7e53d9360a
dev/vendor/MANIFEST.toml pins bcda-app@7decdcc (v3 handler + tests, request validation middleware, OperationOutcome writer, v3 Postman collection, gzip fixtures, sandbox config, LICENSE) and the bcda.cms.gov v3 data dictionary, v2 dictionary and official v3 sample ndjson. vendor_bcda_app.py --verify | --check | --sync (stdlib only); the bcda-vendor workflow runs --check weekly and files an issue on drift — nothing auto-commits, a payload change upstream is something a human reads before the flattener is re-pointed. gen_bcda_v3_crosswalk.py writes dev/seeds/bcda_v3_data_dictionary.csv (fhirPath, IDR sourceColumn, ccwMapping, cclfMapping per v3 field), bcda_v3_cclf_crosswalk.csv (293 CCLF elements -> v3 field) and bcda_v3_cclf_absent.csv (52 CCLF fields v3 does not carry); the CCLF sheet has label/name swapped on data rows and is normalised. Tests assert the committed seeds match the vendored workbook. refs #1139
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201 KiB
| 1 | row | fhir_resource | claim_type | field_name | description | fhir_path | example | source_view | source_column | sources | reference_table | cclf_mapping | ccw_mapping | profiles |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2 | 0 | ExplanationOfBenefit | Pharmacy | Claim Unique ID | An Integrated Data Repository (IDR) assigned surrogate key used to identify a claim. | ExplanationOfBenefit.identifier.where(type.coding.system = 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType' and type.coding.code = 'uc' ).value | PHARM-2024-0012345 | V2_MDCR_CLM | CLM_UNIQ_ID | DDPS | CCLF7.CUR_CLM_UNIQ_ID | PDE_ID | Basis;Regular;CMS | |
| 3 | 1 | ExplanationOfBenefit | Pharmacy | Original Claim Control Number | This field contains the original claim control number for adjusted or corrected claims. It provides a reference to the prior claim that this claim is adjusting or correcting. | ExplanationOfBenefit.identifier.where(system = 'https://bluebutton.cms.gov/identifiers/CLM-CNTL-NUM').value | CNTL20240012340 | V2_MDCR_CLM | CLM_ORIG_CNTL_NUM | DDPS | Basis;Regular;CMS | |||
| 4 | 2 | ExplanationOfBenefit | Pharmacy | Claim Type Code | A code identifying the source and type of claim submitted through the Medicare or Medicaid program. For example: 60 = Medicare National Claims History (NCH) inpatient claim. 8900 = Medicaid fee for service dental. Reference table: CLM_TYPE_CD | ExplanationOfBenefit.type.coding.where(system = 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-TYPE-CD').code | 1 | V2_MDCR_CLM | CLM_TYPE_CD | DDPS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-TYPE-CD | CCLF7.CLM_TYPE_CD | Basis;Regular;CMS | |
| 5 | 3 | ExplanationOfBenefit | Pharmacy | Beneficiary Source Key - On Claim | Beneficiary Source Key - On Claim | ExplanationOfBenefit.patient.reference.substring(8) | 123456789 | DDPS | Basis;Regular;CMS | |||||
| 6 | 4 | ExplanationOfBenefit | Pharmacy | Claim From Date | A date identifying the first day services are provided to a beneficiary. | ExplanationOfBenefit.billablePeriod.start | 2024-01-15 | V2_MDCR_CLM | CLM_FROM_DT | DDPS | Basis;Regular;CMS | |||
| 7 | 5 | ExplanationOfBenefit | Pharmacy | Claim Thru Date | A date identifying the last day services are provided to a beneficiary. Note: For drug claims, this date is when the prescription was filled. | ExplanationOfBenefit.billablePeriod.end | 2024-01-15 | V2_MDCR_CLM | CLM_THRU_DT | DDPS | Basis;Regular;CMS | |||
| 8 | 6 | ExplanationOfBenefit | Pharmacy | Claim Effective Date | A date corresponding to the National Claim History (NCH) weekly processing date and used in final action processing to identify a version of a claim. It will always be a Friday date. | ExplanationOfBenefit.created | 2024-01-15 | V2_MDCR_CLM | CLM_EFCTV_DT | DDPS | CCLF7.CLM_EFCTV_DT | Basis;Regular;CMS | ||
| 9 | 7 | ExplanationOfBenefit | Pharmacy | Claim Source ID | An identifier indicating where the source of the claim data in the Integrated Data Repository (IDR) originated from. Valid values: 20000 = National Claims History (NCH). 21000 = Fiscal Intermediary Shared System (FISS). 22000 = Multi-Carrier System (MCS). 23000 = Viable Information Processing Systems (VIPS) Medicare System (VMS). 24000 = Encounter Data Processing System (EDPS). 25000 = Encounter Medicaid Duals 837 claims and Duals Medicaid Drug Claims (DMDC). N/A = Medicaid | ExplanationOfBenefit.meta.source | DDPS | V2_MDCR_CLM | CLM_SRC_ID | DDPS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-SRC-ID | Basis;Regular;CMS | ||
| 10 | 8 | ExplanationOfBenefit | Pharmacy | Service Provider Generic ID Number | A number used to identify a service provider. | ExplanationOfBenefit.contained.where(id = %context.provider.reference.substring(1)).identifier.where(system='http://bluebutton.cms.gov/fhir/identifiers/GenericIdNum').value | 1942945159 | V2_MDCR_CLM | CLM_SRVC_PRVDR_GNRC_ID_NUM | DDPS | CCLF7.CLM_SRVC_PRVDR_GNRC_ID_NUM | SRVC_PRVDR_ID | Basis;Regular;CMS | |
| 11 | 9 | ExplanationOfBenefit | Pharmacy | Service Provider NPI Number | A number identifying the National Provider Identifier (NPI) of a service provider as sourced from the NPI crosswalk reference information provided by the National Plan and Provider Enumeration System (NPPES). | ExplanationOfBenefit.contained.where(id = %root.provider.reference.substring(1)).identifier.where(system='http://hl7.org/fhir/sid/us-npi').value | V2_MDCR_CLM | PRVDR_SRVC_PRVDR_NPI_NUM | DDPS | SRVC_PRVDR_ID | Basis;Regular;CMS | |||
| 12 | 10 | ExplanationOfBenefit | Pharmacy | Provider Service Identifier Qualifier Code | A code indicating the type of number used to identify a service provider on a claim. For example: 01 = NPI. 07 = NCPDP number. 08 = State license number. Reference table: CLM_PRVDR_ID_QLFYR_CD | ExplanationOfBenefit.contained.where(id = %context.provider.reference.substring(1)).identifier.type.where(system='http://bluebutton.cms.gov/fhir/CodeSystem/PRVDR-ID-QLFYR-CD').code | V2_MDCR_CLM | PRVDR_SRVC_ID_QLFYR_CD | DDPS | CCLF7.PRVDR_SRVC_ID_QLFYR_CD | Basis;Regular;CMS | |||
| 13 | 11 | ExplanationOfBenefit | Pharmacy | Provider Prescribing Identifier Qualifier Code | A code indicating the type of number used to identify a prescribing provider on a claim. For example: 01 = NPI. 07 = NCPDP number. 08 = State license number. Reference table: CLM_PRVDR_ID_QLFYR_CD | ExplanationOfBenefit.careTeam.where(role.coding.where(code = 'prescribing').exists()).provider.identifier.type.coding.where(system='http://bluebutton.cms.gov/fhir/CodeSystem/PRVDR-ID-QLFYR-CD').code | 01 | V2_MDCR_CLM | PRVDR_PRSBNG_ID_QLFYR_CD | DDPS | CCLF7.PRVDR_PRSBNG_ID_QLFYR_CD | Basis;Regular;CMS | ||
| 14 | 12 | ExplanationOfBenefit | Pharmacy | Prescribing Provider Generic ID Number | A number identifying a generic identifier of a prescribing provider submitted on a drug claim. | ExplanationOfBenefit.careTeam.where(role.coding.where(code='prescribing').exists()).provider.identifier.where(system='http://bluebutton.cms.gov/fhir/identifiers/GenericIdNum').value | V2_MDCR_CLM | CLM_PRSBNG_PRVDR_GNRC_ID_NUM | DDPS | CCLF7.CLM_PRSBNG_PRVDR_GNRC_ID_NUM | PRSCRBR_ID | Basis;Regular;CMS | ||
| 15 | 13 | ExplanationOfBenefit | Pharmacy | Prescribing Provider NPI Number | A number identifying the National Provider Identifier (NPI) of a prescribing provider as sourced from the NPI crosswalk reference information provided by the National Plan and Provider Enumeration System (NPPES). | ExplanationOfBenefit.careTeam.where(role.coding.where(code='prescribing').exists()).provider.identifier.where(system='http://hl7.org/fhir/sid/us-npi').value | 1942945159 | V2_MDCR_CLM | PRVDR_PRSCRBNG_PRVDR_NPI_NUM | DDPS | PRSCRBR_ID | Basis;Regular;CMS | ||
| 16 | 14 | ExplanationOfBenefit | Pharmacy | Prescribing Provider Last Name | Last name of the prescribing provider | ExplanationOfBenefit.careTeam.where(role.coding.where(code='prescribing').exists()).provider.display | Stark, Tony | V2_MDCR_PRVDR_HSTRY | PRVDR_LAST_NAME | DDPS | Basis;Regular;CMS | |||
| 17 | 15 | ExplanationOfBenefit | Pharmacy | Payment Date | A date indicating when a claim was paid. | ExplanationOfBenefit.payment.date | 2024-01-20 | V2_MDCR_CLM | CLM_PD_DT | DDPS | PD_DT | Basis;Regular;CMS | ||
| 18 | 16 | ExplanationOfBenefit | Pharmacy | Claim Process Date | Date a claim or prescription drug event was processed by a CMS front end system, such as the DDPS operational data store. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_CMS_PROC_DT').exists()).timing | 2024-01-18 | V2_MDCR_CLM_DT_SGNTR | CLM_CMS_PROC_DT | DDPS | CMS | |||
| 19 | 17 | ExplanationOfBenefit | Pharmacy | Claim Submission Format Code | A code identifying the format of the claim as submitted. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_SBMT_FRMT_CD').exists()).code.coding.code | X | V2_MDCR_CLM | CLM_SBMT_FRMT_CD | DDPS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-SBMT-FRMT-CD | NSTD_FRMT_CD | Regular;CMS | |
| 20 | 18 | ExplanationOfBenefit | Pharmacy | Beneficiary Payment Amount | An amount paid by a beneficiary for services rendered on a claim. | ExplanationOfBenefit.total.where(category.coding.where(system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' and code='paidbypatient').exists() and category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_BENE_PMT_AMT').exists()).amount.value | 100 | V2_MDCR_CLM | CLM_BENE_PMT_AMT | DDPS | PTNT_PAY_AMT | Regular;CMS | ||
| 21 | 19 | ExplanationOfBenefit | Pharmacy | Other Third Party Paid Amount | An amount identifying how much was paid by a third party payer. | ExplanationOfBenefit.total.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_OTHR_TP_PD_AMT').exists()).amount.value | 100 | V2_MDCR_CLM | CLM_OTHR_TP_PD_AMT | DDPS | Regular;CMS | |||
| 22 | 20 | ExplanationOfBenefit | Pharmacy | Submitter Contract Number | The contract number of the plan that submitted the claim. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_SBMTR_CNTRCT_NUM').exists()).value | H1234 | V2_MDCR_CLM | CLM_SBMTR_CNTRCT_NUM | DDPS | PLAN_CNTRCT_REC_ID | Basis;Regular;CMS | ||
| 23 | 21 | ExplanationOfBenefit | Pharmacy | Submitter PBP Number | The Plan Benefit Package (PBP) number of the plan that submitted the claim. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_SBMTR_CNTRCT_PBP_NUM').exists()).value | 001 | V2_MDCR_CLM | CLM_SBMTR_CNTRCT_PBP_NUM | DDPS | PLAN_PBP_REC_NUM | Basis;Regular;CMS | ||
| 24 | 22 | ExplanationOfBenefit | Pharmacy | Contract PBP Name | This field contains the name of the plan benefit package (PBP) for the beneficiary's Part D plan of record for the year. | ExplanationOfBenefit.contained.where(id='insurer-org').name | Super Saver Medicare Rx Saver Plus (PDP) | V2_MDCR_CNTRCT_PBP_NUM | CNTRCT_PBP_NAME | DDPS | Basis;Regular;CMS | |||
| 25 | 23 | ExplanationOfBenefit | Pharmacy | Line Item Sequence Number | A number identifying the position of the service or item on the claim. This is a component of the 5-part key used for joining claims. | ExplanationOfBenefit.item.sequence | 1 | V2_MDCR_CLM_LINE | CLM_LINE_NUM | DDPS | Basis;Regular;CMS | |||
| 26 | 24 | ExplanationOfBenefit | Pharmacy | Line Item From Date | A date indicating the first day of service for a line item. | ExplanationOfBenefit.item.serviced | 2024-01-15 | V2_MDCR_CLM_LINE | CLM_LINE_FROM_DT | DDPS | CCLF7.CLM_LINE_FROM_DT | SRVC_DT | Basis;Regular;CMS | |
| 27 | 25 | ExplanationOfBenefit | Pharmacy | National Drug Code | The National Drug Code that identifies specific drugs. | (ExplanationOfBenefit.item.productOrService.coding|ExplanationOfBenefit.item.detail.productOrService.coding).where(system = 'http://hl7.org/fhir/sid/ndc').code | 00071015523 | V2_MDCR_CLM_LINE | CLM_LINE_NDC_CD | DDPS | CCLF7.CLM_LINE_NDC_CD | PROD_SRVC_ID | Basis;Regular;CMS | |
| 28 | 26 | ExplanationOfBenefit | Pharmacy | Line Item NDC Quantity | The quantity of an NDC applicable to institutional claims. | (ExplanationOfBenefit.item.quantity|ExplanationOfBenefit.item.detail.quantity).value | 60 | V2_MDCR_CLM_LINE | CLM_LINE_NDC_QTY | DDPS | CCLF7.CLM_LINE_SRVC_UNIT_QTY | QTY_DSPNSD_NUM | Basis;Regular;CMS | |
| 29 | 27 | ExplanationOfBenefit | Pharmacy | Line Item NDC Quantity Qualifier Code | Qualifies the type of quantity applicable to an NDC present on all institutional claim types (inpatient/SNF, outpatient, home health, and hospice). | (ExplanationOfBenefit.item.quantity|ExplanationOfBenefit.item.detail.quantity).unit | UN | V2_MDCR_CLM_LINE | CLM_LINE_NDC_QTY_QLFYR_CD | DDPS | Basis;Regular;CMS | |||
| 30 | 28 | ExplanationOfBenefit | Pharmacy | Claim Line Covered Paid Amount | An amount identifying the Medicare payment for a line item service. | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='http://terminology.hl7.org/CodeSystem/adjudication' and code='benefit').exists()).amount.value | 45.5 | V2_MDCR_CLM_LINE | CLM_LINE_CVRD_PD_AMT | DDPS | CVRD_D_PLAN_PD_AMT | Regular;CMS | ||
| 31 | 29 | ExplanationOfBenefit | Pharmacy | Patient Responsibility Payment Amount | An amount identifying the payment made by a beneficiary for a detail line of service on a claim. Note: For Part D, this amount counts towards a beneficiary's true-out-of-pocket (TROOP) cost. | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' and code='paidbypatient').exists() and category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_LINE_BENE_PMT_AMT').exists()).amount.value | 10 | V2_MDCR_CLM_LINE | CLM_LINE_BENE_PMT_AMT | DDPS | CCLF7.CLM_LINE_BENE_PMT_AMT | PTNT_PAY_AMT | Regular;CMS | |
| 32 | 30 | ExplanationOfBenefit | Pharmacy | Gross Drug Cost Above Out Of Pocket Threshold | The gross drug cost amount that was covered by Part D's catastrophic coverage. | ExplanationOfBenefit.item.adjudication.where(category.coding.system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and category.coding.code='CLM_LINE_GRS_ABOVE_THRSHLD_AMT').amount.value | 25 | V2_MDCR_CLM_LINE_RX | CLM_LINE_GRS_ABOVE_THRSHLD_AMT | DDPS | GDC_ABV_OOPT_AMT | CMS | ||
| 33 | 31 | ExplanationOfBenefit | Pharmacy | Gross Drug Cost Below Out Of Pocket Threshold | The gross drug cost amount that was not covered by Part D's catastrophic coverage. | ExplanationOfBenefit.item.adjudication.where(category.coding.system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and category.coding.code='CLM_LINE_GRS_BLW_THRSHLD_AMT').amount.value | 75 | V2_MDCR_CLM_LINE_RX | CLM_LINE_GRS_BLW_THRSHLD_AMT | DDPS | GDC_BLW_OOPT_AMT | CMS | ||
| 34 | 32 | ExplanationOfBenefit | Pharmacy | Low Income Cost Sharing Subsidy Amount | The Low Income Cost Sharing Subsidy amount for the line item. | ExplanationOfBenefit.item.adjudication.where(category.coding.system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and category.coding.code='CLM_LINE_LIS_AMT').amount.value | 10 | V2_MDCR_CLM_LINE_RX | CLM_LINE_LIS_AMT | DDPS | LICS_AMT | CMS | ||
| 35 | 33 | ExplanationOfBenefit | Pharmacy | Patient Liability Reduction Other Paid Amount | The Patient Liability Reduction Other paid amount for the line item. | ExplanationOfBenefit.item.adjudication.where(category.coding.system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and category.coding.code='CLM_LINE_PLRO_AMT').amount.value | 1 | V2_MDCR_CLM_LINE_RX | CLM_LINE_PLRO_AMT | DDPS | PLRO_AMT | CMS | ||
| 36 | 34 | ExplanationOfBenefit | Pharmacy | Claim Line Reported Gap Discount Amount | The reported amount that the sponsor advanced at point-of-sale for the gap discount for applicable drugs. | ExplanationOfBenefit.item.adjudication.where(category.coding.system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and category.coding.code='CLM_LINE_RPTD_GAP_DSCNT_AMT').amount.value | 10 | V2_MDCR_CLM_LINE_RX | CLM_LINE_RPTD_GAP_DSCNT_AMT | DDPS | RPTD_GAP_DSCNT_NUM | CMS | ||
| 37 | 35 | ExplanationOfBenefit | Pharmacy | Total drug cost (Part D) | This variable is the total cost of the prescription drug event and is taken directly from the original PDE. It is the sum of the following components: the ingredient cost (INGRDNT_CST_PD_AMT), the dispensing fee (DSPNSNG_FEE_PD_AMT), the sales tax, if any (TOT_AMT_ATTR_SLS_TAX_AMT), and the vaccine administration fee, if any (VCCN_ADMIN_FEE_AMT, included starting in 2010). | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='TOT_RX_CST_AMT')).amount.value | 45.5 | DDPS | TOT_RX_CST_AMT | Regular;CMS | ||||
| 38 | 36 | ExplanationOfBenefit | Pharmacy | Pricing Exception Code | The pricing exception code indicating network status. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator' and code='benefitpaymentstatus').exists()).reason.coding.where(system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus').code | outofnetwork | V2_MDCR_CLM_LINE_RX | CLM_PRCNG_EXCPTN_CD | DDPS | PRCNG_EXCPTN_CD | Basis;Regular;CMS | ||
| 39 | 37 | ExplanationOfBenefit | Pharmacy | Authorized Fill Number | The number of refills authorized for the prescription. | ExplanationOfBenefit.supportingInfo.where(category.coding.system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' and category.coding.code='refillsauthorized').valueQuantity.value | 0 | V2_MDCR_CLM_LINE_RX | CLM_LINE_AUTHRZD_FILL_NUM | DDPS | FILL_NUM | Basis;Regular;CMS | ||
| 40 | 38 | ExplanationOfBenefit | Pharmacy | Pharmacy Service Type Code | Code indicating the type of pharmacy service. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information' and code='CLM_PHRMCY_SRVC_TYPE_CD').exists()).code.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-PHRMCY-SRVC-TYPE-CD').code | 01 | V2_MDCR_CLM_LINE_RX | CLM_PHRMCY_SRVC_TYPE_CD | DDPS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-PHRMCY-SRVC-TYPE-CD | CCLF7.CLM_PHRMCY_SRVC_TYPE_CD | PHRMCY_SRVC_TYPE_CD | CMS |
| 41 | 39 | ExplanationOfBenefit | Pharmacy | RX Origin Code | Code indicating the origin of the prescription. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' and code='rxorigincode').exists()).code.coding.where(system='http://terminology.hl7.org/CodeSystem/NCPDPPrescriptionOriginCode').code | 3 | V2_MDCR_CLM_LINE_RX | CLM_LINE_RX_ORGN_CD | DDPS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-LINE-RX-ORGN-CD | RX_ORGN_CD | Basis;Regular;CMS | |
| 42 | 40 | ExplanationOfBenefit | Pharmacy | Brand/Generic Code | Code indicating if a drug is brand or generic. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' and code='brandgenericindicator').exists()).code.coding.where(system='http://terminology.hl7.org/CodeSystem/NCPDPBrandGenericIndicator').code | G | V2_MDCR_CLM_LINE_RX | CLM_BRND_GNRC_CD | DDPS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BRND-GNRC-CD | BRND_GNRC_CD | Basis;Regular;CMS | |
| 43 | 41 | ExplanationOfBenefit | Pharmacy | Patient Residence Code | Code indicating the patient's residence at the time of service. | ExplanationOfBenefit.supportingInfo.code.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-PTNT-RSDNC-CD').code | 01 | V2_MDCR_CLM_LINE_RX | CLM_PTNT_RSDNC_CD | DDPS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-PTNT-RSDNC-CD | PTNT_RSDNC_CD | CMS | |
| 44 | 42 | ExplanationOfBenefit | Pharmacy | LTC Dispensing Method Code | Long Term Care (LTC) dispensing method code. | ExplanationOfBenefit.supportingInfo.code.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-LTC-DSPNSNG-MTHD-CD').code | 05 | V2_MDCR_CLM_LINE_RX | CLM_LTC_DSPNSNG_MTHD_CD | DDPS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-LTC-DSPNSNG-MTHD-CD | SUBMSN_CLR_CD | CMS | |
| 45 | 43 | ExplanationOfBenefit | Pharmacy | Compound Code | Code indicating if a drug is a compound. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' and code='compoundcode').exists()).code.coding.where(system='http://terminology.hl7.org/CodeSystem/NCPDPCompoundCode').code | 0 | V2_MDCR_CLM_LINE_RX | CLM_CMPND_CD | DDPS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-CMPND-CD | CMPND_CD | Basis;Regular;CMS | |
| 46 | 44 | ExplanationOfBenefit | Pharmacy | Days Supply Quantity | The number of days supply for the prescription. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' and code='dayssupply').exists()).valueQuantity.value | 30 | V2_MDCR_CLM_LINE_RX | CLM_LINE_DAYS_SUPLY_QTY | DDPS | CCLF7.CLM_LINE_DAYS_SUPLY_QTY | DAYS_SUPLY_NUM | Basis;Regular;CMS | |
| 47 | 45 | ExplanationOfBenefit | Pharmacy | RX Fill Number | The fill number for the prescription. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' and code='refillnum').exists()).valueQuantity.value | 1 | V2_MDCR_CLM_LINE_RX | CLM_LINE_RX_FILL_NUM | DDPS | CCLF7.CLM_LINE_RX_FILL_NUM | FILL_NUM | Basis;Regular;CMS | |
| 48 | 46 | ExplanationOfBenefit | Pharmacy | DAW Product Selection Code | Dispense As Written (DAW) / Product Selection Code. | ExplanationOfBenefit.supportingInfo.code.coding.where(system='http://terminology.hl7.org/CodeSystem/NCPDPDispensedAsWrittenOrProductSelectionCode').code | 0 | V2_MDCR_CLM_LINE_RX | CLM_DAW_PROD_SLCTN_CD | DDPS | CCLF7.CLM_DAW_PROD_SLCTN_CD | DAW_PROD_SLCTN_CD | Basis;Regular;CMS | |
| 49 | 47 | ExplanationOfBenefit | Pharmacy | Drug Coverage Status Code | Code indicating the drug coverage status. | ExplanationOfBenefit.supportingInfo.code.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DRUG-CVRG-STUS-CD').code | C | V2_MDCR_CLM_LINE_RX | CLM_DRUG_CVRG_STUS_CD | DDPS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DRUG-CVRG-STUS-CD | DRUG_CVRG_STUS_CD | CMS | |
| 50 | 48 | ExplanationOfBenefit | Pharmacy | Catastrophic Coverage Indicator Code | Code indicating if the claim is catastrophic coverage. | ExplanationOfBenefit.supportingInfo.code.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-CTSTRPHC-CVRG-IND-CD').code | C | V2_MDCR_CLM_LINE_RX | CLM_CTSTRPHC_CVRG_IND_CD | DDPS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-CTSTRPHC-CVRG-IND-CD | CTSTRPHC_CVRG_CD | CMS | |
| 51 | 49 | ExplanationOfBenefit | Pharmacy | Claim Adjustment Type Code | A code identifying the type of adjustment record represented on a claim or encounter. Reference table: CLM_ADJSTMT_TYPE_CD | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_ADJSTMT_TYPE_CD').exists()).code.coding.code | 0 | V2_MDCR_CLM | CLM_ADJSTMT_TYPE_CD | DDPS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-ADJSTMT-TYPE-CD | CCLF7.CLM_ADJSMT_TYPE_CD | ADJSTMT_DLTN_CD | Basis;Regular;CMS |
| 52 | 50 | ExplanationOfBenefit | Pharmacy | Dispensing Status Code | Code indicating the dispensing status. | ExplanationOfBenefit.supportingInfo.code.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DSPNSNG-STUS-CD').code | P | V2_MDCR_CLM_LINE_RX | CLM_DSPNSNG_STUS_CD | DDPS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DSPNSNG-STUS-CD | CCLF7.CLM_DSPNSNG_STUS_CD | DSPNSNG_STUS_CD | CMS |
| 53 | 51 | ExplanationOfBenefit | Pharmacy | Claim IDR Load Date | A date identifying when Part A and Part B data are loaded into the Integrated Data Repository (IDR). | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_IDR_LD_DT').exists()).timing | 2025-01-18 | V2_MDCR_CLM | CLM_IDR_LD_DT | DDPS | CCLF7.CLM_IDR_LD_DT | CMS | ||
| 54 | 52 | ExplanationOfBenefit | Pharmacy | RX Number | The pharmacy's internal invoice number on pharmaceutical claims. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information' and code='CLM_LINE_RX_NUM').exists()).value | 900001 | V2_MDCR_CLM_LINE | CLM_LINE_RX_NUM | DDPS | CCLF7.CLM_LINE_RX_SRVC_RFRNC_NUM | RX_SRVC_RFRNC_NUM | CMS | |
| 55 | 53 | ExplanationOfBenefit | Pharmacy | Noncovered Paid Amount | The net amount paid by a plan for a noncovered product or service, such as a noncovered drug for Part D. | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_NCVRD_PD_AMT')).amount.value | 10.08 | V2_MDCR_CLM_LINE | CLM_LINE_NCVRD_PD_AMT | DDPS | NCVRD_PLAN_PD_AMT | CMS | ||
| 56 | 54 | ExplanationOfBenefit | Pharmacy | Other Third Party Paid Amount | The total amount paid by all sources other than Medicaid, Medicare, and the recipient's personal funds. | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_OTHR_TP_PD_AMT')).amount.value | 10.05 | V2_MDCR_CLM_LINE | CLM_LINE_OTHR_TP_PD_AMT | DDPS | OTHR_TROOP_AMT | CMS | ||
| 57 | 55 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | The claim unique ID is a unique ID for the claim within the source system. | An Integrated Data Repository (IDR) assigned surrogate key used to identify a claim. | ExplanationOfBenefit.identifier.where(type.coding.system = 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType' and type.coding.code = 'uc' ).value | NON-UNIQUE-ID-HERE | V2_MDCR_CLM | CLM_UNIQ_ID | FISS;MCS;NCH;VMS | CCLF1.CUR_CLM_UNIQ_ID;CCLF2.CUR_CLM_UNIQ_ID;CCLF3.CUR_CLM_UNIQ_ID;CCLF4.CUR_CLM_UNIQ_ID;CCLF5.CUR_CLM_UNIQ_ID;CCLF6.CUR_CLM_UNIQ_ID;CCLFA.CUR_CLM_UNIQ_ID;CCLFB.CUR_CLM_UNIQ_ID | CLM_ID | Basis;Regular;CMS | |
| 58 | 56 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Final Action Indicator | A value indicating a final action claim. Valid values: Y = Final action claim, not voided. N = Not final action claim | ExplanationOfBenefit.meta.tag.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Final-Action').code | FinalAction | V2_MDCR_CLM | CLM_FINL_ACTN_IND | FISS;MCS;NCH;VMS | https://bluebutton.cms.gov/fhir/CodeSystem/Final-Action | Basis;Regular;CMS | ||
| 59 | 57 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Claim Control Number | An identifier assigned by the claim processor (i.e., Medicare Administrative Contractor, Part D plan, or Encounter Data Processing Contractor) to a claim. | ExplanationOfBenefit.identifier.where(system = 'https://bluebutton.cms.gov/identifiers/CLM-CNTL-NUM').value | DOOPITY-DOOP-DOOP | V2_MDCR_CLM | CLM_CNTL_NUM | FISS;MCS;NCH;VMS | CCLF1.CLM_CNTL_NUM;CCLF5.CLM_CNTL_NUM;CCLF6.CLM_CNTL_NUM | CARR_CLM_CNTL_NUM;FI_DOC_CLM_CNTL_NUM | Basis;Regular;CMS | |
| 60 | 58 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | This field is the original identification value assigned. | A number identifying the original Claim Control Number (CCN) on an adjusted claim. | ExplanationOfBenefit.related.where(relationship.coding.system = 'http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship').reference.where(system='https://bluebutton.cms.gov/identifiers/CLM-CNTL-NUM').value | V2_MDCR_CLM | CLM_ORIG_CNTL_NUM | FISS;MCS;NCH;VMS | CCLF1.CLM_ORG_CNTL_NUM | Basis;Regular;CMS | |||
| 61 | 59 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Claim Type Code | A code identifying the source and type of claim submitted through the Medicare or Medicaid program. For example: 60 = Medicare National Claims History (NCH) inpatient claim. 8900 = Medicaid fee for service dental. Reference table: CLM_TYPE_CD | ExplanationOfBenefit.type.coding.where(system = 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-TYPE-CD').code | 72 | V2_MDCR_CLM | CLM_TYPE_CD | FISS;MCS;NCH;VMS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-TYPE-CD | CCLF1.CLM_TYPE_CD;CCLF2.CLM_TYPE_CD;CCLF3.CLM_TYPE_CD;CCLF4.CLM_TYPE_CD;CCLF5.CLM_TYPE_CD;CCLF6.CLM_TYPE_CD;CCLFA.CLM_TYPE_CD;CCLFB.CLM_TYPE_CD | NCH_CLM_TYPE_CD | Basis;Regular;CMS |
| 62 | 60 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Beneficiary Source Key - On Claim | A unique number assigned by the Enrollment Data Base (EDB) to each EDB record to identify a beneficiary. | ExplanationOfBenefit.patient.reference.substring(8) | 12345 | V2_MDCR_CLM | BENE_SK | FISS;MCS;NCH;VMS | Basis;Regular;CMS | |||
| 63 | 61 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Claim From Date | A date identifying the first day services are provided to a beneficiary. | ExplanationOfBenefit.billablePeriod.start | 2025-01-03 | V2_MDCR_CLM | CLM_FROM_DT | FISS;MCS;NCH;VMS | CCLF1.CLM_FROM_DT;CCLF2.CLM_FROM_DT;CCLF3.CLM_FROM_DT;CCLF4.CLM_FROM_DT;CCLF5.CLM_FROM_DT;CCLF6.CLM_FROM_DT | CLM_FROM_DT | Basis;Regular;CMS | |
| 64 | 62 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Claim Thru Date | A date identifying the last day services are provided to a beneficiary. Note: For drug claims, this date is when the prescription was filled. | ExplanationOfBenefit.billablePeriod.end | 2025-01-11 | V2_MDCR_CLM | CLM_THRU_DT | FISS;MCS;NCH;VMS | CCLF1.CLM_THRU_DT;CCLF2.CLM_THRU_DT;CCLF3.CLM_THRU_DT;CCLF4.CLM_THRU_DT;CCLF5.CLM_THRU_DT;CCLF6.CLM_THRU_DT | CLM_THRU_DT | Basis;Regular;CMS | |
| 65 | 63 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Claim Effective Date | A date corresponding to the National Claim History (NCH) weekly processing date and used in final action processing to identify a version of a claim. It will always be a Friday date. | ExplanationOfBenefit.created | 2025-01-18 | V2_MDCR_CLM | CLM_EFCTV_DT | FISS;MCS;NCH;VMS | CCLF1.CLM_EFCTV_DT;CCLF5.CLM_EFCTV_DT;CCLF6.CLM_EFCTV_DT | Basis;Regular;CMS | ||
| 66 | 64 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Claim IDR Load Date | A date identifying when Part A and Part B data are loaded into the Integrated Data Repository (IDR). | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_IDR_LD_DT').exists()).timing | 2025-01-18 | V2_MDCR_CLM | CLM_IDR_LD_DT | FISS;MCS;NCH;VMS | CCLF1.CLM_IDR_LD_DT;CCLF5.CLM_IDR_LD_DT;CCLF6.CLM_IDR_LD_DT | CMS | ||
| 67 | 65 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Claim Source ID | A unique numeric value assigned by the Integrated Data Repository (IDR) used to identify the specific source of the data when a row is loaded into the IDR. Reference table: V2_MDCR_META_DCTNRY_SRC | ExplanationOfBenefit.meta.tag.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/System-Type').value | V2_MDCR_CLM | CLM_SRC_ID | FISS;MCS;NCH;VMS | https://bluebutton.cms.gov/fhir/CodeSystem/System-Type | Basis;Regular;CMS | |||
| 68 | 66 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Source ID | Identifies the source system of the ExplanationOfBenefit data. | ExplanationOfBenefit.meta.source | NCH | V2_MDCR_CLM | META_SRC_SK | FISS;MCS;NCH;VMS | Basis;Regular;CMS | |||
| 69 | 67 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Provider billing NPI number | A number identifying the National Provider Identifier (NPI) of the billing provider associated with the claim, as sourced from the National Plan and Provider Enumeration System (NPPES). Note: This column is populated if the billing provider NPI on the claim, as provided by the source system, can be found in the Integrated Deposit Repository (IDR) provider data as sourced from NPPES. | ExplanationOfBenefit.contained.where(id = %root.provider.reference.substring(1)).identifier.where(system='http://hl7.org/fhir/sid/us-npi').value | 1942945159 | V2_MDCR_CLM | PRVDR_BLG_PRVDR_NPI_NUM | FISS;MCS;NCH;VMS | CCLF1.FAC_PRVDR_NPI_NUM;CCLF1.CLM_BLG_PRVDR_NPI_NUM;CCLF6.CLM_BLG_PRVDR_NPI_NUM;CCLF6.PAYTO_PRVDR_NPI_NUM | ORG_NPI_NUM;PRVDR_NPI;CARR_CLM_BLG_NPI_NUM | Basis;Regular;CMS | |
| 70 | 68 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Billing Provider Zip Code | A five-digit ZIP code defined by the United States Postal Service (USPS) that identifies a destination post office or delivery area associated with a beneficiary, provider, or claim address. Reference table: GEO_ZIP5_CD | ExplanationOfBenefit.contained.where(id = %root.provider.reference.substring(1)).address.postalCode | 77550 | V2_MDCR_CLM | CLM_BLG_PRVDR_ZIP5_CD | FISS;MCS;NCH;VMS | PRVDR_ZIP | Basis;Regular;CMS | ||
| 71 | 69 | ExplanationOfBenefit | DME;Inpatient;Outpatient;SNF | Provider Tax Number | Provider Tax Number | ExplanationOfBenefit.contained.where(id = %root.provider.reference.substring(1)).identifier.where(system = 'urn:oid:2.16.840.1.113883.4.4').value | V2_MDCR_CLM | CLM_BLG_PRVDR_TAX_NUM | FISS;MCS;NCH;VMS | Basis;Regular;CMS | ||||
| 72 | 70 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Claim Query Code | Indication of the type of claim record being processed with respect to payment (debit/credit indicator - original, full, replacement; interim/final indicator). [HRMZ] Code indicating the type of claim record being processed with respect to payment (debit/credit indicator; interim/final indicator). [NCH] | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_QUERY_CD').exists()).code.coding.code | 3 | V2_MDCR_CLM | CLM_QUERY_CD | FISS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-QUERY-CD | CCLF1.CLM_QUERY_CD | CARR_CLM_ENTRY_CD;CLAIM_QUERY_CODE | CMS;Basis;Regular |
| 73 | 71 | ExplanationOfBenefit | Inpatient;SNF | Noncovered Charge Amount | An amount identifying the portion of a charge not covered by Medicare. | ExplanationOfBenefit.total.where(category.coding.where(system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' and code='noncovered').exists() and category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_NCVRD_CHRG_AMT').exists()).amount.value | 11.5 | V2_MDCR_CLM | CLM_NCVRD_CHRG_AMT | FISS;NCH | CCLFA.CLM_NCVRD_CHRG_AMT | NCH_IP_NCVRD_CHRG_AMT | Regular;CMS | |
| 74 | 72 | ExplanationOfBenefit | Carrier;DME;Inpatient;Outpatient;SNF | Inpatient/Outpatient Total Deduction Amount | An amount identifying the portion applied toward the deductible a beneficiary is responsible for. | ExplanationOfBenefit.total.where(category.coding.where(system='http://terminology.hl7.org/CodeSystem/adjudication' and code='deductible').exists() and category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_MDCR_DDCTBL_AMT').exists()).amount.value | 17.85 | V2_MDCR_CLM | CLM_MDCR_DDCTBL_AMT | FISS;MCS;NCH;VMS | CCLFA.CLM_MDCR_DDCTBL_AMT;CCLFB.CLM_MDCR_DDCTBL_AMT | NCH_BENE_PTB_DDCTBL_AMT;NCH_IP_TOT_DDCTN_AMT;CARR_CLM_CASH_DDCTBL_APLD_AMT | Regular;CMS | |
| 75 | 73 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Near Line Record Identification Code | A code defining the type of claim record being processed. [NCH] | ExplanationOfBenefit.supportingInfo.where(code.coding.system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-NRLN-RIC-CD').code.coding.code | O | V2_MDCR_CLM_DCMTN | CLM_NRLN_RIC_CD | NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-NRLN-RIC-CD | NCH_NEAR_LINE_REC_IDENT_CD | Basis;Regular;CMS | |
| 76 | 74 | ExplanationOfBenefit | Outpatient | Claim Outpatient Service Type Code | Code indicating type and priority of outpatient service. [NCH] | ExplanationOfBenefit.supportingInfo.where(code.coding.system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OP-SRVC-TYPE-CD').code.coding.code | 3 | V2_MDCR_CLM_INSTNL | CLM_OP_SRVC_TYPE_CD | NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OP-SRVC-TYPE-CD | CCLF1.CLM_OP_SRVC_TYPE_CD | CMS | |
| 77 | 75 | ExplanationOfBenefit | Inpatient | Operating Disproportionate Share Amount | This is one component of the total amount that is payable on prospective payment system (PPS) claims and reflects the DSH (disproportionate share hospital) payments for operating expenses (such as labor) for the claim. Note: This field is a sum of the CLM_VAL.CLM_VAL_AMT amounts where CLM_VAL_CD is the disproportionate share code. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_OPRTNL_DSPRTNT_AMT').exists()).amount.value | 14.14 | FISS;NCH | CCLF1.CLM_OPRTNL_DSPRPRTNT_AMT | DSH_OP_CLM_VAL_AMT | CMS | |||
| 78 | 76 | ExplanationOfBenefit | Inpatient | Operating Indirect Medical Education Amount | This is one component of the total amount that is payable on PPS claims, and reflects the IME (indirect medical education) payments for operating expenses (such as labor) for the claim. Note: This field is a sum of the CLM_VAL.CLM_VAL_AMT amounts where CLM_VAL_CD is the IME share code. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_OPRTNL_IME_AMT').exists()).amount.value | 12342.14 | FISS;NCH | CCLF1.CLM_OPRTNL_IME_AMT | IME_OP_CLM_VAL_AMT | CMS | |||
| 79 | 77 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim Process Date | Date a claim or prescription drug event was processed by a CMS front end system, such as the DDPS operational data store. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_CMS_PROC_DT').exists()).timing | 2025-01-01 | V2_MDCR_CLM_DT_SGNTR | CLM_CMS_PROC_DT | FISS;NCH | FI_CLM_PROC_DT | CMS | ||
| 80 | 78 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Payment Amount | An amount identifying how much was paid on an adjudicated claim. | ExplanationOfBenefit.payment.amount.value | 3.5 | V2_MDCR_CLM | CLM_PMT_AMT | FISS;MCS;NCH | CCLF1.CLM_PMT_AMT | CLM_PMT_AMT | Regular;CMS | |
| 81 | 79 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Attending Physician NPI | A number identifying the National Provider Identifier (NPI) of an attending provider as sourced from the NPI crosswalk reference information provided by the National Plan and Provider Enumeration System (NPPES). | ExplanationOfBenefit.careTeam.where(role.coding.where(code = 'attending').exists()).provider.identifier.value | 1942945159 | V2_MDCR_CLM | PRVDR_ATNDG_PRVDR_NPI_NUM | FISS;NCH | CCLF1.ATNDG_PRVDR_NPI_NUM;CCLF1.CLM_ATNDG_PRVDR_NPI_NUM | AT_PHYSN_NPI | Basis;Regular;CMS | |
| 82 | 80 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Operating Physician NPI | A number identifying the National Provider Identifier (NPI) of an operating provider as sourced from the NPI crosswalk reference information provided by the National Plan and Provider Enumeration System (NPPES). | ExplanationOfBenefit.careTeam.where(role.coding.where(code = 'otheroperating').exists()).provider.identifier.value | 1942945159 | V2_MDCR_CLM | PRVDR_OPRTG_PRVDR_NPI_NUM | FISS;NCH | CCLF1.OPRTG_PRVDR_NPI_NUM;CCLF1.CLM_OPRTG_PRVDR_NPI_NUM | OP_PHYSN_NPI | Basis;Regular;CMS | |
| 83 | 81 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Claim Diagnosis Code | A CODE IDENTIFYING AN INTERNATIONAL CLASSIFICATION OF DISEASES, CLINICAL MODIFICATION (ICD_CM) DIAGNOSIS RELEVANT TO THE SERVICE BEING PROVIDED OR THE REASON FOR THE SERVICE. | ExplanationOfBenefit.diagnosis.diagnosis.coding.code | M48.062 | V2_MDCR_CLM_PROD | CLM_DGNS_CD | FISS;MCS;NCH;VMS | CCLF1.PRNCPL_DGNS_CD;CCLF1.ADMTG_DGNS_CD;CCLF4.CLM_DGNS_CD;CCLF5.CLM_DGNS_1_CD;CCLF5.CLM_DGNS_2_CD;CCLF5.CLM_DGNS_3_CD;CCLF5.CLM_DGNS_4_CD;CCLF5.CLM_DGNS_5_CD;CCLF5.CLM_DGNS_6_CD;CCLF5.CLM_DGNS_7_CD;CCLF5.CLM_DGNS_8_CD;CCLF5.CLM_DGNS_9_CD;CCLF5.CLM_DGNS_10_CD;CCLF5.CLM_DGNS_11_CD;CCLF5.CLM_DGNS_12_CD | FST_DGNS_E_CD;RSN_VISIT_CD1;RSN_VISIT_CD2;RSN_VISIT_CD3;ICD_DGNS_CD1;ICD_DGNS_CD2;ICD_DGNS_CD3;ICD_DGNS_CD4;ICD_DGNS_CD5;ICD_DGNS_CD6;ICD_DGNS_CD7;ICD_DGNS_CD8;ICD_DGNS_CD9;ICD_DGNS_CD10;ICD_DGNS_CD11;ICD_DGNS_CD12;ICD_DGNS_CD13;ICD_DGNS_CD14;ICD_DGNS_CD15;ICD_DGNS_CD16;ICD_DGNS_CD17;ICD_DGNS_CD18;ICD_DGNS_CD19;ICD_DGNS_CD20;ICD_DGNS_CD21;ICD_DGNS_CD22;ICD_DGNS_CD23;ICD_DGNS_CD24;ICD_DGNS_CD25;ICD_DGNS_E_CD1;ICD_DGNS_E_CD2;ICD_DGNS_E_CD3;ICD_DGNS_E_CD4;ICD_DGNS_E_CD5;ICD_DGNS_E_CD6;ICD_DGNS_E_CD7;ICD_DGNS_E_CD8;ICD_DGNS_E_CD9;ICD_DGNS_E_CD10;ICD_DGNS_E_CD11;ICD_DGNS_E_CD12;PRNCPAL_DGNS_CD | Basis;Regular;CMS | |
| 84 | 82 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Diagnosis Procedure ICD indicator | THIS IS THE CLAIM PROD VERSION CODE WHICH IS SPACES OR 9 FOR ICD 9 AND 0 FOR ICD 10. | ExplanationOfBenefit.diagnosis.diagnosis.coding.system | http://hl7.org/fhir/sid/icd-10-cm | V2_MDCR_CLM_PROD | CLM_DGNS_PRCDR_ICD_IND | FISS;MCS;NCH;VMS | CCLF1.DGNS_PRCDR_ICD_IND;CCLF2.DGNS_PRCDR_ICD_IND;CCLF4.DGNS_PRCDR_ICD_IND;CCLF5.DGNS_PRCDR_ICD_IND | FST_DGNS_E_VRSN_CD;RSN_VISIT_VRSN_CD1;RSN_VISIT_VRSN_CD2;RSN_VISIT_VRSN_CD3;ADMTG_DGNS_VRSN_CD;ICD_DGNS_E_VRSN_CD1;ICD_DGNS_E_VRSN_CD2;ICD_DGNS_E_VRSN_CD3;ICD_DGNS_E_VRSN_CD4;ICD_DGNS_E_VRSN_CD5;ICD_DGNS_E_VRSN_CD6;ICD_DGNS_E_VRSN_CD7;ICD_DGNS_E_VRSN_CD8;ICD_DGNS_E_VRSN_CD9;ICD_DGNS_E_VRSN_CD10;ICD_DGNS_E_VRSN_CD11;ICD_DGNS_E_VRSN_CD12;ICD_DGNS_VRSN_CD1;ICD_DGNS_VRSN_CD2;ICD_DGNS_VRSN_CD3;ICD_DGNS_VRSN_CD4;ICD_DGNS_VRSN_CD5;ICD_DGNS_VRSN_CD6;ICD_DGNS_VRSN_CD7;ICD_DGNS_VRSN_CD8;ICD_DGNS_VRSN_CD9;ICD_DGNS_VRSN_CD10;ICD_DGNS_VRSN_CD11;ICD_DGNS_VRSN_CD12;ICD_DGNS_VRSN_CD13;ICD_DGNS_VRSN_CD14;ICD_DGNS_VRSN_CD15;ICD_DGNS_VRSN_CD16;ICD_DGNS_VRSN_CD17;ICD_DGNS_VRSN_CD18;ICD_DGNS_VRSN_CD19;ICD_DGNS_VRSN_CD20;ICD_DGNS_VRSN_CD21;ICD_DGNS_VRSN_CD22;ICD_DGNS_VRSN_CD23;ICD_DGNS_VRSN_CD24;ICD_DGNS_VRSN_CD25;PRNCPAL_DGNS_VRSN_CD;LINE_ICD_DGNS_VRSN_CD | Basis;Regular;CMS | |
| 85 | 83 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Diagnosis Prod Type Code | UNIQUELY IDENTIFIES A TYPE OF PROCEDURE OR A DIAGNOSIS CATEGORY. | ExplanationOfBenefit.diagnosis.type.coding | {'system': 'http://terminology.hl7.org/CodeSystem/ex-diagnosistype', 'code': 'principal'} | V2_MDCR_CLM_PROD | CLM_PROD_TYPE_CD | FISS;NCH | CCLF4.CLM_PROD_TYPE_CD | Basis;Regular;CMS | ||
| 86 | 84 | ExplanationOfBenefit | Inpatient;SNF | Claim Present on Admission Indicator | THE CODE USED TO INDICATE A CONDITION WAS PRESENT AT THE TIME THE BENEFICIARY WAS ADMITTED TO A GENERAL ACUTE CARE FACILITY.NOT APPLICABLE TO NON-DIAGNOSTIC PRODUCTS. | ExplanationOfBenefit.diagnosis.onAdmission.coding | {'system': 'https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding', 'code': 'Y'} | V2_MDCR_CLM_PROD | CLM_POA_IND | FISS;NCH | CCLF4.CLM_POA_IND | CLM_E_POA_IND_SW1;CLM_E_POA_IND_SW2;CLM_E_POA_IND_SW3;CLM_E_POA_IND_SW4;CLM_E_POA_IND_SW5;CLM_E_POA_IND_SW6;CLM_E_POA_IND_SW7;CLM_E_POA_IND_SW8;CLM_E_POA_IND_SW9;CLM_E_POA_IND_SW10;CLM_E_POA_IND_SW11;CLM_E_POA_IND_SW12;CLM_POA_IND_SW1;CLM_POA_IND_SW2;CLM_POA_IND_SW3;CLM_POA_IND_SW4;CLM_POA_IND_SW5;CLM_POA_IND_SW6;CLM_POA_IND_SW7;CLM_POA_IND_SW8;CLM_POA_IND_SW9;CLM_POA_IND_SW10;CLM_POA_IND_SW11;CLM_POA_IND_SW12;CLM_POA_IND_SW13;CLM_POA_IND_SW14;CLM_POA_IND_SW15;CLM_POA_IND_SW16;CLM_POA_IND_SW17;CLM_POA_IND_SW18;CLM_POA_IND_SW19;CLM_POA_IND_SW20;CLM_POA_IND_SW21;CLM_POA_IND_SW22;CLM_POA_IND_SW23;CLM_POA_IND_SW24;CLM_POA_IND_SW25 | Basis;Regular;CMS | |
| 87 | 85 | ExplanationOfBenefit | Hospice;Inpatient;Outpatient;SNF | Procedure Performed Date | The date on which the principal or other procedure was performed. (NCH) | ExplanationOfBenefit.procedure.date | 2024-01-01 | V2_MDCR_CLM_PROD | CLM_PRCDR_PRFRM_DT | FISS;NCH | CCLF3.CLM_PRCDR_PRFRM_DT | PRCDR_DT1;PRCDR_DT2;PRCDR_DT3;PRCDR_DT4;PRCDR_DT5;PRCDR_DT6;PRCDR_DT7;PRCDR_DT8;PRCDR_DT9;PRCDR_DT10;PRCDR_DT11;PRCDR_DT12;PRCDR_DT13;PRCDR_DT14;PRCDR_DT15;PRCDR_DT16;PRCDR_DT17;PRCDR_DT18;PRCDR_DT19;PRCDR_DT20;PRCDR_DT21;PRCDR_DT22;PRCDR_DT23;PRCDR_DT24;PRCDR_DT25 | Basis;Regular;CMS | |
| 88 | 86 | ExplanationOfBenefit | Hospice;Inpatient;Outpatient;SNF | Claim Procedure Code | Stores procedure codes. | ExplanationOfBenefit.procedure.procedure.coding.code | 0SG30AJ | V2_MDCR_CLM_PROD | CLM_PRCDR_CD | FISS;NCH | CCLF3.CLM_PRCDR_CD | ICD_PRCDR_CD1;ICD_PRCDR_CD2;ICD_PRCDR_CD3;ICD_PRCDR_CD4;ICD_PRCDR_CD5;ICD_PRCDR_CD6;ICD_PRCDR_CD7;ICD_PRCDR_CD8;ICD_PRCDR_CD9;ICD_PRCDR_CD10;ICD_PRCDR_CD11;ICD_PRCDR_CD12;ICD_PRCDR_CD13;ICD_PRCDR_CD14;ICD_PRCDR_CD15;ICD_PRCDR_CD16;ICD_PRCDR_CD17;ICD_PRCDR_CD18;ICD_PRCDR_CD19;ICD_PRCDR_CD20;ICD_PRCDR_CD21;ICD_PRCDR_CD22;ICD_PRCDR_CD23;ICD_PRCDR_CD24;ICD_PRCDR_CD25 | Basis;Regular;CMS | |
| 89 | 87 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Diagnosis Procedure ICD indicator | This is the claim product version code which is spaces or 9 for ICD-9 and 0 for ICD-10. | ExplanationOfBenefit.procedure.procedure.coding.system | http://www.cms.gov/Medicare/Coding/ICD10 | V2_MDCR_CLM_PROD | CLM_DGNS_PRCDR_ICD_IND | FISS;NCH | CCLF3.DGNS_PRCDR_ICD_IND | ICD_PRCDR_VRSN_CD1;ICD_PRCDR_VRSN_CD2;ICD_PRCDR_VRSN_CD3;ICD_PRCDR_VRSN_CD4;ICD_PRCDR_VRSN_CD5;ICD_PRCDR_VRSN_CD6;ICD_PRCDR_VRSN_CD7;ICD_PRCDR_VRSN_CD8;ICD_PRCDR_VRSN_CD9;ICD_PRCDR_VRSN_CD10;ICD_PRCDR_VRSN_CD11;ICD_PRCDR_VRSN_CD12;ICD_PRCDR_VRSN_CD13;ICD_PRCDR_VRSN_CD14;ICD_PRCDR_VRSN_CD15;ICD_PRCDR_VRSN_CD16;ICD_PRCDR_VRSN_CD17;ICD_PRCDR_VRSN_CD18;ICD_PRCDR_VRSN_CD19;ICD_PRCDR_VRSN_CD20;ICD_PRCDR_VRSN_CD21;ICD_PRCDR_VRSN_CD22;ICD_PRCDR_VRSN_CD23;ICD_PRCDR_VRSN_CD24;ICD_PRCDR_VRSN_CD25 | Basis;Regular;CMS | |
| 90 | 88 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Submitted Charge Amount | The amount of submitted charges for the line item service on the noninstitutional claim. [NCH] | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_SBMT_CHRG_AMT')).amount.value | 50.11 | V2_MDCR_CLM_LINE | CLM_LINE_SBMT_CHRG_AMT | FISS;MCS;NCH;VMS | LINE_SBMTD_CHRG_AMT;REV_CNTR_TOT_CHRG_AMT | Regular;CMS | ||
| 91 | 89 | ExplanationOfBenefit | Carrier;DME | Line Item Allowed Charge Amount | The maximum amount allowed by the plan for payment. The amount eligible for payment after applying pricing guidelines/discounts. Usually includes copayment, coinsurance, deductible, penalty, and third party savings amounts. For encounters, may be fee-for-service equivalents. | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_ALOWD_CHRG_AMT')).amount.value | 9194.22 | V2_MDCR_CLM_LINE | CLM_LINE_ALOWD_CHRG_AMT | MCS;NCH;VMS | CCLF5.CLM_LINE_ALOWD_CHRG_AMT;CCLF6.CLM_LINE_ALOWD_CHRG_AMT | LINE_ALOWD_CHRG_AMT | Regular;CMS | |
| 92 | 90 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Line Item Sequence Number | A number identifying the position of the service or item on the claim. This is a component of the 5-part key used for joining claims. | ExplanationOfBenefit.item.sequence | 1 | V2_MDCR_CLM_LINE | CLM_LINE_NUM | FISS;NCH | CCLF2.CLM_LINE_NUM;CCLF5.CLM_LINE_NUM;CCLF6.CLM_LINE_NUM;CCLFB.CLM_LINE_NUM | CLM_LINE_NUM;LINE_NUM | Basis;Regular;CMS | |
| 93 | 91 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Line Item HCPCS Code | A code identifying a Healthcare Common Procedure Coding System (HCPCS) procedure, supply, product, or service provided to a Medicare beneficiary or an individual enrolled in private health insurance programs. Reference table: HCPCS_CD | ExplanationOfBenefit.item.productOrService.where(coding.system='http://www.ama-assn.org/go/cpt' or coding.system='https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' or coding.system='http://terminology.hl7.org/CodeSystem/data-absent-reason').coding.code | 99213 | V2_MDCR_CLM_LINE | CLM_LINE_HCPCS_CD | FISS;MCS;NCH;VMS | CCLF2.CLM_LINE_HCPCS_CD;CCLF5.CLM_LINE_HCPCS_CD;CCLF6.CLM_LINE_HCPCS_CD | HCPCS_CD | Basis;Regular;CMS | |
| 94 | 92 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Line Item APC / HIPPS Code | The Ambulatory Payment Classification (APC) code and the HIPPS code. The APC is used to identify groupings of outpatient services. APC codes are used to calculate payment for services under OPPS. The APC is a four byte field. The HIPPS codes are used. | ExplanationOfBenefit.item.productOrService.coding.where(system='https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes').code | NHNC1 | V2_MDCR_CLM_LINE_INSTNL | CLM_REV_APC_HIPPS_CD | FISS;NCH | CCLF2.CLM_REV_APC_HIPPS_CD | REV_CNTR_APC_HIPPS_CD | Basis;Regular;CMS | |
| 95 | 93 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | National Drug Code | The National Drug Code that identifies specific drugs. | ExplanationOfBenefit.item.detail.productOrService.where(coding.system='http://hl7.org/fhir/sid/ndc').coding.code | 00409189001 | V2_MDCR_CLM_LINE | CLM_LINE_NDC_CD | FISS;MCS;NCH;VMS | LINE_NDC_CD;REV_CNTR_IDE_NDC_UPC_NUM | Basis;Regular;CMS | ||
| 96 | 94 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Line Item NDC Quantity | The quantity of an NDC applicable to institutional claims. | ExplanationOfBenefit.item.detail.where(productOrService.where(coding.system='http://hl7.org/fhir/sid/ndc')).quantity.value | 1000 | V2_MDCR_CLM_LINE | CLM_LINE_NDC_QTY | FISS;MCS;NCH | REV_CNTR_NDC_QTY | Basis;Regular;CMS | ||
| 97 | 95 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Line Item NDC Quantity Qualifier Code | Qualifies the type of quantity applicable to an NDC present on all institutional claim types (inpatient/SNF, outpatient, home health, and hospice). | ExplanationOfBenefit.item.detail.where(productOrService.where(coding.system='http://hl7.org/fhir/sid/ndc')).quantity.code | g | V2_MDCR_CLM_LINE | CLM_LINE_NDC_QTY_QLFYR_CD | FISS;MCS;NCH | REV_CNTR_NDC_QTY_QLFR_CD | Basis;Regular;CMS | ||
| 98 | 96 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Line Item Service Unit Quantity | The total units billed for a claim line. | ExplanationOfBenefit.item.quantity.value | 3 | V2_MDCR_CLM_LINE | CLM_LINE_SRVC_UNIT_QTY | FISS;MCS;NCH;VMS | CCLF2.CLM_LINE_SRVC_UNIT_QTY;CCLF5.CLM_LINE_SRVC_UNIT_QTY | LINE_SRVC_CNT;REV_CNTR_UNIT_CNT | Basis;Regular;CMS | |
| 99 | 97 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Line Item Revenue Center Code | A unique identifier of a uniform billing revenue type. The provider-assigned revenue code for each cost center for which a separate charge is billed (type of accommodation or ancillary). A cost center is a division or unit within a hospital (e.g., radiology, emergency room, pathology). Exception: Revenue center code 0001 represents the total of all revenue centers included on the claim. (NCH) Example: 0123 = Semi-private 2 bed (medical or general) - pediatric | ExplanationOfBenefit.item.revenue.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD').code | 0636 | V2_MDCR_CLM_LINE | CLM_LINE_REV_CTR_CD | FISS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-LINE-REV-CTR-CD | CCLF2.CLM_LINE_PROD_REV_CTR_CD | REV_CNTR | Basis;Regular;CMS |
| 100 | 98 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Line Item Revenue Center Code | Code indicating whether the revenue center charges are subject to deductible and/or coinsurance. [NCH] | ExplanationOfBenefit.item.revenue.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD').code | M | V2_MDCR_CLM_LINE_INSTNL | CLM_DDCTBL_COINSRNC_CD | FISS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD | REV_CNTR_DDCTBL_COINSRNC_CD | CMS | |
| 101 | 99 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | HCPCS Modifier Code 1 | (1) A first modifier to the procedure code to enable a more specific procedure identification for the claim. [NCH] (2) A first modifier to the HCPCS procedure code to enable a more specific procedure identification for the line item service on the noninstitutional claim. [NCH] | ExplanationOfBenefit.item.modifier[0].coding.code | A2 | V2_MDCR_CLM_LINE | HCPCS_1_MDFR_CD | FISS;MCS;NCH;VMS | CCLF2.HCPCS_1_MDFR_CD;CCLF5.HCPCS_1_MDFR_CD | HCPCS_1ST_MDFR_CD | Basis;Regular;CMS | |
| 102 | 100 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | HCPCS Modifier Code 2 | (1) A second modifier to the procedure code to make it more specific than the first modifier code to identify the procedures performed on the beneficiary for the claim. [NCH] (2) A second modifier to the HCPCS procedure code to make it more specific than the first modifier code to identify the line item procedures for this claim. [NCH] | ExplanationOfBenefit.item.modifier[1].coding.code | 99 | V2_MDCR_CLM_LINE | HCPCS_2_MDFR_CD | FISS;MCS;NCH;VMS | CCLF2.HCPCS_2_MDFR_CD;CCLF5.HCPCS_2_MDFR_CD | HCPCS_2ND_MDFR_CD | Basis;Regular;CMS | |
| 103 | 101 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | HCPCS Modifier Code 3 | (1) Effective with NCH version I, a third modifier to the procedure code to make it more specific than the second modifier code to identify the procedures performed on the beneficiary for the claim. [NCH] (2) Prior to NCH version H this field was named: HCPCS_3RD_MDFR_CD. [NCH] | ExplanationOfBenefit.item.modifier[2].coding.code | V2_MDCR_CLM_LINE | HCPCS_3_MDFR_CD | FISS;MCS;NCH;VMS | CCLF2.HCPCS_3_MDFR_CD;CCLF5.HCPCS_3_MDFR_CD | HCPCS_3RD_MDFR_CD | Basis;Regular;CMS | ||
| 104 | 102 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | HCPCS Modifier Code 4 | (1) Effective with version I, a fourth modifier to the procedure code to make it more specific than the third modifier code to identify the procedures performed on the beneficiary for the claim. [NCH] (2) Prior to version H this field was named: HCPCS_4TH_MDFR_CD. [NCH] | ExplanationOfBenefit.item.modifier[3].coding.code | V2_MDCR_CLM_LINE | HCPCS_4_MDFR_CD | FISS;MCS;NCH;VMS | CCLF2.HCPCS_4_MDFR_CD;CCLF5.HCPCS_4_MDFR_CD | HCPCS_4TH_MDFR_CD | Basis;Regular;CMS | ||
| 105 | 103 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | HCPCS Modifier Code 5 | Effective with NCH version I, a fifth modifier to the procedure code to make it more specific than the fourth modifier code to identify the procedures performed on the beneficiary for the claim. [NCH] | ExplanationOfBenefit.item.modifier[4].coding.code | V2_MDCR_CLM_LINE | HCPCS_5_MDFR_CD | FISS;MCS;NCH;VMS | CCLF2.HCPCS_5_MDFR_CD;CCLF5.HCPCS_5_MDFR_CD | Basis;Regular;CMS | |||
| 106 | 104 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim Line Institutional Rate Amount | Charges relating to unit cost associated with the revenue center code. Exception (encounter data only): if the plan (e.g., MCO) does not know the actual rate for the accommodations, $1 will be reported in the field. Note 1: For SNF PPS claims (when revenue center code equals 0022), CMS has developed a SNF Pricer to compute the rate based on the provider supplied coding for the MDS RUGS III group and assessment type (HIPPS code, stored in revenue center HCPCS code field). Note 2: For OP PPS claims, CMS has developed a Pricer to compute the rate based on the Ambulatory Payment Classification (APC), discount factor, units of service, and the wage index. Note 3: Under HH PPS (when revenue center code equals 0023), CMS has developed a HHA Pricer to compute the rate. On the RAP, the rate is determined using the case mix weight associated with the HIPPS code, adjusting it for the wage index for the beneficiary's site of service, then multiplying the result by 60% or 50%, depending on whether or not the RAP is for a first episode. On the final claim, the HIPPS code could change the payment if the therapy threshold is not met, or a partial episode payment (PEP) adjustment or a significant change in condition (SCIC) adjustment occurs. In cases of SCICs, there will be more than one 0023 revenue center line, each representing the payment made at each case-mix level. Note 4: For IRF PPS claims (when revenue center code equals 0024), CMS has developed a Pricer to compute the rate based on the HIPPS/CMG (HIPPS code, stored in revenue center HCPCS code field). [NCH] | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_INSTNL_RATE_AMT')).amount.value | 0.85 | V2_MDCR_CLM_LINE_INSTNL | CLM_LINE_INSTNL_RATE_AMT | FISS;NCH | REV_CNTR_RATE_AMT | CMS | ||
| 107 | 105 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim Line Adjustment Reason Code 1 | An American National Standards Institute (ANSI) Claim Adjustment Reason Code (CARC) identifying the reason for an adjustment to a claim or service line that resulted in a difference between the original billed amount and the final paid amount. An adjustment can result in a denial, reduction, or increase in payment. For example: 1 = Deductible amount. B1 = Non-covered visits. | ExplanationOfBenefit.item.adjudication.reason.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/ANSI-RSN-CD').code | B7 | V2_MDCR_CLM_ANSI_SGNTR | CLM_1_REV_CNTR_ANSI_RSN_CD | NCH | CCLFA.CLM_1_REV_CNTR_ANSI_RSN_CD | REV_CNTR_1ST_ANSI_CD | Basis;Regular;CMS | |
| 108 | 106 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim Line Adjustment Group Code 1 | An American National Standards Institute (ANSI) group code identifying who has financial responsibility for an adjustment to a claim or service line that resulted in it being paid differently than it was billed. This group code works in conjunction with a Claim Adjustment Reason Code (CARC). For example: PR = Patient responsibility (patient is financially liable). CO = Contractual obligations (provider is financially liable). | ExplanationOfBenefit.item.adjudication.reason.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/ANSI-GRP-CD').code | PR | V2_MDCR_CLM_ANSI_SGNTR | CLM_1_REV_CNTR_ANSI_GRP_CD | NCH | CCLFA.CLM_1_REV_CNTR_ANSI_GRP_CD | REV_CNTR_1ST_ANSI_CD | Basis;Regular;CMS | |
| 109 | 107 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim Line Adjustment Reason Code 2 | An American National Standards Institute (ANSI) Claim Adjustment Reason Code (CARC) identifying the reason for an adjustment to a claim or service line that resulted in a difference between the original billed amount and the final paid amount. An adjustment can result in a denial, reduction, or increase in payment. For example: 1 = Deductible amount. B1 = Non-covered visits. | ExplanationOfBenefit.item.adjudication.reason.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/ANSI-RSN-CD').code | B7 | V2_MDCR_CLM_ANSI_SGNTR | CLM_2_REV_CNTR_ANSI_RSN_CD | NCH | REV_CNTR_2ND_ANSI_CD | Basis;Regular;CMS | ||
| 110 | 108 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim Line Adjustment Group Code 2 | An American National Standards Institute (ANSI) group code identifying who has financial responsibility for an adjustment to a claim or service line that resulted in it being paid differently than it was billed. This group code works in conjunction with a Claim Adjustment Reason Code (CARC). For example: PR = Patient responsibility (patient is financially liable). CO = Contractual obligations (provider is financially liable). | ExplanationOfBenefit.item.adjudication.reason.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/ANSI-GRP-CD').code | PR | V2_MDCR_CLM_ANSI_SGNTR | CLM_2_REV_CNTR_ANSI_GRP_CD | NCH | REV_CNTR_2ND_ANSI_CD | Basis;Regular;CMS | ||
| 111 | 109 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim Line Adjustment Reason Code 3 | An American National Standards Institute (ANSI) Claim Adjustment Reason Code (CARC) identifying the reason for an adjustment to a claim or service line that resulted in a difference between the original billed amount and the final paid amount. An adjustment can result in a denial, reduction, or increase in payment. For example: 1 = Deductible amount. B1 = Non-covered visits. | ExplanationOfBenefit.item.adjudication.reason.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/ANSI-RSN-CD').code | B7 | V2_MDCR_CLM_ANSI_SGNTR | CLM_3_REV_CNTR_ANSI_RSN_CD | NCH | REV_CNTR_3RD_ANSI_CD | Basis;Regular;CMS | ||
| 112 | 110 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim Line Adjustment Group Code 3 | An American National Standards Institute (ANSI) group code identifying who has financial responsibility for an adjustment to a claim or service line that resulted in it being paid differently than it was billed. This group code works in conjunction with a Claim Adjustment Reason Code (CARC). For example: PR = Patient responsibility (patient is financially liable). CO = Contractual obligations (provider is financially liable). | ExplanationOfBenefit.item.adjudication.reason.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/ANSI-GRP-CD').code | PR | V2_MDCR_CLM_ANSI_SGNTR | CLM_3_REV_CNTR_ANSI_GRP_CD | NCH | REV_CNTR_3RD_ANSI_CD | Basis;Regular;CMS | ||
| 113 | 111 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim Line Adjustment Reason Code 4 | An American National Standards Institute (ANSI) Claim Adjustment Reason Code (CARC) identifying the reason for an adjustment to a claim or service line that resulted in a difference between the original billed amount and the final paid amount. An adjustment can result in a denial, reduction, or increase in payment. For example: 1 = Deductible amount. B1 = Non-covered visits. | ExplanationOfBenefit.item.adjudication.reason.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/ANSI-RSN-CD').code | B7 | V2_MDCR_CLM_ANSI_SGNTR | CLM_4_REV_CNTR_ANSI_RSN_CD | NCH | REV_CNTR_4TH_ANSI_CD | Basis;Regular;CMS | ||
| 114 | 112 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim Line Adjustment Group Code 4 | An American National Standards Institute (ANSI) group code identifying who has financial responsibility for an adjustment to a claim or service line that resulted in it being paid differently than it was billed. This group code works in conjunction with a Claim Adjustment Reason Code (CARC). For example: PR = Patient responsibility (patient is financially liable). CO = Contractual obligations (provider is financially liable). | ExplanationOfBenefit.item.adjudication.reason.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/ANSI-GRP-CD').code | PR | V2_MDCR_CLM_ANSI_SGNTR | CLM_4_REV_CNTR_ANSI_GRP_CD | NCH | REV_CNTR_4TH_ANSI_CD | Basis;Regular;CMS | ||
| 115 | 113 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Non-Covered Charge Amount | The charge amount related to a revenue center code for services that are not covered by Medicare. Note: Prior to NCH version H the field size was S9(7)V99 and the element was only present on the inpatient/SNF format. As of NCH weekly process date 10/3/97 this field was added to all institutional claim types. [NCH] | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_NCVRD_CHRG_AMT')).amount.value | 0.1 | V2_MDCR_CLM_LINE | CLM_LINE_NCVRD_CHRG_AMT | FISS;NCH | REV_CNTR_NCVRD_CHRG_AMT | Regular;CMS | ||
| 116 | 114 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Provider Payment Amount | (1) Effective with NCH version H, the payment made to the provider for the line item service on the noninstitutional claim. Note: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain zeroes in this field. [NCH] (2) Effective with version I, the amount paid to the provider for the services reported on the line item. Note 1: This field is populated for those claims that are required to process through outpatient PPS Pricer. The types of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian health providers, hospitals located in American Samoa, Guam, and Saipan, and critical access hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field. Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward. Anomaly: For dates of service August 1, 2000 to the present, the OPPS revenue center fields are being processed differently by FISS and APASS (standard systems). For more information on OPPS data problems for this time period see the Limitations Appendix. The following is how each system handles this field: FISS: Populated correctly with provider payment amount. APASS: Provider payment amount plus interest on 1st revenue center line (CMM will instruct APASS not to include interest). Currently, the following FI numbers are under the APASS system and all other FI numbers are under FISS. See FI_NUM table of codes for all FI numbers. 52280 -- Mutual of Omaha (until 6/1/2003). 00430 -- Washington/Alaska (until 11/1/2003). 00310 -- North Carolina BC (until 12/1/2003). 00370 -- Rhode Island (until 2/1/2004). 00270 -- New Hampshire/Vermont (until 3/1/2004). 00181 -- Maine/Massachusetts (until 5/1/2004). Note 2: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of claim line expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the standard systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service. [NCH] | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_PRVDR_PMT_AMT')).amount.value | 11.15 | V2_MDCR_CLM_LINE | CLM_LINE_PRVDR_PMT_AMT | FISS;MCS;NCH;VMS | LINE_PRVDR_PMT_AMT;REV_CNTR_PRVDR_PMT_AMT | CMS | ||
| 117 | 115 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Patient Responsibility Payment Amount | An amount identifying the payment made by a beneficiary for a detail line of service on a claim. Note: For Part D, this amount counts towards a beneficiary's true-out-of-pocket (TROOP) cost. | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_BENE_PMT_AMT')).amount.value | 17.99 | V2_MDCR_CLM_LINE | CLM_LINE_BENE_PMT_AMT | NCH | REV_CNTR_PTNT_RSPNSBLTY_PMT | Regular;CMS | ||
| 118 | 116 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Beneficiary Paid Amount | An amount identifying the payment made to a beneficiary for a detail line of service. | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_BENE_PD_AMT')).amount.value | 13.22 | V2_MDCR_CLM_LINE | CLM_LINE_BENE_PD_AMT | FISS;MCS;NCH;VMS | LINE_BENE_PMT_AMT;REV_CNTR_BENE_PMT_AMT | Regular;CMS | ||
| 119 | 117 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Claim Line Covered Paid Amount | An amount identifying the Medicare payment for a line item service. | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_CVRD_PD_AMT')).amount.value | 11.14 | V2_MDCR_CLM_LINE | CLM_LINE_CVRD_PD_AMT | FISS;MCS;NCH | CCLF2.CLM_LINE_CVRD_PD_AMT;CCLF5.CLM_LINE_CVRD_PD_AMT;CCLF6.CLM_LINE_CVRD_PD_AMT | LINE_NCH_PMT_AMT;REV_CNTR_PMT_AMT_AMT | Regular;CMS | |
| 120 | 118 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim Line Blood Deductible Amount | An amount identifying the blood deductible a beneficiary is responsible for on a detail line of service. | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_BLOOD_DDCTBL_AMT')).amount.value | 17.11 | V2_MDCR_CLM_LINE | CLM_LINE_BLOOD_DDCTBL_AMT | NCH | REV_CNTR_BLOOD_DDCTBL_AMT | CMS | ||
| 121 | 119 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Part B Deductible Amount | (1) Effective with NCH version I, the amount of cash deductible the beneficiary paid for the line item service. Note 1: This field is populated for those claims that are required to process through outpatient PPS Pricer. The types of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian health providers, hospitals located in American Samoa, Guam, and Saipan, and critical access hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field. Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward. Note 2: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of claim line expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the standard systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service. [NCH] (2) The amount of money for which the carrier has determined that the beneficiary is liable for the Part B cash deductible for the line item service on the noninstitutional claim. [NCH] | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_MDCR_DDCTBL_AMT')).amount.value | 3.5 | V2_MDCR_CLM_LINE | CLM_LINE_MDCR_DDCTBL_AMT | FISS;MCS;NCH;VMS | CCLFB.CLM_LINE_MDCR_DDCTBL_AMT | REV_CNTR_CASH_DDCTBL_AMT;LINE_BENE_PTB_DDCTBL_AMT | Regular;CMS | |
| 122 | 120 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount | Effective with NCH version I, the amount of coinsurance applicable to the line item service defined by the revenue center and HCPCS codes. For those services subject to outpatient PPS, the applicable coinsurance is wage adjusted. Note 1: This field is populated for those claims that are required to process through outpatient PPS Pricer. The types of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian health providers, and critical access hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. The above claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field. Note 2: This field will have either a zero (for services for which coinsurance is not applicable), a regular coinsurance amount (calculated on either charges or a fee schedule), or if subject to OP PPS the national coinsurance amount will be wage adjusted. The wage adjusted coinsurance is based on the MSA where the provider is located or assigned as a result of a reclassification. Note 3: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of claim line expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the standard systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service. [NCH] | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_INSTNL_ADJSTD_AMT')).amount.value | 4.5 | V2_MDCR_CLM_LINE_INSTNL | CLM_LINE_INSTNL_ADJSTD_AMT | FISS;NCH | REV_CNTR_COINSRNC_WGE_ADJSTD_C | CMS | ||
| 123 | 121 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Revenue Center Reduced Coinsurance Amount | Effective with NCH version I, for all services subject to outpatient PPS, the amount of coinsurance applicable to the line for a particular service (HCPCS) for which the provider has elected to reduce the coinsurance amount. Note 1: This field is populated for those claims that are required to process through outpatient PPS Pricer. The types of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian health providers, hospitals located in American Samoa, Guam, and Saipan, and critical access hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field. Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward. Note 2: The reduced coinsurance amount cannot be lower than 20% of the payment rate for the APC line. Note 3: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of claim line expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the standard systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service. [NCH] | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_INSTNL_RDCD_AMT')).amount.value | 11.11 | V2_MDCR_CLM_LINE_INSTNL | CLM_LINE_INSTNL_RDCD_AMT | FISS;NCH | REV_CNTR_RDCD_COINSRNC_AMT | CMS | ||
| 124 | 122 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Revenue Center 1st Medicare Secondary Payer Paid Amount | Effective with NCH version I, the amount paid by the primary payer when the payer is primary to Medicare (Medicare is secondary). Note 1: This field is populated for those claims that are required to process through outpatient PPS Pricer. The types of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian health providers, hospitals located in American Samoa, Guam, and Saipan, and critical access hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field. Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward. Note 2: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of claim line expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the standard systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service. [NCH] | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_INSTNL_MSP1_PD_AMT')).amount.value | 17 | V2_MDCR_CLM_LINE_INSTNL | CLM_LINE_INSTNL_MSP1_PD_AMT | FISS;NCH | REV_CNTR_1ST_MSP_PD_AMT | CMS | ||
| 125 | 123 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Revenue Center 2nd Medicare Secondary Payer Paid Amount | Effective with NCH version I, the amount paid by the secondary payer when two payers are primary to Medicare (Medicare is the tertiary payer). Note 1: This field is populated for those claims that are required to process through outpatient PPS Pricer. The types of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian health providers, hospitals located in American Samoa, Guam, and Saipan, and critical access hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field. Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward. Note 2: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of claim line expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the standard systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service. [NCH] | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_INSTNL_MSP2_PD_AMT')).amount.value | 14.21 | V2_MDCR_CLM_LINE_INSTNL | CLM_LINE_INSTNL_MSP2_PD_AMT | FISS;NCH | REV_CNTR_2ND_MSP_PD_AMT | CMS | ||
| 126 | 124 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Revenue Center Date | Revenue center date for the institutional line item. | ExplanationOfBenefit.item.servicedDate | 2025-01-01 | V2_MDCR_CLM_LINE_INSTNL | CLM_LINE_INSTNL_REV_CTR_DT | FISS;NCH | CCLF2.CLM_LINE_INSTNL_REV_CTR_DT | REV_CNTR_DT | Basis;Regular;CMS | |
| 127 | 125 | ExplanationOfBenefit | HHA;Hospice;Inpatient;SNF | Claim Active Care From Date | The date the beneficiary's from-date of active care begins. | ExplanationOfBenefit.supportingInfo.where(category.coding.system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' and category.coding.code='admissionperiod').timing.start | 2021-01-01 | V2_MDCR_CLM_DT_SGNTR | CLM_ACTV_CARE_FROM_DT | FISS;NCH | CCLFA.CLM_ACTV_CARE_FROM_DT | CLM_HOSPC_START_DT_ID;CLM_ADMSN_DT | Basis;Regular;CMS | |
| 128 | 126 | ExplanationOfBenefit | HHA;Hospice;Inpatient;SNF | Beneficiary Discharge Date | The date the beneficiary was discharged from the facility (hospital, skilled nursing facility, home health agency, or hospice). [NCH] | ExplanationOfBenefit.supportingInfo.where(category.coding.system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' and category.coding.code='admissionperiod').timing.end | 2021-01-02 | V2_MDCR_CLM_DT_SGNTR | CLM_DSCHRG_DT | FISS;NCH | NCH_BENE_DSCHRG_DT | Basis;Regular;CMS | ||
| 129 | 127 | ExplanationOfBenefit | Inpatient;SNF | Claim Admission Type Code | The code indicating the type and priority of an inpatient admission associated with the service on an intermediary submitted claim. [NCH] | ExplanationOfBenefit.supportingInfo.where(category.coding.system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' and category.coding.code='admtype').code.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-ADMSN-TYPE-CD').code | 3 | V2_MDCR_CLM_INSTNL | CLM_ADMSN_TYPE_CD | FISS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-ADMSN-TYPE-CD | CCLF1.CLM_ADMSN_TYPE_CD | CLM_IP_ADMSN_TYPE_CD | Basis;Regular;CMS |
| 130 | 128 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Claim Submission Date | (1) The date the fiscal intermediary received the institutional claim from the provider. [NCH] (2) The date the carrier receives the non-institutional claim. [NCH] | ExplanationOfBenefit.supportingInfo.where(category.coding.system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' and category.coding.code='clmrecvddate').timing | 2020-01-13 | V2_MDCR_CLM_DT_SGNTR | CLM_SUBMSN_DT | FISS;MCS;NCH;VMS | Basis;Regular;CMS | |||
| 131 | 129 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Patient Discharge Status Code | The code used to identify the status of the patient as of the claim through date. [NCH] | ExplanationOfBenefit.supportingInfo.where(category.coding.system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' and category.coding.code='discharge-status').code.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/BENE-PTNT-STUS-CD').code | 06 | V2_MDCR_CLM_INSTNL | BENE_PTNT_STUS_CD | FISS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/BENE-PTNT-STUS-CD | CCLF1.BENE_PTNT_STUS_CD | NCH_PTNT_STATUS_IND_CD;PTNT_DSCHRG_STUS_CD | Basis;Regular;CMS |
| 132 | 130 | ExplanationOfBenefit | Inpatient;SNF | Claim Diagnosis Related Group Code | On an institutional claim, the code that identifies the diagnosis related group to which a beneficiary stay is classified for payment purposes. [NCH] | ExplanationOfBenefit.supportingInfo.where(category.coding.system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' and category.coding.code='drg').code.coding.where(system='https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-Classifications-and-Software').code | 460 | V2_MDCR_CLM_INSTNL | DGNS_DRG_CD | FISS;NCH | CCLF1.DGNS_DRG_CD | CLM_DRG_CD | Basis;Regular;CMS | |
| 133 | 131 | ExplanationOfBenefit | Carrier;Inpatient;Outpatient;SNF | Blood Pints Furnished Quantity | A quantity indicating the whole pints of blood furnished to a beneficiary. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_BLOOD_PT_FRNSH_QTY').exists()).value.value | 15 | V2_MDCR_CLM | CLM_BLOOD_PT_FRNSH_QTY | NCH | NCH_BLOOD_PNTS_FRNSHD_QTY | CMS | ||
| 134 | 132 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | MCO Paid Switch | A switch indicating whether or not a Managed Care Organization (MCO) has paid the provider for an institutional claim. [NCH] | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_MDCR_INSTNL_MCO_PD_SW').exists()).code.coding.code | 1 | V2_MDCR_CLM_INSTNL | CLM_MDCR_INSTNL_MCO_PD_SW | FISS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-MDCR-INSTNL-MCO-PD-SW | CLM_MCO_PD_SW | CMS | |
| 135 | 133 | ExplanationOfBenefit | Inpatient;SNF | Source Admission Code | The code indicating the means by which the beneficiary was admitted to the inpatient health care facility or SNF if the type of admission is (1) emergency, (2) urgent, or (3) elective. [NCH] | ExplanationOfBenefit.supportingInfo.where(category.coding.system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' and category.coding.code='pointoforigin').code.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-ADMSN-SRC-CD').code | 2 | V2_MDCR_CLM_INSTNL | CLM_ADMSN_SRC_CD | FISS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-ADMSN-SRC-CD | CCLF1.CLM_ADMSN_SRC_CD | CLM_SRC_IP_ADMSN_CD | Basis;Regular;CMS |
| 136 | 134 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Type of Bill Code | The Type of Bill Code. Composed of a 0, followed by the Claim Facility Type Code, then the Claim Service Classification Type Code, and finally the Claim Frequency Code. | ExplanationOfBenefit.supportingInfo.where(category.coding.system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' and category.coding.code='typeofbill').code.coding.where(system='https://www.nubc.org/CodeSystem/TypeOfBill').code | 0123 | FISS;NCH | Basis;Regular;CMS | |||||
| 137 | 135 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Bill Facility Type Code | A code identifying the type of facility that provided care to a beneficiary on an institutional claim. It is the first digit of the Type of Bill (TOB). Reference table: CLM_BILL_FAC_TYPE_CD | ExplanationOfBenefit.supportingInfo.where(category.coding.system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' and category.coding.code='typeofbill').code.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-FAC-TYPE-CD').code | 1 | V2_MDCR_CLM | CLM_BILL_FAC_TYPE_CD | FISS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-FAC-TYPE-CD | CCLF1.CLM_BILL_FAC_TYPE_CD | CLM_FAC_TYPE_CD | Basis;Regular;CMS |
| 138 | 136 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim Bill Classification Code | A code classifying the type of service provided to a beneficiary on an institutional claim. It is the second digit of the Type of Bill (TOB). | ExplanationOfBenefit.supportingInfo.where(category.coding.system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' and category.coding.code='typeofbill').code.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-CLSFCTN-CD').code | 12 | V2_MDCR_CLM | CLM_BILL_CLSFCTN_CD | FISS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-CLSFCTN-CD | CCLF1.CLM_BILL_CLSFCTN_CD | CLM_SRVC_CLSFCTN_TYPE_CD | Basis;Regular;CMS |
| 139 | 137 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Bill Frequency Code | A code indicating the sequence of an institutional claim in the beneficiary's current episode of care. It is the third digit of the Type of Bill (TOB). | ExplanationOfBenefit.supportingInfo.where(category.coding.system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' and category.coding.code='typeofbill').code.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-FREQ-CD').code | 123 | V2_MDCR_CLM | CLM_BILL_FREQ_CD | FISS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-FREQ-CD | CCLF1.CLM_BILL_FREQ_CD | CLM_FREQ_CD | Basis;Regular;CMS |
| 140 | 138 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Weekly Process Date | The date the weekly NCH database load process cycle begins, during which the claim records are loaded into the nearline file. This date will always be a Friday, although the claims will actually be appended to the database subsequent to the date. (NCH) | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_NCH_WKLY_PROC_DT').exists()).timing | 2025-01-18 | V2_MDCR_CLM_DT_SGNTR | CLM_NCH_WKLY_PROC_DT | NCH | NCH_WKLY_PROC_DT | CMS | ||
| 141 | 139 | ExplanationOfBenefit | Inpatient;SNF | Noncovered Stay From Date | Effective with NCH version H, the beginning date of the beneficiary's noncovered stay (used for internal CWFMQA editing purposes). Note: During the version H conversion this field was populated with data throughout history (back to service year 1991). [NCH] | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_NCVRD_FROM_DT').exists()).timing | 2025-01-01 | V2_MDCR_CLM_DT_SGNTR | CLM_NCVRD_FROM_DT | NCH | NCH_VRFD_NCVRD_STAY_FROM_DT | CMS | ||
| 142 | 140 | ExplanationOfBenefit | Inpatient;SNF | Noncovered Stay Through Date | Effective with NCH version H, the ending date of the beneficiary's noncovered stay (used for internal CWFMQA editing purposes). Note: During the NCH version H conversion this field was populated with data throughout history (back to service year 1991). [NCH] | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_NCVRD_THRU_DT').exists()).timing | 2025-01-02 | V2_MDCR_CLM_DT_SGNTR | CLM_NCVRD_THRU_DT | NCH | NCH_VRFD_NCVRD_STAY_THRU_DT | CMS | ||
| 143 | 141 | ExplanationOfBenefit | HHA;Inpatient;SNF | Qualified Stay From Date | The beginning date of the beneficiary's qualifying stay (used for internal CWFMQA editing purposes). For inpatient claims, the date relates to the PPS portion of the inlier for which there is no utilization to benefits. For SNF claims, the date relates to a qualifying stay from a hospital that is at least two days in a row if the source of admission is an A, or at least three days in a row if the source of admission is other than A. [HRMZ] Note: During the NCH version H conversion this field was populated with data throughout history (back to service year 1991). | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_QLFY_STAY_FROM_DT').exists()).timing | 2025-01-02 | V2_MDCR_CLM_DT_SGNTR | CLM_QLFY_STAY_FROM_DT | FISS;NCH | NCH_QLFYD_STAY_FROM_DT | CMS | ||
| 144 | 142 | ExplanationOfBenefit | HHA;Inpatient;SNF | Qualified Stay Through Date | The ending date of the beneficiary's qualifying stay (used for internal CWFMQA editing purposes). For inpatient claims, the date relates to the PPS portion of the inlier for which there is no utilization to benefits. For SNF claims, the date relates to a qualifying stay from a hospital that is at least two days in a row if the source of admission is an A, or at least three days in a row if the source of admission is other than A. [HRMZ] Note: During the NCH version H conversion this field was populated with data throughout history (back to service year 1991). [NCH] | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_QLFY_STAY_THRU_DT').exists()).timing | 2025-01-01 | V2_MDCR_CLM_DT_SGNTR | CLM_QLFY_STAY_THRU_DT | FISS;NCH | CLM_QLFY_STAY_THRU_DT | CMS | ||
| 145 | 143 | ExplanationOfBenefit | Inpatient;SNF | Covered Care Through Date | The date on a claim for which the covered level of care ended in a general hospital or the active care ended in a psychiatric/TB hospital. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_ACTV_CARE_THRU_DT').exists()).timing | 2025-01-11 | V2_MDCR_CLM_DT_SGNTR | CLM_ACTV_CARE_THRU_DT | NCH | NCH_ACTV_OR_CVRD_LVL_CARE_THRU | CMS | ||
| 146 | 144 | ExplanationOfBenefit | Hospice;Inpatient;SNF | Medicare Benefits Exhausted Date | The date the beneficiary's Medicare benefits were exhausted. [NCH] | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_MDCR_EXHSTD_DT').exists()).timing | 2025-01-11 | V2_MDCR_CLM_DT_SGNTR | CLM_MDCR_EXHSTD_DT | NCH | NCH_BENE_MDCR_BNFTS_EXHTD_DT_I | CMS | ||
| 147 | 145 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | FI Claim Action Code | The type of action requested by the intermediary to be taken on an institutional claim. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_FI_ACTN_CD').exists()).code.coding.code | 1 | V2_MDCR_CLM_INSTNL | CLM_FI_ACTN_CD | FISS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-FI-ACTN-CD | FI_CLM_ACTN_CD | CMS | |
| 148 | 146 | ExplanationOfBenefit | Inpatient;SNF | Lifetime Reserved Days Used Count | The number of lifetime reserve days that the beneficiary has elected to use during the period covered by the institutional claim. Under Medicare, each beneficiary has a one-time reserve of sixty additional days of inpatient hospital coverage that can be used after 90 days of inpatient care have been provided in a single benefit period. This count is used to subtract from the total number of lifetime reserve days that a beneficiary has available. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_MDCR_IP_LRD_USE_CNT').exists()).value | 7 | V2_MDCR_CLM_INSTNL | CLM_MDCR_IP_LRD_USE_CNT | FISS;NCH | BENE_LRD_USED_CNT | CMS | ||
| 149 | 147 | ExplanationOfBenefit | Inpatient;SNF | Claim Uncompensated Care Payment Amount | This is a payment for DSH hospitals as part of Section 3133 of the ACA. It represents the uncompensated care amount of the payment. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_HIPPS_UNCOMPD_CARE_AMT').exists()).amount.value | 15 | V2_MDCR_CLM_INSTNL | CLM_HIPPS_UNCOMPD_CARE_AMT | FISS;NCH | CCLF1.CLM_HIPPS_UNCOMPD_CARE_AMT | CLM_UNCOMPD_CARE_PMT_AMT | CMS | |
| 150 | 148 | ExplanationOfBenefit | Inpatient;SNF | Total Coinsurance Days Count | The count of the total number of coinsurance days involved with the beneficiary's stay in a facility. [NCH, HRMZ] For Medicaid, the number of covered inpatient hospital days occurring after the 60th day and before the 91st day, or the number of covered inpatient skilled nursing facility days occurring after the 20th day and before the 101st day of the benefit period. [HRMZ] | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_INSTNL_MDCR_COINS_DAY_CNT').exists()).value | 3 | V2_MDCR_CLM_INSTNL | CLM_INSTNL_MDCR_COINS_DAY_CNT | FISS;NCH | BENE_TOT_COINSRNC_DAYS_CNT | CMS | ||
| 151 | 149 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Claim Disposition Code | A code indicating the disposition or outcome of a processed claim record. Reference table: CLM_DISP_CD | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_DISP_CD').exists()).code.coding.code | 01 | V2_MDCR_CLM | CLM_DISP_CD | FISS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DISP-CD | CCLF5.CLM_DISP_CD;CCLF6.CLM_DISP_CD | CLM_DISP_CD | CMS |
| 152 | 150 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Total Charge Amount | An amount totaling the sum of all the line item submitted charges on a claim. | ExplanationOfBenefit.total.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication').exists() and category.coding.where(code='CLM_SBMT_CHRG_AMT').exists() ).amount.value | 9001.55 | V2_MDCR_CLM | CLM_SBMT_CHRG_AMT | FISS;MCS;NCH;VMS | CCLF1.CLM_MDCR_INSTNL_TOT_CHRG_AMT | NCH_CARR_CLM_SBMTD_CHRG_AMT;CLM_TOT_CHRG_AMT | Regular;CMS | |
| 153 | 151 | ExplanationOfBenefit | Inpatient;SNF | Non Utilization Day Count | The number of inpatient days of care not covered by the primary provider or by Medicare facility utilization. [HRMZ] | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_INSTNL_NCVRD_DAY_CNT').exists()).value | 4 | V2_MDCR_CLM_INSTNL | CLM_INSTNL_NCVRD_DAY_CNT | FISS;NCH | CLM_NON_UTLZTN_DAYS_CNT | CMS | ||
| 154 | 152 | ExplanationOfBenefit | Inpatient;SNF | Pass Through Per Diem Amount | The maximum amount a provider can be paid for each day of care. [HRMZ] For Medicare IP, the amount of the established reimbursable costs for the current year divided by the estimated Medicare days for the current year (all PPS claims), as calculated by the FI and reimbursement staff. Items reimbursed as a pass through include capital-related costs; direct medical education costs; kidney acquisition costs for hospitals approved as RTCs; and bad debts (per Provider Reimbursement Manual, Part 1, Section 2405.2). Note: Pass through amounts are not included in the claim payment amount. [NCH, HRMZ] | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_INSTNL_PER_DIEM_AMT').exists()).amount.value | 5 | V2_MDCR_CLM_INSTNL | CLM_INSTNL_PER_DIEM_AMT | FISS;NCH | CCLFA.CLM_INSTNL_PER_DIEM_AMT | CLM_PASS_THRU_PER_DIEM_AMT | CMS | |
| 155 | 153 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim Non Payment Reason Code | The reason that no Medicare payment is made for services on an institutional claim. Note: Effective with NCH version I, this field was put on all institutional claim types. Note 1: This field was put on all institutional claim types but data did not start coming in on OP/HHA/hospice until 4/1/02. Prior to 4/1/02, data only came in on inpatient/SNF claims. Note 2: Effective 4/1/02, this field was also expanded to two bytes to accommodate new values. The NCH nearline file did not expand the current 1-byte field but instituted a crosswalk of the 2-byte field to the 1-byte character value. See table of codes for the crosswalk. [NCH] | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_MDCR_NPMT_RSN_CD').exists()).code.coding.code | P | V2_MDCR_CLM_INSTNL | CLM_MDCR_NPMT_RSN_CD | FISS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-MDCR-NPMT-RSN-CD | CCLF1.CLM_MDCR_NPMT_RSN_CD | CLM_MDCR_NON_PMT_RSN_CD | CMS |
| 156 | 154 | ExplanationOfBenefit | Inpatient;SNF | Claim PPS Capital DRG Weight Number | Effective 3/2/92, the number used to determine a transfer adjusted case mix index for capital PPS. The number is determined by multiplying the DRG weight times the discharge fraction. [NCH] | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_MDCR_IP_PPS_DRG_WT_NUM').exists()).value | 1.08 | V2_MDCR_CLM_INSTNL | CLM_MDCR_IP_PPS_DRG_WT_NUM | FISS;NCH | CLM_PPS_CPTL_DRG_WT_NUM | CMS | ||
| 157 | 155 | ExplanationOfBenefit | Inpatient;SNF | Claim PPS Capital Disproportionate Share Amount | Effective 3/2/92, the amount of disproportionate share (rate reflecting indigent population served) portion of the PPS payment for capital. [NCH] | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_MDCR_IP_PPS_DSPRPRTNT_AMT').exists()).amount.value | 15.11 | V2_MDCR_CLM_INSTNL | CLM_MDCR_IP_PPS_DSPRPRTNT_AMT | FISS;NCH | CCLF1.CLM_MDCR_IP_PPS_DSPRPRTNT_AMT | CLM_PPS_CPTL_DSPRPRTNT_SHR_AMT | CMS | |
| 158 | 156 | ExplanationOfBenefit | Inpatient;SNF | Claim PPS Capital Exception Amount | Effective 3/2/92, the capital PPS amount of exception payments provided for hospitals with inordinately high levels of capital obligations. Exception payments expire at the end of the 10-year transition period. [NCH] | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_MDCR_IP_PPS_EXCPTN_AMT').exists()).amount.value | 11.5 | V2_MDCR_CLM_INSTNL | CLM_MDCR_IP_PPS_EXCPTN_AMT | FISS;NCH | CLM_PPS_CPTL_EXCPTN_AMT | CMS | ||
| 159 | 157 | ExplanationOfBenefit | Inpatient;SNF | Claim PPS Capital FSP Amount | Effective 3/2/92, the amount of the federal specific portion of the PPS payment for capital. [NCH] | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_MDCR_IP_PPS_CPTL_FSP_AMT').exists()).amount.value | 11.81 | V2_MDCR_CLM_INSTNL | CLM_MDCR_IP_PPS_CPTL_FSP_AMT | FISS;NCH | CLM_PPS_CPTL_FSP_AMT | CMS | ||
| 160 | 158 | ExplanationOfBenefit | Inpatient;SNF | Claim PPS Capital IME Amount | Effective 3/2/92, the amount of the Indirect Medical Education (IME) portion of the PPS payment for capital. IME is a reimbursable amount for teaching hospitals only; an added amount passed by Congress to augment normal PPS payments for teaching hospitals to compensate them for higher patient costs resulting from medical education programs for interns and residents. [NCH] | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_MDCR_IP_PPS_CPTL_IME_AMT').exists()).amount.value | 14.11 | V2_MDCR_CLM_INSTNL | CLM_MDCR_IP_PPS_CPTL_IME_AMT | FISS;NCH | CCLF1.CLM_MDCR_IP_PPS_CPTL_IME_AMT | CLM_PPS_CPTL_IME_AMT | CMS | |
| 161 | 159 | ExplanationOfBenefit | Inpatient;SNF | Claim PPS Capital Outlier Amount | Effective 3/2/92, the amount of the outlier portion of the PPS payment for capital. [NCH] | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_MDCR_IP_PPS_OUTLIER_AMT').exists()).amount.value | 40.11 | V2_MDCR_CLM_INSTNL | CLM_MDCR_IP_PPS_OUTLIER_AMT | FISS;NCH | CLM_PPS_CPTL_OUTLIER_AMT | CMS | ||
| 162 | 160 | ExplanationOfBenefit | Inpatient;SNF | Claim PPS Old Capital Hold Harmless Amount | Effective 3/2/92, this amount is the hold harmless amount payable for old capital as computed by Pricer for providers with a payment code equal to A. The hold harmless amount for old capital is 100 percent of the reasonable costs of old capital for sole community hospitals, or 85 percent of the reasonable costs associated with old capital for all other hospitals, plus a payment for new capital. [NCH] | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_MDCR_IP_PPS_CPTL_HRMLS_AMT').exists()).amount.value | 13.31 | V2_MDCR_CLM_INSTNL | CLM_MDCR_IP_PPS_CPTL_HRMLS_AMT | FISS;NCH | CLM_PPS_OLD_CPTL_HLD_HRMLS_AMT | CMS | ||
| 163 | 161 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim PPS Indicator Code | Effective with NCH version H, the code indicating whether or not (1) the claim is PPS and/or (2) the beneficiary is a deemed insured Medicare Qualified Government Employee (MQGE). Note: Beginning with NCH weekly process date 10/3/97 through 5/29/98, this field was populated with only the PPS indicator. Beginning with NCH weekly process date 6/5/98, this field was additionally populated with the deemed MQGE indicator. Claims processed prior to 10/3/97 will contain spaces. [NCH] | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_PPS_IND_CD').exists()).code.coding.code | 2 | V2_MDCR_CLM_INSTNL | CLM_PPS_IND_CD | NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-PPS-IND-CD | CLM_PPS_IND_CD | CMS | |
| 164 | 162 | ExplanationOfBenefit | Inpatient;SNF | Claim Total PPS Capital Amount | The total amount that is payable for capital PPS for the claim. This is the sum of the capital hospital specific portion, federal specific portion, outlier portion, disproportionate share portion, indirect medical education portion, exception payments, and hold harmless payments. [NCH] | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_MDCR_IP_PPS_CPTL_TOT_AMT').exists()).amount.value | 11.11 | V2_MDCR_CLM_INSTNL | CLM_MDCR_IP_PPS_CPTL_TOT_AMT | FISS;NCH | CLM_TOT_PPS_CPTL_AMT | CMS | ||
| 165 | 163 | ExplanationOfBenefit | Hospice;Inpatient;SNF | Utilization Day Count | The number of inpatient days covered by the primary provider. For Medicare IP and hospice, the number of covered days of care that are chargeable to Medicare facility utilization that includes full days, coinsurance days, and lifetime reserve days. [HRMZ] | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_INSTNL_CVRD_DAY_CNT').exists()).value | 30 | V2_MDCR_CLM_INSTNL | CLM_INSTNL_CVRD_DAY_CNT | FISS;NCH | CMS | |||
| 166 | 164 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | FI Number | A number assigned by Centers for Medicare and Medicaid Services (CMS) identifying a Medicare Administrative Contractor (MAC) authorized to process Medicare claims. Reference table: CLM_CNTRCTR_NUM | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_CNTRCTR_NUM').exists()).code.coding.code | 10312 | V2_MDCR_CLM | CLM_CNTRCTR_NUM | FISS;MCS;NCH;VMS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-CNTRCTR-NUM | CCLF1.CLM_CNTRCTR_NUM;CCLF5.CLM_CNTRCTR_NUM | CARR_NUM;FI_NUM | CMS |
| 167 | 165 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | The code outlining the primary payer. | A code identifying the coverage type of the primary payer when Medicare is the secondary payer as defined by the Common Working File (CWF). Reference table: CLM_NCH_PRMRY_PYR_CD | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_NCH_PRMRY_PYR_CD').exists()).code.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-PRMRY-PYR-CD').code | I | V2_MDCR_CLM | CLM_NCH_PRMRY_PYR_CD | FISS;MCS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-NCH-PRMRY-PYR-CD | CCLF1.CLM_NCH_PRMRY_PYR_CD | NCH_PRMRY_PYR_CD | CMS |
| 168 | 166 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Primary Payer Paid Amount | The amount of a payment made on behalf of a Medicare beneficiary by a primary payer other than Medicare, that the provider is applying to covered Medicare charges on an institutional, carrier, or DMERC claim. [NCH] | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_MDCR_INSTNL_PRMRY_PYR_AMT').exists()).amount.value | 50.5 | V2_MDCR_CLM_INSTNL | CLM_MDCR_INSTNL_PRMRY_PYR_AMT | NCH | NCH_PRMRY_PYR_CLM_PD_AMT | CMS | ||
| 169 | 167 | ExplanationOfBenefit | HHA;Inpatient;SNF | Rendering Physician NPI - Header Level | A number identifying the National Provider Identifier (NPI) of the provider who rendered the service, as sourced from the National Plan and Provider Enumeration System (NPPES). Note: This column is populated for certain types of claims where the same rendering provider NPI applies to all lines of the claim, and if the rendering provider NPI on the claim, as provided by the source system, can be found in the Integrated Deposit Repository (IDR) provider data as sourced from NPPES. | ExplanationOfBenefit.careTeam.where(role.coding.where(code = 'rendering').exists()).provider.identifier.value | 1942945159 | V2_MDCR_CLM | PRVDR_RNDRNG_PRVDR_NPI_NUM | FISS;NCH | Basis;Regular;CMS | |||
| 170 | 168 | ExplanationOfBenefit | Carrier | Rendering Provider NPI Number - Line Level | A number identifying the National Provider Identifier (NPI) of the provider who rendered the service, as sourced from the National Plan and Provider Enumeration System (NPPES). Note: This column is populated if the rendering provider NPI on the claim, as provided by the source system, can be found in the Integrated Deposit Repository (IDR) provider data as sourced from NPPES. | ExplanationOfBenefit.careTeam.where(role.coding.where(code = 'rendering').exists()).provider.identifier.value | 1942945159 | V2_MDCR_CLM_LINE | PRVDR_RNDRNG_PRVDR_NPI_NUM | MCS;NCH | CCLF5.RNDRG_PRVDR_NPI_NUM;CCLF5.CLM_RNDRG_PRVDR_NPI_NUM | CARR_LINE_PRFRMG_NPI_NUM;RNDRNG_PHYSN_NPI;PRF_PHYSN_NPI | Basis;Regular;CMS | |
| 171 | 169 | ExplanationOfBenefit | Inpatient;Outpatient;SNF | Professional Component Charge | For inpatient and outpatient claims, the amount of physician and other professional charges covered under Medicare Part B (e.g., if computing interim payment these charges are deducted). | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_INSTNL_PRFNL_AMT').exists()).amount.value | 93.22 | V2_MDCR_CLM_INSTNL | CLM_INSTNL_PRFNL_AMT | NCH | CCLFA.CLM_INSTNL_PRFNL_AMT | NCH_PROFNL_CMPNT_CHRG_AMT | CMS | |
| 172 | 170 | ExplanationOfBenefit | Inpatient;Outpatient;SNF | Blood Deductible Liability Amount | An amount identifying the portion of the blood deductible a beneficiary is liable for. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_BLOOD_LBLTY_AMT').exists()).amount.value | 121.1 | V2_MDCR_CLM | CLM_BLOOD_LBLTY_AMT | FISS;NCH | CCLFA.CLM_BLOOD_LBLTY_AMT | NCH_BENE_BLOOD_DDCTBL_LBLTY_AM | CMS | |
| 173 | 171 | ExplanationOfBenefit | Inpatient;SNF | Deductible Amount | The amount of the deductible the beneficiary paid for inpatient services, as originally submitted on the institutional claim. [NCH] NCH derivation: Derived from CLM_VAL_CD and CLM_VAL_AMT. Derivation rule: Based on the presence of value code equal to A1, B1, or C1, move the corresponding value amount to the NCH_BENE_IP_DDCTBL_AMT. [NCH] | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_MDCR_IP_BENE_DDCTBL_AMT').exists()).amount.value | 19.11 | V2_MDCR_CLM_INSTNL | CLM_MDCR_IP_BENE_DDCTBL_AMT | NCH | CCLFA.CLM_MDCR_IP_BENE_DDCTBL_AMT | NCH_BENE_IP_DDCTBL_AMT | CMS | |
| 174 | 172 | ExplanationOfBenefit | Inpatient;Outpatient;SNF | Part A/B Coinsurance Liability Amount | An amount identifying the portion applied toward the coinsurance a beneficiary is responsible for. | ExplanationOfBenefit.total.where(category.coding.where(system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' and code='coinsurance').exists() and category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_MDCR_COINSRNC_AMT').exists()).amount.value | 9.82 | V2_MDCR_CLM | CLM_MDCR_COINSRNC_AMT | FISS;NCH;VMS | CCLFA.CLM_MDCR_COINSRNC_AMT | NCH_BENE_PTA_COINSRNC_LBLTY_AM;NCH_BENE_PTB_COINSRNC_AMT | Regular;CMS | |
| 175 | 173 | ExplanationOfBenefit | Carrier;HHA;Hospice;Inpatient;Outpatient;SNF | Other Physician NPI | A number identifying the National Provider Identifier (NPI) of another provider as sourced from the NPI crosswalk reference information provided by the National Plan and Provider Enumeration System (NPPES). | ExplanationOfBenefit.careTeam.where(role.coding.where(code = 'otheroperating').exists()).provider.identifier.value or ExplanationOfBenefit.careTeam.where(role.coding.where(code = 'supervisor').exists()).provider.identifier.value | V2_MDCR_CLM | PRVDR_OTHR_PRVDR_NPI_NUM | FISS;MCS;NCH | CCLF1.OTHR_PRVDR_NPI_NUM;CCLF1.CLM_OTHR_PRVDR_NPI_NUM | OT_PHYSN_NPI | Basis;Regular;CMS | ||
| 176 | 174 | ExplanationOfBenefit | Inpatient;SNF | DRG Outlier Approved Payment Amount | On an institutional claim, the additional payment amount approved by the peer review organization due to an outlier situation for a beneficiary's stay under the prospective payment system, which has been classified into a specific diagnosis related group. [NCH] | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_INSTNL_DRG_OUTLIER_AMT').exists()).amount.value | 15.89 | V2_MDCR_CLM_INSTNL | CLM_INSTNL_DRG_OUTLIER_AMT | FISS;NCH | NCH_DRG_OUTLIER_APRVD_PMT_AMT | CMS | ||
| 177 | 175 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Provider Number (OSCAR/CCN) | A number assigned to a billing provider by the Centers for Medicare and Medicaid Services (CMS) verifying that the provider is Medicare certified and for what types of services. Note: The OSCAR was renamed to CMS Certification Number (CCN) in 2007 by CMS. | ExplanationOfBenefit.contained.where(id = %root.provider.reference.substring(1)).identifier.where(system='http://terminology.hl7.org/NamingSystem/CCN').value | V2_MDCR_CLM | CLM_BLG_PRVDR_OSCAR_NUM | FISS;NCH | CCLF1.PRVDR_OSCAR_NUM;CCLF1.CLM_BLG_PRVDR_OSCAR_NUM;CCLF2.PRVDR_OSCAR_NUM;CCLF2.CLM_FAC_PRVDR_OSCAR_NUM;CCLF3.PRVDR_OSCAR_NUM;CCLF3.CLM_BLG_PRVDR_OSCAR_NUM;CCLF4.PRVDR_OSCAR_NUM;CCLF4.CLM_BLG_PRVDR_OSCAR_NUM | PRVDR_NUM | Basis;Regular;CMS | ||
| 178 | 176 | ExplanationOfBenefit | Outpatient | Outpatient Beneficiary Payment Amount | Effective with NCH version H, the amount paid, from the Medicare Trust Fund, to the beneficiary for the services reported on the outpatient claim. Note: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain zeroes in this field. [NCH] | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_BENE_PD_AMT').exists()).amount.value | V2_MDCR_CLM_INSTNL | CLM_MDCR_INSTNL_BENE_PD_AMT | NCH | CLM_OP_BENE_PMT_AMT | Regular;CMS | |||
| 179 | 177 | ExplanationOfBenefit | Carrier;DME;Outpatient | Provider Payment Amount | An amount identifying the total payment made to a provider/supplier for services rendered on an individual claim. | ExplanationOfBenefit.total.where(category.coding.where(system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' and code='paidtoprovider').exists() and category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_PRVDR_PMT_AMT').exists()).amount.value | 11.11 | V2_MDCR_CLM | CLM_PRVDR_PMT_AMT | FISS;MCS;NCH;VMS | CLM_OP_PRVDR_PMT_AMT;NCH_CLM_PRVDR_PMT_AMT | Regular;CMS | ||
| 180 | 178 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Revenue Center Discount Indicator Code | Effective with NCH version I, this code represents a factor that specifies the amount of any APC discount. The discounting factor is applied to a line item with a service indicator (part of the REV_CNTR_PMT_MTHD_IND_CD) of T. The flag is applicable when more than one significant procedure is performed. If there is no discounting the factor will be 1.0. [NCH] Note 1: This field is populated for those claims that are required to process through outpatient PPS Pricer. The types of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian health providers, hospitals located in American Samoa, Guam, and Saipan, and critical access hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field. Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward. Note 2: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of claim line expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the standard systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service. Note 3: Values D, U, and T represent the following: D = Discounting fraction (currently 0.5). U = Number of units. T = Terminated procedure discount (currently 0.5). | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD').value.code | 1 | V2_MDCR_CLM_LINE_INSTNL | CLM_REV_DSCNT_IND_CD | FISS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD | REV_CNTR_DSCNT_IND_CD | CMS | |
| 181 | 179 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Revenue Center Obligation to Accept As Full Payment Code | Effective with version I, indication that the provider was obligated to accept as full payment the amount received from the primary (or secondary) payer. | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD').value.code | Y | V2_MDCR_CLM_LINE_INSTNL | CLM_OTAF_ONE_IND_CD | NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-IND-CD | REV_CNTR_OTAF_PMT_CD | CMS | |
| 182 | 180 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Revenue Center Packaging Indicator Code | Effective with NCH version I, the code used to identify those services that are packaged/bundled with another service. Note 1: This field is populated for those claims that are required to process through outpatient PPS Pricer. The types of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian health providers, hospitals located in American Samoa, Guam, and Saipan, and critical access hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field. Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward. Note 2: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of claim line expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the standard systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service. [NCH] | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD').value.code | 2 | V2_MDCR_CLM_LINE_INSTNL | CLM_REV_PACKG_IND_CD | FISS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD | REV_CNTR_PACKG_IND_CD | CMS | |
| 183 | 181 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Revenue Center Payment Method Indicator Code | Effective with NCH version I, the code used to identify how the service is priced for payment. This field is made up of two pieces of data, the 1st position being the service indicator and the 2nd position being the payment indicator. Note 1: This field is populated for those claims that are required to process through outpatient PPS Pricer. The types of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian health providers, hospitals located in American Samoa, Guam, and Saipan, and critical access hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field. Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward. Note 2: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of claim line expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the standard systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service. Note 3: Effective 10/2005, this field will no longer represent the service indicator and the payment indicator. This field will now house the 2-byte payment indicator. The status indicator will be housed in a new field named: REV_CNTR_STUS_IND_CD. [NCH] | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD').value.code | 3 | V2_MDCR_CLM_LINE_INSTNL | CLM_REV_PMT_MTHD_CD | FISS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD | REV_CNTR_PMT_MTHD_IND_CD | CMS | |
| 184 | 182 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Revenue Center Status Indicator Code | Effective 10/3/2005 with the implementation of NCH/NMUD CR#2, the code used to identify the status of the line item service. This field along with the payment method indicator field is used to identify how the service was priced for payment. Note 1: This 2-byte indicator is being added due to an expansion of a field that currently exists on the revenue center trailer. The status indicator is currently the 1st position of the revenue center payment method indicator code. The payment method indicator code is being split into two 2-byte fields (payment indicator and status indicator). The expanded payment indicator will continue to be stored in the existing payment method indicator field. The split of the current payment method indicator field is due to the expansion of both pieces of data from 1-byte to 2-bytes. Note 2: This field is populated for those claims that are required to process through outpatient PPS Pricer. The types of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian health providers, hospitals located in American Samoa, Guam, and Saipan, and critical access hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field. Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services. [NCH] | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD').value.code | J | V2_MDCR_CLM_LINE_INSTNL | CLM_REV_CNTR_STUS_CD | NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD | REV_CNTR_STUS_IND_CD | CMS | |
| 185 | 183 | ExplanationOfBenefit | Hospice | Hospice Period Count | The count of the number of hospice period trailers present for the beneficiary's record. Prior to BBA a beneficiary was entitled to a maximum of 4 hospice benefit periods that may be elected in lieu of standard Part A hospital benefits. The BBA changed the hospice benefit to the following: 2 initial 90-day periods followed by an unlimited number of 60-day periods (effective 8/5/97). [NCH] Edit rules: Range 1 through 3: 1 = 1st 90-day period; 2 = 2nd 90-day period; 3 = 60-day period (3 or greater periods). | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_MDCR_HOSPC_PRD_CNT').exists()).value | 1 | V2_MDCR_CLM_INSTNL | CLM_MDCR_HOSPC_PRD_CNT | NCH | BENE_HOSPC_PRD_CNT | CMS | ||
| 186 | 184 | ExplanationOfBenefit | HHA | Claim LUPA Indicator Code | Effective with NCH version I, the code used to identify those home health PPS claims that have 4 visits or fewer in a 60-day episode. If an HHA provides 4 visits or fewer, they will be reimbursed based on a national standardized per visit rate instead of HHRGs. Note: Beginning 10/1/00, this field will be populated with data. Claims processed prior to 10/1/00 will contain spaces. [NCH] | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_HHA_LUP_IND_CD').exists()).code.coding.code | L | V2_MDCR_CLM_INSTNL | CLM_HHA_LUP_IND_CD | NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-HHA-LUP-IND-CD | CLM_HHA_LUPA_IND_CD | CMS | |
| 187 | 185 | ExplanationOfBenefit | HHA | Claim Referral Code | Effective with NCH version I, the code used to identify the means by which the beneficiary was referred for home health services. Note: Beginning 10/1/00, this field will be populated with data. Claims processed prior to 10/1/00 will contain spaces in this field. [NCH] | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_HHA_RFRL_CD').exists()).code.coding.code | C | V2_MDCR_CLM_INSTNL | CLM_HHA_RFRL_CD | NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-HHA-RFRL-CD | CLM_HHA_RFRL_CD | CMS | |
| 188 | 186 | ExplanationOfBenefit | HHA | Claim Total Visit Count | Effective with NCH version H, the count of the number of HHA visits as derived by CWF. Note 1: During the NCH version H conversion this field was populated with data throughout history (back to service year 1991) using the CWF derivation rule (units associated with revenue center codes 042X, 043X, 044X, 055X, 056X, 057X, 058X, and 059X). Value 999 will be displayed if the sum of the revenue center unit count equals or exceeds 999. Note 2: Effective 7/1/99, all HHA claims received with service from dates 7/1/99 and after will be processed as if the units field contains the 15-minute interval count; and each visit revenue code line item will be counted as one visit. This field is calculated correctly; but users who derive the count themselves will need to revise their routine. The count is no longer derived by adding up the units fields associated with the HHA visit revenue codes. [NCH] | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_MDCR_HHA_TOT_VISIT_CNT').exists()).value | 2 | V2_MDCR_CLM_INSTNL | CLM_MDCR_HHA_TOT_VISIT_CNT | FISS;NCH | CLM_HHA_TOT_VISIT_CNT | CMS | ||
| 189 | 187 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Claim Status Code | The current status information for the pending and paid claims currently in the system. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_AUDT_TRL_STUS_CD').exists()).code.coding.code | V2_MDCR_CLM_LCTN_HSTRY | CLM_AUDT_TRL_STUS_CD | FISS;MCS;VMS | CMS | ||||
| 190 | 188 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Claim Paid Status Code | A code identifying the status of a claim. Reference table: CLM_PD_STUS_CD | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_PD_STUS_CD').exists()).code.coding.code | V2_MDCR_CLM | CLM_PD_STUS_CD | FISS;MCS;VMS | Basis;Regular;CMS | ||||
| 191 | 189 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Outpatient | Referring Provider NPI Number | A number identifying the National Provider Identifier (NPI) of a referring provider as sourced from the NPI crosswalk reference information provided by the National Plan and Provider Enumeration System (NPPES). | ExplanationOfBenefit.careTeam.where(role.coding.where(code = 'referring').exists()).provider.identifier.value | V2_MDCR_CLM | PRVDR_RFRG_PRVDR_NPI_NUM | FISS;MCS;NCH;VMS | CCLF5.CLM_RFRG_PRVDR_NPI_NUM;CCLF6.ORDRG_PRVDR_NPI_NUM;CCLF6.CLM_RFRG_PRVDR_NPI_NUM | RFR_PHYSN_NPI | Basis;Regular;CMS | ||
| 192 | 190 | ExplanationOfBenefit | Carrier;DME | Allowed Charge Amount | An amount identifying the sum of all the line item allowed charges on a claim. | ExplanationOfBenefit.total.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication').exists() and category.coding.where(code='CLM_ALOWD_CHRG_AMT').exists() ).amount.value | 10.22 | V2_MDCR_CLM | CLM_ALOWD_CHRG_AMT | MCS;NCH;VMS | NCH_CARR_CLM_ALOWD_AMT | Regular;CMS | ||
| 193 | 191 | ExplanationOfBenefit | Carrier;DME | Beneficiary Payment Amount | An amount paid by a beneficiary for services rendered on a claim. | ExplanationOfBenefit.total.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication').exists() and category.coding.where(code='CLM_BENE_PMT_AMT').exists() ).amount.value | 19.94 | V2_MDCR_CLM | CLM_BENE_PMT_AMT | MCS;NCH;VMS | Regular;CMS | |||
| 194 | 192 | ExplanationOfBenefit | Carrier;DME | Paid to Beneficiary Amount | An amount paid to a beneficiary for a submitted claim. | ExplanationOfBenefit.total.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication').exists() and category.coding.where(code='CLM_BENE_PD_AMT').exists() ).amount.value | 1.5 | V2_MDCR_CLM | CLM_BENE_PD_AMT | MCS;NCH;VMS | Regular;CMS | |||
| 195 | 193 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Near Line Record Identification Code | A code identifying the claim record type being processed. Valid values: W = Part B, V = Part A, U = Both | ExplanationOfBenefit.supportingInfo.where(code.coding.system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-NRLN-RIC-CD').code.coding.code | O | V2_MDCR_CLM | CLM_RIC_CD | FISS;MCS;VMS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-RIC-CD | CMS;Basis;Regular | ||
| 196 | 194 | ExplanationOfBenefit | Inpatient;SNF | Claim Diagnosis Related Group Outlier Stay Code | On an institutional claim, the code that indicates the beneficiary stay under the prospective payment system which, although classified into a specific diagnosis related group, has an unusually long length (day outlier) or exceptionally high cost (cost outlier). [NCH] | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='DGNS_DRG_OUTLIER_CD').exists()).code.coding.code | 6 | V2_MDCR_CLM_INSTNL | DGNS_DRG_OUTLIER_CD | NCH | https://bluebutton.cms.gov/fhir/CodeSystem/DGNS-DRG-OUTLIER-CD | CMS | ||
| 197 | 195 | ExplanationOfBenefit | Carrier | Anesthesia Unit Count | A quantity identifying the number of services billed for an anesthesia service on a claim line of service. | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-LINE-ANSTHSA-UNIT-CNT').value | 11 | V2_MDCR_CLM_LINE | CLM_LINE_ANSTHSA_UNIT_CNT | NCH | CARR_LINE_ANSTHSA_UNIT_CNT | CMS;Basis;Regular | ||
| 198 | 196 | ExplanationOfBenefit | Carrier;DME | Provider Tax Number | Line provider tax number. | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-PRVDR-TAX-NUM').value | {'type': {'coding': [{'system': 'http://terminology.hl7.org/CodeSystem/v2-0203', 'code': 'TAX', 'display': 'Tax ID number'}]}, 'system': 'urn:oid:2.16.840.1.113883.4.4', 'value': '15'} | V2_MDCR_CLM_LINE | CLM_RNDRG_PRVDR_TAX_NUM | NCH;VMS | CCLF5.CLM_RNDRG_PRVDR_TAX_NUM | TAX_NUM | CMS | |
| 199 | 197 | ExplanationOfBenefit | Carrier | RX Number | The pharmacy's internal invoice number on pharmaceutical claims. | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-LINE-RX-NUM').value | no rx num here! | V2_MDCR_CLM_LINE | CLM_LINE_RX_NUM | MCS;NCH | CARR_LINE_RX_NUM | CMS | ||
| 200 | 198 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Line Item From Date | A date indicating the first day of service for a line item. | ExplanationOfBenefit.item.serviced.start | 2025-01-01 | V2_MDCR_CLM_LINE | CLM_LINE_FROM_DT | FISS;MCS;NCH;VMS | CCLF2.CLM_LINE_FROM_DT;CCLF5.CLM_LINE_FROM_DT;CCLF6.CLM_LINE_FROM_DT | LINE_1ST_EXPNS_DT | Basis;Regular;CMS | |
| 201 | 199 | ExplanationOfBenefit | Carrier;DME | Coinsurance Amount | Effective with NCH version H, the beneficiary coinsurance liability amount for this line item service on the noninstitutional claim. Note: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain zeroes in this field. [NCH] | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_MDCR_COINSRNC_AMT')).amount.value | 11111.1 | V2_MDCR_CLM_LINE | CLM_LINE_MDCR_COINSRNC_AMT | MCS;NCH;VMS | LINE_COINSRNC_AMT | Regular;CMS | ||
| 202 | 200 | ExplanationOfBenefit | Carrier;DME | Line Item Diagnosis Code | A code identifying an International Classification of Disease Clinical Modification, ninth or tenth revision (ICD-9/10-CM) diagnosis. Reference table: DGNS_CD | ExplanationOfBenefit.item.select(%root.diagnosis[diagnosisSequence-1].diagnosis.coding.code) | M48.062 | V2_MDCR_CLM_LINE | CLM_LINE_DGNS_CD | MCS;NCH;VMS | CCLF5.CLM_LINE_DGNS_CD | LINE_ICD_DGNS_CD | Basis;Regular;CMS | |
| 203 | 201 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Last Expense Date | The ending date of service for the claim line. | ExplanationOfBenefit.item.serviced.end | 2025-01-02 | V2_MDCR_CLM_LINE | CLM_LINE_THRU_DT | FISS;MCS;NCH;VMS | CCLF2.CLM_LINE_THRU_DT;CCLF5.CLM_LINE_THRU_DT;CCLF6.CLM_LINE_THRU_DT | LINE_LAST_EXPNS_DT | Basis;Regular;CMS | |
| 204 | 202 | ExplanationOfBenefit | Carrier;DME | Place Of Service Code | Indication of where the service was performed. | ExplanationOfBenefit.item.location.coding.where(system='https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set').code | 07 | V2_MDCR_CLM_LINE | CLM_POS_CD | MCS;NCH;VMS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-POS-CD | CCLF5.CLM_POS_CD;CCLF6.CLM_POS_CD | LINE_PLACE_OF_SRVC_CD | CMS |
| 205 | 203 | ExplanationOfBenefit | Carrier;DME | Provider Participating Indicator Code | Indication that a provider is participating or accepting assignment for this claim. [HRMZ] Code indicating whether or not a provider is participating or accepting assignment for this line item service on the noninstitutional claim. [NCH] | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-RNDRG-PRVDR-PRTCPTG-CD').value.code | 1 | V2_MDCR_CLM_LINE | CLM_RNDRG_PRVDR_PRTCPTG_CD | NCH;VMS | https://bluebutton.cms.gov/fhir/CodeSystem/PRTCPTNG-IND-CD | PRTCPTNG_IND_CD | CMS;Basis;Regular | |
| 206 | 204 | ExplanationOfBenefit | Carrier | Claim Rendering Provider Type Code | The type of provider furnishing the service for this line item on the carrier claim (non-DMERC). | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-PRVDR-TYPE-CD').value.code | 5 | V2_MDCR_CLM_LINE | CLM_RNDRG_PRVDR_TYPE_CD | MCS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-PRVDR-TYPE-CD | CARR_LINE_PRVDR_TYPE_CD | CMS;Basis;Regular | |
| 207 | 205 | ExplanationOfBenefit | Carrier;DME | Claim Payment Denial Code | Reasons for denying payment to carriers. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_CARR_PMT_DNL_CD').exists()).code.coding.code | 8 | V2_MDCR_CLM_PRFNL | CLM_CARR_PMT_DNL_CD | NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-CARR-PMT-DNL-CD | CCLF5.CLM_CARR_PMT_DNL_CD;CCLF6.CLM_CARR_PMT_DNL_CD | CARR_CLM_PMT_DNL_CD | CMS |
| 208 | 206 | ExplanationOfBenefit | Carrier;DME | Carrier Primary Payer Paid Amount | Carrier Primary Payer Paid Amount | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication').exists() and category.coding.where(code='CLM_MDCR_PRFNL_PRMRY_PYR_AMT').exists()).amount.value | 8201.1 | V2_MDCR_CLM_PRFNL | CLM_MDCR_PRFNL_PRMRY_PYR_AMT | MCS;NCH;VMS | CARR_CLM_PRMRY_PYR_PD_AMT | CMS | ||
| 209 | 207 | ExplanationOfBenefit | Carrier;DME | Provider Assignement Indicator | A switch indicating whether or not the provider accepts assignement for the noninstitutional claim. [NCH] | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_MDCR_PRFNL_PRVDR_ASGNMT_SW').exists()).code.coding.code | L | V2_MDCR_CLM_PRFNL | CLM_MDCR_PRFNL_PRVDR_ASGNMT_SW | MCS;NCH;VMS | CARR_CLM_PRVDR_ASGNMT_IND_SW | CMS | ||
| 210 | 208 | ExplanationOfBenefit | Carrier;DME | Clinical Trial Number | Effective September 1, 2008 with the implementation of CR#3, the number used to identify all items and services provided to a beneficiary during their participation in a clinical trial. (From NCH Claim Clinical Trial Number) | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_CLNCL_TRIL_NUM').exists()).code.coding.code | V2_MDCR_CLM_PRFNL | CLM_CLNCL_TRIL_NUM | MCS;NCH;VMS | CLM_CLNCL_TRIL_NUM | CMS | |||
| 211 | 209 | ExplanationOfBenefit | Carrier;DME | Hematocrit/Hemoglobin Result Number | The hematocrit or hemoglobin result value for the claim line. | ExplanationOfBenefit.contained.where(id = %root.supportingInfo.valueReference.reference.substring(1)).value | 1.11 | V2_MDCR_CLM_LINE_PRFNL | CLM_LINE_HCT_HGB_RSLT_NUM | NCH;VMS | LINE_HCT_HGB_RSLT_NUM | CMS | ||
| 212 | 210 | ExplanationOfBenefit | Carrier;DME | Hematocrit/Hemoglobin Type Code | Code indicating if the result is for hematocrit or hemoglobin. | ExplanationOfBenefit.contained.where(id = %root.supportingInfo.valueReference.reference.substring(1)).code.coding | {'system': 'http://loinc.org', 'code': '718-7'} | V2_MDCR_CLM_LINE_PRFNL | CLM_LINE_HCT_HGB_TYPE_CD | NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-LINE-HCT-HGB-TYPE-CD | LINE_HCT_HGB_TYPE_CD | CMS | |
| 213 | 211 | ExplanationOfBenefit | Carrier | Carrier Clinical Lab Number | The clinical laboratory identifier for the carrier claim line. | ExplanationOfBenefit.contained.where(id = %root.supportingInfo.valueReference.reference.substring(1)).performer.identifier.value | 11D1343434 | V2_MDCR_CLM_LINE_PRFNL | CLM_LINE_CARR_CLNCL_LAB_NUM | NCH | CARR_LINE_CLIA_LAB_NUM | CMS;Basis;Regular | ||
| 214 | 212 | ExplanationOfBenefit | Carrier;DME | Line Primary Payer Paid Amount | Line beneficiary primary payer paid amount. | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_BENE_PRMRY_PYR_PD_AMT')).amount.value | 123479.22 | V2_MDCR_CLM_LINE_PRFNL | CLM_BENE_PRMRY_PYR_PD_AMT | NCH | LINE_BENE_PRMRY_PYR_PD_AMT | Regular;CMS | ||
| 215 | 213 | ExplanationOfBenefit | Carrier;DME | Carrier MTUS Indicator Code | (1) Code indicating the units associated with services needing unit reporting on the line item for the carrier claim (non-DMERC). [NCH] (2) Prior to version H this field was named: CWFB_DME_MTUS_IND_CD. [NCH] | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MTUS-IND-CD').value.code | 3 | V2_MDCR_CLM_LINE_PRFNL | CLM_MTUS_IND_CD | NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-MTUS-IND-CD | CARR_LINE_MTUS_CD;DMERC_LINE_MTUS_CD | CMS | |
| 216 | 214 | ExplanationOfBenefit | Carrier;DME | Carrier MTUS Count | (1) The count of the total units associated with services needing unit reporting such as transportation, miles, anesthesia time units, number of services, volume of oxygen, or blood units. This is a line item field on the carrier claim (non-DMERC) and is used for both allowed and denied services. Note: For anesthesia (MTUS indicator = 2) this field should be reported in time unit intervals, i.e., 15-minute intervals or fraction thereof. It appears that some carriers are reporting minutes instead of time units. [NCH] (2) Effective with NCH version G, the count of the total units associated with the DMERC line item service needing unit reporting, including number of services, volume of oxygen, and drug dose. [NCH] | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-LINE-PRFNL-MTUS-CNT').value | 3.1 | V2_MDCR_CLM_LINE_PRFNL | CLM_LINE_PRFNL_MTUS_CNT | NCH | CARR_LINE_MTUS_CNT;DMERC_LINE_MTUS_CNT | CMS | ||
| 217 | 215 | ExplanationOfBenefit | Carrier;DME | Line Pricing Locality Code | Code denoting the carrier-specific locality used for pricing the service for this line item on the carrier claim (non-DMERC). [NCH] | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-PRCNG-LCLTY-CD').value.code | 42 | V2_MDCR_CLM_LINE_PRFNL | CLM_PRCNG_LCLTY_CD | NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-PRCNG-LCLTY-CD | CARR_LINE_PRCNG_LCLTY_CD;DMERC_LINE_PRCNG_STATE_CD | CMS;Basis;Regular | |
| 218 | 216 | ExplanationOfBenefit | Carrier | Reduced Payment Physician Assistant Code | Effective 1/92, identification of claims that have been paid a reduced fee schedule amount (65%, 75%, or 85%) because a physician's assistant performed the services. | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-PHYSN-ASTNT-CD').value.code | 1 | V2_MDCR_CLM_LINE_PRFNL | CLM_PHYSN_ASTNT_CD | NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-PHYSN-ASTNT-CD | CARR_LINE_RDCD_PMT_PHYS_ASTN_C | CMS | |
| 219 | 217 | ExplanationOfBenefit | Carrier | HPSA Scarcity Code | A code used to track the Health Professional Shortage Area (HPSA) and Physician Scarcity Area (PSA) related bonus payments on Part B professional claims. Reference table: CLM_CARR_HPSA_SCRCTY_CD | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-LINE-CARR-HPSA-SCRCTY-CD').value.code | 1 | V2_MDCR_CLM_LINE_PRFNL | CLM_LINE_CARR_HPSA_SCRCTY_CD | MCS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-LINE-CARR-HPSA-SCRCTY-CD | CCLFB.CLM_LINE_CARR_HPSA_SCRCTY_CD | HPSA_SCRCTY_IND_CD | CMS |
| 220 | 218 | ExplanationOfBenefit | Carrier;DME | Line Primary Payer Code | A code identifying the coverage type of the primary payer when Medicare is the secondary payer at the claim line as defined by the Common Working File (CWF). Reference table: CLM_PRMRY_PYR_CD | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-PRMRY-PYR-CD').value.code | H | V2_MDCR_CLM_LINE_PRFNL | CLM_PRMRY_PYR_CD | NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-PRMRY-PYR-CD | CCLF5.CLM_LINE_PRMRY_PYR_CD;CCLF6.CLM_PRMRY_PYR_CD | LINE_BENE_PRMRY_PYR_CD | CMS |
| 221 | 219 | ExplanationOfBenefit | Carrier;DME | CMS Service Type Code | Type of service as defined in the HCFA Medicare Carrier Manual, for this line item on the non-institutional claim. (NCH) | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-FED-TYPE-SRVC-CD').value.code | D | V2_MDCR_CLM_LINE_PRFNL | CLM_FED_TYPE_SRVC_CD | NCH;VMS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-FED-TYPE-SRVC-CD | CCLF5.CLM_FED_TYPE_SRVC_CD;CCLF6.CLM_FED_TYPE_SRVC_CD | LINE_CMS_TYPE_SRVC_CD | CMS |
| 222 | 220 | ExplanationOfBenefit | Carrier;DME | Payment Code | The code indicating that the amount shown in the payment field on the non-institutional line item represents either 80% or 100% of the allowed charges less any deductible, or 100% limitation of liability only. | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-PMT-80-100-CD').value.code | 3 | V2_MDCR_CLM_LINE_PRFNL | CLM_PMT_80_100_CD | MCS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-PMT-80-100-CD | LINE_PMT_80_100_CD | CMS | |
| 223 | 221 | ExplanationOfBenefit | Carrier;DME | Processing Indicator Code | The code indicating the reason a line item on the noninstitutional claim was allowed or denied. Note 2: Effective 4/1/02, this field was expanded to two bytes to accommodate new values. The NCH nearline file did not expand the current 1-byte field but instituted a crosswalk of the 2-byte field to the 1-byte character value. See table of codes for the crosswalk. [NCH] | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-PRCSG-IND-CD').value.code | J | V2_MDCR_CLM_LINE_PRFNL | CLM_PRCSG_IND_CD | NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-PRCSG-IND-CD | CCLF5.CLM_PRCSG_IND_CD;CCLF6.CLM_PRCSG_IND_CD | LINE_PRCSG_IND_CD | CMS |
| 224 | 222 | ExplanationOfBenefit | Carrier;DME | Service Deductible Code | A value identifying whether a service line is subject to the deductible. Reference table: CLM_SRVC_DDCTBL_SW | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-SRVC-DDCTBL-SW').value.code | 0 | V2_MDCR_CLM_LINE_PRFNL | CLM_SRVC_DDCTBL_SW | MCS;NCH;VMS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-SRVC-DDCTBL-SW | LINE_SERVICE_DEDUCTIBLE | Basis;Regular;CMS | |
| 225 | 223 | ExplanationOfBenefit | Carrier | Provider Speciality Code | A code identifying the Centers for Medicare and Medicaid Services (CMS) specialty of a provider or supplier. For example: 11 = Internal medicine. 49 = Ambulatory surgical center. Reference table: CLM_PRVDR_SPCLTY_CD | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-PRVDR-SPCLTY-CD').value.code | 11 | V2_MDCR_CLM_LINE_PRFNL | CLM_PRVDR_SPCLTY_CD | MCS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-PRVDR-SPCLTY-CD | CCLF5.CLM_PRVDR_SPCLTY_CD | PRVDR_SPCLTY | CMS |
| 226 | 224 | ExplanationOfBenefit | DME | Screen Savings Amount | Prior to NCH version H this field was named: CWFB_DME_SCRN_SVGS_AMT and the field size was S9(5)V99. [NCH] | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_DMERC_SCRN_SVGS_AMT')).amount.value | 15.11 | V2_MDCR_CLM_LINE_PRFNL | CLM_LINE_DMERC_SCRN_SVGS_AMT | NCH;VMS | DMERC_LINE_SCRN_SVGS_AMT | CMS | ||
| 227 | 225 | ExplanationOfBenefit | DME | Supplier Type Code | The type of supplier. | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-PRVDR-TYPE-CD').value.code | 0 | V2_MDCR_CLM_LINE_PRFNL | CLM_SUPLR_TYPE_CD | NCH;VMS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-PRVDR-TYPE-CD | DMERC_LINE_SUPPLR_TYPE_CD | Basis;Regular;CMS | |
| 228 | 226 | ExplanationOfBenefit | Carrier;DME | Purchase Price Amount | Effective 5/92, the amount representing the lower of fee schedule for purchase of new or used DME, or actual charge. In case of rental DME, this amount represents the purchase cap; rental payments can only be made until the cap is met. This line item field is applicable to non-institutional claims involving DME, prosthetic, orthotic and supply items, immunosuppressive drugs, PEN, ESRD, and oxygen items referred to as DMEPOS. [NCH] | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_PRFNL_DME_PRICE_AMT')).amount.value | 11.5 | V2_MDCR_CLM_LINE_PRFNL | CLM_LINE_PRFNL_DME_PRICE_AMT | NCH;VMS | LINE_DME_PRCHS_PRICE_AMT | |||
| 229 | 227 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Claim Adjustment Type Code | A code identifying the type of adjustment record represented on a claim or encounter. Reference table: CLM_ADJSTMT_TYPE_CD | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_ADJSTMT_TYPE_CD').exists()).code.coding.code | 0 | V2_MDCR_CLM | CLM_ADJSTMT_TYPE_CD | FISS;MCS;NCH;VMS | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-ADJSTMT-TYPE-CD | CCLF1.CLM_ADJSMT_TYPE_CD;CCLF5.CLM_ADJSMT_TYPE_CD;CCLF6.CLM_ADJSMT_TYPE_CD | Basis;Regular;CMS | |
| 230 | 228 | ExplanationOfBenefit | Carrier;DME | Beneficiary Interest Paid Amount | An amount identifying the interest paid to a beneficiary due to a delay in the payment of a claim. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_BENE_INTRST_PD_AMT')).amount.value | V2_MDCR_CLM | CLM_BENE_INTRST_PD_AMT | MCS;VMS | CMS | ||||
| 231 | 229 | ExplanationOfBenefit | Carrier;HHA;Hospice;Inpatient;Outpatient;SNF | Beneficiary Coinsurance Amount | An amount identifying the portion of cost that is the responsibility of a beneficiary for payment. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_BENE_PMT_COINSRNC_AMT')).amount.value | V2_MDCR_CLM | CLM_BENE_PMT_COINSRNC_AMT | MCS | Regular;CMS | ||||
| 232 | 230 | ExplanationOfBenefit | Inpatient;SNF | Blood Charge Amount | An amount identifying the total charge for blood usage. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_BLOOD_CHRG_AMT')).amount.value | 10.01 | V2_MDCR_CLM | CLM_BLOOD_CHRG_AMT | NCH | CMS | |||
| 233 | 231 | ExplanationOfBenefit | Inpatient;SNF | Blood Noncovered Charge Amount | An amount identifying the total non-covered charge for blood usage. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_BLOOD_NCVRD_CHRG_AMT')).amount.value | 10.02 | V2_MDCR_CLM | CLM_BLOOD_NCVRD_CHRG_AMT | NCH | CMS | |||
| 234 | 232 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Coordination of Benefits Patient Responsibility Amount | An amount identifying a beneficiary's patient responsibility on a Coordination of Benefits (COB) claim. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_COB_PTNT_RESP_AMT')).amount.value | 95.01 | V2_MDCR_CLM | CLM_COB_PTNT_RESP_AMT | FISS | CMS | |||
| 235 | 233 | ExplanationOfBenefit | DME | Other Third Party Payer Paid Amount | An amount identifying how much was paid by a third party payer. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_OTHR_TP_PD_AMT')).amount.value | V2_MDCR_CLM | CLM_OTHR_TP_PD_AMT | VMS | Regular;CMS | ||||
| 236 | 234 | ExplanationOfBenefit | Carrier;DME;HHA;Hospice;Inpatient;Outpatient;SNF | Provider Interest Paid Amount | An amount identifying the interest paid to a provider due to the late processing of a claim. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_PRVDR_INTRST_PD_AMT')).amount.value | V2_MDCR_CLM | CLM_PRVDR_INTRST_PD_AMT | FISS;MCS;VMS | CMS | ||||
| 237 | 235 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Provider Obligation To Accept as Full Amount | An amount identifying a provider's obligation to accept in full (OTAF) from Medicare as payment. A beneficiary cannot be charged for any amount exceeding the OTAF total. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_PRVDR_OTAF_AMT')).amount.value | V2_MDCR_CLM | CLM_PRVDR_OTAF_AMT | FISS;MCS;VMS | CMS | ||||
| 238 | 236 | ExplanationOfBenefit | DME;HHA;Outpatient | Remaining Amount to Provider | An amount identifying how much payment is still owed to a provider minus prior payments, offsets, or adjustments on a claim. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_PRVDR_RMNG_DUE_AMT')).amount.value | 11.18 | V2_MDCR_CLM | CLM_PRVDR_RMNG_DUE_AMT | FISS;VMS | CMS | |||
| 239 | 237 | ExplanationOfBenefit | Inpatient;Outpatient;SNF | Total Contractual Amount Discrepancy | An amount identifying the portion of a charge that exceeds the maximum allowable amount or a contracted fee arrangement for a service. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_TOT_CNTRCTL_AMT')).amount.value | 10.08 | V2_MDCR_CLM | CLM_TOT_CNTRCTL_AMT | FISS | CMS | |||
| 240 | 238 | ExplanationOfBenefit | HHA;Inpatient | Final Standardized Payment Amount | A monetary amount signifying the final standard payment amount for hospitals paid under the Inpatient Prospective Payment Systems (IPPS), Maryland hospitals, and home health agencies. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_FINL_STDZD_PYMT_AMT')).amount.value | 98.44 | V2_MDCR_CLM_INSTNL | CLM_FINL_STDZD_PYMT_AMT | FISS;NCH | CMS | |||
| 241 | 239 | ExplanationOfBenefit | Inpatient | Hospital Acquired Condition Reduction Amount | Section 3008 of the Patient Protection and Affordable Care Act (ACA) established the Hospital-Acquired Condition (HAC) Reduction Program. Effective beginning fiscal year (FY) 2015 (discharges beginning on October 1, 2014), the HAC Reduction Program requires the Secretary of the Department of Health and Human Services to adjust payments to applicable hospitals that rank in the worst-performing quartile of all subsection (D) hospitals with respect to risk-adjusted HAC quality measures. These hospitals will have their payments reduced to 99 percent of what would otherwise have been paid for such discharges. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_HAC_RDCTN_PYMT_AMT')).amount.value | 10.01 | V2_MDCR_CLM_INSTNL | CLM_HAC_RDCTN_PYMT_AMT | FISS;NCH | CMS | |||
| 242 | 240 | ExplanationOfBenefit | Inpatient | Blended Payment Amount | For hospitals participating in BPCI Model 1, this field represents the amount the claim was reduced by. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_HIPPS_MODEL_BNDLD_PYMT_AMT')).amount.value | V2_MDCR_CLM_INSTNL | CLM_HIPPS_MODEL_BNDLD_PMT_AMT | FISS;NCH | CMS | ||||
| 243 | 241 | ExplanationOfBenefit | Inpatient;SNF | Readmission Reduction Amount | This field represents the Hospital Readmission Reduction Program amount. This is a reduction to the claim for readmissions. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_HIPPS_READMSN_RDCTN_AMT')).amount.value | 10.03 | V2_MDCR_CLM_INSTNL | CLM_HIPPS_READMSN_RDCTN_AMT | FISS;NCH | CMS | |||
| 244 | 242 | ExplanationOfBenefit | Inpatient;SNF | HIPPS Value Based Purchasing Amount | This field represents the Hospital Value Based Purchasing amount. This could be an additional payment on the claim or a reduction, depending on the hospital's score. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_HIPPS_VBP_AMT')).amount.value | 10.04 | V2_MDCR_CLM_INSTNL | CLM_HIPPS_VBP_AMT | FISS;NCH | CMS | |||
| 245 | 243 | ExplanationOfBenefit | Inpatient;SNF | Low Volume Payment Amount | A payment adjustment given to hospitals to account for the higher costs per discharge for low-income hospitals under the Inpatient Prospective Payment System (IPPS). | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_INSTNL_LOW_VOL_PMT_AMT')).amount.value | 10.05 | V2_MDCR_CLM_INSTNL | CLM_INSTNL_LOW_VOL_PMT_AMT | NCH | CMS | |||
| 246 | 244 | ExplanationOfBenefit | Inpatient;SNF | First Year Rate Amount | Effective with NCH version H, the charge for each day of coinsurance during the first year in the bill (used for internal CWFMQA editing purposes). Note: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 should contain zeroes in this field. Exception: During the NCH version H conversion invalid data may have been populated for prior periods. Disregard any data present in this field on claims with NCH weekly process date earlier than 10/3/97. [NCH] | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_MDCR_IP_1ST_YR_RATE_AMT')).amount.value | 10.06 | V2_MDCR_CLM_INSTNL | CLM_MDCR_IP_1ST_YR_RATE_AMT | NCH | CMS | |||
| 247 | 245 | ExplanationOfBenefit | Inpatient;SNF | Second Year Rate Amount | Effective with NCH version H, the charge for each day of coinsurance during the second year in a bill which spans two years (used for internal CWFMQA editing purposes). Note: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 should contain zeroes in this field. Exception: During the NCH version H conversion invalid data may have been populated for prior periods. Disregard any data in this field on claims with NCH weekly process date earlier than 10/3/97. [NCH] | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_MDCR_IP_SCND_YR_RATE_AMT')).amount.value | 10.07 | V2_MDCR_CLM_INSTNL | CLM_MDCR_IP_SCND_YR_RATE_AMT | NCH | CMS | |||
| 248 | 246 | ExplanationOfBenefit | Inpatient;SNF | Maryland Waiver Standardized Amount | The standardized amount produced by Pricer for an Inpatient Prospective Payment System (IPPS) and Maryland waiver hospital claim. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_PPS_MD_WVR_STDZD_VAL_AMT')).amount.value | 10.08 | V2_MDCR_CLM_INSTNL | CLM_PPS_MD_WVR_STDZD_VAL_AMT | FISS;NCH | CMS | |||
| 249 | 247 | ExplanationOfBenefit | Inpatient | Site-Neutral Cost-Based Payment Amount | Section 1206(a) of Public Law 113-67 amended Section 1886(m) of the Act to establish patient-level criteria for payments under the LTCH PPS (Long Term Care Hospital Prospective Payment System) for implementation beginning for cost reporting periods beginning on or after October 1, 2015. The site-neutral cost amount will be paid for patients discharged from the LTCH that do not meet criteria to be paid at the standard LTCH PPS amount. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_SITE_NTRL_CST_BSD_PYMT_AMT')).amount.value | 10.09 | V2_MDCR_CLM_INSTNL | CLM_SITE_NTRL_CST_BSD_PYMT_AMT | FISS;NCH | CMS | |||
| 250 | 248 | ExplanationOfBenefit | Inpatient | Site-Neutral IPPS Payment Amount | Section 1206(a) of Public Law 113-67 amended Section 1886(m) of the Act to establish patient-level criteria for payments under the LTCH PPS (Long Term Care Hospital Prospective Payment System) for implementation beginning for cost reporting periods beginning on or after October 1, 2015. The site-neutral Inpatient Prospective Payment System (IPPS) amount will be paid for patients discharged from the LTCH that do not meet criteria to be paid at the standard LTCH PPS amount. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_SITE_NTRL_IP_PPS_PYMT_AMT')).amount.value | 10.1 | V2_MDCR_CLM_INSTNL | CLM_SITE_NTRL_IP_PPS_PYMT_AMT | FISS;NCH | CMS | |||
| 251 | 249 | ExplanationOfBenefit | Inpatient | Short Stay Outlier Payment Amount | This is the short stay outlier (SSO) payment amount. | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_SS_OUTLIER_STD_PYMT_AMT')).amount.value | 10.11 | V2_MDCR_CLM_INSTNL | CLM_SS_OUTLIER_STD_PYMT_AMT | FISS;NCH | CMS | |||
| 252 | 250 | ExplanationOfBenefit | Carrier;DME | Provider Account Receivable Offset Amount | Provider Account Receivable Offset Amount | ExplanationOfBenefit.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_PRVDR_ACNT_RCVBL_OFST_AMT')).amount.value | 19 | V2_MDCR_CLM_PRFNL | CLM_PRVDR_ACNT_RCVBL_OFST_AMT | MCS;VMS | CMS | |||
| 253 | 251 | ExplanationOfBenefit | Carrier;DME;Outpatient;SNF | Provider Obligation To Accept as Full Amount | An amount identifying a provider's obligation to accept in full (OTAF) from Medicare as payment. A beneficiary cannot be charged for any amount exceeding the OTAF total. | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_OTAF_AMT')).amount.value | V2_MDCR_CLM_LINE | CLM_LINE_OTAF_AMT | FISS;MCS;NCH;VMS | CMS | ||||
| 254 | 252 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim Related Condition Code | A related condition that has within some set of claims. | ExplanationOfBenefit.supportingInfo.where(code.coding.system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-RLT-COND-CD').code.coding.code | V2_MDCR_CLM | CLM_RLT_COND_SGNTR_SK | FISS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-RLT-COND-CD | CCLFA.CLM_RLT_COND_CD | CMS | ||
| 255 | 253 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Add On Payment Amount | The new patient or initial Medicare visit add-on payment amount of the Federally Qualified Health Center (FQHC) claim. | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_ADD_ON_PYMT_AMT')).amount.value | V2_MDCR_CLM_LINE_INSTNL | CLM_LINE_ADD_ON_PYMT_AMT | FISS;NCH | CMS | ||||
| 256 | 254 | ExplanationOfBenefit | Inpatient | Non-EHR Reduction Amount | This field identifies the payment reduction amount for hospitals that are not meaningful users of certified Electronic Health Record (EHR) technology. | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_NON_EHR_RDCTN_AMT')).amount.value | 11.12 | V2_MDCR_CLM_LINE_INSTNL | CLM_LINE_NON_EHR_RDCTN_AMT | FISS | CMS | |||
| 257 | 255 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Transitional Drug Add-On Payment Adjustment | A monetary amount signifying the Transitional Drug Add-On Payment Adjustment (TDAPA) for End Stage Renal Disease (ESRD) claims for injectable, intravenous, and oral calcimimetics when reported with an AX modifier. | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_REV_CNTR_TDAPA_AMT')).amount.value | V2_MDCR_CLM_LINE_INSTNL | CLM_REV_CNTR_TDAPA_AMT | FISS;NCH | CMS | ||||
| 258 | 256 | ExplanationOfBenefit | Carrier | Carrier Clinical Charge Amount | Fee schedule charge amount applied for the line item clinical laboratory service on the carrier claim (non-DMERC). | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_CARR_CLNCL_CHRG_AMT')).amount.value | 11.11 | V2_MDCR_CLM_LINE_PRFNL | CLM_LINE_CARR_CLNCL_CHRG_AMT | MCS;NCH | CMS | |||
| 259 | 257 | ExplanationOfBenefit | Carrier | Therapy Amount Applied to Limit | For type of service psychiatric, occupational therapy, or physical therapy, the amount of allowed charges applied toward the limit cap for this line item service on the noninstitutional claim. [NCH] | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_CARR_PSYCH_OT_LMT_AMT')).amount.value | 11.12 | V2_MDCR_CLM_LINE_PRFNL | CLM_LINE_CARR_PSYCH_OT_LMT_AMT | MCS;NCH | CMS | |||
| 260 | 258 | ExplanationOfBenefit | Carrier;DME | Professional Interest Amount | Amount of interest to be paid for this line item service on the non-institutional claim. Note: This is not included in the line item NCH payment (reimbursement) amount. | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_LINE_PRFNL_INTRST_AMT')).amount.value | 11.13 | V2_MDCR_CLM_LINE_PRFNL | CLM_LINE_PRFNL_INTRST_AMT | MCS;NCH;VMS | CMS | |||
| 261 | 259 | ExplanationOfBenefit | Carrier;DME | Line Primary Payer Allowed Amount | Line primary payer allowed charge amount. | ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication') and category.coding.where(code='CLM_MDCR_PRMRY_PYR_ALOWD_AMT')).amount.value | 11.14 | V2_MDCR_CLM_LINE_PRFNL | CLM_MDCR_PRMRY_PYR_ALOWD_AMT | MCS;NCH;VMS | CMS | |||
| 262 | 260 | ExplanationOfBenefit | Hospice;Inpatient | Patient Status Code | Effective with NCH version H, the code on an inpatient/SNF and hospice claim, indicating whether the beneficiary was discharged, died, or is still a patient (used for internal CWFMQA editing purposes). Note: During the NCH version H conversion this field was populated throughout history (back to service year 1991). [NCH] | ExplanationOfBenefit.supportingInfo.where(code.coding.system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-MDCR-NCH-PTNT-STUS-IND-CD').code.coding.code | V2_MDCR_CLM_INSTNL | CLM_MDCR_NCH_PTNT_STUS_IND_CD | FISS;NCH | https://bluebutton.cms.gov/fhir/CodeSystem/CLM-MDCR-NCH-PTNT-STUS-IND-CD | CMS | |||
| 263 | 261 | ExplanationOfBenefit | Carrier;DME;HHA;Inpatient;Inpatient;Outpatient | Claim Line Prior Authorization Unique Tracking Number (Adjudicated) | The unique tracking number for the prior authorization associated with this claim line from claims. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_LINE_PMD_UNIQ_TRKNG_NUM').exists()).value | ALA00000047747 | V2_MDCR_CLM_LINE | CLM_LINE_PMD_UNIQ_TRKNG_NUM | NCH | CMS | |||
| 264 | 262 | ExplanationOfBenefit | Carrier;DME;Hospice;Inpatient;Inpatient;Outpatient;SNF | Claim Line Prior Authorization Unique Tracking Number (Partially Adjudicated) | A number identifying a unique tracking number (UTN) for a prior authorization (PA). | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_LINE_PMD_UNIQ_TRKNG_NUM').exists()).value | ALA00000047747 | V2_MDCR_CLM_LINE_DCMTN | CLM_LINE_PA_UNIQ_TRKNG_NUM | FISS;MCS | CMS | |||
| 265 | 263 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim Benefit Enhancement Code 1 | A code identifying the first applicable Accountable Care Organization (ACO) Benefit Enhancement Indicator (BEI) that applied to the claim. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_BNFT_ENHNCMT_CD').exists()).value | V2_MDCR_CLM_DCMTN | CLM_BNFT_ENHNCMT_1_CD | FISS;NCH | CCLFA.CLM_DEMO_1ST_NUM | CMS | |||
| 266 | 264 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim Benefit Enhancement Code 2 | A code identifying the second applicable Accountable Care Organization (ACO) Benefit Enhancement Indicator (BEI) that applied to the claim. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_BNFT_ENHNCMT_CD').exists()).value | V2_MDCR_CLM_DCMTN | CLM_BNFT_ENHNCMT_2_CD | FISS;NCH | CCLFA.CLM_DEMO_2ND_NUM | CMS | |||
| 267 | 265 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim Benefit Enhancement Code 3 | A code identifying the third applicable Accountable Care Organization (ACO) Benefit Enhancement Indicator (BEI) that applied to the claim. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_BNFT_ENHNCMT_CD').exists()).value | V2_MDCR_CLM_DCMTN | CLM_BNFT_ENHNCMT_3_CD | FISS;NCH | CCLFA.CLM_DEMO_3RD_NUM | CMS | |||
| 268 | 266 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim Benefit Enhancement Code 4 | A code identifying the fourth applicable Accountable Care Organization (ACO) Benefit Enhancement Indicator (BEI) that applied to the claim. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_BNFT_ENHNCMT_CD').exists()).value | V2_MDCR_CLM_DCMTN | CLM_BNFT_ENHNCMT_4_CD | FISS;NCH | CCLFA.CLM_DEMO_4TH_NUM | CMS | |||
| 269 | 267 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim Benefit Enhancement Code 5 | A code identifying the fifth applicable Accountable Care Organization (ACO) Benefit Enhancement Indicator (BEI) that applied to the claim. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_BNFT_ENHNCMT_CD').exists()).value | V2_MDCR_CLM_DCMTN | CLM_BNFT_ENHNCMT_5_CD | FISS;NCH | CCLFA.CLM_DEMO_5TH_NUM | CMS | |||
| 270 | 268 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim NGACO PBPMT Switch | An Integrated Data Repository (IDR) derived indicator based on the claim Next Generation (NG) Accountable Care Organization (ACO) indicator code from CWF (Common Working File), which identifies claims that qualify for specific claim processing edits. Valid values: Y = If any of the five claim NG ACO indicator codes contains population-based payments (PBP). N = If applicable codes are found and none of the five NG ACO indicator codes contains PBP. Null = Default | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_NGACO_PBPMT_SW').exists()).value | V2_MDCR_CLM_DCMTN | CLM_NGACO_PBPMT_SW | NCH | CCLFA.CLM_NGACO_PBPMT_SW | CMS | |||
| 271 | 269 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim NGACO Post Discharge HCBS Switch | An Integrated Data Repository (IDR) derived indicator based on the claim Next Generation (NG) Accountable Care Organization (ACO) indicator code from CWF (Common Working File), which identifies claims that qualify for specific claim processing edits. Valid values: Y = If any of the five claim NG ACO indicator codes contains post-discharge home visits. N = If applicable codes are found and none of the five NG ACO indicator codes contains post-discharge home visits. Null = Default | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_NGACO_PDSCHRG_HCBS_SW').exists()).value | V2_MDCR_CLM_DCMTN | CLM_NGACO_PDSCHRG_HCBS_SW | NCH | CCLFA.CLM_NGACO_PDSCHRG_HCBS_SW | CMS | |||
| 272 | 270 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim NGACO SNF Waiver Switch | An Integrated Data Repository (IDR) derived indicator based on the claim Next Generation (NG) Accountable Care Organization (ACO) indicator code from CWF (Common Working File), which identifies claims that qualify for specific claim processing edits. Valid values: Y = If any of the five claim NG ACO indicator codes contains 3-day SNF waiver. N = If applicable codes are found and none of the five NG ACO indicator codes contains 3-day SNF waiver. Null = Default | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_NGACO_SNF_WVR_SW').exists()).value | V2_MDCR_CLM_DCMTN | CLM_NGACO_SNF_WVR_SW | NCH | CCLFA.CLM_NGACO_SNF_WVR_SW | CMS | |||
| 273 | 271 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim NGACO Telehealth Switch | An Integrated Data Repository (IDR) derived indicator based on the claim Next Generation (NG) Accountable Care Organization (ACO) indicator code from CWF (Common Working File), which identifies claims that qualify for specific claim processing edits. Valid values: Y = If any of the five claim NG ACO indicator codes contains telehealth. N = If applicable codes are found and none of the five NG ACO indicator codes contains telehealth. Null = Default | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_NGACO_TLHLTH_SW').exists()).value | V2_MDCR_CLM_DCMTN | CLM_NGACO_TLHLTH_SW | NCH | CCLFA.CLM_NGACO_TLHLTH_SW | CMS | |||
| 274 | 272 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim NGACO Capitation Switch | An Integrated Data Repository (IDR) derived indicator based on the claim Next Generation (NG) Accountable Care Organization (ACO) indicator code from CWF (Common Working File), which identifies claims that qualify for specific claim processing edits. Valid values: Y = If any of the five claim NG ACO indicator codes contains capitation. N = If applicable codes are found and none of the five NG ACO indicator codes contains capitation. Null = Default | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_NGACO_CPTATN_SW').exists()).value | V2_MDCR_CLM_DCMTN | CLM_NGACO_CPTATN_SW | NCH | CCLFA.CLM_NGACO_CPTATN_SW | CMS | |||
| 275 | 273 | ExplanationOfBenefit | HHA;Hospice;Inpatient;Outpatient;SNF | Claim ACO Care Management HCBS Switch | An Integrated Data Repository (IDR) derived indicator based on the claim line Next Generation (NG) Accountable Care Organization (ACO) indicator code from CWF (Common Working File), which identifies claims that qualify for specific claim processing edits. Valid values: Y = If any of the five claim line NG ACO indicator codes contains care management home visits. N = If applicable codes are found and none of the five NG ACO indicator codes contains care management home visits. Null = Default | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_ACO_CARE_MGMT_HCBS_SW').exists()).value | V2_MDCR_CLM_DCMTN | CLM_ACO_CARE_MGMT_HCBS_SW | NCH | CCLFA.CLM_NGACO_CMG_WVR_SW | CMS | |||
| 276 | 274 | ExplanationOfBenefit | Carrier | Claim Line NGACO PBPMT Switch | An Integrated Data Repository (IDR) derived indicator based on the claim line Next Generation (NG) Accountable Care Organization (ACO) indicator code from CWF (Common Working File), which identifies claims that qualify for specific claim processing edits. Valid values: Y = If any of the five claim NG ACO indicator codes contains population-based payments (PBP). N = If applicable codes are found and none of the five NG ACO indicator codes contains PBP. Null = Default | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_LINE_NGACO_PBPMT_SW').exists()).value | V2_MDCR_CLM_LINE_DCMTN | CLM_LINE_NGACO_PBPMT_SW | NCH | CCLFB.CLM_LINE_NGACO_PBPMT_SW | CMS | |||
| 277 | 275 | ExplanationOfBenefit | Carrier | Claim Line NGACO Post Discharge HCBS Switch | An Integrated Data Repository (IDR) derived indicator based on the claim line Next Generation (NG) Accountable Care Organization (ACO) indicator code from CWF (Common Working File), which identifies claims that qualify for specific claim processing edits. Valid values: Y = If any of the five claim NG ACO indicator codes contains post-discharge home visits. N = If applicable codes are found and none of the five NG ACO indicator codes contains post-discharge home visits. Null = Default | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_LINE_NGACO_PDSCHRG_HCBS_SW').exists()).value | V2_MDCR_CLM_LINE_DCMTN | CLM_LINE_NGACO_PDSCHRG_HCBS_SW | NCH | CCLFB.CLM_LINE_NGACO_PDSCHRG_HCBS_SW | CMS | |||
| 278 | 276 | ExplanationOfBenefit | Carrier | Claim Line NGACO SNF Waiver Switch | An Integrated Data Repository (IDR) derived indicator based on the claim line Next Generation (NG) Accountable Care Organization (ACO) indicator code from CWF (Common Working File), which identifies claims that qualify for specific claim processing edits. Valid values: Y = If any of the five claim NG ACO indicator codes contains 3-day SNF waiver. N = If applicable codes are found and none of the five NG ACO indicator codes contains 3-day SNF waiver. Null = Default | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_LINE_NGACO_SNF_WVR_SW').exists()).value | V2_MDCR_CLM_LINE_DCMTN | CLM_LINE_NGACO_SNF_WVR_SW | NCH | CCLFB.CLM_LINE_NGACO_SNF_WVR_SW | CMS | |||
| 279 | 277 | ExplanationOfBenefit | Carrier | Claim Line NGACO Telehealth Switch | An Integrated Data Repository (IDR) derived indicator based on the claim line Next Generation (NG) Accountable Care Organization (ACO) indicator code from CWF (Common Working File), which identifies claims that qualify for specific claim processing edits. Valid values: Y = If any of the five claim NG ACO indicator codes contains telehealth. N = If applicable codes are found and none of the five NG ACO indicator codes contains telehealth. Null = Default | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_LINE_NGACO_TLHLTH_SW').exists()).value | V2_MDCR_CLM_LINE_DCMTN | CLM_LINE_NGACO_TLHLTH_SW | NCH | CCLFB.CLM_LINE_NGACO_TLHLTH_SW | CMS | |||
| 280 | 278 | ExplanationOfBenefit | Carrier | Claim Line NGACO Capitation Switch | An Integrated Data Repository (IDR) derived indicator based on the claim line Next Generation (NG) Accountable Care Organization (ACO) indicator code from CWF (Common Working File), which identifies claims that qualify for specific claim processing edits. Valid values: Y = If any of the five claim NG ACO indicator codes contains capitation. N = If applicable codes are found and none of the five NG ACO indicator codes contains capitation. Null = Default | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_LINE_NGACO_CPTATN_SW').exists()).value | V2_MDCR_CLM_LINE_DCMTN | CLM_LINE_NGACO_CPTATN_SW | NCH | CCLFB.CLM_LINE_NGACO_CPTATN_SW | CMS | |||
| 281 | 279 | ExplanationOfBenefit | Carrier | Claim Line ACO Care Management HCBS Switch | An Integrated Data Repository (IDR) derived indicator based on the claim line Next Generation (NG) Accountable Care Organization (ACO) indicator code from CWF (Common Working File), which identifies claims that qualify for specific claim processing edits. Valid values: Y = If any of the five claim line NG ACO indicator codes contains care management home visits. N = If applicable codes are found and none of the five NG ACO indicator codes contains care management home visits. Null = Default | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_LINE_ACO_CARE_MGMT_HCBS_SW').exists()).value | V2_MDCR_CLM_LINE_DCMTN | CLM_LINE_ACO_CARE_MGMT_HCBS_SW | NCH | CCLFB.CLM_NGACO_CMG_WVR_SW | CMS | |||
| 282 | 280 | ExplanationOfBenefit | Carrier | Claim Line Benefit Enhancement 1 Code | A code identifying the first applicable Accountable Care Organization (ACO) Benefit Enhancement Indicator (BEI) that applied to the claim line. Reference table: CLM_BNFT_ENHNCMT_CD | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_BNFT_ENHNCMT_CD').exists()).value | V2_MDCR_CLM_LINE_DCMTN | CLM_LINE_BNFT_ENHNCMT_1_CD | MCS;NCH | CCLFB.CLM_DEMO_1ST_NUM | CMS | |||
| 283 | 281 | ExplanationOfBenefit | Carrier | Claim Line Benefit Enhancement 2 Code | A code identifying the second applicable Accountable Care Organization (ACO) Benefit Enhancement Indicator (BEI) that applied to the claim line. Reference table: CLM_BNFT_ENHNCMT_CD | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_BNFT_ENHNCMT_CD').exists()).value | V2_MDCR_CLM_LINE_DCMTN | CLM_LINE_BNFT_ENHNCMT_2_CD | MCS;NCH | CCLFB.CLM_DEMO_2ND_NUM | CMS | |||
| 284 | 282 | ExplanationOfBenefit | Carrier | Claim Line Benefit Enhancement 3 Code | A code identifying the third applicable Accountable Care Organization (ACO) Benefit Enhancement Indicator (BEI) that applied to the claim line. Reference table: CLM_BNFT_ENHNCMT_CD | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_BNFT_ENHNCMT_CD').exists()).value | V2_MDCR_CLM_LINE_DCMTN | CLM_LINE_BNFT_ENHNCMT_3_CD | MCS;NCH | CCLFB.CLM_DEMO_3RD_NUM | CMS | |||
| 285 | 283 | ExplanationOfBenefit | Carrier | Claim Line Benefit Enhancement 4 Code | A code identifying the fourth applicable Accountable Care Organization (ACO) Benefit Enhancement Indicator (BEI) that applied to the claim line. Reference table: CLM_BNFT_ENHNCMT_CD | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_BNFT_ENHNCMT_CD').exists()).value | V2_MDCR_CLM_LINE_DCMTN | CLM_LINE_BNFT_ENHNCMT_4_CD | MCS;NCH | CCLFB.CLM_DEMO_4TH_NUM | CMS | |||
| 286 | 284 | ExplanationOfBenefit | Carrier | Claim Line Benefit Enhancement 5 Code | A code identifying the fifth applicable Accountable Care Organization (ACO) Benefit Enhancement Indicator (BEI) that applied to the claim line. Reference table: CLM_BNFT_ENHNCMT_CD | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='CLM_BNFT_ENHNCMT_CD').exists()).value | V2_MDCR_CLM_LINE_DCMTN | CLM_LINE_BNFT_ENHNCMT_5_CD | MCS;NCH | CCLFB.CLM_DEMO_5TH_NUM | CMS | |||
| 287 | 285 | ExplanationOfBenefit | DME;HHA;Hospice;Inpatient;Outpatient;SNF | State FIPS Code | Identifies the state where the facility providing services is located. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='PRVDR_FAC_FIPS_ST_CD').exists()).code | {'coding': [{'system': 'https://bluebutton.cms.gov/fhir/CodeSystem/US-FIPS-STATE-CODES', 'code': '04'}]} | V2_MDCR_CLM | GEO_BLG_SSA_STATE_CD | NCH | CCLF1.PRVDR_FAC_FIPS_ST_CD | CMS | ||
| 288 | 286 | ExplanationOfBenefit | Carrier;DME | State FIPS Code | Identifies the state that the provider providing the service is located in. | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information').exists() and category.coding.where(code='RNDRG_PRVDR_FIPS_ST_CD').exists()).code | {'coding': [{'system': 'https://bluebutton.cms.gov/fhir/CodeSystem/US-FIPS-STATE-CODES', 'code': '04'}]} | V2_MDCR_CLM_LINE | GEO_RNDRG_SSA_STATE_CD | NCH | CCLF5.RNDRG_PRVDR_FIPS_ST_CD | CMS | ||
| 289 | 287 | ExplanationOfBenefit | PriorAuth | Last Updated Time | This field represents the last time that an ExplanationOfBenefit was updated. | ExplanationOfBenefit.meta.lastUpdated | 2026-01-01T03:02:28.000000Z | CWF | ||||||
| 290 | 288 | ExplanationOfBenefit | PriorAuth | Created Date | EOB created date. | ExplanationOfBenefit.created | 2020-09-07 | CWF | ||||||
| 291 | 289 | ExplanationOfBenefit | PriorAuth | Beneficiary Source Key | Beneficiary Source Key | ExplanationOfBenefit.patient.reference.substring(8) | -147748784 | CWF | ||||||
| 292 | 290 | ExplanationOfBenefit | PriorAuth | Derived Outcome | Derived outcome code. | ExplanationOfBenefit.outcome | partial | CWF | ||||||
| 293 | 291 | ExplanationOfBenefit | PriorAuth | Claim Type | Claim Type | ExplanationOfBenefit.type.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-TYPE').code | C | CWF | ||||||
| 294 | 292 | ExplanationOfBenefit | PriorAuth | Unique Tracking Number | Unique Tracking Number | ExplanationOfBenefit.identifier.where(system='https://bluebutton.cms.gov/identifiers/Unique-Tracking-Number').value | -9CKKWTEAH0AHP | CWF | ||||||
| 295 | 293 | ExplanationOfBenefit | PriorAuth | Internal Control Number / DCN | Internal Control Number / DCN | ExplanationOfBenefit.identifier.where(system='https://bluebutton.cms.gov/identifiers/PA-ICN-DCN').value | CWF | |||||||
| 296 | 294 | ExplanationOfBenefit | PriorAuth | UTN Valid Start Date | UTN Valid Start Date | ExplanationOfBenefit.preAuthRefPeriod.start | 2020-09-17 | CWF | ||||||
| 297 | 295 | ExplanationOfBenefit | PriorAuth | UTN Valid End Date | UTN Valid End Date | ExplanationOfBenefit.preAuthRefPeriod.end | 2021-09-17 | CWF | ||||||
| 298 | 296 | ExplanationOfBenefit | PriorAuth | MAC ID | MAC ID | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information' and code='CLM_CNTRCTR_NUM').exists()).code.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/CLM-CNTRCTR-NUM').code | 04111 | CWF | ||||||
| 299 | 297 | ExplanationOfBenefit | PriorAuth | Type of Bill | Type of Bill | ExplanationOfBenefit.supportingInfo.where(category.coding.where(system='http://terminology.hl7.org/CodeSystem/claiminformationcategory' and code='info').exists() and code.coding.system='https://www.nubc.org/CodeSystem/TypeOfBill').code.coding.code | 32X | CWF | ||||||
| 300 | 298 | ExplanationOfBenefit | PriorAuth | NPI | NPI | ExplanationOfBenefit.contained.where(id = %root.provider.reference.substring(1)).identifier.where(system='http://hl7.org/fhir/sid/us-npi').value | 2560707830 | CWF | ||||||
| 301 | 299 | ExplanationOfBenefit | PriorAuth | Name | Name | ExplanationOfBenefit.contained.where(id = %root.provider.reference.substring(1)).name | HEALTHCARE CENTER | CWF | ||||||
| 302 | 300 | ExplanationOfBenefit | PriorAuth | CMS Certification Number | CMS Certification Number | ExplanationOfBenefit.contained.where(id = %root.provider.reference.substring(1)).identifier.where(system='http://terminology.hl7.org/NamingSystem/CCN').value | 39T14 | CWF | ||||||
| 303 | 301 | ExplanationOfBenefit | PriorAuth | Current Segment | Current Segment | ExplanationOfBenefit.item.sequence | 1 | CWF | ||||||
| 304 | 302 | ExplanationOfBenefit | PriorAuth | HCPCS/CPT/HIPPS | HCPCS/CPT/HIPPS code | ExplanationOfBenefit.item.productOrService.coding.code | G0493 | CWF | ||||||
| 305 | 303 | ExplanationOfBenefit | PriorAuth | Price Modifier 1 | Price Modifier 1 | ExplanationOfBenefit.item.modifier.coding.code | RR | CWF | ||||||
| 306 | 304 | ExplanationOfBenefit | PriorAuth | Price Modifier 2 | Price Modifier 2 | ExplanationOfBenefit.item.modifier.coding.code | RR | CWF | ||||||
| 307 | 305 | ExplanationOfBenefit | PriorAuth | Place of Service | Place of Service | ExplanationOfBenefit.item.location.coding.code | 41 | CWF | ||||||
| 308 | 306 | ExplanationOfBenefit | PriorAuth | Revenue Code 1 | Revenue Code 1 | ExplanationOfBenefit.item.revenue.coding.code | CWF | |||||||
| 309 | 307 | ExplanationOfBenefit | PriorAuth | PA Date Added | PA Date Added | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/PA-DT-ADDED').value | 2020-09-07 | CWF | ||||||
| 310 | 308 | ExplanationOfBenefit | PriorAuth | PA Date Updated | PA Date Updated | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/PA-DT-UPDATED').value | 2020-09-07 | CWF | ||||||
| 311 | 309 | ExplanationOfBenefit | PriorAuth | PA Decision | PA Decision | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/PA-DECISION').value.code | P | CWF | ||||||
| 312 | 310 | ExplanationOfBenefit | PriorAuth | PA Request Submitted Date | PA Request Submitted Date | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/PA-REQ-SUB-DT').value | 2020-09-08 | CWF | ||||||
| 313 | 311 | ExplanationOfBenefit | PriorAuth | PA Request Received Date | PA Request Received Date | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/PA-REQ-REC-DT').value | 2020-09-07 | CWF | ||||||
| 314 | 312 | ExplanationOfBenefit | PriorAuth | PA Decision Date | PA Decision Date | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/PA-DECISION-DT').value | 2020-09-08 | CWF | ||||||
| 315 | 313 | ExplanationOfBenefit | PriorAuth | PA Decision Expiration Date | PA Decision Expiration Date | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/PA-DECISION-EXP-DT').value | 2021-09-08 | CWF | ||||||
| 316 | 314 | ExplanationOfBenefit | PriorAuth | Service Counts | Service Counts | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/SERVICE-CNTS').value | 13 | CWF | ||||||
| 317 | 315 | ExplanationOfBenefit | PriorAuth | Service Rendering State | Service Rendering State | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/SVC-RENDER-ST').value.code | TX | CWF | ||||||
| 318 | 316 | ExplanationOfBenefit | PriorAuth | MR Count Indicator | MR Count Indicator | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/MR-COUNT-IND').value | 43 | CWF | ||||||
| 319 | 317 | ExplanationOfBenefit | PriorAuth | MR Count Start Date | MR Count Start Date | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/MR-COUNT-ST-DT').value | 2020-08-19 | CWF | ||||||
| 320 | 318 | ExplanationOfBenefit | PriorAuth | MR Count End Date | MR Count End Date | ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/MR-COUNT-END-DT').value | 2021-08-19 | CWF | ||||||
| 321 | 319 | ExplanationOfBenefit | PriorAuth | RRB Exclusion Indicator | RRB Exclusion Indicator | iif(ExplanationOfBenefit.item.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/RRB-EXCL-IND').value = true, 'Y', ' ') | ['Y'] | CWF | ||||||
| 322 | 320 | Patient | Beneficiary First Name | A first name for a Medicare beneficiary. | Patient.name.given[0] | Frankie | V2_MDCR_BENE_HSTRY | BENE_1ST_NAME | CCLF8.BENE_1ST_NAME | BENE_GVN_NAME | ||||
| 323 | 321 | Patient | Beneficiary Last Name | A last name or surname, including any following titles or suffixes, for a Medicare beneficiary. | Patient.name.family | Sheep | V2_MDCR_BENE_HSTRY | BENE_LAST_NAME | CCLF8.BENE_LAST_NAME | BENE_SRNM_NAME | ||||
| 324 | 322 | Patient | Beneficiary Middle Name | The first initial of the Medicare beneficiarys middle name. | Patient.name.given[1] | Le Petit Prince | V2_MDCR_BENE_HSTRY | BENE_MIDL_NAME | CCLF8.BENE_MIDL_NAME | BENE_MDL_NAME | ||||
| 325 | 323 | Patient | Beneficiary Date of Birth | A date identifying when a beneficiary is born. | Patient.birthDate | 1995-03-11 | V2_MDCR_BENE_HSTRY | BENE_BRTH_DT | CCLF8.BENE_DOB | BENE_BIRTH_DT | ||||
| 326 | 324 | Patient | Beneficiary Date of Death | A date identifying when a beneficiary died. | Patient.deceasedDateTime | 2024-03-11 | V2_MDCR_BENE_HSTRY | BENE_DEATH_DT | CCLF8.BENE_DEATH_DT | BENE_DEATH_DT | ||||
| 327 | 325 | Patient | Current Patient FHIR ID | The current Patient ID for the beneficary. | iif(Patient.link.where(type = 'replaced-by').other.exists(),Patient.link.where(type = 'replaced-by').other.reference.substring(8),Patient.id) | ['123456789'] | V2_MDCR_BENE_HSTRY | BENE_XREF_EFCTV_SK | ||||||
| 328 | 326 | Patient | Beneficiary Source Key List | A list of all source keys for the beneficiary. | Patient.link.other.display.union(Patient.id) | ['123456789'] | ||||||||
| 329 | 327 | Patient | Patient FHIR ID | A unique number assigned by the enrollment database (EDB) to each EDB record to identify a beneficiary. | Patient.id | 123456789 | V2_MDCR_BENE_HSTRY | BENE_SK | ||||||
| 330 | 328 | Patient | Last Updated Time | The time the Patient resource was last updated. | Patient.meta.lastUpdated | 2020-01-07T03:02:28.000000Z | ||||||||
| 331 | 329 | Patient | USPS State Code | A code identifying the two-character alphabetic abbreviation for a state in the United States as defined by the United States Postal Service (USPS). Reference table: GEO_USPS_STATE_CD | Patient.address.state | TX | V2_MDCR_BENE_HSTRY | GEO_USPS_STATE_CD | CCLF8.GEO_USPS_STATE_CD | BENE_STATE_CD | ||||
| 332 | 330 | Patient | Beneficiary Zip Code - First 5 | A five-digit ZIP code defined by the United States Postal Service (USPS) that identifies the destination post office or delivery area. Reference table: GEO_ZIP5_CD | Patient.address.postalCode | 77840 | V2_MDCR_BENE_HSTRY | GEO_ZIP5_CD | CCLF8.GEO_ZIP5_CD | BENE_MLG_CNTCT_ZIP_CD | ||||
| 333 | 331 | Patient | City Name | A name of the city for a given ZIP code of a Medicare beneficiary's mailing address. Reference table: GEO_ZIP5_CD | Patient.address.city | College Station | V2_MDCR_BENE_HSTRY | GEO_ZIP_PLC_NAME | CCLF8.GEO_ZIP_PLC_NAME | CITY_NAME | ||||
| 334 | 332 | Patient | Contact Language Code | A code identifying the language that the beneficiary requested Centers for Medicare and Medicaid Services (CMS) use when sending the Medicare handbook. English and Spanish are the only language choices that CMS supports. This language preference code is used exclusively for the Medicare handbook. It is not used for any other type of mail sent to beneficiaries. Reference table: CNTCT_LANG_CD | Patient.communication.language.coding.where(system='urn:ietf:bcp:47').code | en | V2_MDCR_BENE_HSTRY | CNTCT_LANG_CD | ||||||
| 335 | 333 | Patient | Beneficiary Sex Code | A code identifying the sex of a Medicare beneficiary. Reference table: BENE_SEX_CD | Patient.extension.where(url='http://hl7.org/fhir/us/core/StructureDefinition/us-core-sex').value | 248152002 | V2_MDCR_BENE_HSTRY | BENE_SEX_CD | CCLF8.BENE_SEX_CD | BENE_SEX_IDENT_CD | ||||
| 336 | 334 | Patient | Beneficiary Race Code | A code identifying a beneficiary's race. Reference table: BENE_RACE_CD | Patient.extension.where(url='http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity' or url='http://hl7.org/fhir/us/core/StructureDefinition/us-core-race').extension.valueCoding | {'system': 'urn:oid:2.16.840.1.113883.6.238', 'code': '2135-2', 'display': 'Hispanic or Latino'} | V2_MDCR_BENE_HSTRY | BENE_RACE_CD | CCLF8.BENE_RACE_CD | BENE_RACE_CD | ||||
| 337 | 335 | Patient | Medicare Beneficiary Identifier | An identifier that uniquely identifies a beneficiary and replaces the Health Insurance Claim Number (HICN) on Medicare cards. The format of the Medicare Beneficiary Identifier (MBI) is 11-positions in length and contains the following values: position 1 numeric values: 1 - 9 position 2 alphabetic values: A - Z (minus S, L, O, I, B, Z) position 3 alphanumeric values: 0 - 9 and A - Z (minus S, L, O, I, B, Z) position 4 numeric values: 0 - 9 position 5 alphabetic values: A - Z (minus S, L, O, I, B, Z) position 6 alphanumeric values: 0 - 9 and a - z (minus S, L, O, I, B, Z) position 7 numeric values: 0 - 9 position 8 alphabetic values: A - Z (minus S, L, O, I, B, Z) position 9 alphabetic values: A - Z (minus S, L, O, I, B, Z) position 10 numeric values: 0 - 9 position 11 numeric values: 0 - 9 | Patient.identifier.where(system='http://hl7.org/fhir/sid/us-mbi').value | AAA1AA0AA11 | V2_MDCR_BENE_HSTRY | BENE_MBI_ID | CCLF1.BENE_MBI_ID;CCLF2.BENE_MBI_ID;CCLF3.BENE_MBI_ID;CCLF4.BENE_MBI_ID;CCLF5.BENE_MBI_ID;CCLF6.BENE_MBI_ID;CCLF7.BENE_MBI_ID;CCLF8.BENE_MBI_ID;CCLF9.CRNT_NUM;CCLF9.PRVS_NUM;CCLFA.BENE_MBI_ID;CCLFB.BENE_MBI_ID | MBI_NUM | ||||
| 338 | 336 | Patient | MBI Effective Date | The effective date when an MBI is assigned to a beneficiary. | Patient.identifier.where(system='http://hl7.org/fhir/sid/us-mbi').period.start | 2017-05-11 | V2_MDCR_BENE_MBI_ID | BENE_MBI_EFCTV_DT | CCLF9.PRVS_ID_EFCTV_DT | EFCTV_BGN_DT | ||||
| 339 | 337 | Patient | MBI Obsolete Date | The end date when an MBI period is closed due to being compromised or involved in a merge cross reference action. (replaced by a new MBI). | Patient.identifier.where(system='http://hl7.org/fhir/sid/us-mbi').period.end | 2017-07-01 | V2_MDCR_BENE_MBI_ID | BENE_MBI_OBSLT_DT | CCLF9.PRVS_ID_OBSLT_DT | EFCTV_END_DT | ||||
| 340 | 338 | Coverage | PartA;PartB | Coverage Part | The 'Part' of Medicare Coverage desired to transform. | Coverage.class.where(type.coding.code='plan').value | Part A | |||||||
| 341 | 339 | Coverage | PartA;PartB | Beneficiary MBI ID | An identifier that uniquely identifies a beneficiary and replaces the Health Insurance Claim Number (HICN) on Medicare cards. The format of the Medicare Beneficiary Identifier (MBI) is 11-positions in length and contains the following values: position 1 numeric values: 1 - 9 position 2 alphabetic values: A - Z (minus S, L, O, I, B, Z position 3 alphanumeric values: 0 - 9 and A - Z (minus S, L, O, I, B, Z) position 4 numeric values: 0 - 9 position 5 alphabetic values: A - Z (minus S, L, O, I, B, Z) position 6 alphanumeric values: 0 - 9 and a - z (minus S, L, O, I, B, Z) position 7 numeric values: 0 - 9 position 8 alphabetic values: A - Z (minus S, L, O, I, B, Z) position 9 alphabetic values: A - Z (minus S, L, O, I, B, Z) position 10 numeric values: 0 - 9 position 11 numeric values: 0 - 9 | Coverage.subscriberId | ABB2BB0BB22 | V2_MDCR_BENE | BENE_MBI_ID | |||||
| 342 | 340 | Coverage | PartA;PartB | Beneficiary FHIR ID | A unique number assigned by the Enrollment Database (EDB) to each EDB record to identify a beneficiary. | Coverage.beneficiary.reference.substring(8) | 123456789 | V2_MDCR_BENE | BENE_SK | |||||
| 343 | 341 | Coverage | PartA;PartB | Medicare Status Code | A code identifying the reason for a beneficiary's entitlement to Medicare benefits. Reference table: BENE_MDCR_STUS_CD | Coverage.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/BENE-MDCR-STUS-CD').value.code | 31 | V2_MDCR_BENE_MDCR_STUS | BENE_MDCR_STUS_CD | https://bluebutton.cms.gov/fhir/CodeSystem/BENE-MDCR-STUS-CD | CCLF8.BENE_MDCR_STUS_CD | BENE_MDCR_STATUS_CD | ||
| 344 | 342 | Coverage | PartA;PartB | Medicare Entitlement Status Code | The reason for entitlement or termination of a beneficiary's benefits during a period of coverage. | Coverage.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/BENE-MDCR-ENTLMT-STUS-CD').value.code | E | V2_MDCR_BENE_MDCR_ENTLMT | BENE_MDCR_ENTLMT_STUS_CD | https://bluebutton.cms.gov/fhir/CodeSystem/BENE-MDCR-ENTLMT-STUS-CD | BENE_PTA_TRMNTN_CD;BENE_PTB_TRMNTN_CD | |||
| 345 | 343 | Coverage | PartA;PartB | Buy-in Code | A code that indicates the reason for part a/part b state buy-in eligibility. | Coverage.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/BENE-BUYIN-CD').value.code | A | V2_MDCR_BENE_TP | BENE_BUYIN_CD | https://bluebutton.cms.gov/fhir/CodeSystem/BENE-BUYIN-CD | CCLF8.BENE_ENTLMT_BUYIN_IND | MDCR_ENTLMT_BUYIN_1_IND;MDCR_ENTLMT_BUYIN_2_IND;MDCR_ENTLMT_BUYIN_3_IND;MDCR_ENTLMT_BUYIN_4_IND;MDCR_ENTLMT_BUYIN_5_IND;MDCR_ENTLMT_BUYIN_6_IND;MDCR_ENTLMT_BUYIN_7_IND;MDCR_ENTLMT_BUYIN_8_IND;MDCR_ENTLMT_BUYIN_9_IND;MDCR_ENTLMT_BUYIN_10_IND;MDCR_ENTLMT_BUYIN_11_IND;MDCR_ENTLMT_BUYIN_12_IND | ||
| 346 | 344 | Coverage | PartA;PartB | Beneficiary Range Begin Date | The primary begin date for a beneficiary date range. | Coverage.period.start | 2018-04-11 | V2_MDCR_BENE_MDCR_ENTLMT | BENE_RNG_BGN_DT | CCLF8.BENE_PART_A_ENRLMT_BGN_DT;CCLF8.BENE_PART_B_ENRLMT_BGN_DT | COVSTART | |||
| 347 | 345 | Coverage | PartA;PartB | Beneficiary Range End Date | The primary end date for a beneficiary date range. | Coverage.period.end | V2_MDCR_BENE_MDCR_ENTLMT | BENE_RNG_END_DT | ||||||
| 348 | 346 | Coverage | PartA;PartB | Last Updated Time | The date the coverage information was last updated | Coverage.meta.lastUpdated | 2020-01-07T03:02:28.000000Z | |||||||
| 349 | 347 | Coverage | PartA;PartB | Beneficiary Enrollment Reason Code | The reason for a beneficiary's enrolment to Part A/Part B benefits. | Coverage.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/BENE-ENRLMT-RSN-CD').value.code | I | V2_MDCR_BENE_MDCR_ENTLMT | BENE_MDCR_ENRLMT_RSN_CD | https://bluebutton.cms.gov/fhir/CodeSystem/BENE-MDCR-ENRLMT-RSN-CD | ||||
| 350 | 348 | Coverage | PartA;PartB | Beneficiary Entitlement Reason Code | A code identifying the basis in determining a beneficiary's entitlement to Medicare benefits. | Coverage.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/BENE-MDCR-ENTLMT-RSN-CD').value.code | 2 | V2_MDCR_BENE_MDCR_ENTLMT_RSN | BENE_MDCR_ENTLMT_RSN_CD | https://bluebutton.cms.gov/fhir/CodeSystem/BENE-MDCR-ENTLMT-RSN-CD | CCLF8.BENE_ORGNL_ENTLMT_RSN_CD | BENE_ENTLMT_RSN_ORIG | ||
| 351 | 349 | Coverage | PartA;PartB | Beneficiary ESRD Status ID | A beneficiary's end stage renal disease status indicator. | Coverage.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/BENE-ESRD-STUS-ID').value.code | Y | V2_MDCR_BENE_MDCR_STUS_CD | BENE_ESRD_STUS_ID | https://bluebutton.cms.gov/fhir/CodeSystem/BENE-ESRD-STUS-ID | BENE_ESRD_IND | |||
| 352 | 350 | Coverage | PartA;PartB | Beneficiary Disabled Status Code | AN IDENTIFIER INDICATING WHETHER DISABILITY IS A REASON FOR A BENEFICIARYS ENTITLEMENT TO MEDICARE. | Coverage.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/BENE-DSBLD-STUS-ID').value.code | N | V2_MDCR_BENE_MDCR_STUS_CD | BENE_DSBLD_STUS_ID | https://bluebutton.cms.gov/fhir/CodeSystem/BENE-DSBLD-STUS-ID | ||||
| 353 | 351 | Coverage | DUAL | Beneficiary Dual Status Code | A code identifying the entitlement status for a dual eligible beneficiary. | Coverage.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/BENE-DUAL-STUS-CD').value.code | 01 | V2_MDCR_BENE_CMBND_DUAL_MDCR | BENE_DUAL_STUS_CD | https://bluebutton.cms.gov/fhir/CodeSystem/BENE-DUAL-STUS-CD | CCLF8.BENE_DUAL_STUS_CD | DUAL_STUS_CD_01;DUAL_STUS_CD_02;DUAL_STUS_CD_03;DUAL_STUS_CD_04;DUAL_STUS_CD_05;DUAL_STUS_CD_06;DUAL_STUS_CD_07;DUAL_STUS_CD_08;DUAL_STUS_CD_09;DUAL_STUS_CD_10;DUAL_STUS_CD_11;DUAL_STUS_CD_12 | ||
| 354 | 352 | Coverage | DUAL | Medicare/Medicaid Dual Type Code | A code identifying a beneficiary's dual Medicaid designation, whether a beneficiary is partial or dual Medicare. | Coverage.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/BENE-DUAL-TYPE-CD').value.code | P | V2_MDCR_BENE_CMBND_DUAL_MDCR | BENE_DUAL_TYPE_CD | https://bluebutton.cms.gov/fhir/CodeSystem/BENE-DUAL-TYPE-CD | ||||
| 355 | 353 | Coverage | DUAL | Medicaid State Code | A code identifying the two-character alphabetic abbreviation for a state in the United States as defined by the United States Postal Service (USPS) associated with a beneficiary, provider, or claim address and used in the geocoding process. | Coverage.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/MEDICAID-STATE-CD').value.code | TX | V2_MDCR_BENE_CMBND_DUAL_MDCR | GEO_USPS_STATE_CD | |||||
| 356 | 354 | Coverage | DUAL | Medicaid Eligibility Begin Date | A date that indicates the beginning of a beneficiary's Medicaid eligibility period. It is the effective start date of the Medicaid period calculated according to Medicare Advantage Prescription Drug (MARX) requirements. The date will always be the first of a month. | Coverage.period.start | 2018-04-11 | V2_MDCR_BENE_CMBND_DUAL_MDCR | BENE_MDCD_ELGBLTY_BGN_DT | |||||
| 357 | 355 | Coverage | DUAL | Medicaid Eligibility End Date | A date that indicates the end of a beneficiary's Medicaid eligibility period. It is the effective end date of the Medicaid period calculated according to Medicare Advantage Prescription Drug (MARX) requirements. The date will always be the end of a month or 12/31/9999. | Coverage.period.end | V2_MDCR_BENE_CMBND_DUAL_MDCR | BENE_MDCD_ELGBLTY_END_DT | ||||||
| 358 | 356 | Coverage | PartC;PartD | Beneficiary Enrollment Begin Date | The date that the beneficiary enrolled in the service election. [Source: plan transaction, automatic enrollment] | Coverage.period.start | 2018-04-11 | V2_MDCR_BENE_MAPD_ENRLMT | BENE_ENRLMT_BGN_DT | |||||
| 359 | 357 | Coverage | PartC;PartD | Beneficiary Enrollment End Date | The date that the beneficiary disenrolled in the service elections. | Coverage.period.end | V2_MDCR_BENE_MAPD_ENRLMT | BENE_ENRLMT_END_DT | ||||||
| 360 | 358 | Coverage | PartC;PartD | Beneficiary Contract Number | Unique identifier enabling an entity to provide coverage to eligible Medicare beneficiaries. | Coverage.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/BENE-CNTRCT-NUM').value | H1234 | V2_MDCR_BENE_MAPD_ENRLMT | BENE_CNTRCT_NUM | PTC_CNTRCT_ID_01;PTC_CNTRCT_ID_02;PTC_CNTRCT_ID_03;PTC_CNTRCT_ID_04;PTC_CNTRCT_ID_05;PTC_CNTRCT_ID_06;PTC_CNTRCT_ID_07;PTC_CNTRCT_ID_08;PTC_CNTRCT_ID_09;PTC_CNTRCT_ID_10;PTC_CNTRCT_ID_11;PTC_CNTRCT_ID_12;PTD_CNTRCT_ID_01;PTD_CNTRCT_ID_02;PTD_CNTRCT_ID_03;PTD_CNTRCT_ID_04;PTD_CNTRCT_ID_05;PTD_CNTRCT_ID_06;PTD_CNTRCT_ID_07;PTD_CNTRCT_ID_08;PTD_CNTRCT_ID_09;PTD_CNTRCT_ID_10;PTD_CNTRCT_ID_11;PTD_CNTRCT_ID_12 | ||||
| 361 | 359 | Coverage | PartC;PartD | Beneficiary PBP Number | A unique identifier for the plan benefit package offered under the contract. For Part D this number is a unique identification for an agreement between CMS and a Part D provider enabling the Part D provider to provide drug coverage to eligible beneficiaries. MARX definition: a 3-position numeric identifier assigned to a Plan Benefit Package (PBP) offered within a managed care or prescription drug contract. Values beginning with 8 are reserved for employer group plans. A value of 999 is reserved for cost contractors who do not choose to offer a prescription drug benefit | Coverage.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/BENE-PBP-NUM').value | 001 | V2_MDCR_BENE_MAPD_ENRLMT | BENE_PBP_NUM | PTC_PBP_ID_01;PTC_PBP_ID_02;PTC_PBP_ID_03;PTC_PBP_ID_04;PTC_PBP_ID_05;PTC_PBP_ID_06;PTC_PBP_ID_07;PTC_PBP_ID_08;PTC_PBP_ID_09;PTC_PBP_ID_10;PTC_PBP_ID_11;PTC_PBP_ID_12;PTD_PBP_ID_01;PTD_PBP_ID_02;PTD_PBP_ID_03;PTD_PBP_ID_04;PTD_PBP_ID_05;PTD_PBP_ID_06;PTD_PBP_ID_07;PTD_PBP_ID_08;PTD_PBP_ID_09;PTD_PBP_ID_10;PTD_PBP_ID_11;PTD_PBP_ID_12 | ||||
| 362 | 360 | Coverage | PartC;PartD | Beneficiary Coverage Type Code | A code identifying the type of coverage in which the beneficiary is enrolled. Reference table: BENE_CVRG_TYPE_CD | Coverage.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/BENE-CVRG-TYPE-CD').value.code | 3 | V2_MDCR_BENE_MAPD_ENRLMT | BENE_CVRG_TYPE_CD | https://bluebutton.cms.gov/fhir/CodeSystem/BENE-CVRG-TYPE-CD | PTC_PLAN_TYPE_CD_01;PTC_PLAN_TYPE_CD_02;PTC_PLAN_TYPE_CD_03;PTC_PLAN_TYPE_CD_04;PTC_PLAN_TYPE_CD_05;PTC_PLAN_TYPE_CD_06;PTC_PLAN_TYPE_CD_07;PTC_PLAN_TYPE_CD_08;PTC_PLAN_TYPE_CD_09;PTC_PLAN_TYPE_CD_10;PTC_PLAN_TYPE_CD_11;PTC_PLAN_TYPE_CD_12 | |||
| 363 | 361 | Coverage | PartC;PartD | Contract PBP Name | Text label describing the PBP, usually the product name. | Coverage.contained.where(resourceType='Organization').name | Sample Medicare Advantage Plan | V2_MDCR_CNTRCT_PBP_NUM | CNTRCT_PBP_NAME | |||||
| 364 | 362 | Coverage | PartC;PartD | Contract Plan Contact Telephone Number | A sequence of numbers that identifies a particular telephone and that must be dialed for the caller to connect to the telephone of the contact. | Coverage.contained.where(resourceType='Organization').contact.telecom.where(system='phone').value | 1-800-555-1234 | V2_MDCR_CNTRCT_PBP_CNTCT | CNTRCT_PLAN_CNTCT_TEL_NUM | |||||
| 365 | 363 | Coverage | PartD | Beneficiary PDP Enrollment Member ID Number | Member ID assigned to the beneficiary. | Coverage.class.where(type.coding.code='rxid').value | M123456789 | V2_MDCR_BENE_MAPD_ENRLMT_RX | BENE_PDP_ENRLMT_MMBR_ID_NUM | |||||
| 366 | 364 | Coverage | PartD | Beneficiary PDP Enrollment Group Number | Identifying number assigned to the cardholder group or employer group. | Coverage.class.where(type.coding.code='rxgroup').value | G987654321 | V2_MDCR_BENE_MAPD_ENRLMT_RX | BENE_PDP_ENRLMT_GRP_NUM | |||||
| 367 | 365 | Coverage | PartD | Beneficiary PDP Enrollment Processor Number | Number assigned by the processor. | Coverage.class.where(type.coding.code='rxpcn').value | P123456 | V2_MDCR_BENE_MAPD_ENRLMT_RX | BENE_PDP_ENRLMT_PRCSR_NUM | |||||
| 368 | 366 | Coverage | PartD | Beneficiary PDP Enrollment Bank ID Number | A card issuer identifier or a bank identifying number used for network routing. | Coverage.class.where(type.coding.code='rxbin').value | BIN123456 | V2_MDCR_BENE_MAPD_ENRLMT_RX | BENE_PDP_ENRLMT_BANK_ID_NUM | |||||
| 369 | 367 | Coverage | PartD | Beneficiary LIS Effective Code | Switch indicating that this record is the current effective Low Income Subsidy (LIS) determination record. | Coverage.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/BENE-LIS-EFCTV-CD').value.code | Y | V2_MDCR_BENE_LIS | BENE_LIS_EFCTV_CD | https://bluebutton.cms.gov/fhir/CodeSystem/BENE-LIS-EFCTV-CD | CST_SHR_GRP_CD_01;CST_SHR_GRP_CD_02;CST_SHR_GRP_CD_03;CST_SHR_GRP_CD_04;CST_SHR_GRP_CD_05;CST_SHR_GRP_CD_06;CST_SHR_GRP_CD_07;CST_SHR_GRP_CD_08;CST_SHR_GRP_CD_09;CST_SHR_GRP_CD_10;CST_SHR_GRP_CD_11;CST_SHR_GRP_CD_12 | |||
| 370 | 368 | Coverage | PartD | Beneficiary LIS Copayment Level Code | A code identifying the generic level used to compute the Low Income Subsidy (LIS) co-payment amount. This generic level translates to a specific numeric value that will be used in the computation. Reference table: BENE_LIS_COPMT_LVL_CD | Coverage.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/BENE-LIS-COPMT-LVL-CD').value.code | 1 | V2_MDCR_BENE_LIS | BENE_LIS_COPMT_LVL_CD | https://bluebutton.cms.gov/fhir/CodeSystem/BENE-LIS-COPMT-LVL-CD | CST_SHR_GRP_CD_01;CST_SHR_GRP_CD_02;CST_SHR_GRP_CD_03;CST_SHR_GRP_CD_04;CST_SHR_GRP_CD_05;CST_SHR_GRP_CD_06;CST_SHR_GRP_CD_07;CST_SHR_GRP_CD_08;CST_SHR_GRP_CD_09;CST_SHR_GRP_CD_10;CST_SHR_GRP_CD_11;CST_SHR_GRP_CD_12 | |||
| 371 | 369 | Coverage | PartD | Beneficiary LIS Part D Premium Percentage | Identifies the portion of the Part D premium subsidized, based on a sliding scale linked to the Federal Poverty Level (FPL) percentage. If the person is under 135% FPL the premium subsidy percent will be 100%. If the person is 136-140% FPL the premium subsidy percent will be 75%. If the person is 141-145% FPL the premium subsidy will be 50%. If the person is 146-149% FPL the premium subsidy will be 25%. | Coverage.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/BENE-LIS-PTD-PRM-PCT').value | 100 | V2_MDCR_BENE_LIS | BENE_LIS_PTD_PRM_PCT | CST_SHR_GRP_CD_01;CST_SHR_GRP_CD_02;CST_SHR_GRP_CD_03;CST_SHR_GRP_CD_04;CST_SHR_GRP_CD_05;CST_SHR_GRP_CD_06;CST_SHR_GRP_CD_07;CST_SHR_GRP_CD_08;CST_SHR_GRP_CD_09;CST_SHR_GRP_CD_10;CST_SHR_GRP_CD_11;CST_SHR_GRP_CD_12 | ||||
| 372 | 370 | Coverage | PartD | Contract PBP Segment Number | Identification number for a portion of the PBP designated as a Segment. Must be present. | Coverage.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/CNTRCT-PBP-SGMT-NUM').value | 000 | V2_MDCR_CNTRCT_PBP_SGMT | CNTRCT_PBP_SGMT_NUM | PTD_SGMT_ID_01;PTD_SGMT_ID_02;PTD_SGMT_ID_03;PTD_SGMT_ID_04;PTD_SGMT_ID_05;PTD_SGMT_ID_06;PTD_SGMT_ID_07;PTD_SGMT_ID_08;PTD_SGMT_ID_09;PTD_SGMT_ID_10;PTD_SGMT_ID_11;PTD_SGMT_ID_12 | ||||
| 373 | 371 | Coverage | PartD | Retiree Drug Subsidy Switch | A switch indicating that enrollment in Part D was requested by the beneficiary who has employer subsidy enrollment. | Coverage.extension.where(url='https://bluebutton.cms.gov/fhir/StructureDefinition/BENE-ENRLMT-EMPLR-SBSDY-SW').value | {'system': 'https://bluebutton.cms.gov/fhir/CodeSystem/BENE-ENRLMT-EMPLR-SBSDY-SW', 'code': 'Y'} | V2_MDCR_BENE_MAPD_ENRLMT | BENE_ENRLMT_EMPLR_SBSDY_SW | https://bluebutton.cms.gov/fhir/CodeSystem/BENE-ENRLMT-EMPLR-SBSDY-SW | RDS_IND_01;RDS_IND_02;RDS_IND_03;RDS_IND_04;RDS_IND_05;RDS_IND_06;RDS_IND_07;RDS_IND_08;RDS_IND_09;RDS_IND_10;RDS_IND_11;RDS_IND_12 |