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 | |
SubscriberLastName | AN | N | 1 | 35 | |
SubscriberFirstName | AN | N | 1 | 25 | |
SubscriberMiddleName | AN | N | 1 | 25 | |
SubscriberBirthDate | AN | N | 1 | 10 | |
BillingProviderLastName | AN | N | 1 | 35 | |
BillingProviderFirstName | AN | N | 1 | 25 | |
BillingProviderMiddleName | AN | N | 1 | 25 | |
BillingProviderIDQualifier | AN | C | 1 | 10 | |
BillingProviderElectronicID | AN | C | 1 | 80 | |
ServiceProviderLastName | AN | N | 1 | 35 | |
ServiceProviderFirstName | AN | N | 1 | 25 | |
ServiceProviderMiddleName | 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
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