Field # | Field Name | Format | Min | Max | Req'd | Comment |
---|---|---|---|---|---|---|
1 | Record ID | "IMCRA10" | 7 | 7 | Y | |
2 | ClaimID | AN | 1 | 18 | S | Internal Claim ID REF*9A field |
3 | PayerClaimNumber | AN | 1 | 30 | N | CLP07 |
4 | ClaimSubmitterIdentifier | AN | 1 | 38 | Y | CLP01 |
5 | ClaimCharges | DEC | Y | |||
6 | ClaimPayment | DEC | S | Available when transaction status is Paid | ||
7 | PaymentDate | AN | 8 | 8 | S | YYYYMMDD, Available when transaction status is Paid |
8 | DisbursmentTraceNumber | AN | 1 | 30 | S | Disbursed check/trace number to provider; Available when transaction status is paid |
9 | DisbursmentEntity | AN | 10 | 42 | S | Available when transaction status is Paid |
10 | FundingTraceNumber | AN | 1 | 30 | S | |
11 | FundingEntity | AN | 10 | 42 | S | |
12 | Payer Name | AN | 1 | 35 | Y | |
13 | Payee Last | AN | 1 | 35 | Y | |
14 | Payee First | AN | 1 | 35 | S | |
15 | Payee Primary ID Qualifier | AN | 2 | 2 | Y | |
16 | Payee Primary ID | AN | 1 | 80 | Y | |
17 | Patient Last Name | AN | 1 | 35 | Y | |
18 | Patient First Name | AN | 1 | 35 | Y | |
19 | Patient Middle Name | AN | 1 | 25 | S | |
20 | Patient ID Qualifier | AN | 2 | 2 | Y | |
21 | Patient ID | AN | 1 | 80 | Y | |
22 | Status | AN | 1 | 20 | Y | PAID: Payment was disbursed to provider RETURNED: Returned checks SETTLED: Settled payments CANCELLED: Cancelled, Reissued, or Expired virtual card payments |
23 | Freeform | AN | 1 | 100 | S | |
24 | Payment Method | AN | 1 | 30 | Y | ACH CHK VirtualCard |