Chiapas EDI 2012 Mapping Guide

5010_835 5010 Health Care Claim Payment/Advice - Code:U0

ISA - GROUP HEADERS

Loop	Segment	Segment Name	Chiapas Gate Mapping
OEISA	ISA	Interchange Control Header
OEISA	ISA02	No Authorization Information Present	OEISA_S01_ISA02_AUTH_NFO_OVL_NO_AUTH_NFO
OEISA	ISA02	Additional Data Identification	OEISA_S01_ISA02_AUTH_NFO_OVL_ADDL_ID
OEISA	ISA04	No Security Information Present	OEISA_S01_ISA04_SEC_NFO_OVL_NO_SEC_NFO
OEISA	ISA04	Password	OEISA_S01_ISA04_SEC_NFO_OVL_PASSWD
OEISA	ISA06	Dun and Brandstreet	OEISA_S01_ISA06_SENDR_ID_OVL_DUNS_ID
OEISA	ISA06	Duns Plus Suffix	OEISA_S01_ISA06_SENDR_ID_OVL_DUNS_SUFFX_ID
OEISA	ISA06	Health Industry Number	OEISA_S01_ISA06_SENDR_ID_OVL_HIN_ID
OEISA	ISA06	Carrier Identification Number as assigned by Health Care Financing Administration	OEISA_S01_ISA06_SENDR_ID_OVL_HCFA_CARR_ID
OEISA	ISA06	Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration	OEISA_S01_ISA06_SENDR_ID_OVL_HCFA_FIIN_ID
OEISA	ISA06	Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration	OEISA_S01_ISA06_SENDR_ID_OVL_HCFA_MEDCR_ID
OEISA	ISA06	US Federal Tax Identification Number	OEISA_S01_ISA06_SENDR_ID_OVL_TAX_ID
OEISA	ISA06	National Association of Insurance Commissioners Company Code	OEISA_S01_ISA06_SENDR_ID_OVL_NAIC_ID
OEISA	ISA06	Mutually Defined	OEISA_S01_ISA06_SENDR_ID_OVL_MUTLY_DEFND_ID
OEISA	ISA08	Dun and Brandstreet	OEISA_S01_ISA08_RECVR_ID_OVL_DUNS_ID
OEISA	ISA08	Duns Plus Suffix	OEISA_S01_ISA08_RECVR_ID_OVL_DUNS_SUFFX_ID
OEISA	ISA08	Health Industry Number	OEISA_S01_ISA08_RECVR_ID_OVL_HIN_ID
OEISA	ISA08	Carrier Identification Number as assigned by Health Care Financing Administration	OEISA_S01_ISA08_RECVR_ID_OVL_HCFA_CARR_ID
OEISA	ISA08	Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration	OEISA_S01_ISA08_RECVR_ID_OVL_HCFA_FIIN_ID
OEISA	ISA08	Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration	OEISA_S01_ISA08_RECVR_ID_OVL_HCFA_MEDCR_ID
OEISA	ISA08	US Federal Tax Identification Number	OEISA_S01_ISA08_RECVR_ID_OVL_TAX_ID
OEISA	ISA08	National Association of Insurance Commissioners Company Code	OEISA_S01_ISA08_RECVR_ID_OVL_NAIC_ID
OEISA	ISA08	Mutually Defined	OEISA_S01_ISA08_RECVR_ID_OVL_MUTLY_DEFND_ID
OEISA	ISA09	Interchange Date	OEISA_S01_ISA09_DT
OEISA	ISA10	Interchange Time	OEISA_S01_ISA10_TM
OEISA	ISA11	Repetition Separator	OEISA_S01_ISA11_REPTN_SEPRTR
OEISA	ISA12	Interchang Control Version Number	OEISA_S01_ISA12_VERSN_NR
OEISA	ISA13	Interchange Control Number	OEISA_S01_ISA13_ICN
OEISA	ISA14	Acknowledgment Requested	OEISA_S01_ISA14_ACK_REQ
OEISA	ISA15	Interchange Usage Indicator	OEISA_S01_ISA15_USG_IND
OEISA	ISA16	Component Element Separator	OEISA_S01_ISA16_SUBELE_SEP
OEISA	IEA	Interchange Control Trailer
OEISA	IEA01	Number of Included Functional Groups	OEISA_S03_IEA01_GS_CT
OEISA	IEA02	Interchange Control Number	OEISA_S03_IEA02_ICN

GSHDR - GROUP HEADER

Loop	Segment	Segment Name	Chiapas Gate Mapping
GSHDR	GS	Functional Group Header
GSHDR	GS01	Functional Identifier Code	GSHDR_S01_GS01_FUNCTL_ID_CD
GSHDR	GS02	Application Senders Code	GSHDR_S01_GS02_APP_SENDR_CD
GSHDR	GS03	Application Receivers Code	GSHDR_S01_GS03_APP_RECVR_CD
GSHDR	GS04	Date	GSHDR_S01_GS04_DT
GSHDR	GS05	Time	GSHDR_S01_GS05_TM
GSHDR	GS06	Group Control Number	GSHDR_S01_GS06_GCN
GSHDR	GS07	Responsible Agency Code	GSHDR_S01_GS07_RESP_AGNCY_CD
GSHDR	GE	Functional Group Trailer
GSHDR	GE01	Number of Transaction Sets Included	GSHDR_S03_GE01_TS_CT
GSHDR	GE02	Group Control Number	GSHDR_S03_GE02_GCN

STHDR - TRANSACTION SET HEADER

Loop	Segment	Segment Name	Chiapas Gate Mapping
STHDR	ST	Transaction Set Header
STHDR	ST01	Transaction Set Identifier Code	STHDR_S01_ST01_ID_CD
STHDR	ST02	Transaction Set Control Number	STHDR_S01_ST02_CONTRL_NR
STHDR	BPR	Financial Information
STHDR	BPR02	Payment Accompanies Remittance Advice	STHDR_S02_BPR02_TOTL_ACTL_PROV_PMT_AMT_OVL_PMT_ACMPNS_REMTNC_ADVC
STHDR	BPR02	Make Payment Only	STHDR_S02_BPR02_TOTL_ACTL_PROV_PMT_AMT_OVL_MAK_PMT_ONLY
STHDR	BPR02	Notification Only	STHDR_S02_BPR02_TOTL_ACTL_PROV_PMT_AMT_OVL_NOTFCTN_ONLY
STHDR	BPR02	Remittance Information Only	STHDR_S02_BPR02_TOTL_ACTL_PROV_PMT_AMT_OVL_REMTNC_NFO_ONLY
STHDR	BPR02	Prenotification of Future Transfers	STHDR_S02_BPR02_TOTL_ACTL_PROV_PMT_AMT_OVL_PRENTFCTN_FUTR_XFERS
STHDR	BPR02	Split Payment and Remittance	STHDR_S02_BPR02_TOTL_ACTL_PROV_PMT_AMT_OVL_SPLIT_PMT_REMTNC
STHDR	BPR02	Handling Party’s Option to Split Payment and Remittance	STHDR_S02_BPR02_TOTL_ACTL_PROV_PMT_AMT_OVL_OPTN_TO_SPLIT_PMT_REMTNC
STHDR	BPR03	Credit or Debit Flag Code	STHDR_S02_BPR03_CREDT_DEBT_FLAG_CD
STHDR	BPR04	Payment Method Code	STHDR_S02_BPR04_PMT_METHD_CD
STHDR	BPR05	Payment Format Code	STHDR_S02_BPR05_PMT_FORMT_CD
STHDR	BPR07	ABA Transit Routing Number Including Check Digits (9 digits)	STHDR_S02_BPR07_SENDR_DFI_ID_OVL_ABA_ROUTNG_NR_9DIGT
STHDR	BPR07	Canadian Bank Branch and Institution Number	STHDR_S02_BPR07_SENDR_DFI_ID_OVL_CANDN_BANK_BRANCH_INSTN_NR
STHDR	BPR09	Demand Deposit	STHDR_S02_BPR09_SENDR_BANK_ACNT_NR_OVL_DEMND_DEPST
STHDR	BPR10	Payer Identifier	STHDR_S02_BPR10_PAYR_ID
STHDR	BPR11	Originating Company Supplemental Code	STHDR_S02_BPR11_ORGNTNG_CO_SUPP_CD
STHDR	BPR13	ABA Transit Routing Number Including Check Digits (9 digits)	STHDR_S02_BPR13_RECVR_PROV_BANK_ID_NR_OVL_ABA_ROUTNG_NR_9DIGT
STHDR	BPR13	Canadian Bank Branch and Institution Number	STHDR_S02_BPR13_RECVR_PROV_BANK_ID_NR_OVL_CANDN_BANK_BRANCH_INSTN_NR
STHDR	BPR15	Demand Deposit	STHDR_S02_BPR15_RECVR_PROV_ACNT_NR_OVL_DEMND_DEPST
STHDR	BPR15	Savings	STHDR_S02_BPR15_RECVR_PROV_ACNT_NR_OVL_SAVNGS
STHDR	BPR16	Check Issue or EFT Effective Date	STHDR_S02_BPR16_CHK_IS_EFT_EFF_DT
STHDR	TRN	Reassociation Trace Number
STHDR	TRN01	Trace Type Code	STHDR_S03_TRN01_TYPE_CD
STHDR	TRN02	Check or EFT Trace Number	STHDR_S03_TRN02_CHK_EFT_TRAC_NR
STHDR	TRN03	Payer Identifier	STHDR_S03_TRN03_PAYR_ID
STHDR	TRN04	Originating Company Supplemental Code	STHDR_S03_TRN04_ORGNTNG_CO_SUPP_CD
STHDR	CUR	Foreign Currency Information
STHDR	CUR01	Entity Identifier Code	STHDR_S04_CUR01_ENTY_ID_CD
STHDR	CUR02	Currency Code	STHDR_S04_CUR02_CURNCY_CD
STHDR	REF	Receiver Identification
STHDR	REF02	Receiver Identification Number	STHDR_S05_REF02_RECVR_ID_OVL_RECVR_ID_NR
STHDR	REF	Version Identification
STHDR	REF02	Version Code - Local	STHDR_S06_REF02_ID_CD_OVL_VERSN_COD_LOCL
STHDR	DTM	Production Date
STHDR	DTM02	Production	STHDR_S07_DTM02_PRODCTN_DT_OVL_PRODCTN
STHDR	PLB	Provider Adjustment
STHDR	PLB01	Provider Identifier	STHDR_S11_PLB01_PROV_ID
STHDR	PLB02	Fiscal Period Date	STHDR_S11_PLB02_FISCL_PERD_DT
STHDR	PLB03-01	Adjustment Reason Code	STHDR_S11_PLB03_01_ADJ_RSN_CD
STHDR	PLB03-02	Provider Adjustment Identifier	STHDR_S11_PLB03_02_PROV_ADJ_ID
STHDR	PLB04	Provider Adjustment Amount	STHDR_S11_PLB04_ADJ_AMT
STHDR	PLB05-01	Adjustment Reason Code	STHDR_S11_PLB05_01_ADJ_RSN_CD
STHDR	PLB05-02	Provider Adjustment Identifier	STHDR_S11_PLB05_02_PROV_ADJ_ID
STHDR	PLB06	Provider Adjustment Amount	STHDR_S11_PLB06_ADJ_AMT
STHDR	PLB07-01	Adjustment Reason Code	STHDR_S11_PLB07_01_ADJ_RSN_CD
STHDR	PLB07-02	Provider Adjustment Identifier	STHDR_S11_PLB07_02_PROV_ADJ_ID
STHDR	PLB08	Provider Adjustment Amount	STHDR_S11_PLB08_ADJ_AMT
STHDR	PLB09-01	Adjustment Reason Code	STHDR_S11_PLB09_01_ADJ_RSN_CD
STHDR	PLB09-02	Provider Adjustment Identifier	STHDR_S11_PLB09_02_PROV_ADJ_ID
STHDR	PLB10	Provider Adjustment Amount	STHDR_S11_PLB10_ADJ_AMT
STHDR	PLB11-01	Adjustment Reason Code	STHDR_S11_PLB11_01_ADJ_RSN_CD
STHDR	PLB11-02	Provider Adjustment Identifier	STHDR_S11_PLB11_02_PROV_ADJ_ID
STHDR	PLB12	Provider Adjustment Amount	STHDR_S11_PLB12_ADJ_AMT
STHDR	PLB13-01	Adjustment Reason Code	STHDR_S11_PLB13_01_ADJ_RSN_CD
STHDR	PLB13-02	Provider Adjustment Identifier	STHDR_S11_PLB13_02_PROV_ADJ_ID
STHDR	PLB14	Provider Adjustment Amount	STHDR_S11_PLB14_ADJ_AMT
STHDR	SE	Transaction Set Trailer
STHDR	SE01	Transaction Segment Count	STHDR_S12_SE01_SEG_CT
STHDR	SE02	Transaction Set Control Number	STHDR_S12_SE02_TCN

1000A - PAYER IDENTIFICATION

Loop	Segment	Segment Name	Chiapas Gate Mapping
L1000A	N1	Payer Identification
L1000A	N102	Payer Name	L1000A_S01_N102_PAYR_NM
L1000A	N104	Centers for Medicare and Medicaid Services PlanID	L1000A_S01_N104_PAYR_ID_OVL_MDCR_MDCD_SVCS_PLAND
L1000A	N3	Payer Address
L1000A	N301	Payer Address Line	L1000A_S02_N301_ADRS_LIN
L1000A	N302	Payer Address Line	L1000A_S02_N302_ADRS_LIN
L1000A	N4	Payer City, State, ZIP Code
L1000A	N401	Payer City Name	L1000A_S03_N401_CITY_NM
L1000A	N402	Payer State Code	L1000A_S03_N402_STAT_CD
L1000A	N403	Payer Postal Zone or ZIP Code	L1000A_S03_N403_PAYR_POSTL_ZON_ZIP_CD
L1000A	N404	Country Code	L1000A_S03_N404_CNTRY_CD
L1000A	N407	Country Subdivision Code	L1000A_S03_N407_COUNTRY_SUBDVSN_CD
L1000A	REF	Additional Payer Identification
L1000A	REF02	Payer Identification Number	L1000A_S04_REF02_PAYR_ID_OVL_PAYR_ID_NR
L1000A	REF02	Submitter Identification Number	L1000A_S04_REF02_PAYR_ID_OVL_SUBMTR_ID_NR
L1000A	REF02	Health Industry Number (HIN)	L1000A_S04_REF02_PAYR_ID_OVL_HIN
L1000A	REF02	National Association of Insurance Commissioners	L1000A_S04_REF02_PAYR_ID_OVL_NAIC
L1000A	PER	Payer Business Contact Information
L1000A	PER01	Contact Function Code	L1000A_S05_PER01_FUNCTN_CD
L1000A	PER02	Payer Contact Name	L1000A_S05_PER02_CONTCT_NM
L1000A	PER04	Electronic Mail	L1000A_S05_PER04_PAYR_CONTCT_COMNCTN_NR_OVL_EMAIL
L1000A	PER04	Facsimile	L1000A_S05_PER04_PAYR_CONTCT_COMNCTN_NR_OVL_FACSML
L1000A	PER04	Telephone	L1000A_S05_PER04_PAYR_CONTCT_COMNCTN_NR_OVL_TELPHN
L1000A	PER06	Electronic Mail	L1000A_S05_PER06_PAYR_CONTCT_COMNCTN_NR_OVL_EMAIL
L1000A	PER06	Telephone Extension	L1000A_S05_PER06_PAYR_CONTCT_COMNCTN_NR_OVL_PHN_EXTNS
L1000A	PER06	Facsimile	L1000A_S05_PER06_PAYR_CONTCT_COMNCTN_NR_OVL_FACSML
L1000A	PER06	Telephone	L1000A_S05_PER06_PAYR_CONTCT_COMNCTN_NR_OVL_TELPHN
L1000A	PER08	Telephone Extension	L1000A_S05_PER08_PAYR_CONTCT_COMNCTN_NR_OVL_PHN_EXTNS
L1000A	PER	Payer Technical Contact Information
L1000A	PER01	Contact Function Code	L1000A_S06_PER01_FUNCTN_CD
L1000A	PER02	Payer Technical Contact Name	L1000A_S06_PER02_PAYR_TECHNCL_CONTCT_NM
L1000A	PER04	Electronic Mail	L1000A_S06_PER04_PAYR_CONTCT_COMNCTN_NR_OVL_EMAIL
L1000A	PER04	Telephone	L1000A_S06_PER04_PAYR_CONTCT_COMNCTN_NR_OVL_TELPHN
L1000A	PER04	Uniform Resource Locator (URL)	L1000A_S06_PER04_PAYR_CONTCT_COMNCTN_NR_OVL_URL
L1000A	PER06	Electronic Mail	L1000A_S06_PER06_COMM_NR_OVL_EMAIL
L1000A	PER06	Telephone Extension	L1000A_S06_PER06_COMM_NR_OVL_PHN_EXTNS
L1000A	PER06	Facsimile	L1000A_S06_PER06_COMM_NR_OVL_FACSML
L1000A	PER06	Telephone	L1000A_S06_PER06_COMM_NR_OVL_TELPHN
L1000A	PER06	Uniform Resource Locator (URL)	L1000A_S06_PER06_COMM_NR_OVL_URL
L1000A	PER08	Electronic Mail	L1000A_S06_PER08_PAYR_CONTCT_COMNCTN_NR_OVL_EMAIL
L1000A	PER08	Telephone Extension	L1000A_S06_PER08_PAYR_CONTCT_COMNCTN_NR_OVL_PHN_EXTNS
L1000A	PER08	Facsimile	L1000A_S06_PER08_PAYR_CONTCT_COMNCTN_NR_OVL_FACSML
L1000A	PER08	Uniform Resource Locator (URL)	L1000A_S06_PER08_PAYR_CONTCT_COMNCTN_NR_OVL_URL
L1000A	PER	Payer WEB Site
L1000A	PER01	Contact Function Code	L1000A_S07_PER01_CONTCT_FUNCTN_CD
L1000A	PER04	Uniform Resource Locator (URL)	L1000A_S07_PER04_COMM_NR_OVL_URL

1000B - PAYEE IDENTIFICATION

Loop	Segment	Segment Name	Chiapas Gate Mapping
L1000B	N1	Payee Identification
L1000B	N102	Payee Name	L1000B_S01_N102_PAY_NM
L1000B	N104	Federal Taxpayer’s Identification Number	L1000B_S01_N104_ID_CD_OVL_FED_TAX_ID_NR
L1000B	N104	Centers for Medicare and Medicaid Services PlanID	L1000B_S01_N104_ID_CD_OVL_MDCR_MDCD_SVCS_PLAND
L1000B	N104	Centers for Medicare and Medicaid Services National Provider Identifier	L1000B_S01_N104_ID_CD_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L1000B	N3	Payee Address
L1000B	N301	Payee Address Line	L1000B_S02_N301_ADRS_LIN
L1000B	N302	Payee Address Line	L1000B_S02_N302_ADRS_LIN
L1000B	N4	Payee City, State, ZIP Code
L1000B	N401	Payee City Name	L1000B_S03_N401_CITY_NM
L1000B	N402	Payee State Code	L1000B_S03_N402_STAT_CD
L1000B	N403	Payee Postal Zone or ZIP Code	L1000B_S03_N403_PAY_POSTL_ZON_ZIP_CD
L1000B	N404	Country Code	L1000B_S03_N404_CNTRY_CD
L1000B	N407	Country Subdivision Code	L1000B_S03_N407_COUNTRY_SUBDVSN_CD
L1000B	REF	Payee Additional Identification
L1000B	REF02	State License Number	L1000B_S04_REF02_PAY_ID_OVL_STAT_LICNS_NR
L1000B	REF02	National Council for Prescription Drug Programs	L1000B_S04_REF02_PAY_ID_OVL_NATNL_COUNCL_RX_DRUG_PROGRMS
L1000B	REF02	Payee Identification	L1000B_S04_REF02_PAY_ID_OVL_PAY_ID
L1000B	REF02	Federal Taxpayer’s Identification Number	L1000B_S04_REF02_PAY_ID_OVL_FED_TAX_ID_NR
L1000B	RDM	Remittance Delivery Method
L1000B	RDM01	Report Transmission Code	L1000B_S05_RDM01_REPRT_TRANSMSN_CD
L1000B	RDM02	Name	L1000B_S05_RDM02_NM
L1000B	RDM03	Communication Number	L1000B_S05_RDM03_COMM_NR

2000 - HEADER NUMBER

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2000	LX	Header Number
L2000	LX01	Assigned Number	L2000_S01_LX01_ASGND_NR
L2000	TS3	Provider Summary Information
L2000	TS301	Provider Identifier	L2000_S02_TS301_PROV_ID
L2000	TS302	Facility Type Code	L2000_S02_TS302_FACLTY_TYPE_CD
L2000	TS303	Fiscal Period Date	L2000_S02_TS303_FISCL_PERD_DT
L2000	TS304	Total Claim Count	L2000_S02_TS304_TOTL_CLM_CT
L2000	TS305	Total Claim Charge Amount	L2000_S02_TS305_TOTL_CLM_CHG_AMT
L2000	TS313	Total MSP Payer Amount	L2000_S02_TS313_TOTL_MSP_PAYR_AMT
L2000	TS315	Total Non-Lab Charge Amount	L2000_S02_TS315_TOTL_NONLB_CHG_AMT
L2000	TS317	Total HCPCS Reported Charge Amount	L2000_S02_TS317_TOTL_HCPCS_REPRTD_CHG_AMT
L2000	TS318	Total HCPCS Payable Amount	L2000_S02_TS318_TOTL_HCPCS_PAYBL_AMT
L2000	TS320	Total Professional Component Amount	L2000_S02_TS320_TOTL_PROF_COMPNT_AMT
L2000	TS321	Total MSP Patient Liability Met Amount	L2000_S02_TS321_TOTL_MSP_PATNT_LIABLTY_MET_AMT
L2000	TS322	Total Patient Reimbursement Amount	L2000_S02_TS322_TOTL_PATNT_REIMBRSMNT_AMT
L2000	TS323	Total PIP Claim Count	L2000_S02_TS323_TOTL_PIP_CLM_CT
L2000	TS324	Total PIP Adjustment Amount	L2000_S02_TS324_TOTL_PIP_ADJ_AMT
L2000	TS2	Provider Supplemental Summary Information
L2000	TS201	Total DRG Amount	L2000_S03_TS201_TOTL_DRG_AMT
L2000	TS202	Total Federal Specific Amount	L2000_S03_TS202_TOTL_FEDRL_SPECFC_AMT
L2000	TS203	Total Hospital Specific Amount	L2000_S03_TS203_TOTL_HOSPTL_SPECFC_AMT
L2000	TS204	Total Disproportionate Share Amount	L2000_S03_TS204_TOTL_DISPRPRTNT_SHAR_AMT
L2000	TS205	Total Capital Amount	L2000_S03_TS205_TOTL_CAPTL_AMT
L2000	TS206	Total Indirect Medical Education Amount	L2000_S03_TS206_TOTL_INDRCT_MEDCL_EDCTN_AMT
L2000	TS207	Total Outlier Day Count	L2000_S03_TS207_TOTL_OUTLR_DAY_CT
L2000	TS208	Total Day Outlier Amount	L2000_S03_TS208_TOTL_DAY_OUTLR_AMT
L2000	TS209	Total Cost Outlier Amount	L2000_S03_TS209_TOTL_COST_OUTLR_AMT
L2000	TS210	Average DRG Length of Stay	L2000_S03_TS210_AVRG_DRG_LENGTH_STAY
L2000	TS211	Total Discharge Count	L2000_S03_TS211_TOTL_DISCHRG_CT
L2000	TS212	Total Cost Report Day Count	L2000_S03_TS212_TOTL_COST_REPRT_DAY_CT
L2000	TS213	Total Covered Day Count	L2000_S03_TS213_TOTL_COVRD_DAY_CT
L2000	TS214	Total Noncovered Day Count	L2000_S03_TS214_TOTL_NONCVRD_DAY_CT
L2000	TS215	Total MSP Pass-Through Amount	L2000_S03_TS215_TOTL_MSP_PASTHRGH_AMT
L2000	TS216	Average DRG weight	L2000_S03_TS216_AVRG_DRG_WEIGHT
L2000	TS217	Total PPS Capital FSP DRG Amount	L2000_S03_TS217_TOTL_PS_CAPTL_FSP_DRG_AMT
L2000	TS218	Total PPS Capital HSP DRG Amount	L2000_S03_TS218_TOTL_PS_CAPTL_HSP_DRG_AMT
L2000	TS219	Total PPS DSH DRG Amount	L2000_S03_TS219_TOTL_PS_DSH_DRG_AMT

2100 - CLAIM PAYMENT INFORMATION

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2100	CLP	Claim Payment Information
L2100	CLP01	Patient Control Number	L2100_S01_CLP01_PATNT_CONTRL_NR
L2100	CLP02	Claim Status Code	L2100_S01_CLP02_STATS_CD
L2100	CLP03	Total Claim Charge Amount	L2100_S01_CLP03_TOTL_CLM_CHG_AMT
L2100	CLP04	Claim Payment Amount	L2100_S01_CLP04_PMT_AMT
L2100	CLP05	Patient Responsibility Amount	L2100_S01_CLP05_PATNT_RESP_AMT
L2100	CLP06	Claim Filing Indicator Code	L2100_S01_CLP06_CLM_FILNG_IND_CD
L2100	CLP07	Payer Claim Control Number	L2100_S01_CLP07_PAYR_CLM_CONTRL_NR
L2100	CLP08	Facility Type Code	L2100_S01_CLP08_FACLTY_TYPE_CD
L2100	CLP09	Claim Frequency Code	L2100_S01_CLP09_FREQNCY_CD
L2100	CLP11	Diagnosis Related Group (DRG) Code	L2100_S01_CLP11_DRG_CD
L2100	CLP12	Diagnosis Related Group (DRG) Weight	L2100_S01_CLP12_DRG_WEIGHT
L2100	CLP13	Discharge Fraction	L2100_S01_CLP13_DISCHRG_FRACTN
L2100	CAS	Claim Adjustment
L2100	CAS01	Claim Adjustment Group Code	L2100_S02_CAS01_CLM_ADJ_GRP_CD
L2100	CAS02	Adjustment Reason Code	L2100_S02_CAS02_ADJ_RSN_CD
L2100	CAS03	Adjustment Amount	L2100_S02_CAS03_ADJ_AMT
L2100	CAS04	Adjustment Quantity	L2100_S02_CAS04_ADJ_QTY
L2100	CAS05	Adjustment Reason Code	L2100_S02_CAS05_ADJ_RSN_CD
L2100	CAS06	Adjustment Amount	L2100_S02_CAS06_ADJ_AMT
L2100	CAS07	Adjustment Quantity	L2100_S02_CAS07_ADJ_QTY
L2100	CAS08	Adjustment Reason Code	L2100_S02_CAS08_ADJ_RSN_CD
L2100	CAS09	Adjustment Amount	L2100_S02_CAS09_ADJ_AMT
L2100	CAS10	Adjustment Quantity	L2100_S02_CAS10_ADJ_QTY
L2100	CAS11	Adjustment Reason Code	L2100_S02_CAS11_ADJ_RSN_CD
L2100	CAS12	Adjustment Amount	L2100_S02_CAS12_ADJ_AMT
L2100	CAS13	Adjustment Quantity	L2100_S02_CAS13_ADJ_QTY
L2100	CAS14	Adjustment Reason Code	L2100_S02_CAS14_ADJ_RSN_CD
L2100	CAS15	Adjustment Amount	L2100_S02_CAS15_ADJ_AMT
L2100	CAS16	Adjustment Quantity	L2100_S02_CAS16_ADJ_QTY
L2100	CAS17	Adjustment Reason Code	L2100_S02_CAS17_ADJ_RSN_CD
L2100	CAS18	Adjustment Amount	L2100_S02_CAS18_ADJ_AMT
L2100	CAS19	Adjustment Quantity	L2100_S02_CAS19_ADJ_QTY
L2100	NM1	Patient Name
L2100	NM101	Entity Identifier Code	L2100_S03_NM101_ENTY_ID_CD
L2100	NM102	Entity Type Qualifier	L2100_S03_NM102_ENTY_TYPE_QUAL
L2100	NM103	Patient Last Name	L2100_S03_NM103_PATNT_LNAME
L2100	NM104	Patient First Name	L2100_S03_NM104_PATNT_FNAME
L2100	NM105	Patient Middle Name or Initial	L2100_S03_NM105_MNAME_INTL
L2100	NM107	Patient Name Suffix	L2100_S03_NM107_NM_SUFX
L2100	NM109	Social Security Number	L2100_S03_NM109_PATNT_ID_OVL_SSN
L2100	NM109	Health Insurance Claim (HIC) Number	L2100_S03_NM109_PATNT_ID_OVL_HIC_NR
L2100	NM109	Standard Unique Health Identifier for each Individual in the United States	L2100_S03_NM109_PATNT_ID_OVL_STANDRD_UNQ_HEALTH_ID
L2100	NM109	Member Identification Number	L2100_S03_NM109_PATNT_ID_OVL_MEM_ID_NR
L2100	NM109	Medicaid Recipient Identification Number	L2100_S03_NM109_PATNT_ID_OVL_MEDCD_RECPNT_ID_NR
L2100	NM1	Insured Name
L2100	NM101	Entity Identifier Code	L2100_S04_NM101_ENTY_ID_CD
L2100	NM102	Entity Type Qualifier	L2100_S04_NM102_ENTY_TYPE_QUAL
L2100	NM103	Subscriber Last Name	L2100_S04_NM103_SUB_LNAME
L2100	NM104	Subscriber First Name	L2100_S04_NM104_SUB_FNAME
L2100	NM105	Subscriber Middle Name or Initial	L2100_S04_NM105_SUB_MNAME_INTL
L2100	NM107	Subscriber Name Suffix	L2100_S04_NM107_SUB_NM_SUFX
L2100	NM109	Federal Taxpayer’s Identification Number	L2100_S04_NM109_SUB_ID_OVL_FED_TAX_ID_NR
L2100	NM109	Standard Unique Health Identifier for each Individual in the United States	L2100_S04_NM109_SUB_ID_OVL_STANDRD_UNQ_HEALTH_ID
L2100	NM109	Member Identification Number	L2100_S04_NM109_SUB_ID_OVL_MEM_ID_NR
L2100	NM1	Corrected Patient/Insured Name
L2100	NM101	Entity Identifier Code	L2100_S05_NM101_ENTY_ID_CD
L2100	NM102	Entity Type Qualifier	L2100_S05_NM102_ENTY_TYPE_QUAL
L2100	NM103	Corrected Patient or Insured Last Name	L2100_S05_NM103_CORCTD_PATNT_INSRD_LNAME
L2100	NM104	Corrected Patient or Insured First Name	L2100_S05_NM104_CORCTD_PATNT_INSRD_FNAME
L2100	NM105	Corrected Patient or Insured Middle Name	L2100_S05_NM105_CORCTD_PATNT_INSRD_MNAME
L2100	NM107	Corrected Patient or Insured Name Suffix	L2100_S05_NM107_INSRD_NM_SUFX
L2100	NM109	Insured’s Changed Unique Identification Number	L2100_S05_NM109_CORCTD_INSRD_ID_IND_OVL_INSRD_CHGD_UNQ_ID_NR
L2100	NM1	Service Provider Name
L2100	NM101	Entity Identifier Code	L2100_S06_NM101_ENTY_ID_CD
L2100	NM102	Entity Type Qualifier	L2100_S06_NM102_ENTY_TYPE_QUAL
L2100	NM103	Rendering Provider Last or Organization Name	L2100_S06_NM103_REND_PROV_LAST_ORG_NM
L2100	NM104	Rendering Provider First Name	L2100_S06_NM104_RENDRNG_PROV_FNAME
L2100	NM105	Rendering Provider Middle Name or Initial	L2100_S06_NM105_RENDRNG_PROV_MNAME_INTL
L2100	NM107	Rendering Provider Name Suffix	L2100_S06_NM107_RENDRNG_PROV_NM_SUFX
L2100	NM109	Blue Cross Provider Number	L2100_S06_NM109_RENDRNG_PROV_ID_OVL_BLUE_CROS_PROV_NR
L2100	NM109	Blue Shield Provider Number	L2100_S06_NM109_RENDRNG_PROV_ID_OVL_BLUE_SHIELD_PROV_NR
L2100	NM109	Federal Taxpayer’s Identification Number	L2100_S06_NM109_RENDRNG_PROV_ID_OVL_FED_TAX_ID_NR
L2100	NM109	Medicaid Provider Number	L2100_S06_NM109_RENDRNG_PROV_ID_OVL_MEDCD_PROV_NR
L2100	NM109	Provider Commercial Number	L2100_S06_NM109_RENDRNG_PROV_ID_OVL_PROV_COMRCL_NR
L2100	NM109	State License Number	L2100_S06_NM109_RENDRNG_PROV_ID_OVL_STAT_LICNS_NR
L2100	NM109	Unique Physician Identification Number (UPIN)	L2100_S06_NM109_RENDRNG_PROV_ID_OVL_UNQ_PHYSCN_ID_NR
L2100	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2100_S06_NM109_RENDRNG_PROV_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2100	NM1	Crossover Carrier Name
L2100	NM101	Entity Identifier Code	L2100_S07_NM101_ENTY_ID_CD
L2100	NM103	Non-Person Entity	L2100_S07_NM103_COB_CAR_NM_OVL_NONPRSN_ENTY
L2100	NM109	Blue Cross Blue Shield Association Plan Code	L2100_S07_NM109_COB_CAR_ID_OVL_BLCRS_BLSHD_ASCTN_PLAN_CD
L2100	NM109	Federal Taxpayer’s Identification Number	L2100_S07_NM109_COB_CAR_ID_OVL_FED_TAX_ID_NR
L2100	NM109	National Association of Insurance Commissioners (NAIC) Identification	L2100_S07_NM109_COB_CAR_ID_OVL_NAIC_ID
L2100	NM109	Payor Identification	L2100_S07_NM109_COB_CAR_ID_OVL_PAYR_ID
L2100	NM109	Pharmacy Processor Number	L2100_S07_NM109_COB_CAR_ID_OVL_PHARMCY_PROCSR_NR
L2100	NM109	Centers for Medicare and Medicaid Services PlanID	L2100_S07_NM109_COB_CAR_ID_OVL_MDCR_MDCD_SVCS_PLAND
L2100	NM1	Corrected Priority Payer Name
L2100	NM101	Entity Identifier Code	L2100_S08_NM101_ENTY_ID_CD
L2100	NM103	Non-Person Entity	L2100_S08_NM103_CORCTD_PRIORTY_PAYR_NM_OVL_NONPRSN_ENTY
L2100	NM109	Blue Cross Blue Shield Association Plan Code	L2100_S08_NM109_ID_NR_OVL_BLCRS_BLSHD_ASCTN_PLAN_CD
L2100	NM109	Federal Taxpayer’s Identification Number	L2100_S08_NM109_ID_NR_OVL_FED_TAX_ID_NR
L2100	NM109	National Association of Insurance Commissioners (NAIC) Identification	L2100_S08_NM109_ID_NR_OVL_NAIC_ID
L2100	NM109	Payor Identification	L2100_S08_NM109_ID_NR_OVL_PAYR_ID
L2100	NM109	Pharmacy Processor Number	L2100_S08_NM109_ID_NR_OVL_PHARMCY_PROCSR_NR
L2100	NM109	Centers for Medicare and Medicaid Services PlanID	L2100_S08_NM109_ID_NR_OVL_MDCR_MDCD_SVCS_PLAND
L2100	NM1	Other Subscriber Name
L2100	NM101	Entity Identifier Code	L2100_S09_NM101_ENTY_ID_CD
L2100	NM102	Entity Type Qualifier	L2100_S09_NM102_ENTY_TYPE_QUAL
L2100	NM103	Other Subscriber Last Name	L2100_S09_NM103_SUB_LNAME
L2100	NM104	Other Subscriber First Name	L2100_S09_NM104_SUB_FNAME
L2100	NM105	Other Subscriber Middle Name or Initial	L2100_S09_NM105_OTHR_SUB_MNAME_INTL
L2100	NM107	Other Subscriber Name Suffix	L2100_S09_NM107_OTHR_SUB_NM_SUFX
L2100	NM109	Federal Taxpayer’s Identification Number	L2100_S09_NM109_SUB_ID_OVL_FED_TAX_ID_NR
L2100	NM109	Standard Unique Health Identifier for each Individual	L2100_S09_NM109_SUB_ID_OVL_UNQ_HEALTH_ID
L2100	NM109	Member Identification Number	L2100_S09_NM109_SUB_ID_OVL_MEM_ID_NR
L2100	MIA	Inpatient Adjudication Information
L2100	MIA01	Covered Days or Visits Count	L2100_S10_MIA01_COVRD_DAYS_VISTS_CT
L2100	MIA02	PPS Operating Outlier Amount	L2100_S10_MIA02_PS_OPRTNG_OUTLR_AMT
L2100	MIA03	Lifetime Psychiatric Days Count	L2100_S10_MIA03_LIFTM_PSYCH_DAYS_CT
L2100	MIA04	Claim DRG Amount	L2100_S10_MIA04_CLM_DRG_AMT
L2100	MIA05	Claim Payment Remark Code	L2100_S10_MIA05_CLM_PMT_REMRK_CD
L2100	MIA06	Claim Disproportionate Share Amount	L2100_S10_MIA06_CLM_DISPRPRTNT_SHAR_AMT
L2100	MIA07	Claim MSP Pass-through Amount	L2100_S10_MIA07_CLM_MSP_PASTHRGH_AMT
L2100	MIA08	Claim PPS Capital Amount	L2100_S10_MIA08_CLM_PS_CAPTL_AMT
L2100	MIA09	PPS-Capital FSP DRG Amount	L2100_S10_MIA09_PSCAPTL_FSP_DRG_AMT
L2100	MIA10	PPS-Capital HSP DRG Amount	L2100_S10_MIA10_PSCAPTL_HSP_DRG_AMT
L2100	MIA11	PPS-Capital DSH DRG Amount	L2100_S10_MIA11_PSCAPTL_DSH_DRG_AMT
L2100	MIA12	Old Capital Amount	L2100_S10_MIA12_OLD_CAPTL_AMT
L2100	MIA13	PPS-Capital IME amount	L2100_S10_MIA13_PSCAPTL_IM_AMT
L2100	MIA14	PPS-Operating Hospital Specific DRG Amount	L2100_S10_MIA14_HOSPTL_SPECFC_DRG_AMT
L2100	MIA15	Cost Report Day Count	L2100_S10_MIA15_COST_REPRT_DAY_CT
L2100	MIA16	PPS-Operating Federal Specific DRG Amount	L2100_S10_MIA16_FEDRL_SPECFC_DRG_AMT
L2100	MIA17	Claim PPS Capital Outlier Amount	L2100_S10_MIA17_CLM_PS_CAPTL_OUTLR_AMT
L2100	MIA18	Claim Indirect Teaching Amount	L2100_S10_MIA18_CLM_INDRCT_TEACHNG_AMT
L2100	MIA19	Nonpayable Professional Component Amount	L2100_S10_MIA19_NONPYBL_PROF_COMPNT_AMT
L2100	MIA20	Claim Payment Remark Code	L2100_S10_MIA20_CLM_PMT_REMRK_CD
L2100	MIA21	Claim Payment Remark Code	L2100_S10_MIA21_CLM_PMT_REMRK_CD
L2100	MIA22	Claim Payment Remark Code	L2100_S10_MIA22_CLM_PMT_REMRK_CD
L2100	MIA23	Claim Payment Remark Code	L2100_S10_MIA23_CLM_PMT_REMRK_CD
L2100	MIA24	PPS-Capital Exception Amount	L2100_S10_MIA24_PSCAPTL_EXCPTN_AMT
L2100	MOA	Outpatient Adjudication Information
L2100	MOA01	Reimbursement Rate	L2100_S11_MOA01_REIMBRSMNT_RAT
L2100	MOA02	Claim HCPCS Payable Amount	L2100_S11_MOA02_CLM_HCPCS_PAYBL_AMT
L2100	MOA03	Claim Payment Remark Code	L2100_S11_MOA03_CLM_PMT_REMRK_CD
L2100	MOA04	Claim Payment Remark Code	L2100_S11_MOA04_CLM_PMT_REMRK_CD
L2100	MOA05	Claim Payment Remark Code	L2100_S11_MOA05_CLM_PMT_REMRK_CD
L2100	MOA06	Claim Payment Remark Code	L2100_S11_MOA06_CLM_PMT_REMRK_CD
L2100	MOA07	Claim Payment Remark Code	L2100_S11_MOA07_CLM_PMT_REMRK_CD
L2100	MOA08	Claim ESRD Payment Amount	L2100_S11_MOA08_CLM_ESRD_PMT_AMT
L2100	MOA09	Nonpayable Professional Component Amount	L2100_S11_MOA09_NONPYBL_PROF_COMPNT_AMT
L2100	REF	Other Claim Related Identification
L2100	REF02	Group or Policy Number	L2100_S12_REF02_OTHR_CLM_RELTD_ID_OVL_GRP_POLCY_NR
L2100	REF02	Member Identification Number	L2100_S12_REF02_OTHR_CLM_RELTD_ID_OVL_MEM_ID_NR
L2100	REF02	Employee Identification Number	L2100_S12_REF02_OTHR_CLM_RELTD_ID_OVL_EMPLY_ID_NR
L2100	REF02	Group Number	L2100_S12_REF02_OTHR_CLM_RELTD_ID_OVL_GRP_NR
L2100	REF02	Repriced Claim Reference Number	L2100_S12_REF02_OTHR_CLM_RELTD_ID_OVL_REPRCD_CLM_REF_NR
L2100	REF02	Adjusted Repriced Claim Reference Number	L2100_S12_REF02_OTHR_CLM_RELTD_ID_OVL_ADJSTD_REPRCD_CLM_REF_NR
L2100	REF02	Authorization Number	L2100_S12_REF02_OTHR_CLM_RELTD_ID_OVL_AUTH_NR
L2100	REF02	Class of Contract Code	L2100_S12_REF02_OTHR_CLM_RELTD_ID_OVL_CLAS_CONTRCT_CD
L2100	REF02	Medical Record Identification Number	L2100_S12_REF02_OTHR_CLM_RELTD_ID_OVL_MEDCL_RECRD_ID_NR
L2100	REF02	Original Reference Number	L2100_S12_REF02_OTHR_CLM_RELTD_ID_OVL_ORGNL_REF_NR
L2100	REF02	Prior Authorization Number	L2100_S12_REF02_OTHR_CLM_RELTD_ID_OVL_PRI_AUTH_NR
L2100	REF02	Predetermination of Benefits Identification Number	L2100_S12_REF02_OTHR_CLM_RELTD_ID_OVL_PREDTRMNTN_BENFTS_ID_NR
L2100	REF02	Insurance Policy Number	L2100_S12_REF02_OTHR_CLM_RELTD_ID_OVL_INS_POLCY_NR
L2100	REF02	Social Security Number	L2100_S12_REF02_OTHR_CLM_RELTD_ID_OVL_SSN
L2100	REF	Rendering Provider Identification
L2100	REF02	State License Number	L2100_S13_REF02_RENDRNG_PROV_2ND_ID_OVL_STAT_LICNS_NR
L2100	REF02	Blue Cross Provider Number	L2100_S13_REF02_RENDRNG_PROV_2ND_ID_OVL_BLUE_CROS_PROV_NR
L2100	REF02	Blue Shield Provider Number	L2100_S13_REF02_RENDRNG_PROV_2ND_ID_OVL_BLUE_SHIELD_PROV_NR
L2100	REF02	Medicare Provider Number	L2100_S13_REF02_RENDRNG_PROV_2ND_ID_OVL_MEDCR_PROV_NR
L2100	REF02	Medicaid Provider Number	L2100_S13_REF02_RENDRNG_PROV_2ND_ID_OVL_MEDCD_PROV_NR
L2100	REF02	Provider UPIN Number	L2100_S13_REF02_RENDRNG_PROV_2ND_ID_OVL_PROV_UPN_NR
L2100	REF02	CHAMPUS Identification Number	L2100_S13_REF02_RENDRNG_PROV_2ND_ID_OVL_CHAMPS_ID_NR
L2100	REF02	Facility ID Number	L2100_S13_REF02_RENDRNG_PROV_2ND_ID_OVL_FACLTY_ID_NR
L2100	REF02	National Council for Prescription Drug Programs Pharmacy Number	L2100_S13_REF02_RENDRNG_PROV_2ND_ID_OVL_NATL_COUNCL_RX_DRUG_PROG_PHAMRCY_NR
L2100	REF02	Provider Commercial Number	L2100_S13_REF02_RENDRNG_PROV_2ND_ID_OVL_PROV_COMRCL_NR
L2100	REF02	Location Number	L2100_S13_REF02_RENDRNG_PROV_2ND_ID_OVL_LOC_NR
L2100	DTM	Statement From or To Date
L2100	DTM02	Claim Statement Period Start	L2100_S14_DTM02_CLM_DT_OVL_CLM_STATMNT_PERD_START
L2100	DTM02	Claim Statement Period End	L2100_S14_DTM02_CLM_DT_OVL_CLM_STATMNT_PERD_END
L2100	DTM	Coverage Expiration Date
L2100	DTM02	Expiration	L2100_S15_DTM02_DT_OVL_EXPRTN
L2100	DTM	Claim Received Date
L2100	DTM02	Received	L2100_S16_DTM02_DT_OVL_RECVD
L2100	PER	Claim Contact Information
L2100	PER01	Contact Function Code	L2100_S17_PER01_FUNCTN_CD
L2100	PER02	Claim Contact Name	L2100_S17_PER02_CONTCT_NM
L2100	PER04	Electronic Mail	L2100_S17_PER04_CLM_CONTCT_COMM_NR_OVL_EMAIL
L2100	PER04	Facsimile	L2100_S17_PER04_CLM_CONTCT_COMM_NR_OVL_FACSML
L2100	PER04	Telephone	L2100_S17_PER04_CLM_CONTCT_COMM_NR_OVL_TELPHN
L2100	PER06	Electronic Mail	L2100_S17_PER06_CLM_CONTCT_COMM_NR_OVL_EMAIL
L2100	PER06	Telephone Extension	L2100_S17_PER06_CLM_CONTCT_COMM_NR_OVL_PHN_EXTNS
L2100	PER06	Facsimile	L2100_S17_PER06_CLM_CONTCT_COMM_NR_OVL_FACSML
L2100	PER06	Telephone	L2100_S17_PER06_CLM_CONTCT_COMM_NR_OVL_TELPHN
L2100	PER08	Telephone Extension	L2100_S17_PER08_COMNCTN_NR_EXTNSN_OVL_PHN_EXTNS
L2100	AMT	Claim Supplemental Information
L2100	AMT02	Coverage Amount	L2100_S18_AMT02_CLM_SUPP_NFO_AMT_OVL_COVG_AMT
L2100	AMT02	Discount Amount	L2100_S18_AMT02_CLM_SUPP_NFO_AMT_OVL_DISCNT_AMT
L2100	AMT02	Per Day Limit	L2100_S18_AMT02_CLM_SUPP_NFO_AMT_OVL_PER_DAY_LIMT
L2100	AMT02	Patient Amount Paid	L2100_S18_AMT02_CLM_SUPP_NFO_AMT_OVL_PATNT_AMT_PAID
L2100	AMT02	Interest	L2100_S18_AMT02_CLM_SUPP_NFO_AMT_OVL_INTRST
L2100	AMT02	Negative Ledger Balance	L2100_S18_AMT02_CLM_SUPP_NFO_AMT_OVL_NEGTV_LEDGR_BALNC
L2100	AMT02	Tax	L2100_S18_AMT02_CLM_SUPP_NFO_AMT_OVL_TAX
L2100	AMT02	Total Claim Before Taxes	L2100_S18_AMT02_CLM_SUPP_NFO_AMT_OVL_TOTL_CLM_B4_TAXS
L2100	AMT02	Federal Medicare or Medicaid Payment Mandate - Category 1	L2100_S18_AMT02_CLM_SUPP_NFO_AMT_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT1
L2100	AMT02	Federal Medicare or Medicaid Payment Mandate - Category 2	L2100_S18_AMT02_CLM_SUPP_NFO_AMT_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT2
L2100	AMT02	Federal Medicare or Medicaid Payment Mandate - Category 3	L2100_S18_AMT02_CLM_SUPP_NFO_AMT_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT3
L2100	AMT02	Federal Medicare or Medicaid Payment Mandate - Category 4	L2100_S18_AMT02_CLM_SUPP_NFO_AMT_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT4
L2100	AMT02	Federal Medicare or Medicaid Payment Mandate - Category 5	L2100_S18_AMT02_CLM_SUPP_NFO_AMT_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT5
L2100	QTY	Claim Supplemental Information Quantity
L2100	QTY02	Covered - Actual	L2100_S19_QTY02_CLM_SUPP_NFO_QTY_OVL_COVRD_ACTL
L2100	QTY02	Co-insured - Actual	L2100_S19_QTY02_CLM_SUPP_NFO_QTY_OVL_CONSRD_ACTL
L2100	QTY02	Life-time Reserve - Actual	L2100_S19_QTY02_CLM_SUPP_NFO_QTY_OVL_LIFTM_RESRV_ACTL
L2100	QTY02	Life-time Reserve - Estimated	L2100_S19_QTY02_CLM_SUPP_NFO_QTY_OVL_LIFTM_RESRV_EST
L2100	QTY02	Non-Covered - Estimated	L2100_S19_QTY02_CLM_SUPP_NFO_QTY_OVL_NONCVRD_EST
L2100	QTY02	Not Replaced Blood Units	L2100_S19_QTY02_CLM_SUPP_NFO_QTY_OVL_NOT_REPLCD_BLOD_UNTS
L2100	QTY02	Outlier Days	L2100_S19_QTY02_CLM_SUPP_NFO_QTY_OVL_OUTLR_DAYS
L2100	QTY02	Prescription	L2100_S19_QTY02_CLM_SUPP_NFO_QTY_OVL_RX
L2100	QTY02	Visits	L2100_S19_QTY02_CLM_SUPP_NFO_QTY_OVL_VISTS
L2100	QTY02	Federal Medicare or Medicaid Payment Mandate - Category 1	L2100_S19_QTY02_CLM_SUPP_NFO_QTY_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT1
L2100	QTY02	Federal Medicare or Medicaid Payment Mandate - Category 2	L2100_S19_QTY02_CLM_SUPP_NFO_QTY_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT2
L2100	QTY02	Federal Medicare or Medicaid Payment Mandate - Category 3	L2100_S19_QTY02_CLM_SUPP_NFO_QTY_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT3
L2100	QTY02	Federal Medicare or Medicaid Payment Mandate - Category 4	L2100_S19_QTY02_CLM_SUPP_NFO_QTY_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT4
L2100	QTY02	Federal Medicare or Medicaid Payment Mandate - Category 5	L2100_S19_QTY02_CLM_SUPP_NFO_QTY_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT5

2110 - SERVICE PAYMENT INFORMATION

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2110	SVC	Service Payment Information
L2110	SVC01-02	American Dental Association Codes	L2110_S01_SVC01_02_ADJDCTD_PROC_CD_OVL_AMRCN_DENTL_ASCTN_CD
L2110	SVC01-02	Jurisdiction Specific Procedure and Supply Codes	L2110_S01_SVC01_02_ADJDCTD_PROC_CD_OVL_JURSDCTN_SPECFC_PROC_SUPLY_CD
L2110	SVC01-02	Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes	L2110_S01_SVC01_02_ADJDCTD_PROC_CD_OVL_HCPCS_CD
L2110	SVC01-02	Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code	L2110_S01_SVC01_02_ADJDCTD_PROC_CD_OVL_HIPPS_SNIF_RAT
L2110	SVC01-02	Home Infusion EDI Coalition (HIEC) Product/Service	L2110_S01_SVC01_02_ADJDCTD_PROC_CD_OVL_HIEC_PRODCT_SRVC
L2110	SVC01-02	National Drug Code in 5-4-2 Format	L2110_S01_SVC01_02_ADJDCTD_PROC_CD_OVL_NDC_542_FORMT
L2110	SVC01-02	National Health Related Item Code in 4-6 Format	L2110_S01_SVC01_02_ADJDCTD_PROC_CD_OVL_NATNL_HEALTH_RELTD_ITM_COD_IN_46_FORMT
L2110	SVC01-02	National Uniform Billing Committee (NUBC) UB92 Codes	L2110_S01_SVC01_02_ADJDCTD_PROC_CD_OVL_NUBC_UB92_CD
L2110	SVC01-02	U.P.C. Consumer Package Code (1-5-5)	L2110_S01_SVC01_02_ADJDCTD_PROC_CD_OVL_UPC_CD_155
L2110	SVC01-02	Advanced Billing Concepts (ABC) Codes	L2110_S01_SVC01_02_ADJDCTD_PROC_CD_OVL_ABC_CD
L2110	SVC01-03	Procedure Modifier	L2110_S01_SVC01_03_PROC_MODFR
L2110	SVC01-04	Procedure Modifier	L2110_S01_SVC01_04_PROC_MODFR
L2110	SVC01-05	Procedure Modifier	L2110_S01_SVC01_05_PROC_MODFR
L2110	SVC01-06	Procedure Modifier	L2110_S01_SVC01_06_PROC_MODFR
L2110	SVC02	Line Item Charge Amount	L2110_S01_SVC02_LIN_ITM_CHG_AMT
L2110	SVC03	Line Item Provider Payment Amount	L2110_S01_SVC03_LIN_ITM_PROV_PMT_AMT
L2110	SVC04	National Uniform Billing Committee Revenue	L2110_S01_SVC04_NATNL_UNFRM_BILNG_COMT_REVN
L2110	SVC05	Units of Service Paid Count	L2110_S01_SVC05_UNTS_SVC_PD_CT
L2110	SVC06-02	American Dental Association Codes	L2110_S01_SVC06_02_PROC_CD_OVL_AMRCN_DENTL_ASCTN_CD
L2110	SVC06-02	Jurisdiction Specific Procedure and Supply Codes	L2110_S01_SVC06_02_PROC_CD_OVL_JURSDCTN_SPECFC_PROC_SUPLY_CD
L2110	SVC06-02	Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes	L2110_S01_SVC06_02_PROC_CD_OVL_HCPCS_CD
L2110	SVC06-02	Health Insurance Prospective Payment System	L2110_S01_SVC06_02_PROC_CD_OVL_HEALTH_INS_PROSPCTV_PMT_SYS
L2110	SVC06-02	Home Infusion EDI Coalition (HIEC) Product/Service Code	L2110_S01_SVC06_02_PROC_CD_OVL_HIEC_PRODCT_SRVC_CD
L2110	SVC06-02	National Drug Code in 5-4-2 Format	L2110_S01_SVC06_02_PROC_CD_OVL_NDC_542_FORMT
L2110	SVC06-02	National Uniform Billing Committee (NUBC) UB92 Codes	L2110_S01_SVC06_02_PROC_CD_OVL_NUBC_UB92_CD
L2110	SVC06-02	Advanced Billing Concepts (ABC) Codes	L2110_S01_SVC06_02_PROC_CD_OVL_ABC_CD
L2110	SVC06-03	Procedure Modifier	L2110_S01_SVC06_03_PROC_MODFR
L2110	SVC06-04	Procedure Modifier	L2110_S01_SVC06_04_PROC_MODFR
L2110	SVC06-05	Procedure Modifier	L2110_S01_SVC06_05_PROC_MODFR
L2110	SVC06-06	Procedure Modifier	L2110_S01_SVC06_06_PROC_MODFR
L2110	SVC06-07	Procedure Code Description	L2110_S01_SVC06_07_PROC_CD_DESCRPTN
L2110	SVC07	Original Units of Service Count	L2110_S01_SVC07_ORGNL_UNTS_SVC_CT
L2110	DTM	Service Date
L2110	DTM02	Service Period Start	L2110_S02_DTM02_SVC_DT_OVL_SVC_PERD_START
L2110	DTM02	Service Period End	L2110_S02_DTM02_SVC_DT_OVL_SVC_PERD_END
L2110	DTM02	Service	L2110_S02_DTM02_SVC_DT_OVL_SVC
L2110	CAS	Service Adjustment
L2110	CAS01	Claim Adjustment Group Code	L2110_S03_CAS01_CLM_ADJ_GRP_CD
L2110	CAS02	Adjustment Reason Code	L2110_S03_CAS02_ADJ_RSN_CD
L2110	CAS03	Adjustment Amount	L2110_S03_CAS03_ADJ_AMT
L2110	CAS04	Adjustment Quantity	L2110_S03_CAS04_ADJ_QTY
L2110	CAS05	Adjustment Reason Code	L2110_S03_CAS05_ADJ_RSN_CD
L2110	CAS06	Adjustment Amount	L2110_S03_CAS06_ADJ_AMT
L2110	CAS07	Adjustment Quantity	L2110_S03_CAS07_ADJ_QTY
L2110	CAS08	Adjustment Reason Code	L2110_S03_CAS08_ADJ_RSN_CD
L2110	CAS09	Adjustment Amount	L2110_S03_CAS09_ADJ_AMT
L2110	CAS10	Adjustment Quantity	L2110_S03_CAS10_ADJ_QTY
L2110	CAS11	Adjustment Reason Code	L2110_S03_CAS11_ADJ_RSN_CD
L2110	CAS12	Adjustment Amount	L2110_S03_CAS12_ADJ_AMT
L2110	CAS13	Adjustment Quantity	L2110_S03_CAS13_ADJ_QTY
L2110	CAS14	Adjustment Reason Code	L2110_S03_CAS14_ADJ_RSN_CD
L2110	CAS15	Adjustment Amount	L2110_S03_CAS15_ADJ_AMT
L2110	CAS16	Adjustment Quantity	L2110_S03_CAS16_ADJ_QTY
L2110	CAS17	Adjustment Reason Code	L2110_S03_CAS17_ADJ_RSN_CD
L2110	CAS18	Adjustment Amount	L2110_S03_CAS18_ADJ_AMT
L2110	CAS19	Adjustment Quantity	L2110_S03_CAS19_ADJ_QTY
L2110	REF	Service Identification
L2110	REF02	Ambulatory Patient Group (APG) Number	L2110_S04_REF02_PROV_ID_OVL_AMBLTRY_PATNT_GRP_NR
L2110	REF02	Ambulatory Payment Classification	L2110_S04_REF02_PROV_ID_OVL_AMBLTRY_PMT_CLASFCTN
L2110	REF02	Authorization Number	L2110_S04_REF02_PROV_ID_OVL_AUTH_NR
L2110	REF02	Attachment Code	L2110_S04_REF02_PROV_ID_OVL_ATCHMNT_CD
L2110	REF02	Prior Authorization Number	L2110_S04_REF02_PROV_ID_OVL_PRI_AUTH_NR
L2110	REF02	Predetermination of Benefits Identification Number	L2110_S04_REF02_PROV_ID_OVL_PREDTRMNTN_BENFTS_ID_NR
L2110	REF02	Location Number	L2110_S04_REF02_PROV_ID_OVL_LOC_NR
L2110	REF02	Rate code number	L2110_S04_REF02_PROV_ID_OVL_RAT_COD_NR
L2110	REF	Line Item Control Number
L2110	REF02	Provider Control Number	L2110_S05_REF02_LIN_ITM_CONTRL_NR_OVL_PROV_CONTRL_NR
L2110	REF	Rendering Provider Information
L2110	REF02	State License Number	L2110_S06_REF02_PROV_ID_OVL_STAT_LICNS_NR
L2110	REF02	Blue Cross Provider Number	L2110_S06_REF02_PROV_ID_OVL_BLUE_CROS_PROV_NR
L2110	REF02	Blue Shield Provider Number	L2110_S06_REF02_PROV_ID_OVL_BLUE_SHIELD_PROV_NR
L2110	REF02	Medicare Provider Number	L2110_S06_REF02_PROV_ID_OVL_MEDCR_PROV_NR
L2110	REF02	Medicaid Provider Number	L2110_S06_REF02_PROV_ID_OVL_MEDCD_PROV_NR
L2110	REF02	Provider UPIN Number	L2110_S06_REF02_PROV_ID_OVL_PROV_UPN_NR
L2110	REF02	CHAMPUS Identification Number	L2110_S06_REF02_PROV_ID_OVL_CHAMPS_ID_NR
L2110	REF02	Facility ID Number	L2110_S06_REF02_PROV_ID_OVL_FACLTY_ID_NR
L2110	REF02	National Council for Prescription Drug Programs Pharmacy Number	L2110_S06_REF02_PROV_ID_OVL_NATL_COUNCL_RX_DRUG_PROG_PHAMRCY_NR
L2110	REF02	Provider Commercial Number	L2110_S06_REF02_PROV_ID_OVL_PROV_COMRCL_NR
L2110	REF02	Centers for Medicare and Medicaid Services National Provider Identifier	L2110_S06_REF02_PROV_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2110	REF02	Social Security Number	L2110_S06_REF02_PROV_ID_OVL_SSN
L2110	REF02	Federal Taxpayer’s Identification Number	L2110_S06_REF02_PROV_ID_OVL_FED_TAX_ID_NR
L2110	REF	HealthCare Policy Identification
L2110	REF02	Policy Form Identifying Number	L2110_S07_REF02_POLCY_ID_OVL_POLCY_FORM_IDNTFYNG_NR
L2110	AMT	Service Supplemental Amount
L2110	AMT02	Allowed - Actual	L2110_S08_AMT02_SVC_SUPP_AMT_OVL_ALWD_ACTL
L2110	AMT02	Deduction Amount	L2110_S08_AMT02_SVC_SUPP_AMT_OVL_DEDCTN_AMT
L2110	AMT02	Tax	L2110_S08_AMT02_SVC_SUPP_AMT_OVL_TAX
L2110	AMT02	Total Claim Before Taxes	L2110_S08_AMT02_SVC_SUPP_AMT_OVL_TOTL_CLM_B4_TAXS
L2110	AMT02	Federal Medicare or Medicaid Payment Mandate - Category 1	L2110_S08_AMT02_SVC_SUPP_AMT_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT1
L2110	AMT02	Federal Medicare or Medicaid Payment Mandate - Category 2	L2110_S08_AMT02_SVC_SUPP_AMT_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT2
L2110	AMT02	Federal Medicare or Medicaid Payment Mandate - Category 3	L2110_S08_AMT02_SVC_SUPP_AMT_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT3
L2110	AMT02	Federal Medicare or Medicaid Payment Mandate - Category 4	L2110_S08_AMT02_SVC_SUPP_AMT_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT4
L2110	AMT02	Federal Medicare or Medicaid Payment Mandate - Category 5	L2110_S08_AMT02_SVC_SUPP_AMT_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT5
L2110	QTY	Service Supplemental Quantity
L2110	QTY02	Federal Medicare or Medicaid Payment Mandate - Category 1	L2110_S09_QTY02_SVC_SUPP_QTY_CT_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT1
L2110	QTY02	Federal Medicare or Medicaid Payment Mandate - Category 2	L2110_S09_QTY02_SVC_SUPP_QTY_CT_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT2
L2110	QTY02	Federal Medicare or Medicaid Payment Mandate - Category 3	L2110_S09_QTY02_SVC_SUPP_QTY_CT_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT3
L2110	QTY02	Federal Medicare or Medicaid Payment Mandate - Category 4	L2110_S09_QTY02_SVC_SUPP_QTY_CT_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT4
L2110	QTY02	Federal Medicare or Medicaid Payment Mandate - Category 5	L2110_S09_QTY02_SVC_SUPP_QTY_CT_OVL_FEDRL_MEDCR_MEDCD_PMT_MANDT_CAT5
L2110	LQ	Health Care Remark Codes
L2110	LQ02	Claim Payment Remark Codes	L2110_S10_LQ02_REMRK_CD_OVL_CLM_PMT_REMRK_CD
L2110	LQ02	National Council for Prescription Drug Programs Reject/Payment Codes	L2110_S10_LQ02_REMRK_CD_OVL_NATNL_COUNCL_RX_DRIG_PROGRMS_REJCT_PYMNT_CD