PayerID | AN | Y | 2 | 80 | Note: InstaMed Payers IDs are available in InstaMed Online under User Guide ? InstaMed Payer List or using Payer List Search in EDI Enrollment |
PayerIDQualifier | See Payer ID Qualifier Codes (Claim Status Inquiries) | Y | 1 | 2 | |
PayerName | AN | Y | 1 | 35 | |
ProviderID | AN | Y | 2 | 80 | |
ProviderIDQualifier | AN | Y | 1 | 2 | |
ProviderLastName | AN | N | 1 | 35 | |
ProviderFirstName | AN | N | 1 | 25 | |
ProviderMiddleName | AN | N | 1 | 25 | |
SubscriberID | AN | Y | 2 | 80 | |
SubscriberIDQualifier | See Subscriber/Patient ID Qualifiers | Y | 1 | 2 | |
SubscriberLastName | AN | Y | 1 | 35 | |
SubscriberFirstName | AN | N | 1 | 25 | |
SubscriberMiddleName | AN | N | 1 | 25 | |
SubscriberDateOfBirth | DT | Y | 1 | 35 | (MM/DD/YYYY) |
PatientID | AN | Y | 2 | 80 | |
PatientIDQualifier | See Subscriber/Patient ID Qualifiers | Y | 1 | 2 | |
PatientLastName | AN | Y | 1 | 35 | |
PatientFirstName | AN | N | 1 | 25 | |
PatientMiddleName | AN | N | 1 | 25 | |
PatientDateOfBirth | DT | Y | 1 | 35 | (MM/DD/YYYY) |
PatientGender | See Patient Gender Codes | Y | 1 | 1 | |
PatientRelationshipCode | See Relationship Codes (Claim Status Inquiries) | S | 2 | 2 | Required if PatientRelationshipCode is not 18 |
TraceNumber | AN | Y | 1 | 30 | |
PayerClaimNumber | AN | Y | 1 | 30 | |
InstitutionalBillType | AN | Y | 1 | 30 | |
MedicalRecordID | AN | Y | 1 | 30 | |
SubmittedCharges | NUM | Y | 1 | 18 | |
ServiceBeginDate | DT | Y | 1 | 35 | (MM/DD/YYYY) |
ServiceEndDate | DT | Y | 1 | 35 | (MM/DD/YYYY) |
RecordID | AN | Y | 1 | 35 | |