RequestEntityID | AN | | | | |
ResponseDetailText | AN | Y | | | |
InformationSourceName | AN | Y | 1 | 35 | |
InformationSourceID | AN | Y | 2 | 3 | |
InformationSourceIDQualifier | AN | Y | 1 | 1 | |
ProviderOrganizationName | AN | Y | 1 | 35 | |
ProviderIDQualifierCode | See Provider ID Qualifier Codes (Claim Status Inquiries) | Y | 1 | 2 | |
ProviderIDQualifierDescription | AN | Y | 1 | 1 | |
ProviderID | AN | Y | 2 | 80 | |
SubscriberLastName | AN | Y | 1 | 35 | |
SubscriberFirstName | AN | N | 1 | 25 | |
SubscriberMiddleName | AN | N | 1 | 25 | |
SubscriberBirthDate | DT | Y | 1 | 35 | |
SubscriberGender | See Patient Gender Codes | Y | 1 | 1 | |
PatientRelationshipCode | See Relationship Codes (Claim Status Inquiries) | | 2 | 10 | Returned if PatientRelationshipCode is not 18 |
PatientRelationshipDescription | AN | | 1 | 30 | Returned if PatientRelationshipCode is set |
SubscriberID | AN | Y | 2 | 80 | |
SubscriberIDQualifier | AN | Y | 1 | 2 | |
PayerClaimIdentifier | AN | Y | 1 | 30 | |
InstitutionalBillType | AN | Y | 1 | 30 | |
MedicalRecordIdentifier | AN | Y | 1 | 30 | |
ServiceBeginDate | DT | Y | 1 | 35 | (MM/DD/YYYY) |
ServiceEndDate | DT | Y | 1 | 35 | (MM/DD/YYYY) |
TraceNumber | AN | Y | 1 | 30 | |
EffectiveDate | DT | Y | 8 | 8 | (MM/DD/YYYY) |
TotalClaimCharge | NUM | Y | 1 | 18 | |
ClaimPaymentAmount | NUM | Y | 1 | 18 | |
PaymentDate | DT | N | 8 | 8 | (MM/DD/YYYY) |
PaymentMethod | See Payment Method Codes (Claim Status Response) | N | 3 | 3 | |
ServiceLineDetails | See Service Line Details | | | | |
PatientLastName | AN | Y | 1 | 35 | |
PatientFirstName | AN | N | 1 | 25 | |
PatientMiddleName | AN | N | 1 | 25 | |
PatientBirthDate | DT | | 1 | 35 | (MM/DD/YYYY) Returned if PatientRelationshipCode is not 18 |
PatientGender | See Patient Gender Codes | | 1 | 1 | Returned if PatientRelationshipCode is not 18 |
PatientID1 | AN | N | 2 | 80 | |
PatientIDQualifier1 | AN | N | 1 | 2 | |
AdjudicationDate | DT | N | 8 | 8 | (MM/DD/YYYY) |
ClearinghouseClaimNumber | AN | N | | | |
ClaimStatusResponseReceivedDate | DT | Y | 8 | 8 | (MM/DD/YYYY) |