STHDR | BPR | Financial Information |
| |
01 | | STHDR_BPR01_TRANS_HANDL_CD | String | Transaction Handling Code |
02 | | STHDR_BPR02_TOT_ACTL_PVR_PMT | Decimal | Total Actual Provider Payment Amount |
03 | | STHDR_BPR03_CRED_DEB_FLG_CD | String | Credit or Debit Flag Code |
04 | | STHDR_BPR04_PMT_METHD_CD | String | Payment Method Code |
05 | | STHDR_BPR05_PMT_FMT_CD | String | Payment Format Code |
07 | | STHDR_BPR07_ABA_RT_NR | String | ABA Transit Routing Number Including Check Digits (9 digits) |
07 | | STHDR_BPR07_CAN_BNK_NR | String | Canadian Bank Branch and Institution Number |
09 | | STHDR_BPR09_SNDR_BNK_ACT_NR | String | Sender Bank Account Number |
10 | | STHDR_BPR10_PYR_ID | String | Payer Identifier |
11 | | STHDR_BPR11_ORG_CO_SUPP_CD | String | Originating Company Supplemental Code |
13 | | STHDR_BPR13_ABA_RT_NR | String | ABA Transit Routing Number Including Check Digits (9 digits) |
13 | | STHDR_BPR13_CAN_BNK_NR | String | Canadian Bank Branch and Institution Number |
15 | | STHDR_BPR15_DEMND_DEPST | String | Demand Deposit |
15 | | STHDR_BPR15_SAVNGS | String | Savings |
16 | | STHDR_BPR16_CHK_EFT_EFDT_D8 | Date/Time | Check Issue or EFT Effective Date |
L2000 | TS3 | Provider Summary Information |
| |
01 | | L2000_TS301_PVR_ID | String | Provider Identifier |
02 | | L2000_TS302_FAC_TYP_CD | String | Facility Type Code |
03 | | L2000_TS303_FISCL_PERD_D8 | Date/Time | Fiscal Period Date |
04 | | L2000_TS304_TOT_CLM_CT | Decimal | Total Claim Count |
05 | | L2000_TS305_TOT_CLM_CHG_AMT | Decimal | Total Claim Charge Amount |
13 | | L2000_TS313_TOT_MSP_PYR_AMT | Decimal | Total MSP Payer Amount |
15 | | L2000_TS315_TOT_NONLAB_CHG_AMT | Decimal | Total Non-Lab Charge Amount |
17 | | L2000_TS317_TOT_HCPCS_CHG_AMT | Decimal | Total HCPCS Reported Charge Amount |
18 | | L2000_TS318_TOT_HCPCS_PYBL_AMT | Decimal | Total HCPCS Payable Amount |
20 | | L2000_TS320_TOT_PROF_COMP_AMT | Decimal | Total Professional Component Amount |
21 | | L2000_TS321_TOT_MSP_LIAB_MET | Decimal | Total MSP Patient Liability Met Amount |
22 | | L2000_TS322_TOT_PT_REIM_AMT | Decimal | Total Patient Reimbursement Amount |
23 | | L2000_TS323_TOT_PIP_CLM_CT | Decimal | Total PIP Claim Count |
24 | | L2000_TS324_TOT_PIP_ADJ_AMT | Decimal | Total PIP Adjustment Amount |
L2000 | TS2 | Provider Supplemental Summary Information |
| |
01 | | L2000_TS201_TOT_DRG_AMT | Decimal | Total DRG Amount |
02 | | L2000_TS202_TOT_FED_SPEC_AMT | Decimal | Total Federal Specific Amount |
03 | | L2000_TS203_TOT_HSP_SPEC_AMT | Decimal | Total Hospital Specific Amount |
04 | | L2000_TS204_TOT_DISP_SHAR_AMT | Decimal | Total Disproportionate Share Amount |
05 | | L2000_TS205_TOT_CAP_AMT | Decimal | Total Capital Amount |
06 | | L2000_TS206_IND_MED_EDU_AMT | Decimal | Total Indirect Medical Education Amount |
07 | | L2000_TS207_TOT_OUTLR_DAYS | Decimal | Total Outlier Day Count |
08 | | L2000_TS208_TOT_DAY_OUTLR_AMT | Decimal | Total Day Outlier Amount |
09 | | L2000_TS209_TOT_CST_OUTLR_AMT | Decimal | Total Cost Outlier Amount |
10 | | L2000_TS210_AVG_DRG_LENOFSTAY | Decimal | Average DRG Length of Stay |
11 | | L2000_TS211_TOT_DISCHG_AMT | Decimal | Total Discharge Count |
12 | | L2000_TS212_TOT_CST_REP_DY_CT | Decimal | Total Cost Report Day Count |
13 | | L2000_TS213_TOT_COVD_DAY_CT | Decimal | Total Covered Day Count |
14 | | L2000_TS214_TOT_NONCD_DAY_CT | Decimal | Total Noncovered Day Count |
15 | | L2000_TS215_TOT_MSP_AMT | Decimal | Total MSP Pass-Through Amount |
16 | | L2000_TS216_AVG_DRG_WGT | Decimal | Average DRG weight |
17 | | L2000_TS217_PPSCAPFSP_DRG_AMT | Decimal | Total PPS Capital FSP DRG Amount |
18 | | L2000_TS218_TOT_CAP_DRG_AMT | Decimal | Total PPS Capital HSP DRG Amount |
19 | | L2000_TS219_PPS_DSH_DRG_AMT | Decimal | Total PPS DSH DRG Amount |
L2100 | CLP | Claim Payment Information |
| |
01 | | L2100_CLP01_PT_CTL_NR | String | Patient Control Number |
02 | | L2100_CLP02_CLM_STAT_CD | String | Claim Status Code |
03 | | L2100_CLP03_TOT_CLM_CHG_AMT | Decimal | Total Claim Charge Amount |
04 | | L2100_CLP04_CLM_PMT_AMT | Decimal | Claim Payment Amount |
05 | | L2100_CLP05_PT_RESP_AMT | Decimal | Patient Responsibility Amount |
06 | | L2100_CLP06_CLM_FIL_IND_CD | String | Claim Filing Indicator Code |
07 | | L2100_CLP07_PYR_CLM_CTL_NR | String | Payer Claim Control Number |
08 | | L2100_CLP08_FAC_TYP_CD | String | Facility Type Code |
09 | | L2100_CLP09_CLM_FREQ_CD | String | Claim Frequency Code |
11 | | L2100_CLP11_DRG_CD | String | Diagnosis Related Group (DRG) Code |
12 | | L2100_CLP12_DRG_WGT | Decimal | Diagnosis Related Group (DRG) Weight |
13 | | L2100_CLP13_DISCHG_FRACTN | Decimal | Discharge Fraction |
L2100 | NM1 | Corrected Patient/Insured Name |
Segment Suffix:
| |
02 | | L2100_NM1D02_ENT_TYP_QUAL | String | Entity Type Qualifier |
03 | | L2100_NM1D03_CORR_PT_INS_LNM | String | Corrected Patient or Insured Last Name |
04 | | L2100_NM1D04_CORR_PT_INS_FNM | String | Corrected Patient or Insured First Name |
05 | | L2100_NM1D05_CORR_PT_INS_MNM | String | Corrected Patient or Insured Middle Name |
07 | | L2100_NM1D07_CORR_PT_INS_SFX | String | Corrected Patient or Insured Name Suffix |
09 | | L2100_NM1D09_CORR_INS_ID_IND | String | Corrected Insured Identification Indicator |
L2100 | NM1 | Service Provider Name |
Segment Suffix:
| |
02 | | L2100_NM1E02_ENT_TYP_QUAL | String | Entity Type Qualifier |
03 | | L2100_NM1E03_RND_PVR_LNM | String | Rendering Provider Last or Organization Name |
04 | | L2100_NM1E04_REND_PVR_FNM | String | Rendering Provider First Name |
05 | | L2100_NM1E05_REND_PVR_MNM | String | Rendering Provider Middle Name or Initial |
07 | | L2100_NM1E07_REND_PROV_SFX | String | Rendering Provider Name Suffix |
09 | | L2100_NM1E09_BLCS_PROV_NR | String | Blue Cross Provider Number |
09 | | L2100_NM1E09_BLSH_PROV_NR | String | Blue Shield Provider Number |
09 | | L2100_NM1E09_TAX_ID | String | Federal Taxpayer?s Identification Number |
09 | | L2100_NM1E09_MDCD_PROV_NR | String | Medicaid Provider Number |
09 | | L2100_NM1E09_PROV_COMRCL_NR | String | Provider Commercial Number |
09 | | L2100_NM1E09_STAT_LICNS_NR | String | State License Number |
09 | | L2100_NM1E09_UNQ_PHYS_ID_NR | String | Unique Physician Identification Number (UPIN) |
09 | | L2100_NM1E09_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
L2100 | NM1 | Crossover Carrier Name |
Segment Suffix:
| |
03 | | L2100_NM1F03_COB_CARR_NM | String | Coordination of Benefits Carrier Name |
09 | | L2100_NM1F09_BLCSBLSH_PLN_CD | String | Blue Cross Blue Shield Association Plan Code |
09 | | L2100_NM1F09_TAX_ID | String | Federal Taxpayer?s Identification Number |
09 | | L2100_NM1F09_NAIC_ID | String | National Association of Insurance Commissioners (NAIC) Identification |
09 | | L2100_NM1F09_PAYR_ID | String | Payor Identification |
09 | | L2100_NM1F09_PHM_PRCSR_NR | String | Pharmacy Processor Number |
09 | | L2100_NM1F09_HCFA_PLAN_ID | String | Centers for Medicare and Medicaid Services PlanID |
L2100 | NM1 | Corrected Priority Payer Name |
Segment Suffix:
| |
03 | | L2100_NM1G03_CORR_PRI_PYR_NM | String | Corrected Priority Payer Name |
09 | | L2100_NM1G09_BLCSBLSH_PLN_CD | String | Blue Cross Blue Shield Association Plan Code |
09 | | L2100_NM1G09_TAX_ID | String | Federal Taxpayer?s Identification Number |
09 | | L2100_NM1G09_NAIC_ID | String | National Association of Insurance Commissioners (NAIC) Identification |
09 | | L2100_NM1G09_PAYR_ID | String | Payor Identification |
09 | | L2100_NM1G09_PHM_PRCSR_NR | String | Pharmacy Processor Number |
09 | | L2100_NM1G09_HCFA_PLAN_ID | String | Centers for Medicare and Medicaid Services PlanID |
L2100 | MIA | Inpatient Adjudication Information |
| |
01 | | L2100_MIA01_COV_DAYS_VST_CT | Decimal | Covered Days or Visits Count |
02 | | L2100_MIA02_PPS_OPR_OUTLR_AMT | Decimal | PPS Operating Outlier Amount |
03 | | L2100_MIA03_LFTM_PSYCH_DAYS | Decimal | Lifetime Psychiatric Days Count |
04 | | L2100_MIA04_CLM_DRG_AMT | Decimal | Claim DRG Amount |
05 | | L2100_MIA05_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
06 | | L2100_MIA06_CLM_DIS_SHR_AMT | Decimal | Claim Disproportionate Share Amount |
07 | | L2100_MIA07_CLM_MSP_PSS_AMT | Decimal | Claim MSP Pass-through Amount |
08 | | L2100_MIA08_CLM_PPS_CAP_AMT | Decimal | Claim PPS Capital Amount |
09 | | L2100_MIA09_PPS_FSP_DRG_AMT | Decimal | PPS-Capital FSP DRG Amount |
10 | | L2100_MIA10_PPS_HSP_DRG_AMT | Decimal | PPS-Capital HSP DRG Amount |
11 | | L2100_MIA11_PPS_DSH_DRG_AMT | Decimal | PPS-Capital DSH DRG Amount |
12 | | L2100_MIA12_OLD_CAP_AMT | Decimal | Old Capital Amount |
13 | | L2100_MIA13_PPS_CAP_IME_AMT | Decimal | PPS-Capital IME amount |
14 | | L2100_MIA14_PPS_OPRS_DRGAMT | Decimal | PPS-Operating Hospital Specific DRG Amount |
15 | | L2100_MIA15_COST_RPT_DAY_CT | Decimal | Cost Report Day Count |
16 | | L2100_MIA16_PPS_FED_DRG_AMT | Decimal | PPS-Operating Federal Specific DRG Amount |
17 | | L2100_MIA17_CLM_CAP_OUT_AMT | Decimal | Claim PPS Capital Outlier Amount |
18 | | L2100_MIA18_CLM_IND_TCH_AMT | Decimal | Claim Indirect Teaching Amount |
19 | | L2100_MIA19_NONPAY_PROF_AMT | Decimal | Nonpayable Professional Component Amount |
20 | | L2100_MIA20_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
21 | | L2100_MIA21_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
22 | | L2100_MIA22_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
23 | | L2100_MIA23_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
24 | | L2100_MIA24_PPS_EXCPTN_AMT | Decimal | PPS-Capital Exception Amount |
L2100 | MOA | Outpatient Adjudication Information |
| |
01 | | L2100_MOA01_REIMBRSMT_RT | Decimal | Reimbursement Rate |
02 | | L2100_MOA02_CLMHCPCS_PY_AMT | Decimal | Claim HCPCS Payable Amount |
03 | | L2100_MOA03_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
04 | | L2100_MOA04_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
05 | | L2100_MOA05_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
06 | | L2100_MOA06_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
07 | | L2100_MOA07_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
08 | | L2100_MOA08_CLMESRD_PMT_AMT | Decimal | Claim ESRD Payment Amount |
09 | | L2100_MOA09_NONPAY_PROF_AMT | String | Nonpayable Professional Component Amount |
L2100 | REF | Other Claim Related Identification |
Iterated: [01-05]
| |
02 | | L2100_nnREF_GRP_POLCY_NR | String | Group or Policy Number |
02 | | L2100_nnREF_MEM_ID | String | Member Identification Number |
02 | | L2100_nnREF_EMPLE_ID_NR | String | Employee Identification Number |
02 | | L2100_nnREF_GRP_NR | String | Group Number |
02 | | L2100_nnREF_REP_CLM_ID | String | Repriced Claim Reference Number |
02 | | L2100_nnREF_ADJ_REP_CLM_ID | String | Adjusted Repriced Claim Reference Number |
02 | | L2100_nnREF_AUTH_NR | String | Authorization Number |
02 | | L2100_nnREF_CLSS_CONT | String | Class of Contract Code |
02 | | L2100_nnREF_MED_REC_ID | String | Medical Record Identification Number |
02 | | L2100_nnREF_ORIG_REF_NR | String | Original Reference Number |
02 | | L2100_nnREF_PRIOR_AUTH | String | Prior Authorization Number |
02 | | L2100_nnREF_PREF_BEN_ID_NR | String | Predetermination of Benefits Identification Number |
02 | | L2100_nnREF_INS_PLCY_NR | String | Insurance Policy Number |
02 | | L2100_nnREF_SSN | String | Social Security Number |
L2100 | AMT | Claim Supplemental Information |
| |
02 | | L2100_AMT02_COVG_AMT | Date Timestamp | Coverage Amount |
02 | | L2100_AMT02_DISCT_AMT | Date Timestamp | Discount Amount |
02 | | L2100_AMT02_PER_DAY_LIM | Date Timestamp | Per Day Limit |
02 | | L2100_AMT02_PT_AMT_PD | Date Timestamp | Patient Amount Paid |
02 | | L2100_AMT02_INTRST | Date Timestamp | Interest |
02 | | L2100_AMT02_NEG_LEDGR_BAL | Date Timestamp | Negative Ledger Balance |
02 | | L2100_AMT02_TAX | Date Timestamp | Tax |
02 | | L2100_AMT02_TOT_CLM_B4_TAX | Date Timestamp | Total Claim Before Taxes |
02 | | L2100_AMT02_MDCRMDCD_PMTCAT1 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 1 |
02 | | L2100_AMT02_MDCRMDCD_PMTCAT2 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 2 |
02 | | L2100_AMT02_MDCRMDCD_PMTCAT3 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 3 |
02 | | L2100_AMT02_MDCRMDCD_PMTCAT4 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 4 |
02 | | L2100_AMT02_MCRMCD_PMTCAT5 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 5 |
L2100 | QTY | Claim Supplemental Information Quantity |
| |
02 | | L2100_QTY02_COVD_ACTL | Date Timestamp | Covered - Actual |
02 | | L2100_QTY02_COINS_ACTL | Date Timestamp | Co-insured - Actual |
02 | | L2100_QTY02_LFTM_RSRV_ACTL | Date Timestamp | Life-time Reserve - Actual |
02 | | L2100_QTY02_LFTM_RSRV_EST | Date Timestamp | Life-time Reserve - Estimated |
02 | | L2100_QTY02_NONCOV_EST | Date Timestamp | Non-Covered - Estimated |
02 | | L2100_QTY02_NOTREP_BLD_UN | Date Timestamp | Not Replaced Blood Units |
02 | | L2100_QTY02_OUTLIER_DYS | Date Timestamp | Outlier Days |
02 | | L2100_QTY02_RX | Date Timestamp | Prescription |
02 | | L2100_QTY02_VIST | Date Timestamp | Visits |
02 | | L2100_QTY02_MDCRMDCD_PMTCAT1 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 1 |
02 | | L2100_QTY02_MDCRMDCD_PMTCAT2 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 2 |
02 | | L2100_QTY02_MDCRMDCD_PMTCAT3 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 3 |
02 | | L2100_QTY02_MDCRMDCD_PMTCAT4 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 4 |
02 | | L2100_QTY02_MCRMCD_PMTCAT5 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 5 |
L2110 | SVC | Service Payment Information |
| |
01 | 02 | L2110_SVC0102_ADA_CD | String | American Dental Association Codes |
01 | 02 | L2110_SVC0102_JS_PRC_SPY_CD | String | Jurisdiction Specific Procedure and Supply Codes |
01 | 02 | L2110_SVC0102_HCPCS_CD | String | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes |
01 | 02 | L2110_SVC0102_HIPPA_SNF_RT_CD | String | Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code |
01 | 02 | L2110_SVC0102_HIC_PRD_SVCCD | String | Home Infusion EDI Coalition (HIEC) Product/Service |
01 | 02 | L2110_SVC0102_NDC542 | String | National Drug Code in 5-4-2 Format |
01 | 02 | L2110_SVC0102_NATLHLTH_46 | String | National Health Related Item Code in 4-6 Format |
01 | 02 | L2110_SVC0102_NUBC_UB92_CD | String | National Uniform Billing Committee (NUBC) UB92 Codes |
01 | 02 | L2110_SVC0102_UP_CD_155 | String | U.P.C. Consumer Package Code (1-5-5) |
01 | 02 | L2110_SVC0102_ABC_CD | String | Advanced Billing Concepts (ABC) Codes |
01 | 03 | L2110_SVC0103_PROC_MOD | String | Procedure Modifier |
01 | 04 | L2110_SVC0104_PROC_MOD | String | Procedure Modifier |
01 | 05 | L2110_SVC0105_PROC_MOD | String | Procedure Modifier |
01 | 06 | L2110_SVC0106_PROC_MOD | String | Procedure Modifier |
02 | | L2110_SVC02_LIN_ITM_CHG_AMT | Decimal | Line Item Charge Amount |
03 | | L2110_SVC03_LINITM_PV_PMT_AMT | Decimal | Line Item Provider Payment Amount |
04 | | L2110_SVC04_NUBC_REV_CD | String | National Uniform Billing Committee Revenue |
05 | | L2110_SVC05_UN_SVC_PD_CT | Decimal | Units of Service Paid Count |
06 | 02 | L2110_SVC0602_ADA_CD | String | American Dental Association Codes |
06 | 02 | L2110_SVC0602_JS_PRC_SPY_CD | String | Jurisdiction Specific Procedure and Supply Codes |
06 | 02 | L2110_SVC0602_HCPCS_CD | String | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes |
06 | 02 | L2110_SVC0602_HPPS | String | Health Insurance Prospective Payment System |
06 | 02 | L2110_SVC0602_HIC_PRD_SVCCD | String | Home Infusion EDI Coalition (HIEC) Product/Service Code |
06 | 02 | L2110_SVC0602_NDC542 | String | National Drug Code in 5-4-2 Format |
06 | 02 | L2110_SVC0602_NUBC_UB92_CD | String | National Uniform Billing Committee (NUBC) UB92 Codes |
06 | 02 | L2110_SVC0602_ABC_CD | String | Advanced Billing Concepts (ABC) Codes |
06 | 03 | L2110_SVC0603_PROC_MOD | String | Procedure Modifier |
06 | 04 | L2110_SVC0604_PROC_MOD | String | Procedure Modifier |
06 | 05 | L2110_SVC0605_PROC_MOD | String | Procedure Modifier |
06 | 06 | L2110_SVC0606_PROC_MOD | String | Procedure Modifier |
06 | 07 | L2110_SVC0607_PROC_CD_DESC | String | Procedure Code Description |
07 | | L2110_SVC07_ORG_UN_SVC_CT | Decimal | Original Units of Service Count |
L2110 | AMT | Service Supplemental Amount |
| |
02 | | L2110_AMT02_ALLWD_ACTL | Date Timestamp | Allowed - Actual |
02 | | L2110_AMT02_DDCTN_AMT | Date Timestamp | Deduction Amount |
02 | | L2110_AMT02_TAX | Date Timestamp | Tax |
02 | | L2110_AMT02_TOT_CLM_B4_TAX | Date Timestamp | Total Claim Before Taxes |
02 | | L2110_AMT02_MDCRMDCD_PMTCAT1 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 1 |
02 | | L2110_AMT02_MDCRMDCD_PMTCAT2 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 2 |
02 | | L2110_AMT02_MDCRMDCD_PMTCAT3 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 3 |
02 | | L2110_AMT02_MDCRMDCD_PMTCAT4 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 4 |
02 | | L2110_AMT02_MCRMCD_PMTCAT5 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 5 |
L2110 | QTY | Service Supplemental Quantity |
| |
02 | | L2110_QTY02_MDCRMDCD_PMTCAT1 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 1 |
02 | | L2110_QTY02_MDCRMDCD_PMTCAT2 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 2 |
02 | | L2110_QTY02_MDCRMDCD_PMTCAT3 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 3 |
02 | | L2110_QTY02_MDCRMDCD_PMTCAT4 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 4 |
02 | | L2110_QTY02_MCRMCD_PMTCAT5 | Date Timestamp | Federal Medicare or Medicaid Payment Mandate - Category 5 |
STHDRX | PLB | Provider Adjustment |
| |
01 | | STHDRX_PLB01_PVR_ID | String | Provider Identifier |
02 | | STHDRX_PLB02_FISCL_PERD_D8 | Date/Time | Fiscal Period Date |
03 | 01 | STHDRX_PLB0301_ADJ_RSN_CD | String | Adjustment Reason Code |
03 | 02 | STHDRX_PLB0302_PVR_ADJ_ID | String | Provider Adjustment Identifier |
04 | | STHDRX_PLB04_PVR_ADJ_AMT | Decimal | Provider Adjustment Amount |
05 | 01 | STHDRX_PLB0501_ADJ_RSN_CD | String | Adjustment Reason Code |
05 | 02 | STHDRX_PLB0502_PVR_ADJ_ID | String | Provider Adjustment Identifier |
06 | | STHDRX_PLB06_PVR_ADJ_AMT | Decimal | Provider Adjustment Amount |
07 | 01 | STHDRX_PLB0701_ADJ_RSN_CD | String | Adjustment Reason Code |
07 | 02 | STHDRX_PLB0702_PVR_ADJ_ID | String | Provider Adjustment Identifier |
08 | | STHDRX_PLB08_PVR_ADJ_AMT | Decimal | Provider Adjustment Amount |
09 | 01 | STHDRX_PLB0901_ADJ_RSN_CD | String | Adjustment Reason Code |
09 | 02 | STHDRX_PLB0902_PVR_ADJ_ID | String | Provider Adjustment Identifier |
10 | | STHDRX_PLB10_PVR_ADJ_AMT | Decimal | Provider Adjustment Amount |
11 | 01 | STHDRX_PLB1101_ADJ_RSN_CD | String | Adjustment Reason Code |
11 | 02 | STHDRX_PLB1102_PVR_ADJ_ID | String | Provider Adjustment Identifier |
12 | | STHDRX_PLB12_PVR_ADJ_AMT | Decimal | Provider Adjustment Amount |
13 | 01 | STHDRX_PLB1301_ADJ_RSN_CD | String | Adjustment Reason Code |
13 | 02 | STHDRX_PLB1302_PVR_ADJ_ID | String | Provider Adjustment Identifier |
14 | | STHDRX_PLB14_PVR_ADJ_AMT | Decimal | Provider Adjustment Amount |