Version 1.1 of the Patient demographics import interface supports the ability to import and maintain patient balance information.
Record ID: IMPAT11
| Field # | Field Name | Format | Min | Max | Req’d | Comment |
|---|---|---|---|---|---|---|
| 1 | Record ID | AN | 7 | 7 | Y | IMPAT11 |
| 2 | Patient Account Number | AN | 1 | 80 | C | Required if Patient Date of Birth is not entered |
| 3 | Patient Last Name | AN | 1 | 60 | Y | |
| 4 | Patient First Name | AN | 1 | 25 | Y | |
| 5 | Patient Middle Name | AN | 1 | 25 | O | |
| 6 | Patient Prefix | AN | 1 | 10 | O | |
| 7 | Patient Suffix | AN | 1 | 10 | O | |
| 8 | Patient Date Of Birth | DT | 8 | 8 | C | Required if Patient Account Number is not entered |
| CCYYMMDD format req’d | ||||||
| 9 | Patient Gender | AN | 1 | 1 | O | |
| 10 | Patient Street 1 | AN | 1 | 30 | O | |
| 11 | Patient Street 2 | AN | 1 | 30 | O | |
| 12 | Patient City | AN | 1 | 30 | O | |
| 13 | Patient State | AN | 2 | 2 | O | |
| 14 | Patient Zip 1 | AN | 5 | 5 | O | |
| 15 | Patient Zip 2 | AN | 4 | 4 | O | |
| 16 | Patient Phone Number | Num | 10 | 10 | O | Phone number without punctuation |
| 17 | Insurance Rank | AN | 1 | 1 | C | P – Primary, S – Secondary, O- Other; required if other conditional insurance and subscriber fields are given. |
| 18 | Insurance Name | AN | 1 | 35 | C | Required if other conditional insurance and subscriber fields are given. |
| 19 | Insurance ID Qualifier | AN | 1 | 2 | C | Required if other conditional insurance and subscriber fields are given. |
| 20 | Insurance ID | AN | 1 | 80 | C | Required if other conditional insurance and subscriber fields are given. Note: InstaMed Payers IDs are available in InstaMed Online under User Guide à InstaMed Payer List or using Payer List Search in EDI Enrollment. |
| 21 | Insurance Type | AN | 2 | 2 | O | |
| 22 | Insurance Filing Indicator | AN | 2 | 2 | O | |
| 23 | Insurance Street 1 | AN | 1 | 30 | O | |
| 24 | Insurance Street 2 | AN | 1 | 30 | O | |
| 25 | Insurance City | AN | 1 | 30 | O | |
| 26 | Insurance State | AN | 2 | 2 | O | |
| 27 | Group ID | AN | 2 | 80 | O | Recommended – [DEFAULT] if no Group ID available. |
| 28 | Insurance Zip 1 | AN | 5 | 5 | O | |
| 29 | Insurance Phone Number | Num | 10 | 10 | O | Phone number without punctuation |
| 30 | Relationship To Patient | AN | 2 | 2 | C | Required if other conditional insurance and subscriber fields are given. |
| 31 | Policy Number | AN | 2 | 80 | C | Required if other conditional insurance and subscriber fields are given. |
| 32 | Group Number | AN | 2 | 80 | O | Subscriber Group Number. |
| 33 | Subscriber Last Name | AN | 1 | 35 | C | Required if other conditional insurance and subscriber fields are given. |
| 34 | Subscriber First Name | AN | 1 | 25 | C | Required if other conditional insurance and subscriber fields are given. |
| 35 | Subscriber Middle Name | AN | 1 | 25 | O | |
| 36 | Subscriber Prefix | AN | 1 | 10 | O | |
| 37 | Subscriber Suffix | AN | 1 | 10 | O | |
| 38 | Subscriber Street 1 | AN | 1 | 30 | O | |
| 39 | Subscriber Street 2 | AN | 1 | 30 | O | |
| 40 | Subscriber City | AN | 1 | 30 | O | |
| 41 | Subscriber State | AN | 2 | 2 | O | |
| 42 | Subscriber Zip 1 | AN | 5 | 5 | O | |
| 43 | Subscriber Zip 2 | AN | 4 | 4 | O | |
| 44 | Subscriber Phone Number | Num | 10 | 10 | O | Phone number without punctuation. |
| 45 | Active Flag | AN | 1 | 1 | O | Set to "N" in order to inactivate a patient. |
| 46 | Patient Balance Due | Dec | 1 | 25 | O | |
| 47 | Patient Balance Due Effective Date | DT | 1 | 35 | C | Required if Patient Balance Due populated. |
| 48 | Medical Record Number | AN | 1 | 100 | O | |
| 49 | Patient Email Address | EM | 1 | 50 | O | |
| 50 | Guarantor ID | AN | 1 | 80 | O | |
| 51 | Guarantor First Name | AN | 1 | 25 | O | |
| 52 | Guarantor Last Name | AN | 1 | 80 | O | |
| 53 | Additional Field 6 | 1 | 100 | O | Reserved for future use. | |
| 54 | Additional Field 7 | 1 | 100 | O | Reserved for future use. | |
| 55 | Additional Field 8 | 1 | 100 | O | Reserved for future use. | |
| 56 | Additional Field 9 | 1 | 100 | O | Reserved for future use. | |
| 57 | Additional Field 10 | 1 | 100 | O | Reserved for future use. | |
| 58 | Recipient First Name | AN | 1 | 25 | O | |
| 59 | Recipient Middle Name | AN | 1 | 25 | O | |
| 60 | Recipient Last Name | AN | 1 | 80 | O | |
| 61 | Recipient Street 1 | AN | 1 | 30 | O | |
| 62 | Recipient Street 2 | AN | 1 | 30 | O | |
| 63 | Recipient City | AN | 1 | 30 | O | |
| 64 | Recipient State | AN | 2 | 2 | O | |
| 65 | Recipient Zip 1 | AN | 5 | 5 | O | |
| 66 | Recipient Zip 2 | AN | 4 | 4 | O | |
| 67 | Guarantor ID | AN | 1 | 80 | O | |
| 68 | Guarantor First Name | AN | 1 | 25 | O | |
| 69 | Guarantor Last Name | AN | 1 | 80 | O | |
| 70 | Master Patient Account ID | AN | 1 | 80 | O |