Field # | Field Name | Format | Min | Max | Req'd | Comment |
---|---|---|---|---|---|---|
1 | Record ID | "IMCSI10" | 7 | 7 | Y | |
2 | ClaimEntityID | AN | 1 | 38 | O | |
3 | PayerClaimNumber | AN | 1 | 38 | O | |
4 | PayerIDQualifier | AN | 1 | 2 | C | Required if Entity ID is not present. |
5 | PayerID | AN | 1 | 80 | C | Required if Entity ID is not present. Note: InstaMed Payers IDs are available in InstaMed Online under User Guide → InstaMed Payer List or using Payer List Search in EDI Enrollment. |
6 | PayerName | AN | 1 | 35 | C | Required if Entity ID is not present. |
7 | ProviderIDQualifier | AN | 1 | 2 | C | Required if Entity ID is not present. |
8 | ProviderID | AN | 2 | 80 | C | Required if Entity ID is not present. |
9 | ProviderLastName | AN | 1 | C | Required if Entity ID is not present. | |
10 | ProviderFirstName | AN | 1 | 25 | O | |
11 | ProviderMiddleName | AN | 1 | 25 | O | |
12 | ProviderPrefix | AN | 1 | 10 | O | |
13 | ProviderSuffix | AN | 1 | 10 | O | |
14 | SubscriberIDQualifier | AN | 1 | 2 | C | Required if Entity ID is not present. |
15 | SubscriberID | AN | 2 | 80 | C | Required if Entity ID is not present. |
16 | SubscriberLastName | AN | 1 | 35 | Required if Entity ID is not present. | |
17 | SubscriberFirstName | AN | 1 | C | Required if Entity ID is not present. | |
18 | SubscriberMiddleName | AN | 1 | 25 | O | |
19 | SubscriberPrefix | AN | 1 | 10 | O | |
20 | SubscriberSuffix | AN | 1 | 10 | O | |
21 | SubscriberDateOfBirth | DT | 1 | 35 | C | Required if Entity ID is not present. |
22 | PatientIDQualifer | AN | 1 | 2 | C | Required if Entity ID is not present. |
23 | PatientID | AN | 2 | 80 | C | Required if Entity ID is not present. |
24 | PatientLastName | AN | 1 | 35 | C | Required if Entity ID is not present. |
25 | PatientFirstName | AN | 1 | 25 | C | Required if Entity ID is not present. |
26 | PatientMiddleName | AN | 1 | 25 | O | |
27 | PatientPrefix | AN | 1 | 10 | O | |
28 | PatientSuffix | AN | 1 | 10 | O | |
29 | PatientDateOfBirth | DT | 1 | 35 | C | Required if Entity ID is not present. |
30 | PatientGender | AN | 1 | 1 | C | Required if Entity ID is not present. |
31 | PatientRelationshipCode | AN | 1 | 35 | O | |
32 | TraceNumber | AN | 1 | 30 | Y | |
33 | PayerClaimNumber | AN | 1 | 38 | O | |
34 | MedicalRecordID | AN | 1 | 38 | O | |
35 | SubmittedCharges | DEC | 1 | 18 | O | Recommended. |
36 | ServiceDateStart | DT | 1 | 35 | C | Required if Entity ID is not present. |
37 | ServiceDateEnd | DT | 1 | 35 | C | Required if Entity ID is not present. |