11.0
DOLLAR AMOUNT4
7
N
68
74
NSF (National Standard Format) User Manual
100
12.0
CLAIM REASON CODE5
6
X
75
80
13.0
DOLLAR AMOUNT5
7
N
81
87
14.0
CLAIM REASON CODE6
6
X
88
93
15.0
DOLLAR AMOUNT6
7
N
94
100
16.0
CLAIM REASON CODE7
6
X
101
106
17.0
DOLLAR AMOUNT7
7
N
107
113
18.0
CLAIM MESSAGE CODE1
5
X
114
118
19.0
CLAIM MESSAGE CODE2
5
X
119
123
20.0
CLAIM MESSAGE CODE3
5
X
124
128
21.0
CLAIM MESSAGE CODE4
5
X
129
133
22.0
CLAIM MESSAGE CODE5
5
X
134
138
23.0
CLAIM DETAIL LINE COUNT
2
X
139
140
24.0
CLAIM ADJUST IND
1
X
141
141
25.0
PROV ADJUST AMT
7
N
142
148
26.0
BENE ADJUST AMT
7
N
149
155
27.0
ORIG APPROVE AMT
7
N
156
162
28.0
ORIG PAID AMT
7
N
163
169
29.0
ORIG PAYOR CLM CONTROL NO
17
X
170
186
30.0
FILLER-NATIONAL
134
X
187
320
RECORD/FIELD: DA3-01.0
DATA ELEMENT: Record Identifier (RECORD ID "DA3")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: Field used to identify the "INSURANCE INFORMATION" - "PAYOR DATA 4" record.
CODE VALUES: See the C-24 table for valid field values.
VALIDATION: Must be entered.
Must be "DA3".
FORM LOCATION: N/A
REMARKS: N/A
NSF (National Standard Format) User Manual
101
RECORD/FIELD: DA3-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: A numeric value from 01 through 03 used to sequence the "DA3" records, and to associate
"DA3" records with "DA0", "DA1" AND "DA2" records.
CODE VALUES: See the C-21 table for valid field values.
VALIDATION: Must be entered.
Must be a valid code from the above list.
The value entered must match the SEQUENCE NUMBER (DA0-02.0) submitted in the preceding "DA0"
record.
FORM LOCATION: N/A
REMARKS: See sequencing instructions on page DA0.04.
RECORD/FIELD: DA3-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: A unique number assigned by the provider to identify the patient.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered.
Must be identical to the "Patient Control Number" (CA0-03.0) of this claim.
See GENERAL INSTRUCTIONS for "Patient Account Number" entry.
FORM LOCATION: CMS-1500 Block 26
REMARKS: The Patient Account Number field is used to associate all of the records for a single claim.
RECORD/FIELD: DA3-04.0 DA3-05.0
DATA ELEMENT: Claim Reason Code 1 Dollar Amount 1
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(06)
LEFT
SPACES
23
28
05.0
S9(5)V99
RIGHT
ZEROS
29
35
DEFINITION: Claim adjustment reason code and amount of adjustment.
NSF (National Standard Format) User Manual
102
The code shows the reason for an adjustment, such as denial or reduction in payment from the amount
billed, that are made on claims and may have a financial effect.
CODE VALUES: Not used by MO HealthNet.
For Medicare, use the American National Standards Institute (ANSI) Accredited Standards Committee
(ASC) X12 835 claim adjustment (CAS) codes and applicable group code.
VALIDATION: At least one reason code must be shown per claim. This can be at service or claim level.
REMARKS: Claim adjustment reason codes are available from:
Electronic File:
Washington Publishing Company World Wide Web Site www.wpc-edi.com
Paper Copy:
Blue Cross and Blue Shield Association
Inter-Plan Teleprocessing Services Dept.
676 North St. Clair Street
Chicago, IL 60611
For Medicare, the first two positions contain the X12 835 group code which is part of the ANSI ASC X12
835 standard. The remaining positions contain the claim adjustment reason code, starting with the third
position.
RECORD/FIELD: DA3-06 DA3-07.0
DATA ELEMENT: Claim Reason Code 2 Dollar Amount 2
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(06)
LEFT
SPACES
36
41
07.0
S9(5)V99
RIGHT
ZEROS
42
48
DEFINITION: Claim adjustment reason code and amount of adjustment. The code shows the reason for
an adjustment, such as denial or reduction in payment from the amount billed, that are made on claims
and may have a financial effect.
CODE VALUES: Not used by MO HealthNet.
For Medicare, use the American National Standards Institute (ANSI) Accredited Standards Committee
(ASC) X12 835 claim adjustment (CAS) codes and applicable group code.
VALIDATION: At least one reason code must be shown per claim. This can be at service or claim level.
REMARKS: Claim adjustment reason codes are available from:
Electronic File:
Washington Publishing Company World Wide Web Site www.wpc-edi.com
Paper Copy:
NSF (National Standard Format) User Manual
103
Blue Cross and Blue Shield Association
Inter-Plan Teleprocessing Services Dept.
676 North St. Clair Street
Chicago, IL 60611
For Medicare, the first two positions contain the X12 835 group code which is part of the ANSI ASC X12
835 standard. The remaining positions contain the claim adjustment reason code, starting with the third
position.
RECORD/FIELD: DA3-08.0 DA3-09.0
DATA ELEMENT: Claim Reason Code 3 Dollar Amount 3
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
08.0
X(06)
LEFT
SPACES
49
54
09.0
S9(5)V99
RIGHT
ZEROS
55
61
DEFINITION: Claim adjustment reason code and amount of adjustment.
The code shows the reason for an adjustment, such as denial or reduction in payment from the amount
billed, that are made on claims and may have a financial effect.
CODE VALUES: Not used by MO HealthNet.
For Medicare, use the American National Standards Institute (ANSI) Accredited Standards Committee
(ASC) X12 835 claim adjustment (CAS) codes and applicable group code.
VALIDATION: At least one reason code must be shown per claim. This can be at service or claim level.
REMARKS: Claim adjustment reason codes are available from:
Electronic File:
Washington Publishing Company World Wide Web Site www.wpc-edi.com
Paper Copy:
Blue Cross and Blue Shield Association
Inter-Plan Teleprocessing Services Dept.
676 North St. Clair Street
Chicago, IL 60611
For Medicare, the first two positions contain the X12 835 group code which is part of the ANSI SC X12
835 standard. The remaining positions contain the claim adjustment reason code, starting with the third
position.
RECORD/FIELD: DA3-10.0 DA3-11.0
DATA ELEMENT: Claim Reason Code 4 Dollar Amount 4
FIELD
COBOL PICTURE
NSF (National Standard Format) User Manual
JUSTIFY
INITIAL
FROM
THRU
104
10.0
X(06)
LEFT
SPACES
62
67
11.0
S9(5)V99
RIGHT
ZEROS
68
74
DEFINITION: Claim adjustment reason code and amount of adjustment.
The code shows the reason for an adjustment, such as denial or reduction in payment from the amount
billed, that are made on claims and may have a financial effect.
CODE VALUES: Not used by MO HealthNet.
For Medicare, use the American National Standards Institute (ANSI) Accredited Standards Committee
(ASC) X12 835 claim adjustment (CAS) codes and applicable group code.
VALIDATION: At least one reason code must be shown per claim. This can be at service or claim level.
REMARKS: Claim adjustment reason codes are available from:
Electronic File:
Washington Publishing Company World Wide Web Site www.wpc-edi.com
Paper Copy:
Blue Cross and Blue Shield Association
Inter-Plan Teleprocessing Services Dept.
676 North St. Clair Street
Chicago, IL 60611
For Medicare, the first two positions contain the X12 835 group code which is part of the ANSI ASC X12
835 standard. The remaining positions contain the claim adjustment reason code, starting with the third
position.
RECORD/FIELD: DA3-12.0 DA3-13.0
DATA ELEMENT: Claim Reason Code 5 Dollar Amount 5
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(06)
LEFT
SPACES
75
80
13.0
S9(5)V99
RIGHT
ZEROS
81
87
DEFINITION: Claim adjustment reason code and amount of adjustment. The code shows the reason for
an adjustment, such as denial or reduction in payment from the amount billed, that are made on claims
and may have a financial effect.
CODE VALUES: Not used by MO HealthNet.
For Medicare, use the American National Standards Institute (ANSI) Accredited Standards Committee
(ASC) X12 835 claim adjustment (CAS) codes and applicable group code.
VALIDATION: At least one reason code must be shown per claim. This can be at service or claim level.
NSF (National Standard Format) User Manual
105
REMARKS: Claim adjustment reason codes are available from:
Electronic File:
Washington Publishing Company World Wide Web Site www.wpc-edi.com
Paper Copy:
Blue Cross and Blue Shield Association
Inter-Plan Teleprocessing Services Dept.
676 North St. Clair Street
Chicago, IL 60611
For Medicare, the first two positions contain the X12 835 group code which is part of the ANSI ASC X12
835 standard. The remaining positions contain the claim adjustment reason code, starting with the third
position.
RECORD/FIELD: DA3-14.0 DA3-15.0
DATA ELEMENT: Claim Reason Code 6 Dollar Amount 6
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
14.0
X(06)
LEFT
SPACES
88
93
15.0
S9(5)V99
RIGHT
ZEROS
94
99
DEFINITION: Claim adjustment reason code and amount of adjustment. The code shows the reason for
an adjustment, such as denial or reduction in payment from the amount billed, that are made on claims
and may have a financial effect.
CODE VALUES: Not used by MO HealthNet.
For Medicare, use the American National Standards Institute (ANSI) Accredited Standards Committee
(ASC) X12 835 claim adjustment (CAS) codes and applicable group code.
VALIDATION: At least one reason code must be shown per claim. This can be at service or claim level.
REMARKS: Claim adjustment reason codes are available from:
Electronic File:
Washington Publishing Company World Wide Web Site www.wpc-edi.com
Paper Copy:
Blue Cross and Blue Shield Association
Inter-Plan Teleprocessing Services Dept.
676 North St. Clair Street
Chicago, IL 60611
NSF (National Standard Format) User Manual
106
For Medicare, the first two positions contain the X12 835 group code which is part of the ANSI ASC X12
835 standard. The remaining positions contain the claim adjustment reason code, starting with the third
position.
RECORD/FIELD: DA3-16.0 DA3-17.0
DATA ELEMENT: Claim Reason Code 7 Dollar Amount 7
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
16.0
X(06)
LEFT
SPACES
100
105
17.0
S9(5)V99
RIGHT
ZEROS
106
113
DEFINITION: Claim adjustment reason code and amount of adjustment. The code shows the reason for
an adjustment, such as denial or reduction in payment from the amount billed, that are made on claims
and may have a financial effect.
CODE VALUES: Not used by MO HealthNet.
For Medicare, use the American National Standards Institute (ANSI) Accredited Standards Committee
(ASC) X12 835 claim adjustment (CAS) codes and applicable group code.
VALIDATION: At least one reason code must be shown per claim. This can be at service or claim level.
REMARKS: Claim adjustment reason codes are available from:
Electronic File:
Washington Publishing Company World Wide Web Site www.wpc-edi.com
Paper Copy:
Blue Cross and Blue Shield Association
Inter-Plan Teleprocessing Services Dept.
676 North St. Clair Street
Chicago, IL 60611
For Medicare, the first two positions contain the X12 835 group code which is part of the ANSI ASC X12
835 standard. The remaining positions contain the claim adjustment reason code, starting with the third
position.
RECORD/FIELD: DA3-18.0 DA3-19.0 DA3-20.0 DA3-21.0 DA3-22.0
DATA ELEMENT:
Claim Message Code 1
Claim Message Code 2
Claim Message Code 3
Claim Message Code 4
Claim Message Code 5
NSF (National Standard Format) User Manual
107
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
X(05)
LEFT
SPACES
114
118
19.0
X(05)
LEFT
SPACES
119
123
20.0
X(05)
LEFT
SPACES
124
128
21.0
X(05)
LEFT
SPACES
129
133
22.0
X(05)
LEFT
SPACES
134
138
DEFINITION: Claim level information message codes to convey appeal or other claim-specific
information that does not involve a financial adjustment.
CODE VALUES: Not used by MO HealthNet.
For Medicare, use the current Medicare Inpatient (MIA) or Medicare Outpatient (MOA) message codes.
VALIDATION: If entered, Medicare requires a valid MIA/MOA code.
REMARKS: MIA/MOA codes are maintained by CMS.
RECORD/FIELD: DA3-23.0
DATA ELEMENT: Claim Detail Line Count
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
23.0
X(02)
LEFT
SPACES
139
140
DEFINITION: Number of total detail lines from the original claim.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: N/A
REMARKS: Required for COB exchange.
RECORD/FIELD: DA3-24.0
DATA ELEMENT: Claim Adjustment Indicator
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
24.0
X(01)
LEFT
SPACES
141
141
DEFINITION: Indicates if this is an adjustment to a prior claim.
CODE VALUES: Not used by MO HealthNet.
Y = Adjustment to Prior Claim blank = Not an adjustment to a prior claim.
VALIDATION: If entered, must be a valid code from code list.
VALIDATION: If entered, must be a valid code from code list.
NSF (National Standard Format) User Manual
108
REMARKS: Required for COB exchange if this is an adjustment to a prior claim.
RECORD/FIELD: DA3-25.0
DATA ELEMENT: Provider Adjustment Amount (PROV ADJUST AMT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
25.0
S9(5)V99
RIGHT
ZEROS
142
148
DEFINITION: The Medicare provider adjustment amount.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: N/A
REMARKS: Required for COB exchange if this is an adjustment to the provider amount.
RECORD/FIELD: DA3-26.0
DATA ELEMENT: Beneficiary Adjustment Amount (BENE ADJUST AMT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
26.0
S9(5)V99
RIGHT
ZEROS
149
155
DEFINITION: The Medicare beneficiary adjustment amount.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: N/A
REMARKS: Required for COB exchange if this is an adjustment to the beneficiary amount.
RECORD/FIELD: DA3-27.0
DATA ELEMENT: Original Approved Amount (ORIG APPROVE AMT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
27.0
S9(5)V99
RIGHT
ZEROS
156
162
DEFINITION: The last processed claim approved amount for the claim that is being adjusted.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: N/A
REMARKS: Required for COB exchange if this is an adjustment.
RECORD/FIELD: DA3-28.0
DATA ELEMENT: Original Paid Amount (ORIG PAID AMT)
FIELD
COBOL PICTURE
NSF (National Standard Format) User Manual
JUSTIFY
INITIAL
FROM
THRU
109
28.0
S9(5)V99
RIGHT
ZEROS
163
169
DEFINITION: The last processed claim payment amount for the claim that is being adjusted. This can be
the original claim payment or the amount of most recent adjustment.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: N/A
REMARKS: Required for COB exchange, if this is an adjustment.
RECORD/FIELD: DA3-29.0
DATA ELEMENT: Original Payor Claim Control Number
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
29.0
X(17)
LEFT
SPACES
170
186
DEFINITION: The original claim control number or the most recent adjustment control number assigned
by the payor to identify the claim to which adjustment is being made.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: N/A
REMARKS: Required for COB exchange if this is an adjustment.
RECORD/FIELD: DA3-30.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
30.0
X(134)
LEFT
SPACES
187
320
DEFINITION: Unused record space. Reserved for national use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: CLAIM RECORD TYPE EA0 "CLAIM DATA"
Required for MO HealthNet processing
Must follow DA0, DA1 or DA2
Must be followed by EA1, EA2 or FA0
NSF (National Standard Format) User Manual
110
Field No.
Field Name
Table
Value
Default
01
RECORD ID "EA0"
C-24
EA0
02
RESERVED (EA0-02.0)
Not Used
03
PAT CONTROL NO
Not Used
04
EMPL RELATED IND
Not Used
05
ACCIDENT IND
NO
06
SYMPTOM IND
C-62
NO
07
ACCIDENT/SYMPTOM DATE
C-63
NO
08
EXT CAUSE OF ACCIDENT
Not Used
09
RESPONSIBILITY IND
Not Used
10
ACCIDENT STATE
Not Used
11
ACCIDENT HOUR
Not Used
12
ABUSE IND
Not Used
13
RELEASE OF INFO IND
Not Used
14
RELEASE OF INFO DATE
Not Used
15
SAME/SIMILAR SYMP IND
Not Used
16
SAME/SIMILAR SYMP DT
Not Used
17
DISABILITY TYPE
Not Used
18
DISABILITY-FROM DATE
Not Used
19
DISABILITY-TO DATE
Not Used
20
REFER PROV ID NO
21
REFER PROV UPIN
Not Used
22
REFER PROV TAX TYPE
Not Used
23
REFER PROV TAX ID
Not Used
24
REFER PROV LAST
Not Used
25
REFER PROV FIRST
Not Used
26
REFER PROV MI
Not Used
27
REFER PROV STATE
Not Used
28
ADMISSION DATE-1
NSF (National Standard Format) User Manual
C-15
C-16
NO
NO
111
29
DISCHARGE DATE-1
C-16
NO
30
LAB IND
C-44
NO
31
LAB CHARGES
32
DIAGNOSIS CODE-1
C-17
YES
33
DIAGNOSIS CODE-2
C-17
NO
34
DIAGNOSIS CODE-3
C-17
NO
35
DIAGNOSIS CODE-4
C-17
NO
36
PROV ASSIGN IND
Not Used
37
PROV SIGNATURE IND
Not Used
38
PROV SIGNATURE DATE
Not Used
39
FACILITY/LAB NAME
40
DOCUMENTATION IND
Not Used
41
TYPE OF DOCUMENTATION
Not Used
42
FUNCTIONAL STATUS CODE
Not Used
43
SPECIAL PROGRAM IND
Not Used
44
CHAMPUS NON AVAIL IND
Not Used
45
SUPV PROV IND
Not Used
46
RESUBMISSION CODE
Not Used
47
RESUB REFERENCE NO
48
DATE LAST SEEN
Not Used
49
DATE DOCUMENT SENT
Not Used
50
HOMEBOUND IND
Not Used
51
BLOOD UNITS PAID
Not Used
52
BLOOD UNITS REMAINING
Not Used
53
FILLER-NATIONAL
YES
Not Used
C-64
C-41
NO
NO
RECORD TYPE: EA0
LEVEL:CLAIM
PURPOSE: To identify claim level information.
REQUIREMENTS: One EA0 is required on every claim.
NSF (National Standard Format) User Manual
112
ORDER:
Preceding Record Type
Following Record Type
DA0, DA1 or DA2
EA1, EA2, or FA0
NOTES: Only one EA0 record is allowed on each claim.
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "EA0"
3
X
01
03
02.0
RESERVED(EA0-02.0)
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
0EMPL RELATED IND
1
X
23
23
05.0
ACCIDENT IND
1
X
24
24
06.0
SYMPTOM IND
1
X
25
25
07.0
ACCIDENT/SYMPTON DATE
8
X
26
33
08.0
EXT CAUSE OF ACCIDENT
5
X
34
38
09.0
RESPONSIBILITY IND
1
X
39
39
10.0
ACCIDENT STATE
2
X
40
41
11.0
ACCIDENT HOUR
2
X
42
43
12.0
ABUSE IND
1
X
44
44
13.0
RELEASE OF INFO IND
1
X
45
45
14.0
RELEASE OF INFO DATE
8
X
46
53
15.0
SAME/SIMILAR SYMP IND
1
X
54
54
16.0
SAME/SIMILAR SYMP DT
8
X
55
54
17.0
DISABILITY TYPE
1
X
63
63
18.0
DISABILITY-FROM DATE
8
X
64
71
19.0
DISABILITY-TO DATE
8
X
72
79
20.0
REFER PROV NPI
15
X
80
94
21.0
REFER PROV UPIN
15
X
95
109
22.0
REFER PROV TAX TYPE
1
X
110
110
23.0
REFER PROV TAX ID
9
X
111
119
24.0
REFER PROV LAST
20
X
120
139
NSF (National Standard Format) User Manual
113
25.0
REFER PROV FIRST
12
X
140
151
26.0
REFER PROV MI
1
X
152
152
27.0
REFER PROV STATE
2
X
153
154
28.0
ADMISSION DATE
18
X
155
162
29.0
DISCHARGE DATE
18
X
163
170
30.0
LAB IND
1
X
171
171
31.0
LAB CHARGES
7
N
172
178
32.0
DIAGNOSIS CODE-1
5
X
179
183
33.0
DIAGNOSIS CODE-2
5
X
184
188
34.0
DIAGNOSIS CODE-3
5
X
189
193
35.0
DIAGNOSIS CODE-4
5
X
194
198
36.0
PROV ASSIGN IND
1
X
199
199
37.0
PROV SIGNATURE IND
1
X
200
200
38.0
PROV SIGNATURE DATE
8
X
201
208
39.0
FACILITY/LAB NAME
33
X
209
241
40.0
DOCUMENTATION IND
1
X
242
242
41.0
TYPE OF DOCUMENTATION
1
X
243
243
42.0
FUNCTNL STATUS CODE
2
X
244
245
43.0
SPECIAL PROGRAM IND
2
X
246
247
44.0
CHAMPUS NONAVAIL IND
1
X
248
248
45.0
SUPV PROV IND
1
X
249
249
46.0
SUB/RESUBMISSION CODE
2
X
250
251
47.0
RESUB REFERENCE NO
15
X
252
266
48.0
DATE LAST SEEN
8
X
267
274
49.0
DATE DOCUMENT SENT
8
X
275
282
50.0
HOMEBOUND IND
1
X
283
283
51.0
BLOOD UNITS PAID
3
X
284
286
52.0
BLOOD UNITS REMAINING
3
X
287
289
53.0
CPO PROV NUMBER
6
X
290
295
54.0
IDE NUMBER
15
X
296
310
NSF (National Standard Format) User Manual
114
55.0
FILLER-NATIONAL
10
X
311
320
RECORD/FIELD: EA0-01.0
DATA ELEMENT: Record Identification(RECORD ID "EA0")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: This is the record identifier for the Claim Detail Record - EA0.
CODE VALUES: See the C-24 table for valid field values.
VALIDATION: Must be entered.
Must be "EA0".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA0-02.0
DATA ELEMENT: Reserved (EA0-02.0)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: Unused reserved record space.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA0-03.0 "CLAIM DATA"
DATA ELEMENT: Patient Control Number(PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION:A unique number assigned by the provider to identify the patient.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered.
NSF (National Standard Format) User Manual
115
Must be identical to the "Patient Control Number"
(CA0-03.0) of this claim.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: CMS-1500 Block 26
REMARKS: N/A
RECORD/FIELD: EA0-04.0 "CLAIM DATA"
DATA ELEMENT: Employment Related Indicator(EMPL RELATED IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(01)
LEFT
SPACE
23
23
DEFINITION:A code to indicate whether the patient alleges that his/her medical condition is due to the
environment or events resulting from employment.
CODE VALUES: Not used by MO HealthNet.
Y = Yes (Employment related)
N = No (Not employment related)
U = Unknown
VALIDATION: Must be entered.
Must be a valid code from above list.
FORM LOCATION: CMS-1500 Block 10a
REMARKS: N/A
RECORD/FIELD: EA0-05.0
DATA ELEMENT: Accident Indicator(ACCIDENT IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(01)
LEFT
SPACE
24
24
DEFINITION:A code to indicate whether the patient's condition was the result of an accident.
CODE VALUES: See the C-18 table for valid field values.
VALIDATION: Must be entered.
Must be a valid code from above list.
If "A" or "O" is entered, EA0-07.0 thru EA0-11.0 must be completed according to payor requirements.
FORM LOCATION: CMS-1500 Blocks 10b, 10c
REMARKS: N/A
NSF (National Standard Format) User Manual
116
RECORD/FIELD: EA0-06.0
DATA ELEMENT: Symptom Indicator(SYMPTOM IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(01)
RIGHT
ZERO
25
25
DEFINITION: An indicator as to whether the "Accident/Symptom Date" (EA0-07.0) represents the date
that symptoms were first experienced or the date of last menstrual period (LMP).
CODE VALUES: See the C-62 table for valid field values.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
If code "2" is entered, "Patient Sex" (CA0-09.0) must = "F" (Female).
FORM LOCATION: CMS-1500 Block 14
REMARKS: N/A
RECORD/FIELD: EA0-07.0
DATA ELEMENT: Accident/Symptom Date
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(08)
LEFT
SPACES
26
33
DEFINITION: The date of the accident or the date that patient first experienced symptoms of illness or
the date of the last menstrual period (LMP).
CODE VALUES: See the C-63 table for valid field values.
VALIDATION: If "Symptom Indicator" (EA0-06.0) equals "1" or "2", this field must be completed
according to payor requirements.
If "Accident Indicator" (EA0-05.0) equals "A" or "O", this field must be completed according to payor
requirements.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: CMS-1500 Block 14
REMARKS: N/A
RECORD/FIELD: EA0-08.0
DATA ELEMENT: External Cause of Accident (EXT CAUSE OF ACCIDENT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
08.0
X(05)
LEFT
SPACES
34
38
NSF (National Standard Format) User Manual
117
DEFINITION:A code from the Supplemental Classification of
External Causes of Injury and Poisoning section of
the ICD-9-CM manual.
CODE VALUES: Not used by MO HealthNet.
ICD-9-CM Diagnosis Codes from E8000 thru E9999
VALIDATION: If "Accident Indicator" (EA0-05.0) equals "O", this field must be completed according to
payor requirements.
If entered:
1. Must be the most specific/precise 4 digit or 5 digit code allowed for in the ICD-9-CM coding format.
2. Do not submit a decimal point. The decimal point is implied because each ICD-9-CM code is unique.
3. The first character may only be an 'E'.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA0-09.0
DATA ELEMENT: Responsibility Indicator(RESPONSIBILITY IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
X(01)
LEFT
SPACE
39
39
DEFINITION: A code to indicate whether or not the accident or illness was caused by another party.
Y = Yes, accident or illness was caused by another party.
N = No, accident or illness was not caused by another party.
VALIDATION: If "Accident Indicator" (EA0-05.0) equals "A" or "O", this field must be completed
according to payor requirements.
If entered, must be a valid code from above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA0-10.0
DATA ELEMENT: Accident State
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
X(02)
LEFT
SPACES
40
41
NSF (National Standard Format) User Manual
118
DEFINITION: State Postal Code identifying the state in which the automobile accident occurred.
CODE VALUES: Not used by MO HealthNet.
See EXHIBIT 1.
VALIDATION: If "Accident Indicator" (EA0-05.0) equals "A", this field must be completed according to
payor requirements.
If entered, must be a valid code from EXHIBIT 1.
See GENERAL INSTRUCTIONS for "Address" entry.
FORM LOCATION: CMS-1500 Block 10b
REMARKS: N/A
RECORD/FIELD: EA0-11.0
DATA ELEMENT: Accident Hour
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
X(02)
LEFT
SPACES
42
43
DEFINITION: The hour when the accident occurred that necessitated the rendering of a service submitted
on this claim.
CODE VALUES: Not used by MO HealthNet.
Code
Time AM
Code
Time PM
00
12:00 - 12:59 Midnight
12
12:00 - 12:59 Noon
01
01:00 – 01:59
13
01:00 - 01:59
02
02:00 - 02:59
14
02:00 - 02:59
03
03:00 - 03:59
15
03:00 - 03:59
04
04:00 - 04:59
16
04:00 - 04:59
05
05:00 – 05:59
17
05:00 - 05:59
06
06:00 – 06:59
18
06:00 - 06:59
07
07:00 – 07:59
19
07:00 - 07:59
08
08:00 – 08:59
20
08:00 - 08:59
09
09:00 – 09:59
21
09:00 - 09:59
10
10:00 – 10:59
22
10:00 - 10:59
11
11:00 – 11:59
23
11:00 - 11:59
99
Unknown
NSF (National Standard Format) User Manual
119
VALIDATION: If "Accident Indicator" (EA0-05.0) equals "A" or "O", this field must be completed
according to payor requirements.
If entered, must be a valid code from above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA0-12.0
DATA ELEMENT: Abuse Indicator(ABUSE IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(01)
LEFT
SPACE
44
44
DEFINITION:A code to indicate whether the patient's condition, in the provider's opinion, may be the
result of abuse.
CODE VALUES: Not used by MO HealthNet.
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA0-13.0
DATA ELEMENT: Release of Information Indicator (RELEASE OF INFO IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
X(01)
LEFT
SPACE
45
45
DEFINITION: A code indicating whether the provider has on file a signed statement permitting the
release of medical data to other organizations in order to adjudicate the claim.
CODE VALUES: Not used by MO HealthNet.
Y = Yes
The provider has on file a signed statement permitting the release of
medical/billing information for purposes of claiming insurance benefits.
M = Modified or Restricted
Release
The provider has limited or restricted authority to release some
medical/billing information release for purposes of claiming insurance
benefits.
N = No Release
The provider does not have permission to release any medical/billing
information.
NSF (National Standard Format) User Manual
120
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
FORM LOCATION: CMS-1500 Block 12
REMARKS: N/A
RECORD/FIELD: EA0-14.0
DATA ELEMENT: Release of Information Date (RELEASE OF INFO DATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
14.0
X(08)
LEFT
SPACES
46
53
DEFINITION: Date that the Release of Information statement was signed by the patient.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: If "Release of Information Indicator" (EA0-13.0) equals "Y" or "M", this field must be
completed according to payor requirements.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: CMS-1500 Block 12
REMARKS: N/A
RECORD/FIELD: EA0-15.0
DATA ELEMENT: Same or Similar Symptom Indicator SAME/SIMILAR SYMP IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
15.0
X(01)
LEFT
SPACE
54
54
DEFINITION: An indicator as to whether the Patient reported that they have previously experienced
symptoms similar or identical to those for which services submitted on this claim were rendered.
CODE VALUES: Not used by MO HealthNet.
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
FORM LOCATION: CMS-1500 Block 15
REMARKS: N/A
RECORD/FIELD: EA0-16.0
NSF (National Standard Format) User Manual
121
DATA ELEMENT: Same or Similar Symptom Date (SAME/SIMILAR SYMP DT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
16.0
X(08)
LEFT
SPACES
55
62
DEFINITION: The previous date that the patient experienced symptoms similar or identical to those for
which services submitted on this claim were rendered.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: If "Same or Similar Symptom Indicator" (EA0-15.0) equals "Y", this field must be
completed according to payor requirements.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: CMS-1500 Block 15
REMARKS: N/A
RECORD/FIELD: EA0-17.0
DATA ELEMENT: Disability Type
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
17.0
X(01)
LEFT
SPACE
63
63
DEFINITION: An indicator to describe type of disability.
CODE VALUES: Not used by MO HealthNet.
1 = Short Term Disability
2 = Long Term Disability
3 = Permanent/Total Disability
4 = No Disability
VALIDATION: Must be entered if required by payor.
If entered, must be valid code from above list.
FORM LOCATION: CMS-1500 Block 16
REMARKS: N/A
RECORD/FIELD: EA0-18.0 EA0-19.0
DATA ELEMENT: Disability-From Date Disability-To Date
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
X(08)
LEFT
SPACES
64
71
NSF (National Standard Format) User Manual
122
19.0
X(08)
LEFT
SPACES
72
79
DEFINITION: The beginning and ending date the patient, in the provider's opinion, was or will be unable
to perform the duties normally associated with his/her work.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: If "Disability Type" (EA0-17.0) equals "1" or "2", this field must be completed
according to payor requirements.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: CMS-1500 Block 16
REMARKS: N/A
RECORD/FIELD: EA0-20.0
DATA ELEMENT: Referring Provider National Provider Identifier (REFER PROV NPI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
20.0
X(15)
LEFT
SPACES
80
94
DEFINITION: The National Provider Identifier assigned to the Referring provider.
CODE VALUES: See the C-15 table for valid field values.
VALIDATION: Must be entered if required by payor.
This field must contain the National Provider Identifier (NPI) once the NPI is implemented.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: CMS-1500 Block 17a
REMARKS: N/A
RECORD/FIELD: EA0-21.0
DATA ELEMENT: REFER PROV UPIN
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
21.0
X(15)
LEFT
SPACES
95
109
DEFINITION: The Referring Provider's UPIN.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: N/A
NSF (National Standard Format) User Manual
123
REMARKS: N/A
RECORD/FIELD: EA0-22.0
DATA ELEMENT: REFER PROV TAX TYPE
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
22.0
X(01)
LEFT
SPACES
10
110
DEFINITION:A code which identifies the referring provider's Tax ID entered in EA0-23.0.
CODE VALUES: Not used by MO HealthNet.
T = TIN Number
S = SS Number
VALIDATION: If entered, must be a valid code from code list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA0-23.0
DATA ELEMENT: REFER PROV TAX ID
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
23.0
X(09)
LEFT
SPACES
111
119
DEFINITION: The federally assigned Tax identification number (TIN) or the social security number
(SSN) of the referring provider.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: See GENERAL INSTRUCTIONS for "identification Number" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA0-24.0 EA0-25.0 EA0-26.0
DATA ELEMENT: Referring Provider Last Name(REFER PROV LAST) Referring Provider First Name(REFER
PROV FIRST) Referring Provider Middle Initial (REFER PROV MI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
24.0
X(20)
LEFT
SPACES
120
139
25.0
X(12)
LEFT
SPACES
140
151
26.0
X(01)
LEFT
SPACES
152
152
NSF (National Standard Format) User Manual
124
DEFINITION: Name of Provider who referred the patient to the provider of service on this claim.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
See GENERAL INSTRUCTIONS for "Name 1" entry.
FORM LOCATION: CMS-1500 Block 17
REMARKS: N/A
RECORD/FIELD: EA0-27.0
DATA ELEMENT: Referring Provider State(REFER PROV STATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
27.0
X(02)
LEFT
SPACES
153
154
DEFINITION: State Postal Code of the Referring Provider.
CODE VALUES: Not used by MO HealthNet.
See EXHIBIT 1.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from EXHIBIT 1.
See GENERAL INSTRUCTIONS for "Address" entry.
FORM LOCATION: CMS-1500 Block 17
REMARKS: N/A
RECORD/FIELD: EA0-28.0 EA0-29.0
DATA ELEMENT: Admission Date-1 Discharge Date-1
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
28.0
X(08)
LEFT
SPACES
155
162
29.0
X(08)
LEFT
SPACES
163
170
DEFINITION: If services submitted in this claim were performed while the patient was confined in a
health care facility, enter the beginning date and if applicable, the ending date of confinement.
CODE VALUES: See the C-16 table for valid field values.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: CMS-1500 Block 18
NSF (National Standard Format) User Manual
125
REMARKS: Use "Admission-2" (EA1-14.0) and "Discharge-2" (EA1-15.0) fields if multiple admissions
occurred during the service period of this claim.
RECORD/FIELD: EA0-30.0
DATA ELEMENT: Laboratory Indicator(LAB IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
30.0
X(01)
LEFT
SPACE
171
171
DEFINITION:A code to indicate whether or not the Laboratory work was performed outside the
provider's office.
CODE VALUES: See the C-44 table for valid field values.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
If "Y" is submitted, "Laboratory Charges" (EA0-29.0), "Facility/Laboratory Name" (EA0-39.0) and fields
EA1-04.0 thru EA1-10.0 must be completed according to payor requirements.
FORM LOCATION: CMS-1500 Block 20
REMARKS: N/A
RECORD/FIELD: EA0-31.0
DATA ELEMENT: Laboratory Charges (LAB CHARGES)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
31.0
9(5)V99
RIGHT
ZEROS
172
178
DEFINITION: Charges billed to the provider by the Independent Laboratory.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: If "Laboratory Indicator" (EA0-30.0) equals "Y", this field must be completed according
to payor requirements.
If entered, must be a positive unsigned numeric value.
FORM LOCATION: CMS-1500 Block 20
REMARKS: N/A
RECORD/FIELD: EA0-32.0 EA0-33.0 EA0-34.0 EA0-35.0
DATA ELEMENT: Diagnosis Code-1 Diagnosis Code-2 Diagnosis Code-3 Diagnosis Code-4
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
32.0
X(05)
LEFT
SPACES
179
183
33.0
X(05)
LEFT
SPACES
184
188
NSF (National Standard Format) User Manual
126
34.0
X(05)
LEFT
SPACES
189
193
35.0
X(05)
LEFT
SPACES
194
198
DEFINITION: An ICD-9-CM Diagnosis Code identifying a diagnosed medical condition resulting in a
line item service.
CODE VALUES: See the C-17 table for valid field values.
VALIDATION: Must be the most specific/precise 3 digit, 4 digit or 5 digit code allowed for in the ICD9-CM coding format.
Do not submit a decimal point. The decimal point is implied because each ICD-9-CM code is unique.
The submission of "V", "E" and/or "M" Diagnosis Codes may or may not be accepted by a payor.
FORM LOCATION: CMS-1500 Block 21
REMARKS: The Diagnosis Code should correspond with the age and sex of the patient.
RECORD/FIELD: EA0-36.0
DATA ELEMENT: Provider Assignment Indicator(PROV ASSIGN IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
36.0
X(01)
LEFT
SPACE
199
199
DEFINITION:A code indicating whether the provider accepts assignment.
CODE VALUES: Not used by MO HealthNet.
A = Assigned
N = Not Assigned
B = Assignment accepted on Clinical Lab services only.
P = Patient Refuses to Assign Benefits
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
FORM LOCATION: CMS-1500 Block 27
REMARKS: N/A
RECORD/FIELD: EA0-37.0
DATA ELEMENT: Provider Signature Indicator (PROV SIGNATURE IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
37.0
X(01)
LEFT
SPACE
200
200
NSF (National Standard Format) User Manual
127
DEFINITION: The signature of the provider of service(s) reported on this claim which acknowledges the
performance of the service(s) and authorizes payment is on file in the provider's office.
CODE VALUES: Not used by MO HealthNet.
Y = Signature of provider is on file.
N = Signature of provider is not on file.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
FORM LOCATION: CMS-1500 Block 31
REMARKS: N/A
RECORD/FIELD: EA0-38.0
DATA ELEMENT: Provider Signature Date(PROV SIGNATURE DATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
38.0
X(08)
LEFT
SPACES
201
208
DEFINITION: Date of the provider's signature.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: CMS-1500 Block 31
REMARKS: N/A
RECORD/FIELD: EA0-39.0
DATA ELEMENT: Facility/Laboratory Name (FACILITY/LAB NAME)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
39.0
X(33)
LEFT
SPACES
209
241
DEFINITION: The name of the Hospital, Nursing Facility, Laboratory or other facility where services
being submitted on this claim were rendered.
CODE VALUES: See the C-64 table for valid field values.
VALIDATION: If "Laboratory Indicator" (EA0-30.0) equals "Y", this field must be completed according
to payor requirements.
See GENERAL INSTRUCTIONS for "Name 2" entry.
FORM LOCATION: CMS-1500 Block 32
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REMARKS: For Medicare, this field must be completed, if available, if the place of service is other than
the patient's home or physician's office.
RECORD/FIELD: EA0-40.0
DATA ELEMENT: Documentation Indicator(DOCUMENTATION IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
40.0
X(01)
LEFT
SPACE
242
242
DEFINITION: An indicator describing if there is documentation pertaining to this claim.
CODE VALUES: Not used by MO HealthNet.
1 = In mail
2 = FAX
3 = On file at Provider's site
4 = On file at Payor's site
5 = Cert Record in this claim
6 = Narrative Record included in this claim
9 = No documentation
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA0-41.0
DATA ELEMENT: Type of Documentation
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
41.0
X(01)
LEFT
SPACE
243
243
DEFINITION:A code to indicate the Type of Documentation being/or submitted by the provider.
CODE VALUES: Not used by MO HealthNet.
A = DME Prescription
B = Explanation of Benefits (MSP or COB)
C = Diagnostic Report
D = Operative Note
E = PEN Certification
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F = Ambulance Certification
G = Physical Therapy Certification
H = Chiropractic Justification
I = Prosthetics/Orthotic Certification
J = Oxygen Prescription
Y = Multiple Documentation Items
Z = Other
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA0-42.0
DATA ELEMENT: Functional Status Code (FUNCTNL STATUS CODE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
42.0
X(02)
LEFT
SPACES
244
245
DEFINITION:A code based upon the Karnofsky Scale to describe the patient's level of disability.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: Do not default to "00" (zero zero).
RECORD/FIELD: EA0-43.0
DATA ELEMENT: Special Program Indicator(SPECIAL PROGRAM IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
43.0
X(02)
LEFT
SPACES
246
247
DEFINITION:A code indicating the Special Program/Project under which the services rendered to the
patient were performed.
CODE VALUES: Not used by MO HealthNet.
03 = Special Federal Funding
05 = Disability
06 = PPV/Medicare 100% Payment
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07 = Induced Abortion - Danger to Women's Life
08 = Induced Abortion - Victim of Rape/Incest
09 = Second Opinion/Surgery
30 = Medicare Demonstration Project for Lung Volume Reduction Surgery Study
70 thru 99 = Reserved for Local Use
A= CHAMPUS Program For The Handicapped; Patient is Sponsor
B= CHAMPUS Program For The Handicapped; Patient is Spouse
D= CHAMPUS Program For The Handicapped; Patient is Widow Of Sponsor
W= CHAMPUS Program For The Handicapped; Patient is a Child; however, the individual's assigned
PFTH Suffix is unknown.
C1 thru C9= CHAMPUS Program For The Handicapped; Patient is a Child (up to nine PFTH Suffix(s)
are available for assignment when more than one child from the same family is enrolled in the program).
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA0-44.0
DATA ELEMENT: CHAMPUS Non-availability Indicator (CHAMPUS NONAVAIL IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
44.0
X(01)
LEFT
SPACE
248
248
DEFINITION:A code to indicate whether or not the provider has a signed CHAMPUS statement of nonavailability on file (statement indicates the service was not available at a Military Treatment Facility).
CODE VALUES: Not used by MO HealthNet.
Y = Yes, statement on file
N = No, statement not on file or statement not necessary.
VALIDATION: If "Source of Payment - National" (DA0-05.0) equals "H", this field must be completed
according to payor requirements.
If entered, must be a valid code from above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA0-45.0
DATA ELEMENT: Supervising Provider Indicator(SUPV PROV IND)
NSF (National Standard Format) User Manual
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FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
45.0
X(01)
LEFT
SPACE
249
249
DEFINITION:A code to indicate whether any service billed on this claim was supervised by a provider
other than the rendering provider.
CODE VALUES: Not used by MO HealthNet.
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be valid code from above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA0-46.0
DATA ELEMENT: Submission/Resubmission Code (SUB/RESUBMISSION CODE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
46.0
X(02)
LEFT
SPACES
250
251
DEFINITION:A code to indicate the reason for the claim submission.
CODE VALUES: Not used by MO HealthNet.
00 = Original claim
01 = Void/Cancel prior claim (Disregard claim previously submitted - should be an exact duplicate of
previous claim).
02 = Resubmission (This claim is a Replacement of a previously submitted claim).
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
FORM LOCATION: CMS-1500 Block 22
REMARKS: Not all payers support submission of Electronic adjustments. Obtain authorization From
your payer prior to submitting adjustments.
RECORD/FIELD: EA0-47.0
DATA ELEMENT: Resubmission Reference Number (RESUB REFERENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
47.0
X(15)
LEFT
SPACES
252
266
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DEFINITION: Reference Number assigned by payor to the original claim.
CODE VALUES: See the C-41 table for valid field values.
VALIDATION: Must be entered if required by payor.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: CMS-1500 Block 22
REMARKS: N/A
RECORD/FIELD: EA0-48.0
DATA ELEMENT: Date Last Seen
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
48.0
X(08)
LEFT
SPACES
267
274
DEFINITION: The date the patient was last seen by the referring/ordering physician for a claim billed by
an independent physical therapist or podiatrist.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: CMS-1500 Block 19
REMARKS: N/A
RECORD/FIELD: EA0-49.0
DATA ELEMENT: Date Documentation Sent (DATE DOCUMENT SENT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
49.0
X(08)
LEFT
SPACES
275
282
DEFINITION: The date that the documentation noted the in "Documentation Indicator" (EA0-38.0) was
sent to payor of this claim.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: N/A
REMARKS: Applicable only if the "Documentation Indicator" (EA0-38.0) equals "1", "2", "4" or "6" and
the payor requires the information.
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RECORD/FIELD: EA0-50.0
DATA ELEMENT: Homebound Indicator (HOMEBOUND IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
50.0
X(1)
LEFT
SPACES
283
283
DEFINITION: To indicate whether an independent lab rendered services to a homebound patient.
CODE VALUES: Not used by MO HealthNet.
Y = Patient is homebound
N = Patient is not homebound
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: CMS-1500, Block 19
REMARKS: N/A
RECORD/FIELD: EA0-51.0
DATA ELEMENT: BLOOD UNITS PAID
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
51.0
X(03)
LEFT
SPACES
284
286
DEFINITION: Number of blood units paid.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: For COB, this is required if blood units were paid.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA0-52.0
DATA ELEMENT: BLOOD UNITS REMAINING
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
52.0
X(03)
LEFT
SPACES
287
289
DEFINITION: Number of blood units remaining.
CODE VALUES: Not used by MO HealthNet.
VALIDATION: For Coordination of Benefits (COB), this is required if blood units were paid.
FORM LOCATION: N/A
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REMARKS: N/A
RECORD/FIELD: EA0-53.0
DATA ELEMENT: Care Plan Oversight Provider Number (CPO PRV NUMBER)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
53.0
X(06)
LEFT
SPACES
290
295
DEFINITION: This is the Medicare provider number of the Home Health Agency or hospice providing
Medicare covered services to the beneficiary for the period during which CPO services were furnished
and for which the physician signed the plan of care.
CODE VALUES: N/A
VALIDATION: Must be entered if required by the payor.
See GENERAL INSTRUCTIONS for "Identification
Number" entry.
FORM LOCATION: CMS-1500, item 19
REMARKS: For Medicare, physicians billing CPO must enter the HHA or hospice provider number that
is treating the beneficiary.
RECORD/FIELD: EA0-54.0
DATA ELEMENT: Investigational Device Exemption Number (IDE NUMBER)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
54.0
X(15)
LEFT
SPACES
296
310
DEFINITION: Investigational device exemption number for FDA-Approved clinical trials.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: CMS-1500, Item 23
REMARKS: For Medicare, enter the IDE number when an investigational device is used in a FDAapproved clinical trial.
RECORD/FIELD: EA0-55.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
55.0
X(10)
LEFT
SPACES
311
320
DEFINITION: Unused reserved filler for national use.
NSF (National Standard Format) User Manual
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CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: CLAIM RECORD TYPE EA1
Not Required by MO HealthNet
Must follow EA0
Must be followed by EA2 or FA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "EA1"
C-24
EA1
02
RESERVED (EA1-02.0)
Not Used
03
PAT CONTROL NO
Not Used
04
FACILITY/LAB ID NO
Not Used
05
RESERVED (EA1-05.0)
Not Used
06
FACILITY/LAB ADDR1
Not Used
07
FACILITY/LAB ADDR2
Not Used
08
FACILITY/LAB CITY
Not Used
09
FACILITY/LAB STATE
Not Used
10
FACILITY/LAB ZIP CODE
Not Used
11
MEDICAL RECORD NO
Not Used
12
RETURN TO WORK DATE
Not Used
13
CONSULT/SURGERY DATE
Not Used
14
ADMISSION DATE-2
Not Used
15
DISCHARGE DATE-2
Not Used
16
SUPV PROV ID NO
Not Used
17
RESERVED (EA1-17.0)
Not Used
18
SUPV PROV LAST
Not Used
19
SUPV PROV FIRST
Not Used
20
SUPV PROV MI
Not Used
NSF (National Standard Format) User Manual
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21
SUPV PROV STATE
Not Used
22
EMT/PARAMEDIC LAST
Not Used
23
EMT/PARAMEDIC FIRST
Not Used
24
EMT/PARAMEDIC MI
Not Used
25
DATE CARE ASSUMED
Not Used
26
DIAGNOSIS CODE - 5
Not Used
27
DIAGNOSIS CODE - 6
Not Used
28
DIAGNOSIS CODE - 7
Not Used
29
DIAGNOSIS CODE - 8
Not Used
30
FILLER-NATIONAL
YES
RECORD TYPE: EA1
LEVEL:CLAIM
PURPOSE: To identify additional claim level information.
REQUIREMENTS:A maximum one EA1 record may be submitted, if required by payor.
ORDER:
Preceding Record Type
Following Record Type
EA0
EA2 or FA0
NOTES: Only one EA1 record is allowed per claim.
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "EA1"
3
X
01
03
02.0
RESERVED(EA1-02.0)
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
FACILITY/LAB NPI
15
X
23
37
05.0
RESERVED (EA1-05.0)
15
X
38
52
06.0
FACILITY/LAB ADDR1
30
X
53
82
07.0
FACILITY/LAB ADDR2
30
X
83
112
08.0
FACILITY/LAB CITY
20
X
113
132
09.0
FACILITY/LAB STATE
20
X
113
132
NSF (National Standard Format) User Manual
137
10.0
FACILITY/LAB ZIP CODE
9
X
135
143
11.0
MEDICAL RECORD NO
17
X
144
160
12.0
RETURN TO WORK DATE
8
X
161
168
13.0
CONSULT/SURGERY DATE
8
X
169
176
14.0
ADMISSION DATE-2
8
X
177
184
15.0
DISCHARGE DATE-2
8
X
185
192
16.0
SUPV PROV NPI
15
X
193
207
17.0
RESERVED (EA1-17.0)
15
X
208
222
18.0
SUPV PROV LAST
20
X
223
242
19.0
SUPV PROV FIRST
12
X
243
254
20.0
SUPV PROV MI
1
X
255
255
21.0
SUPV PROV STATE
2
X
256
257
22.0
EMT/PARAMEDIC LAST
20
X
258
277
23.0
EMT/PARAMEDIC FIRST
12
X
278
289
24.0
EMT/PARAMEDIC MI
1
X
290
290
25.0
DATE CARE ASSUMED
8
X
291
298
26.0
DIAGNOSIS CODE-5
5
X
299
303
27.0
DIAGNOSIS CODE-6
5
X
304
308
28.0
DIAGNOSIS CODE-7
5
X
309
313
29.0
DIAGNOSIS CODE-8
5
X
314
318
30.0
FILLER-NATIONAL
2
X
319
320
RECORD/FIELD: EA1-01.0
DATA ELEMENT: Record Identification(RECORD ID "EA1")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: This is the record identifier for the Claim Detail Record - EA1.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be "EA1".
NSF (National Standard Format) User Manual
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FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA1-02.0
DATA ELEMENT: Reserved (EA1-02.0)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: Unused reserved record space.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA1-03.0
DATA ELEMENT: Patient Control Number(PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION:A unique number assigned by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be identical to the "Patient Control Number" (CA0-03.0) of this claim.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: CMS-1500 Block 26
REMARKS: N/A
RECORD/FIELD: EA1-04.0
DATA ELEMENT: Facility/Laboratory National Provider Identifier(FACILITY/LAB NPI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(15)
LEFT
SPACES
23
37
DEFINITION: The National Provider Identifier assigned to the Facility or Laboratory.
CODE VALUES: N/A
NSF (National Standard Format) User Manual
139
VALIDATION: If "Laboratory Indicator" (EA0-28.0) equals "Y", this field must be completed according
to payor requirements.
This field must contain the National Provider Identifier (NPI) once the NPI is implemented.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: CMS-1500 Block 32
REMARKS: N/A
RECORD/FIELD: EA1-05.0
DATA ELEMENT: Reserved (EA1-05.0)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(15)
LEFT
SPACES
38
52
DEFINITION: Unused reserved space for the future assignment of a "USIN" Number.
CODE VALUES: "USIN" as assigned.
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA1-06.0 EA1-07.0 EA1-08.0 EA1-09.0 EA1-10.0
DATA ELEMENT:
Facility/Laboratory Street Address-1
(FACILITY/LAB ADDR1)
Facility/Laboratory Street Address-2
(FACILITY/LAB ADDR2)
Facility/Laboratory City
(FACILITY/LAB CITY)
Facility/Laboratory State
(FACILITY/LAB STATE)
Facility/Laboratory Zip Code
(FACILITY/LAB ZIP CODE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(30)
LEFT
SPACES
53
82
07.0
X(30)
LEFT
SPACES
83
112
08.0
X(20)
LEFT
SPACES
113
132
09.0
X(02)
LEFT
SPACES
133
134
10.0
X(09)
LEFT
SPACES
135
143
DEFINITION: The mailing address of the Facility or Laboratory where the services being submitted on
this claim were rendered.
CODE VALUES: N/A
NSF (National Standard Format) User Manual
140
VALIDATION: If "Laboratory Indicator" (EA0-28.0) equals "Y", these fields must be completed
according to payor requirements.
See GENERAL INSTRUCTIONS for "Address" entry.
FORM LOCATION: CMS-1500 Block 32
REMARKS: N/A
RECORD/FIELD: EA1-11.0
DATA ELEMENT: Medical Record Number (MEDICAL RECORD NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
X(17)
LEFT
SPACES
144
160
DEFINITION: A number assigned by the provider to identify the patient's medical records.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA1-12.0
DATA ELEMENT: Return to Work Date
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(08)
LEFT
SPACES
161
168
DEFINITION: The date the patient, in the provider's opinion, will be able to resume the performance of
the duties normally associated with his/her work.
CODE VALUES: N/A
VALIDATION: If "Disability Type" (EA0-17.0) equals "1" or "2", this field must be completed
according to payor requirements.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: CMS-1500 Block 16
REMARKS: N/A
RECORD/FIELD: EA1-13.0
DATA ELEMENT: Consult/Surgery Date
NSF (National Standard Format) User Manual
141
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
X(08)
LEFT
SPACES
169
176
DEFINITION: Date of Consult/Surgery for a condition for which this claim is being submitted.
CODE VALUES: N/A
VALIDATION: Must be entered if required by the payor.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA1-14.0 EA1-15.0
DATA ELEMENT: Admission Date-2 Discharge Date-2
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
14.0
X(08)
LEFT
SPACES
177
184
15.0
X(08)
LEFT
SPACES
185
192
DEFINITION: If services submitted in this claim were performed while the patient was confined in a
health care facility, enter the Admission Date and, if applicable, the Discharge Date of the second
confinement.
Use the "Admission-2" and "Discharge-2" fields if multiple admissions to a health care facility occurred
during the service period of this claim.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA1-16.0
DATA ELEMENT: Supervising Provider National Provider Identifier (SUPV PROV NPI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
16.0
X(15)
LEFT
SPACES
193
207
DEFINITION: The National Provider Identifier assigned to the supervising provider.
NSF (National Standard Format) User Manual
142
CODE VALUES: N/A
VALIDATION: If "Supervising Provider Indicator" (EA0-43.0) equals "Y", this field must be completed
according to payor requirements.
This field must contain the National Provider Identifier (NPI) once the NPI is implemented.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA1-17.0
DATA ELEMENT: Reserved (EA1-17.0)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
17.0
X(15)
LEFT
SPACES
208
222
DEFINITION: Unused reserved space for the future assignment of a "UPIN" Number.
CODE VALUES: "UPIN" as assigned.
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA1-18.0 EA1-19.0 EA1-20.0
DATA ELEMENT:
Supervising Provider Last Name
SUPV PROV LAST)
Supervising Provider First Name
(SUPV PROV FIRST)
Supervising Provider Middle Initial
(SUPV PROV MI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
X(20)
LEFT
SPACES
223
242
19.0
X(12)
LEFT
SPACES
243
254
20.0
X(01)
LEFT
SPACES
255
255
DEFINITION: Name of Provider who supervised the rendering of a service on this claim.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If "Supervising Provider Indicator" (EA0-43.0) equals "Y", these fields must be completed according to
payor requirements.
See GENERAL INSTRUCTIONS for "Name 1" entry.
NSF (National Standard Format) User Manual
143
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA1-21.0
DATA ELEMENT: Supervising Provider State (SUPV PROV STATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
21.0
X(02)
LEFT
SPACES
256
257
DEFINITION: State Postal Code of the Supervising Provider.
CODE VALUES: See EXHIBIT 1.
VALIDATION: If "Supervising Provider Indicator" (EA0-43.0) equals "Y", this field must be completed
according to payor requirements.
If entered, must be a valid code from EXHIBIT 1.
See GENERAL INSTRUCTIONS for "Address" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: EA1-22.0 EA1-23.0 EA1-24.0
DATA ELEMENT:
Emergency Technician/Paramedic Last
Name
(EMT/PARAMEDIC LAST)
Emergency Technician/Paramedic First
Name
(EMT/PARAMEDIC FIRST)
Emergency Technician/Paramedic Middle
Initial
(EMT/PARAMEDIC MI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
22.0
X(20)
LEFT
SPACES
258
277
23.0
X(12)
LEFT
SPACES
278
289
24.0
X(01)
LEFT
SPACES
290
290
DEFINITION: Name of the emergency technician/paramedic on the ambulance run sheet.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
See GENERAL INSTRUCTIONS for "Name 1" entry.
FORM LOCATION: N/A
NSF (National Standard Format) User Manual
144
REMARKS: N/A
RECORD/FIELD: EA1-25.0
DATA ELEMENT: Date Care Was Assumed (DATE CARE ASSUMED)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
25.0
X(08)
LEFT
SPACES
291
298
DEFINITION: The date the care of the patient was assumed by another physician.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS, for "Date" entry.
FORM LOCATION: CMS-1500, Item 19
REMARKS: N/A
RECORD/FIELD: EA1-26 EA1-27 EA1-28 EA1-29
DATA ELEMENT:
Diagnosis Code-5
Diagnosis Code-6
Diagnosis Code-7
Diagnosis Code-8
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
26.0
X(05)
LEFT
SPACES
299
303
27.0
X(05)
LEFT
SPACES
304
308
28.0
X(05)
LEFT
SPACES
309
313
29.0
X(05)
LEFT
SPACES
314
318
DEFINITION: An ICD-9-CM Diagnosis Code identifying a diagnosed medical condition resulting in a
line item service.
CODE VALUES: ICD-9-CM Diagnosis Codes.
VALIDATION: Must be the most specific/precise 3 digit, 4 digit or 5 digit code allowed for in the ICD9-CM coding format.
Do not submit a decimal point. The decimal point is implied because each ICD-9-CM code is unique.
The submission of "V", "E" and/or "M" Diagnosis
Codes may or may not be accepted by a payor.
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FORM LOCATION: N/A
REMARKS: The Diagnosis Code should correspond with the age and sex of the patient.
RECORD/FIELD: EA1-30.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
30.0
X(02)
LEFT
SPACES
319
320
DEFINITION: Unused reserved filler for National use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: CLAIM RECORD TYPE EA2 "EARLY PERIODIC SCREENING
DIAGNOSTIC TESTING (EPSDT)"
Not Required by MO HealthNet
Must follow EA0 or EA1
Must be followed by FA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "EA2"
C-24
EA2
02
RESERVED (EA2-02.0)
Not Used
03
PAT CONTROL NO
Not Used
04
SCREENING TYPE
Not Used
05
MED HIST OBTAIN PERF
Not Used
06
MED HIST OBTAIN FIND
Not Used
07
PHYSICAL EXAM PERF
Not Used
08
PHYSICAL EXAM FIND
Not Used
09
VISION ASSESS PERF
Not Used
10
VISION ASSESS FIND
Not Used
11
HEARING ASSESS PERF
Not Used
12
HEARING ASSESS FIND
Not Used
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13
DENTAL ASSESS PERF
Not Used
14
DENTAL ASSESS FIND
Not Used
15
DEVELOP ASSESS PERF
Not Used
16
DEVELOP ASSESS FIND
Not Used
17
NUT ASSESS PERF
Not Used
18
NUT ASSESS FIND
Not Used
19
CARD ASSESS PERF
Not Used
20
CARD ASSESS FIND
Not Used
21
GEN/UR ASSESS PERF
Not Used
22
GEN/UR ASSESS FIND
Not Used
23
DIABETES ASSESS PERF
Not Used
24
DIABETES ASSESS FIND
Not Used
25
OTH. SYS. ASSESS PERF
Not Used
26
OTH. SYS. ASSESS FIND
Not Used
27
OTH. SYS. ASSESS DESC
Not Used
28
HBG/HCT LAB TEST PERF
Not Used
29
HBG/HCT LAB TEST FIND
Not Used
30
URINALY LAB TST PERF
Not Used
31
URINALY LAB TST FIND
Not Used
32
SICKLE CELL LAB PERF
Not Used
33
SICKLE CELL LAB FIND
Not Used
34
BLOOD LEAD LAB PERF
Not Used
35
BLOOD LEAD LAB FIND
Not Used
36
TINE TEST PERF
Not Used
37
TINE TEST FIND
Not Used
38
OTHER TEST 1 PERF
Not Used
39
OTHER TEST 1 FIND
Not Used
40
OTHER TEST 1 DESC
Not Used
41
OTHER TEST 2 PERF
Not Used
42
OTHER TEST 2 FIND
Not Used
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43
OTHER TEST 2 DESC
Not Used
44
TREATMENT ITEM NO 1
Not Used
45
TREATMENT ITEM NO 2
Not Used
46
TREATMENT ITEM NO 3
Not Used
47
TREATMENT ITEM NO 4
Not Used
48
TREATMENT ITEM NO 5
Not Used
49
TREATMENT ITEM NO 6
Not Used
50
TREATMENT ITEM NO 7
Not Used
51
TREATMENT ITEM NO 8
Not Used
52
TREATMENT ITEM NO 9
Not Used
53
TREATMENT ITEM NO 10
Not Used
54
TREATMENT ITEM NO 11
Not Used
55
TREATMENT ITEM NO 12
Not Used
56
TREATMENT ITEM NO 13
Not Used
57
TREATMENT ITEM NO 14
Not Used
58
TREATMENT ITEM NO 15
Not Used
59
TREATMENT ITEM NO 16
Not Used
60
TREATMENT STAT NO1 IN
Not Used
61
TREATMENT STAT NO2 IN
Not Used
62
TREATMENT STAT NO3 IN
Not Used
63
TREATMENT STAT NO4 IN
Not Used
64
TREATMENT STAT NO1 DE
Not Used
65
TREATMENT STAT NO2 DE
Not Used
66
TREATMENT STAT NO3 DE
Not Used
67
TREATMENT STAT NO4 DE
Not Used
68
TREATMENT STAT NO1 NR
Not Used
69
TREATMENT STAT NO2 NR
Not Used
70
TREATMENT STAT NO3 NR
Not Used
71
TREATMENT STAT NO4 NR
Not Used
72
REFERRAL ITEM NO 1
Not Used
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73
REFERRAL ITEM NO 2
Not Used
74
REFERRAL ITEM NO 3
Not Used
75
REFERRAL ITEM NO 4
Not Used
76
REFERRAL ITEM NO 5
Not Used
77
REFERRAL ITEM NO 6
Not Used
78
REFERRAL ITEM NO 7
Not Used
79
REFERRAL ITEM NO 8
Not Used
80
IMMUN POLIO GIVEN
Not Used
81
IMMUN POLIO NOT
Not Used
82
IMMUN DPT/TD GIVEN
Not Used
83
IMMUN DPT/TD NOT
Not Used
84
IMMUN MEAS GIVEN
Not Used
85
IMMUN MEAS NOT
Not Used
86
IMMUN MUMPS GIVEN
Not Used
87
IMMUN MUMPS NOT
Not Used
88
IMMUN RUBELLA GIVEN
Not Used
89
IMMUN RUBELLA NOT
Not Used
90
IMMUN HIB GIVEN
Not Used
91
IMMUN HIB NOT
Not Used
92
IMMUN OTHER GIVEN
Not Used
93
IMMUN OTHER DESC
Not Used
94
FILLER-NATIONAL
YES
RECORD TYPE:EA2
LEVEL:CLAIM
PURPOSE: To provide information from the Primary Care Physician, Health Maintenance Organization, or other
qualified MO HealthNet enrolled provider regarding status and results of MO HealthNet Early Periodic Screening
Diagnostic Testing. The fields contained in this record are those on the Colorado-103 form which are not covered
in other National Standard Format records.
REQUIREMENTS: If required by the payor, an "EA2" record must be submitted after the initial or follow-up
medical screening examinations are performed.
ORDER:
Preceding Record Type
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149
EA0 or EA1
FA0
NOTES: When used, this record must follow the EA0 or EA1 records related to this claim.
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "EA2"
3
X
01
03
02.0
RESERVED (EA2-02.0)
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
SCREENING TYPE
1
X
23
23
05.0
MED HIST OBTAIN PERF
1
X
24
24
06.0
MED HIST OBTAIN FIND
1
X
25
25
07.0
PHYSICAL EXAM PERF
1
X
26
26
08.0
PHYSICAL EXAM FIND
1
X
27
27
09.0
VISION ASSESS PERF
1
X
28
28
10.0
VISION ASSESS FIND
1
X
29
29
11.0
HEARING ASSESS PERF
1
X
30
30
12.0
HEARING ASSESS FIND
1
X
31
31
13.0
DENTAL ASSESS PERF
1
X
32
32
14.0
DENTAL ASSESS FIND
1
X
33
33
15.0
DEVELOP ASSESS PERF
1
X
34
34
16.0
DEVELOP ASSESS FIND
1
X
35
35
17.0
NUT ASSESS PERF
1
X
36
36
18.0
NUT ASSESS FIND
1
X
37
37
19.0
CARD ASSESS PERF
1
X
38
38
20.0
CARD ASSESS FIND
1
X
39
39
21.0
GEN/UR ASSESS PERF
1
X
40
40
22.0
GEN/UR ASSESS FIND
1
X
41
41
23.0
DIABETES ASSESS PERF
1
X
42
42
24.0
DIABETES ASSESS FIND
1
X
43
43
25.0
OTH. SYS. ASSESS PERF
1
X
44
44
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26.0
OTH. SYS. ASSESS FIND
1
X
45
45
27.0
OTH. SYS. ASSESS DESC
20
X
46
65
28.0
HBG/HCT LAB TEST PERF
1
X
66
66
29.0
HBG/HCT LAB TEST FIND
1
X
67
67
30.0
URINALY LAB TST PERF
1
X
68
68
31.0
URINALY LAB TST FIND
1
X
69
69
32.0
SICKLE CELL LAB PERF
1
X
70
70
33.0
SICKLE CELL LAB FIND
1
X
71
71
34.0
BLOOD LEAD LAB PERF
1
X
72
72
35.0
BLOOD LEAD LAB FIND
1
X
73
73
36.0
TINE TEST PERF
1
X
74
74
37.0
TINE TEST FIND
1
X
75
75
38.0
OTHER TEST 1 PERF
1
X
76
76
39.0
OTHER TEST 1 FIND
1
X
77
77
40.0
OTHER TEST 1 DESC
20
X
78
97
41.0
OTHER TEST 2 PERF
1
X
98
98
42.0
OTHER TEST 2 FIND
1
X
99
99
43.0
OTHER TEST 2 DESC
20
X
100
119
44.0
TREATMENT ITEM NO 1
2
X
120
121
45.0
TREATMENT ITEM NO 2
2
X
122
123
46.0
TREATMENT ITEM NO 3
2
X
124
125
47.0
TREATMENT ITEM NO 4
2
X
126
127
48.0
TREATMENT ITEM NO 5
2
X
128
129
49.0
TREATMENT ITEM NO 6
2
X
130
131
50.0
TREATMENT ITEM NO 7
2
X
132
133
51.0
TREATMENT ITEM NO 8
2
X
134
135
52.0
TREATMENT ITEM NO 9
2
X
136
137
53.0
TREATMENT ITEM NO 10
2
X
138
139
54.0
TREATMENT ITEM NO 11
2
X
140
141
55.0
TREATMENT ITEM NO 12
2
X
142
143
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56.0
TREATMENT ITEM NO 13
2
X
144
145
57.0
TREATMENT ITEM NO 14
2
X
146
147
58.0
TREATMENT ITEM NO 15
2
X
148
149
59.0
TREATMENT ITEM NO 16
2
X
150
151
60.0
TREATMENT STAT NO1 IN
2
X
152
153
61.0
TREATMENT STAT NO2 IN
2
X
154
155
62.0
TREATMENT STAT NO3 IN
2
X
156
157
63.0
TREATMENT STAT NO4 IN
2
X
158
159
64.0
TREATMENT STAT NO1 DE
2
X
160
161
65.0
TREATMENT STAT NO2 DE
2
X
162
163
66.0
TREATMENT STAT NO3 DE
2
X
164
165
67.0
TREATMENT STAT NO4 DE
2
X
166
167
68.0
TREATMENT STAT NO1 NR
2
X
168
169
69.0
TREATMENT STAT NO2 NR
2
X
170
171
70.0
TREATMENT STAT NO3 NR
2
X
172
173
71.0
TREATMENT STAT NO4 NR
2
X
174
175
72.0
REFERRAL ITEM NO
12
X
176
177
73.0
REFERRAL ITEM NO
22
X
178
179
74.0
REFERRAL ITEM NO
32
X
180
181
75.0
REFERRAL ITEM NO
42
X
182
183
76.0
REFERRAL ITEM NO
52
X
184
185
77.0
REFERRAL ITEM NO
62
X
186
187
78.0
REFERRAL ITEM NO
72
X
188
189
79.0
REFERRAL ITEM NO
82
X
190
191
80.0
IMMUN POLIO GIVEN
1
X
192
192
81.0
IMMUN POLIO NOT
1
X
193
193
82.0
IMMUN DPT/TD GIVEN
1
X
194
194
83.0
IMMUN DPT/TD NOT
1
X
195
195
84.0
IMMUN MEAS GIVEN
1
X
196
196
85.0
IMMUN MEAS NOT
1
X
197
197
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86.0
IMMUN MUMPS GIVEN
1
X
198
198
87.0
IMMUN MUMPS NOT
1
X
199
199
88.0
IMMUN RUBELLA GIVEN
1
X
200
200
89.0
IMMUN RUBELLA NOT
1
X
201
201
90.0
IMMUN HIB GIVEN
1
X
202
202
91.0
IMMUN HIB NOT
1
X
203
203
92.0
IMMUN OTHER GIVEN
1
X
204
204
93.0
IMMUN OTHER DESC
20
X
205
224
94.0
FILLER-NATIONAL
96
X
225
320
RECORD/FIELD:EA2-01.0
DATA ELEMENT: Record Identifier (RECORD ID "EA2")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: Code used to identify the "EPSDT Screening" record.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be "EA2".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD:EA2-02.0
DATA ELEMENT: Reserved(RESERVED EA2-02.0)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: Unused reserved record space
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
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RECORD/FIELD:EA2-03.0
DATA ELEMENT: Patient Control Number(PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: An identification assigned to the patient by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Patient Control Number".
Must be entered.
FORM LOCATION: CMS-1500 Block 26
REMARKS: The patient control number is used by the EMC system to link all records for a claim. All
records between the record type CA0, up to and including the record type XA0, must have the same
patient control number.
Although up to seventeen characters are allowed, not all payors' systems will record and return seventeen
characters on remittance advices or other documents.
RECORD/FIELD:EA2-04.0
DATA ELEMENT: Type of Screening(SCREENING TYPE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(01)
N/A
SPACE
23
23
DEFINITION: The type of screening being billed.
CODE VALUES:
I = Initial Screening
P = Periodic Screening
F = Follow-up Screening
VALIDATION: Must be entered if required by payor.
Must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD:EA2-05.0 EA2-06.0
DATA ELEMENT:
Medical History Obtained – Performed
(MED HIST OBTAIN PERF)
Medical History Obtained – Findings
(MED HIST OBTAIN FIND)
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FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(01)
LEFT
SPACES
24
24
06.0
X(01)
LEFT
SPACES
25
25
DEFINITION: Verification that the medical history for the patient was obtained, not obtained or not
required and that findings from the medical history were either normal or abnormal.
CODE VALUES:
PERFORMED:
Y = Yes, it was obtained
N = No, it was not obtained
R = It was not required
FINDINGS:
N= Normal findings
A= Abnormal findings
Blank = Not applicable
VALIDATION:PERFORMED:
Must be entered.
FINDINGS:
Must be entered if response other than "not required" was entered in EA2-05.0.
FORM LOCATION: 4A - Item 01
REMARKS: Enter the appropriate response to indicate if the medical history was obtained or not
obtained. Indicate findings in EA2-06.0 as indicated by contents of EA2-05.0.
RECORD/FIELD:EA2-07.0 EA2-08.0
DATA ELEMENT:
Physical Examination Performed?
(PHYSICAL EXAM PERF)
Physical Examination Findings
(PHYSICAL EXAM FIND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(01)
LEFT
SPACES
26
26
08.0
X(01)
LEFT
SPACES
27
27
DEFINITION: Verification that either a physical examination was performed, not performed, or was not
required at this time and that findings from the physical examination were either normal or abnormal.
CODE VALUES:
PERFORMED:
Y = Yes, it was performed
N = No, it was not performed
R = It was not required
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FINDINGS:
N= Normal findings
A= Abnormal findings
Blank = Not applicable
VALIDATION: PERFORMED:
Must be entered.
FINDINGS:
Must be entered if response other than "not required" was entered in EA2-07.0.
FORM LOCATION: 4A - Item 02
REMARKS: Enter the appropriate response to indicate if a physical examination was performed or not
performed. Enter findings in EA2-08.0 as indicated by contents of EA2-07.0.
RECORD/FIELD:EA2-09.0 EA2-10.0
DATA ELEMENT:
Vision Assessment Performed?
(VISION ASSESS PERF)
Vision Assessment Findings
(VISION ASSESS FIND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
X(01)
LEFT
SPACES
28
28
10.0
X(01)
LEFT
SPACES
29
29
DEFINITION: Verification that either a vision assessment was performed, not performed, or was not
required at this time and that findings from the vision assessment were either normal or abnormal.
CODE VALUES:
PERFORMED:
Y = Yes, it was performed
N = No, it was not performed
R = It was not required
FINDINGS:
N= Normal findings
A= Abnormal findings
Blank = Not applicable
VALIDATION: PERFORMED:
Must be entered.
FINDINGS:
Must be entered if response other than "not required" was entered in EA2-09.0.
FORM LOCATION: 4A - Item 03
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REMARKS: Enter the appropriate response to indicate if a vision assessment was performed or not
performed. Enter findings in EA2-10.0 as indicated by contents of EA2-09.0.
RECORD/FIELD:EA2-11.0 EA2-12.0
DATA ELEMENT:
Hearing Assessment Performed?
(HEARING ASSESS PERF)
Hearing Assessment Findings
(HEARING ASSESS FIND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
X(01)
LEFT
SPACES
30
30
12.0
X(01)
LEFT
SPACES
31
31
DEFINITION: Verification that either a hearing assessment was performed, not performed, or was not
required at this time and that findings from the hearing assessment were either normal or abnormal.
CODE VALUES:
PERFORMED:
Y = Yes, it was performed
N = No, it was not performed
R = It was not required
FINDINGS:
N= Normal findings
A= Abnormal findings
Blank = Not applicable
VALIDATION: PERFORMED:
Must be entered.
FINDINGS:
Must be entered if response other than "not required" was entered in EA2-11.0.
FORM LOCATION: 4A - Item 04
REMARKS: Enter the appropriate response to indicate if a hearing assessment was performed or not
performed. Enter findings in EA2-12.0 as indicated by contents of EA2-11.0.
RECORD/FIELD:EA2-13.0 EA2-14.0
DATA ELEMENT:
Dental Assessment Performed?
(DENTAL ASSESS PERF)
Dental Assessment Findings
(DENTAL ASSESS FIND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
X(01)
LEFT
SPACES
32
32
14.0
X(01)
LEFT
SPACES
33
33
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DEFINITION: Verification that either a dental assessment was performed, not performed, or was not
required at this time and that findings from the dental assessment were either normal or abnormal.
CODE VALUES:
PERFORMED:
Y = Yes, it was performed
N = No, it was not performed
R = It was not required
FINDINGS:
N= Normal findings
A= Abnormal findings
Blank = Not applicable
VALIDATION: PERFORMED:
Must be entered.
FINDINGS:
Must be entered if response other than "not required" was entered in EA2-13.0.
FORM LOCATION: 4A - Item 05
REMARKS: Enter the appropriate response to indicate if a dental examination was performed or not
performed. Enter findings in EA2-14.0 as indicated by contents of EA2-13.0.
RECORD/FIELD:EA2-15.0 EA2-16.0
DATA ELEMENT:
Developmental
(Phys. Growth/Emotional Dev./Learning)
Assessment Performed
(DEVELOP ASSESS PERF)
Developmental
(Phys. Growth/Emotional Dev./Learning)
Assessment Findings
(DEVELOP ASSESS FIND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
15.0
X(01)
LEFT
SPACES
34
34
16.0
X(01)
LEFT
SPACES
35
35
DEFINITION: Verification that either a developmental assessment was performed, not performed, or was
not required at this time and that findings from the develop-mental assessment were either normal or
abnormal.
CODE VALUES:
PERFORMED:
Y = Yes, it was performed
N = No, it was not performed
R = It was not required
FINDINGS:
N= Normal findings
A= Abnormal findings
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Blank = Not applicable
VALIDATION: PERFORMED:
Must be entered.
FINDINGS:
Must be entered if response other than "not required" was entered in EA2-15.0.
FORM LOCATION: 4A - Item 06
REMARKS: Enter the appropriate response to indicate if a developmental examination was performed or
not performed. Enter findings in EA2-16.0 as indicated by contents of EA2-15.0.
RECORD/FIELD:EA2-17.0 EA2-18.0
DATA ELEMENT:
Nutritional Assessment Performed
(NUT ASSESS PERF)
Nutritional Assessment Findings
(NUT ASSESS FIND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
17.0
X(01)
LEFT
SPACES
36
36
18.0
X(01)
LEFT
SPACES
37
37
DEFINITION: Verification that either a nutritional assessment was performed, not performed, or was not
required at this time and that findings from the nutritional assessment were either normal or abnormal.
CODE VALUES:
PERFORMED:
Y = Yes, it was performed
N = No, it was not performed
R = It was not required
FINDINGS:
N= Normal findings
A= Abnormal findings
Blank = Not applicable
VALIDATION: PERFORMED:
Must be entered.
FINDINGS:
Must be entered if response other than "not required" was entered in EA2-18.0.
FORM LOCATION: 4A - Item 07
REMARKS: Enter the appropriate response to indicate if a nutritional examination was performed or not
performed. Enter findings in EA2-18.0 as indicated by contents of EA2-17.0.
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159
RECORD/FIELD:EA2-19.0 EA2-20.0
DATA ELEMENT:
Cardiovascular/Circulatory/Pulmonary/Respiratory (CARD ASSESS PERF)
Assessment Performed
Cardiovascular/Circulatory/Pulmonary/Respiratory (CARD ASSESS FIND)
Assessment Findings
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
19.0
X(01)
LEFT
SPACES
38
38
20.0
X(01)
LEFT
SPACES
39
39
DEFINITION: Verification that either a cardiovascular assessment was performed, not performed, or was
not required at this time and that findings from the cardiovascular assessment were either normal or
abnormal.
CODE VALUES:
PERFORMED:
Y = Yes, it was performed
N = No, it was not performed
R = It was not required
FINDINGS:
N= Normal findings
A= Abnormal findings
Blank = Not applicable
VALIDATION:PERFORMED:
Must be entered.
FINDINGS:
Must be entered if response other than "not required" was entered in EA2-19.0.
FORM LOCATION: 4A - Item 08
REMARKS: Enter the appropriate response to indicate if a cardiovascular assessment was performed or
not performed. Enter findings in EA2-20.0 as indicated by contents of EA2-19.0.
RECORD/FIELD:EA2-21.0 EA2-22.0
DATA ELEMENT:
Genital/Urinary Tract Assessment
Performed
(GEN/UR ASSESS PERF)
Genital/Urinary Tract Assessment Findings
(GEN/UR ASSESS FIND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
21.0
X(01)
LEFT
SPACES
40
40
22.0
X(01)
LEFT
SPACES
41
41
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DEFINITION: Verification that either a genital/urinary tract assessment was performed, not performed,
or was not required at this time and that findings from the genital/urinary tract assessment were either
normal or abnormal.
CODE VALUES:
PERFORMED:
Y = Yes, it was performed
N = No, it was not performed
R = It was not required
FINDINGS:
N= Normal findings
A= Abnormal findings
Blank = Not applicable
VALIDATION: PERFORMED:
Must be entered.
FINDINGS:
Must be entered if response other than "not required" was entered in EA2-21.0.
FORM LOCATION: 4A - Item 09
REMARKS: Enter the appropriate response to indicate if a genital/urinary tract assessment was
performed or not performed. Enter findings in EA2-22.0 as indicated by contents of EA2-21.0.
RECORD/FIELD:EA2-23.0 EA2-24.0
DATA ELEMENT:
Diabetes Assessment Performed
(DIABETES ASSESS PERF)
Diabetes Assessment Findings
(DIABETES ASSESS FIND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
23.0
X(01)
LEFT
SPACES
42
42
24.0
X(01)
LEFT
SPACES
43
43
DEFINITION: Verification that either a diabetes assessment was performed, not performed, or was not
required at this time and that findings from the diabetes assessment were either normal or abnormal.
CODE VALUES:
PERFORMED:
Y = Yes, it was performed
N = No, it was not performed
R = It was not required
FINDINGS:
N= Normal findings
A= Abnormal findings
Blank = Not applicable
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VALIDATION:PERFORMED:
Must be entered.
FINDINGS:
Must be entered if response other than "not required" was entered in EA2-23.0.
FORM LOCATION: 4A - Item 10
REMARKS: Enter the appropriate response to indicate if a diabetes examination was performed or not
performed. Enter findings in EA2-24.0 as indicated by contents of EA2-23.0.
RECORD/FIELD:EA2-25.0 EA2-26.0 EA2-27.0
DATA ELEMENT:
Other Systems Assessment Performed
(OTH SYS ASSESS PERF)
Other Systems Assessment Findings
(OTH SYS ASSESS FIND)
Other Systems Assessment Description
(OTH SYS ASSESS DESC)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
25.0
X(01)
LEFT
SPACES
44
44
26.0
X(01)
LEFT
SPACES
45
45
27.0
X(20)
LEFT
SPACES
46
65
DEFINITION: Verification that an assessment not designated in previous fields was performed at this
time and that findings from the assessment were either normal or abnormal. Up to 20 characters of
description may be entered.
CODE VALUES:
PERFORMED:
Y = Yes, it was performed
N = No, it was not performed
FINDINGS:
N= Normal findings
A= Abnormal findings
Blank = Not applicable
VALIDATION:PERFORMED:
Enter if needed.
FINDINGS:
Must be entered if response was entered in EA2-25.0.
DESCRIPTION:
Must be entered if response was entered in EA2-25.0
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162
FORM LOCATION: 4A - Item 11
REMARKS: N/A
RECORD/FIELD:EA2-28.0 EA2-29.0
DATA ELEMENT:
HGB/HCT Lab Test Performed
(HGB/HCT LAB TEST PERF)
HGB/HCT Lab Test Findings
(HGB/HCT LAB TEST FIND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
28.0
X(01)
LEFT
SPACES
66
66
29.0
X(01)
LEFT
SPACES
67
67
DEFINITION: Verification that either an HGB/HCT lab test was performed, not performed, or was not
required at this time and that findings from the lab test were either normal or abnormal.
CODE VALUES:
PERFORMED:
Y = Yes, it was performed
N = No, it was not performed
R = It was not required
FINDINGS:
N= Normal findings
A= Abnormal findings
Blank = Not applicable
VALIDATION:PERFORMED:
Must be entered.
FINDINGS:
Must be entered if response other than "not required" was entered in EA2-28.0.
FORM LOCATION: 4A - Item 12
REMARKS: Enter the appropriate response to indicate if an HGB/HCT lab test was performed or not
performed. Indicate findings in EA2-29.0 as indicated by contents of EA2-28.0.
RECORD/FIELD:EA2-30.0 EA2-31.0
DATA ELEMENT:
Urinalysis Lab Test Performed
(URINALY LAB TEST PERF)
Urinalysis Lab Test Findings
(URINALY LAB TEST FIND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
30.0
X(01)
LEFT
SPACES
68
68
31.0
X(01)
LEFT
SPACES
69
69
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163
DEFINITION: Verification that either a Urinalysis lab test was performed, not performed, or was not
required at this time and that findings from the lab test were either normal or abnormal.
CODE VALUES:
PERFORMED:
Y = Yes, it was performed
N = No, it was not performed
R = It was not required
FINDINGS:
N= Normal findings
A= Abnormal findings
Blank = Not applicable
VALIDATION:PERFORMED:
Must be entered.
FINDINGS:
Must be entered if response other than "not required" was entered in EA2-30.0.
FORM LOCATION: 4A - Item 13
REMARKS: Enter the appropriate response to indicate if a Urinalysis lab test was performed or not
performed. Indicate findings in EA2-31.0 as indicated by contents of EA2-30.0.
RECORD/FIELD:EA2-32.0 EA2-33.0
DATA ELEMENT:
Sickle Cell Lab Test Performed
(SICKLE CELL LAB PERF)
Sickle Cell Lab Test Findings
(SICKLE CELL LAB FIND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
32.0
X(01)
LEFT
SPACES
70
70
33.0
X(01)
LEFT
SPACES
71
71
DEFINITION: Verification that either a Sickle Cell lab test was performed, not performed, or was not
required at this time and that findings from the lab test were either normal or abnormal.
CODE VALUES:
PERFORMED:
Y = Yes, it was performed
N = No, it was not performed
R = It was not required
FINDINGS:
N= Normal findings
A= Abnormal findings
Blank = Not applicable
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164
VALIDATION:PERFORMED:
Must be entered.
FINDINGS:
Must be entered if response other than "not required" was entered in EA2-32.0.
FORM LOCATION: 4A - Item 14
REMARKS: Enter the appropriate response to indicate if an Sickle Cell lab test was performed or not
performed. Indicate findings in EA2-33.0 as indicated by contents of EA2-32.0.
RECORD/FIELD:EA2-34.0 EA2-35.0
DATA ELEMENT:
Blood Lead Lab Test Performed
(BLOOD LEAD LAB PERF)
Blood Lead Lab Test Findings
(BLOOD LEAD LAB FIND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
34.0
X(01)
LEFT
SPACES
72
72
35.0
X(01)
LEFT
SPACES
73
73
DEFINITION: Verification that either a Blood Lead lab test was performed, not performed, or was not
required at this time and that findings from the lab test were either normal or abnormal.
CODE VALUES:
PERFORMED:
Y = Yes, it was performed
N = No, it was not performed
R = It was not required
FINDINGS:
N= Normal findings
A= Abnormal findings
Blank = Not applicable
VALIDATION:PERFORMED:
Must be entered.
FINDINGS:
Must be entered if response other than "not required" was entered in EA2-34.0.
FORM LOCATION: 4A - Item 15
REMARKS: Enter the appropriate response to indicate if a Blood Lead lab test was performed or not
performed. Indicate findings in EA2-35.0 as indicated by contents of EA2-34.0.
RECORD/FIELD:EA2-36.0 EA2-37.0
DATA ELEMENT:
Tine Test Performed
NSF (National Standard Format) User Manual
(TINE TEST PERF)
165
Tine Test Findings
(TINE TEST FIND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
36.0
X(01)
LEFT
SPACES
74
74
37.0
X(01)
LEFT
SPACES
75
75
DEFINITION: Verification that either a Tine lab test was performed, not performed, or was not required
at this time and that findings from the lab test were either normal or abnormal.
CODE VALUES:
PERFORMED:
Y = Yes, it was performed
N = No, it was not performed
R = It was not required
FINDINGS:
N= Normal findings
A= Abnormal findings
Blank = Not applicable
VALIDATION:PERFORMED:
Must be entered.
FINDINGS:
Must be entered if response other than "not required" was entered in EA2-36.0.
FORM LOCATION: 4A - Item 16
REMARKS: Enter the appropriate response to indicate if a Tine lab test was performed or not performed
Indicate findings in EA2-37.0 as indicated by contents of EA2-36.0.
RECORD/FIELD:EA2-38.0 EA2-39.0 EA2-40.0
DATA ELEMENT:
Other Test 1 Performed
(OTHER TEST 1 PERF)
Other Test 1 Findings
(OTHER TEST 1 FIND)
Other Test 1 Description
(OTHER TEST 1 DESC)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
38.0
X(01)
LEFT
SPACES
76
76
39.0
X(01)
LEFT
SPACES
77
77
40.0
X(20)
LEFT
SPACES
78
97
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DEFINITION: Verification that a lab test not designated in previous fields was performed at this time and
that findings from the lab test were either normal or abnormal. Up to 20 characters of description may be
entered.
CODE VALUES:
PERFORMED:
Y = Yes, it was performed
N = No, it was not performed
FINDINGS:
N= Normal findings
A= Abnormal findings
Blank = Not applicable
VALIDATION:PERFORMED:
Enter if needed.
FINDINGS:
Must be entered if response was entered in EA2-38.0.
DESCRIPTION:
Must be entered if response was entered in EA2-38.0.
FORM LOCATION: 4A - Item 17
RECORD/FIELD:EA2-41.0 EA2-42.0 EA2-43
DATA ELEMENT:
Other Test 2 Performed
(OTHER TEST 2 PERF)
Other Test 2 Findings
(OTHER TEST 2 FIND)
Other Test 2 Description
(OTHER TEST 2 DESC)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
41.0
X(01)
LEFT
SPACES
98
98
42.0
X(01)
LEFT
SPACES
99
99
43.0
X(20)
LEFT
SPACES
100
119
DEFINITION: Verification that a lab test not designated in previous fields was performed at this time and
that findings from the lab test were either normal or abnormal. Up to 20 characters of description may be
entered.
CODE VALUES:
PERFORMED:
Y = Yes, it was performed
N = No, it was not performed
FINDINGS:
N= Normal findings
A= Abnormal findings
Blank = Not applicable
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167
VALIDATION:PERFORMED:
Enter if needed.
FINDINGS:
Must be entered if response was entered in
EA2-41.0.
DESCRIPTION:
Must be entered if response was entered in EA2-41.0.
FORM LOCATION: 4A - Item 18
REMARKS: N/A
RECORD/FIELD:EA2-44.0 THRU EA2-59
DATA ELEMENT: Treatment Item Number 1 Thru 16 (TREATMENT ITEM NO 1 THRU 16)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
44.0
X(02)
LEFT
SPACES
120
121
45.0
X(02)
LEFT
SPACES
122
123
46.0
X(02)
LEFT
SPACES
124
125
47.0
X(02)
LEFT
SPACES
126
127
48.0
X(02)
LEFT
SPACES
128
129
49.0
X(02)
LEFT
SPACES
130
131
50.0
X(02)
LEFT
SPACES
132
133
51.0
X(02)
LEFT
SPACES
134
135
52.0
X(02)
LEFT
SPACES
136
137
53.0
X(02)
LEFT
SPACES
138
139
54.0
X(02)
LEFT
SPACES
140
141
55.0
X(02)
LEFT
SPACES
142
143
56.0
X(02)
LEFT
SPACES
144
145
57.0
X(02)
LEFT
SPACES
146
147
58.0
X(02)
LEFT
SPACES
148
149
59.0
X(02)
LEFT
SPACES
150
151
DEFINITION: Identification of screening items which may require treatment.
NSF (National Standard Format) User Manual
168
CODE VALUES:
01 - MEDICAL HISTORY OBTAINED
02 - PHYSICAL EXAMINATION PERFORMED
03 - VISION
04 - HEARING
05 - DENTAL
06 - DEVELOPMENTAL
07 - NUTRITIONAL
08 - CARDIOVASCULAR/ CIRCULATORY/ PULMONARY / RESP.
09 - GENITAL/URINARY TRACT
10 - DIABETES
11 - OTHER SYSTEMS ASSESSMENT
12 - HBC/HCT LAB TEST
13 - URINALYSIS LAB TEST
14 - SICKLE CELL LAB TEST
15 - BLOOD LEAD LAB TEST
16 - TINE TEST
17 - OTHER 1 SPECIFY
18 - OTHER 2 SPECIFY
VALIDATION: N/A
FORM LOCATION: 5A
REMARKS: Enter up to sixteen numbers from EA2-05.0 thru EA2-41.0 (screening) that resulted in
abnormal findings requiring or potentially requiring treatment, or reflecting treatment initiated on the
same date as the screening.
RECORD/FIELD:EA2-60.0 THRU EA2-63.0
DATA ELEMENT: Treatment Status Number 1 thru 4IN (TREATMENT STAT NO1 THRU 4 IN)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
60.0
X(02)
LEFT
SPACES
153
153
61.0
X(02)
LEFT
SPACES
154
155
62.0
X(02)
LEFT
SPACES
156
157
63.0
X(02)
LEFT
SPACES
158
159
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169
DEFINITION: Identification of status of screening items which were initiated with this screening.
CODE VALUES: 01 - 18 (Per list on page EA2.27)
VALIDATION: N/A
FORM LOCATION: 6
REMARKS: Enter up to four item numbers from the screening items identified in the treatment items
fields (EA2-44.0 thru EA2-59.0 which were initiated with this screening.
RECORD/FIELD:EA2-64.0 THRU EA2-67.0
DATA ELEMENT: Treatment Status Number 1 thru 4DE (TREATMENT STAT NO1 THRU 4 DE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
64.0
X(02)
LEFT
SPACES
160
161
65.0
X(02)
LEFT
SPACES
162
163
66.0
X(02)
LEFT
SPACES
164
165
67.0
X(02)
LEFT
SPACES
166
167
DEFINITION: Identification of status of screening items which were declined with this screening.
CODE VALUES: 01 - 18 (Per list on page EA2.27)
VALIDATION: N/A
FORM LOCATION: 6
REMARKS: Enter up to four item numbers from the screening items identified in the treatment items
fields (EA2-44.0 thru EA2-59.0 which were declined with this screening.
RECORD/FIELD:EA2-68.0 THRU EA2-71.0
DATA ELEMENT: Treatment Status Number 1 thru 4NR (TREATMENT STAT NO1 THRU 4 NR)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
68.0
X(02)
LEFT
SPACES
168
169
69.0
X(02)
LEFT
SPACES
170
171
70.0
X(02)
LEFT
SPACES
172
173
71.0
X(02)
LEFT
SPACES
174
175
DEFINITION: Identification of status of screening items which were not required with this screening.
CODE VALUES: 01 - 18 (Per list on page EA2.27)
VALIDATION: N/A
FORM LOCATION: 6
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170
REMARKS: Enter up to four item numbers from the screening items identified in the treatment items
fields (EA2-44.0 thru EA2-59.0 which were not required with this screening.
RECORD/FIELD:EA2-72.0 THRU EA2-79.0
DATA ELEMENT: REFERRAL ITEM NO 1THRU 8
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
72.0
X(02)
LEFT
SPACES
176
177
73.0
X(02)
LEFT
SPACES
178
179
74.0
X(02)
LEFT
SPACES
180
181
75.0
X(02)
LEFT
SPACES
182
183
76.0
X(02)
LEFT
SPACES
184
185
77.0
X(02)
LEFT
SPACES
186
187
78.0
X(02)
LEFT
SPACES
188
189
79.0
X(02)
LEFT
SPACES
190
191
DEFINITION: Identification of screening items which are being referred to another doctor
CODE VALUES: 01 - 18 (Per list on page EA2.27)
VALIDATION: N/A
FORM LOCATION: 5B
REMARKS: Enter the treatment line item numbers (1-18) which are being referred to another provider
for diagnosis and/or treatment.
RECORD/FIELD:EA2-80.0 EA2-81.0
DATA ELEMENT:
Immunization Polio Given Today
(IMMUN POLIO GIVEN)
Immunization Polio Not Given Today
(IMMUN POLIO NOT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
80.0
X(01)
LEFT
SPACES
192
192
81.0
X(01)
LEFT
SPACES
193
193
DEFINITION: Verification that the patient's immunization treatment for this condition has been given
today, not given today, and why.
CODE VALUES:
GIVEN:
C= Current - now up to date
N= Not up to date or more doses to be given
NOT GIVEN:
C= Already up to date, immunization is current
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171
R= Refused by participant or contraindications present
O= Omitted for other reasons
VALIDATION: Either EA2-80.0 or EA2-81.0 must be entered - both cannot be left blank.
FORM LOCATION: 4B - Item 01
REMARKS: Enter the appropriate response to indicate if this immunization has been given at the time of
this screening.
RECORD/FIELD:EA2-82.0 EA2-83.0
DATA ELEMENT:
Immunization DPT/TD Given Today
(IMMUN DPT/TD GIVEN)
Immunization DPT/TD Not Given Today
(IMMUN DPT/TD NOT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
82.0
X(01)
LEFT
SPACES
194
194
83.0
X(01)
LEFT
SPACES
195
195
DEFINITION: Verification that the patient's immunization treatment for this condition has been given
today, not given today, and why.
CODE VALUES:
GIVEN:
C= Current - now up to date
N= Not up to date or more doses to be given
NOT GIVEN:
C= Already up to date, immunization is current
R= Refused by participant or contraindications present
O= Omitted for other reasons
VALIDATION: Either EA2-82.0 or EA2-83.0 must be entered - both cannot be left blank.
FORM LOCATION: 4B - Item 02
REMARKS: Enter the appropriate response to indicate if this immunization has been given at the time of
this screening.
RECORD/FIELD:EA2-84.0 EA2-85.
DATA ELEMENT:
Immunization Measles (Rubeola) Given
Today
Immunization Measles (Rubeola) Not Given
Today
FIELD
COBOL PICTURE
NSF (National Standard Format) User Manual
JUSTIFY
(IMMUN MEASLES GIVEN)
(IMMUN MEASLES NOT)
INITIAL
FROM
THRU
172
84.0
X(01)
LEFT
SPACES
196
196
85.0
X(01)
LEFT
SPACES
197
197
DEFINITION: Verification that the patient's immunization treatment for this condition has been given
today, not given today, and why.
CODE VALUES:
GIVEN:
C= Current - now up to date
N= Not up to date or more doses to be given
NOT GIVEN:
C= Already up to date, immunization is current
R= Refused by participant or contraindications present
O= Omitted for other reasons
VALIDATION: Either EA2-84.0 or EA2-85.0 must be entered - both cannot be left blank.
FORM LOCATION: 4B - Item 03
REMARKS: Enter the appropriate response to indicate if this immunization has been given at the time of
this screening.
RECORD/FIELD:EA2-86.0 EA2-87.0
DATA ELEMENT:
Immunization Mumps Given Today
(IMMUN MUMPS GIVEN)
Immunization Mumps Not Given Today
(IMMUN MUMPS NOT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
86.0
X(01)
LEFT
SPACES
198
198
87.0
X(01)
LEFT
SPACES
199
199
DEFINITION: Verification that the patient's immunization treatment for this condition has been given
today, not given today, and why.
CODE VALUES:
GIVEN:
C= Current - now up to date
N= Not up to date or more doses to be given
NOT GIVEN:
C= Already up to date, immunization is current
R= Refused by participant or contraindications present
O= Omitted for other reasons
VALIDATION: Either EA2-86.0 or EA2-87.0 must be entered - both cannot be left blank.
FORM LOCATION: 4B - Item 04
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173
REMARKS: Enter the appropriate response to indicate if this immunization has been given at the time of
this screening.
RECORD/FIELD:EA2-88.0 EA2-89.0
DATA ELEMENT:
Immunization Rubella Given Today
(IMMUN RUBELLA GIVEN)
Immunization Rubella Not Given Today
(IMMUN RUBELLA NOT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
88.0
X(01)
LEFT
SPACES
200
200
89.0
X(01)
LEFT
SPACES
201
201
DEFINITION: Verification that the patient's immunization treatment for this condition has been given
today, not given today, and why.
CODE VALUES:
GIVEN:
C= Current - now up to date
N= Not up to date or more doses to be given
NOT GIVEN:
C= Already up to date, immunization is current
R= Refused by participant or contraindications present
O= Omitted for other reasons
VALIDATION: Either EA2-88.0 or EA2-89.0 must be entered - both cannot be left blank.
FORM LOCATION: 4B - Item 05
REMARKS: Enter the appropriate response to indicate if this immunization has been given at the time of
this screening.
RECORD/FIELD:EA2-90.0 EA2-91.0
DATA ELEMENT:
Immunization HIB Given Today
(IMMUN HIB GIVEN)
Immunization HIB Not Given Today
(IMMUN HIB NOT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
90.0
X(01)
LEFT
SPACES
202
202
91.0
X(01)
LEFT
SPACES
203
203
DEFINITION: Verification that the patient's immunization treatment for this condition has been given
today, not given today, and why.
CODE VALUES:
GIVEN:
C= Current - now up to date
N= Not up to date or more doses to be given
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174
NOT GIVEN:
C= Already up to date, immunization is current
R= Refused by participant or contraindications present
O= Omitted for other reasons
VALIDATION: Either EA2-90.0 or EA2-91.0 must be entered - both cannot be left blank.
FORM LOCATION: 4B - Item 06
REMARKS: Enter the appropriate response to indicate if this immunization has been given at the time of
this screening.
RECORD/FIELD:EA2-92.0 EA2-93.0
DATA ELEMENT:
Immunization Other Given Today
(IMMUN OTHER GIVEN)
Immunization Other Description
(IMMUN OTHER DESC.)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
92.0
X(01)
LEFT
SPACES
204
204
93.0
X(20)
LEFT
SPACES
205
224
DEFINITION: Verification that the patient's immunization treatment for a condition other than one listed
in the previous immunization fields has been given today and if it is up to date or not up to date.
CODE VALUES:
GIVEN:
C= Current - now up to date
N= Not up to date or more doses to be given
VALIDATION: Optional, if needed.
FORM LOCATION: 4B - Item 07
REMARKS: Enter the appropriate response to indicate if this immunization has been given at the time of
this screening. If a response is entered in EA2-92.0, EA2-93.0 must be entered.
RECORD/FIELD:EA2-94.0
DATA ELEMENT: Filler - National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
94.0
X(96)
LEFT
SPACES
225
320
DEFINITION: Unused reserved filler for National use.
CODE VALUES: N/A
VALIDATION: N/A
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FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: SERVICE LINE DETAIL RECORD TYPE FA0 "ROOT SEGMENT"
Required for MO HealthNet processing
Must follow EA0, EA1 or EA2
Must be followed by FB0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "FA0"
C-24
FA0
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
04
LINE ITEM CONTROL NO
C-65
NO
05
SVC FROM DATE
C-16
YES
06
SVC TO DATE
C-16
YES
07
PLACE OF SVC
C-14
YES
08
TYPE OF SVC CODE
C-11
YES
09
HCPCS PROCEDURE CODE
C-30
YES
10
HCPCS MODIFIER 1
C-35
NO
11
HCPCS MODIFIER 2
C-35
NO
12
HCPCS MODIFIER 3
13
LINE CHARGES
C-10
YES
14
DIAG CODE POINTER1
C-66
YES
15
DIAG CODE POINTER2
Not Used
16
DIAG CODE POINTER3
Not Used
17
DIAG CODE POINTER4
Not Used
18
UNITS OF SVC
19
ANESTHESIA/OXYGEN MIN
Not Used
20
EMERGENCY IND
Not Used
21
COB IND
Not Used
22
HPSA IND
Not Used
NSF (National Standard Format) User Manual
Not Used
Not Used
C-28
YES
176
23
RENDERING PROV ID
24
REFERRING PROV ID
Not Used
25
REFERRING PROV STATE
Not Used
26
PUR SVC IND
Not Used
27
DISALLOWED COST CONT
Not Used
28
DISALLOWED OTHER
Not Used
29
REVIEW BY CODE IND
Not Used
30
MULTI PROCEDURE IND
Not Used
31
MAMMOGRAPHY CERT NO
Not Used
32
CLASS FINDINGS
Not Used
33
PODIATRY SVC COND
Not Used
34
CLIA ID NO
Not Used
35
PRIMARY PAID AMOUNT
Not Used
36
HCPCS MODIFIER 4
Not Used
37
PROVIDER SPECIALTY
Not Used
38
PODIATRY THERAPY IND
Not Used
39
PODIATRY THERAPY TYPE
Not Used
40
HOSPICE EMPLOYED PROV IND
Not Used
41
HGB/HCT DATE
Not Used
42
HGB RESULT
Not Used
43
HCT RESULT
Not Used
44
PATIENT WEIGHT
Not Used
45
EPO DOSAGE
Not Used
46
SERUM CREATINE DATE
Not Used
47
CREATINE RESULT
Not Used
48
OBLIGATED ACCEPT AMT
Not Used
49
DRUG DISCOUNT AMT
Not Used
50
TYPE OF UNITS IND
Not Used
51
APPROVED AMT
Not Used
52
PAID AMT
Not Used
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C-19
NO
177
53
BENE LIABILITY AMT
Not Used
54
BALANCE BILL LIMIT CHG
Not Used
55
LIMIT CHARGE PRCNT
Not Used
56
PERFORM PROV PHONE
Not Used
57
PERFORM PROV TAX TYPE
Not Used
58
PERFORM PROV TAX ID
Not Used
59
PERFORM PROV ASSIGN IND
Not Used
60
PRETRANSPLANT INDICATOR
Not Used
61
ICD-10-PCS
Not Used
62
UNIVERSAL PRODUCT CODE
Not Used
63
DIAG CODE POINTER5
Not Used
64
DIAG CODE POINTER6
Not Used
65
DIAG CODE POINTER7
Not Used
66
DIAG CODE POINTER8
Not Used
67
FILLER-NATIONAL
YES
RECORD TYPE: FA0
LEVEL: CLAIM - ROOT SEGMENT
PURPOSE: To provide information related to the medical/dental services rendered to the patient by the provider.
REQUIREMENTS: This record is required on all claims.
ORDER:
Preceding Record Type
Following Record Type
EA0, EA1, EA2, FA0,
FB0, FB1, FB2, FB3, FD0, FE0
FB0, FB1, FB2, FB3,
FD0 CERT Records, HA0 or XA0
FE0, CERT Records, or HA0
NOTES: 1. There must be at least 1 record type FA0 entered for a claim.
2. There may be up to 99 FXX records entered for a claim. (All "F" records).
FIELD NO.
01.0
FIELD NAME
RECORD ID "FA0"
NSF (National Standard Format) User Manual
FIELD
LENGTH
3
TYPE
X
POSITIONS
FROM
THRU
01
03
178
02.0
SEQUENCE NO
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
LINE ITEM CONTROL NO
17
X
23
39
05.0
SVC FROM DATE
8
X
40
47
06.0
SVC TO DATE
8
X
48
55
07.0
PLACE OF SVC
2
X
56
57
08.0
TYPE OF SVC CODE
2
X
58
59
09.0
HCPCS PROCEDURE CODE
5
X
60
64
10.0
HCPCS MODIFIER 1
2
X
65
66
11.0
HCPCS MODIFIER 2
2
X
67
68
12.0
HCPCS MODIFIER 3
2
X
69
70
13.0
LINE CHARGES
7
N
71
77
14.0
DIAG CODE POINTER1
1
X
78
78
15.0
DIAG CODE POINTER2
1
X
79
79
16.0
DIAG CODE POINTER3
1
X
80
80
17.0
DIAG CODE POINTER4
1
X
81
81
18.0
UNITS OF SVC
4
N
82
85
19.0
ANESTHESIA/OXYGEN MIN
4
N
86
89
20.0
EMERGENCY IND
1
X
90
90
21.0
COB IND
1
X
91
91
22.0
HPSA IND
1
X
92
92
23.0
RENDERING PROV NPI
15
X
93
107
24.0
REFERRING PROV NPI
15
X
108
122
25.0
REFERRING PROV STATE
2
X
123
124
26.0
PUR SVC IND
1
X
125
125
27.0
DISALLOWED COST CONT
7
N
126
132
28.0
DISALLOWED OTHER
7
N
133
139
29.0
REVIEW BY CODE IND
1
X
140
140
30.0
MULTI PROCEDURE IND
1
X
141
141
31.0
MAMMOGRAPHY CERT NO
10
X
142
151
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179
32.0
CLASS FINDINGS
9
X
152
160
33.0
PODIATRY SVC COND
3
X
161
163
34.0
CLIA ID NO
15
X
164
178
35.0
PRIMARY PAID AMOUNT
7
N
179
185
36.0
HCPCS MODIFIER 4
2
X
186
187
37.0
PROVIDER SPECIALTY
3
X
188
190
38.0
PODIATRY THERAPY IND
1
X
191
191
39.0
PODIATRY THERAPY TYPE
1
X
192
192
40.0
HOSPICE EMPLOYED PROV IND
1
X
192
192
41.0
HGB/HCT DATE
8
X
194
201
42.0
HGB RESULT
3
N
202
204
43.0
HCT RESULT
2
N
205
206
44.0
PATIENT WEIGHT
3
N
207
209
45.0
EPO DOSAGE
3
N
210
212
46.0
SERUM CREATINE DATE
8
X
213
220
47.0
CREATINE RESULT
3
N
221
223
48.0
OBLIGATED ACCEPT AMT
7
N
224
230
49.0
DRUG DISCOUNT AMT
7
N
231
237
50.0
TYPE OF UNITS IND
1
X
238
238
51.0
APPROVED AMT
7
N
239
245
52.0
PAID AMT
7
N
246
252
53.0
BENE LIABILITY AMT
7
N
253
259
54.0
BALANCE BILL LIMIT CHG
7
N
260
266
55.0
LIMIT CHARGE PRCNT
7
N
267
273
56.0
PERFORM PROV PHONE
10
X
274
283
57.0
PERFORM PROV TAX TYPE
1
X
284
284
58.0
PERFORM PROV TAX ID
9
X
285
293
59.0
PERFORM PROV ASSIGN IND
1
X
294
294
60.0
PRETRANSPLANT INDICATOR
1
X
295
295
61.0
ICD-10-PCS
7
X
296
302
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62.0
UNIVERSAL PRODUCT CODE
14
X
303
316
63.0
DIAG CODE POINTER5
1
X
317
317
64.0
DIAG CODE POINTER6
1
X
318
318
65.0
DIAG CODE POINTER7
1
X
319
319
66.0
DIAG CODE POINTER8
1
X
320
320
RECORD/FIELD: FA0-01.0
DATA ELEMENT: Record Identifier (RECORD ID "FA0")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: This is the record identifier for the Service
Line Detail Record - FA0.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be 'FA0'.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FA0-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: This is the record sequence number of the Service Line Detail Record.
CODE VALUES: 01 through 99
VALIDATION: Must be entered.
Must be a valid code from the above list.
All Fxx records must be grouped as FA0, FB0, FB1, FB2 followed by any applicable CERT record(s)
and/or Narrative record(s) (or for Dental claims, FA0, FD0) by Sequence Number.
FORM LOCATION: N/A
REMARKS: Consult the Matrix/User Guide document supplied by the payor/receiver to determine the
maximum number (sequences) of "FA0" records allowed.
NSF (National Standard Format) User Manual
181
RECORD/FIELD: FA0-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: A unique number assigned by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: Must be entered.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: CMS-1500 Block 26
REMARKS: N/A
RECORD/FIELD: FA0-04.0
DATA ELEMENT: Line Item Control Number (LINE ITEM CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(17)
LEFT
SPACES
23
39
DEFINITION: An identifier assigned by the submitter/provider to this line item.
CODE VALUES: N/A
VALIDATION: May be entered if payor allowed.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: N/A
REMARKS: If accepted by Payor, it should be returned on the EMC electronic remittance to facilitate the
provider's posting of line item adjudication information.
RECORD/FIELD: FA0-05.0 FA0-06.0
DATA ELEMENT:
Service From Date
(SVC FROM DATE)
Service To Date
(SVC TO DATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(08)
LEFT
SPACES
40
47
06.0
X(08)
LEFT
SPACES
48
55
DEFINITION: The date the service was initiated and the date the service extends through.
CODE VALUES: N/A
NSF (National Standard Format) User Manual
182
VALIDATION: Must be entered.
See GENERAL INSTRUCTIONS for "Date" entry.
Service To Date must be equal or greater than the Service From Date.
FORM LOCATION: CMS-1500 Block 24a
REMARKS: N/A
RECORD/FIELD: FA0-07.0
DATA ELEMENT: Place of Service(PLACE OF SVC)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(02)
LEFT
SPACES
56
57
DEFINITION: The code that identifies where the service was performed.
CODE VALUES:
00-09 Unassigned
11 Office
12 Home
10, 13-19 Unassigned
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
20, 27-29 Unassigned
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
30, 35-39 Unassigned
41 Ambulance - Land
42 Ambulance - Air or Water
40, 43-49 Unassigned
51 Inpatient Psychiatric Facility
NSF (National Standard Format) User Manual
183
52 Psychiatric Facility Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
50 Federally Qualified Health Center
57-59 Unassigned
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End Stage Renal Disease Treatment Facility
60, 63, 64 Unassigned
66-69 Unassigned
71 State or Local Public Health Clinic
72 Rural Health Clinic
70, 73-79 Unassigned
81 Independent Laboratory
80, 82-89 Unassigned
99 Other Unlisted Facility
90-98 Unassigned
VALIDATION: Must be entered
Must be a valid code from the above list.
FORM LOCATION: CMS-1500 Block 24b
REMARKS: N/A
RECORD/FIELD: FA0-08.0
DATA ELEMENT: Type of Service Code (TYPE OF SVC CODE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
08.0
X(02)
LEFT
SPACES
58
59
DEFINITION: A code that classifies the service.
NSF (National Standard Format) User Manual
184
See the C-11 table for valid field values.
VALIDATION: Must be entered if required by Payor.
If entered, must be valid code form above list.
FORM LOCATION: CMS-1500 Block 24c
REMARKS: N/A
RECORD/FIELD: FA0-09.0
DATA ELEMENT: HCPCS Procedure Code
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
X(05)
LEFT
SPACES
60
64
DEFINITION: This is the HCPCS/CPT-4 code that describes the service.
CODE VALUES: HCPCS/CPT-4 code set.
VALIDATION: Must be entered if required by payor.
Must be entered if National Drug Code (FB0-15.0) is blank.
If entered, must be a valid HCPCS/CPT-4 procedure code.
FORM LOCATION: CMS-1500 Block 24d
REMARKS: N/A
RECORD/FIELD: FA0-10.0 FA0-11.0 FA0-12.0
DATA ELEMENT:
HCPCS Modifier 1
HCPCS Modifier 2
HCPCS Modifier 3
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
X(02)
LEFT
SPACES
65
66
11.0
X(02)
LEFT
SPACES
67
68
12.0
X(02)
LEFT
SPACES
69
70
DEFINITION: These codes identify special circumstances related to the performance of the service.
CODE VALUES: See current HCPCS Modifier codes.
VALIDATION: Must be entered if required for proper adjudication of the service.
FORM LOCATION: CMS-1500 Block 24D
REMARKS: N/A
NSF (National Standard Format) User Manual
185
RECORD/FIELD: FA0-13.0
DATA ELEMENT: Line Charges
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
9(05)V99
RIGHT
ZEROS
71
77
DEFINITION: The charges related to this service.
CODE VALUES: N/A
VALIDATION: Must be positive unsigned numeric value.
FORM LOCATION: CMS-1500 Block 24f
REMARKS: N/A
RECORD/FIELD: FA0-14.0 FA0-15.0 FA0-16.0 FA0-17.0
DATA ELEMENT:
Diagnosis Code Pointer 1
(DIAG CODE POINTER1)
Diagnosis Code Pointer 2
(DIAG CODE POINTER2)
Diagnosis Code Pointer 3
(DIAG CODE POINTER3)
Diagnosis Code Pointer 4
(DIAG CODE POINTER4)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
14.0
X(01)
LEFT
SPACE
78
78
15.0
X(01)
LEFT
SPACE
79
79
16.0
X(01)
LEFT
SPACE
80
80
17.0
X(01)
LEFT
SPACE
81
81
DEFINITION: A pointer to the claim diagnosis code in the order of importance to this service.
CODE VALUES:
1 - indicates the 1st header diagnosis
2 - indicates the 2nd header diagnosis
3 - indicates the 3rd header diagnosis
4 - indicates the 4th header diagnosis
VALIDATION: Pointer 1 must be a valid code from the list above. Values used must point to non-blank
header diagnosis field.
FORM LOCATION: CMS-1500 Block 24e
REMARKS: Example:
Header diagnosis entered; 11111 22222 33333 44444
NSF (National Standard Format) User Manual
186
Diagnosis pointer 1 -- 3
Diagnosis pointer 2 -- 4
Diagnosis pointer 3 -- 1
In this example the diagnosis pointers indicate that header diagnosis 3 is the primary code with header
diagnosis 4 being the secondary code and header diagnosis 1 as the tertiary code. The 4th diagnosis
pointer was not entered because it was not related to this service.
RECORD/FIELD: FA0-18.0
DATA ELEMENT: Units of Service(UNITS OF SVC)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
9(03)V9
RIGHT
ZEROS
82
85
DEFINITION: The number of services rendered in days or units.
CODE VALUES: N/A
VALIDATION: Must be Positive unsigned numeric value.
FORM LOCATION: CMS-1500 Block 24g
REMARKS: In order to capture fractional services, use the fourth position with an assumed decimal
position.
RECORD/FIELD: FA0-19.0
DATA ELEMENT: Anesthesia/Oxygen Minutes (ANESTHESIA/OXYGEN MIN)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
19.0
9(04)
RIGHT
ZEROS
86
89
DEFINITION: The actual number of minutes patient was anesthetized or number of minutes of oxygen.
CODE VALUES: N/A
VALIDATION: When required by Payor, must be positive unsigned numeric value.
FORM LOCATION: CMS-1500 Block 24G
REMARKS: N/A
RECORD/FIELD: FA0-20.0
DATA ELEMENT: Emergency Indicator (EMERGENCY IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
20.0
X(01)
LEFT
SPACE
90
90
NSF (National Standard Format) User Manual
187
DEFINITION: An indicator of whether or not emergency care was rendered in response to the sudden and
unexpected onset of a medical condition; a severe injury, or an acute exacerbation of a chronic condition
which was threatening to life, limb or sight, and which required immediate medical or surgical treatment.
CODE VALUES:
Y - Yes, emergency related (sudden onset of a of a medical condition)
N - No, emergency not related
VALIDATION: Must be entered if required by Payor.
If entered, must be valid code from the above list.
FORM LOCATION: CMS-1500 Block 24i
REMARKS: N/A
RECORD/FIELD: FA0-21.0
DATA ELEMENT: COB Indicator (COB IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
21.0
X(01)
LEFT
SPACE
91
91
DEFINITION: Codes indicating the liability of the primary carrier.
CODE VALUES:
A thru Z = RESERVED FOR NATIONAL ASSIGNMENT
0 thru 9 = RESERVED FOR LOCAL ASSIGNMENT
VALIDATION: Must be entered if required by Payor.
If entered, must be valid code from the above list.
FORM LOCATION: CMS-1500 Block 24j
REMARKS: N/A
RECORD/FIELD: FA0-22.0
DATA ELEMENT: HPSA Indicator (HPSA IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
22.0
X(01)
LEFT
SPACE
92
92
DEFINITION: A code that identifies a Health Professional Shortage Area (HPSA).
CODE VALUES: 1, 2, 3, 4
VALIDATION: Must be entered if required by Payor. If entered, must be valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
NSF (National Standard Format) User Manual
188
RECORD/FIELD: FA0-23.0
DATA ELEMENT: Rendering Provider National Provider Identifier (RENDERING PROV NPI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
23.0
X(15)
LEFT
SPACES
93
107
DEFINITION: The National Provider Identifier assigned to the rendering provider.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
This field must contain the National Provider Identifier (NPI) once the NPI is implemented.
See GENERAL INSTRUCTIONS for "Identification Numbers" entry.
FORM LOCATION: CMS-1500 Block 24K
REMARKS: N/A
RECORD/FIELD: FA0-24.0
DATA ELEMENT: Referring Provider National Provider Identifier (REFERRING PROV NPI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
24.0
X(15)
LEFT
SPACES
108
122
DEFINITION: The National Provider Identifier assigned To the referring provider (who referred the
services).
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
This field must contain the National Provider Identifier (NPI) once the NPI is implemented.
See GENERAL INSTRUCTIONS for "Identification Numbers" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FA0-25.0
DATA ELEMENT: Referring Provider State (REFERRING PROV STATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
25.0
X(02)
LEFT
SPACES
123
124
DEFINITION: The referring provider's state code.
CODE VALUES: N/A
NSF (National Standard Format) User Manual
189
VALIDATION: Must be entered if required by Payor.
See GENERAL INSTRUCTIONS for "Address" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FA0-26.0
DATA ELEMENT: Purchase Service Indicator (PUR SVC IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
26.0
X(01)
LEFT
SPACE
125
125
DEFINITION: The Purchase Service Indicator.
CODE VALUES:
Y = Service was purchased from another entity.
N = Service was not purchased.
VALIDATION: Must be entered if required by Payor.
If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FA0-27.0
DATA ELEMENT: Disallowed Cost Containment (DISALLOWED COST CONT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
27.0
9(05)V99
RIGHT
ZEROS
126
132
DEFINITION: The portion of line charges disallowed by the payor due to the failure of either the
provider or insured to meet the cost containment provisions of the insurance contract, managed care
contract or PPO contract under which payment has been requested for this claim.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
When entered, must be positive unsigned numeric value.
Must not be greater than Line Charges (FA0-13.0).
FORM LOCATION: EOB/REMITTANCE
REMARKS: N/A
RECORD/FIELD: FA0-28.0
NSF (National Standard Format) User Manual
190
DATA ELEMENT: Disallowed Other
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
28.0
9(05)V99
RIGHT
ZEROS
133
139
DEFINITION: The portion of line charges disallowed by the payor for reasons OTHER than the failure of
the provider or insured to meet the cost containment provisions of the insurance contract, managed care
contract or PPO contract under which payment has been requested for this claim.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
When entered, must be positive unsigned numeric value.
Must not be greater than Line Charges (FA0-13.0).
FORM LOCATION: EOB/REMITTANCE
REMARKS: N/A
RECORD/FIELD: FA0-29.0
DATA ELEMENT: Review By Code Indicator (REVIEW BY CODE IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
29.0
X(01)
LEFT
SPACE
140
140
DEFINITION: Indicator describing extenuating circumstances or justifications which might assist in any
review of the medical necessity for this service.
CODE VALUES:
A = Case turned over to a consultant
B = Pre-Admission testing
C = XRAY/Lab procedure related to a covered surgery
D = Provider / supplier determined the service is not covered, but the patient is requesting a
formal review by the payor.
E = Beneficiary was notified that the item might not be considered medically necessary and has
agreed in writing to pay for the item. A signed waiver is on file with the provider.
F = Beneficiary was notified that the item might not be considered medically necessary and has
not agreed to pay for the item. No signed waiver is on file with the provider.
G = Testing for hearing aid. Provider Wants to obtain an intentional because other payors are
Involved.
VALIDATION: Must be entered if required by Payor.
If entered, must be valid code from the above list.
FORM LOCATION: CMS-1500, Item 19
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REMARKS: N/A
RECORD/FIELD: FA0-30.0
DATA ELEMENT: Multiple Procedure Indicator (MULTI PROCEDURE IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
30.0
X(01)
LEFT
SPACE
141
141
DEFINITION: An indicator to assist in the proper adjudication and payment determination in cases
involving multiple surgical procedures during the same surgical session.
CODE VALUES:
P = Primary
S = Secondary = non multiple procedure
VALIDATION: Must be entered if required by Payor.
If entered, must be valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FA0-31.0
DATA ELEMENT: Mammography Certification Number (MAMMOGRAPHY CERT NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
31.0
X(10)
LEFT
SPACES
142
151
DEFINITION: CMS assigned Certification Number of the certified mammography screening center.
CODE VALUES: N/A
VALIDATION: Must be entered is required by payor.
FORM LOCATION: CMS-1500 Block 32
REMARKS: N/A
RECORD/FIELD: FA0-32.0
DATA ELEMENT: Class Findings
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
32.0
X(09)
LEFT
SPACES
152
160
DEFINITION: Code for class findings for routine foot care.
One Class A, or 2 Class B, or 1 Class B and 2 Class C findings.
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CODE VALUES:
CLASS "A" FINDINGS
A10 - Non-traumatic amputation of the foot or integral
skeletal portion thereof.
CLASS "B" FINDINGS
B10 - Absent posterior tibial pulse.
B20 - Absent dorsalis pedis. pulse.
B31 - Advanced changes (three of the following conditions
must exist to be considered advanced):
- hair growth (decrease or absence).
- nail changes (thickening).
- pigmentary changes (discoloration).
- skin texture (thin shiny).
- skin color (rubor or redness).
CLASS "C" FINDINGS
C10 - Claudication.
C20 - Temperature changes (e.g. cold feet).
C30 - Paresthesia (abnormal spontaneous sensations in the
feet).
C40 - Burning.
C50 - Edema.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: CMS-1500 Block 21
REMARKS: N/A
RECORD/FIELD: FA0-33.0
DATA ELEMENT: Podiatry Service Condition (PODIATRY SVC COND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
33.0
X(03)
LEFT
SPACES
161
163
DEFINITION: Condition justifying necessity of foot care.
CODE VALUES: See the chart on pages FA0.32 and FA0.33.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: CMS-1500 Block 21
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REMARKS: N/A
The following chart lists specific values for field FA0-33.0.
CODE
NARRATIVE
E01
Amputation: leg, foot or part or foot.
E02
ASO (arteriosclerosis obliterans) of the feet.
E03
Arteriosclerosis of the lower extremities.
E04
ASO of the feet, or just ASO.
E05
Buerger's disease: lower extremities.
E06
Generalized arteriosclerosis.
E07
Lumbosacral syringomyelia.
E08
Occlusive peripheral arteriosclerosis: feet
Peripheral neuropathies involving the feet associated with:
E09
Carcinoma
E10
Hereditary disorders (amyloid neuropathy, angiokeratoma
corposis deffusum (fabry's disease), hereditary sensory
radicular neuopathy).
E11
Leprosy.
E12
Neurosyphilis.
E13
Traumatic injury.
E20
Chronic phlebitis.
E21
Chronic thrombophlebitis.
E22
Diabetes (non-specified).
E23
Diabetes mellitus.
Peripheral neuropathies involving the feet associated with:
E24
Diabetes (non-specified).
E25
Diabetes mellitus.
E26
Drugs.
E27
Malnutrition and vitamin deficiency (alcoholism,
malabsorption-celiac duseasem trioical sprue, malnutrition,
pernicious anemia).
E28
Multiple sclerosis.
E29
Uremia (chronic renal disease).
E30
Toxins.
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E31
Peripheral vasculas disease: arteries foot or toes.
E32
PVD of the foot or toes.
E40
Acute thromphoplebitis.
E41
Acute plebitis.
The following chart lists specific values for field FA0-33.0.
CODE
NARRATIVE
Systemic conditions for routine foot care required specific primary disease
diagnosed required anatomical site for reported services:
H01
Arterial insufficiency.
H02
Blockage of leg vessels.
H03
Chronic vascular disease.
H04
Circulatory deficiency.
H05
Circulatory impairment.
H06
Circulatory insufficiency.
H07
Clot in leg.
H08
Impaired arterial circulation.
H09
Peripheral arterial insufficiency.
H10
Peripheral neuritis.
H11
Peripheral occlusive disease.
H12
Peripheral vascular disease non-specified. Condition
Statement:
A01
The Condition is of such severity that it markedly limits the
patient's ability to ambulate and the treatment would allow
improvement.
B01
The patient is non-ambulatory and if the condition is left
untreated it will likely result in serious medical complications.
RECORD/FIELD: FA0-34.0
DATA ELEMENT: Clinical Laboratory Improvement Amendments of 1988 Identification Number (CLIA ID
NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
34.0
X(15)
LEFT
SPACES
164
178
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DEFINITION: To submit the CLIA Certificate of Waiver or the CLIA Certificate of Registration
Identification Number assigned to the laboratory testing site that rendered this service.
CODE VALUES: As assigned by the Health Standards and Quality Bureau at Health Care Financing
Administration's Central Office.
VALIDATION: Must be entered if required by the payor.
If entered, must be a valid CLIA Number as issued by CMS.
FORM LOCATION: CMS-1500, item 23
REMARKS: Consult the Matrix/Users Guide supplied by the Payor/Receiver for additional details
regarding submission instructions.
RECORD/FIELD: FA0-35.0
DATA ELEMENT: Primary Paid Amount
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
35.0
9(5)V99
RIGHT
ZEROS
179
185
DEFINITION: The actual amount paid by the payor under the provisions of the contract.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
If entered, must be positive unsigned numeric value.
FORM LOCATION: EOB/REMITTANCE
REMARKS: This field may be used to report the amount paid by detail line item for Medicare Secondary
Payor claims.
Consult the Matrix/User Guide document supplied by the payor/receiver to determine usage of this data
element.
RECORD/FIELD: FA0-36.0
DATA ELEMENT: HCPCS Modifier 4
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
36.0
X(2)
LEFT
SPACES
186
187
DEFINITION: These codes identify special circumstances related to the performance of the service.
CODE VALUES: See current HCPCS Modifier codes.
VALIDATION: Must be entered if required for proper adjudication of the services.
FORM LOCATION: CMS-1500 Block 24D
REMARKS: N/A
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RECORD/FIELD: FA0-37.0
DATA ELEMENT: Provider Specialty
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
37.0
X(3)
LEFT
SPACES
188
190
DEFINITION: A code indicating the primary specialty of the provider, as defined by the receiver.
CODE VALUES: N/A
VALIDATION: Must be entered if required by receiver.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FA0-38.0
DATA ELEMENT: Podiatry Therapy Indicator (PODIATRY THERAPY IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
38.0
X(01)
LEFT
SPACES
191
191
DEFINITION: An indicator of whether or not the podiatry patient is receiving anti-fungal therapy.
CODE VALUES:
Y - Yes, patient is receiving anti-fungal therapy.
N - No, patient is not receiving anti-fungal therapy.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FA0-39.0
DATA ELEMENT: Podiatry Therapy Type (PODIATRY THERAPY TYPE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
39.0
X(01)
LEFT
SPACES
192
192
DEFINITION: The type of anti-fungal therapy the podiatry patient is receiving.
CODE VALUES:
O - Oral
T - Topical
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VALIDATION: If entered, must be a valid code from the above list.
Must be entered if PODIATRY THERAPY IND (FA0.38) has a value of "Y".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FA0-40.0
DATA ELEMENT: Hospice Employed Provider Indicator (HOSPICE EMPLOYED PROV IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
40.0
X(01)
LEFT
SPACES
193
193
DEFINITION: An indicator of whether or not the treatment in the Hospice was rendered by a Hospice
employed physician.
CODE VALUES:
Y - Yes, Physician is employed by the Hospice
N - No, Physician is not employed by the Hospice
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: CMS-1500, Item 19
REMARKS: N/A
RECORD/FIELD: FA0-41.0
DATA ELEMENT: Hgb/HCT DATE (HGB/HCT DATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
41.0
X(08)
LEFT
SPACES
194
201
DEFINITION: Date of the most recent hemoglobin/hematocrit.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: N/A
REMARKS: Medicare requires this date for the initial Epoetin therapy claim. It is not required for
subsequent claims.
RECORD/FIELD: FA0-42.0
DATA ELEMENT: Hemoglobin Result (HGB RESULT)
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FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
42.0
9(03)
RIGHT
ZEROES
202
204
DEFINITION: Result, in grams, of the hemoglobin test.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: Medicare requires this data for the initial Epoetin claim. It is not required for subsequent
claims.
RECORD/FIELD: FA0-43.0
DATA ELEMENT: Hematocrit Result (HCT RESULT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
43.0
9(02)
RIGHT
ZEROES
205
206
DEFINITION: Result (percentage) of the hematocrit test.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: Medicare requires this data for the initial Epoetin claim. It is not required for subsequent
claims.
RECORD/FIELD: FA0-44.0
DATA ELEMENT: Patient Weight (PATIENT WEIGHT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
44.0
9(03)
RIGHT
ZEROES
207
209
DEFINITION: Patient's current weight in kilograms.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: Medicare requires this data for the initial Epoetin claim. It is not required for subsequent
claims.
RECORD/FIELD: FA0-45.0
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DATA ELEMENT: Epoetin Dosage (EPO DOSAGE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
45.0
9(03)
RIGHT
ZEROES
210
212
DEFINITION: Epoetin starting dosage in units per kilograms.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: Medicare requires this data for the initial Epoetin claim. It is not required for subsequent
claims.
RECORD/FIELD: FA0-46.0
DATA ELEMENT: Serum Creatine Date (SERUM CREATINE DATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
46.0
X(08)
LEFT
SPACES
213
220
DEFINITION: Date of the most recent serum creatine.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: N/A
REMARKS: Medicare requires this date for the initial Epoetin claim. It is not required for subsequent
claims.
RECORD/FIELD: FA0-47.0
DATA ELEMENT: Creatine Result (CREATINE RESULT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
47.0
9(03)
RIGHT
ZEROES
221
223
DEFINITION: Results of the creatine to the nearest tenths.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: Medicare requires this data for the initial Epoetin claim. It is not required for subsequent
claims.
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RECORD/FIELD: FA0-48.0
DATA ELEMENT: Obligated to Accept Amount (OBLIGATED ACCEPT AMT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
48.0
9(05)V99
RIGHT
ZEROES
224
230
DEFINITION: The amount the provider agreed to accept as payment in full under the provisions of the
contract.
CODE VALUES: N/A
VALIDATION: Must be entered if applicable and the payor requires the information for the filing of
secondary claims EMC.
FORM LOCATION: EOB (Explanation of Benefits) or remittance of primary payor.
REMARKS: This field may be used for Medicare Secondary Payor submission purposes.
RECORD/FIELD: FA0-49.0
DATA ELEMENT: Drug Discount Amount (DRUG DISCOUNT AMT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
49.0
S9(5)V99
RIGHT
ZEROES
231
237
DEFINITION: Discount drug amount (HCPCS "J" codes) that the provider received.
CODE VALUES: N/A
VALIDATION: Must be entered if required by the payor.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FA0-50.0
DATA ELEMENT: Type of Units Indicator (TYPE OF UNITS IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
50.0
X(01)
LEFT
SPACES
238
238
DEFINITION: Describes the value in FA0-18.0 (Units of Service).
CODE VALUES:
1 = Transportation miles
2 = Anesthesia Time
3 = Number of Services
4 = Oxygen volume units
5 = Blood units
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VALIDATION: If entered, must be a valid code from code list.
FORM LOCATION: N/A
REMARKS: Required for Coordination of Benefits exchange.
RECORD/FIELD: FA0-51.0
DATA ELEMENT: Approved Amount (APPROVE AMT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
51.0
S9(5)V99
RIGHT
ZEROES
239
245
DEFINITION: The approved amount for this line item.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: Required for Coordination of Benefits exchange.
RECORD/FIELD: FA0-52.0
DATA ELEMENT: Paid Amount (PAID AMT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
52.0
S9(5)V99
RIGHT
ZEROES
246
252
DEFINITION: The amount paid for this line item.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: Required for Coordination of Benefits exchange, if payment was made.
RECORD/FIELD: FA0-53.0
DATA ELEMENT: Beneficiary Liability Amount (BENE LIABILITY AMT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
53.0
S9(5)V99
RIGHT
ZEROES
253
259
DEFINITION: The amount determined to be the patient's liability.
CODE VALUES: N/A
NSF (National Standard Format) User Manual
202
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: Required for Coordination of Benefits exchange if patient is liable for amount.
RECORD/FIELD: FA0-54.0
DATA ELEMENT: Balance Bill Limiting Charge (BALANCE BILL LIMIT CHG)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
54.0
S9(5)V99
RIGHT
ZEROES
260
266
DEFINITION: The limiting charge amount.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: Required for Coordination of Benefits exchange when the limiting charge is exceeded.
RECORD/FIELD: FA0-55.0
DATA ELEMENT: Limiting Charge Percent (LIMIT CHARGE PRCNT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
55.0
9(5)V99
RIGHT
ZEROES
267
273
DEFINITION: The percent used for limiting charge.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: Required for Coordination of Benefits exchange when the limiting charge is exceeded.
RECORD/FIELD: FA0-56.0
DATA ELEMENT: Performing Provider Phone (PERFORM PROV PHONE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
56.0
X(10)
LEFT
SPACES
274
283
DEFINITION: The phone number of the performing provider for this service line.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
NSF (National Standard Format) User Manual
203
REMARKS: Required, if submitted on a claim, for Coordination of Benefits exchange.
RECORD/FIELD: FA0-57.0
DATA ELEMENT: Performing Provider Tax Type (PERFORM PROV TAX TYPE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
57.0
X(01)
LEFT
SPACES
284
284
DEFINITION: A code which identifies the performing provider's Tax ID entered in FA0-58.0
CODE VALUES:
T = TIN Number
S = SS Number
VALIDATION: If entered, must be a valid code from code list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FA0-58.0
DATA ELEMENT: Performing Provider Tax ID (PERFORM PROV TAX ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
58.0
X(09)
LEFT
SPACES
285
293
DEFINITION: The federally assigned Tax identification number (TIN) or the social security number
(SSN) of the performing provider.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Identification Number" entry.
REMARKS: N/A
RECORD/FIELD: FA0-59.0
DATA ELEMENT: Performing Provider Assignment Indicator (PERFORM PROV ASSIGN IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
59.0
X(01)
LEFT
SPACES
294
294
DEFINITION: A code indicating whether the performing provider accepts assignment.
CODE VALUES:
A = Assigned
N = Not Assigned
B = Assignment accepted on Clinical Lab services only
NSF (National Standard Format) User Manual
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P = Patient refuses to assign benefits
VALIDATION: See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FA0-60.0
DATA ELEMENT: Pre-Transplant Indicator
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
60.0
X(01)
LEFT
SPACES
295
295
DEFINITION: Indicates whether the patient is a potential lung/heart Transplant participant.
CODE VALUES:
Y = Yes, potential transplant patient
N = No, not a potential transplant patient
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above List.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FA0-61.0
DATA ELEMENT: ICD-10-PCS
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
61.0
X(07)
LEFT
SPACES
296
302
DEFINITION: This is the ICD-10-PCS codes that describes The services.
CODE VALUES: ICD-10-PCS code set.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid ICD-10-PCS
Procedure code.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FA0-62.0
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205
DATA ELEMENT: Universal Product Code Number (UNIVERSAL PRODUCT CODE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
62.0
X(14)
LEFT
SPACES
303
316
DEFINITION: Universal Product Code Number.
CODE VALUES: UPC Code List.
VALIDATION: Must be entered, if required by payor.
If entered, must be a valid UPC code.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FA0-63.0 FA0-64.0 FA0-65.0 FA0-66.0
DATA ELEMENT:
Diagnosis Code Pointer 5
(DIAG CODE POINTER5)
Diagnosis Code Pointer 6
(DIAG CODE POINTER6)
Diagnosis Code Pointer 7
(DIAG CODE POINTER7)
Diagnosis Code Pointer 8
(DIAG CODE POINTER8)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
63.0
X(01)
LEFT
SPACE
317
317
64.0
X(01)
LEFT
SPACE
318
318
65.0
X(01)
LEFT
SPACE
319
319
66.0
X(01)
LEFT
SPACE
320
320
DEFINITION: A pointer to the claim diagnosis code in the order of importance to this service.
CODE VALUES:
5 - indicates the 5th header diagnosis
6 - indicates the 6th header diagnosis
7 - indicates the 7th header diagnosis
8 - indicates the 8th header diagnosis
VALIDATION: Values used must point to non-blank header diagnosis field.
FORM LOCATION: N/A
REMARKS: Example:
Header diagnosis entered; 11111 22222 33333 44444
NSF (National Standard Format) User Manual
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Diagnosis pointer 5 -- 2
Diagnosis pointer 6 -- 4
Diagnosis pointer 7 -- 1
In this example the diagnosis pointers indicate that header diagnosis 2 is the fifth code with header
diagnosis 4 being the sixth code and header diagnosis 1 as the seventh code. The 8th diagnosis pointer
was not entered because it was not related to this service.
RECORD NAME: SERVICE LINE DETAIL
SEGMENT"
RECORD TYPE FB0 "MEDICAL
Not required for MO HealthNet processing
Must follow FA0
Must be followed by FA0, FB1, FB2, FB3, FD0, GA0, GC0, GD0, GD1, GE0, GP0,
GU0, GX0, GX1, GX2, HA0 or XA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "FB0"
C-24
FB0
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
Not Used
04
LINE ITEM CONTROL NO
Not Used
05
PUR SVC CHARGE
Not Used
06
ALLOWED AMOUNT
Not Used
07
DEDUCTIBLE AMOUNT
Not Used
08
COINSURANCE AMOUNT
Not Used
09
ORDERING PROV ID
Not Used
10
ORDERING PROV STATE
Not Used
11
PUR SVC PROV ID
Not Used
12
PUR SVC STATE
Not Used
13
PEN GRAMS OF PROTEIN
Not Used
14
PEN CALORIES
Not Used
15
NATIONAL DRUG CODE
Not Used
16
NATIONAL DRUG UNITS
Not Used
17
PRESCRIPTION NO
Not Used
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18
PRESCRIPTION DATE
Not Used
19
PRESCRIPT NO OF MOS
Not Used
20
SPEC PRICING IND
Not Used
21
COPAY STATUS IND
Not Used
22
EPSDT IND
C-44
NO
23
FAMILY PLANNING IND
C-44
NO
24
DME CHARGE IND
Not Used
25
HPSA FACILITY ID
Not Used
26
HPSA FACILITY ZIP
Not Used
27
PUR SVC NAME
Not Used
28
PUR SVC ADDR1
Not Used
29
PUR SVC ADDR2
Not Used
30
PUR SVC CITY
Not Used
31
PUR SVC ZIP
Not Used
32
PUR SVC PHONE
Not Used
33
DRUG DAYS SUPPLY
Not Used
34
PAYMENT TYPE IND
Not Used
35
FILLER-NATIONAL
YES
RECORD TYPE: FB0
LEVEL: CLAIM - MEDICAL SEGMENT
PURPOSE: To provide information related to the medical services rendered to the patient by the provider.
REQUIREMENTS: If required by the payor, this record must be submitted.
ORDER:
Preceding Record Type
Following Record Type
FA0
FA0, FB1, FB2, FB3, FD0, FE0 CERT records, HA0
or XA0
NOTES: There may be up to 99 FXX records entered for a claim. (All "F" records).
MEDICAL SEGMENT
FIELD NO.
FIELD NAME
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FIELD
LENGTH
TYPE
POSITIONS
208
FROM
THRU
01.0
RECORD ID "FB0"
3
X
01
03
02.0
SEQUENCE NO
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
LINE ITEM CONTROL NO
17
X
23
39
05.0
PUR SVC CHARGE
7
N
40
46
06.0
ALLOWED AMOUNT
7
N
47
53
07.0
DEDUCTIBLE AMOUNT
7
N
54
60
08.0
COINSURANCE AMOUNT
7
N
61
67
09.0
ORDERING PROV NPI
15
X
68
82
10.0
ORDERING PROV STATE
2
X
83
84
11.0
PUR SVC PROV NPI
15
X
85
99
12.0
PUR SVC STATE
2
X
100
101
13.0
PEN GRAMS OF PROTEIN
4
N
102
105
14.0
PEN CALORIES
4
N
106
109
15.0
NATIONAL DRUG CODE
11
X
110
120
16.0
NATIONAL DRUG UNITS
7
N
121
127
17.0
PRESCRIPTION NO
15
X
128
142
18.0
PRESCRIPTION DATE
8
X
143
150
19.0
PRESCRIPT NO OF MOS
2
N
151
152
20.0
SPEC PRICING IND
1
X
153
153
21.0
COPAY STATUS IND
1
X
154
154
22.0
EPSDT IND
1
X
155
155
23.0
EPSDT IND
1
X
155
155
24.0
DME CHARGE IND
1
X
157
157
25.0
HPSA FACILITY ID
15
X
158
172
26.0
HPSA FACILITY ZIP
9
X
173
181
27.0
PUR SVC NAME
33
X
182
214
28.0
PUR SVC ADDR1
30
X
215
244
29.0
PUR SVC ADDR2
30
X
245
274
NSF (National Standard Format) User Manual
209
30.0
PUR SVC CITY
20
X
275
294
31.0
PUR SVC ZIP
9
X
295
303
32.0
PUR SVC PHONE
10
X
304
313
33.0
DRUG DAYS SUPPLY
3
N
314
316
34.0
PAYMENT TYPE IND
1
X
317
317
35.0
FILLER-NATIONAL
3
X
318
320
RECORD/FIELD: FB0-01.0
DATA ELEMENT: Record Identifier (RECORD ID "FB0")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: This is the record identifier for the Service Line Detail Record - FB0.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be 'FB0'.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB0-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: This is the record sequence number of the Service Line Detail Record.
CODE VALUES: 01 through 99
VALIDATION: Must be entered.
Must be a valid code from the above list.
The value entered must match the SEQUENCE NUMBER (FA0-02.0) submitted in the preceding "FA0"
record.
FORM LOCATION: N/A
REMARKS: See sequencing instructions on page FA0.04.
NSF (National Standard Format) User Manual
210
RECORD/FIELD: FB0-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: A unique number assigned by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: Must be entered.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: CMS-1500 Block 26
REMARKS: N/A
RECORD/FIELD: FB0-04.0
DATA ELEMENT: Line Item Control Number (LINE ITEM CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(17)
LEFT
SPACES
23
39
DEFINITION: An identifier assigned by the submitter/provider to this line item.
CODE VALUES: N/A
VALIDATION: May be entered if payor allowed.
If entered, value must match the "Line Item Control Number" (FA0-04.0) submitted in the preceding FA0
record.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB0-05.0
DATA ELEMENT: Purchase Service Charge (PUR SVC CHARGE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
9(05)V99
RIGHT
ZEROS
40
46
DEFINITION: The net cost for the purchased service.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
NSF (National Standard Format) User Manual
211
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB0-06.0
DATA ELEMENT: Allowed Amount
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
9(05)V99
RIGHT
ZEROS
47
53
DEFINITION: The maximum amount determined by the payor as being "allowable" under the provisions
of the contract prior to the determination of actual payment.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
If entered, must be positive unsigned numeric value.
FORM LOCATION: EOB/REMITTANCE
REMARKS: This field may be used to report the amount allowed by detail line item for Medicare
Secondary Payor claims.
Consult the Matrix/User Guide document supplied by the payor/receiver to determine usage of this data
element.
RECORD/FIELD: FB0-07.0
DATA ELEMENT: Deductible Amount
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
9(05)V99
RIGHT
ZEROS
54
60
DEFINITION: This is the amount applied to deductible by this payor. The amount deducted, by the
payor, from the allowed amount in order to meet the contract "deductible" provisions.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor. If entered, must be positive unsigned numeric
value.
FORM LOCATION: EOB/REMITTANCE
REMARKS: This field may be used to report the amount of deductible by detail line item for Medicare
Secondary Payor claims.
Consult the Matrix/User Guide document supplied by the payor/receiver to determine usage of this data
element.
RECORD/FIELD: FB0-08.0
DATA ELEMENT: Coinsurance Amount
NSF (National Standard Format) User Manual
212
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
08.0
9(05)V99
RIGHT
ZEROS
61
67
DEFINITION: The amount deducted, by the payor, from the allowed amount in order to meet the
"coinsurance" provisions of the contract. The amount applied toward the coinsurance by this payor.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
If entered, must be positive unsigned numeric value.
FORM LOCATION: EOB/REMITTANCE
REMARKS: This field may be used to report the amount of coinsurance by detail line item for Medicare
Secondary Payor claims.
Consult the Matrix/User Guide document supplied by the payor/receiver to determine usage of this data
element.
RECORD/FIELD: FB0-09.0
DATA ELEMENT: Ordering Provider National Provider Identifier (ORDERING PROV NPI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
X(15)
LEFT
SPACES
68
82
DEFINITION: The National Provider Identifier assigned to the physician who ordered the service.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
See GENERAL INSTRUCTIONS for "Identification Numbers" entry.
This field must contain the National Provider Identifier (NPI) once the NPI is implemented.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB0-10.0
DATA ELEMENT: Ordering Provider State (ORDERING PROV STATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
X(02)
LEFT
SPACES
83
84
DEFINITION: The ordering provider's state code.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
NSF (National Standard Format) User Manual
213
See GENERAL INSTRUCTIONS for "Address" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB0-11.0
DATA ELEMENT: Purchase Service Provider National Provider Identifier (PUR SVC PROV NPI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
X(15)
LEFT
SPACES
85
99
DEFINITION: The National Provider Identifier (NPI) assigned to the Provider where the service was
purchased.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
See GENERAL INSTRUCTIONS for "Identification Numbers" entry.
This field must contain the National Provider
Identifier (NPI) once the NPI is implemented.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB0-12.0
DATA ELEMENT: Purchase Service State (PUR SVC STATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(02)
LEFT
SPACES
100
101
DEFINITION: The state code of the state in which the service was purchased.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
See GENERAL INSTRUCTIONS for "Address" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB0-13.0
DATA ELEMENT: Pen Grams of Protein
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
9(04)
RIGHT
ZEROS
102
105
NSF (National Standard Format) User Manual
214
DEFINITION: The grams of Amino Acids prescribed per day.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
If entered, must be positive unsigned numeric value.
FORM LOCATION: N/A
REMARKS: Used on Parenteral claims.
RECORD/FIELD: FB0-14.0
DATA ELEMENT: Pen Calories
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
14.0
9(04)
RIGHT
ZEROS
106
109
DEFINITION: The number of calories prescribed per day.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
If entered, must be positive unsigned numeric value.
FORM LOCATION: N/A
REMARKS: Used on Enteral claims.
RECORD/FIELD: FB0-15.0
DATA ELEMENT: National Drug Code
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
15.0
X(11)
LEFT
SPACES
110
120
DEFINITION: The national drug identification number assigned by the Federal Drug Administration
(FDA).
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
FORM LOCATION: CMS-1500 Block 24D
REMARKS: N/A
RECORD/FIELD: FB0-16.0
DATA ELEMENT: National Drug Units
FIELD
COBOL PICTURE
NSF (National Standard Format) User Manual
JUSTIFY
INITIAL
FROM
THRU
215
16.0
9(07)
RIGHT
ZEROS
121
127
DEFINITION: The dispensing quantity, based upon the unit of measure as defined by the NDC No.
(FB0-15.0).
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
If entered, must be positive unsigned numeric value.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB0-17.0
DATA ELEMENT: Prescription Number (PRESCRIPTION NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
17.0
X(15)
LEFT
SPACES
128
142
DEFINITION: The unique identification number assigned by the pharmacy or supplier.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB0-18.0
DATA ELEMENT: Prescription Date
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
X(08)
LEFT
SPACES
143
150
DEFINITION: The date the prescription was issued by the referring physician.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB0-19.0
DATA ELEMENT: Prescription, Number of Months (PRESCRIPTION NO OF MONTHS)
NSF (National Standard Format) User Manual
216
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
19.0
9(02)
RIGHT
ZEROS
151
152
DEFINITION: The number of months the prescription will be in effect.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB0-20.0
DATA ELEMENT: Special Pricing Indicator (SPEC PRICING IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
20.0
X(01)
LEFT
SPACE
153
153
DEFINITION: N/A
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB0-21.0
DATA ELEMENT: Copay Status Indicator(COPAY STATUS IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
21.0
X(01)
LEFT
SPACE
154
154
DEFINITION: An indication of whether or not co-payment requirements were met on a line by line basis.
CODE VALUES:
0 = Copay exempt.
1 = Participant did not pay when asked.
2 = Participant did pay when asked.
3 = Participant was not asked.
VALIDATION: Must be entered if required by Payor.
If entered, must be valid code from the above list.
FORM LOCATION: N/A
NSF (National Standard Format) User Manual
217
REMARKS: Generally this is not required by payor, however some payors (usually MEDICAID) have
opted to require this information in some states, but only for some procedures.
RECORD/FIELD: FB0-22.0
DATA ELEMENT: EPSDT Indicator(EPSDT IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
22.0
X(01)
LEFT
SPACE
155
155
DEFINITION: An indicator of whether or not "Early and Periodic Screen for Diagnosis and Treatment of
children" services are involved with this detail line.
CODE VALUES:
Y - yes, EPSDT involvement
N - no, EPSDT not involved
VALIDATION: Must be entered if required by Payor.
If entered, must be valid code from the above list.
FORM LOCATION: CMS-1500 Block 24h
REMARKS: N/A
RECORD/FIELD: FB0-23.0
DATA ELEMENT: Family Planning Indicator (FAMILY PLANNING IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
23.0
X(01)
LEFT
SPACE
156
156
DEFINITION: An indicator of whether or not Family Planning Services are involved with this detail line.
CODE VALUES:
Y - Yes, family planning involved
N - No, family planning not involved
VALIDATION: Must be entered if required by Payor.
If entered, must be valid code from the above list.
FORM LOCATION: CMS-1500 Block 24h
REMARKS: N/A
RECORD/FIELD: FB0-24.0
DATA ELEMENT: DME Charge Indicator (DME CHARGE IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
24.0
X(01)
LEFT
SPACE
157
157
NSF (National Standard Format) User Manual
218
DEFINITION: Indicates whether it is the first time a charge for Durable Medical Equipment is being
submitted.
CODE VALUES:
0 - Not a DME rental, repeat purchase or PEN claim.
1 - First charge for DME rental, or DME repeat purchase.
2 - Subsequent Charge for DME rental, Purchase, or PEN.
3 - Re-certified PEN claim or a PEN claim containing new caloric values as prescribed by the
referring physician.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB0-25.0
DATA ELEMENT: HPSA Facility Identification (HPSA FACILITY ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
25.0
X(15)
LEFT
SPACES
158
172
DEFINITION: The identifier assigned by the Payor to the HPSA facility.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: CMS-1500 Block 32
REMARKS: N/A
RECORD/FIELD: FB0-26.0
DATA ELEMENT: HPSA Facility Zip Code (HPSA FACILITY ZIP)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
26.0
X(09)
LEFT
SPACES
173
181
DEFINITION: The zip code of the HPSA facility location.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
See GENERAL INSTRUCTIONS for "Address" entry.
NSF (National Standard Format) User Manual
219
FORM LOCATION: CMS-1500 Block 32
REMARKS: N/A
RECORD/FIELD: FB0-27.0
DATA ELEMENT: Purchase Service Name (PUR SVC NAME)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
27.0
X(33)
LEFT
SPACES
182
214
DEFINITION: The name of the entity from which service was purchased.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
See GENERAL INSTRUCTIONS for "Name 2" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB0-28.0 FB0-29.0 FB0-30.0 FB0-31.0
DATA ELEMENT:
Purchase Service Address 1
(PUR SVC ADDR1)
Purchase Service Address 2
(PUR SVC ADDR2)
Purchase Service City
(PUR SVC CITY)
Purchase Service Zip
(PUR SVC ZIP)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
28.0
X(30)
LEFT
SPACES
215
244
29.0
X(30)
LEFT
SPACES
245
274
30.0
X(20)
LEFT
SPACES
275
294
31.0
X(09)
LEFT
SPACES
295
303
DEFINITION: The address of the entity from which service was purchased.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
See GENERAL INSTRUCTIONS for "Address" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB0-32.0
NSF (National Standard Format) User Manual
220
DATA ELEMENT: Purchase Service Phone (PUR SVC PHONE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
32.0
X(10)
LEFT
SPACES
304
313
DEFINITION: The phone number of the entity from which service was purchased.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
See GENERAL INSTRUCTIONS for "Telephone" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB0-33.0
DATA ELEMENT: Drug Days Supply (DRUG DAYS SUPPLY)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
33.0
9(03)
RIGHT
ZEROS
314
316
DEFINITION: Represents from 1 to 100 days supply currently dispensed with this prescription service.
CODE VALUES: 01 Through 100
VALIDATION: Must be entered if required by payor.
Must be an unsigned numeric if National Drug Code (FB0-15.0) is other than spaces and Type of Service
(FA0-08.0) is "99" (Other).
If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB0-34.0
DATA ELEMENT: PAYMENT TYPE INDICATOR
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
34.0
X(01)
LEFT
SPACES
317
317
DEFINITION: Indicates at what percentage of the approved amount Medicare paid.
CODE VALUES:
O = Regular detail = 80%
R = Radiology/Lab = 100%
T - Physical Therapy
NSF (National Standard Format) User Manual
221
P - Psychiatry - 50%*
B = Blood = 80%
VALIDATION: If entered, but be a valid code form code list.
FORM LOCATION: N/A
REMARKS: Used for Coordination of Benefits exchange.
*Once the Medicare Part B deductible is met, coinsurance for most Medigap policies is 50%. MO
HealthNet is only responsible for 20%.
RECORD/FIELD: FB0-35.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
35.0
X(03)
LEFT
SPACES
318
320
DEFINITION: Unused national reserved filler.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: SERVICE LINE DETAIL
SEGMENT"
RECORD TYPE FB1 "MEDICAL
Not Required by MO HealthNet
Must follow FB0
Must be followed by FB2 - XA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "FB1"
C-24
FB1
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
Not Used
04
LINE ITEM CONTROL NO
Not Used
05
PLACE OF SVC NAME
Not Used
06
ORDERING PROV LAST
Not Used
NSF (National Standard Format) User Manual
222
07
ORDERING PROV FIRST
Not Used
08
ORDERING PROV MI
Not Used
09
ORDERING PROV UPIN
Not Used
10
REFERRING PROV LAST
Not Used
11
REFERRING PROV FIRST
Not Used
12
REFERRING PROV MI
Not Used
13
REFERRING PROV UPIN
Not Used
14
RENDERING PROV LAST
Not Used
15
RENDERING PROV FIRST
Not Used
16
RENDERING PROV MI
Not Used
17
RENDERING PROV UPIN
Not Used
18
SUPV PROV LAST
Not Used
19
SUPV PROV FIRST
Not Used
20
SUPV PROV MI
Not Used
21
SUPV PROV ID
Not Used
22
SUPV PROV UPIN
Not Used
23
FILLER-NATIONAL
YES
RECORD TYPE: FB1
LEVEL: CLAIM - MEDICAL SEGMENT
PURPOSE: To provide information related to the medical services rendered to the patient by the provider.
REQUIREMENTS: If required by payor, this record must be submitted.
ORDER:
Preceding Record Type
Following Record Type
FA0 or FB0
FA0, FB2, FB3, FD0, FE0 CERT Records, HA0 or
XA0
NOTES: There may be up to 99 FXX records entered for a claim. (All "F" records).
MEDICAL SEGMENT
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
NSF (National Standard Format) User Manual
THRU
223
01.0
RECORD ID "FB1"
3
X
01
03
02.0
RECORD ID "FB1"
3
X
01
03
03.0
PAT CONTROL NO
17
X
06
22
04.0
LINE ITEM CONTROL NO
17
X
23
39
05.0
PLACE OF SVC NAME
33
X
40
72
06.0
ORDERING PROV LAST
20
X
73
92
07.0
ORDERING PROV FIRST
12
X
93
104
08.0
ORDERING PROV MI
1
X
105
105
09.0
ORDERING PROV UPIN
15
X
106
120
10.0
REFERRING PROV LAST
20
X
121
140
11.0
REFERRING PROV FIRST
12
X
141
152
12.0
REFERRING PROV MI
1
X
153
153
13.0
REFERRING PROV UPIN
15
X
154
168
14.0
RENDERING PROV LAST
20
X
169
188
15.0
RENDERING PROV FIRST
12
X
189
200
16.0
RENDERING PROV MI
1
X
201
201
17.0
RENDERING PROV UPIN
15
X
202
216
18.0
SUPV PROV LAST
20
X
217
236
19.0
SUPV PROV FIRST
12
X
237
248
20.0
SUPV PROV MI
1
X
249
249
21.0
SUPV PROV NPI
15
X
250
264
22.0
SUPV PROV UPIN
15
X
265
279
23.0
FILLER-NATIONAL
41
X
280
320
RECORD/FIELD: FB1-01.0
DATA ELEMENT: Record Identifier (RECORD ID 'FB1')
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: This is the record identifier for the Service Line Detail Record - FB1.
CODE VALUES: N/A
NSF (National Standard Format) User Manual
224
VALIDATION: Must be entered.
Must be 'FB1'.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB1-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: This is the record sequence number of the Service Line Detail Record.
CODE VALUES: 01 through 99
VALIDATION: Must be entered.
Must be a valid code from the above list.
The value entered must match the SEQUENCE NUMBER (FA0-02.0) submitted in the preceding "FA0"
record.
FORM LOCATION: N/A
REMARKS: See sequencing instructions on page FA0.04.
RECORD/FIELD: FB1-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: A unique number assigned by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: Must be entered.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: CMS-1500 Block 26
REMARKS: N/A
RECORD/FIELD: FB1-04.0
DATA ELEMENT: Line Item Control Number (LINE ITEM CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(17)
LEFT
SPACES
23
39
NSF (National Standard Format) User Manual
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DEFINITION: An identifier assigned by the submitter/provider to this line item.
CODE VALUES: N/A
VALIDATION: May be entered if payor allowed.
If entered, value must match the "Line Item
Control Number" (FA0-04.0) submitted in the preceding FA0 record.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB1-05.0
DATA ELEMENT: Place of Service Name(PLACE OF SVC NAME)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(33)
LEFT
SPACES
40
72
DEFINITION: Enter the name of the place of service.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
See GENERAL INSTRUCTIONS for "Name 2" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB1-06.0 FB1-07.0 FB1-08.0
DATA ELEMENT:
Ordering Provider Last
(ORDERING PROV LAST)
Ordering Provider First
(ORDERING PROV FIRST)
Ordering Prov Middle Initial
(ORDERING PROV MI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(20)
LEFT
SPACES
73
92
07.0
X(12)
LEFT
SPACES
93
104
08.0
X(01)
LEFT
SPACES
105
105
DEFINITION: The ordering provider's name.
CODE VALUES: N/A
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VALIDATION: Must be entered if required by Payor.
See GENERAL INSTRUCTIONS for "Name 1" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB1-09.0
DATA ELEMENT: Ordering Provider UPIN (ORDERING PROV UPIN)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
X(15)
LEFT
SPACES
106
120
DEFINITION: The ordering provider's UPIN (unique physician identification number).
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB1-10.0 FB1-11.0 FB1-12.0
DATA ELEMENT:
Referring Provider Last
(REFERRING PROV LAST)
Referring Provider First
(REFERRING PROV FIRST)
Referring Provider Middle Initial
(REFERRING PROV MI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
X(20)
LEFT
SPACES
121
40
11.0
X(12)
LEFT
SPACES
141
152
12.0
X(01)
LEFT
SPACE
153
153
DEFINITION: The referring physician name.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
See GENERAL INSTRUCTIONS for "Name 1" entry.
FORM LOCATION: CMS-1500, Block 17
REMARKS: N/A
RECORD/FIELD: FB1-13.0
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DATA ELEMENT: Referring Provider UPIN (REFERRING PROV UPIN)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
X(15)
LEFT
SPACES
154
168
DEFINITION: The referring provider's UPIN (unique physician identification number).
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: CMS-1500, Block 17a
REMARKS: N/A
RECORD/FIELD: FB1-14.0 FB1-15.0 FB1-16.0
DATA ELEMENT:
Rendering Provider Last
(RENDERING PROV LAST)
Rendering Provider First
(RENDERING PROV FIRST)
Rendering Provider Middle Initial
(RENDERING PROV MI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
14.0
X(20)
LEFT
SPACES
169
188
15.0
X(12)
LEFT
SPACES
189
200
16.0
X(01)
LEFT
SPACE
201
201
DEFINITION: The rendering provider's name.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
See GENERAL INSTRUCTIONS for "Name 1" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB1-17.0
DATA ELEMENT: Rendering Provider UPIN (RENDERING PROV UPIN)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
17.0
X(15)
LEFT
SPACES
202
216
DEFINITION: The rendering physician's UPIN (unique physician identification number).
NSF (National Standard Format) User Manual
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CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB1-18.0 FB1-19.0 FB1-20.0
DATA ELEMENT:
Supervising Provider Last
(SUPV PROV LAST)
Supervising Provider First
(SUPV PROV FIRST)
Supervising Prov Middle Initial
(SUPV PROV MI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
X(20)
LEFT
SPACES
217
236
19.0
X(12)
LEFT
SPACES
237
248
20.0
X(01)
LEFT
SPACES
249
249
DEFINITION: The supervising provider's name.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
See GENERAL INSTRUCTIONS for "Name 1" entry.
REMARKS: N/A
RECORD/FIELD: FB1-21.0
DATA ELEMENT: Supervising Provider National Provider Identifier (SUPV PROV NPI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
21.0
X(15)
LEFT
SPACES
250
264
DEFINITION: The National Provider Identifier assigned to the supervising provider (who supervised the
service).
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor. This field must contain the National Provider
Identifier (NPI) once the NPI is implemented.
See GENERAL INSTRUCTIONS for "Identification Numbers" entry.
FORM LOCATION: N/A
REMARKS: N/A
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229
RECORD/FIELD: FB1-22.0
DATA ELEMENT: Supervising Provider UPIN (SUPV PROV UPIN)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
22.0
X(15)
LEFT
SPACES
265
279
DEFINITION: The supervising provider's UPIN (unique provider identification number).
CODE VALUES: N/A
FORM LOCATION: N/A
VALIDATION: Must be entered if required by Payor.
See GENERAL INSTRUCTIONS for "Identification Number" entry.
REMARKS: N/A
RECORD/FIELD: FB1-23.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
23.0
X(41)
LEFT
SPACES
280
320
DEFINITION: Unused national reserved filler.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: SERVICE LINE DETAIL
SEGMENT"
RECORD TYPE FB2 "MEDICAL
Not Required by MO HealthNet
Must follow FB0 and FB1
Must be follow by FB3 - XA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "FB2"
C-24
FB2
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
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Not Used
230
04
LINE ITEM CONTROL NO
Not Used
05
PROV TYPE IND A
Not Used
06
PROV A ADDR 1
Not Used
07
PROV A ADDR 2
Not Used
08
PROV A CITY
Not Used
09
PROV A STATE
Not Used
10
PROV A ZIP
Not Used
11
PROV TYPE IND B
Not Used
12
PROV B ADDR 1
Not Used
13
PROV B ADDR 2
Not Used
14
PROV B CITY
Not Used
15
PROV B STATE
Not Used
16
PROV B ZIP
Not Used
17
PROV TYPE IND C
Not Used
18
PROV C ADDR 1
Not Used
19
PROV C ADDR 2
Not Used
20
PROV C CITY
Not Used
21
PROV C STATE
Not Used
22
PROV C ZIP
Not Used
23
FILLER-NATIONAL
YES
RECORD TYPE: FB2
LEVEL: CLAIM - MEDICAL SEGMENT
PURPOSE: To provide additional provider address information.
REQUIREMENTS: If required by payor, this record must be submitted.
ORDER:
Preceding Record Type
Following Record Type
FA0, FB0, FB1, or FB3
FA0, FD0, FE0, CERT Records, HA0 or XA0
NOTES: There may be up to 99 FXX records entered for a claim. (All "F" records).
MEDICAL SEGMENT
NSF (National Standard Format) User Manual
231
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "FB2"
3
X
01
03
02.0
SEQUENCE NO
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
LINE ITEM CONTROL NO
17
X
23
39
05.0
PROV TYPE IND A
2
X
40
41
06.0
PROV A ADDR 1
30
X
42
71
07.0
PROV A ADDR 2
30
X
72
101
08.0
PROV A CITY
20
X
102
121
09.0
PROV A STATE
2
X
122
123
10.0
PROV A ZIP
9
X
124
132
11.0
PROV TYPE IND B
2
X
133
134
12.0
PROV B ADDR 1
30
X
135
164
13.0
PROV B ADDR 2
30
X
165
194
14.0
PROV B CITY
20
X
195
214
15.0
PROV B STATE
2
X
215
216
16.0
PROV B ZIP
9
X
217
225
17.0
PROV TYPE IND C
2
X
226
227
18.0
PROV C ADDR 1
30
X
228
257
19.0
PROV C ADDR 2
30
X
258
287
20.0
PROV C CITY
20
X
288
307
21.0
PROV C STATE
2
X
308
309
22.0
PROV C ZIP
9
X
310
318
23.0
FILLER-NATIONAL
2
X
319
320
RECORD/FIELD: FB2-01.0
DATA ELEMENT: Record Identifier (RECORD ID "FB2")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
NSF (National Standard Format) User Manual
232
DEFINITION: This is the record identifier for the Service Line Detail Record - FB2.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be "FB2".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB2-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: This is the record sequence number of the Service Line Detail Record.
CODE VALUES: 01 through 99
VALIDATION: Must be entered.
Must be a valid code from the above list.
The value entered must match the SEQUENCE NUMBER (FA0-02.0) submitted in the preceding
"FA0"record.
FORM LOCATION: N/A
REMARKS: See sequencing instructions on page FA0.04.
RECORD/FIELD: FB2-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: A unique number assigned by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: Must be entered.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: CMS-1500 Block 26
REMARKS: N/A
RECORD/FIELD: FB2-04.0
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DATA ELEMENT: Line Item Control Number (LINE ITEM CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(17)
LEFT
SPACES
23
39
DEFINITION: An identifier assigned by the submitter/provider to this line item.
CODE VALUES: N/A
VALIDATION: May be entered if payor allowed.
If entered, value must match the "Line Item
Control Number" (FA0-04.0) submitted in the preceding FA0 record.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB2-05.0
DATA ELEMENT: Provider Type Indicator A (PROV TYPE IND A)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(02)
LEFT
SPACES
40
41
DEFINITION: A code to indicate the type of provider to whom the address information in FB2-06.0
through FB2-10.0 applies.
CODE VALUES:
OD = Ordering Provider
RF = Referring Provider
SP = Supervising Provider
SU = Surrogate Provider
CP = Consulting Provider
AP = Attending Provider
OO = Other Ordering Provider
PE = Performing Provider
VALIDATION: Must be entered if required by Payor. If entered, must be a valid code value from the
above list.
For DMEPOS claims, use only values of CP, AP or OO.
For Non-DMEPOS claims, use only values of OD, RF, SP, or SU.
FORM LOCATION: N/A
NSF (National Standard Format) User Manual
234
REMARKS: N/A
RECORD/FIELD: FB2-06.0, FB2-07.0, FB2-08.0, FB2-09.0, FB2-10.0
DATA ELEMENT:
Provider A Address 1
(PROV A ADDR 1)
Provider A Address 2
(PROV A ADDR 2)
Provider A City
(PROV A CITY)
Provider A State
(PROV A STATE)
Provider A Zip Code
(PROV A ZIP)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(30)
LEFT
SPACES
42
71
07.0
X(30)
LEFT
SPACES
72
101
08.0
X(20)
LEFT
SPACES
102
121
09.0
X(02)
LEFT
SPACES
122
123
10.0
X(09)
LEFT
SPACES
124
132
DEFINITION: The mailing address of the Provider identified in FB2-05.0.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Address" entry.
Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB2-11.0
DATA ELEMENT: Provider Type Indicator B (PROV TYPE IND B)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
X(02)
LEFT
SPACES
133
134
DEFINITION: A code to indicate the type of provider to whom the address information in FB2-12.0
through FB2-16.0 applies.
CODE VALUES:
OD = Ordering Provider
RF = Referring Provider
SP = Supervising Provider
SU = Surrogate Provider
NSF (National Standard Format) User Manual
235
CP = Consulting Provider
AP = Attending Provider
OO = Other Ordering Provider
PE = Performing Provider
VALIDATION: Must be entered if required by Payor.
If entered, must be a valid code value from the above list.
For DMEPOS claims, use only values of CP, AP or OO.
For Non-DMEPOS claims, use only values of OD, RF, SP, or SU.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB2-12.0, FB2-13.0, FB2-14.0, FB2-15.0, FB2-16.0
DATA ELEMENT:
Provider B Address 1
(PROV B ADDR 1)
Provider B Address 2
(PROV B ADDR 2)
Provider B City
(PROV B CITY)
Provider B State
(PROV B STATE)
Provider B Zip Code
(PROV B ZIP)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(30)
LEFT
SPACES
135
164
13.0
X(30)
LEFT
SPACES
165
194
14.0
X(20)
LEFT
SPACES
195
214
15.0
X(02)
LEFT
SPACES
215
216
16.0
X(09)
LEFT
SPACES
217
225
DEFINITION: The mailing address of the Provider identified in FB2-11.0.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Address" entry.
Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: N/A
NSF (National Standard Format) User Manual
236
RECORD/FIELD: FB2-17.0
DATA ELEMENT: Provider Type Indicator C (PROV TYPE IND C)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
17.0
X(02)
LEFT
SPACES
226
227
DEFINITION: A code to indicate the type of provider to whom the address information in FB2-18.0
through FB2-22.0 applies.
CODE VALUES:
OD = Ordering Provider
RF = Referring Provider
SP = Supervising Provider
SU = Surrogate Provider
CP = Consulting Provider
AP = Attending Provider
OO = Other Ordering Provider
PE = Performing Provider
VALIDATION: Must be entered if required by Payor.
If entered, must be a valid code value from the above list.
For DMEPOS claims, use only values of CP, AP or OO.
For Non-DMEPOS claims, use only values of OD, RF, SP, or SU.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB2-18.0 FB2-19.0 FB2-20.0 FB2-21.0 FB2-22.0
DATA ELEMENT:
Provider C Address 1
(PROV C ADDR 1)
Provider C Address 2
(PROV C ADDR 2)
Provider C City
(PROV C CITY)
Provider C State
(PROV C STATE)
Provider C Zip Code
(PROV C ZIP)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
X(30)
LEFT
SPACES
228
257
19.0
X(30)
LEFT
SPACES
258
287
NSF (National Standard Format) User Manual
237
20.0
X(20)
LEFT
SPACES
288
307
21.0
X(02)
LEFT
SPACES
308
309
22.0
X(09)
LEFT
SPACES
310
318
DEFINITION: The mailing address of the Provider identified in FB2-17.0.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Address" entry.
Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB2-23.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
23.0
X(02)
LEFT
SPACES
319
320
DEFINITION: Unused national reserved filler.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: SERVICE LINE DETAIL
RECORD TYPE FB3
Not Required by MO HealthNet
Must follow FB0 and FB2
Must be follow by FB3 - XA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "FB3"
C-24
FB3
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
Not Used
04
LINE ITEM CONTROL NO
Not Used
05
REASON CODE1
Not Used
NSF (National Standard Format) User Manual
238
06
DOLLAR AMOUNT1
Not Used
07
REASON CODE2
Not Used
08
DOLLAR AMOUNT2
Not Used
09
REASON CODE3
Not Used
10
DOLLAR AMOUNT
Not Used
11
REASON CODE4
Not Used
12
DOLLAR AMOUNT
Not Used
13
REASON CODE5
Not Used
14
DOLLAR AMOUNT
Not Used
15
REASON CODE6
Not Used
16
DOLLAR AMOUNT6
Not Used
17
REASON CODE7
Not Used
18
DOLLAR AMOUNT7
Not Used
19
FILLER-NATIONAL
YES
RECORD TYPE: FB3
PURPOSE: To supply prior adjudication status information from primary payors.
REQUIREMENTS: This record must be entered if this is a Coordination of Benefits file and service level
adjustments have been applied.
ORDER:
Preceding Record Type
Following Record Type
FB2
FA0 or XA0
NOTES: When requesting payment from a secondary payor it is extremely important that the EOB/remittance
information be provided from the primary payor(s). This is of major importance in allowing the secondary claim
to be processed without having to request a hardcopy EOB.
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "FB3"
3
X
01
03
02.0
SEQUENCE NO
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
LINE ITEM CONTROL NO
17
X
23
39
NSF (National Standard Format) User Manual
239
05.0
REASON CODE 1
6
X
40
45
06.0
DOLLAR AMOUNT 1
7
N
46
52
07.0
REASON CODE 2
6
X
53
58
08.0
DOLLAR AMOUNT 1
7
N
46
52
09.0
REASON CODE 3
6
X
53
58
10.0
DOLLAR AMOUNT 3
7
N
72
78
11.0
REASON CODE 4
6
X
79
84
12.0
DOLLAR AMOUNT 4
7
N
85
91
13.0
REASON CODES
6
X
92
97
14.0
DOLLAR AMOUNT 5
7
N
98
104
15.0
REASON CODE 6
6
X
105
110
16.0
DOLLAR AMOUNT 6
7
N
111
117
17.0
REASON CODE 7
6
X
118
123
18.0
DOLLAR AMOUNT 7
7
N
124
130
19.0
FILLER-NATIONAL
190
X
131
320
RECORD/FIELD: FB3-01.0
DATA ELEMENT: Record Identifier (RECORD ID "FB3")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: Field used to identify the "SERVICE LINE DETAIL" record.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be "FB3".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FB3-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
NSF (National Standard Format) User Manual
240
DEFINITION: This is the record sequence number of the service line detail record.
CODE VALUES: 01 through 99
VALIDATION: Must be entered.
Must be a valid code from the above list.
The value entered must match the SEQUENCE NUMBER (FB0-02.0) submitted in the preceding "FB0"
record.
FORM LOCATION: N/A
REMARKS: See sequencing instructions on page FB0.04.
RECORD/FIELD: FB3-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: A unique number assigned by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be identical to the "Patient Control Number" (CA0-03.0) of this claim.
See GENERAL INSTRUCTIONS for "Patient Account Number" entry.
FORM LOCATION: CMS-1500 Block 26
REMARKS: The Patient Account Number field is used to associate all of the records for a single claim.
RECORD/FIELD: FB3-04.0
DATA ELEMENT: Line Item Control Number (LINE ITEM CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(17)
LEFT
SPACES
23
39
DEFINITION: An identifier assigned by the submitter/provider to this line item.
CODE VALUES: N/A
VALIDATION: May be entered if payor required.
See GENERAL INSTRUCTIONS for "Patient Account Number" entry.
FORM LOCATION: CMS-1500 Block 26
REMARKS: The Patient Account Number field is used to associate all of the records for a single claim.
NSF (National Standard Format) User Manual
241
RECORD/FIELD: FB3-05.0 FB3-06.0
DATA ELEMENT: Reason Code 1 Dollar Amount 1
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(06)
LEFT
SPACES
40
45
06.0
S9(5)V99
RIGHT
ZEROS
46
52
DEFINITION: Service line adjustment reason code and amount of adjustment. The code shows the reason
for an adjustment, such as denial or reduction in payment from the amount billed, that are made on line
items and may have a financial effect.
CODE VALUES: For Medicare, use the American National Standards Institute (ANSI) Accredited
Standards Committee (ASC) X12 835 claim adjustment (CAS) codes and applicable group code.
VALIDATION: At least one reason code must be shown per claim. This can be at service or claim level.
REMARKS: Claim adjustment reason codes are available from:
Electronic File:
Washington Publishing Company World Wide Web Site
www.wpc-edi.com
Paper Copy:
Blue Cross and Blue Shield Association
Inter-Plan Teleprocessing Services Dept.
676 North St. Clair Street
Chicago, IL 60611
For Medicare, the first two positions contain the X12 835 group code which is part of the ANSI ASC X12
835 standard. The remaining positions contain the claim adjustment reason code, starting with the third
position.
Used for COB exchange.
RECORD/FIELD: FB3-07.0 FB3-08.0
DATA ELEMENT: Reason Code 2 Dollar Amount 2
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(06)
LEFT
SPACES
53
58
08.0
S9(5)V99
RIGHT
ZEROS
59
65
DEFINITION: Service line adjustment reason code and amount of adjustment. The code shows the reason
for an adjustment, such as denial or reduction in payment from the amount billed, that are made on claims
and may have a financial effect.
NSF (National Standard Format) User Manual
242
CODE VALUES: For Medicare, use the American National Standards Institute (ANSI) Accredited
Standards Committee (ASC) X12 835 claim adjustment (CAS) codes and applicable group code.
VALIDATION: At least one reason code must be shown per claim. This can be at service or claim level.
REMARKS: Claim adjustment reason codes are available from:
Electronic File:
Washington Publishing Company World Wide Web Site
www.wpc-edi.com
Paper Copy:
Blue Cross and Blue Shield Association
Inter-Plan Teleprocessing Services Dept.
676 North St. Clair Street
Chicago, IL 60611
For Medicare, the first two positions contain the X12 835 group code which is part of the ANSI ASC X12
835 standard. The remaining positions contain the claim adjustment reason code, starting with the third
position. Used for COB exchange.
RECORD/FIELD: FB3-09.0 FB3-10.0
DATA ELEMENT: Reason Code 3 Dollar Amount 3
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
X(06)
LEFT
SPACES
66
71
10.0
S9(5)V99
RIGHT
ZEROS
72
78
DEFINITION: Service line adjustment reason code and amount of adjustment.
The code shows the reason for an adjustment, such as denial or reduction in payment from the amount
billed, that are made on claims and may have a financial effect.
CODE VALUES: For Medicare, use the American National Standards Institute (ANSI) Accredited
Standards Committee (ASC) X12 835 claim adjustment (CAS) codes and applicable group code.
VALIDATION: At least one reason code must be shown per claim. This can be at service or claim level.
REMARKS: Claim adjustment reason codes are available from:
Electronic File:
Washington Publishing Company World Wide Web Site
www.wpc-edi.com
Paper Copy:
Blue Cross and Blue Shield Association
NSF (National Standard Format) User Manual
243
Inter-Plan Teleprocessing Services Dept.
676 North St. Clair Street
Chicago, IL 60611
For Medicare, the first two positions contain the X12 835 group code which is part of the ANSI ASC X12
835 standard. The remaining positions contain the claim adjustment reason code, starting with the third
position. Used for COB exchange.
RECORD/FIELD: FB3-11.0 FB3-12.0
DATA ELEMENT: Reason Code 4 Dollar Amount 4
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
X(06)
LEFT
SPACES
79
84
12.0
S9(5)V99
RIGHT
ZEROS
85
91
DEFINITION: Service line adjustment reason code and amount of adjustment.
The code shows the reason for an adjustment, such as denial or reduction in payment from the amount
billed, that are made on claims and may have a financial effect.
CODE VALUES: For Medicare, use the American National Standards Institute (ANSI) Accredited
Standards Committee (ASC) X12 835 claim adjustment (CAS) codes and applicable group code.
VALIDATION: At least one reason code must be shown per claim. This can be at service or claim level.
REMARKS: Claim adjustment reason codes are available from:
Electronic File:
Washington Publishing Company World Wide Web Site
www.wpc-edi.com
Paper Copy:
Blue Cross and Blue Shield Association
Inter-Plan Teleprocessing Services Dept.
676 North St. Clair Street
Chicago, IL 60611
For Medicare, the first two positions contain the X12 835 group code which is part of the ANSI ASC X12
835 standard. The remaining positions contain the claim adjustment reason code, starting Used for COB
exchange.
RECORD/FIELD: FB3-13.0 FB3-14.0
DATA ELEMENT: Reason Code 5 Dollar Amount 5
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
X(06)
LEFT
SPACES
92
97
NSF (National Standard Format) User Manual
244
14.0
S9(5)V99
RIGHT
ZEROS
98
104
DEFINITION: Service line adjustment reason code and amount of adjustment.
The code shows the reason for an adjustment, such as denial or reduction in payment from the amount
billed, that are made on claims and may have a financial effect.
CODE VALUES: For Medicare, use the American National Standards Institute (ANSI) Accredited
Standards Committee (ASC) X12 835 claim adjustment (CAS) codes and applicable group code.
VALIDATION: At least one reason code must be shown per claim. This can be at service or claim level.
REMARKS: Claim adjustment reason codes are available from:
Electronic File:
Washington Publishing Company World Wide Web Site
www.wpc-edi.com
Paper Copy:
Blue Cross and Blue Shield Association
Inter-Plan Teleprocessing Services Dept.
676 North St. Clair Street
Chicago, IL 60611
For Medicare, the first two positions contain the X12 835 group code which is part of the ANSI ASC X12
835 standard. The remaining positions contain the claim adjustment reason code, starting with the third
position.
Used for COB exchange.
RECORD/FIELD: FB3-15.0 FB3-16.0
DATA ELEMENT: Reason Code 6 Dollar Amount 6
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
15.0
X(06)
LEFT
SPACES
105
110
16.0
S9(5)V99
RIGHT
ZEROS
111
117
DEFINITION: Service line adjustment reason code and amount of adjustment.
The code shows the reason for an adjustment, such as denial or reduction in payment from the amount
billed, that are made on claims and may have a financial effect.
CODE VALUES: For Medicare, use the American National Standards Institute (ANSI) Accredited
Standards Committee (ASC) X12 835 claim adjustment (CAS) codes and applicable group code.
VALIDATION: At least one reason code must be shown per claim. This can be at service or claim level.
REMARKS: Claim adjustment reason codes are available from:
NSF (National Standard Format) User Manual
245
Electronic File:
Washington Publishing Company World Wide Web Site
www.wpc-edi.com
Paper Copy:
Blue Cross and Blue Shield Association
Inter-Plan Teleprocessing Services Dept.
676 North St. Clair Street
Chicago, IL 60611
For Medicare, the first two positions contain the X12 835 group code which is part of the ANSI ASC X12
835 standard. The remaining positions contain the claim adjustment reason code, starting with the third
position.
RECORD/FIELD: FB3-17.0 FB3-18.0
DATA ELEMENT: Reason Code 7 Dollar Amount 7
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
17.0
X(06)
LEFT
SPACES
118
123
18.0
S9(5)V99
RIGHT
ZEROS
124
130
DEFINITION: Service line adjustment reason code and amount of adjustment.
The code shows the reason for an adjustment, such as denial or reduction in payment from the amount
billed, that are made on claims and may have a financial effect.
CODE VALUES: For Medicare, use the American National Standards Institute (ANSI) Accredited
Standards Committee (ASC) X12 835 claim adjustment (CAS) codes and applicable group code.
VALIDATION: At least one reason code must be shown per claim. This can be at service or claim level.
REMARKS: Claim adjustment reason codes are available from:
Electronic File:
Washington Publishing Company World Wide Web Site
www.wpc-edi.com
Paper Copy:
Blue Cross and Blue Shield Association
Inter-Plan Teleprocessing Services Dept.
676 North St. Clair Street
Chicago, IL 60611
NSF (National Standard Format) User Manual
246
For Medicare, the first two positions contain the X12 835 group code which is part of the ANSI ASC X12
835 standard. The remaining positions contain the claim adjustment reason code, starting with the third
position.
Used for COB exchange.
RECORD/FIELD: FB3-29.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
29.0
X(190)
LEFT
SPACES
131
320
DEFINITION: Unused record space. Reserved for national use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: SERVICE LINE DETAIL
SEGMENT"
RECORD TYPE FD0 "DENTAL
Required for MO HealthNet processing-Dental claims only
Must follow FB0 - FB3
Must be followed by FA0 OR XA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "FD0"
C-24
FD0
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
Not Used
04
LINE ITEM CONTROL NO
Not Used
05
TOOTH CODE NUMBER 1
C-38
YES
06
TOOTH SURFACE(S) 1
C-39
NO
07
TOOTH CODE NUMBER 2
Not Used
08
TOOTH SURFACE(S) 2
Not Used
09
TOOTH CODE NUMBER 3
Not Used
10
TOOTH SURFACE(S) 3
Not Used
11
TOOTH CODE NUMBER 4
Not Used
NSF (National Standard Format) User Manual
247
12
TOOTH SURFACE(S) 4
13
INITIAL PLACE IND
14
PRIOR PLACE DATE
Not Used
15
IMPRESS/PRESCRIPT DT
Not Used
16
REPLACEMENT REASON
Not Used
17
ORTHO TREAT IND
Not Used
18
TREATMENT LENGTH
Not Used
19
DATE APPL INSERTED
Not Used
20
DATE APPL REMOVED
Not Used
21
RESERVED (FD0-21.0)
Not Used
22
DATE APPL REPLACED
Not Used
23
MOS TREAT REMAINING
Not Used
24
DT 1ST VISIT CUR SER
Not Used
25
RESERVED (FD0-25.0)
Not Used
26
PRE DETERMINATION ID
Not Used
27
RESERVED (FD0-27.0)
Not Used
28
MISSING PRIMARY TEETH
Not Used
29
MISSING PERM TOOTH
Not Used
30
MISSING PERM TOOTH
Not Used
31
MISSING PERM TOOTH
Not Used
32
MISSING PERM TOOTH
Not Used
33
MISSING PERM TOOTH
Not Used
34
MISSING PERM TOOTH
Not Used
35
MISSING PERM TOOTH
Not Used
36
MISSING PERM TOOTH
Not Used
37
MISSING PERM TOOTH
Not Used
38
MISSING PERM TOOTH
Not Used
39
MISSING PERM TOOTH
Not Used
40
MISSING PERM TOOTH
Not Used
41
MISSING PERM TOOTH
Not Used
NSF (National Standard Format) User Manual
Not Used
C-37
NO
248
42
MISSING PERM TOOTH
Not Used
43
MISSING PERM TOOTH
Not Used
44
MISSING PERM TOOTH
Not Used
45
MISSING PERM TOOTH
Not Used
46
MISSING PERM TOOTH
Not Used
47
MISSING PERM TOOTH
Not Used
48
MISSING PERM TOOTH
Not Used
49
MISSING PERM TOOTH
Not Used
50
MISSING PERM TOOTH
Not Used
51
MISSING PERM TOOTH
Not Used
52
MISSING PERM TOOTH
Not Used
53
MISSING PERM TOOTH
Not Used
54
MISSING PERM TOOTH
Not Used
55
MISSING PERM TOOTH
Not Used
56
MISSING PERM TOOTH
Not Used
57
MISSING PERM TOOTH
Not Used
58
MISSING PERM TOOTH
Not Used
59
MISSING PERM TOOTH
Not Used
60
MISSING PERM TOOTH
Not Used
61
MISSING PERM TOOTH
Not Used
62
QUANDRANT
Not Used
63
TOOTH POCKET MEASURE
Not Used
64
FILLER-NATIONAL
YES
RECORD TYPE: FD0
LEVEL: CLAIM - DENTAL SEGMENT
PURPOSE: To provide information related to dental services rendered to the patient by the provider.
REQUIREMENTS: If required by the payor, this record must be submitted for dental claims.
ORDER:
Preceding Record Type
Following Record Type
FA0, FB0, FB1, FB2, FB3 or FD0
FE0, FA0, HA0 or XA0
NSF (National Standard Format) User Manual
249
NOTES: There may be up to 99 FXX records entered for a claim. (All "F" records).
DENTAL SEGMENT
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "FDO"
3
X
01
03
02.0
SEQUENCE NO
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
LINE ITEM CONTROL NO
17
X
23
39
05.0
TOOTH CODE NUMBER 1
2
X
40
41
06.0
TOOTH SURFACE (S) 1
5
X
42
46
07.0
TOOTH CODE NUMBER 2
2
X
47
48
08.0
TOOTH SURFACE (S) 2
5
X
49
53
09.0
TOOTH CODE NUMBER 3
2
X
54
55
10.0
TOOTH SURFACE (S) 3
5
X
56
60
11.0
TOOTH CODE NUMBER 4
2
X
61
62
12.0
TOOTH SURFAC (S) 4
5
X
63
67
13.0
INITIAL PLACE IND
1
X
68
68
14.0
PRIOR PLACE DATE
8
X
69
76
15.0
IMPRESS/PRESCRIPT DT
8
X
77
84
16.0
REPLACEMENT REASON
1
X
85
85
17.0
ORTHO TREAT IND
1
X
86
86
18.0
TREATMENT LENGTH
2
X
87
88
19.0
DATE APPL INSERTED
8
X
89
96
20.0
DATE APPL REMOVED
8
X
97
104
21.0
RESERVED (FDO-21.0)
10
X
105
114
22.0
DATE APPL REPLACED
8
X
115
122
23.0
MOS TREAT REMAINING
2
X
123
124
24.0
DT 1ST VISIT CUR SER
8
X
125
132
25.0
RESERVED (FD0-25.0)
10
X
133
142
NSF (National Standard Format) User Manual
250
26.0
PRE DETERMINATION ID
20
X
143
162
27.0
RESERVED (FD0-27.0)
10
X
163
172
28.0
MISSING PRIMARY TEETH
20
X
173
192
29.0
MISSING PERM TOOTH
2
X
193
194
30.0
MISSING PERM TOOTH
2
X
195
196
31.0
MISSING PERM TOOTH
2
X
197
198
32.0
MISSING PERM TOOTH
2
X
199
200
33.0
MISSING PERM TOOTH
2
X
201
202
34.0
MISSING PERM TOOTH
2
X
203
204
35.0
MISSING PERM TOOTH
2
X
205
206
36.0
MISSING PERM TOOTH
2
X
207
208
37.0
MISSING PERM TOOTH
2
X
209
210
38.0
MISSING PERM TOOTH
2
X
211
212
39.0
MISSING PERM TOOTH
2
X
213
214
40.0
MISSING PERM TOOTH
2
X
215
216
41.0
MISSING PERM TOOTH
2
X
217
218
42.0
MISSING PERM TOOTH
2
X
219
220
43.0
MISSING PERM TOOTH
2
X
221
222
44.0
MISSING PERM TOOTH
2
X
223
224
45.0
MISSING PERM TOOTH
2
X
225
226
46.0
MISSING PERM TOOTH
2
X
227
228
47.0
MISSING PERM TOOTH
2
X
229
230
48.0
MISSING PERM TOOTH
2
X
231
232
49.0
MISSING PERM TOOTH
2
X
233
234
50.0
MISSING PERM TOOTH
2
X
235
236
51.0
MISSING PERM TOOTH
2
X
237
238
52.0
MISSING PERM TOOTH
2
X
239
240
53.0
MISSING PERM TOOTH
2
X
241
242
54.0
MISSING PERM TOOTH
2
X
243
244
55.0
MISSING PERM TOOTH
2
X
245
246
NSF (National Standard Format) User Manual
251
56.0
MISSING PERM TOOTH
2
X
247
248
57.0
MISSING PERM TOOTH
2
X
249
250
58.0
MISSING PERM TOOTH
2
X
251
252
59.0
MISSING PERM TOOTH
2
X
253
254
60.0
MISSING PERM TOOTH
2
X
255
256
61.0
MISSING PERM TOOTH
2
X
257
258
62.0
QUADRANT
2
X
259
260
63.0
TOOTH POCKET MEASURE2
X
261
262
64.0
FILLER-NATIONAL
58
X
263
320
RECORD/FIELD: FD0-01.0
DATA ELEMENT: Record Identifier (RECORD ID "FD0")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: This is the record identifier for the Service
Line Detail Record - FD0.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be "FD0".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: This is the record sequence number of the Service Line Detail Record.
CODE VALUES: 01 through 99
VALIDATION: Must be entered. Must be a valid code from the above list. The value entered must match
the "Sequence Number" (FA0-02.0) submitted in the preceding "FA0" record.
FORM LOCATION: N/A
NSF (National Standard Format) User Manual
252
REMARKS: See sequencing instructions on page FA0.04.
RECORD/FIELD: FD0-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: A unique number assigned by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: Must be entered.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
Must be identical to the "Patient Control Number" (CA0-03.0) of this claim.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-04.0
DATA ELEMENT: Line Item Control Number (LINE ITEM CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(17)
LEFT
SPACES
23
39
DEFINITION: An identifier assigned by the submitter/provider to this line item.
CODE VALUES: N/A
VALIDATION: May be entered if payor allowed.
If entered, value must match the "Line Item Control Number" (FA0-04.0) submitted in the preceding
"FA0" record.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-05.0
DATA ELEMENT: Tooth Code Number 1
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(02)
LEFT
SPACES
40
41
DEFINITION: An indication of the tooth on which services were performed or will be performed.
NSF (National Standard Format) User Manual
253
CODE VALUES:
01 Through 09 - Permanent
10 Through 32 - Permanent
A Through T - Primary
SN - Supernumerary
VALIDATION: If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-06.0
DATA ELEMENT: Tooth Surface(s) 1
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(05)
LEFT
SPACES
42
46
DEFINITION: The surface(s) of the tooth on which services were performed or will be performed.
CODE VALUES:
M - Mesial
O - Occlusal
D - Distal
L - Lingual
F - Facial
I - Incisal
B - Buccal
VALIDATION: If entered must be a valid code or combination of up to five codes from the above table.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-07.0
DATA ELEMENT: Tooth Code Number 2
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(02)
LEFT
SPACES
47
48
DEFINITION: An indication of the tooth on which services were performed or will be performed.
CODE VALUES:
01 Through 09 - Permanent
NSF (National Standard Format) User Manual
254
10 Through 32 - Permanent
A Through T - Primary
SN - Supernumerary
VALIDATION: If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-08.0
DATA ELEMENT: Tooth Surface(s) 2
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
08.0
X(05)
LEFT
SPACES
49
53
DEFINITION: The surface(s) of the tooth on which services were performed or will be performed.
CODE VALUES:
M - Mesial
O - Occlusal
D - Distal
L - Lingual
F - Facial
I - Incisal
B - Buccal
VALIDATION: If entered must be valid code or combination of up to five codes from the above table.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-09.0
DATA ELEMENT: Tooth Code Number 3
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
X(02)
LEFT
SPACES
54
55
DEFINITION: An indication of the tooth on which services were performed or will be performed.
CODE VALUES: 01 Through 09 - Permanent 10 Through 32 - Permanent A Through T - Primary SN Supernumerary
NSF (National Standard Format) User Manual
255
VALIDATION: If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-10.0
DATA ELEMENT: Tooth Surface(s) 3
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
X(05)
LEFT
SPACES
56
60
DEFINITION: The surface(s) of the tooth on which services were performed or will be performed.
CODE VALUES:
M - Mesial
O - Occlusal
D - Distal
L - Lingual
F - Facial
I - Incisal
B - Buccal
VALIDATION: If entered must be a valid code or combination of up to five codes from the above table.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-11.0
DATA ELEMENT: Tooth Code Number 4
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
X(02)
LEFT
SPACES
61
62
DEFINITION: An indication of the tooth on which services were performed or will be performed.
CODE VALUES:
01 Through 09 - Permanent
10 Through 32 - Permanent
A Through T - Primary
SN - Supernumerary
VALIDATION: If entered, must be a valid date code from the above list.
NSF (National Standard Format) User Manual
256
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-12.0
DATA ELEMENT: Tooth Surface(s) 4
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(05)
LEFT
SPACES
63
67
DEFINITION: The surface(s) of the tooth on which services were performed or will be performed.
CODE VALUES:
M - Mesial
O - Occlusal
D - Distal
L - Lingual
F - Facial
I - Incisal
B - Buccal
VALIDATION: If entered must be a valid code or combination of up to five codes from the above table.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-13.0
DATA ELEMENT: Initial Placement Indicator (INITIAL PLACE IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
X(01)
LEFT
SPACE
68
68
DEFINITION: A code to indicate whether the prosthesis or restorative service reported is an initial
placement.
CODE VALUES:
Y = Yes
N = No
VALIDATION: If entered, must be a valid code from the above list.
If "N", "Prior Placement Date" (FD0-14.0) must be completed according to payor instructions.
FORM LOCATION: N/A
NSF (National Standard Format) User Manual
257
REMARKS: Must apply to all the tooth codes/numbers reported on this line (Ex: Initial placement
indicator is reported "Y". All tooth codes/numbers reported on this line must be initial placement.)
RECORD/FIELD: FD0-14.0
DATA ELEMENT: Prior Placement Date (PRIOR PLACE DATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
14.0
X(08)
LEFT
SPACES
69
76
DEFINITION: The date of Prior Placement of the Prosthesis, Crown or Inlay, if reason for service is
replacement.
CODE VALUES: N/A
VALIDATION: If entered, must be a valid date.
If "Initial Placement Indicator" = "N", complete according to payor instructions.
See GENERAL INSTRUCTIONS for "date" entry.
FORM LOCATION: N/A
REMARKS: Must be completed according to payor instructions, if service involves replacement of a
prothesis, crown or inlay and the date of prior placement is known.
RECORD/FIELD: FD0-15.0
DATA ELEMENT: Impression/Prescription Date (IMPRESS/PRESCRIPT DT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
15.0
X(08)
LEFT
SPACES
77
84
DEFINITION: The date the impressions were taken for the prosthetic / restorative device.
CODE VALUES: N/A
VALIDATION: If entered, must be valid date.
See GENERAL INSTRUCTIONS for "date" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-16.0
DATA ELEMENT: Replacement Reason
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
16.0
X(01)
LEFT
SPACE
85
85
DEFINITION: Reason the reported prosthetic/restorative device is being replaced.
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CODE VALUES:
1 = Loot
2 = Broken
3 = Accident
4 = No longer serviceable
VALIDATION: If replacement, must be completed according payor instructions.
If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: If services were rendered for orthodontic treatment, this field must be completed according
to payor instructions.
RECORD/FIELD: FD0-17.0
DATA ELEMENT: Orthodontic Treatment Indicator (ORTHO TREAT IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
17.0
X(01)
LEFT
SPACE
86
86
DEFINITION: An indicator as to whether the services performed were or will be for orthodontic
treatment.
CODE VALUES: Y = Yes
VALIDATION: If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-18.0
DATA ELEMENT: Treatment Length
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
X(02)
LEFT
SPACES
87
88
DEFINITION: Length of Treatment, in months, that the patient will be under orthodontic care.
CODE VALUES: 01 through 99.
VALIDATION: If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-19.0
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DATA ELEMENT: Date Appliance Inserted (DT APPL INSERTED)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
19.0
X(08)
LEFT
SPACES
89
96
DEFINITION: The Date an Orthodontic / Prosthetic Appliance was placed.
CODE VALUES: N/A
VALIDATION: If entered, must be valid date.
See GENERAL INSTRUCTIONS for "date" entry.
FORM LOCATION: N/A
REMARKS: If an orthodontic appliance was placed, this field must be completed according to payor
instructions.
RECORD/FIELD: FD0-20.0
DATA ELEMENT: Date Appliance Removed (DT APPL REMOVED)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
20.0
X(08)
LEFT
SPACES
97
104
DEFINITION: The date the Orthodontic / Prosthetic appliance was removed.
CODE VALUES: N/A
VALIDATION: If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "date" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-21.0
DATA ELEMENT: Reserved (FD0-21.0)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
21.0
X(10)
LEFT
SPACES
105
114
DEFINITION: Unused reserved record space.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
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RECORD/FIELD: FD0-22.0
DATA ELEMENT: Date Appliance Replaced (DATE APPL REPLACED)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
22.0
X(08)
LEFT
SPACES
115
122
DEFINITION: The date that the Orthodontic / Prosthetic appliance was replaced.
CODE VALUES: N/A
VALIDATION: If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "date" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-23.0
DATA ELEMENT: Months of Treatment Remaining (MOS TREAT REMAINING)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
23.0
X(02)
LEFT
SPACES
123
124
DEFINITION: The number of months remaining in the Orthodontic series.
CODE VALUES:
01 through 09
10 through 36
VALIDATION: If entered:
Must be numeric.
Must equal 01 through 36.
FORM LOCATION: N/A
REMARKS: Must be completed according to payor instructions if claim is for Dental Orthodontic
treatment and this is the initial and/or transfer claim.
RECORD/FIELD: FD0-24.0
DATA ELEMENT: Date of First Visit Current Series (DT 1ST VISIT CUR SER)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
24.0
X(08)
LEFT
SPACES
125
132
DEFINITION: Date course of treatment began or is expected to begin.
CODE VALUES: N/A
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VALIDATION: If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "date" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-25.0
DATA ELEMENT: Reserved (FD0-25.0)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
25.0
X(10)
LEFT
SPACES
133
142
DEFINITION: Unused reserved record space.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-26.0
DATA ELEMENT: Pre Determination Identifier (PRE DETERMINATION ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
26.0
X(20)
LEFT
SPACES
143
162
DEFINITION: The unique number assigned by the third party payor which identifies the pre-treatment
estimate of requested services for this patient.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: The assigned Pre-treatment Identification Number must be entered if a numbered Pretreatment estimate was returned by the third party payor and any part of this claim is being presented for
the actual completed services.
RECORD/FIELD: FD0-27.0
DATA ELEMENT: Reserved (FD0-27.0)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
27.0
X(10)
LEFT
SPACES
163
172
DEFINITION: Unused reserved record space.
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CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-28.0
DATA ELEMENT: Missing Primary Teeth
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
28.0
X(20)
LEFT
SPACES
173
192
DEFINITION: This field identifies missing primary teeth by tooth letter.
CODE VALUES: A through T.
VALIDATION: If entered, must be a valid value from the above list. Twenty positions are provided to
identify missing primary teeth. One character must be input for each missing tooth. Characters must be
entered in sequence without regard for teeth which are not missing. Imbedded blanks are not allowed.
Example: 'ADT'
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-29.0, FD0-61.0
DATA ELEMENT: Missing Permanent Tooth (MISSING PERM TOOTH)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
29.0
X(02)
LEFT
SPACES
193
194
30.0
X(02)
LEFT
SPACES
195
196
31.0
X(02)
LEFT
SPACES
197
198
32.0
X(02)
LEFT
SPACES
199
200
33.0
X(02)
LEFT
SPACES
201
202
34.0
X(02)
LEFT
SPACES
203
204
35.0
X(02)
LEFT
SPACES
205
206
36.0
X(02)
LEFT
SPACES
207
208
37.0
X(02)
LEFT
SPACES
209
210
38.0
X(02)
LEFT
SPACES
211
212
39.0
X(02)
LEFT
SPACES
213
214
40.0
X(02)
LEFT
SPACES
215
216
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41.0
X(02)
LEFT
SPACES
217
218
42.0
X(02)
LEFT
SPACES
219
220
43.0
X(02)
LEFT
SPACES
221
222
44.0
X(02)
LEFT
SPACES
223
224
45.0
X(02)
LEFT
SPACES
225
226
46.0
X(02)
LEFT
SPACES
227
228
47.0
X(02)
LEFT
SPACES
229
230
48.0
X(02)
LEFT
SPACES
231
232
49.0
X(02)
LEFT
SPACES
233
234
50.0
X(02)
LEFT
SPACES
235
236
51.0
X(02)
LEFT
SPACES
237
238
52.0
X(02)
LEFT
SPACES
239
240
53.0
X(02)
LEFT
SPACES
241
242
54.0
X(02)
LEFT
SPACES
243
244
55.0
X(02)
LEFT
SPACES
245
246
56.0
X(02)
LEFT
SPACES
247
248
57.0
X(02)
LEFT
SPACES
249
250
58.0
X(02)
LEFT
SPACES
251
252
59.0
X(02)
LEFT
SPACES
253
254
60.0
X(02)
LEFT
SPACES
255
256
61.0
X(02)
LEFT
SPACES
257
258
DEFINITION: A series of two digit fields identifying missing permanent teeth or a set of missing teeth by
tooth number.
RECORD/FIELD: FD0-29.0, FD0-61.0
DATA ELEMENT: Missing Permanent Tooth (MISSING PERM TOOTH)
CODE VALUES:
01 through 09
10 through 32
93 - All permanent teeth missing
94 - All upper permanent teeth missing.
95 - All lower permanent teeth missing.
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VALIDATION: If entered:
Must be a valid code from the above list. Missing teeth must be entered in sequence without regard for
teeth which are not missing. Beginning with FD0-29.0, individual fields cannot be entered unless the
immediately preceding field is entered.
Tooth numbers 01 through 32 cannot be entered if 93 (all permanent teeth missing) is entered.
Tooth numbers 01 through 16 cannot be entered if 94 (all upper permanent teeth missing) is entered.
Tooth numbers 17 through 32 cannot be entered if 95 (all lower permanent teeth missing) is entered.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-62.0
DATA ELEMENT: Quadrant
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
62.0
X(02)
LEFT
SPACES
259
260
DEFINITION: The quadrant on which the service was performed or will be performed.
CODE VALUES:
FM - Full Mouth
LL - Lower Left
LR - Lower Right
UL - Upper Left
UR - Upper Right
VALIDATION: If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: Must be completed according to payor instructions, if the corresponding procedure requires
identification of a section of the mouth.
RECORD/FIELD: FD0-63.0
DATA ELEMENT: Tooth Pocket Measurement (TOOTH POCKET MEASURE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
63.0
X(02)
LEFT
SPACES
261
262
DEFINITION: Quantity measurement in millimeters of the distance between the gingival crest and the
base of the tooth pocket.
CODE VALUES: 01 thru 99
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VALIDATION: Must be entered if required by payor. If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FD0-64.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
64.0
X(48)
LEFT
SPACES
263
320
DEFINITION: Unused national reserved filler.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: THIRD PARTY ORGANIZATION RECORD TYPE FEO
Not Required by MO HealthNet
Must follow FB0 - FD0
Must be followed by GC0 - XA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "FEO"
C-24
FEO
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
Not Used
04
LINE ITEM CONTROL NO
Not Used
05
TPO ID NUMBER
Not Used
06
TPO REFERENCE NUMBER
Not Used
07
PRICING METHODOLOGY 2
Not Used
08
ALLOWED AMOUNT
Not Used
09
SAVINGS AMOUNT
Not Used
10
APPROVED HCPCS
Not Used
11
APPROVED UNITS
Not Used
12
REJECTION MESSAGE
Not Used
NSF (National Standard Format) User Manual
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13
AUTHORIZATION NUMBER
Not Used
14
POLICY COMPIANCE CODE
Not Used
15
EXCEPTION CODE
Not Used
16
FILLER-NATIONAL
YES
RECORD TYPE: FE0
LEVEL: CLAIM - THIRD PARTY ORGANIZATION SEGMENT
PURPOSE: To provide information related to Third Party Organization (TPO) claims.
REQUIREMENTS: If required by payor, this record must be submitted.
ORDER:
Preceding Record Type
Following Record Type
FA0, FB0, FB1
FA0, CERT Records, HA0 or XA0
FB2, or FD0
NOTES: There may be up to 99 FXX records entered for a claim. (All "F" records).
TPO SEGMENT
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "FEO"
3
X
01
03
02.0
SEQUENCE NO
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
LINE ITEM CONTROL NO
17
X
23
39
05.0
TPO ID NUMBER
9
X
40
48
06.0
TPO REFERENCE NUMBER
15
X
49
63
07.0
PRICING METHODOLOGY 2
X
64
65
08.0
ALLOWED AMOUNT
7
N
66
72
09.0
SAVINGS AMOUNT
7
N
73
79
10.0
APPROVED HCPCS
5
X
80
84
11.0
APPROVED UNITS
4
N
85
88
12.0
REJECTION MESSAGE
2
X
89
90
13.0
AUTHORIZATION NUMBER
20
X
91
110
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267
14.0
POLICY COMPLIANCE CODE
2
X
111
112
15.0
EXCEPTION CODE
2
X
113
114
16.0
FILLER-NATIONAL
206
X
115
320
RECORD/FIELD: FE0-01.0
DATA ELEMENT: Record Identifier (RECORD ID 'FE0')
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: This is the record identifier for the Service Line Detail Record - FE0.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be 'FE0'.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FE0-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: This is the record sequence number of the Service Line Detail Record.
CODE VALUES: 01 through 99
VALIDATION: Must be entered.
Must be a valid code from the above list.
The value entered must match the SEQUENCE NUMBER (FA0-02.0) submitted in the preceding "FA0"
record.
FORM LOCATION: N/A
REMARKS: See sequencing instructions on page FA0.04.
RECORD/FIELD: FE0-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
NSF (National Standard Format) User Manual
JUSTIFY
INITIAL
FROM
THRU
268
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: A unique number assigned by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: Must be entered.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: CMS-1500 Block 26
REMARKS: N/A
RECORD/FIELD: FE0-04.0
DATA ELEMENT: Line Item Control Number (LINE ITEM CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(17)
LEFT
SPACES
23
39
DEFINITION: An identifier assigned by the submitter/provider to this line item.
CODE VALUES: N/A
VALIDATION: May be entered if payor allowed.
If entered, value must match the "Line Item Control Number" (FA0-04.0) submitted in the preceding FA0
record.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FE0-05.0
DATA ELEMENT: Third Party Organization Identification Number (TPO ID NUMBER)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(09)
LEFT
SPACES
40
48
DEFINITION: Repricing organization identification number.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FE0-06.0
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269
DATA ELEMENT: Third Party Organization Reference Number (TPO REFERENCE NUMBER)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(15)
LEFT
SPACES
49
63
DEFINITION: TPO reference number.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FE0-07.0
DATA ELEMENT: PRICING METHODOLOGY
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(02)
LEFT
SPACES
64
65
DEFINITION: Code specifying pricing methodology at which the claim or line item has been priced or
repriced.
CODE VALUES:
00 = Zero Pricing (Not Covered Under Contract)
01 = Priced as Billed at 100%
02 = Priced at the Standard Fee Schedule
04 = Bundled Pricing
05 = Peer Review Pricing
10 = Other Pricing
11 = Lower of Cost
12 = Ratio of Cost
13 = Cost Reimbursed
14 = Adjustment Pricing
VALIDATION: Must be entered if required by Payor. If entered, must be a valid code value from the
above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FE0-08.0
DATA ELEMENT: ALLOWED AMOUNT
NSF (National Standard Format) User Manual
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FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
08.0
9(05)v99
IGHT
ZEROS
66
72
DEFINITION: The amount allowed by the payor.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
When entered, must be positive unsigned numeric value.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FE0-09.0
DATA ELEMENT: SAVINGS AMOUNT
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
9(05)V99
RIGHT
ZEROS
73
79
DEFINITION: The amount of savings.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
When entered, must be positive unsigned numeric value.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FE0-10.0
DATA ELEMENT: Approved HCPCS Procedure Code (APPROVED HCPCS)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
X(05)
LEFT
SPACES
80
84
DEFINITION: The approved HCPCS code that describes the service.
CODE VALUES: HCPCS code set.
VALIDATION: Must be entered if required by Payor.
If entered, must be a valid HCPCS code.
FORM LOCATION: N/A
REMARKS: N/A
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RECORD/FIELD: FE0-11.0
DATA ELEMENT: Approved Units of Service (APPROVED UNITS)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
9(03)V9
RIGHT
ZEROS
85
88
DEFINITION: The approved number of services rendered in days or units.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
Must be positive unsigned numeric value.
FORM LOCATION: CMS-1500, Block 24G
REMARKS: In order to capture fractional services, use the fourth position with an assumed decimal
position.
RECORD/FIELD: FE0-12.0
DATA ELEMENT: REJECTION MESSAGE
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(02)
LEFT
SPACES
89
90
FROM
THRU
DEFINITION: The reject code returned from the Third Party Organization.
CODE VALUES:
T1 = Cannot Identify Provider as TPO Participant
T2 = Cannot Identify Payer as TPO Participant
T3 = Cannot Identify Insured as TPO Participant
T4 = Payer Name or Identifier Missing
T5 = Certification Information Missing
T6 = Claim Does Not Contain Enough Information for Repricing
VALIDATION: Must be entered if required by Payor.
If entered, must be a valid code from the list above.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FE0-13.0
DATA ELEMENT: AUTHORIZATION NUMBER
FIELD
COBOL PICTURE
NSF (National Standard Format) User Manual
JUSTIFY
INITIAL
272
13.0
X(20)
LEFT
SPACES
91
110
DEFINITION: The TPO authorization number.
CODE VALUES: N/A
VALIDATION: Must be entered if required by Payor.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FE0-14.0
DATA ELEMENT: POLICY COMPLIANCE CODE
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
14.0
X(02)
LEFT
SPACES
111
112
DEFINITION: The code specifying policy compliance.
CODE VALUES:
1 = Procedure Followed (Compliance)
2 = Not Followed - Call Not Made (Non-Compliance Call Not Made)
3 = Not Medically Necessary (Non-Compliance Non-Medically Necessary)
4 = Not Followed Other (Non-Compliance Other)
5 = Emergency Admit to Non-Network Hospital
FORM LOCATION: N/A
VALIDATION: Must be entered if required by Payor.
If entered, must be a valid code from the list above.
REMARKS: N/A
RECORD/FIELD: FE0-15.0
DATA ELEMENT: EXCEPTION CODE
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
15.0
X(02)
LEFT
SPACES
113
114
DEFINITION: Exception code generated by a third party organization.
CODE VALUES:
1 = Non-Network Professional Provider in Network Hospital
2 = Emergency Care
3 = Services or Specialist Not in Network
NSF (National Standard Format) User Manual
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4 = Out of Service Area
5 = State Mandates
6 = Other
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: FE0-16.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
16.0
X(206)
LEFT
SPACES
115
320
DEFINITION: Unused national reserved filler.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: AMBULANCE CERT RECORD TYPE GA0
Not Required by MO HealthNet
Must follow FB0 - FD0
Must be followed by GC0 - XA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "GA0"
C-24
GA0
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
Not Used
04
RESERVED (GA0-04.0)
Not Used
05
PATIENTS WEIGHT
Not Used
06
HOSPITAL ADMIT
Not Used
07
TYPE OF TRANSPORT
Not Used
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08
BED CONFINED-BEFORE
Not Used
09
BED CONFINED-AFTER
Not Used
10
MOVED BY STRETCHER
Not Used
11
UNCONSCIOUS/SHOCK
Not Used
12
EMERGENCY SITUATION
Not Used
13
PHYSICAL RESTRAINTS
Not Used
14
VISIBLE HEMORRHAGING
Not Used
15
TRANSPORTED TO/FOR
Not Used
16
MEDICALLY NECESSARY
Not Used
17
MILES
Not Used
18
ORIGIN INFO
Not Used
19
DESTINATION INFO
Not Used
20
PURPOSE OF ROUND TRIP
Not Used
21
PURPOSE OF STRETCHER
Not Used
22
PATIENT DISCHARGED
Not Used
23
PATIENT ADMITTED
Not Used
24
SERVICES AVAILABLE
Not Used
25
FILLER-NATIONAL
YES
RECORD TYPE: GA0
LEVEL: SERVICE LINE
PURPOSE: To provide additional information related to the ambulance service rendered to the patient.
REQUIREMENTS: If required by the payor, this record must be submitted.
ORDER:
Preceding Record Type
Following Record Type
FA0, FB0, FB1, FB2 or FE0
FA0, HA0, or XA0
NOTES: When used, this record must follow the FA0, FB0, FB1, FB2, or FE0 record related to this service.
FIELD NO.
01.0
FIELD NAME
RECORD ID "GA0"
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FIELD
LENGTH
3
TYPE
X
POSITIONS
FROM
THRU
01
03
275
02.0
SEQUENCE NO
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
RESERVED (GA0-04.0)
17
X
23
39
05.0
PATIENTS WEIGHT
3
X
40
42
06.0
HOSPITAL ADMIT
1
X
43
43
07.0
TYPE OF TRANSPORT
1
X
44
44
08.0
BED CONFINED-BEFORE
1
X
45
45
09.0
BED CONFINED-AFTER
1
X
46
46
10.0
MOVED BY STRETCHER
1
X
47
47
11.0
UNCONSCIOUS/SHOCK
1
X
48
48
12.0
EMERGENCY SITUATION
1
X
49
49
13.0
PHYSICAL RESTRAINTS
1
X
50
50
14.0
VISIBLE HEMORRHAGING
1
X
51
51
15.0
TRANSPORTED TO/FOR
1
X
52
52
16.0
MEDICALLY NECESSARY
1
X
53
53
17.0
MILES
4
X
54
57
18.0
ORIGIN INFO
40
X
58
97
19.0
DESTINATION INFO
40
X
98
137
20.0
PURPOSE OF ROUND TRIP
80
X
138
217
21.0
PURPOSE OF STRETCHER
80
X
218
297
22.0
PATIENT DISCHARGED
1
X
298
298
23.0
PATIENT ADMITTED
1
X
299
299
24.0
SERVICES AVAILABLE
1
X
300
300
25.0
FILLER-NATIONAL
20
X
301
320
RECORD/FIELD: GA0-01.0
DATA ELEMENT: Record Identification (RECORD ID "GA0")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: This is the record identifier for the Ambulance Cert Record - GA0.
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CODE VALUES: N/A
VALIDATION: Must be entered.
Must be "GA0".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GA0-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: A numeric value from 01 through 99 used to sequence the "GA0" record to the
corresponding "FA0" record.
CODE VALUES: 01 through 99
VALIDATION: Must be entered.
Must be a valid code from the above list.
The value entered must match the SEQUENCE NUMBER (FA0-02.0) submitted in the preceding "FA0"
record.
FORM LOCATION: N/A
REMARKS: See sequencing instructions on page FA0.04.
RECORD/FIELD: GA0-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: A unique number assigned by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be identical to the "Patient Control Number" (CA0-03.0) of this claim.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: CMS-1500 Block 26
REMARKS: N/A
RECORD/FIELD: GA0-04.0
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DATA ELEMENT: Reserved Field (GAO 04.0)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(17)
N/A
SPACES
23
39
DEFINITION: Unused reserved record space.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GA0-05.0
DATA ELEMENT: Patient's Weight
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(03)
LEFT
SPACES
40
42
DEFINITION: Weight of patient at time of transport.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, must be numeric values.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GA0-06.0
DATA ELEMENT: Hospital Admit
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(01)
N/A
SPACE
43
43
DEFINITION: A code to indicate if the patient was admitted to a hospital.
CODE VALUES:
Y = Admitted.
N = Not admitted.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid value from above list.
FORM LOCATION: N/A
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REMARKS: N/A
RECORD/FIELD: GA0-07.0
DATA ELEMENT: Type of Transport
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(01)
N/A
SPACE
44
44
DEFINITION: A code to indicate the type of transport.
CODE VALUES:
I = Initial Trip
R = Return Trip
T = Transfer Trip
X = Round Trip
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
If "X" is entered, complete GA0-20.0 according to payor requirements.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GA0-08.0
DATA ELEMENT: Bed Confined-Before
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
08.0
X(01)
N/A
SPACE
45
45
DEFINITION: A code to indicate whether the patient was bed confined before the ambulance service.
CODE VALUES:
Y = Patient was bed confined.
N = Patient was not bed confined.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GA0-09.0
DATA ELEMENT: Bed Confined-After
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FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
X(01)
N/A
SPACE
46
46
DEFINITION: A code to indicate whether the patient was bed confined after the ambulance service.
CODE VALUES:
Y = Patient was bed confined.
N = Patient was not bed confined.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GA0-10.0
DATA ELEMENT: Moved by Stretcher
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
X(01)
N/A
SPACE
47
47
DEFINITION: A code to indicate whether the patient was moved by stretcher.
CODE VALUES:
Y = Patient was moved by stretcher.
N = Patient was not moved by stretcher.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
If "Y" is entered, complete GA0-21.0 according to payor requirements.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GA0-11.0
DATA ELEMENT: Unconscious/Shock
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
X(01)
N/A
SPACE
48
48
DEFINITION: A code to indicate whether the patient was unconscious or in shock.
CODE VALUES:
Y = Patient was unconscious or in shock.
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280
N = Patient was not unconscious or in shock.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GA0-12.0
DATA ELEMENT: Emergency Situation
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(01)
N/A
SPACE
49
49
DEFINITION: A code to indicate whether the patient was transported in an emergency situation.
CODE VALUES:
Y = Emergency situation.
N = Not an emergency situation.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GA0-13.0
DATA ELEMENT: Physical Restraints
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
X(01)
N/A
SPACE
50
50
DEFINITION: A code to indicate whether the patient had to be physically restrained.
CODE VALUES:
Y = Physical restraints needed.
N = No physical restraints used.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
FORM LOCATION: N/A
REMARKS: N/A
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RECORD/FIELD: GA0-14.0
DATA ELEMENT: Visible Hemorrhaging
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
14.0
X(01)
N/A
SPACE
51
51
DEFINITION: A code to indicate whether the patient had visible hemorrhaging.
CODE VALUES:
Y = Visible hemorrhaging noted.
N = No visible hemorrhaging noted.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GA0-15.0
DATA ELEMENT: Transported To/For
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
15.0
X(01)
N/A
SPACE
52
52
DEFINITION: A code to indicate whether the patient was transported to the nearest facility or for other
considerations.
CODE VALUES:
Patient was transported:
A = To nearest facility for care of symptoms and/or complaints.
B = For the benefit of a preferred physician.
C = For the nearness of family members.
D = For the care of a specialist or for availability of specialized equipment.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GA0-16.0
DATA ELEMENT: Medically Necessary
FIELD
COBOL PICTURE
NSF (National Standard Format) User Manual
JUSTIFY
INITIAL
FROM
THRU
282
16.0
X(01)
N/A
SPACE
53
53
DEFINITION: A code to indicate whether the ambulance service was medically necessary.
CODE VALUES:
Y = Medically necessary.
N = Not medically necessary.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GA0-17.0
DATA ELEMENT: Miles
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
17.0
X(04)
LEFT
SPACES
54
57
DEFINITION: Number of miles traveled during this ambulance service.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, must be numeric values.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GA0-18.0
DATA ELEMENT: Origin Information (ORIGIN INFO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
X(40)
LEFT
SPACES
58
97
DEFINITION: Free form description to indicate address, etc.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: N/A
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283
RECORD/FIELD: GA0-19.0
DATA ELEMENT: Destination Information (DESTINATION INFO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
19.0
X(40)
LEFT
SPACES
98
137
DEFINITION: Free form description to indicate address, etc.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GA0-20.0
DATA ELEMENT: Purpose of Round Trip
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
20.0
X(80)
LEFT
SPACES
138
217
DEFINITION: Free form description to indicate the purpose for the round trip ambulance service.
CODE VALUES: N/A
VALIDATION: If "Type of Transport" (GA0-07.0) equals "X", must be completed according to payor
requirements.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GA0-21.0
DATA ELEMENT: Purpose of Stretcher
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
21.0
X(80)
LEFT
SPACES
218
297
DEFINITION: Free form description to indicate the purpose for the usage of a stretcher during the
ambulance service.
CODE VALUES: N/A
VALIDATION: If "Moved by Stretcher" (GA0-10.0) equals "Y", must be completed according to payor
requirements.
FORM LOCATION: N/A
REMARKS: N/A
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RECORD/FIELD: GA0-22.0
DATA ELEMENT: Patient Discharged (PATIENT DISCHARGED)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
22.0
X(01)
LEFT
SPACES
298
298
DEFINITION: A code to indicate if the patient was discharged from the first facility.
CODE VALUES:
Y - Yes, patient was discharged
N - No, patient was not discharged
VALIDATION: Must be entered if required by payor.
If entered, must be a valid value from the above list. This applies only when the patient is being
transported from one facility to another.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GA0-23.0
DATA ELEMENT: Patient Admitted (PATIENT ADMITTED)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
23.0
X(01)
LEFT
SPACES
299
299
DEFINITION: A code to indicate if the patient was admitted to the second facility.
CODE VALUES:
Y - Yes, patient was admitted
N - No, patient was not admitted
VALIDATION: Must be entered if required by payor.
If entered, must be a valid value from the above list. This applies only when the patient is being
transported from one facility to another.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GA0-24.0
DATA ELEMENT: Services Available at Facility (SERVICES AVAILABLE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
24.0
X(01
LEFT
SPACES
300
300
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DEFINITION: A code to indicate if the services provided at the second facility were available at the first
facility.
CODE VALUES:
Y - Yes, services were available at first facility
N - No, services were not available at first facility
VALIDATION: Must be entered if required by payor.
If entered, must be a valid value from the above list.
This applies only when the patient is being transported from one facility to another.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GA0-25.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
25.0
X(20)
LEFT
SPACES
301
320
DEFINITION: Unused reserved filler for National use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: CHIROPRACTIC CERT RECORD TYPE GC0
Not Required by MO HealthNet
Must follow FD0 - GA0
Must be followed by GD0 - XA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "GC0"
C-24
GC0
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
Not Used
04
RESERVED (GC0-04.0)
Not Used
05
INITIAL TREATMENT DATE
Not Used
06
DATE OF LAST X-RAY
Not Used
NSF (National Standard Format) User Manual
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07
NOIN SERIES
Not Used
08
LEVEL OF SUBLUXATION
Not Used
09
TREATMENT MONTHS/YEARS
Not Used
10
NOTREATMENTS - MONTH
Not Used
11
NATURE OF CONDITION
Not Used
12
DATE OF MANIFESTATION
Not Used
13
COMPLICATION IND
Not Used
14
SYMPTOMS DESCRIPTION
Not Used
15
X-RAY IND
Not Used
16
FILLER-NATIONAL
YES
RECORD TYPE: GC0
LEVEL: SERVICE LINE
PURPOSE: To provide additional information related to the chiropractic service rendered to the patient.
REQUIREMENTS: If required by the payor, this record must be submitted.
ORDER:
Preceding Record Type
Following Record Type
FA0, FB0, FB1, FB2 or FE0
FA0, HA0 or XA0
NOTES: When used, this record must follow the FA0, FB0, FB1, FB2, or FE0 record related to this service.
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIO
FROM
01.0
RECORD ID "GC0"
3
X
01
02.0
SEQUENCE NO
2
X
04
03.0
PAT CONTROL NO
17
X
06
04.0
RESERVED (GC0-04.0)
17
X
23
05.0
INITIAL TREATMENT DATE
8
X
40
06.0
DATE OF LAST X-RAY
8
X
48
07.0
NO IN SERIES
7
X
56
08.0
LEVEL OF SUBLUXATION
7
X
63
09.0
TREATMENT MONTHS/YEARS
3
X
70
NSF (National Standard Format) User Manual
287
10.0
NO TREATMENTS - MONTH
2
X
73
11.0
NATURE OF CONDITION
1
X
75
12.0
DATE OF MANIFESTATION
8
X
76
13.0
COMPLICATION IND
1
X
84
14.0
SYMPTOMS DESCRIPTION
160
X
85
15.0
X-RAY IND
1
X
245
16.0
FILLER-NATIONAL
75
X
246
RECORD/FIELD: GC0-01.0
DATA ELEMENT: Record Identification (RECORD ID "GC0")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: This is the record identifier for the Chiropractic Cert Record - GC0.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be "GC0".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GC0-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: A numeric value from 01 through 99 used to sequence the "GC0" record to the
corresponding "FA0" record.
CODE VALUES: 01 through 99
VALIDATION: Must be entered.
Must be a valid code from the above list.
The value entered must match the SEQUENCE NUMBER (FA0-02.0) submitted in the preceding "FA0"
record.
FORM LOCATION: N/A
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REMARKS: See sequencing instructions on page FA0.05.
RECORD/FIELD: GC0-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: A unique number assigned by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be identical to the "Patient Control Number" (CA0-03.0) of this claim.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: CMS-1500 Block 26
REMARKS: N/A
RECORD/FIELD: GC0-04.0
DATA ELEMENT: Reserved Field (GC0 04.0)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(17)
N/A
SPACES
23
39
DEFINITION: Unused reserved record space.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GC0-05.0
DATA ELEMENT: Initial Treatment Date
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(08)
LEFT
SPACES
40
47
DEFINITION: Date that the patient initially sought treatment for this condition.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
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See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GC0-06.0
DATA ELEMENT: Date of Last X-Ray
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(08)
LEFT
SPACES
48
55
DEFINITION: Date of last X-Ray.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GC0-07.0
DATA ELEMENT: Number in Series (NO IN SERIES)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(07)
LEFT
SPACES
56
62
DEFINITION: Number in the series of treatment being submitted on this service line.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, positions 56 through 58 and 60 through 62 must be numeric, and position 59 must contain the
value of dash (-).
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GC0-08.0
DATA ELEMENT: Level of Subluxation
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
08.0
X(07)
LEFT
SPACES
NSF (National Standard Format) User Manual
FROM
THRU
9
290
DEFINITION: Code or codes to identify the specific level of subluxation.
CODE VALUES:
OC = Occiput
T7 = Thoracic 7
C1 = Cervical 1
T8 = Thoracic 8
C2 = Cervical 2
T9 = Thoracic 9
C3 = Cervical 3
T10 = Thoracic 10
C4 = Cervical 4
T11 = Thoracic 11
C5 = Cervical 5
T12 = Thoracic 12
C6 = Cervical 6
L1 = Lumbar 1
C7 = Cervical 7
L2 = Lumbar 2
T1 = Thoracic 1
L3 = Lumbar 3
T2 = Thoracic 2
L4 = Lumbar 4
T3 = Thoracic 3
L5 = Lumbar 5
T4 = Thoracic 4
SA = Sacrum
T5 = Thoracic 5
CO = Coccyx
T6 = Thoracic 6
IL = Ilium
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from above list.
To report consecutive codes, position 66 must be the value of dash (-). Otherwise, blank fill.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GC0-09.0
DATA ELEMENT: Treatment Months or Years for this Series
(TREATMENT MONTHS/YEARS)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
X(03)
LEFT
SPACES
70
72
DEFINITION: Months or years involved in this series of treatments.
CODE VALUES:
For position 70:
M = Month(s).
Y = Year(s).
For positions 71-72:
NSF (National Standard Format) User Manual
291
01-12 if position 70 = M.
01-99 if position 70 = Y.
VALIDATION: Must be entered if required by payor.
If entered, must be valid values from above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GC0-10.0
DATA ELEMENT: Number of Treatments this Month (NO TREATMENTS - MONTH)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
X(02)
LEFT
SPACES
73
74
DEFINITION: Number of treatments rendered to the patient during this current month.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, must be numeric values.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GC0-11.0
DATA ELEMENT: Nature of Condition
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
X(01)
LEFT
SPACES
75
75
DEFINITION: A code to indicate the Nature of the Patient's Condition.
CODE VALUES:
A = Acute Condition
C = Chronic Condition
M = Acute Manifestation of a Chronic Condition
VALIDATION: Must be entered if required by payor.
If entered, must be a valid value from above list.
FORM LOCATION: N/A
REMARKS: N/A
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RECORD/FIELD: GC0-12.0
DATA ELEMENT: Date of Acute Manifestation
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(08)
LEFT
SPACES
76
83
DEFINITION: Date of Acute Manifestation of a Chronic Condition.
CODE VALUES: N/A
VALIDATION: If "Nature of Condition" (GC0-11.0) equals "M", this field must be completed according
to payor
requirements.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GC0-13.0
DATA ELEMENT: Complication Indicator (COMPLICATION IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
X(01)
LEFT
SPACES
84
84
DEFINITION: A code to indicate whether the Patient's condition is Complicated or Uncomplicated.
CODE VALUES:
C = Complicated Condition
U = Uncomplicated Condition
VALIDATION: Must be entered if required by payor.
If entered, must be a valid value from above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GC0-14.0
DATA ELEMENT: Symptoms Description
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
14.0
X(160)
LEFT
SPACES
85
244
DEFINITION: Free form Description of the Patient's condition.
CODE VALUES: N/A
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VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GC0-15.0
DATA ELEMENT: X-Ray Indicator (X-RAY IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
15.0
X(01)
LEFT
SPACES
245
245
DEFINITION: An indicator of whether or not X-Rays are on file for chiropractor spinal manipulation.
CODE VALUES:
Y - Yes, X-Rays are on file, maintained and ready for review.
N - No, X-Rays are not maintained and not available for review.
VALIDATION: Must be entered if required by payor.
If entered, must be valid values from above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GC0-16.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
16.0
X(75)
LEFT
SPACES
246
320
DEFINITION: Unused reserved filler for National use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: CERTIFICATION RECORD TYPE GD0 "DURABLE MEDICAL
EQUIPMENT"
Not Required by MO HealthNet
Must follow FB0 - GC0
Must be followed by GD1 - XA0
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Field No.
Field Name
Table
Value
Default
01
RECORD ID "GD0"
C-24
GD0
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
Not Used
04
CERTIFICATION TYPE
Not Used
05
MEDICAL NECESSITY
Not Used
06
PROGNOSIS
Not Used
07
HCPCS PROCEDURE CODE
Not Used
08
AMBULATORY
Not Used
09
AMBULATION/THERAPY
Not Used
10
CONFINED BED/CHAIR
Not Used
11
ROOM CONFINED
Not Used
12
AMBULATION/MOBILITY
Not Used
13
BODY POSITIONING
Not Used
14
RESPIRATORY/OTHER
Not Used
15
BREATHING IMPAIRED
Not Used
16
FREQ/IMMED CHANGES
Not Used
17
OPERATE CONTROLS
Not Used
18
SIDERAILS PART/BED
Not Used
19
OWNS EQUIPMENT
Not Used
20
MATTRESS/SIDERAILS
Not Used
21
EQUIPMENT/ASSISTANCE
Not Used
22
ORTHOPEDIC IMPAIR
Not Used
23
PLANNED REGIMEN
Not Used
24
DECUBITUS ULCERS
Not Used
25
EQUIPMENT USE
Not Used
26
INSULIN DEPENDENT
Not Used
27
DIABETIC CONTROL
Not Used
28
APNEA EPISODES
Not Used
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29
SURGERY ALTERNATIVE
Not Used
30
TOTAL KNEE REPLACE
Not Used
31
DATE SURGERY
Not Used
32
DATE CPM
Not Used
33
LYMPHEDEMA
Not Used
34
ORDERING PROV LAST
Not Used
35
ORDERING PROV FIRST
Not Used
36
ORDERING PROV MI
Not Used
37
ORDERING PROV ID
Not Used
38
ORDERING PROV PHONE
Not Used
39
DATE CERTIFICATION
Not Used
40
CERTIFICATION ON FILE
Not Used
41
DIAGNOSIS CODE-1
Not Used
42
DIAGNOSIS CODE-2
Not Used
43
DIAGNOSIS CODE-3
Not Used
44
DIAGNOSIS CODE-4
Not Used
45
NURSING HOME IND
Not Used
46
NH FROM DATE
Not Used
47
NH TO DATE
Not Used
48
RESPIRATORY TRACT
Not Used
49
SUPV OF EQUIPMENT USE
Not Used
50
PROPEL/LIFT CHAIR
Not Used
51
LEG ELEVATION
Not Used
52
PATIENT WEIGHT
Not Used
53
RECLINING WHEELCHAIR
Not Used
54
MANUAL OPERATION
Not Used
55
SIDE TRANSFER CHAIR
Not Used
56
FILLER-NATIONAL
YES
RECORD TYPE: GD0
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LEVEL: SERVICE LINE
PURPOSE: To provide information regarding attending physician's certification for durable medical equipment.
REQUIREMENTS: If required by the payor, a "GD0" record must be submitted for the initial certification or
renewal certification when billing for durable medical equipment.
ORDER:
Preceding Record Type
Following Record Type
FA0, FB0, FB1, FB2
FA0, GD1, HA0 or XA0
NOTES: Multiple GD0 records can be submitted when billing for more than one durable medical equipment code
which requires a certification for the initial billing. When used, this record must follow the FA0, FB0, FB1, or
FB2 records related to this service.
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "GD0"
3
X
01
03
02.0
SEQUENCE NO
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
CERTIFICATION TYPE
1
X
23
23
05.0
MEDICAL NECESSITY
2
X
24
25
06.0
PROGNOSIS
20
X
26
45
07.0
HCPCS PROCEDURE CODE
5
X
46
50
08.0
AMBULATORY
1
X
51
51
09.0
AMBULATION/THERAPY
1
X
52
52
10.0
CONFINED BED/CHAIR
1
X
53
53
11.0
ROOM CONFINED
1
X
54
54
12.0
AMBULATION/MOBILITY
1
X
55
55
13.0
BODY POSITIONING
1
X
56
56
14.0
RESPIRATORY/OTHER
1
X
57
57
15.0
BREATHING IMPAIRED
1
X
58
58
16.0
FREQ/IMMED CHANGES
1
X
59
59
17.0
OPERATE CONTROLS
1
X
60
60
18.0
SIDERAILS PART/BED
1
X
61
61
19.0
OWNS EQUIPMENT
1
X
62
62
20.0
MATTRESS/SIDERAILS
1
X
63
63
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21.0
EQUIPMENT/ASSISTANCE
1
X
64
64
22.0
ORTHOPEDIC IMPAIR
1
X
65
65
23.0
PLANNED REGIMEN
1
X
66
66
24.0
DECUBITUS ULCERS
1
X
67
67
25.0
EQUIPMENT USE
1
X
68
68
26.0
INSULIN DEPENDENT
3
X
69
71
27.0
DIABETIC CONTROL
1
X
72
72
28.0
APNEA EPISODES
1
X
73
73
29.0
SURGERY ALTERNATIVE
1
X
74
74
30.0
TOTAL KNEE REPLACE
1
X
75
75
31.0
DATE SURGERY
8
X
76
83
32.0
DATE CPM
8
X
84
91
33.0
LYMPHEDEMA
1
X
92
92
34.0
ORDERING PROV LAST
20
X
93
112
35.0
ORDERING PROV FIRST
12
X
113
124
36.0
ORDERING PROV MI
1
X
125
125
37.0
ORDERING PROV ID
15
X
126
140
38.0
ORDERING PROV PHONE
10
X
141
150
39.0
DATE CERTIFICATION
8
X
151
158
40.0
CERTIFICATION ON FILE
1
X
159
159
41.0
DIAGNOSIS CODE-1
5
X
160
164
42.0
DIAGNOSIS CODE-2
5
X
165
169
43.0
DIAGNOSIS CODE-3
5
X
170
174
44.0
DIAGNOSIS CODE-4
5
X
175
179
45.0
NURSING HOME IND
1
X
180
180
46.0
NH FROM DATE
8
X
181
188
47.0
NH TO DATE
8
X
189
196
48.0
RESPIRATORY TRACT
1
X
197
197
49.0
SUPV OF EQUIPMENT USE
1
X
198
198
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50.0
PROPEL/LIFT CHAIR
1
X
199
199
51.0
LEG ELEVATION
1
X
200
200
52.0
PATIENT WEIGHT
1
X
201
201
53.0
RECLINING WHEELCHAIR
1
X
202
202
54.0
MANUAL OPERATION
1
X
203
203
55.0
SIDE TRANSFER CHAIR
1
X
204
204
56.0
FILLER-NATIONAL
116
X
205
320
RECORD/FIELD: GD0-01.0
DATA ELEMENT: Record Identifier (RECORD ID "GD0")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: Code used to identify the "Durable Medical Equipment Certification" record.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be "GD0".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: A numeric value from 01 through 99 used to sequence the "GD0" records and to associate
"GD0" records with "GD1" records.
CODE VALUES: 01 through 99
VALIDATION: Must be entered.
Must be a valid code from the above list.
The value entered must match the SEQUENCE NUMBER (FA0-02.0) submitted in the preceding "FA0"
record.
FORM LOCATION: N/A
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REMARKS: See sequencing instructions on page FA0.04.
RECORD/FIELD: GD0-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: An identification assigned to the patient by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Patient Control Number".
Must be entered.
FORM LOCATION: CMS-1500 Block 26
REMARKS: The patient control number is used by the EMC system to link all records for a claim. All
records between the record type CA0, up to and including the record type XA0, must have the same
patient control number.
Although up to seventeen characters are allowed, not all payors' systems will record and return seventeen
characters on remittance advices or other documents.
RECORD/FIELD: GD0-04.0
DATA ELEMENT: Type of Certification (CERTIFICATION TYPE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(01)
N/A
SPACE
23
23
INITIAL
FROM
THRU
DEFINITION: The type of certification being billed.
CODE VALUES:
I = Initial Certification
R = Renewal Certification
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-05.0
DATA ELEMENT: Period of Medical Necessity
(MEDICAL NECESSITY)
FIELD
COBOL PICTURE
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300
05.0
X(02)
LEFT
SPACES
24
25
DEFINITION: The number of months this certification covers as prescribed by the ordering physician.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
Enter the number of months this certification covers. Cannot exceed 18 months, unless a lifetime
certification; then enter 99.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-06.0
DATA ELEMENT: Prognosis
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(20)
LEFT
SPACES
26
45
DEFINITION: Enter the prognosis of the patient.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-07.0
DATA ELEMENT: HCPCS Procedure Code
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(05)
LEFT
SPACES
46
50
DEFINITION: Enter a HCPCS code describing the equipment prescribed by the physician.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, must be a valid HCPCS code.
FORM LOCATION: N/A
REMARKS: This will be the same code as entered in the corresponding FA0 record field 09.0.
RECORD/FIELD: GD0-08.0
DATA ELEMENT: Patient Ambulatory (AMBULATORY)
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FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
08.0
X(01)
N/A
SPACE
51
51
DEFINITION: Is the patient ambulatory?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for cane, crutches, walker or wheelchair.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-09.0
DATA ELEMENT: Ambulation/Therapy
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
X(01)
N/A
SPACE
52
52
DEFINITION: Is ambulation impaired and is walking aid used for therapy or mobility?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be one a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for cane, crutches or walker.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-10.0
DATA ELEMENT: Confined to Bed or Chair (CONFINED BED/CHAIR)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
X(01)
N/A
SPACE
53
53
DEFINITION: Is the patient confined to a bed or chair?
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CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for wheelchair, a special wheelchair, decubitus care,
commode, bed pan/urinal, or trapeze bar.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-11.0
DATA ELEMENT: Room Confined
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
X(01)
N/A
SPACE
54
54
DEFINITION: Is patient confined to a room or area without bathroom facilities?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for commode.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-12.0
DATA ELEMENT: Ambulation Impaired/Mobility (AMBULATION/MOBILITY)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(01)
N/A
SPACE
55
55
DEFINITION: Is ambulation impaired and is walking aid used for mobility?
CODE VALUE:
Y = Yes
N = No
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VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for cane, walker or crutches.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-13.0
DATA ELEMENT: Body Positioning
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
X(01)
N/A
SPACE
56
56
DEFINITION: Does the patient's condition require positioning of the body or attachments which would
not be feasible with the use of an ordinary bed?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for standard hospital bed, variable height hospital bed or
an electric hospital bed.
If No, explanation must be given in narrative, GD1-04.0.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-14.0
DATA ELEMENT: Respiratory Condition/Other (RESPIRATORY/OTHER)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
14.0
X(01)
N/A
SPACE
57
57
DEFINITION: Does patient need a trapeze bar to sit up due to respiratory condition or change body
positions for other medical reasons?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
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If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0 is for trapeze bar.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-15.0
DATA ELEMENT: Breathing Impaired
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
15.0
X(01)
N/A
SPACE
58
58
DEFINITION: Is patient's ability to breathe severely impaired?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for compressor, IPPB or nebulizer.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-16.0
DATA ELEMENT: Frequent/Immediate Changes (FREQ/IMMED CHANGES)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
16.0
X(01)
N/A
SPACE
59
59
DEFINITION: Does patient condition require frequent and/or immediate changes in body positions.
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for an electric hospital bed.
FORM LOCATION: N/A
REMARKS: N/A
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RECORD/FIELD: GD0-17.0
DATA ELEMENT: Operate Controls
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
17.0
X(01)
N/A
SPACE
60
60
DEFINITION: Can patient operate controls?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for an electric hospital bed.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-18.0
DATA ELEMENT: Siderails Part of Bed (SIDERAILS PART/BED)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
X(01)
N/A
SPACE
61
61
DEFINITION: Are siderails to be attached to a hospital bed owned by the beneficiary?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0 is for siderails.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-19.0
DATA ELEMENT: Owns Equipment
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
19.0
X(01)
N/A
SPACE
62
62
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DEFINITION: Does patient own equipment?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for repairs, replacement parts, siderails, or mattress.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-20.0
DATA ELEMENT: Mattress/Siderails Used (MATTRESS/SIDERAILS)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
20.0
X(01)
N/A
SPACE
63
63
DEFINITION: Are mattress/siderails being used with prescribed medically necessary hospital bed owned
by the beneficiary?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for mattress or siderails.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-21.0
DATA ELEMENT: Equipment/Assistance
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
21.0
X(01)
N/A
SPACE
64
64
DEFINITION: Does patient need lift to get in or out of bed or to assist in transfer from bed to wheelchair?
CODE VALUE:
Y = Yes
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N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for lift.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-22.0
DATA ELEMENT: Orthopedic Impairment (ORTHOPEDIC IMPAIR)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
22.0
X(01)
N/A
SPACE
65
65
DEFINITION: Does patient have an orthopedic impairment requiring traction equipment which prevents
ambulation during period of use?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for traction and fracture frame.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-23.0
DATA ELEMENT: Planned Regimen of Treatment (PLANNED REGIMEN)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
23.0
X(01)
N/A
SPACE
66
66
DEFINITION: Has item been prescribed as part of a planned regimen of treatment in patient home?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
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If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0 is for decubitus care, heat treatment or pneumatic pump.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-24.0
DATA ELEMENT: Decubitus Ulcers
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
24.0
X(01)
N/A
SPACE
67
67
DEFINITION: Is patient highly susceptible to decubitus ulcers?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0 is for decubitus care.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-25.0
DATA ELEMENT: Equipment Use
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
25.0
X(01)
N/A
SPACE
68
68
DEFINITION: Has patient or a care-giver been instructed in use of equipment?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0 is for pneumatic pump or glucose monitors.
FORM LOCATION: N/A
REMARKS: N/A
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309
RECORD/FIELD: GD0-26.0
DATA ELEMENT: Insulin Dependent
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
26.0
X(03)
N/A
SPACE
69
71
DEFINITION: Describe the condition that demonstrates insulin dependence.
CODE VALUE:
1 - Widely fluctuating blood sugars
2 = Frequent episodes of insulin reactions
3 = Evidence of frequent significant ketosis
N = Patient is not insulin dependent
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for blood glucose monitor.
FORM LOCATION: N/A
REMARKS: Entry of multiple codes is acceptable. Example: if both 1 and 2 apply, enter "12 ".
RECORD/FIELD: GD0-27.0
DATA ELEMENT: Poor Diabetic Control (DIABETIC CONTROL)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
27.0
X(01)
N/A
SPACE
72
72
DEFINITION: Does patient have poor diabetic control?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for blood glucose monitor.
If yes, explanation must be given in narrative, GD1-04.0.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-28.0
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DATA ELEMENT: Episodes of Apnea (APNEA EPISODES)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
28.0
X(01)
N/A
SPACE
73
73
DEFINITION: Does a 6-7 hour nocturnal study document 30 episodes of apnea each lasting more than 10
seconds?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for nasal CPAP.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-29.0
DATA ELEMENT: Surgery Alternative
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
29.0
X(01)
N/A
SPACE
74
74
DEFINITION: Without the equipment, would the patient require surgery?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for nasal CPAP.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-30.0
DATA ELEMENT: Total Knee Replacement (TOTAL KNEE REPLACE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
30.0
X(01)
N/A
SPACE
75
75
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DEFINITION: Has patient had a total knee replacement?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0 is for continuous positive motion device.
If yes, date of surgery, GD0-31.0, and date started CPM, GD0-32.0, must be completed.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-31.0
DATA ELEMENT: Date of Surgery (DATE SURGERY)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
31.0
X(08)
LEFT
SPACES
76
83
DEFINITION: The date surgery was performed for total knee replacement.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Date" entry.
Must be entered if required by payor.
If entered, must be a valid date.
Must be entered if total knee replacement, GD0-30.0 is "Y".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-32.0
DATA ELEMENT: Date CPM Started (DATE CPM)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
32.0
X(08)
LEFT
SPACES
84
91
DEFINITION: The date the patient began using CPM.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Date" entry.
Must be entered if required by payor.
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If entered, must be a valid date.
Must be entered if total knee replacement, GD0-30.0 is "Y".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-33.0
DATA ELEMENT: Intractable Lymphedema (LYMPHEDEMA)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
33.0
X(01)
N/A
SPACE
92
92
DEFINITION: Does patient have intractable lymphedema of the extremities?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for pneumatic pump.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-34.0 GD0-35.0 GD0-36.0
DATA ELEMENT:
Ordering Physician Last Name
(ORDERING PROV LAST)
Ordering Physician First Name
(ORDERING PROV FIRST)
Ordering Physician Middle Initial
(ORDERING PROV MI)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
34.0
X(20)
LEFT
SPACES
93
112
35.0
X(12)
LEFT
SPACES
113
124
36.0
X(01)
N/A
SPACE
125
125
DEFINITION: The name of the physician who prescribed the durable medical equipment.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
See GENERAL INSTRUCTIONS for "Name 1" entry.
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FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-37.0
DATA ELEMENT: Ordering Provider ID (ORDERING PROV ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
37.0
X(15)
LEFT
SPACES
126
140
DEFINITION: The identifier assigned by the payor to the physician who prescribed the durable medical
equipment.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-38.0
DATA ELEMENT: Ordering Provider Phone (ORDERING PROV PHONE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
38.0
X(10)
LEFT
SPACES
141
150
DEFINITION: The telephone number of the physician who prescribed the durable medical equipment.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
See GENERAL INSTRUCTIONS for "Phone" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-39.0
DATA ELEMENT: Date of Certification (DATE CERTIFICATION)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
39.0
X(08)
LEFT
SPACES
151
158
DEFINITION: The date the certification was completed by the prescribing physician.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Date" entry.
NSF (National Standard Format) User Manual
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Must be entered if required by payor.
If entered, must be a valid date.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-40.0
DATA ELEMENT: Certification on File (CERTIFICATION ON FILE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
40.0
X(01)
N/A
SPACE
159
159
DEFINITION: The certification signed by the physician is on file at the supplier's office.
CODE VALUES:
Y = Yes, certification is on file.
N = No, certification is not on file.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-41.0 GD0-42.0 GD0-43.0 GD0-44.0
DATA ELEMENT:
Diagnosis Code-1
Diagnosis Code-2
Diagnosis Code-3
Diagnosis Code-4
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
41.0
X(05)
LEFT
SPACES
160
164
42.0
X(05)
LEFT
SPACES
165
169
43.0
X(05)
LEFT
SPACES
170
174
44.0
X(05)
LEFT
SPACES
175
179
DEFINITION: The ICD-9-CM diagnosis code identifying a diagnosed medical condition resulting in the
prescription for durable medical equipment.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
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Must be the most specific/precise 3 digit, 4 digit or 5 digit code allowed for in the ICD-9-CM coding
format.
Do not submit a decimal point. The decimal point is implied.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-45.0
DATA ELEMENT: Nursing Home Indicator (NURSING HOME IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
45.0
X(01)
N/A
SPACE
180
180
DEFINITION: Is the patient in a nursing home?
CODE VALUES:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-46.0 GD0-47.0
DATA ELEMENT:
Nursing Home From Date
(NH FROM DATE)
Nursing Home To Date
(NH TO DATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
46.0
X(08)
LEFT
SPACES
181
188
47.0
X(08)
LEFT
SPACES
189
196
DEFINITION: The from and to dates the patient was in a nursing home.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Date" entry.
Must be entered if required by payor.
If entered, must be a valid date.
FORM LOCATION: N/A
REMARKS: N/A
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RECORD/FIELD: GD0-48.0
DATA ELEMENT: Respiratory Tract Secretions (RESPIRATORY TRACT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
48.0
X(01)
N/A
SPACE
197
197
DEFINITION: Does patient have mobilizing respiratory tract secretions?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for percussor.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-49.0
DATA ELEMENT: Supervision of Equipment Use (SUPV OF EQUIPMENT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
49.0
X(01)
N/A
SPACE
198
198
DEFINITION: Is patient or care giver capable of using the equipment without technical or professional
supervision?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for a suction machine.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-50.0
DATA ELEMENT: Propel/Lift Wheelchair (PROPEL/LIFT CHAIR)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
50.0
X(01)
N/A
SPACE
199
199
NSF (National Standard Format) User Manual
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DEFINITION: Is patient or care giver unable to propel or lift a standard weight wheelchair?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for a light weight wheelchair.
Explanation must be given in narrative, GD1-04.0.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-51.0
DATA ELEMENT: Leg Elevation
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
51.0
X(01)
N/A
SPACE
200
200
DEFINITION: Does the patient require leg elevation edema or body alignment?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for an elevating legs wheelchair.
Explanation must be given in narrative, GD1-04.0.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-52.0
DATA ELEMENT: Patient's Weight (PATIENT WEIGHT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
52.0
X(01)
N/A
SPACE
201
201
DEFINITION: Does the patient's weight or usage needs necessitate a heavy duty wheelchair?
NSF (National Standard Format) User Manual
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CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for an extra wide / heavy duty wheelchair.
Explanation must be given in narrative, GD1-04.0.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-53.0
DATA ELEMENT: Reclining Wheelchair
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
53.0
X(01)
N/A
SPACE
202
202
DEFINITION: Does patient require reclining function of wheelchair?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for a reclining wheelchair.
Explanation must be given in narrative, GD1-04.0.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-54.0
DATA ELEMENT: Manual Operation Chair (MANUAL OPERATION)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
54.0
X(01)
N/A
SPACE
203
203
DEFINITION: Is patient unable to operate a wheelchair manually?
CODE VALUE:
Y = Yes
N = No
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VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for a power/electric wheelchair.
Explanation must be given in narrative, GD1-04.0.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-55.0
DATA ELEMENT: Side Transfer Wheelchair (SIDE TRANSFER CHAIR)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
55.0
X(01)
N/A
SPACE
204
204
DEFINITION: Does patient or caregiver require side transfer into wheelchair, commode or other?
CODE VALUE:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
Must be entered if HCPCS code, GD0-07.0, is for a detachable arms wheelchair.
Explanation must be given in narrative, GD1-04.0.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD0-56.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
56.0
X(116)
LEFT
SPACES
205
320
DEFINITION: Reserved record space for national use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
NSF (National Standard Format) User Manual
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The following chart lists specific fields which must be completed for the various types of equipment.
EQUIPMENT
FIELD(S)
Cane, Crutches, Walker
GD0-08.0, GD0-09.0, GD0-12.0
Wheelchair
GD0-08.0, GD0-10.0
Special Wheelchair
GD0-08.0, GD0-10.0, GD0-50.0, GD0-51.0, GD052.0, GD0-53.0, GD0-54.0, GD0-55.0, GD1-04.0
Decubitus Care
GD0-10.0, GD0-23.0, GD0-24.0
Compressor, IPPB or Nebulizer
GD0-15.0
Repairs and Replacement Parts
GD0-19.0, GD1-04.0 and any other fields necessary to
certify equipment
Traction and Fracture Frame
GD0-22.0
Continuous Passive Motion
GD0-30.0, GD0-31.0, GD0-32.0
Heat Application
GD0-23.0, GD1-04.0
Commode
GD0-10.0, GD0-11.0
Bed Plan/Urinal
GD0-10.0
Sitz Bath
GD1-04.0
Standard Hospital Bed
GD0-13.0
Variable Height Hospital Bed
GD0-13.0, GD1-04.0
Electric Hospital Bed
GD0-13.0, GD0-16.0, GD0-17.0, GD1-04.0
Mattress
GD0-19.0, GD0-20.0
Siderails
GD0-18.0, GD0-19.0, GD0-20.0
Trapeze Bar
GD0-10.0, GD0-14.0
Lift
GD0-21.0
Pneumatic Pump
GD0-23.0, GD0-25.0, GD0-33.0
Infusion Pump
GD1-04.0
Blood Glucose Monitors
GD0-25.0, GD0-26.0, GD0-27.0
Nasal CPAP
GD0-28.0, GD0-29.0, GD1-04.0
Percussor
GD0-48.0
RECORD NAME: CERTIFICATION RECORD TYPE GD1 "NARRATIVE
INFORMATION FOR DME"
Not Required by MO HealthNet
NSF (National Standard Format) User Manual
321
Must follow FB0 - GD0
Must be followed by GE0 - XA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "GD1"
C-24
GD1
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
Not Used
04
NARRATIVE
Not Used
05
FILLER-NATIONAL
YES
RECORD TYPE: GD1
LEVEL: SERVICE LINE
PURPOSE: To provide NARRATIVE information regarding the attending physician's certification of durable
medical equipment.
REQUIREMENTS: If required by payor a "GD1" record must be submitted the initial certification or renewal
certification for the following:
1. Special wheelchair
2. Heat application
3. Sitz bath
4. Variable height hospital bed
5. Electric hospital bed
6. Nasal CPAP
7. Infusion pump
8. Repairs
ORDER:
FIELD NO.
Preceding Record Type
Following Record Type
GD0
FA0, HA0 or XA0
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "GD1"
3
X
01
03
02.0
SEQUENCE NO
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
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04.0
NARRATIVE
250
X
23
272
05.0
FILLER-NATIONAL
48
X
273
320
RECORD/FIELD: GD1-01.0
DATA ELEMENT: Record Identifier (RECORD ID "GD1")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: Code used to identify the "Narrative Information for DME" record.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be "GD1".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD1-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: A numeric value from 01 through 99 used to sequence the "GD1" records and to associate
"GD0" records with "GD1" records.
CODE VALUES: 01 through 99
VALIDATION: Must be entered.
Must be a valid code from the above list.
The value entered must match the SEQUENCE NUMBER (GD0-02.2) submitted in the preceding "GD0"
record.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD1-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
NSF (National Standard Format) User Manual
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DEFINITION: An identification assigned to the patient by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Patient Control Number".
Must be entered.
FORM LOCATION: CMS-1500 Block 26
REMARKS: The patient control number is used by the EMC system to link all records for a claim. All
records between the record type CA0, up to and including the record type XA0, must have the same
patient control number. Although up to seventeen characters are allowed, not all payors' systems will
record and return seventeen characters on remittance advices or other documents.
RECORD/FIELD: GD1-04.0
DATA ELEMENT: Narrative
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(250)
LEFT
SPACES
23
272
DEFINITION: Enter a detailed explanation for the medical necessity of the equipment including the
following for listed equipment.
Special wheelchair, heat application equipment, Sitz bath, variable height hospital bed, electric hospital
bed, nasal CPAP:
Explanation of how equipment is therapeutically beneficial to the patient's treatment program or
necessary for the patient's condition.
Hospital bed:
What body position or special attachments are required?
Infusion pump:
Drugs or agents being administered with infusion pump.
Repairs:
HCPCS code and/or a complete narrative description of the item being repaired.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GD1-05.0
DATA ELEMENT: Filler-National
NSF (National Standard Format) User Manual
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FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(48)
LEFT
SPACES
273
320
DEFINITION: Reserved record space for national use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: CERTIFICATION RECORD TYPE GE0 "ENTERAL NUTRITION
THERAPY"
Not Required by MO HealthNet
Must follow FB0 - GD1
Must be followed by GP0 - XA0
Field No.
Field Name
Table
Value
01
RECORD ID "GE0"
C-24
GE0
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
Not Used
04
CERTIFICATION TYPE
Not Used
05
ONSET DT OF THERAPY
Not Used
06
THERAPY DURATION
Not Used
07
LAST CERT DATE
Not Used
08
NO OF MONTHS CERT
Not Used
09
DT LAST SEEN BY PHY
Not Used
10
NON VISIT IND
Not Used
11
PAT AGE
Not Used
12
PAT HEIGHT
Not Used
13
PAT WEIGHT
Not Used
14
LEVEL OF CONS IND
Not Used
15
AMBULATORY IND
Not Used
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325
16
OTHER FORMS OF NUTR IND
Not Used
17
METHOD ADMIN IND
Not Used
18
ADMIN TECH IND
Not Used
19
TOTAL CAL PER DAY
Not Used
20
PRODUCT NAME 1
Not Used
21
CAL PER PRODUCT 1
Not Used
22
HCPCS PROCEDURE CODE
Not Used
23
HCPCS MODIFIER 1
Not Used
24
HCPCS MODIFIER 2
Not Used
25
ENTERAL FREQ FED 1
Not Used
26
NARRATIVE FIELD
Not Used
27
PRODUCT NAME 2
Not Used
28
CAL PER PRODUCT 2
Not Used
29
ENTERAL FREQ FED 2
Not Used
30
FILLER-NATIONAL
YES
RECORD TYPE: GE0
LEVEL: SERVICE LINE
PURPOSE: To provide information regarding certification of medical necessity for ENTERAL Nutrition
Therapy.
REQUIREMENTS: If required by the payor, the "GE0" record must be submitted for the initial certification,
revised certification and renewal certification when billing for Enteral Nutrition Therapy.
ORDER:
Preceding Record Type
Following Record Type
FA0, FB0, FB1, or FB2
FA0, HA0 or XA0
NOTES: When used, this record must follow the FA0, FB0, FB1 or FB2 records related to this service.
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "GE0"
3
X
01
03
02.0
SEQUENCE NO
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
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04.0
CERTIFICATION TYPE
1
X
23
23
05.0
ONSET DT OF THERAPY
8
X
24
31
06.0
THERAPY DURATION
2
X
32
33
07.0
LAST CERT DATE
8
X
34
41
08.0
NO OF MONTHS CERT
2
X
42
43
09.0
DT LAST SEEN BY PHY
8
X
44
51
10.0
NON VISIT IND
1
X
52
52
11.0
PAT AGE
3
X
53
55
12.0
PAT HEIGHT
3
X
56
58
13.0
PAT WEIGHT
3
X
59
61
14.0
LEVEL OF CONS IND
1
X
62
62
15.0
AMBULATORY IND
1
X
63
63
16.0
OTHER FORMS OF NUTR IND
1
X
64
64
17.0
METHOD ADMIN IND
1
X
65
65
18.0
ADMIN TECH IND
1
X
66
66
19.0
TOTAL CAL PER DAY
4
N
67
70
20.0
PRODUCT NAME 1
15
X
71
85
21.0
CAL PER PRODUCT 1
4
N
86
89
22.0
HCPCS PROCEDURE CODE
5
X
90
94
23.0
HCPCS MODIFIER 1
2
X
95
96
24.0
HCPCS MODIFIER 2
2
X
97
98
25.0
ENTERAL FREQ FED 1
3
X
99
101
26.0
NARRATIVE FIELD
100
X
102
201
27.0
PRODUCT NAME 2
15
X
202
216
28.0
CAL PER PRODUCT 2
4
N
217
220
29.0
ENTERAL FREQ FED 2
3
X
221
223
30.0
FILLER-NATIONAL
97
X
224
320
RECORD/FIELD: GE0-01.0
DATA ELEMENT: Record Identifier (RECORD ID "GE0")
NSF (National Standard Format) User Manual
327
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: This field is used to identify the "ENTERAL NUTRITION THERAPY" record.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be "GE0".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GE0-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: A numeric value from 01 through 99 used to sequence the "GE0" record to the
corresponding "FA0" record.
CODE VALUES: 01 through 99
VALIDATION: Must be entered.
Must be a valid code from the above list.
The value entered must match the SEQUENCE NUMBER (FA0-02.0) submitted in the preceding "FA0"
record.
FORM LOCATION: N/A
REMARKS: See sequencing instructions on page FA0.04.
RECORD/FIELD: GE0-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: An identification assigned to the patient by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS FOR "Patient Control Number".
Must be entered.
NSF (National Standard Format) User Manual
328
FORM LOCATION: CMS-1500 BLOCK 26
REMARKS: The patient control number is used by the EMC system to link all records for a claim. All
records between the record type CA0, up to and including the record type XA0, must have the same
patient control number.
Although up to seventeen characters are allowed, not all carrier's systems will record and return seventeen
characters on remittance advices or other documents.
RECORD/FIELD: GE0-04.0
DATA ELEMENT: Type of Certification (CERTIFICATION TYPE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(01)
N/A
SPACE
23
23
DEFINITION: The type of certification being billed.
CODE VALUES:
I = Initial Certification
R = Renewal Certification
S = Revised Certification
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: OMB 09380233 Block A1-3
REMARKS: N/A
RECORD/FIELD: GE0-05.0
DATA ELEMENT: Date Therapy Began (ONSET DT OF THERAPY)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(08)
LEFT
SPACES
24
31
DEFINITION: The date the patient began receiving Enteral Therapy.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: OMB 09380233, II.A.
REMARKS: N/A
RECORD/FIELD: GE0-06.0
NSF (National Standard Format) User Manual
329
DATA ELEMENT: Therapy Duration
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(02)
LEFT
SPACES
32
33
DEFINITION: The estimated duration of therapy. (number of months, years or life (99)).
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233, II.A.
REMARKS: N/A
RECORD/FIELD: GE0-07.0
DATA ELEMENT: Last Date of Certification (LAST CERT DATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(08)
LEFT
SPACES
34
41
DEFINITION: The date of the last certification.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry
FORM LOCATION: OMB 09380233
REMARKS: N/A
RECORD/FIELD: GE0-08.0
DATA ELEMENT: Number of Months of Certification (NO OF MONTHS CERT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
08.0
X(02)
LEFT
SPACES
42
43
DEFINITION: The number of months covered by this certification.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233
REMARKS: N/A
RECORD/FIELD: GE0-09.0
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330
DATA ELEMENT: Date Last Seen By Physician (DT LAST SEEN BY PHY)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
X(08)
LEFT
SPACES
44
51
DEFINITION: The date the patient was last seen by the referring/ordering physician during this
certification/recertification period.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
See GENERAL INSTRUCTION for "Date" entry.
FORM LOCATION: OMB 09380233, III.D.
REMARKS: If no visit, then provide reason in GE0-26.0.
RECORD/FIELD: GE0-10.0
DATA ELEMENT: Non Physician Visit Indicator (NON VISIT IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
X(01)
LEFT
SPACES
52
52
DEFINITION: A code used to describe what the medical evaluation is based on, when not based on
physician visit.
CODE VALUES:
N = Visiting Nurse
L = Lab/Clinical Reports
O = Other
Blank = Not applicable
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: OMB 09380233, III.D.
REMARKS: If the physician has not seen the patient during this certification/recertification period an
entry must be made in this field and an additional explanation should be entered in the "Narrative Field"
(GE0-26.0).
RECORD/FIELD: GE0-11.0
DATA ELEMENT: Patient Age (PAT AGE)
FIELD
COBOL PICTURE
NSF (National Standard Format) User Manual
JUSTIFY
INITIAL
FROM
THRU
331
11.0
X(03)
LEFT
SPACES
53
55
DEFINITION: The patient's age.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233, II.B.
REMARKS: N/A
RECORD/FIELD: GE0-12.0
DATA ELEMENT: Patient's Height (PAT HEIGHT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(03)
LEFT
SPACES
56
58
DEFINITION: The patient's height (inches).
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233, II.B.
REMARKS: N/A
RECORD/FIELD: GE0-13.0
DATA ELEMENT: Patient's Weight (PAT WEIGHT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
X(03)
LEFT
SPACES
59
61
DEFINITION: The patient's weight in pounds.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233, II.B.
REMARKS: N/A
RECORD/FIELD: GE0-14.0
DATA ELEMENT: Level of Consciousness Indicator (LEVEL OF CONS IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
14.0
X(01)
LEFT
SPACES
62
62
NSF (National Standard Format) User Manual
332
DEFINITION: An indicator used to describe the patient's level of consciousness.
CODE VALUES:
C = Conscious
I = Consciousness Impaired
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
FORM LOCATION: OMB 09380233, II.B.
REMARKS: N/A
RECORD/FIELD: GE0-15.0
DATA ELEMENT: Ambulatory Indicator (AMBULATORY IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
15.0
X(01)
LEFT
SPACES
63
63
DEFINITION: An indicator used to describe whether or not the patient is ambulatory.
CODE VALUES:
A = Ambulatory
N = Non-Ambulatory
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
FORM LOCATION: OMB 09380233, II.C.
REMARKS: N/A
RECORD/FIELD: GE0-16.0
DATA ELEMENT: Other Forms of Nutrient Indicator (OTHER FORMS OF NUTR IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
16.0
X(01)
LEFT
SPACES
64
64
DEFINITION: An indicator used to describe whether or not this feeding is the only form of nutritional
intake for this patient.
CODE VALUES:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
NSF (National Standard Format) User Manual
333
If entered, must be a valid code from the list above.
FORM LOCATION: OMB 09380233, III.C.
REMARKS: If this field equals "N" an explanation should be entered in the "Narrative Field" (GE0-26.0)
giving name, amount (calories or %), and method of consumption of the additional nutrients
administered.
RECORD/FIELD: GE0-17.0
DATA ELEMENT: Method of Administration Indicator (METHOD ADMIN IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
17.0
X(01)
LEFT
SPACES
65
65
DEFINITION: An indicator used to describe the method used to administer the nutrient to the patient.
CODE VALUES:
S = Syringe
G = Gravity
P = Pump
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
FORM LOCATION: OMB 09380233, V.D.
REMARKS: If this field equals "P" an explanation should be entered in the "Narrative Field" (GE0-26.0)
describing patient's condition that necessitates use of the pump.
RECORD/FIELD: GE0-18.0
DATA ELEMENT: Administration Technique Indicator (ADMIN TECH IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
X(01)
LEFT
SPACES
66
66
DEFINITION: An indicator used to describe the technique used to administer the nutrient to the patient.
CODE VALUES:
N = Nasogastric Tube
G = Gastrostomy
J = Jejunostomy
O = Other
VALIDATION: Must be entered if required by payor.
If entered, must a be a valid code from the list above.
NSF (National Standard Format) User Manual
334
FORM LOCATION: OMB 09380233, V.F.
REMARKS: If "O" (other), provide information in "Narrative Field" (GE0-26.0).
RECORD/FIELD: GE0-19.0
DATA ELEMENT: Total Calories Per Day (TOTAL CAL PER DAY)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
19.0
9(04)
RIGHT
ZEROS
67
70
DEFINITION: The total number of calories per day of all nutrients prescribed by the referring/rendering
physician for this patient.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233, V.B.
REMARKS: If number of calories is greater than "2000" an explanation should be entered in the
"Narrative Field" (GE0-26.0).
RECORD/FIELD: GE0-20.0
DATA ELEMENT: Product Name 1
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
20.0
X(15)
LEFT
SPACES
71
85
DEFINITION: The name of the product (nutrient) being administered to the patient.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233, V.A.
REMARKS: N/A
RECORD/FIELD: GE0-21.0
DATA ELEMENT: Calories Per Product 1 (CAL PER PRODUCT 1)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
21.0
9(04)
RIGHT
ZEROS
86
89
DEFINITION: The number of calories per day prescribed by the referring/ordering physician for this
product, for this patient.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
NSF (National Standard Format) User Manual
335
FORM LOCATION: OMB 09380233, V.B.
REMARKS: If number of calories is greater than "2000" an explanation should be entered in the
"Narrative Field" (GE0-26.0).
RECORD/FIELD: GE0-22.0
DATA ELEMENT: HCPCS Procedure Code
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
22.0
X(05)
LEFT
SPACES
90
94
DEFINITION: This is the HCPCS/CPT-4 code that describes the service/nutrient.
CODE VALUES: HCPCS/CPT-4 Code Set.
VALIDATION: Must be entered if required by payor.
If entered, must be a valid HCPCS/CPT-4 procedure code.
FORM LOCATION: CMS-1500 Block 24d
REMARKS: This will be the same code as entered in the corresponding FA0 record (FA0-09.0)
RECORD/FIELD: GE0-23.0
DATA ELEMENT:
HCPCS Modifier 1
HCPCS Modifier 2
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
23.0
X(02)
LEFT
SPACES
95
96
24.0
X(02)
LEFT
SPACES
97
98
DEFINITION: These codes identify special circumstances related to the performance of the service.
CODE VALUES: See current HCPCS Modifier Codes.
VALIDATION: Must be entered if required by payor for proper adjudication of the service.
FORM LOCATION: CMS-1500 Block 24D
REMARKS: N/A
RECORD/FIELD: GE0-25.0
DATA ELEMENT: Enteral Frequency Fed 1 (ENTERAL FREQ FED 1)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
25.
X(03)
LEFT
SPACES
99
101
NSF (National Standard Format) User Manual
336
DEFINITION: The number of times per day that the patient was fed.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233, V.C.
REMARKS: N/A
RECORD/FIELD: GE0-26.0
DATA ELEMENT: Narrative Field
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
26.0
X(100)
LEFT
SPACES
102
201
DEFINITION: A narrative field use to describe special circumstances, medical justification or any
additional comments necessary for proper adjudication of the claim.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor for proper adjudication of the claim.
FORM LOCATION: OMB 09380233
REMARKS: Some examples of when this field is needed are as follows:
1. If GE0-10.0 is other than "blank".
2. If GE0-16.0 is equal to "N".
3. If GE0-17.0 is equal to "P".
4. If GE0-18.0 is equal to "O".
5. If GE0-19.0, GE0-21.0 and/or GE0-28.0 is greater than "2000".
If additional information is needed, an "HA0" record can be used.
RECORD/FIELD: GE0-27.0
DATA ELEMENT: Product Name 2
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
27.0
X(15)
LEFT
SPACES
202
216
DEFINITION: The name of the product (nutrient) being administered to the patient.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233, V.A.
REMARKS: N/A
NSF (National Standard Format) User Manual
337
RECORD/FIELD: GE0-28.0
DATA ELEMENT: Calories Per Product 2 (CAL PER PRODUCT 2)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
28.0
9(04)
RIGHT
ZEROS
217
220
DEFINITION: The number of calories per day prescribed by the referring/ordering physician for this
product, for this patient.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233, V.B.
REMARKS: If number of calories is greater than "2000" an explanation should be entered in the
"Narrative Field" (GE0-26.0).
RECORD/FIELD: GE0-29.0
DATA ELEMENT: Enteral Frequency Fed 2 (ENTERAL FREQ FED 2)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
29.0
X(03)
LEFT
SPACES
221
223
DEFINITION: The number of times per day that the patient was fed.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233, V.C.
REMARKS: N/A
RECORD/FIELD: GE0-30.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
30.0
X(97)
LEFT
SPACES
224
320
DEFINITION: Unused reserved record space for National use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
NSF (National Standard Format) User Manual
338
RECORD NAME: CERTIFICATION RECORD TYPE GP0 "PARENTERAL
NUTRITION THERAPY"
Not Required by MO HealthNet
Must follow FB0 - GE0
Must be followed by GU0 - XA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "GP0"
C-24
GP0
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
Not Used
04
CERTIFICATION TYPE
Not Used
05
ONSET DT OF THERAPY
Not Used
06
THERAPY DURATION
Not Used
07
LAST CERT DATE
Not Used
08
NO OF MONTHS CERT
Not Used
09
DT LAST SEEN BY PHY
Not Used
10
NON VISIT IND
Not Used
11
PAT AGE
Not Used
12
PAT HEIGHT
Not Used
13
PAT WEIGHT
Not Used
14
LEVEL OF CONS IND
Not Used
15
AMBULATORY IND
Not Used
16
OTHER FORMS OF NUTR IND
Not Used
17
TYPE OF MIX IND
Not Used
18
PARENTERAL FREQ FED
Not Used
19
HCPCS PROCEDURE CODE
Not Used
20
HCPCS MODIFIER 1
Not Used
21
HCPCS MODIFIER 2
Not Used
22
AMINO ACID NAME
Not Used
23
AMINO ACID VOLUME
Not Used
24
AMINO ACID CONC
Not Used
NSF (National Standard Format) User Manual
339
25
AMINO ACID WEIGHT
Not Used
26
DEXTROSE VOLUME
Not Used
27
DEXTROSE CONC
Not Used
28
LIPIDS VOLUME
Not Used
29
LIPIDS CONC
Not Used
30
LIPIDS FREQ
Not Used
31
NARRATIVE FIELD
Not Used
32
ADMIN TECH IND
Not Used
33
FILLER-NATIONAL
YES
RECORD TYPE: GP0
LEVEL: SERVICE LINE
PURPOSE: To provide information regarding certification of medical necessity for PARENTERAL Nutrition
Therapy.
REQUIREMENTS: If required by the payor, the "GP0" record must be submitted for the initial certification,
revised certification and renewal certification when billing for Parenteral Nutrition Therapy.
ORDER:
Preceding Record Type
Following Record Type
FA0, FB0, FB1 or FB2
FA0, HA0 or XA0
NOTES: When used, this record must follow the FA0, FB0, FB1 or FB2 records related to this service.
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "GP0"
3
X
01
03
02.0
SEQUENCE NO
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
CERTIFICATION TYPE
1
X
23
23
05.0
ONSET DT OF THERAPY
8
X
24
31
06.0
THERAPY DURATION
2
X
32
33
07.0
LAST CERT DATE
8
X
34
41
08.0
NO OF MONTHS CERT
2
X
42
43
09.0
DT LAST SEEN BY PHY
8
X
44
51
NSF (National Standard Format) User Manual
340
10.0
NON VISIT IND
1
X
52
52
11.0
PAT AGE
3
X
53
55
12.0
PAT HEIGHT
3
X
56
58
13.0
PAT WEIGHT
3
X
59
61
14.0
LEVEL OF CONS IND
1
X
62
62
15.0
AMBULATORY IND
1
X
63
63
16.0
OTHER FORMS OF NUTR IND
1
X
64
64
17.0
TYPE OF MIX IND
1
X
65
65
18.0
PARENTERAL FREQ FED
3
X
66
68
19.0
HCPCS PROCEDURE CODE
5
X
69
73
20.0
HCPCS MODIFIER 1
2
X
74
75
21.0
HCPCS MODIFIER 2
2
X
76
77
22.0
AMINO ACID NAME
15
X
78
92
23.0
AMINO ACID VOLUME
4
N
93
96
24.0
AMINO ACID CONC
5
X
97
101
25.0
AMINO ACID WEIGHT
4
N
102
105
26.0
DEXTROSE VOLUME
4
N
106
109
27.0
DEXTROSE CONC
5
X
110
114
28.0
LIPIDS VOLUME
4
N
115
118
29.0
LIPIDS CONC
5
X
119
123
30.0
LIPIDS FREQ
3
N
124
126
31.0
NARRATIVE FIELD
100
X
127
226
32.0
ADMIN TECH IND
1
X
227
227
33.0
FILLER-NATIONAL
93
X
228
320
RECORD/FIELD: GP0-01.0
DATA ELEMENT: Record Identifier (RECORD ID "GP0")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: This field is used to identify the "PARENTERAL NUTRITION THERAPY" record.
NSF (National Standard Format) User Manual
341
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be "GP0".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GP0-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: A numeric value from 01 through 99 used to sequence the "GP0" record to the
corresponding "FA0" record.
CODE VALUES: 01 through 99
VALIDATION: Must be entered.
Must be a valid code from the above list. The value entered must match the SEQUENCE NUMBER
(FA0-02.0) submitted in the preceding "FA0" record.
FORM LOCATION: N/A
REMARKS: See sequencing instructions on page FA0.04.
RECORD/FIELD: GP0-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: An identification assigned to the patient by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS FOR "Patient Control Number".
Must be entered.
FORM LOCATION: CMS-1500 BLOCK 26
REMARKS: The patient control number is used by the EMC system to link all records for a claim. All
records between the record type CA0, up to and including the record type XA0, must have the same
patient control number.
Although up to seventeen characters are allowed, not all carrier's systems will record and return seventeen
characters on remittance advices or other documents.
NSF (National Standard Format) User Manual
342
RECORD/FIELD: GP0-04.0
DATA ELEMENT: Type of Certification (CERTIFICATION TYPE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(01)
N/A
SPACE
23
23
DEFINITION: The type of certification being billed.
CODE VALUES:
I = Initial Certification
R = Renewal Certification
S = Revised Certification
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: OMB 09380233
REMARKS: N/A
RECORD/FIELD: GP0-05.0
DATA ELEMENT: Date Therapy Began (ONSET DT OF THERAPY)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(08)
LEFT
SPACES
24
31
DEFINITION: The date the patient began receiving Parenteral Therapy.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: OMB 09380233, II.A.
REMARKS: N/A
RECORD/FIELD: GP0-06.0
DATA ELEMENT: Therapy Duration
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(02)
LEFT
SPACES
32
33
DEFINITION: The estimated duration of therapy (number of months).
NSF (National Standard Format) User Manual
343
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233, II.A.
REMARKS: N/A
RECORD/FIELD: GP0-07.0
DATA ELEMENT: Last Date of Certification (LAST CERT DATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(08)
LEFT
SPACES
34
41
DEFINITION: The date of the last certification.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: OMB 09380233
REMARKS: N/A
RECORD/FIELD: GP0-08.0
DATA ELEMENT: Number Of Months Of Certification (NO OF MONTHS CERT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
08.0
X(02)
LEFT
SPACES
42
43
DEFINITION: The number of months covered by this certification.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233
REMARKS: N/A
RECORD/FIELD: GP0-09.0
DATA ELEMENT: Date Last Seen By Physician (DT LAST SEEN BY PHY)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
X(08)
LEFT
SPACES
44
51
NSF (National Standard Format) User Manual
344
DEFINITION: The date the patient was last seen by the referring/ordering physician, during this
certification/recertification period.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: OMB 09380233, III.D.
REMARKS: N/A
RECORD/FIELD: GP0-10.0
DATA ELEMENT: Non Physician Visit Indicator (NON VISIT IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
X(01)
LEFT
SPACES
52
52
DEFINITION: An code used to describe what the medical evaluation is based upon, when not based on
physician visit.
CODE VALUES:
N = Visiting Nurse
L = Lab/Clinical Reports
O = Other
Blank = Not Applicable
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: OMB 09380233, III.D.
REMARKS: If the physician has not seen the patient during this certification/recertification period an
entry must be made in this field and an additional explanation should be entered in the "Narrative Field"
(GP0-31.0).
RECORD/FIELD: GP0-11.0
DATA ELEMENT: Patient's Age (PAT AGE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
X(03)
LEFT
SPACES
53
55
DEFINITION: The patient's age.
CODE VALUES: N/A
NSF (National Standard Format) User Manual
345
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233, II.B.
REMARKS: N/A
RECORD/FIELD: GP0-12.0
DATA ELEMENT: Patient's Height (PAT HEIGHT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(03)
LEFT
SPACES
56
58
DEFINITION: The patient's height (feet and inches).
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
Do not use punctuation for feet or inches. ex: 5 feet, 10 inches would be entered "510".
FORM LOCATION: OMB 09380233, II.B.
REMARKS: N/A
RECORD/FIELD: GP0-13.0
DATA ELEMENT: Patient's Weight (PAT WEIGHT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
X(03)
LEFT
SPACES
59
61
DEFINITION: The patient's weight in pounds.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233, II.B.
REMARKS: N/A
RECORD/FIELD: GP0-14.0
DATA ELEMENT: Level Of Consciousness Indicator (LEVEL OF CONS IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
14.0
X(01)
LEFT
SPACES
62
62
DEFINITION: An indicator used to describe the patient's level of consciousness.
CODE VALUES:
C = Conscious
I = Consciousness Impaired
NSF (National Standard Format) User Manual
346
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
FORM LOCATION: OMB 09380233, II.B.
REMARKS: N/A
RECORD/FIELD: GP0-15.0
DATA ELEMENT: Ambulatory Indicator (AMBULATORY IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
15.0
X(01)
LEFT
SPACES
63
63
DEFINITION: An indicator used to describe whether or not the patient is ambulatory.
CODE VALUES:
A = Ambulatory
N = Non-Ambulatory
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
FORM LOCATION: OMB 09380233, II.C.
REMARKS: N/A
RECORD/FIELD: GP0-16.0
DATA ELEMENT: Other Forms Of Nutrient Indicator (OTHER FORMS OF NUTR IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
16.0
X(01)
LEFT
SPACES
64
64
DEFINITION: An indicator used to describe whether or not this feeding is the only form of nutritional
intake for this patient.
CODE VALUES:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the list above.
FORM LOCATION: OMB 09380233, III.C.
NSF (National Standard Format) User Manual
347
REMARKS: If this field equals "N" an explanation should be entered in the "Narrative Field" (GP0-31.0)
giving name, amount (calories or %), and method of consumption of the additional nutrients
administered.
RECORD/FIELD: GP0-17.0
DATA ELEMENT: Type Of Mix Indicator (TYPE OF MIX IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
17.0
X(01)
LEFT
SPACES
65
65
DEFINITION: An indicator used to describe the type of mix administered to the patient.
CODE VALUES:
H = Homemix
P = Premix
VALIDATION: Must be entered if required by the payor.
If entered, must be a valid code from the list above.
FORM LOCATION: OMB 09380233, IV.A.
REMARKS: If this field equals "P" an explanation should be entered in the "Narrative Field" (GP0-31.0)
as to why beneficiary cannot use self-mix.
RECORD/FIELD: GP0-18.0
DATA ELEMENT: Parenteral Frequency Fed (PARENTERAL FREQ FED)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
X(03)
LEFT
SPACES
66
68
DEFINITION: The number of times per week that the patient was fed.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233, IV.B.
REMARKS: N/A
RECORD/FIELD: GP0-19.0
DATA ELEMENT: HCPCS Procedure Code
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
19.0
X(05)
LEFT
SPACES
69
73
DEFINITION: This is the HCPCS/CPT-4 code that describes the service/nutrient.
NSF (National Standard Format) User Manual
348
CODE VALUES: HCPCS/CPT-4 Code Set
VALIDATION: Must be entered if required by payor.
If entered, must be a valid HCPCS/CPT-4 procedure code.
FORM LOCATION: CMS-1500 Block 24D
REMARKS: This will be the same code as entered in the corresponding FA0 record (FA0-09.0).
RECORD/FIELD: GP0-20.0 GP0-21.0
DATA ELEMENT:
HCPCS Modifier 1
HCPCS Modifier 2
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
20.0
X(02)
LEFT
SPACES
74
75
21.0
X(02)
LEFT
SPACES
76
77
DEFINITION: These codes identify special circumstances related to the performance of the service.
CODE VALUES: See current HCPCS Modifier codes.
VALIDATION: Must be entered if required by payor for proper adjudication of the service.
FORM LOCATION: CMS-1500 Block 24D
REMARKS: N/A
RECORD/FIELD: GP0-22.0
DATA ELEMENT: Amino Acid Name
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
22.0
X(15)
LEFT
SPACES
78
92
DEFINITION: The name of the Amino Acid prescribed by the referring/ordering physician for this
patient.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233
REMARKS: N/A
RECORD/FIELD: GP0-23.0
DATA ELEMENT: Amino Acid Volume
FIELD
COBOL PICTURE
NSF (National Standard Format) User Manual
JUSTIFY
INITIAL
FROM
THRU
349
23.0
9(04)
RIGHT
ZEROS
93
96
DEFINITION: The number of milliliters of Amino Acid Solution used in the RX per day for Parenteral
Nutrition Therapy.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233, IV.C.
REMARKS: N/A
RECORD/FIELD: GP0-24.0
DATA ELEMENT: Amino Acid Concentration (AMINO ACID CONC)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
24.0
X(05)
LEFT
SPACES
97
101
DEFINITION: The percentage of concentration of Amino Acid used in the RX for Parenteral Nutrition
Therapy.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
Maximum of 5 characters - use "." (decimal) when necessary to give a percentage that is less than a whole
percentage; i.e., 10.25.
FORM LOCATION: OMB 09380233, IV.C.
REMARKS: N/A
RECORD/FIELD: GP0-25.0
DATA ELEMENT: Amino Acid Weight (AMINO ACID WEIGHT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
25.0
9(04)
RIGHT
ZEROS
102
105
DEFINITION: The grams of Amino Acid used per day for
Parenteral Nutrition Therapy.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233, IV.C.
REMARKS: If the number of grams per day is greater than "100", an explanation should be entered in the
"Narrative Field" (GP0-31.0).
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350
RECORD/FIELD: GP0-26.0
DATA ELEMENT: Dextrose Volume
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
26.0
9(04)
RIGHT
ZEROS
106
109
DEFINITION: The number of milliliters of Dextrose solution used in the RX per day for Parenteral
Nutrition Therapy.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233, IV.C.
REMARKS: N/A
RECORD/FIELD: GP0-27.0
DATA ELEMENT: Dextrose Concentration (DEXTROSE CONC)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
27.0
X(05)
LEFT
SPACES
FROM
THRU
14
DEFINITION: The percentage of concentration of Dextrose used in the RX for Parenteral Nutrition
Therapy.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
Maximum of 5 characters - use "." (decimal) when necessary to give a percentage that is less than a whole
percentage; i.e., 10.25.
FORM LOCATION: OMB 09380233, IV.C.
REMARKS: N/A
RECORD/FIELD: GP0-28.0
DATA ELEMENT: Lipids Volume
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
28.0
9(04)
RIGHT
ZEROS
115
118
DEFINITION: The number of milliliters of Lipids used in the RX for Parenteral Nutrition Therapy.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233, IV.C.
NSF (National Standard Format) User Manual
351
REMARKS: N/A
RECORD/FIELD: GP0-29.0
DATA ELEMENT: Lipids Concentration (LIPIDS CONC)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
29.0
x(05)
LEFT
SPACES
119
123
DEFINITION: The percentage of concentration of Lipids used in the RX for Parenteral Nutrition
Therapy.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
Maximum of 5 characters - use "." (decimal) when necessary to give a percentage that is less than a whole
percentage; i.e., 10.25.
FORM LOCATION: OMB 09380233, IV.C.
REMARKS: N/A
RECORD/FIELD: GP0-30.0
DATA ELEMENT: Lipids Frequency (LIPIDS FREQ)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
30.0
9(03)
RIGHT
ZEROS
124
126
DEFINITION: The number of times per week Lipids are used in the RX for Parenteral Nutrition Therapy.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: OMB 09380233, IV.C.
REMARKS: N/A
RECORD/FIELD: GP0-31.0
DATA ELEMENT: Narrative Field
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
31.0
X(100)
LEFT
SPACES
127
226
DEFINITION: A narrative field use to describe special circumstances, medical justification or any
additional comments necessary for proper adjudication of the claim.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor for proper adjudication of the claim.
NSF (National Standard Format) User Manual
352
FORM LOCATION: OMB 09380233
REMARKS: Some examples of when this field is needed are as follows:
1. If GP0-10.0 is other than "blank".
2. If GP0-16.0 is equal to "N".
3. If GP0-17.0 is equal to "P".
4. If GP0-25.0 is greater than "100".
5. If GP0-32.0 is equal to "O".
If additional information is needed, an "HA0" record can be used.
RECORD/FIELD: GP0-32.0
DATA ELEMENT: Administration Technique Indicator (ADMIN TECH IND)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
32.0
X(01)
LEFT
SPACES
227
227
DEFINITION: An indicator used to describe the technique used to administer the nutrient to the patient.
CODE VALUES:
N = Nasogastric Tube
G = Gastrostomy
J = Jejunostomy
O = Other
VALIDATION: Must be entered if required by payor.
Must a be a valid code from the list above.
FORM LOCATION: OMB 09380233, V.F.
REMARKS: If "O" (other), provide narrative in GP0-31.0.
RECORD/FIELD: GP0-33.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
33.0
X(93)
LEFT
SPACES
228
320
DEFINITION: Unused reserved record space for national use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
NSF (National Standard Format) User Manual
353
REMARKS: N/A
RECORD NAME: CERTIFICATION RECORD TYPE GU0 "UNIVERSAL DMEPOS
ITEMS"
Not Required by MO HealthNet
Must follow FB0 - GP0
Must be followed by GX0 - XA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "GU0"
C-24
GU0
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
Not Used
04
CERTIFICATION TYPE
Not Used
05
PLACE OF SERVICE
Not Used
06
REPLACEMENT ITEM
Not Used
07
HCPCS PROCEDURE CODE
Not Used
08
HCPCS MODIFIER
Not Used
09
WARRANTY REPLY
Not Used
10
WARRANTY LENGTH
Not Used
11
WARRANTY TYPE
Not Used
12
DIAGNOSIS CODE-1
Not Used
13
DIAGNOSIS CODE-2
Not Used
14
DIAGNOSIS CODE-3
Not Used
15
DIAGNOSIS CODE-4
Not Used
16
PATIENT HEIGHT
Not Used
17
PATIENT WEIGHT
Not Used
18
DT LAST MEDICAL EXAM
Not Used
19
INITIAL DATE
Not Used
20
REV RECERT DATE
Not Used
21
LENGTH OF NEED
Not Used
22
DATE CERT SIGNED
Not Used
NSF (National Standard Format) User Manual
354
23
ORDERING PROV PHONE
Not Used
24
CERT ON FILE
Not Used
25
CERT FORM NUMBER
Not Used
26
REPLY ALN L01 N01
Not Used
27
REPLY ALN L01 N02
Not Used
28
REPLY ALN L01 N03
Not Used
29
REPLY ALN L01 N04
Not Used
30
REPLY ALN L01 N05
Not Used
31
REPLY ALN L01 N06
Not Used
32
REPLY ALN L01 N07
Not Used
33
REPLY ALN L01 N08
Not Used
34
REPLY ALN L01 N09
Not Used
35
REPLY ALN L01 N010
Not Used
36
REPLY ALN L01 N011
Not Used
37
REPLY ALN L01 N012
Not Used
38
REPLY ALN L01 N013
Not Used
39
REPLY ALN L01 N014
Not Used
40
REPLY ALN L01 N015
Not Used
41
REPLY ALN L01 N016
Not Used
42
REPLY ALN L01 N017
Not Used
43
REPLY ALN L01 N018
Not Used
44
REPLY ALN L01 N019
Not Used
45
REPLY ALN L01 N020
Not Used
46
REPLY ALN L01 N021
Not Used
47
REPLY ALN L01 N022
Not Used
48
REPLY ALN L01 N023
Not Used
49
REPLY ALN L01 N024
Not Used
50
REPLY ALN L05 N01
Not Used
51
REPLY ALN L05 N02
Not Used
52
REPLY ALN L05 N03
Not Used
NSF (National Standard Format) User Manual
355
53
REPLY ALN L08 N01
Not Used
54
REPLY ALN L08 N02
Not Used
55
REPLY ALN L08 N03
Not Used
56
REPLY ALN L08 N04
Not Used
57
REPLY ALN L20 N01
Not Used
58
REPLY ALN L60 N01
Not Used
59
REPLY NUM L01 N01
Not Used
60
REPLY NUM L01 N02
Not Used
61
REPLY NUM L01 N03
Not Used
62
REPLY NUM L04 N01
Not Used
63
REPLY NUM L04 N02
Not Used
64
REPLY NUM L04 N03
Not Used
65
REPLY NUM L04 N04
Not Used
66
REPLY NUM L04 N05
Not Used
67
REPLY NUM L04 N06
Not Used
68
REPLY NUM L04 N07
Not Used
69
REPLY PCT L04 N01
Not Used
70
REPLY PCT L04 N02
Not Used
71
REPLY PCT L04 N03
Not Used
72
FILLER-NATIONAL
YES
RECORD TYPE: GU0
LEVEL: SERVICE LINE
PURPOSE: To provide information regarding certification of medical necessity for DMEPOS ITEMS.
REQUIREMENTS: If required by the payor, the "GU0" record must be submitted for the initial certification,
revised certification an renewal certification when billing for DMEPOS ITEMS.
ORDER:
Preceding Record Type
Following Record Type
FA0, FB0, FB1, FB2, FE0
FA0, HA0 or XA0
NOTES: When used, this record must follow the FA0, FB0, FB1 or FB2 or FE0 records related to this service.
NSF (National Standard Format) User Manual
356
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "GU0"
3
X
01
03
02.0
SEQUENCE NO
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
CERTIFICATION TYPE
1
X
23
23
05.0
PLACE OF SERVICE
2
X
24
25
06.0
REPLACEMENT ITEM
1
X
26
26
07.0
HCPCS PROCEDURE CODE
5
X
27
31
08.0
HCPCS MODIFIER
2
X
32
33
09.0
WARRANTY REPLY
1
X
34
34
10.0
WARRANTY LENGTH
2
X
35
36
11.0
WARRANTY TYPE
1
X
37
37
12.0
DIAGNOSIS CODE-1
5
X
38
42
13.0
DIAGNOSIS CODE-2
5
X
43
47
14.0
DIAGNOSIS CODE-3
5
X
48
52
15.0
DIAGNOSIS CODE-4
5
X
53
57
16.0
PATIENT HEIGHT
2
N
58
59
17.0
PATIENT WEIGHT
3
N
60
62
18.0
DT LAST MEDICAL EXAM
8
X
63
70
19.0
INITIAL DATE
8
X
71
78
20.0
REV RECERT DATE
8
X
79
86
21.0
LENGTH OF NEED
2
N
87
88
22.0
DATE CERT SIGNED
8
X
89
96
23.0
ORDERING PROV PHONE
10
X
97
106
24.0
CERT ON FILE
1
X
107
107
25.0
CERT FORM NUMBER
4
N
108
111
26.0
REPLY ALN L01 N01
1
X
112
112
27.0
REPLY ALN L01 N02
1
X
113
113
NSF (National Standard Format) User Manual
357
28.0
REPLY ALN L01 N03
1
X
114
114
29.0
REPLY ALN L01 N04
1
X
115
115
30.0
REPLY ALN L01 N05
1
X
116
116
31.0
REPLY ALN L01 N06
1
X
117
117
32.0
REPLY ALN L01 N07
1
X
118
118
33.0
REPLY ALN L01 N08
1
X
119
119
34.0
REPLY ALN L01 N09
1
X
120
120
35.0
REPLY ALN L01 N10
1
X
121
121
36.0
REPLY ALN L01 N11
1
X
122
122
37.0
REPLY ALN L01 N12
1
X
123
123
38.0
REPLY ALN L01 N13
1
X
124
124
39.0
REPLY ALN L01 N14
1
X
125
125
40.0
REPLY ALN L01 N15
1
X
126
126
41.0
REPLY ALN L01 N16
1
X
127
127
42.0
REPLY ALN L01 N17
1
X
128
128
43.0
REPLY ALN L01 N18
1
X
129
129
44.0
REPLY ALN L01 N19
1
X
130
130
45.0
REPLY ALN L01 N20
1
X
131
131
46.0
REPLY ALN L01 N21
1
X
132
132
47.0
REPLY ALN L01 N22
1
X
133
133
48.0
REPLY ALN L01 N23
1
X
134
134
49.0
REPLY ALN L01 N24
1
X
135
135
50.0
REPLY ALN L05 N01
5
X
136
140
51.0
REPLY ALN L05 N02
5
X
141
145
52.0
REPLY ALN L05 N03
5
X
146
150
53.0
REPLY ALN L08 N01
8
X
151
158
54.0
REPLY ALN L08 N02
8
X
159
166
55.0
REPLY ALN L08 N03
8
X
167
174
56.0
REPLY ALN L08 N04
8
X
175
182
57.0
REPLY ALN L20 N01
20
X
183
202
NSF (National Standard Format) User Manual
358
58.0
REPLY ALN L60 N01
60
X
203
262
59.0
REPLY NUM L01 N01
1
N
263
263
60.0
REPLY NUM L01 N02
1
N
264
264
61.0
REPLY NUM L01 N03
1
N
265
265
62.0
REPLY NUM L04 N01
4
N
266
269
63.0
REPLY NUM L04 N02
4
N
270
273
64.0
REPLY NUM L04 N03
4
N
274
277
65.0
REPLY NUM L04 N04
4
N
278
281
66.0
REPLY NUM L04 N05
4
N
282
285
67.0
REPLY NUM L04 N06
4
N
286
289
68.0
REPLY NUM L04 N07
4
N
290
293
69.0
REPLY PCT L04 N01
4
N
294
297
70.0
REPLY PCT L04 N02
4
N
298
301
71.0
REPLY PCT L04 N03
4
N
302
305
72.0
FILLER - NATIONAL
15
X
306
320
RECORD/FIELD: GU0-01.0
DATA ELEMENT: Record Identifier (RECORD ID "GU0")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: Code used to identify the "Universal DMEPOS Item Certification" record.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be "GU0".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GU0-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
NSF (National Standard Format) User Manual
359
DEFINITION: A numeric value from 01 through 99 used to sequence the "GU0" records and to associate
"GU0" records with "FA0" records.
CODE VALUES: 01 through 99
VALIDATION: Must be entered.
Must be a valid code from the list above.
The value entered must match the SEQUENCE NUMBER (FA0-02.0) submitted in the preceding "FA0"
record.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GU0-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: An identification assigned to the patient by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Patient Control Number".
Must be entered.
FORM LOCATION: CMS-1500, Block 26
REMARKS: N/A
RECORD/FIELD: GU0-04.0
DATA ELEMENT: Certification Type
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(01)
N/A
SPACES
23
23
DEFINITION: Certification type
CODE VALUES:
1 = Initial certification
2 = Revision
3 = Recertification
VALIDATION: Must be entered.
Must be a valid code from the list above.
NSF (National Standard Format) User Manual
360
FORM LOCATION: N/A
REMARKS: The code value should correspond to the certification type box checked in Section A of the
DMERC CMN form.
RECORD/FIELD: GU0-05.0
DATA ELEMENT: Place of Service
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(02)
LEFT
SPACES
24
25
DEFINITION: The code that identifies where the service was performed.
CODE VALUES: Refer to Field FA0-07.0
VALIDATION: Must be entered
FORM LOCATION: All DMERC CMNs, Section A
REMARKS: N/A
RECORD/FIELD: GU0-06.0
DATA ELEMENT: Replacement Item
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(01)
N/A
SPACES
26
26
DEFINITION: Indicates that this certification is for an item replacing a previously purchased item.
CODE VALUES:
Y = Yes
N = No
VALIDATION: Must be entered for all CMNs except DMERC form 08.02.
Must be blank for DMERC form 08.02.
Must be a valid code from the list above.
FORM LOCATION: All DMERC CMNs, except 08.02 Section A
REMARKS: N/A
RECORD/FIELD: GU0-07.0
DATA ELEMENT: HCPCS Procedure Code
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(05)
LEFT
SPACES
27
31
NSF (National Standard Format) User Manual
361
DEFINITION: The HCPCS code describing the certified item.
CODE VALUES: HCPCS code set.
VALIDATION: Must be entered.
Must be a valid HCPCS code.
FORM LOCATION:
DMERC 01.02, 02.02, 03.02, 04.02, 06.02, 07.02, 09.02 and 10.02; Section A
DMERC 05.02, Section B - Reserved for future use
DMERC 08.02, Section B - Question 1.A
REMARKS: N/A
RECORD/FIELD: GU0-08.0
DATA ELEMENT: HCPCS Modifier
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
08.0
X(02)
LEFT
SPACES
32
33
DEFINITION: The code that identifies special circumstances related to the equipment or supply.
CODE VALUES: See current HCPCS modifier codes.
VALIDATION: Must be entered if required by payor for proper adjudication of the equipment or supply.
FORM LOCATION: DMERC 01.02, 02.02, 03.02, 04,02, 06.02, 07.02, 09.02, AND 10.02, Section A
REMARKS: Must be blank for DMERC 05.02 (not currently in use) and 08.02.
RECORD/FIELD: GU0-09.0
DATA ELEMENT: Warranty Reply
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
X(01)
N/A
SPACES
34
34
DEFINITION: Code indicating whether the item is covered by a warranty.
CODE VALUES:
Y = Yes
N = No
D = Does not apply
VALIDATION: If entered, must be a valid code from the list above.
Must be blank for DMERC form 08.02.
FORM LOCATION: All DMERC CMNs, Section A, except form 05.02 (not currently in use) and 08.02.
NSF (National Standard Format) User Manual
362
REMARKS: This response is implied on hardcopy CMNs when the warranty length and type are
completed. However, it must be indicated electronically.
RECORD/FIELD: GU0-10.0
DATA ELEMENT: Warranty Length
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
X(02)
LEFT
SPACES
35
36
DEFINITION: Length of the warranty period in months.
CODE VALUES: 01 through 99
VALIDATION: Must be entered if required by payor and Field GU0-09.0 is equal to "Y".
Not required for DMERC forms 05.02 (not currently in use) and 08.02.
If entered, must be a valid code from the list above.
FORM LOCATION: All DMERC CMNs, Section A, except 05.02 and 08.02.
REMARKS: N/A
RECORD/FIELD: GU0-11.0
DATA ELEMENT: Warranty Type
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
X(01)
N/A
SPACES
37
37
DEFINITION: Code indicating the warranty type and coverage.
CODE VALUES:
1 = Full replacement
2 = Pro-rated replacement
3 = Parts and labor
4 = Parts only
VALIDATION: Must be entered if required by payor and Field GU0-09.0 is equal to "Y".
Must be blank for DMERC form 05.02 (not currently in use) and 08.02.
If entered, must be a valid code from the list above.
FORM LOCATION: All DMERC CMNs, Section A, except 05.02 and 08.02.
REMARKS: N/A
RECORD/FIELD:GU0-12.0 GU0-13.0 GU0-14.0 GU0-15.0
DATA ELEMENT:
NSF (National Standard Format) User Manual
Diagnosis Code-1
363
Diagnosis Code-2
Diagnosis Code-3
Diagnosis Code-4
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(05)
LEFT
SPACES
38
42
13.0
X(05)
LEFT
SPACES
43
47
14.0
X(05)
LEFT
SPACES
48
52
15.0
X(05)
LEFT
SPACES
53
57
DEFINITION: The ICD-9-CM diagnosis code identifying a diagnosed medical condition resulting in the
medical necessity for this item.
CODE VALUES: N/A
VALIDATION: Must be the most specific/precise 3 digit, 4 digit or 5 digit code allowed for in the ICD9-CM coding format.
Do not submit a decimal point. The decimal point is implied.
A diagnosis code must be entered in Field 12.0.
FORM LOCATION: All DMERC CMNs, Section B
REMARKS: All diagnosis codes provided in Section B of the DMERC CMN form should be entered in
Fields 12.0 through 15.0
RECORD/FIELD: GU0-16.0
DATA ELEMENT: Patient Height
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
16.0
9(02)
RIGHT
ZEROS
58
59
INITIAL
FROM
THRU
DEFINITION: Patient height in inches.
CODE VALUES: N/A
VALIDATION: Must be entered for DMERC form 10.02.
FORM LOCATION: DMERC form 10.02, Section B
REMARKS: N/A
RECORD/FIELD: GU0-17.0
DATA ELEMENT: Patient Weight
FIELD
COBOL PICTURE
NSF (National Standard Format) User Manual
JUSTIFY
364
17.0
9(03)
RIGHT
ZEROS
60
62
DEFINITION: Patient weight in pounds.
CODE VALUES: N/A
VALIDATION: Must be entered for DMERC forms 02.02 and 10.02.
FORM LOCATION: DMERC forms 02.02 and 10.02, Section B
REMARKS: N/A
RECORD/FIELD: GU0-18.0
DATA ELEMENT: Date of Last Medical Examination (DT LAST MEDICAL EXAM)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
X(08)
LEFT
SPACES
63
70
DEFINITION: The date that the patient was last seen by the certifying physician.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Date" entry.
May be blank. Not required for DMERC claims.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GU0-19.0
DATA ELEMENT: Initial Date
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
19.0
X(08)
LEFT
SPACES
71
78
DEFINITION: The beginning date of certified period of medical necessity.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Date" entry.
Must be entered.
Must be a valid date.
FORM LOCATION: All DMERC CMNs, Section A
REMARKS: N/A
RECORD/FIELD: GU0-20.0
NSF (National Standard Format) User Manual
365
DATA ELEMENT: Revision or Recertification Date (REV RECERT DATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
20.0
X(08)
LEFT
SPACES
79
86
DEFINITION: The effective date of the revision or recertification provided by the certifying physician.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Date" entry.
Must be entered if Field GU0-04.0 is equal to "2" or "3".
Must be a valid date.
FORM LOCATION: All DMERC CMNs, Section A
REMARKS: N/A
RECORD/FIELD: GU0-21.0
DATA ELEMENT: Length of Need
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
21.0
9(02)
RIGHT
ZEROS
87
88
DEFINITION: The number of months of medical necessity certified by the physician.
CODE VALUES: 01 through 99.
VALIDATION: Must be entered for all DMERC forms except form 08.02.
Must be a valid code from the list above.
FORM LOCATION: All DMERC CMNs, Section B, except 08.02.
REMARKS: Use 99 if the LIFETIME box in Section B of the DMERC CMN form is checked.
RECORD/FIELD: GU0-22.0
DATA ELEMENT: Date of Physician's Signature (DATE CERT SIGNED)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
22.0
X(08)
LEFT
SPACES
89
96
DEFINITION: The date the certificate of medical necessity was completed and signed by the ordering
physician.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Date" entry.
Must be entered.
NSF (National Standard Format) User Manual
366
Must be a valid date.
FORM LOCATION: All DMERC CMNs, Section B
REMARKS: N/A
RECORD/FIELD: GU0-23.0
DATA ELEMENT: Ordering Physician's Telephone Number (ORDERING PROV PHONE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
23.0
X(10)
LEFT
SPACES
97
106
DEFINITION: The telephone number of the ordering physician who prescribed this item.
CODE VALUES: N/A
VALIDATION: Must be entered.
See GENERAL INSTRUCTIONS for "Phone" entry.
FORM LOCATION: All DMERC CMNs, Section B
REMARKS: N/A
RECORD/FIELD: GU0-24.0S
DATA ELEMENT: Certification on File (CERT ON FILE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
24.0
X(01)
N/A
SPACES
107
107
DEFINITION: The supplier's guarantee that a copy of the paper certification, signed and dated by the
physician, is on file at the supplier's office.
CODE VALUES:
Y = Yes, certification is on file.
N = No, certification is not on file.
VALIDATION: Must be entered.
Must be a valid code from the list above.
FORM LOCATION: N/A
REMARKS: A "N" response will cause the claim to reject as there must be a signed, dated CMN on file
with the supplier in order for the claim to be adjudicated.
RECORD/FIELD: GU0-25.0
DATA ELEMENT: Certification Form Number (CERT FORM NUMBER)
FIELD
COBOL PICTURE
NSF (National Standard Format) User Manual
JUSTIFY
INITIAL
FROM
THRU
367
25.0
9(2)V99
RIGHT
ZEROS
108
111
DEFINITION: Form Number of the DMERC Certification of Medical Necessity used as the source of
input to this DMEPOS certification record.
CODE VALUES:
01.02
Hospital Bed and Support Services
02.03
Manual and Motorized Wheelchairs
03.02
Continuous Positive Airway Pressure System
04.03
Lymphedema Pump, Osteogenesis Stimulator
05.02
Reserved for Future Use
06.02
TENS
07.02
Seat Lift Mechanisms and Power Operated Vehicle (POV)
08.02
Immunosuppressive Drugs
09.02
External Infusion Pump
10.02
Parenteral and Enteral Nutrition
VALIDATION: Must be entered.
Must be a valid code from the list above.
FORM LOCATION: DMERC Certification Form
REMARKS: N/A
RECORD/FIELD: GU0-26.0S
DATA ELEMENT: REPLY ALN L01 N01
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
26.0
X(01)
N/A
SPACES
112
112
DEFINITION: Reply to the first question on any DMERC Certification of Medical Necessity form that
requires a one position alphanumeric response.
CODE VALUES:
DMERC forms 01.02, 02.03, 04.03, 06.02, 07.02, and 09.02:
Y = Yes
N = No
D = Does not apply
DMERC 08.02 & 10.02:
Y = Yes
NSF (National Standard Format) User Manual
368
N = No
DMERC Form 03.02 & 05.02:
Reserved for future use.
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION:
DMERC 01.02, Question 1
DMERC 02.03, Question 1
DMERC 04.03, Question 1 (Lymphedema Pumps)
DMERC 04.03, Question 6 (Osteogenesis Stimulator)
DMERC 06.02, Question 1
DMERC 07.02, Question 1
DMERC 08.02, Question 4
DMERC 09.02, Question 7
DMERC 10.02, Question 1
REMARKS: N/A
RECORD/FIELD: GU0-27.0S
DATA ELEMENT: REPLY ALN L01 N02
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
27.0
X(01)
N/A
SPACES
113
113
DEFINITION: Reply to the second question on any DMERC Certification of Medical Necessity form that
requires a one position alphanumeric response.
CODE VALUES:
DMERC forms 02.03, 04.03, 06.02, and 07.02:
Y = Yes
N = No
D = Does not apply
DMERC Form 08.02:
Y = Yes
N = No
DMERC Forms 01.02, 03.02, 05.02
NSF (National Standard Format) User Manual
369
09.02 and 10.02: Reserved for future use.
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION:
DMERC 02.03, Question 2
DMERC 04.03, Question 2 (Lymphedema Pump)
DMERC 04.03, Question 7 (Osteogenesis Stimulator)
DMERC 06.02, Question 3
DMERC 07.02, Question 2
DMERC 08.02, Question 12
REMARKS: N/A
RECORD/FIELD: GU0-28.0
DATA ELEMENT: REPLY ALN L01 N03
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
28.0
X(01)
N/A
SPACES
114
114
DEFINITION: Reply to the third question on any DMERC Certification of Medical Necessity form that
requires a one position alphanumeric response.
CODE VALUES:
DMERC forms 01.02, 02.03, 04.03 and 07.02:
Y = Yes
N = No
D = Does not apply
DMERC form 06.02:
1 = Headache
2 = Visceral abdominal pain
3 = Pelvic pain
4 = Temporomandibular joint (TMJ) pain
5 = None of the above
DMERC form 03.02 and 09.02: Reserved for Future Use
DMERC form 10.02:
1 = Central line
NSF (National Standard Format) User Manual
370
3 = Hemodialysis Access Line
7 = Peripherally Inserted Catheter (PIC) line
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION:
DMERC 01.02, Question 3
DMERC 02.03, Question 3
DMERC 04.03, Question 3 (Lymphedema Pump)
DMERC 04.03, Question 8 (Osteogenesis Stimulator)
DMERC 06.02, Question 5
DMERC 07.03, Question 3
DMERC 10.02, Question 5
REMARKS: N/A
RECORD/FIELD: GU0-29.0
DATA ELEMENT: REPLY ALN L01 N04
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
29.0
X(01)
N/A
SPACES
115
115
DEFINITION: Reply to the fourth question on any DMERC Certification of Medical Necessity form that
requires a one position alphanumeric response.
CODE VALUES:
DMERC forms 01.02, 02.03, 04.03, 06.02, and 07.02:
Y = Yes
N = No
D = Does not apply
DMERC Form 03.02, 09.02, and 10.02: Reserved for future use.
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION:
DMERC 01.02, Question 4
DMERC 02.03, Question 4
DMERC 04.03, Question 4 (Lymphedema Pump)
NSF (National Standard Format) User Manual
371
DMERC 04.03, Question 9 (Osteogenesis Stimulator)
DMERC 06.02, Question 6
DMERC 07.02, Question 4
REMARKS: N/A
RECORD/FIELD: GU0-30.0
DATA ELEMENT: REPLY ALN L01 N05
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
30.0
X(01)
N/A
SPACES
116
116
DEFINITION: Reply to the fifth question on any DMERC Certification of Medical Necessity form that
requires a one position alphanumeric response.
CODE VALUES:
DMERC forms 01.02, 02.03, 04.03, 06.02, and 07.02:
Y = Yes
N = No
D = Does not apply
DMERC Form 10.02:
Y = Yes
N = No
DMERC Form 03.02 & 09.02: Reserved for future use.
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION:
DMERC 01.02, Question 5
DMERC 02.03, Question 8 (Manual Wheelchairs)
DMERC 02.03, Question 6 (Motorized Wheelchairs)
DMERC 04.03, Question 5 (Lymphedema Pump)
DMERC 04.03, Question 10 (Osteogenesis Stimulator)
DMERC 06.02, Question 7
DMERC 07.02, Question 5
DMERC 10.02, Question 7
NSF (National Standard Format) User Manual
372
REMARKS: N/A
RECORD/FIELD: GU0-31.0
DATA ELEMENT: REPLY ALN L01 N06
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
31.0
X(01)
N/A
SPACES
117
117
DEFINITION: Reply to the sixth question on any DMERC Certification of Medical Necessity form that
requires a one position alphanumeric response.
CODE VALUES:
DMERC forms 01.02, 02.03, 04.03, and 07.02:
Y = Yes
N = No
D = Does not apply
DMERC form 10.02:
Y = Yes
N = No
DMERC Form 03.02 & 09.02: Reserved for future use.
DMERC form 06.02:
1 = Daily
2 = 3 to 6 days per week
3 = 2 or less days per week
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION:
DMERC 01.02, Question 6
DMERC 02.03, Question 9 (Manual wheelchairs)
DMERC 02.03, Question 7 (Motorized Wheelchairs)
DMERC 04.03, Question 11 (Osteogenesis Stimulator)
DMERC 06.02, Question 10
DMERC 07.02, Question 6
DMERC 10.02, Question 8
REMARKS: N/A
NSF (National Standard Format) User Manual
373
RECORD/FIELD: GU0-32.0
DATA ELEMENT: REPLY ALN L01 N07
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
32.0
X(01)
N/A
SPACES
118
118
DEFINITION: Reply to the seventh question on any DMERC Certification of Medical Necessity form
that requires a one position alphanumeric response.
CODE VALUES:
DMERC forms 01.02, 06.02 and 07.02:
Y = Yes
N = No
D = Does not apply
DMERC Form 03.02 and 10.02: Reserved for future use.
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION:
DMERC 01.02, Question 7
DMERC 06.02, Question 11
DMERC 07.02, Question 7
REMARKS: N/A
RECORD/FIELD: GU0-33.0
DATA ELEMENT: REPLY ALN L01 N08
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
33.0
X(01)
N/A
SPACES
119
119
DEFINITION: Reply to the eighth question on any DMERC Certification of Medical Necessity form that
requires a one position alphanumeric response.
CODE VALUES:
DMERC form 07.02:
Y = Yes
N = No
D = Does not apply
DMERC Forms 01.02 and 03.02: Reserved for future use.
DMERC form 06.02:
NSF (National Standard Format) User Manual
374
2 = 2 leads
4 = 4 leads
DMERC form 10.02:
1 = syringe
2 = gravity
3 = pump
4 = does not apply
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION:
DMERC 06.02, Question 12
DMERC 07.02, Question 8
DMERC 10.02, Question 13
REMARKS: N/A
RECORD/FIELD: GU0-34.0
DATA ELEMENT: REPLY ALN L01 N09
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
34.0
X(01)
N/A
SPACES
120
120
DEFINITION: Reply to the ninth question on any DMERC Certification of Medical Necessity form that
requires a one position alphanumeric response.
CODE VALUES:
DMERC form 10.02:
Y = Yes
N = No
D = Does not apply
DMERC Forms 01.02, 03.02 and 07.02: Reserved for future use.
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION: DMERC 10.02, Question 14
REMARKS: N/A
NSF (National Standard Format) User Manual
375
RECORD/FIELD: GU0-35.0 ITEMS
DATA ELEMENT: REPLY ALN L01 N10
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
35.0
X(01)
N/A
SPACES
121
121
DEFINITION: Reply to the tenth question on any DMERC Certification of Medical Necessity form that
requires a one position alphanumeric response.
CODE VALUES:
DMERC form (reserved for future use)
Y = Yes
N = No
D = Does not apply
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION: N/A
REMARKS: Reserved for Future Use
RECORD/FIELD: GU0-36.0
DATA ELEMENT: REPLY ALN L01 N11
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
36.0
X(01)
N/A
SPACES
122
122
DEFINITION: Reply to the eleventh question on any DMERC Certification of Medical Necessity form
that requires a one position alphanumeric response.
CODE VALUES:
DMERC form 01.02:
Y = Yes
N = No
D = Does not apply
DMERC forms 03.02 and 07.02: Reserved for future use.
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION: DMERC 01.02, Question 12
REMARKS: N/A
NSF (National Standard Format) User Manual
376
RECORD/FIELD: GU0-37.0
DATA ELEMENT: REPLY ALN L01 N12
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
37.0
X(01)
N/A
SPACES
123
123
DEFINITION: Reply to the twelfth question on any DMERC Certification of Medical Necessity form
that requires a one position alphanumeric response.
CODE VALUES:
DMERC forms 01.02, 03.02, and 07.02:
Y = Yes
N = No
D = Does not apply
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION:
DMERC 01.02, Question 13
DMERC 03.02, Question 14
DMERC 07.02, Question 12
REMARKS: N/A
RECORD/FIELD: GU0-38.0
DATA ELEMENT: REPLY ALN L01 N13
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
38.0
X(01)
N/A
SPACES
124
124
DEFINITION: Reply to the thirteenth question on any DMERC Certification of Medical Necessity form
that requires a one position alphanumeric response.
CODE VALUES:
DMERC forms 01.02 and 07.02:
Y = Yes
N = No
D = Does not apply
DMERC Form 03.02: Reserved for future use.
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
NSF (National Standard Format) User Manual
377
FORM LOCATION: DMERC 01.02, Question 14
DMERC 07.02, Question 13
REMARKS: N/A
RECORD/FIELD: GU0-39.0
DATA ELEMENT: REPLY ALN L01 N14
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
39.0
X(01)
N/A
SPACES
125
125
DEFINITION: Reply to the fourteenth question on any DMERC Certification of Medical Necessity form
that requires a one position alphanumeric response.
CODE VALUES:
DMERC forms 01.02 and 07.02:
Y = Yes
N = No
D = Does not apply
DMERC Form 03.02: Reserved for future use.
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION: DMERC 01.02, Question 15
DMERC 07.02, Question 14
REMARKS: N/A
RECORD/FIELD: GU0-40.0
DATA ELEMENT: REPLY ALN L01 N15
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
40.0
X(01)
N/A
SPACES
126
126
DEFINITION: Reply to the fifteenth question on any DMERC Certification of Medical Necessity form
that requires a one position alphanumeric response.
CODE VALUES:
DMERC forms 01.02:
Y = Yes
N = No
D = Does not apply
DMERC Form 03.02 and 04.02: Reserved for future use.
NSF (National Standard Format) User Manual
378
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION: DMERC 01.02, Question 16
REMARKS: N/A
RECORD/FIELD: GU0-41.0
DATA ELEMENT: REPLY ALN L01 N16
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
41.0
X(01)
N/A
SPACES
127
127
DEFINITION: Reply to the sixteenth question on any DMERC Certification of Medical Necessity form
that requires a one position alphanumeric response.
CODE VALUES:
DMERC form (reserved for future use)
Y = Yes
N = No
D = Does not apply
DMERC forms 01.02 and 03.02: Reserved for future use.
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION: N/A
REMARKS: Reserved for Future Use
RECORD/FIELD: GU0-42.0
DATA ELEMENT: REPLY ALN L01 N17
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
42.0
X(01)
N/A
SPACES
128
128
DEFINITION: Reply to the seventeenth question on any DMERC Certification of Medical Necessity
form that requires a one position alphanumeric response.
CODE VALUES:
Y = Yes
N = No
D = Does not apply
DMERC forms 01.02 and 03.02: Reserved for future use.
NSF (National Standard Format) User Manual
379
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION: N/A
REMARKS: Reserved for future use.
RECORD/FIELD: GU0-43.0
DATA ELEMENT: REPLY ALN L01 N18
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
43.0
X(01)
N/A
SPACES
129
129
DEFINITION: Reply to the eighteenth question on any DMERC Certification of Medical Necessity form
that requires a one position alphanumeric response.
CODE VALUES:
DMERC forms 01.02:
Y = Yes
N = No
D = Does not apply
DMERC form 03.02: Reserved for future use.
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION: DMERC 01.02, Question 19
REMARKS: N/A
RECORD/FIELD: GU0-44.0
DATA ELEMENT: REPLY ALN L01 N19
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
44.0
X(01)
N/A
SPACES
130
130
DEFINITION: Reply to the nineteenth question on any DMERC Certification of Medical Necessity form
that requires a one position alphanumeric response.
CODE VALUES:
DMERC forms 01.02:
Y = Yes
N = No
D = Does not apply
NSF (National Standard Format) User Manual
380
DMERC form 03.02: Reserved for future use.
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION: DMERC 01.02, Question 20
REMARKS: N/A
RECORD/FIELD: GU0-45.0
DATA ELEMENT: REPLY ALN L01 N20
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
45.0
X(01)
N/A
SPACES
131
131
DEFINITION: Reply to the twentieth question on any DMERC Certification of Medical Necessity form
that requires a one position alphanumeric response.
CODE VALUES:
DMERC form 01.02:
1 = Improved
2 = Remained same
3 = Worsened
DMERC form 03.02: Reserved for future use.
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION: DMERC 01.02, Question 22
REMARKS: N/A
RECORD/FIELD: GU0-46.0
DATA ELEMENT: REPLY ALN L01 N21
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
46.0
X(01)
N/A
SPACES
132
132
DEFINITION: Reply to the twenty-first question on any DMERC Certification of Medical Necessity
form that requires a one position alphanumeric response.
CODE VALUES:
DMERC form (reserved for future use)
Y = Yes
N = No
NSF (National Standard Format) User Manual
381
D = Does not apply
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION: N/A
REMARKS: Reserved for future use
RECORD/FIELD: GU0-47.0
DATA ELEMENT: REPLY ALN L01 N22
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
47.0
X(01)
N/A
SPACES
133
133
DEFINITION: Reply to the twenty-second question on any DMERC Certification of Medical Necessity
form that requires a one position alphanumeric response.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: Reserved for future use.
RECORD/FIELD: GU0-48.0
DATA ELEMENT: REPLY ALN L01 N23
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
48.0
X(01)
N/A
SPACES
134
134
DEFINITION: Reply to the twenty-third question on any DMERC Certification of Medical Necessity
form that requires a one position alphanumeric response.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: Reserved for future use.
RECORD/FIELD: GU0-49.0
DATA ELEMENT: REPLY ALN L01 N24
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
49.0
X(01)
N/A
SPACES
135
135
NSF (National Standard Format) User Manual
382
DEFINITION: Reply to the twenty-fourth question on any DMERC Certification of Medical Necessity
form that requires a one position alphanumeric response.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: Reserved for future use.
RECORD/FIELD: GU0-50.0
DATA ELEMENT: REPLY ALN L05 N01
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
50.0
X(05)
LEFT
SPACES
136
140
DEFINITION: Reply to the first question on any DMERC Certification of Medical Necessity form that
requires a five position alphanumeric response.
CODE VALUES:
DMERC form 08.02: Reserved for future use.
DMERC form 09.02: HCPCS code
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION: DMERC 09.02, Question 2
REMARKS: DMERC 09.02: HCPCS code for drug that requires use of pump.
RECORD/FIELD: GU0-51.0
DATA ELEMENT: REPLY ALN L05 N02
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
51.0
X(05)
LEFT
SPACES
141
145
DEFINITION: Reply to the second question on any DMERC Certification of Medical Necessity form that
requires a five position alphanumeric response.
CODE VALUES: DMERC form 08.02: U.S. Postal Service state abbreviation.
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION: DMERC 08.02, Question 10
NSF (National Standard Format) User Manual
383
REMARKS: DMERC 08.02: U.S. Postal Service state abbreviation for the state in which the transplant
operation was performed.
RECORD/FIELD: GU0-52.0
DATA ELEMENT: REPLY ALN L05 N03
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
52.0
X(05)
LEFT
SPACES
146
150
DEFINITION: Reply to the third question on any DMERC Certification of Medical Necessity form that
requires a five position alphanumeric response.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: Reserved for future use.
RECORD/FIELD: GU0-53.0
DATA ELEMENT: REPLY ALN L08 N01
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
53.0
X(08)
LEFT
SPACES
151
158
DEFINITION: Reply to the first question on any DMERC Certification of Medical Necessity form that
requires a eight position alphanumeric response.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
See GENERAL INSTRUCTIONS for "Date" entry.
Must be a valid date.
DMERC form 05.02 and 08.02: Reserved for future use.
DMERC form 06.02: If questions 1 (GU0.26.0) on form 06.02 equals 'N' or 'D', this may be blank.
FORM LOCATION: DMERC 06.02, Question 2
REMARKS: DMERC 06.02: Date of surgery resulting in acute post-operative pain.
RECORD/FIELD: GU0-54.0
DATA ELEMENT: REPLY ALN L08 N02
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
54.0
X(08)
LEFT
SPACES
159
166
NSF (National Standard Format) User Manual
384
DEFINITION: Reply to the second question on any DMERC Certification of Medical Necessity form that
requires a eight position alphanumeric response.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
See GENERAL INSTRUCTIONS for "Date" entry.
Must be a valid date.
FORM LOCATION:
DMERC 06.02, Question 8.A
DMERC 08.02, Question 11
REMARKS: DMERC 06.02: Start date of TENS trial.
DMERC 08.02: Date patient discharged from hospital following transplant surgery.
RECORD/FIELD: GU0-55.0
DATA ELEMENT: REPLY ALN L08 N03
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
55.0
X(08)
LEFT
SPACES
167
174
DEFINITION: Reply to the third question on any DMERC Certification of Medical Necessity form that
requires a eight position alphanumeric response.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
See GENERAL INSTRUCTIONS for "Date" entry.
Must be a valid date.
FORM LOCATION: DMERC 06.02, Question 8.B
REMARKS: DMERC 06.02: Ending date of TENS trial.
RECORD/FIELD: GU0-56.0
DATA ELEMENT: REPLY ALN L08 N04
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
56.0
X(08)
LEFT
SPACES
175
182
DEFINITION: Reply to the fourth question on any DMERC Certification of Medical Necessity form that
requires a eight position alphanumeric response.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
NSF (National Standard Format) User Manual
385
See GENERAL INSTRUCTIONS for "Date" entry.
Must be a valid date.
FORM LOCATION: DMERC 06.02, Question 9
REMARKS: DMERC 06.02: Date that ordering physician saw and evaluated patient following TENS
unit trial.
RECORD/FIELD: GU0-57.0
DATA ELEMENT: REPLY ALN L20 N01
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
57.0
X(20)
LEFT
SPACES
183
202
DEFINITION: Reply to the first DMERC Certification form question that requires a twenty position
alphanumeric answer.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
DMERC form 05.02: Reserved for future use.
FORM LOCATION:
DMERC 08.02, Question 9
DMERC 09.02, Question 3
DMERC 10.02, Question 10
REMARKS:
DMERC 08.02: City where transplant facility located.
DMERC 09.02: Name of drug with non-specific HCPCS code.
DMERC 10.02: Product name.
RECORD/FIELD: GU0-58.0
DATA ELEMENT: REPLY ALN L60 N01
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
58.0
X(60)
LEFT
SPACES
203
262
DEFINITION: Reply to the first DMERC Certification form question that requires a sixty position
alphanumeric answer.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION:
DMERC 08.02, Question 8
NSF (National Standard Format) User Manual
386
DMERC 10.02, Question 15
REMARKS:
DMERC 08.02: Name of transplant facility (maximum of 30 characters).
DMERC 10.02: Additional information when required by policy.
RECORD/FIELD: GU0-59.0
DATA ELEMENT: REPLY NUM L01 N01
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
59.0
9(01)
RIGHT
ZEROS
263
263
DEFINITION: Reply to the first DMERC Certification form question that requires a one position numeric
answer.
CODE VALUES:
DMERC form 01.02:
1 = Stage One
2 = Stage Two
3 = Stage Three
4 = Stage Four
9 = No Ulcer or Pressure Area
DMERC form 08.02:
1 = Heart
2 = Liver
3 = Kidney
4 = Bone marrow
5 = Lung
DMERC form 09.02:
1 = External infusion pump (non-disposable)
3 = Implantable infusion pump
4 = Disposable infusion pump (e.g., elastomeric)
DMERC form 10.02: 1 through 7
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
NSF (National Standard Format) User Manual
387
FORM LOCATION:
DMERC 01.02, Question 21.A
DMERC 08.02, Question 5.A
DMERC 09.02, Question 1
DMERC 10.02, Question 3
REMARKS:
DMERC 01.02: Stage of pressure area/ulcer #1.
DMERC 08.02: Transplanted organ code #1.
DMERC 09.02: Type of prescribed pump code.
DMERC 10.02: Days per week infused.
RECORD/FIELD: GU0-60.0
DATA ELEMENT: REPLY NUM L01 N02
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
60.0
9(01)
RIGHT
ZEROS
264
264
DEFINITION: Reply to the second DMERC Certification form question that requires a one position
numeric answer.
CODE VALUES:
DMERC form 01.02: 1 through 4
DMERC form 08.02:
1 = Heart
2 = Liver
3 = Kidney
4 = Bone marrow
5 = Lung
DMERC form 09.02:
1 = Intravenous
3 = Epidural
4 = Subcutaneous
DMERC form 10.02: 1 through 7
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
NSF (National Standard Format) User Manual
388
FORM LOCATION:
DMERC 01.02, Question 21.D
DMERC 08.02, Question 5.B
DMERC 09.02, Question 4
DMERC 10.02, Question 12
REMARKS:
DMERC 01.02: Stage of pressure area/ulcer #2.
DMERC 08.02:Transplanted organ code #2.
DMERC 09.02: Route of administration.
DMERC 10.02: Days per week administered.
RECORD/FIELD: GU0-61.0
DATA ELEMENT: REPLY NUM L01 N03
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
61.0
9(01)
RIGHT
ZEROS
265
265
DEFINITION: Reply to the third DMERC Certification form question that requires a one position
numeric answer.
CODE VALUES:
DMERC form 01.02: 1 through 4
DMERC form 08.02:
1 = Heart
2 = Liver
3 = Kidney
4 = Bone marrow
5 = Lung
DMERC form 09.02:
1 = Continuous
2 = Intermittent
3 = Bolus
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION:
DMERC 01.02, Question 21.G
NSF (National Standard Format) User Manual
389
DMERC 08.02, Question 5.C
DMERC 09.02, Question 5
REMARKS:
DMERC 01.02:Stage of pressure area/ulcer #3.
DMERC 08.02: Transplanted organ code #3.
DMERC 09.02: Method of administration.
RECORD/FIELD: GU0-62.0
DATA ELEMENT: REPLY NUM L04 N01
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
62.0
9(04)
RIGHT
ZEROS
266
269
DEFINITION: Reply to the first DMERC Certification form question that requires a four position
numeric answer.
CODE VALUES:
DMERC forms 02.03 and 09.02: 0001 through 0024
DMERC forms 03.02, 08.02 and 10.02: 0000 through 9999
DMERC form 04.03: 0001 through 0099
DMERC form 06.02: 0001 through 0099 - If GU0-27.0 is 'N' or 'D' this must be zero filled.
DMERC form 01.02 and 05.02: Reserved for future use.
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION:
DMERC 02.03, Question 5
DMERC 03.02, Question 12
DMERC 04.03, Question 6.B (Osteogenesis Stimulators)
DMERC 06.02, Question 4
DMERC 08.02, Question 1.B
DMERC 09.02, Question 6
DMERC 10.02, Question 4.A
REMARKS:
DMERC 02.03: Hours per day patient usually spends in the wheelchair.
DMERC 03.02: Number of episodes apnea lasting more than 10 seconds in seven hours or less.
DMERC 04.03: Number of months prior to ordering device did patient sustained the fracture.
NSF (National Standard Format) User Manual
390
DMERC 06.02: Number of months patient has had intractable pain.
DMERC 08.02: Milligram dosage of each drug administered.
DMERC 09.02: Number of hours of drug infusion per day.
DMERC 10.02: Milliliters per day of amino acid.
RECORD/FIELD: GU0-63.0
DATA ELEMENT: REPLY NUM L04 N02
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
63.0
9(04)
RIGHT
ZEROS
270
273
DEFINITION: Reply to the second DMERC Certification form question that requires a four position
numeric answer.
CODE VALUES:
DMERC forms 01.02 and 08.02: 0000 through 9999
DMERC form 10.02: 0000 through 0999
DMERC form 04.03: 0001 through 0099
DMERC form 05.02 and 09.02: Reserved for future use.
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION:
DMERC 01.02, Question 21.B
DMERC 04.03, Question 7.B
DMERC 08.02, Question 1.C
DMERC 10.02, Question 4.C
REMARKS:
DMERC 01.02: Maximum length in centimeters of pressure area/ulcer #1.
DMERC 04.03: Number of months, prior to ordering the device did the patient have the fusion
(other than spine).
DMERC 08.02: Times per day of drug administration.
DMERC 10.02: Grams of protein per day.
RECORD/FIELD: GU0-64.0
DATA ELEMENT: REPLY NUM L04 N03
FIELD
COBOL PICTURE
NSF (National Standard Format) User Manual
JUSTIFY
INITIAL
FROM
THRU
391
64.0
9(04)
RIGHT
ZEROS
274
277
DEFINITION: Reply to the third DMERC Certification form question that requires a four position
numeric answer.
CODE VALUES:
DMERC forms 01.02 and 10.02: 0000 through 9999
DMERC form 04.03: 0001 through 0099
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION:
DMERC 01.02, Question 21.C
DMERC 04.03, Question 9.B
DMERC 10.02, Question 4.D
REMARKS:
DMERC 01.02: Maximum width in centimeters of pressure area/ulcer #1.
DMERC 04.03: Number of months, prior to ordering the device, did the patient have the spinal
fusion.
DMERC 10.02: Milliliters per day of dextrose.
RECORD/FIELD: GU0-65.0
DATA ELEMENT: REPLY NUM L04 N04
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
65.0
9(04)
RIGHT
ZEROS
278
281
DEFINITION: Reply to the fourth DMERC Certification form question that requires a four position
numeric answer.
CODE VALUES:
DMERC forms 01.02 and 10.02: 0000 through 9999
DMERC form 04.03: 0001 through 0099
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION:
DMERC 01.02, Question 21.E
DMERC 04.03, Question 10.B
DMERC 10.02, Question 4.F
NSF (National Standard Format) User Manual
392
REMARKS:
DMERC 01.02: Maximum length in centimeters of pressure area/ulcer #2.
DMERC 04.03: Number of months, prior to ordering the device, did the patient have repeat
fusion.
DMERC 10.02: Milliliters per day of lipids.
RECORD/FIELD: GU0-66.0
DATA ELEMENT: REPLY NUM L04 N05
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
66.0
9(04)
RIGHT
ZEROS
282
285
DEFINITION: Reply to the fifth DMERC Certification form question that requires a four position
numeric answer.
CODE VALUES:
DMERC form 01.02: 0000 through 9999
DMERC form 04.03: 0001 through 0099
DMERC form 10.02: 0000 through 0007
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION:
DMERC 01.02, Question 21.F
DMERC 04.03, Question 10.C
DMERC 10.02, Question 4.G
REMARKS:
DMERC 01.02: Maximum width in centimeters of pressure area/ulcer #2.
DMERC 04.03: Number of months prior to ordering the device did the patient have the
previously failed fusion.
DMERC 10.02: Days per week lipids administered.
RECORD/FIELD: GU0-67.0
DATA ELEMENT: REPLY NUM L04 N06
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
67.0
9(04)
RIGHT
ZEROS
286
289
DEFINITION: Reply to the sixth DMERC Certification form question that requires a four position
numeric answer.
NSF (National Standard Format) User Manual
393
CODE VALUES:
DMERC form 01.02 and 10.02: 0000 through 9999
DMERC form 04.03: 0001 through 0099
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION:
DMERC 01.02, Question 21.H
DMERC 04.03, Question 11.B
DMERC 10.02, Question 11
REMARKS:
DMERC 01.02: Maximum length in centimeters of pressure area/ulcer #3.
DMERC 04.03: Number of months prior to ordering the device did the patient have the multilevel fusion.
DMERC 10.02: Calories per day.
RECORD/FIELD: GU0-68.0
DATA ELEMENT: REPLY NUM L04 N07
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
68.0
9(04)
RIGHT
ZEROS
290
293
DEFINITION: Reply to the seventh DMERC Certification form question that requires a four position
numeric answer.
CODE VALUES: DMERC form 01.02: 0000 through 9999
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION: DMERC 01.02, Question 21.I
REMARKS: DMERC 01.02: Maximum width in centimeters of pressure area/ulcer #3.
RECORD/FIELD: GU0-69.0
DATA ELEMENT: REPLY PCT L04 N01
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
69.0
9(3)V9
RIGHT
ZEROS
294
297
DEFINITION: Reply to the first DMERC Certification form question that requires a four position
numeric percentage answer containing an implied decimal place.
NSF (National Standard Format) User Manual
394
CODE VALUES:
DMERC form 03.02: Reserved for future use.
DMERC form 10.02: 000.0% through 099.9%
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION: DMERC 10.02, Question 4.B
REMARKS: DMERC 10.02: Amino acid percentage of concentration.
RECORD/FIELD: GU0-70.0
DATA ELEMENT: REPLY PCT L04 N02
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
70.0
9(3)V9
RIGHT
ZEROS
298
301
DEFINITION: Reply to the second DMERC Certification form question that requires a four position
numeric percentage answer containing an implied decimal place.
CODE VALUES: DMERC form 10.02: 000.0% through 099.9%
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION: DMERC 10.02, Question 4.E
REMARKS: DMERC 10.02: Dextrose percentage of concentration.
RECORD/FIELD: GU0-71.0
DATA ELEMENT: REPLY PCT L04 N03
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
71.0
9(3)V9
RIGHT
ZEROS
302
305
DEFINITION: Reply to the third DMERC Certification form question that requires a four position
numeric percentage answer containing an implied decimal place.
CODE VALUES: DMERC form 10.02: 000.0% through 099.9%
VALIDATION: Must be entered if required by payor.
Must be a valid code from the list above.
FORM LOCATION: DMERC 10.02, Question 4.H
REMARKS: DMERC 10.02: Lipids percentage of concentration.
RECORD/FIELD: GU0-72.0S
NSF (National Standard Format) User Manual
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DATA ELEMENT: Filler - National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
72.0
X(15)
LEFT
SPACES
306
320
DEFINITION: Unused reserved record space for national use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: CERTIFICATION RECORD TYPE GX0 "MEDICAL NECESSITY
FOR OXYGEN"
Not Required by MO HealthNet
Must follow FB0 - GU0
Must be followed by GX1 - XA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "GX0"
C-24
GX0
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
Not Used
04
CERTIFICATION TYPE
Not Used
05
OXYGEN SYSTEM
Not Used
06
LENGTH OF NEED
Not Used
07
EQUIPMENT TYPE 1
Not Used
08
EQUIPMENT TYPE 2
Not Used
09
EQUIPMENT REASON
Not Used
10
PRESCRIBED FROM DATE
Not Used
11
PRESCRIBED TO DATE
Not Used
12
DATE PRESCRIBED
Not Used
13
DATE EVALUATED
Not Used
14
OXY FLOW RATE
Not Used
15
FREQUENCY OF USE
Not Used
NSF (National Standard Format) User Manual
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16
DURATION
Not Used
17
ARTERIAL BLOOD GAS 4LPM
Not Used
18
OXIMETRY 4LPM
Not Used
19
DATE TESTED 4LPM
Not Used
20
INPATIENT/OUTPATIENT IND
Not Used
21
FILLER
Not Used
22
ARTERIAL BLOOD GAS
Not Used
23
OXIMETRY
Not Used
24
DATE TESTED
Not Used
25
ENTITY PERF OXIMETRY TST
Not Used
26
TEST CONDITIONS
Not Used
27
CLINICAL FINDINGS
Not Used
28
PORT OXY FLOW RATE
Not Used
29
ORDERING PROV ID
Not Used
30
ORDERING PROV PHONE
Not Used
31
DIAGNOSIS CODE-1
Not Used
32
DIAGNOSIS CODE-2
Not Used
33
DIAGNOSIS CODE-3
Not Used
34
DIAGNOSIS CODE-4
Not Used
35
CERT ON FILE
Not Used
36
DELIVERY SYSTEM TYPE
Not Used
37
FILLER-NATIONAL
YES
RECORD TYPE: GX0
LEVEL: SERVICE LINE
PURPOSE: To provide information regarding attending physician's certification of medical necessity for home
oxygen therapy (Form HCFA-484).
REQUIREMENTS: If required by payor, a "GX0" record must be submitted for the initial certification, revised
certification or renewal certification when billing for home oxygen therapy.
ORDER:
Preceding Record Type
Following Record Type
FA0, FB0, FB1, FB2, or FE0
FA0, GX1, GX2, HA0 or XA0
NSF (National Standard Format) User Manual
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NOTES: When used, this record must follow the FA0, FB0, FB1, FB2, or FE0 records related to this service.
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "GX0"
3
X
01
03
02.0
SEQUENCE NO
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
CERTIFICATION TYPE
1
X
23
23
05.0
OXYGEN SYSTEM
1
X
24
24
06.0
LENGTH OF NEED
2
X
25
26
07.0
EQUIPMENT TYPE 1
1
X
27
27
08.0
EQUIPMENT TYPE 2
1
X
28
28
09.0
EQUIPMENT REASON
64
X
29
92
10.0
PRESCRIBED FROM DATE
8
X
93
100
11 0
PRESCRIBED TO DATE
8
X
101
108
12.0
DATE PRESCRIBED
8
X
109
116
13.0
DATE EVALUATED
8
X
117
124
14.0
OXY FLOW RATE
3
N
125
127
15.0
FREQUENCY OF USE
2
X
128
129
16.0
DURATION
2
X
130
131
17.0
ARTERIAL BLOOD GAS 4LPM
3
N
132
134
18.0
OXIMETRY 4LPM
3
N
135
137
19.0
DATE TESTED 4LPM
8
X
138
145
20.0
INPATIENT/OUTPATIENT IND
1
X
146
146
21.0
FILLER
65
X
147
211
22.0
ARTERIAL BLOOD GAS
3
N
212
214
23.0
OXIMETRY
3
N
215
217
24.0
DATE TESTED
8
X
218
225
25.0
ENTITY PERF OXIMETRY TST
33
X
226
258
26.0
TEST CONDITIONS
1
X
259
259
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398
27.0
CLINICAL FINDINGS
3
X
260
262
28.0
PORT OXY FLOW RATE
3
N
263
265
29.0
ORDERING PROV ID
15
X
266
280
30.0
ORDERING PROV PHONE
10
X
281
290
31.0
DIAGNOSIS CODE-1
5
X
291
295
32.0
DIAGNOSIS CODE-2
5
X
296
300
33.0
DIAGNOSIS CODE-3
5
X
301
305
34.0
DIAGNOSIS CODE-4
5
X
306
310
35.0
CERT ON FILE
1
X
311
311
36.0
DELIVERY SYSTEM TYPE
1
X
312
312
37.0
FILLER-NATIONAL
8
X
313
320
RECORD/FIELD: GX0-01.0
DATA ELEMENT: Record Identifier (RECORD ID "GX0")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: Code used to identify the "Medical Necessity for Oxygen" record.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be "GX0".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GX0-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: A numeric value from 01 through 99 used to sequence the "GX0" records and to associate
"GX0" records with "GX1" and "GX2" records.
CODE VALUES: 01 through 99
NSF (National Standard Format) User Manual
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VALIDATION: Must be entered.
Must be a valid code from the above list.
The value entered must match the SEQUENCE NUMBER (FA0-02.0) submitted in the preceding "FA0"
record.
FORM LOCATION: N/A
REMARKS: See sequencing instructions on page FA0.04.
RECORD/FIELD: GX0-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: An identification assigned to the patient by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Patient Control Number".
Must be entered.
FORM LOCATION: CMS-1500 Block 26
REMARKS: The patient control number is used by the EMC system to link all records for a claim. All
records between the record type CA0, up to and including the record type XA0, must have the same
patient control number.
Although up to seventeen characters are allowed, not all payors' systems will record and return seventeen
characters on remittance advices or other documents.
RECORD/FIELD: GX0-04.0
DATA ELEMENT: Type of Certification (CERTIFICATION TYPE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(01)
N/A
SPACE
23
23
DEFINITION: The type of certification being billed.
CODE VALUES:
I = Initial Certification
R = Renewal Certification
S = Revised Certification
OR
1 = Initial Certification
2 = Revised Certification
NSF (National Standard Format) User Manual
400
3 = Renewal Certification
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: HCFA-484
REMARKS: Values 1, 2, and 3 are currently used by the Medicare Durable Medical Equipment Regional
Carriers (DMERCs) only.
RECORD/FIELD: GX0-05.0
DATA ELEMENT: Type of Oxygen System (OXYGEN SYSTEM)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(01)
N/A
SPACE
24
24
DEFINITION: To indicate if the patient is mobile within the home when ordering portable oxygen.
CODE VALUES:
Y = Yes, ordering portable oxygen and patient is mobile within the home.
N = No, ordering portable oxygen and patient is NOT mobile within the home.
D = Does Not Apply. (Not ordering portable oxygen)
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: HCFA-484, Question 5
REMARKS: N/A
RECORD/FIELD: GX0-06.0
DATA ELEMENT: Length of Need
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(02)
LEFT
SPACES
26
26
DEFINITION: Estimate of length of time oxygen therapy will be required.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
Enter the number of months covered by this certification. If lifetime, enter 99.
FORM LOCATION: HCFA-484
REMARKS: N/A
NSF (National Standard Format) User Manual
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RECORD/FIELD: GX0-07.0
DATA ELEMENT: Type of Equipment 1 (EQUIPMENT TYPE 1)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(01)
N/A
SPACE
27
27
DEFINITION: Enter a description of the specific type of equipment being prescribed for the delivery of
oxygen.
CODE VALUES:
A = Concentrator
B = Liquid Stationary
C = Gaseous Stationary
D = Liquid Portable
E = Gaseous Portable
O = Other
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: If the prescribing physician ordered both a portable and stationary system, or a concentrator
with a system, enter the second system in "Equipment Type 2" (GX0.08.0).
RECORD/FIELD: GX0-08.0
DATA ELEMENT: Type of Equipment 2 (EQUIPMENT TYPE 2)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
08.0
X(01)
N/A
SPACE
28
28
DEFINITION: Enter a description of the specific type of equipment being prescribed for the delivery of
oxygen.
CODE VALUES:
A = Concentrator
B = Liquid Stationary
C = Gaseous Stationary
D = Liquid Portable
E = Gaseous Portable
O = Other
VALIDATION: Must be entered if required by payor.
NSF (National Standard Format) User Manual
402
If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: If the prescribing physician ordered both a portable and stationary system, or a concentrator
with a system, enter the second system in this field.
RECORD/FIELD: GX0-09.0
DATA ELEMENT: Reason for Equipment (EQUIPMENT REASON)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
X(64)
LEFT
SPACES
29
92
DEFINITION: The reasons why a particular system or piece of equipment is required.
CODE VALUE: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GX0-10.0 GX0-11.0
DATA ELEMENT:
Oxygen Prescribed From Date
(PRESCRIBED FROM DATE)
Oxygen Prescribed To Date
(PRESCRIBED TO DATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
X(08)
LEFT
SPACES
93
100
11.0
X(08)
LEFT
SPACES
101
108
DEFINITION: The from and to dates for which oxygen was prescribed.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: HCFA-484
REMARKS: N/A
RECORD/FIELD: GX0-12.0
NSF (National Standard Format) User Manual
403
DATA ELEMENT: Date Oxygen Prescribed (DATE PRESCRIBED)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(08)
LEFT
SPACES
109
116
DEFINITION: The date oxygen was prescribed. On renewal prescriptions, enter the date the physician
signed the renewal.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: HCFA-484
REMARKS: N/A
RECORD/FIELD: GX0-13.0
DATA ELEMENT: Date Patient Evaluated (DATE EVALUATED)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
X(08)
LEFT
SPACES
117
124
DEFINITION: The date the patient was last examined by the physician to determine the need for oxygen
therapy.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: N\A
REMARKS: A lab test to evaluate the continued need for oxygen is not necessary for all recertification,
but the results of any such test since the last prior certification should be entered.
RECORD/FIELD: GX0-14.0
DATA ELEMENT: Oxygen Flow Rate (OXY FLOW RATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
14.0
X(03)
RIGHT
ZEROES
125
127
DEFINITION: The oxygen flow rate (stationary equipment liters per minute).
CODE VALUES:
001 - 999 LPM
NSF (National Standard Format) User Manual
404
00X = less than 1 LPM
VALIDATION: Must be entered if required by payor.
FORM LOCATION: HCFA-484, Question 6
REMARKS: For oxygen concentrators, the concentrator supplied must accommodate the flow rate
prescribed by the physician. If billing oxygen in excess of 4LPM, or less than 1LPM, the prescription
must support the liter flow output.
If billing oxygen is greater than 4 LPM also Enter the date the test was performed (GX0-20.0).
Claims with flow rates of more than 2 liters per minute usually require review by the insurance carrier's
medical staff.
RECORD/FIELD: GX0-15.0
DATA ELEMENT: Frequency of Use
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
15.0
X(02)
LEFT
SPACES
128
129
DEFINITION: The number of times per day the patient must use oxygen.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: This field is normally used only if the physician has prescribed oxygen for a particular
period of use (i.e. during exercise, nocturnally, etc).
RECORD/FIELD: GX0-16.0
DATA ELEMENT: Duration
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
16.0
X(02)
LEFT
SPACES
130
131
DEFINITION: The hours per period of use.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GX0-17.0
DATA ELEMENT: Arterial Blood Gas on 4LPM
NSF (National Standard Format) User Manual
405
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
17.0
9(2)V9
RIGHT
ZEROES
132
134
DEFINITION: The arterial blood gas test results taken on 4 LPM.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: HCFA-484, Question 7a
REMARKS: N/A
RECORD/FIELD: GX0-18.0
DATA ELEMENT: Oxygen Saturation on 4LPM
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
9(2)V9
RIGHT
ZEROES
135
137
DEFINITION: The oxygen saturation test results taken on 4 LPM with patient in a chronic stable state.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: HCFA-484, Question 7b
REMARKS: N/A
RECORD/FIELD: GX0-19.0
DATA ELEMENT: Date Test Performed on 4 LPM
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
19.0
X(08)
LEFT
SPACES
138
145
DEFINITION: The date the patient was tested for Arterial blood gas and/or oxygen saturation on 4 LPM.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: HCFA-484, Question 7c
REMARKS: N/A
RECORD/FIELD: GX0-20.0
DATA ELEMENT: Inpatient/Outpatient Indicator
FIELD
COBOL PICTURE
NSF (National Standard Format) User Manual
JUSTIFY
INITIAL
FROM
THRU
406
20.0
X(01)
LEFT
SPACES
146
146
DEFINITION: Were the test(s) reported in GX0-22 and/or GX0-23 Performed within ONE day of
discharge from an inpatient facility to home or with the patient in a chronic stable state as an outpatient?
CODE VALUES:
Y = Yes
N = No
VALIDATION: Must be entered is required by payor.
If entered, must be a valid code from above list.
FORM LOCATION: HCFA-484, Question 2
REMARKS: N/A
RECORD/FIELD: GX0-21.0
DATA ELEMENT: Filler
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
21.0
X(65)
LEFT
SPACES
147
211
DEFINITION: Reserved for National use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GX0-22.0
DATA ELEMENT: Arterial Blood Gas
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
22.0
9(2)V9
RIGHT
ZEROES
212
214
DEFINITION: The Arterial Blood Gas test results taken on or before the certification date (furnish results
of recent hospital tests).
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: HCFA-484, Question 1a
REMARKS: N/A
NSF (National Standard Format) User Manual
407
RECORD/FIELD: GX0-23.0
DATA ELEMENT: Oxygen Saturation (OXIMETRY)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
23.0
9(2)V9
RIGHT
ZEROES
215
217
DEFINITION: The oxygen saturation (oximetry) test results taken on or before the certification
date(furnish results of recent hospital tests).
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: HCFA-484, Question 1b
REMARKS: N/A
RECORD/FIELD: GX0-24.0
DATA ELEMENT: Date Test Performed (DATE TESTED)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
24.0
X(08)
LEFT
SPACES
218
225
DEFINITION: The date the patient was tested for arterial blood gas and/or oxygen saturation.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, must be a valid date.
See GENERAL INSTRUCTIONS for "Date" entry.
FORM LOCATION: HCFA-484, Question 1c
REMARKS: N/A
RECORD/FIELD: GX0-25.0
DATA ELEMENT: Entity Performing Oximetry Testing (ENTITY PERF OXIMETRY TST)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
25.0
X(33)
LEFT
SPACES
226
258
DEFINITION: The name of the entity who performed the ABG and/or oximetry tests.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Name 2" entry.
Must be entered if required by payor.
NSF (National Standard Format) User Manual
408
FORM LOCATION: HCFA-484
REMARKS: N/A
RECORD/FIELD: GX0-26.0
DATA ELEMENT: Test Conditions
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
26.0
X(01)
N/A
SPACES
259
259
DEFINITION: Code indicating the conditions under which the patient was tested.
CODE VALUES:
1 = At rest
2 = Exercising
3 = Sleeping
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: HCFA-484, Question 3
REMARKS: N/A
RECORD/FIELD: GX0-27.0
DATA ELEMENT: Clinical Findings
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
27.0
X(03)
LEFT
SPACES
260
262
DEFINITION: If the patient's arterial PO2 is over 55 mm Hg and under 60 mm Hg or the oxygen
saturation is over 88 percent, does the patient have (see validation):
CODE VALUES:
Y = Yes
N = No
(Blank) = Does Not Apply
VALIDATION: Must be entered if required by payor.
If entered, must be valid code from the above list.
Enter Y, N, or (blank) to the following questions:
Position 1 = dependent edema due to congestive heart failure?
Position 2 = cor pulmonale or pulmonary hypertension documented by P pulmonate on EKG or by an
echocardiogram, gated blood pool scan or direct pulmonary artery pressure measurement?
NSF (National Standard Format) User Manual
409
Position 3 = a hematocrit greater than 56 percent?
FORM LOCATION: HCFA-484, Question 8, 9, 10
REMARKS: Up to three codes can be entered in this field. For example, if 1 and 3 are applicable, enter
"Y Y". A "space" means does not apply.
NOTE: Clinical findings are subject to later verification as necessary.
RECORD/FIELD: GX0-28.0
DATA ELEMENT: Portable Oxygen Flow Rate (PORT OXY FLOW RATE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
28.0
9(2)V9
RIGHT
ZEROES
263
265
DEFINITION: The oxygen flow rate (liters per minute) for a portable oxygen system.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
If entered, the medical therapeutic purpose to be served by the portable system that cannot be met by a
stationary system must be entered in segment GX1-06.0.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GX0-29.0
DATA ELEMENT: Ordering Physician ID (ORDERING PROVIDER ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
29.0
X(15)
LEFT
SPACES
266
280
DEFINITION: The identifier assigned by the Payor to the physician who prescribed the oxygen.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GX0-30.0
DATA ELEMENT: Ordering Provider Phone (ORDERING PROV PHONE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
30.0
X(10)
LEFT
SPACES
281
290
NSF (National Standard Format) User Manual
410
DEFINITION: The telephone number of the ordering physician who prescribed the oxygen.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Telephone" entry.
Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GX0-31.0 GX0-32.0 GX0-33.0 GX0-34.0
DATA ELEMENT:
Diagnosis Code-1
Diagnosis Code-2
Diagnosis Code-3
Diagnosis Code-4
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
31.0
X(05)
LEFT
SPACES
291
295
32.0
X(05)
LEFT
SPACES
296
300
33.0
X(05)
LEFT
SPACES
301
305
34.0
X(05)
LEFT
SPACES
306
310
DEFINITION: The ICD-9-CM Diagnosis Code identifying a diagnosed medical condition resulting in the
prescription for oxygen.
CODE VALUES: N/A
VALIDATION: Must be the most specific/precise 3 digit, 4 digit or 5 digit code allowed for in the ICD9-CM coding format.
Do not submit a decimal point. The decimal point is implied because each ICD-9-CM code is unique.
The submission of "V", "E", and/or "M" diagnosis codes may or may not be accepted by a payor.
Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GX0-35.0
DATA ELEMENT: Certification on File (CERT ON FILE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
35.0
X(01)
LEFT
SPACES
311
311
NSF (National Standard Format) User Manual
411
DEFINITION: The certification completed and signed by the physician is on file at the supplier's office.
CODE VALUES:
Y = Yes
N = No
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GX0-36.0
DATA ELEMENT: Delivery System Type
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
36.0
X(01)
N/A
SPACES
312
312
DEFINITION: To indicate if a particular form of delivery was prescribed.
CODE VALUES:
A = Nasal Cannula
B = 02 Conserving Device
C = 02 Conserving Device with Pulse 02 System
D = 02 Conserving Device with Reservoir System
E = Transtracheal Catheter
VALIDATION: Must be entered if required by payor.
If entered, must be a valid code from the above list.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GX0-37.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
37.0
X(08)
LEFT
SPACES
313
320
DEFINITION: Unused reserved filler for National use.
CODE VALUES: N/A
VALIDATION: N/A
NSF (National Standard Format) User Manual
412
FORM LOCATION: N/A
REMARKS: N/A
OXYGEN CERTIFICATION RECORD
RECORD TYPE: GX1
"NARRATIVE INFORMATION FOR OXYGEN"
RECORD NAME: CERTIFICATION RECORD TYPE GX1 "NARRATIVE
INFORMATION FOR OXYGEN"
Not Required by MO HealthNet
Must follow FB0 - GX0
Must be followed by GX2 - XA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "GX1"
C-24
GX1
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
Not Used
04
TEST RESULTS
Not Used
05
MEDICAL FINDINGS
Not Used
06
EXERCISE ROUTINE
Not Used
07
FILLER-NATIONAL
YES
RECORD TYPE: GX1
LEVEL: SERVICE LINE
PURPOSE: To provide NARRATIVE information regarding the attending physician's certification of medical
necessity for home oxygen therapy (Form HCFA-484).
REQUIREMENTS: If required by the payor, a "GX1" record must be submitted for the initial certification,
revised certification or renewal certification when billing for home oxygen therapy.
ORDER:
Preceding Record Type
Following Record Type
GX0
FA0, GX2, HA0 or XA0
NOTES:
FIELD NO.
FIELD NAME
NSF (National Standard Format) User Manual
FIELD
LENGTH
TYPE
POSITIONS
413
FROM
THRU
01.0
RECORD ID "GX1"
3
X
01
03
02.0
SEQUENCE NO
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
TEST RESULTS
90
X
23
112
05.0
MEDICAL FINDINGS
90
X
113
202
06.0
EXERCISE ROUTINE
90
X
203
292
07.0
FILLER-NATIONAL
28
X
293
320
RECORD/FIELD: GX1-01.0
DATA ELEMENT: Record Identifier (RECORD ID "GX1")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: Code used to identify the "Medical Necessity for Oxygen" record.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
Must be "GX1".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GX1-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: A numeric value from 01 through 99 used to sequence the "GX1" records and to associate
"GX1" records with "GX0" and "GX2" records.
CODE VALUES: 01 through 99
VALIDATION: Must be entered.
Must be a valid code from the above list.
The value entered must match the SEQUENCE NUMBER (GA0-02.0) submitted in the preceding "GA0"
record.
NSF (National Standard Format) User Manual
414
FORM LOCATION: N/A
REMARKS: See sequencing instructions on page FA0.04.
RECORD/FIELD: GX1-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: An identification assigned to the patient by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Patient Control Number".
Must be entered.
FORM LOCATION: CMS-1500 Block 26
REMARKS: The patient control number is used by the EMC system to link all records for a claim. All
records between the record type CA0, up to and including the record type XA0, must have the same
patient control number.
Although up to seventeen characters are allowed, not all payors' systems will record and return seventeen
characters on remittance advices or other documents.
RECORD/FIELD: GX1-04.0
DATA ELEMENT: Test Results
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(90)
LEFT
SPACES
23
112
DEFINITION: If tests are performed under other conditions such as oxygen, give test results and
information necessary for interpreting the tests and why performed under these conditions.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: HCFA-484
REMARKS: N/A
RECORD/FIELD: GX1-05.0
DATA ELEMENT: Additional Medical Findings (MEDICAL FINDINGS)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(90)
LEFT
SPACES
113
202
NSF (National Standard Format) User Manual
415
DEFINITION: Enter the additional medical findings justifying the need for oxygen if the PO2 levels are
60 mm Hg or above, or arterial blood oxygen saturation is 90 percent or above.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: HCFA-484
REMARKS: N/A
RECORD/FIELD: GX1-06.0
DATA ELEMENT: Exercise Routine
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(90)
LEFT
SPACES
203
292
DEFINITION: Description of activities or exercise routine that patient undertakes on a regular basis that
requires the portable system in the home that cannot be met by a stationary system (e.g. amount and
frequency of ambulation).
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: HCFA-484
REMARKS: N/A
RECORD/FIELD: GX1-07.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(28)
LEFT
SPACES
293
320
DEFINITION: Reserved record space for national use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: CERTIFICATION RECORD TYPE GX2 "FACILITY
INFORMATION FOR OXYGEN"
Not Required by MO HealthNet
Must follow FB0 - GX1
NSF (National Standard Format) User Manual
416
Must be followed by HA0 - XA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "GX2"
C-24
GX2
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
Not Used
04
TEST FACILITY ADDR 1
Not Used
05
TEST FACILITY ADDR 2
Not Used
06
TEST FACILITY CITY
Not Used
07
TEST FACILITY STATE
Not Used
08
TEST FACILITY ZIP
Not Used
09
PAT FACILITY NAME
Not Used
10
PAT FACILITY ADDR 1
Not Used
11
PAT FACILITY ADDR 2
Not Used
12
PAT FACILITY CITY
Not Used
13
PAT FACILITY STATE
Not Used
14
PAT FACILITY ZIP
Not Used
15
FILLER-NATIONAL
YES
RECORD TYPE: GX2
LEVEL: SERVICE LINE
PURPOSE: To provide FACILITY information regarding where the test was performed or where the patient
resides if other than home.
REQUIREMENTS: If required by payor, a "GX2" record must be submitted for the initial certification, revised
certification or renewal certification when billing for home oxygen therapy.
ORDER:
Preceding Record Type
Following Record Type
GX0 or GX1
FA0, HA0, or XA0
NOTES: N/A
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
NSF (National Standard Format) User Manual
THRU
417
01.0
RECORD ID "GX2"
3
X
01
03
02.0
SEQUENCE NO
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
TEST FACILITY ADDR 1
30
X
23
52
05.0
TEST FACILITY ADDR 2
30
X
53
82
06.0
TEST FACILITY CITY
20
X
83
102
07.0
TEST FACILITY STATE
2
X
103
104
08.0
TEST FACILITY ZIP
9
X
105
113
09.0
PAT FACILITY NAME
33
X
114
146
10.0
PAT FACILITY ADDR 1
30
X
147
176
11.0
PAT FACILITY ADDR 2
30
X
177
206
12.0
PAT FACILITY CITY
20
X
207
226
13.0
PAT FACILITY STATE
2
X
227
228
14.0
PAT FACILITY ZIP
9
X
229
237
15.0
FILLER-NATIONAL
83
X
238
320
RECORD/FIELD: GX2-01.0
DATA ELEMENT: Record Identifier (RECORD ID "GX2")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: Code used to identify the "Facility Information for Oxygen" record.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
Must be "GX2".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: GX2-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
ZEROS
04
05
NSF (National Standard Format) User Manual
418
DEFINITION: A numeric value from 01 through 99 used to sequence the "GX2" records and to associate
"GX2" records with "GX0" and "GX1" records.
CODE VALUES: 01 through 99
VALIDATION: Must be entered .
Must be a valid code from the above list.
The value entered must match the SEQUENCE NUMBER (GA0-02.0) submitted in the preceding "GA0"
record.
FORM LOCATION: N/A
REMARKS: See sequencing instructions on page FA0.04.
RECORD/FIELD: GX2-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: An identification assigned to the patient by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: See GENERAL INSTRUCTIONS for "Patient Control Number".
Must be entered.
FORM LOCATION: CMS-1500 Block 26
REMARKS: The patient control number is used by the EMC system to link all records for a claim. All
records between the record type CA0, up to and including the record type XA0, must have the same
patient control number.
Although up to seventeen characters are allowed, not all payors' systems will record and return seventeen
characters on remittance advices or other documents.
RECORD/FIELD: GX2-04.0 GX2-05.0 GX2-06.0 GX2-07.0 GX2-08.0
DATA ELEMENT:
Test Facility Street Address 1
(TEST FACILITY ADDR 1)
Test Facility Street Address 2
(TEST FACILITY ADDR 2)
Test Facility City
(TEST FACILITY CITY)
Test Facility State
NSF (National Standard Format) User Manual
419
(TEST FACILITY STATE)
Test Facility Zip Code
(TEST FACILITY ZIP)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(30)
LEFT
SPACES
23
52
05.0
X(30)
LEFT
SPACES
53
82
06.0
X(20)
LEFT
SPACES
83
102
07.0
X(02)
LEFT
SPACES
103
104
08.0
X(09)
LEFT
SPACES
105
113
DEFINITION: Enter the address of the facility where the tests were performed. If conducted in the
patient's home, enter the name and address of the physician or the laboratory performing the tests.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: HCFA-484
REMARKS: N/A
RECORD/FIELD: GX2-09.0 GX2-10.0 GX2-11.0 GX2-12.0 GX2-13.0 GX2-14.0
DATA ELEMENT:
PAT Facility Name
(PAT FACILITY NAME)
PAT Facility Street Address 1
(PAT FACILITY ADDR 1)
PAT Facility Street Address 2
(PAT FACILITY ADDR 2)
PAT Facility City
(PAT FACILITY CITY)
PAT Facility State
(PAT FACILITY STATE)
PAT Facility Zip Code
(PAT FACILITY ZIP)
FIELD
COBOL PICTURE
NSF (National Standard Format) User Manual
JUSTIFY
INITIAL
FROM
THRU
420
09.0
X(33)
LEFT
SPACES
114
146
10.0
X(30)
LEFT
SPACES
147
176
11.0
X(30)
LEFT
SPACES
177
206
12.0
X(20)
LEFT
SPACES
207
226
13.0
X(02)
LEFT
SPACES
227
228
14.0
X(09)
LEFT
SPACES
229
237
DEFINITION: Enter the name and address of the facility where the patient resides if other than home.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: HCFA-484
REMARKS: N/A
RECORD/FIELD: GX2-15.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
15.0
X(83)
LEFT
SPACES
238
320
DEFINITION: Reserved record space for national use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: NARRATIVE RECORD TYPE HA0 "CLAIM DATA"
Not Required by MO HealthNet
Must follow FB0 - GX2
Must be followed by XA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "HA0"
C-24
HA0
02
SEQUENCE NO
C-21
YES
03
PAT CONTROL NO
NSF (National Standard Format) User Manual
Not Used
421
04
LINE ITEM CONTROL NO
Not Used
05
EXTRA NARRATIVE DATA
Not Used
RECORD TYPE: HA0
LEVEL: SERVICE LINE
PURPOSE: To provide additional information related to the service rendered to the patient by the provider.
REQUIREMENTS: If required by the payor, this record must be submitted.
ORDER:
Preceding Record Type
Following Record Type
FA0, FB0, FB1, FB2, FE0, FD0,
GA0, GC0, GD0, GD1, GE0, GP0,
GU0, GX0, GX1 or GX2
FA0 or XA0
NOTES: When used, this record must follow the FA0, FB0, FB1, FB2, FD0, FE0, GA0, GC0, GD0, GE0, GP0,
GU0, GX0, GX1 or GX2 record related to this service.
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "HA0"
3
X
01
03
02.0
SEQUENCE NO
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
LINE ITEM CONTROL NO
17
X
23
39
05.0
EXTRA NARRATIVE DATA
281
X
40
320
RECORD/FIELD: HA0-01.0
DATA ELEMENT: Record Identification (RECORD ID "HA0")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: This is the record identifier for the Narrative Record - HA0.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be "HA0".
FORM LOCATION: N/A
NSF (National Standard Format) User Manual
422
REMARKS: N/A
RECORD/FIELD: HA0-02.0
DATA ELEMENT: Sequence Number (SEQUENCE NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: A numeric value from 01 through 99 used to sequence the "HA0" record to the
corresponding "FA0" record.
CODE VALUES: 01 through 99
VALIDATION: Must be entered.
Must be a valid value from the above list.
The value entered must match the SEQUENCE NUMBER (FA0-02.0) submitted in the preceding "FA0"
record.
FORM LOCATION: N/A
REMARKS: See sequencing instructions on page FA0.04.
RECORD/FIELD: HA0-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: A unique number assigned by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be identical to the "Patient Control Number" (CA0-03.0) of this claim.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: CMS-1500 Block 26
REMARKS: N/A
RECORD/FIELD: HA0-04.0
DATA ELEMENT: Line Item Control Number (LINE ITEM CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(17)
LEFT
SPACES
23
39
NSF (National Standard Format) User Manual
423
DEFINITION: An identifier assigned by the submitter/provider to this line item.
CODE VALUES: N/A
VALIDATION: May be entered if payor allowed.
If entered, value must match the "Line Item Control Number" submitted in the preceding FA0-04.0
record.
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: HA0-05.0
DATA ELEMENT: Extra Narrative Data
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(281)
LEFT
SPACES
40
320
DEFINITION: Free form narrative record to submit additional information that may assist in the
adjudication of the Service Line Item in the preceding FA0 record.
CODE VALUES: N/A
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: This field may be used as follows:
1. To describe the service being submitted as an Unlisted/NOC HCPCS Procedure Code in the
preceding FA0 record.
2. To report the substitute physician's UPIN (six bytes in length, alpha numeric) for "Reciprocal" or
"Locum Tenens" billing arrangements.
Consult the Matrix/Users Guide supplied by the Payor/Receiver for additional details regarding
submission instructions.
RECORD NAME: CLAIM TRAILER RECORD TYPE XA0 "RECORD SUMMARY"
Required for MO HealthNet processing
Must follow FB0 - AA0
Must be followed by CA0, YA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "XA0"
C-24
XA0
02
RESERVED (XA0-02.0)
NSF (National Standard Format) User Manual
Not Used
424
03
PAT CONTROL NO
Not Used
04
RECORD CXX COUNT
Not Used
05
RECORD DXX COUNT
Not Used
06
RECORD EXX COUNT
Not Used
07
RECORD FXX COUNT
Not Used
08
RECORD GXX COUNT
Not Used
09
RECORD HXX COUNT
Not Used
10
CLAIM RECORD COUNT
Not Used
11
RESERVED (XA0-11.0)
Not Used
12
TOTAL CLAIM CHARGES
13
TOTAL DISAL COST CONT CHG
Not Used
14
TOTAL DISAL OTHER CHARGES
Not Used
15
TOTAL ALLOWED AMOUNT
Not Used
16
TOTAL DEDUCTIBLE AMOUNT
Not Used
17
TOTAL COINSURANCE AMOUNT
Not Used
18
TOTAL PAYOR AMOUNT PAID
19
PAT AMOUNT PAID
Not Used
20
TOTAL PURCHASE SVC CHARGES
Not Used
21
PROV DISCOUNT INFORMATION
Not Used
22
REMARKS
Not Used
23
FILLER-NATIONAL
YES
C-10
C-10
YES
NO
NOTE: Only positive numeric values are accepted as input, negative values are not allowed.
RECORD TYPE: XA0
LEVEL: CLAIM
PURPOSE: The last record of every claim submitted electronically, it contains information pertinent to the
balancing of each claim (i.e. claim record counts, claim charges) within a batch.
REQUIREMENTS: An 'XA0' Record is a REQUIRED record since it is the CLAIM TRAILER
ORDER:
Preceding Record Type
Following Record Type
FA0, FB0, FB1, FB2, FD0, FE0,
GA0 (CERT RECORDS), HA0
(NARRATIVE RECORD)
CA0, YA0
NSF (National Standard Format) User Manual
425
NOTES: Fields that require balancing should be the sum of all the corresponding fields in Record Type FA0
(SERVICE LINE DETAIL RECORD).
There may be multiple claims per batch.
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "XA0"
3
X
01
03
02.0
RESERVED (XA0-02.0)
2
X
04
05
03.0
PAT CONTROL NO
17
X
06
22
04.0
RECORD CXX COUNT
2
N
23
24
05.0
RECORD DXX COUNT
2
N
25
26
06.0
RECORD EXX COUNT
2
N
27
28
07.0
RECORD FXX COUNT
2
N
29
30
08.0
RECORD GXX COUNT
2
N
31
32
09.0
RECORD HXX COUNT
2
N
33
34
10.0
CLAIM RECORD COUNT
3
N
35
37
11.0
RESERVED (XA0-11.0)
40
X
38
77
12.0
TOTAL CLAIM CHARGES
7
N
78
84
13.0
TOTAL DISAL COST CONT CHGS
7
N
85
91
14.0
TOTAL DISAL OTHER CHARGES
7
N
92
98
15.0
TOTAL ALLOWED AMOUNT
7
N
99
105
16.0
TOTAL DEDUCTIBLE AMOUNT
7
N
106
112
17.0
TOTAL COINSURANCE AMOUNT
7
N
113
119
18.0
TOTAL PAYOR AMOUNT PAID
7
N
120
126
19.0
PAT AMOUNT PAID
7
N
127
133
20.0
TOTAL PURCHASE SVC CHARGES
7
N
134
140
21.0
PROV DISCOUNT INFORMATION
16
X
141
156
22.0
REMARKS
103
X
157
259
23.0
FILLER-NATIONAL
61
X
260
320
NOTE: Only positive numeric values are accepted as input, negative values are not allowable.
NSF (National Standard Format) User Manual
426
RECORD/FIELD: XA0-01.0
DATA ELEMENT: Record Identifier (RECORD ID "XA0")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: Field used to identify the "Claim Trailer Control Record".
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be "XA0".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: XA0-02.0
DATA ELEMENT: RESERVED (XA0-02.0)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(02)
LEFT
SPACES
04
05
DEFINITION: Reserved for national use to maintain file sequence.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: XA0-03.0
DATA ELEMENT: Patient Control Number (PAT CONTROL NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(17)
LEFT
SPACES
06
22
DEFINITION: A unique number assigned by the provider to identify the patient.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be identical to the PATIENT CONTROL NUMBER found in Claim Header Record (CA0-03.0).
See GENERAL INSTRUCTIONS for "Patient Control Number" entry.
FORM LOCATION: CMS-1500 Block 26
NSF (National Standard Format) User Manual
427
REMARKS: N/A
RECORD/FIELD: XA0-04.0 XA0-05.0, XA0-06.0, XA0-07.0, XA0-08.0, XA0-09.0
DATA ELEMENT:
Record Type Cxx Count
Record Type Dxx Count
Record Type Exx Count
Record Type Fxx Count
Record Type Gxx Count
Record Type Hxx Count
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
9(02)
RIGHT
ZEROS
23
24
05.0
9(02)
RIGHT
ZEROS
25
26
06.0
9(02)
RIGHT
ZEROS
27
28
07.0
9(02)
RIGHT
ZEROS
29
30
08.0
9(02)
RIGHT
ZEROS
31
32
09.0
9(02)
RIGHT
ZEROS
33
34
DEFINITION: A summarization by Record Type for all records included in this claim.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be numeric.
Each field must equal the sum of all records of the type indicated, within the claim.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: XA0-10.0
DATA ELEMENT: Claim Record Count
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
9(03)
RIGHT
ZEROS
35
37
DEFINITION: The total number of records submitted for this claim excluding this record.
CODE VALUES: N/A
VALIDATION: Must be entered.
NSF (National Standard Format) User Manual
428
Must be numeric.
Must be the computed sum of all records processed from the Claim Header Record (CA0) to the Claim
Trailer Record (XA0).
This DOES NOT include this record.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: XA0-11.0
DATA ELEMENT: Reserved (XA0-11.0)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
X(40)
LEFT
SPACES
38
77
DEFINITION: Unused reserved record space.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: XA0-12.0
DATA ELEMENT: Total Claim Charges
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
9(05)V99
RIGHT
ZEROS
78
84
DEFINITION: The sum of all line item charges included within this claim.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be a positive, unsigned numeric value.
Must be the computed sum of all LINE CHARGES fields (FA0-13.0) included for this claim.
FORM LOCATION: CMS-1500 Block 28
REMARKS: N/A
RECORD/FIELD: XA0-13.0
DATA ELEMENT: Total Disallowed Cost Containment Charges (TOTAL DISAL COST CONT CHGS)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
13.0
9(05)V99
RIGHT
ZEROS
85
91
NSF (National Standard Format) User Manual
429
DEFINITION: The sum of all the disallowed cost containment charges associated with this claim.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be a positive, unsigned numeric value.
Must be the computed sum of all the DISALLOWED COST CONTAINMENT CHARGES fields (FA027.0) included in this claim.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: XA0-14.0
DATA ELEMENT: Total Disallowed Other Charges (TOTAL DISAL OTHER CHARGES)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
14.0
9(05)V99
RIGHT
ZEROS
92
98
DEFINITION: The sum of any additional disallowed charges associated with this claim.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be a positive, unsigned numeric value.
Must be the computed sum of all the DISALLOWED OTHER CHARGES fields (FA0-28.0) included in
this claim.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: XA0-15.0
DATA ELEMENT: Total Allowed Amount
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
15.0
9(05)V99
RIGHT
ZEROS
99
105
DEFINITION: The sum of all the allowed charges associated with this claims.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be a positive, unsigned numeric value.
Must be the computed sum of all ALLOWED AMOUNT fields (FB0-06.0) included in this claim.
NSF (National Standard Format) User Manual
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FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: XA0-16.0
DATA ELEMENT: Total Deductible Amount
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
16.0
9(05)V99
RIGHT
ZEROS
106
112
DEFINITION: The total amount applied to the patient's deductible by previous payor(s).
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be a positive, unsigned numeric value.
Must be the computed sum of all the DEDUCTIBLE AMOUNT fields (FB0.07.0) included in this claim.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: XA0-17.0
DATA ELEMENT: Total Coinsurance Amount
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
17.0
9(05)V99
RIGHT
ZEROS
113
119
DEFINITION: The total amount applied toward the patient's co-insurance by previous payor(s).
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be a positive, unsigned numeric value.
Must be the computed sum of all COINSURANCE AMOUNT fields (FB0-08.0) included in this claim.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: XA0-18.0
DATA ELEMENT: Total Payor Amount Paid
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
18.0
9(05)V99
RIGHT
ZEROS
120
126
DEFINITION: The amount the provider has received from the payor(s) toward payment of this claim.
NSF (National Standard Format) User Manual
431
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be a positive, unsigned numeric value.
Must be the computed sum of all PAYOR AMOUNT PAID fields (DA1-14.0) included in this claim.
Must not exceed TOTAL CLAIM CHARGES (XA0-12.0).
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: XA0-19.0
DATA ELEMENT: Patient Amount Paid (PAT AMOUNT PAID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
19.0
9(05)V99
RIGHT
ZEROS
127
133
DEFINITION: The amount the provider has received from the patient (or insured) toward payment of this
claim.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be a positive, unsigned numeric value.
Must not exceed TOTAL CLAIM CHARGES (XA0-12.0).
FORM LOCATION: CMS-1500 Block 29
REMARKS: N/A
RECORD/FIELD: XA0-20.0
DATA ELEMENT: Total Purchase Service Charges (TOTAL PURCHASE SVC CHARGE)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
20.0
9(05)V99
RIGHT
ZEROS
134
140
DEFINITION: The sum of all purchase service charges associated with this claim.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be a positive, unsigned numeric value.
Must be the computed sum of all PURCHASE SERVICE CHARGES fields (FB0-05.0).
FORM LOCATION: N/A
REMARKS: N/A
NSF (National Standard Format) User Manual
432
RECORD/FIELD: XA0-21.0
DATA ELEMENT: Provider Discount Information (PROV DISCOUNT INFORMATION)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
21.0
X(16)
LEFT
SPACES
141
156
DEFINITION: Details on a prompt payment discount program offered by the provider.
CODE VALUES: If a prompt payment discount program applies, program details must be input "%/#"
where:
% = rate of Discount
# = the number of days to which that rate applies.
Example: 2/30 (Two percent discount if paid within 30 days).
Free form input must be utilized for other types of discount.
VALIDATION: Must be entered if required by payor.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: XA0-22.0
DATA ELEMENT: Remarks
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
22.0
X(103)
LEFT
SPACES
157
259
DEFINITION: A free form area designed to be used in those situations where supplementary data would
be helpful in processing this claim.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: XA0-23.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
23.0
X(61)
LEFT
SPACES
260
320
DEFINITION: Unused record space reserved for National use.
CODE VALUES: N/A
NSF (National Standard Format) User Manual
433
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: BATCH TRAILER RECORD TYPE YA0
Required to show end of batch
Must follow XA0
Must be followed by BA0 or ZA0
Field No.
Field Name
Table
Value
Default
01
RECORD ID "YA0"
C-24
YA0
02
EMC PROV ID
Not Used
03
BATCH TYPE
Not Used
04
BATCH NO
Not Used
05
BATCH ID
Not Used
06
PROV TAX ID
Not Used
07
RESERVED (YA0-07.0)
Not Used
08
BATCH SVC LINE COUNT
Not Used
09
BATCH RECORD COUNT
Not Used
10
BATCH CLAIM COUNT
Not Used
11
BATCH TOTAL CHARGES
Not Used
12
FILLER-NATIONAL
YES
NOTE: Only positive numeric values are acceptable as input, negative values are not allowed.
RECORD TYPE: YA0
LEVEL: BATCH
PURPOSE: The last record of any batch submitted electronically, it contains information pertinent to the
balancing of each batch (i.e., batch record count, batch charges) within a file.
REQUIREMENTS: A 'YA0' Record is a REQUIRED record since it is the BATCH TRAILER.
ORDER:
Preceding Record Type
Following Record Type
XA0
BA0, ZA0
NSF (National Standard Format) User Manual
434
NOTES: Fields that require balancing should be the sum of all the corresponding fields in Record Type XA0
(CLAIM TRAILER RECORD).
There may be multiple batches per file.
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "YA0"
3
X
01
03
02.0
EMC PROV ID
15
X
04
18
03.0
BATCH TYPE
3
X
19
21
04.0
BATCH NO
4
N
22
25
05.0
BATCH ID
6
X
26
31
06.0
PROV TAX ID
9
X
32
40
07.0
RESERVED (YA0-07.0)
6
X
41
46
08.0
BATCH SVC LINE COUNT
7
N
47
53
09.0
BATCH RECORD COUNT
7
N
54
60
10.0
BATCH CLAIM COUNT
7
N
61
67
11.0
BATCH TOTAL CHARGES
9
N
68
76
12.0
FILLER-NATIONAL
244
X
77
320
NOTE: Only positive numeric values are acceptable as input, negative values are not allowable.
RECORD/FIELD: YA0-01.0
DATA ELEMENT: Record Identifier (RECORD ID "YA0")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: Field used to identify the "Provider Batch Control Record".
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be "YA0".
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: YA0-02.0
NSF (National Standard Format) User Manual
435
DATA ELEMENT: EMC Provider Identifier (EMC PROV ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(15)
LEFT
SPACES
04
18
DEFINITION: Identifies the provider as defined by the receiver.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be identical to the EMC PROVIDER IDENTIFIER in the corresponding Batch Header Record
(BA0-02.0).
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: YA0-03.0
DATA ELEMENT: Batch Type
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(03)
LEFT
SPACES
19
21
DEFINITION: This field indicates the type of claims that are included within this batch.
CODE VALUES:
100 - All Others
200 - Dental
VALIDATION: Must be entered.
Must be a valid code from the above list.
Must be identical to the BATCH TYPE entered in the corresponding Batch Header Record (BA0-03.0).
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: YA0-04.0
DATA ELEMENT: Batch Number (BATCH NO)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
9(04)
RIGHT
ZEROS
22
25
DEFINITION: A sequential number assigned by the submitter to each batch of claims.
CODE VALUES: Must be "0001" through "9999".
NSF (National Standard Format) User Manual
436
VALIDATION: Must be entered.
Must be numeric.
First occurrence must be "0001".
Must be identical to the BATCH NUMBER entered in the corresponding Batch Header Record (BA004.0).
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: YA0-05.0
DATA ELEMENT: Batch Identifier (BATCH ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
X(06)
LEFT
SPACES
26
31
DEFINITION: An identifier assigned by the provider/ submitter to identify a batch in its own system.
CODE VALUES: N/A
VALIDATION: Optional at the provider/submitter's discretion.
FORM LOCATION: N/A
REMARKS: Used to facilitate the communication between the receiver and provider/submitter
concerning problem batches as well as the reporting of claims with errors and accepted claims.
RECORD/FIELD: YA0-06.0
DATA ELEMENT: Provider Tax ID (PROV TAX ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
X(09)
LEFT
SPACES
32
40
DEFINITION: The federally assigned Tax Identification Number (T.I.N.) of the billing provider. This can
be either the Employer Identification Number (EIN) or the Social Security Number (S.S.N.) of the
provider.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be numeric.
Must be identical to the PROVIDER TAX ID entered in the corresponding Batch Header Record (BA006.0).
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: CMS-1500 Block 25
NSF (National Standard Format) User Manual
437
REMARKS: N/A
RECORD/FIELD: YA0-07.0
DATA ELEMENT: Reserved (YA0-07.0)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
X(06)
LEFT
SPACES
41
46
DEFINITION: Unused reserved record space.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: YA0-08.0
DATA ELEMENT: Batch Service Line Count (BATCH SVC LINE COUNT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
08.0
9(07)
RIGHT
ZEROS
47
53
DEFINITION: The number of line items included in this batch.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be numeric.
Must be the computed sum of all Record Type FA0's within this batch.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: YA0-09.0
DATA ELEMENT: Batch Record Count
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
9(07)
RIGHT
ZEROS
54
60
DEFINITION: The number of records included in this batch.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be numeric.
NSF (National Standard Format) User Manual
438
Must be the computed sum of all Record Types BA0 through YA0.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: YA0-10.0
DATA ELEMENT: Batch Claim Count
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
9(07)
RIGHT
ZEROS
61
67
DEFINITION: The number of claims that are included within this batch.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be numeric.
Must be the computed sum of all the Record Type CA0's included between this Batch Trailer Record
(YA0) and the preceding Batch Header Record (BA0).
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: YA0-11.0
DATA ELEMENT: Batch Total Charges
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11.0
9(07)V99
RIGHT
ZEROS
68
76
DEFINITION: The sum of all "Total Claim Charges" fields included within this batch.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be a positive, unsigned numeric value.
Must be the computed sum of all the TOTAL CLAIM CHARGES fields (XA0-12.0) included within this
batch.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: YA0-12.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
NSF (National Standard Format) User Manual
JUSTIFY
INITIAL
FROM
THRU
439
12.0
X(244)
LEFT
SPACES
77
320
DEFINITION: Unused record space reserved for National use.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD NAME: FILE TRAILER RECORD TYPE ZA0
Required to show end of file
Must follow YA0
Last record
Field No.
Field Name
Table
Value
Default
01
RECORD ID "ZA0"
C-24
ZA0
02
SUB ID
Not Used
03
RESERVED (ZA0-03.0)
Not Used
04
RECEIVER ID
Not Used
05
FILE SVC LINE COUNT
Not Used
06
FILE RECORD COUNT
Not Used
07
FILE CLAIM COUNT
Not Used
08
BATCH COUNT
Not Used
09
FILE TOTAL CHARGES
Not Used
10
FILE TOTAL PAID AMT
Not Used
11
FILE TOTAL ALLOWED AMT
Not Used
12
FILLER-NATIONAL
YES
RECORD TYPE: ZA0
LEVEL: FILE
PURPOSE: The last record of any file submitted electronically, it contains information pertinent to the balancing
of the file (i.e. file record counts, file charges).
REQUIREMENTS: A "ZA0" Record is a REQUIRED record since it is the FILE TRAILER RECORD.
NSF (National Standard Format) User Manual
440
ORDER:
Preceding Record Type
Following Record Type
YA0
NONE
NOTES: Fields that require balancing should be the sum of all the corresponding fields in Record Type YA0
(BATCH TRAILER RECORD).
FIELD NO.
FIELD NAME
FIELD
LENGTH
TYPE
POSITIONS
FROM
THRU
01.0
RECORD ID "ZA0"
3
X
01
03
02.0
SUB ID
16
X
04
19
03.0
RESERVED (ZA0-03.0)
9
X
20
28
04.0
RECEIVER ID
16
X
29
44
05.0
FILE SVC LINE COUNT
7
N
45
51
06.0
FILE RECORD COUNT
7
N
52
58
07.0
FILE CLAIM COUNT
7
N
59
65
08.0
BATCH COUNT
4
N
66
69
09.0
FILE TOTAL CHARGES
11
N
70
80
10.0
FILE TOTAL PAID AMT
11
N
81
91
11.0
FILE TOTAL ALLOWED AMT
11
N
92
102
12.0
FILLER-NATIONAL
218
X
103
320
NOTE: Only positive numeric values are accepted as input, negative values are not allowable.
RECORD/FIELD: ZA0-01.0
DATA ELEMENT: Record Identifier (RECORD ID "ZA0")
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
01.0
X(03)
LEFT
SPACES
01
03
DEFINITION: Field used to identify the "File Trailer Record".
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be "ZA0".
FORM LOCATION: N/A
NSF (National Standard Format) User Manual
441
REMARKS: N/A
RECORD/FIELD: ZA0-02.0
DATA ELEMENT: Submitter Identifier (SUB ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
02.0
X(16)
LEFT
SPACES
04
19
DEFINITION: Identifies the submitter as defined by receiver.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be identical to the SUBMITTER ID entered in the File Header Record (AA0-02.0).
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: N/A
REMARKS: May be a Federally assigned Employer Identification Number (EIN). EIN is also referred to
as Tax Identification Number (TIN) depending on the receiver's requirements.
RECORD/FIELD: ZA0-03.0
DATA ELEMENT: Reserved (ZA0-03.0)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
03.0
X(09)
LEFT
SPACES
20
28
DEFINITION: Unused reserved record space.
CODE VALUES: N/A
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: ZA0-04.0
DATA ELEMENT: Receiver Identification (RECEIVER ID)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
04.0
X(16)
LEFT
SPACES
29
44
DEFINITION: A value assigned by the receiver/payor to identify the organization designated to
ultimately receive this file to prevent misrouting of claim data.
CODE VALUES: N/A
NSF (National Standard Format) User Manual
442
VALIDATION: Must be entered if required by payor / receiver.
Must be identical to the RECEIVER IDENTIFICATION value in the File Header Record (AA0-17.0).
See GENERAL INSTRUCTIONS for "Identification Number" entry.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: ZA0-05.0
DATA ELEMENT: File Service Line Count (FILE SVC LINE COUNT)
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
05.0
9(07)
RIGHT
ZEROS
45
51
DEFINITION: The number of service lines included in this file.
CODE VALUES: N/A
VALIDATION: Must be numeric.
Must be the computed sum of all BATCH SERVICE LINE COUNT fields (YA0-08.0) included within
this file.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: ZA0-06.0
DATA ELEMENT: File Record Count
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
06.0
9(07)
RIGHT
ZEROS
52
58
DEFINITION: The number of records included in this file.
CODE VALUES: N/A
VALIDATION: Must be numeric.
Must be the computed sum of all BATCH RECORD COUNT fields (YA0-09.0) within this file.
FORM LOCATION: N/A
REMARKS: This field does not include any count of the AA0 or the ZA0 records.
RECORD/FIELD: ZA0-07.0
DATA ELEMENT: File Claim Count
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
07.0
9(07)
RIGHT
ZEROS
59
65
NSF (National Standard Format) User Manual
443
DEFINITION: The number of claims included in this file.
CODE VALUES: N/A
VALIDATION: Must be numeric.
Must be the computed sum of all BATCH CLAIM COUNT fields (YA0-10.0) included within this file.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: ZA0-08.0
DATA ELEMENT: Batch Count
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
08.0
9(04)
RIGHT
ZEROS
66
69
DEFINITION: The number of batches included within this file.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be numeric.
Must be the computed sum of all Record Type YA0's within this file.
FORM LOCATION: N/A
REMARKS: N/A
RECORD/FIELD: ZA0-09.0
DATA ELEMENT: File Total Charges
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
09.0
9(09)V99
RIGHT
ZEROS
70
80
DEFINITION: The sum of all total charges from each batch contained within this file.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be a positive, unsigned numeric value.
Must be the computed sum of all BATCH TOTAL CHARGES fields (YA0-11.0) included within this
file.
FORM LOCATION: N/A
REMARKS: N/A
NSF (National Standard Format) User Manual
444
RECORD/FIELD: ZA0-10.0
DATA ELEMENT: File Total Paid Amount
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
10.0
9(09)V99
RIGHT
ZEROS
81
91
DEFINITION: The sum of all total amount paid from each batch contained within this file.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be a positive, unsigned numeric value.
Must be the computed sum of all Amount Paid to Bene fields (DA1-30.0) and Amount Paid to Provider
fields (DA1-33.0) included within this file.
FORM LOCATION: N/A
REMARKS: Required for Coordination of Benefits exchange.
RECORD/FIELD: ZA0-11.0
DATA ELEMENT: File Total Approved Amount
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
11
9(09)V99
RIGHT
ZEROS
92
102
DEFINITION: The sum of all total approved amounts from each batch contained within this file.
CODE VALUES: N/A
VALIDATION: Must be entered.
Must be a positive, unsigned numeric value.
Must be the computed sum of all Payor Amount Approved fields (DA1-37.0) included within this file.
FORM LOCATION: N/A
REMARKS: Required for Coordination of Benefits exchange.
RECORD/FIELD: ZA0-12.0
DATA ELEMENT: Filler-National
FIELD
COBOL PICTURE
JUSTIFY
INITIAL
FROM
THRU
12.0
X(218)
LEFT
SPACES
103
320
DEFINITION: Unused record space reserved for National use.
CODE VALUES: N/A
NSF (National Standard Format) User Manual
445
VALIDATION: N/A
FORM LOCATION: N/A
REMARKS: N/A
NSF (National Standard Format) User Manual
446
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