PatientLastName | AN | N | 1 | 35 | |
PatientFirstName | AN | N | 1 | 25 | |
PatientMiddleName | AN | N | 1 | 25 | |
PatientBirthDate | DT | N | 1 | 8 | |
PatientAccountNumber | AN | N | 1 | 80 | |
BillingProviderLastName | AN | N | 1 | 35 | |
BillingProviderFirstName | AN | N | 1 | 25 | |
BillingProviderIDQualifier | AN | C | 1 | 10 | |
BillingProviderElectronicID | AN | C | 1 | 80 | |
ServiceProviderLastName | AN | N | 1 | 35 | |
ServiceProviderFirstName | AN | N | 1 | 25 | |
ServiceProviderIDQualifier | AN | C | 1 | 10 | |
ServiceProviderElectronicID | AN | C | 1 | 80 | |
PrimaryInsuranceName | AN | N | 1 | 100 | |
PrimaryInsuranceIDQualifier | AN | N | 1 | 10 | |
PrimaryInsuranceID | AN | C | 1 | 80 | Note: InstaMed Payer IDs are available in InstaMed Online in the Configure > EDI Enrollment > Payer List Search screen. |
PolicyNumber | AN | N | 1 | 80 | |
Services | See Estimator Request Service Data v1.0 | C | | | |
InstitutionalCode | AN | C | 1 | 4 | |
FacilityName | AN | N | 1 | 35 | |
FacilityIDQualifier | AN | C | 1 | 10 | |
TotalCharge | AN | Y | 1 | 50 | |
InstitutionalTotalCharge | DEC | | 1 | 15 | |
EstimationMethod | AN | R | 7 | 7 | |
EffectiveBenefitInfo | See Estimator Request Effective Benefit Information v1.0 | N | | | |
Service Type | AN | N | 1 | 2 | |