Field | Format | Required? | Min | Max | Comments |
---|---|---|---|---|---|
ServiceBeginDate | DT | Y | 1 | 8 | |
ServiceEndDate | DT | N | 1 | 8 | |
ProcedureCode | AN | Y | 1 | 10 | |
EstimatedMinAllowed | DEC | C | 1 | 15 | |
EstimatedMaxAllowed | DEC | C | 1 | 15 | |
EstimatedAllowed | DEC | Y | 1 | 15 | |
TotalCharge | DEC | N | 1 | 15 | |
ScheduleName | AN | N | 1 | 50 | |
Line Number | NUM | Y | 1 | 10 | |
ServiceLineControlNumer | AN | N | 1 | 10 | |
PatientResponsibility | DEC | N | 1 | 15 | |
PayerResponsibility | DEC | N | 1 | 15 | |
ApplyCopay | B | N | 4 | 5 | |
UseCopayMultiplier | B | N | 4 | 5 | Multiply copay by units |
Units | NUM | N | 1 | 10 | |
NonCovered | B | N | 4 | 5 | |
Description | AN | N | 1 | 30 | |
AdjustmentReasonData | AN | N | 1 | -1 |