C.M.R. 90, 590, ch. 241, app 590-241-B-1
The record types in the file must be in the following order: |
Record Type 01 - Processor Data |
Record Type 20 - Sequence 01 - Patient Data |
Record Type 30 - Sequence 01 - Third Party Payer Data Primary Payer |
Record Type 30 - Sequence 02-99 - Third Party Payer Additional Payer(s) Required for payer(s) other than primary. |
Record Type 40 - Claim Data |
Record Type 50 - IP Accommodations Data |
Record Type 60 - IP Ancillary Services |
Record Type 71 - ICD-10 CM Principal and Admitting Diagnosis Codes, ICD-10 PCS Principal Procedure Code |
Record Type 72 - ICD-10 PCS Other Procedure Codes |
Record Type 73 - ICD-10 CM External Cause of Injury Diagnosis Codes |
Record Type 74 - ICD-10 CM Other Diagnosis Information |
Record Type 80 - Provider Data |
Record Type 90 - Claim Control Screen |
Record Type 99 - File Control |
The individual claim begins with Record Type 20 and ends with Record Type 90. |
The patient control number must be the same on each record type generated for a single patient record. |
The medical record number should not be substituted for the patient control number. |
Record Type 01 - Processor Data
Data Element # | Data Element | Implementation Date for New Data Elements | Type | Length | Description/Codes/Sources |
IP0101 | Record Type | T | 2 | 01 | |
IP0102 | MHDO-Assigned Hospital ID | T | 6 | Must be the MHDO-assigned, 6-digit hospital code, left justified | |
IP0198 | Filler | T | 38 | ||
IP0103 | Hospital Name | T | 21 | ||
IP0104 | Address | T | 18 | ||
IP0105 | City | T | 15 | ||
IP0106 | State | T | 2 | ||
IP0107 | Zip Code | T | 9 | ||
IP0199 | Filler | T | 78 | ||
IP0108 | Version | T | 3 | leave blank | |
IP2001 | Record Type | T | 2 | 20 | |
IP2002 | Filler (National Use) | T | 2 | ||
IP2003 | Patient Control Number | T | 20 | Assigned by the facility | |
IP2095 | Filler | T | 30 | Space filled | |
IP2004 | Patient Sex | T | 1 | M = Male F = Female U = Unknown | |
IP2005 | Patient Birth Date | T | 8 | CCYYMMDD | |
IP2096 | Filler | T | 1 | ||
IP2006 | Priority (Type) of Admission or Visit | T | 1 | ||
IP2007 | Point of Origin for Admission or Visit | T | 1 | ||
IP2097 | Filler | T | 30 | ||
IP2008 | Patient City | T | 15 | ||
IP2009 | Patient State | T | 2 | ||
IP2010 | Patient Zip Code | T | 9 | As defined by US Postal Service Do not include dashes | |
IP2011 | Admission/Start of Care Date | T | 8 | CCYYMMDD | |
IP2012 | Admission Hour | T | 2 | Military Time - Range 00-23 | |
IP2098 | Filler | T | 8 | ||
IP2013 | Statement Covers Period - Thru | T | 8 | CCYYMMDD | |
IP2014 | Patient Discharge Status | T | 2 | ||
IP2015 | Discharge Hour | T | 2 | Military Time - Range 00-23 | |
IP2099 | Filler | T | 20 | ||
IP2016 | Medical/Health Record Number | T | 17 | Assigned by the facility | |
IP2017 | Race | March 1, 2007 | T | 1 | 1 = American Indian or Alaska Native 2 = Asian 3 = Black or African American 4 = Native Hawaiian or Other Pacific Islander 5 = White 6 = Other Race 7 = Patient Elected not to Answer 8 = Unknown The code value "8" (Unknown), should be used ONLY when patient answers unknown. Report only collected data. If not available, leave blank. |
IP2018 | Ethnicity | March 1, 2007 | T | 1 | 1 = Hispanic or Latino 2 = Non-Hispanic or Non-Latino 7 = Patient Elected not to Answer 8 = Unknown The code value "8" (Unknown), should be used ONLY when patient answers unknown. Report only collected data. If not available, leave blank. |
IP2019 | Filler | T | 1 | ||
IP2020 | Statement Covers Period - From | January 1, 2018 | T | 8 | CCYYMMDD |
IP2021 | Patient Country Code | January 1, 2018 | T | 2 | Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A. |
IP2022 | Patient Last Name | January 1, 2018 | T | 60 | |
IP2023 | Patient First Name | January 1, 2018 | T | 35 | |
IP2024 | Patient Middle Name or Initial | January 1, 2018 | T | 25 | |
IP2025 | Patient Name Suffix | January 1, 2018 | T | 10 | |
IP2026 | Patient Address Line 1 | January 1, 2018 | T | 55 | |
IP2027 | Patient Address Line 2 | January 1, 2018 | T | 55 | |
IP3001 | Record Type | T | 2 | 30 | |
IP3002 | Sequence Number | T | 2 | 01 Primary Payer 02 - 99 Secondary Payer | |
IP3003 | Patient Control Number | T | 20 | Assigned by the facility | |
IP3095 | Filler | January 1, 2018 | T | 10 | |
IP3005 | Social Security Number | April 1, 2006 | T | 19 | Do not include the dashes For internal use only - Required if collected |
IP3097 | Filler | January 1, 2018 | T | 26 | |
IP3007 | Insured's Group Number | April 1, 2006 | T | 17 | For internal use only - Required if collected |
IP3008 | Insured's Unique Identifier | T | 20 | Insurance policy or certificate ID | |
IP3099 | Filler | T | 1 | ||
IP3009 | Payer Name | January 1, 2018 | T | 100 | Full or unabbreviated payer name, not plan name |
IP4001 | Record Type | T | 2 | 40 | |
IP4002 | Sequence Number | T | 2 | 01 | |
IP4003 | Patient Control Number | T | 20 | Assigned by the facility | |
IP4004 | Type of Bill | T | 3 | Code indicating the specific type of institutional bill | |
IP4099 | Filler | T | 165 | ||
IP5001 | Record Type | T | 2 | 50 | |
IP5002 | Sequence Number | T | 3 | 001-999 | |
IP5003 | Patient Control Number | T | 20 | Assigned by the facility | |
IP5091 | Filler | T | 3 | ||
IP5004 | Accommodations Revenue Code #1 | T | 4 | Include leading zeros | |
IP5092 | Filler | T | 9 | ||
IP5005 | Accommodations Service Units #1 | N | 4 | Right Justified, leading zeros | |
IP5006 | Accommodations Total Charges #1 | T | 10 | Two decimal places implied | |
IP5093 | Filler | T | 14 | ||
IP5007 | Accommodations Revenue Code #2 | T | 4 | Include leading zeros | |
IP5094 | Filler | T | 9 | ||
IP5008 | Accommodations Service Units #2 | N | 4 | Right Justified, leading zeros | |
IP5009 | Accommodations Total Charges #2 | N | 10 | Two decimal places implied | |
IP5095 | Filler | T | 14 | ||
IP5010 | Accommodations Revenue Code #3 | T | 4 | Include leading zeros | |
IP5096 | Filler | T | 9 | ||
IP5011 | Accommodations Service Units #3 | N | 4 | Right Justified, leading zeros | |
IP5012 | Accommodations Total Charges #3 | N | 10 | Two decimal places implied | |
IP5097 | Filler | T | 14 | ||
IP5013 | Accommodations Revenue Code #4 | T | 4 | Include leading zeros | |
IP5098 | Filler | T | 9 | ||
IP5014 | Accommodations Service Units #4 | N | 4 | Right Justified, leading zeros | |
IP5015 | Accommodations Total Charges #4 | N | 10 | Two decimal places implied | |
IP5099 | Filler | T | 14 |
Record Type 60 - IP Ancillary Services Data
Data Element # | Data Element | Implementation Date for New Data Elements | Type | Length | Description/Codes/Sources |
IP6001 | Record Type | T | 2 | 60 | |
IP6002 | Sequence Number | T | 3 | 001 to 999 | |
IP6003 | Patient Control Number | T | 20 | Assigned by the facility | |
IP6093 | Filler | T | 2 | ||
IP6004 | Inpatient Ancillary Revenue Code #1 | T | 4 | Include leading zeros | |
IP6094 | Filler | T | 16 | ||
IP6005 | Inpatient Ancillary Total Charges #1 | N | 10 | Two decimal places implied | |
IP6095 | Filler | T | 25 | ||
IP6006 | Inpatient Ancillary Revenue Code #2 | T | 4 | Include leading zeros | |
IP6096 | Filler | T | 16 | ||
IP6007 | Inpatient Ancillary Total Charges #2 | N | 10 | Two decimal places implied | |
IP6097 | Filler | T | 25 | ||
IP6008 | Inpatient Ancillary Revenue Code #3 | T | 4 | Include leading zeros | |
IP6098 | Filler | T | 16 | ||
IP6009 | Inpatient Ancillary Total Charge #3 | N | 10 | Two decimal places implied | |
IP6099 | Filler | T | 25 |
Record Type 71 - ICD-10 CM Principal and Admitting Diagnosis Codes, ICD-10 PCS Principal Procedure Code
Data Element # | Data Element | Implementation Date For New Data Elements | Type | Length | Description |
IP7101 | Record Type | 10/1/2014 | T | 2 | 71 |
IP7102 | Sequence Number | 10/1/2014 | T | 2 | 01 |
IP7103 | Patient Control Number | 10/1/2014 | T | 20 | Assigned by facility |
IP7104 | Principal Diagnosis | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7105 | Present On Admission Indicator | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7106 | Admitting Diagnosis | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7107 | Filler | T | 10 | ||
IP7108 | Filler | T | 10 | ||
IP7109 | Filler | T | 10 | ||
IP7110 | Principal Procedure Code | 10/1/2014 | T | 10 | ICD-10 PCS - do not code decimal point - Left Justified |
IP7111 | Principal Procedure Date | 10/1/2014 | T | 8 | CCYYMMDD |
Record Type 72 - ICD-10 PCS Other Procedure Codes
Data Element # | Data Element Name | Implementation Date For New Data Elements | Type | Length | Description |
IP7201 | Record Type | 10/1/2014 | T | 2 | 72 |
IP7202 | Sequence Number | 10/1/2014 | T | 2 | 01 - 03 |
IP7203 | Patient Control Number | 10/1/2014 | T | 20 | Assigned by facility |
IP7204 | Other Procedure Code - 1 | 10/1/2014 | T | 10 | ICD-10 PCS - do not code decimal point - Left Justified |
IP7205 | Other Procedure Date - 1 | 10/1/2014 | T | 8 | CCYYMMDD |
IP7206 | Other Procedure Code - 2 | 10/1/2014 | T | 10 | ICD-10 PCS - do not code decimal point - Left Justified |
IP7207 | Other Procedure Date - 2 | 10/1/2014 | T | 8 | CCYYMMDD |
IP7208 | Other Procedure Code - 3 | 10/1/2014 | T | 10 | ICD-10 PCS - do not code decimal point - Left Justified |
IP7209 | Other Procedure Date - 3 | 10/1/2014 | T | 8 | CCYYMMDD |
IP7210 | Other Procedure Code - 4 | 10/1/2014 | T | 10 | ICD-10 PCS - do not code decimal point - Left Justified |
IP7211 | Other Procedure Date - 4 | 10/1/2014 | T | 8 | CCYYMMDD |
IP7212 | Other Procedure Code - 5 | 10/1/2014 | T | 10 | ICD-10 PCS - do not code decimal point - Left Justified |
IP7213 | Other Procedure Date - 5 | 10/1/2014 | T | 8 | CCYYMMDD |
IP7214 | Other Procedure Code - 6 | 10/1/2014 | T | 10 | ICD-10 PCS - do not code decimal point - Left Justified |
IP7215 | Other Procedure Date - 6 | 10/1/2014 | T | 8 | CCYYMMDD |
IP7216 | Other Procedure Code - 7 | 10/1/2014 | T | 10 | ICD-10 PCS - do not code decimal point - Left Justified |
IP7217 | Other Procedure Date - 7 | 10/1/2014 | T | 8 | CCYYMMDD |
IP7218 | Other Procedure Code - 8 | 10/1/2014 | T | 10 | ICD-10 PCS - do not code decimal point - Left Justified |
IP7219 | Other Procedure Date - 8 | 10/1/2014 | T | 8 | CCYYMMDD |
Record Type 73 - ICD-10 CM Other Diagnosis Information
Data Element # | Data Element Name | Implementation Date For New Data Elements | Type | Length | Description |
IP7301 | Record Type | 10/1/2014 | T | 2 | 73 |
IP7302 | Sequence Number | 10/1/2014 | T | 2 | 01 - 02 |
IP7303 | Patient Control Number | 10/1/2014 | T | 20 | Assigned by facility |
IP7304 | External Cause of Injury Code - 1 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7305 | Present On Admission Indicator - 1 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7306 | External Cause of Injury Code - 2 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7307 | Present On Admission Indicator - 2 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7308 | External Cause of Injury Code - 3 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7309 | Present On Admission Indicator - 3 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7310 | External Cause of Injury Code - 4 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7311 | Present On Admission Indicator - 4 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7312 | External Cause of Injury Code - 5 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7313 | Present On Admission Indicator - 5 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7314 | External Cause of Injury Code - 6 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7315 | Present On Admission Indicator - 6 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7316 | External Cause of Injury Code - 7 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7317 | Present On Admission Indicator - 7 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7318 | External Cause of Injury Code - 8 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7319 | Present On Admission Indicator - 8 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7320 | External Cause of Injury Code - 9 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7321 | Present On Admission Indicator - 9 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7322 | External Cause of Injury Code - 10 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7323 | Present On Admission Indicator - 10 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7324 | External Cause of Injury Code - 11 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7325 | Present On Admission Indicator - 11 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7326 | External Cause of Injury Code - 12 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7327 | Present On Admission Indicator - 12 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
Record Type 74 - ICD-10 CM Other Diagnosis Information
Data Element # | Data Element Name | Implementation Date For New Data Elements | Type | Length | Description |
IP7401 | Record Type | 10/1/2014 | T | 2 | 74 |
IP7402 | Sequence Number | 10/1/2014 | T | 2 | 01 - 02 |
IP7403 | Patient Control Number | 10/1/2014 | T | 20 | Assigned by facility |
IP7404 | Other Diagnosis Code - 1 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7405 | Present On Admission Indicator - 1 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7406 | Other Diagnosis Code - 2 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7407 | Present On Admission Indicator - 2 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7408 | Other Diagnosis Code - 3 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7409 | Present On Admission Indicator - 3 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7410 | Other Diagnosis Code - 4 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7411 | Present On Admission Indicator - 4 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7412 | Other Diagnosis Code - 5 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7413 | Present On Admission Indicator - 5 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7414 | Other Diagnosis Code - 6 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7415 | Present On Admission Indicator - 6 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7416 | Other Diagnosis Code - 7 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7417 | Present On Admission Indicator - 7 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7418 | Other Diagnosis Code - 8 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7419 | Present On Admission Indicator - 8 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7420 | Other Diagnosis Code - 9 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7421 | Present On Admission Indicator - 9 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7422 | Other Diagnosis Code - 10 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7423 | Present On Admission Indicator - 10 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7424 | Other Diagnosis Code - 11 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7425 | Present On Admission Indicator - 11 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
IP7426 | Other Diagnosis Code - 12 | 10/1/2014 | T | 10 | ICD-10 CM - do not code decimal point - Left Justified |
IP7427 | Present On Admission Indicator - 12 | 10/1/2014 | T | 3 | Standard POA code set - Left Justified |
Record Type 80 - Provider Data
Data Element # | Data Element | Implementation Date for New Data Elements | Type | Length | Description/Codes/Sources |
IP8001 | Record Type | T | 2 | 80 | |
IP8002 | Sequence | T | 2 | 01 | |
IP8003 | Patient Control Number | T | 20 | Assigned by the facility | |
IP8097 | Filler | T | 2 | ||
IP8004 | Attending Provider NPI | April 1, 2009 | T | 16 | NPI of Attending Provider |
IP8005 | Operating Physician NPI | April 1, 2009 | T | 16 | NPI of Operating Physician |
IP8098 | Filler | T | 32 | ||
IP8006 | Attending Provider Last Name | T | 16 | Cannot be blank | |
IP8007 | Attending Provider First Name | T | 8 | Cannot be blank | |
IP8008 | Attending Provider Middle Initial | T | 1 | ||
IP8009 | Operating Physician Last Name | T | 16 | Must be populated when IP8005 is populated. | |
IP8010 | Operating Physician First Name | T | 8 | Cannot be blank if IP8005 is populated. | |
IP8011 | Operating Physician Middle Initial | T | 1 | ||
IP8099 | Filler | T | 52 | ||
IP8012 | Billing Provider NPI | T | 16 | National Provider Identifier assigned to the provider submitting the bill. |
Record Type 99 - File Control
Data Element # | Data Element | Implementation Date for New Data Elements | Type | Length | Description/Codes/Sources |
IP9001 | Record Type | T | 2 | 90 | |
IP9002 | Filler (National Use) | T | 2 | ||
IP9003 | Patient Control Number | T | 20 | Assigned by the facility | |
IP9097 | Filler | T | 20 | ||
IP9004 | Total Accommodation Charges - Revenue Centers | N | 10 | Must equal the sum of record type 50 revenue code data Two decimal places implied | |
IP9098 | Filler | T | 10 | ||
IP9005 | Total Ancillary Charges - Revenue Centers | N | 10 | Must equal the sum of record type 60 revenue code data Two decimal places implied | |
IP9099 | Filler | T | 118 |
Inpatient Data Submission Specifications Record Type 99 - File Control
Data Element # | Data Element | Implementation Date for New Data Elements | Type | Length | Description/Codes/Sources |
IP9901 | Record Type | T | 2 | 99 | |
IP9999 | Filler | T | 190 |
Data Element # | Data Element Name | UB-04 Form Locator | HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator |
IP0101 | Record Type | NA | NA |
IP0102 | MHDO-Assigned Hospital ID | NA | NA |
IP0103 | Hospital Name | 1 | 837/2010AA/NM1/85/2/03 |
IP0104 | Address | 1 | 837/2010AA/N3/01 |
IP0105 | City | 1 | 837/2010AA/N4/01 |
IP0106 | State | 1 | 837/2010AA/N4/02 |
IP0107 | Zip Code | 1 | 837/2010AA/N4/03 |
IP0108 | Version | NA | NA |
IP2001 | Record Type | NA | NA |
IP2003 | Patient Control Number | 3A | 837/2300/CLM/01 |
IP2004 | Patient Sex | 11 | 837/2010CA/DMG/03 837/2010BA/DMG/03 |
IP2005 | Patient Birth Date | 10 | 837/2010CA/DMG/D8/02 837/2010BA/DMG/D8/02 |
IP2006 | Priority (Type) of Admission or Visit | 14 | 837/2300/CL1/01 |
IP2007 | Point of Origin for Admission or Visit | 15 | 837/2300/CL1/02 |
IP2008 | Patient City | 9B | 837/2010CA/N4/01 837/2010BA/N4/01 |
IP2009 | Patient State | 9C | 837/2010CA/N4/02 837/2010BA/N4/02 |
IP2010 | Patient Zip Code | 9D | 837/2010CA/N4/03 837/2010BA/N4/03 |
IP2011 | Admission/Start of Care Date | 12 | 837/2300/DTP/435/DT/03 |
IP2012 | Admission Hour | 13 | 837/2300/DTP/435/DT/03 |
IP2013 | Statement Covers Period Thru | 6 | 837/2300/DTP/434/RD8/03 |
IP2014 | Patient Discharge Status | 17 | 837/2300/CL1/03 |
IP2015 | Discharge Hour | 16 | 837/2300/DTP/096/TM/03 |
IP2016 | Medical/Health Record Number | 3B | 837/2300/REF/EA/02 |
IP2017 | Race | NA | 837/2010CA/DMG/05 837/2010BA/DMG/05 |
IP2018 | Ethnicity | NA | 837/2010CA/DMG/05 837/2010BA/DMG/05 |
IP2020 | Statement Covers Period - From | 6 | 837/2300/DTP/434/RD8/03 |
IP2021 | Patient Country Code | 9E | 837/2010CA/N4/04 837/2010BA/N4/04 |
IP2022 | Patient Last Name | 8B | 837/2010CA/NM1/QC/1/03 837/2010BA/NM1/IL/1/03 |
IP2023 | Patient First Name | 8B | 837/2010CA/NM1/QC/1/04 837/2010BA/NM1/IL/1/04 |
IP2024 | Patient Middle Name or Initial | 8B | 837/2010CA/NM1/QC/1/05 837/2010BA/NM1/IL/1/05 |
IP2025 | Patient Name Suffix | 8B | 837/2010CA/NM1/QC/1/07 837/2010BA/NM1/IL/1/07 |
IP2026 | Patient Address Line 1 | 9A | 837/2010CA/N3/01 837/2010BA/N3/01 |
IP2027 | Patient Address Line 2 | 9A | 837/2010CA/N3/02 837/2010BA/N3/02 |
IP3001 | Record Type | NA | NA |
IP3002 | Sequence Number | NA | 837/2000B/SBR/01 |
IP3003 | Patient Control Number | 3A | 837/2300/CLM/01 |
IP3005 | Social Security Number | NA | NA |
IP3007 | Insured's Group Number (Primary) | 62A | 837/2000B/SBR/P/03 |
Insured's Group Number (Secondary) | 62B | 837/2320A/SBR/S/03 | |
IP3008 | Insured's Unique Identifier (Primary) | 60A | 837/2010BA/NM1/MI/09 |
Insured's Unique Identifier (Secondary) | 60B | 837/2330A/NM1/MI/09 | |
IP3009 | Payer Name (Primary) | 50A | 837/2010BB/NM1/PR/2/03 |
Payer Name (Secondary) | 50B | 837/2330B/NM1/PR/2/03 | |
IP4001 | Record Type | NA | NA |
IP4002 | Sequence Number | NA | NA |
IP4003 | Patient Control Number | 3A | 837/2300/CLM/01 |
IP4004 | Type of Bill | 4 | 837/2300/CLM/05-1 837/2300/CLM/05-3 |
IP5001 | Record Type | NA | NA |
IP5002 | Sequence Number | NA | NA |
IP5003 | Patient Control Number | 3A | 837/2300/CLM/01 |
IP5004 | Accommodations Revenue Code - 1 | 42 | 837/2400/SV2/01 |
IP5005 | Accommodations Service Units - 1 | 46 | 837/2400/SV2/DA/05 |
IP5006 | Accommodations Total Charges - 1 | 47 | 837/2400/SV2/03 |
IP5007 | Accommodations Revenue Code - 2 | 42 | 837/2400/SV2/01 |
IP5008 | Accommodations Service Units - 2 | 46 | 837/2400/SV2/DA/05 |
IP5009 | Accommodations Total Charges - 2 | 47 | 837/2400/SV2/03 |
IP5010 | Accommodations Revenue Code - 3 | 42 | 837/2400/SV2/01 |
IP5011 | Accommodations Service Units - 3 | 46 | 837/2400/SV2/DA/05 |
IP5012 | Accommodations Total Charges - 3 | 47 | 837/2400/SV2/03 |
IP5013 | Accommodations Revenue Code - 4 | 42 | 837/2400/SV2/01 |
IP5014 | Accommodations Service Units - 4 | 46 | 837/2400/SV2/DA/05 |
IP5015 | Accommodations Total Charges - 4 | 47 | 837/2400/SV2/03 |
IP6001 | Record Type | NA | NA |
IP6002 | Sequence Number | NA | NA |
IP6003 | Patient Control Number | 3A | 837/2300/CLM/01 |
IP6004 | Inpatient Ancillary Revenue Code - 1 | 42 | 837/2400/SV2/01 |
IP6005 | Inpatient Ancillary Total Charges - 1 | 47 | 837/2400/SV2/03 |
IP6006 | Inpatient Ancillary Revenue Code - 2 | 42 | 837/2400/SV2/01 |
IP6007 | Inpatient Ancillary Total Charges - 2 | 47 | 837/2400/SV2/03 |
IP6008 | Inpatient Ancillary Revenue Code - 3 | 42 | 837/2400/SV2/01 |
IP6009 | Inpatient Ancillary Total Charges - 3 | 47 | 837/2400/SV2/03 |
C.M.R. 90, 590, ch. 241, app 590-241-B-1