[ X12 Examples ]
Com1 Software 837I Institutional Claims Example
Posted: Friday, November 04 2022 5:15:44 PM
Com1 Software, Inc.
P.O. Box 482
Hudson, Ohio 44236
(330) 653-3771
information@com1software.com
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837I Institutional Claims Example
837I Institutional Claims source file.
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *080319*2327*U*00501*002721171*0*P*:~ GS*HC*SENDER*RECEIVER*20080319*2327*27211711*X*005010X223A1~ ST*837*987654~ BHT*0019*00*0123*19960918*0932*CH~ REF*87*004010X096~ NM1*40*2*MEDICARE*****46*00120~ PER*IC*JANE DOE*TE*9005555555~ NM1*41*2*SMITH HOSPITAL*****46*12345~ HL*1**20*1~ PRV*BI*ZZ*203BA0200N~ NM1*85*2*JONES HOSPITAL*****XX*330127~ PRV*AT*ZZ*363LP0200N~ N3*225 MAIN STREET BARKLEY BUILDING~ N4*CENTERVILLE*PA*17111~ REF*G2*987654080~ HL*2*1*22*0~ SBR*P*18*******MB~ NM1*IL*1*BIRTHDAYLESS*STEVE*B***MI*030005074A~ NM1*PR*2*MEDICARE B*****PI*00435~ N3*111 ROAD*~ N4*AKRON*OH*011000000*~ PAT*01*~ NM1*QC*1*TESTER*JOE*X*~ N3*000 STREET*APT 1001~ N4*PARMA*OH*000000000*~ DMG*D8*19580607*M*~ CLM*11111*89.93***14:A:1**Y*Y*Y~ DTP*434*D8*19960911~ CL1*3*1~ PWK*OZ*EL***AC*ZZY~ REF*D9*17312345600006351~ K3*INTO1111111~ NTE*TPO*12345~ HI*ABK:H269:::::::Y~ HI*ABJ:H33319~ HI*BN:E8859~ HI*PR:9999999999~ HI*ABF:H111:::::::U*ABF:H222:::::::Y~ HI*ABF:H333:::::::Y*ABF:H444:::::::U~ HI*BR:3612:D8:20080407~ HI*BQ:3722:D8:20080403*BQ:3615:D8:20090407*~ HI*BH:A1:D8:19261111*BH:A2:D8:19911101* BH:B1:D8:19261111*BH:B2:D8:19870101~ HI*BE:A2:::15.31~ HI*BG:09~ NM1*71*1*JONES*JOHN*J***XX*B99937~ PRV*AT*ZZ*363LP0200N~ SBR*S*01*351630*STATE TEACHERS*GP****CI~ DMG***F~ OI***Y***Y~ NM1*IL*1*SECONDARY*JANE*S***MI*222004433~ N3*222 Second Street AVENUE~ N4*Second*PA*11111~ NM1*PR*2*Second TEACHERS*****PI*1135~ SBR*T*02*11111*Ohio TEACHERS*GP****CI~ DMG***F~ OI***Y***Y~ NM1*IL*1*Third*JANE*S***MI*222004433~ N3*333 Third AVENUE~ N4*Third*111~ NM1*PR*2*Third TEACHERS*****PI*1135~ LX*1~ SV2*305*HC:85025*13.39*UN*1~ DTP*472*D8*19960911~ LX*2~ SV2*730*HC:93005*76.54*UN*3~ DTP*472*D8*19960911~ CLM*1818181*11.11***14:A:1**Y*Y*Y~ DTP*434*D8*19960911~ CL1*3*1~ PWK*OZ*EL***AC*ZZY~ REF*D9*17312345600006351~ K3*INTO1123456~ NTE*TPO*12345~ HI*BK:000*BJ:000.00~ HI*BF:111.0*BF:111.11~ HI*BR:3612:D8:20080407~ HI*BQ:3722:D8:20080403*BQ:3615:D8:20090407*~ HI*BH:A1:D8:19261111*BH:A2:D8:19911101* BH:B1:D8:19261111*BH:B2:D8:19870101~ HI*BE:A2:::15.31~ HI*BG:09~ NM1*71*1*JONES*JOHN*J***XX*B99937~ PRV*AT*ZZ*363LP0200N~ SBR*S*01*351630*STATE TEACHERS*GP****CI~ DMG***F~ OI***Y***Y~ NM1*IL*1*SECONDARY*JANE*S***MI*222004433~ N3*222 Second Street AVENUE~ N4*Second*PA*11111~ NM1*PR*2*Second TEACHERS*****PI*1135~ SBR*T*02*11111*Ohio TEACHERS*GP****CI~ DMG***F~ OI***Y***Y~ NM1*IL*1*Third*JANE*S***MI*222004433~ N3*333 Third AVENUE~ N4*Third*111~ NM1*PR*2*Third TEACHERS*****PI*1135~ LX*1~ SV2*306*HC:85025*13.39*UN*1~ DTP*472*D8*19960911~ HL*2*1*22*0~ SBR*P*18*******MB~ NM1*IL*1*DOE*JOHN*T***MI*030005074A~ N3*111 Town AVENUE~ N4*CENTERVILLE*PA*17111~ DMG*D8*19261111*M~ NM1*PR*2*MEDICARE B*****PI*00435~ PAT*01*~ NM1*QC*1*Testing*Jane*X*~ N3*888 STREET*~ N4*PARMA*OH*1111111111*~ DMG*D8*19550607*F*~ CLM*711111*289.93***14:A:1**Y*Y*Y~ DTP*434*D8*19960911~ CL1*3*1~ HI*BK:366.9*BJ:361.32~ HI*BF:401.9*BF:794.31~ HI*BR:3612:D8:20080407~ HI*BQ:3722:D8:20080403*BQ:3615:D8:20090407*~ HI*BH:A1:D8:19261111*BH:A2:D8:19911101* BH:B1:D8:19261111*BH:B2:D8:19870101~ HI*BE:A2:::15.31~ HI*BG:09~ NM1*71*1*JONES*JOHN*J***XX*B99937~ PRV*AT*ZZ*363LP0200N~ SBR*S*01*351630*STATE TEACHERS*GP****CI~ DMG***F~ OI***Y***Y~ NM1*IL*1*DOE*JANE*S***MI*222004433~ N3*333 CITY AVENUE~ N4*CENTERVILLE*PA*17111~ NM1*PR*2*STATE TEACHERS*****PI*1135~ LX*1~ SV2*307*HC:85025*13.39*UN*1~ DTP*472*D8*19960911~ LX*2~ SV2*731*HC:93005*76.54*UN*3~ DTP*472*D8*19960911~ HL*2*1*22*0~ SBR*P*18*******MB~ NM1*IL*1*WEST*JANE*T***MI*030005074A~ N3*444 CITY AVENUE~ N4*CENTERVILLE*PA*17111~ DMG*D8*19261111*M~ NM1*PR*2*MEDICARE B*****PI*00435~ CLM*752111111*989.93***14:A:1**Y*Y*Y~ DTP*434*D8*19960911~ CL1*3*1~ HI*BK:366.9*BJ:361.32~ HI*BF:401.9*BF:794.31~ HI*BR:3612:D8:20080407~ HI*BQ:3722:D8:20080403*BQ:3615:D8:20090407~ HI*BH:A1:D8:19261111~ BH:B1:D8:19261111*BH:B2:D8:19870101~ HI*BE:A2:::15.31~ HI*BG:09~ NM1*71*1*JONES*JOHN*J***XX*B99937~ PRV*AT*ZZ*363LP0200N~ SBR*S*01*351630*STATE TEACHERS*GP****CI~ DMG***F~ OI***Y***Y~ NM1*IL*1*DOE*JANE*S***MI*222004433~ N3*555 CITY AVENUE~ N4*CENTERVILLE*PA*17111~ NM1*PR*2*STATE TEACHERS*****PI*1135~ LX*1~ SV2*308*HC:85025*13.39*UN*1~ DTP*472*D8*19960911~ LX*2~ SV2*732*HC:93005*76.54*UN*3~ DTP*472*D8*19960911~ HL*2*1*22*0~ SBR*P*18*******MB~ NM1*IL*1*DOE*JOHN*T***MI*030005074A~ N3*1234567 CITY AVENUE~ N4*CENTERVILLE*PA*17111~ DMG*D8*19261111*M~ NM1*PR*2*MEDICARE B*****PI*00435~ CLM*756aaa*9.93***14:A:1**Y*Y*Y~ DTP*434*D8*19960911~ CL1*3*1~ HI*BK:366.9*BJ:361.32~ HI*BF:401.9*BF:794.31~ HI*BR:3612:D8:20080407~ HI*BQ:3722:D8:20080403*~ HI*BH:A1:D8:19261111~ BH:B1:D8:19261111*BH:B2:D8:19870101~ HI*BE:A2:::15.31~ HI*BG:09~ NM1*71*1*JONES*JOHN*J***XX*B99937~ PRV*AT*ZZ*363LP0200N~ SBR*S*01*351630*STATE TEACHERS*GP****CI~ DMG***F~ OI***Y***Y~ NM1*IL*1*DOE*JANE*S***MI*222004433~ N3*8888 CITY AVENUE~ N4*CENTERVILLE*PA*17111~ NM1*PR*2*STATE TEACHERS*****PI*1135~ LX*1~ SV2*309*HC:85025*13.39*UN*1~ DTP*472*D8*19960911~ LX*2~ SV2*734*HC:93005*76.54*UN*3~ DTP*472*D8*19960911~ HL*2*1*22*0~ SBR*P*18*******MB~ NM1*IL*1*WEST*JANE*T***MI*030005074A~ N3*1251010 CITY AVENUE~ N4*CENTERVILLE*PA*17111~ DMG*D8*19261111*M~ NM1*PR*2*MEDICARE B*****PI*00435~ CLM*44444*7777.93***14:A:1**Y*Y*Y~ DTP*434*D8*19960911~ CL1*3*1~ HI*BK:366.9*BJ:361.32~ HI*BF:401.9*BF:794.31~ HI*BR:3612:D8:20080407~ HI*BQ:3722:D8:20080403~ HI*BH:A1:D8:19261111*BH:A2:D8:19911101~ BH:B1:D8:19261111*BH:B2:D8:19870101~ HI*BE:A2:::15.31~ HI*BG:09~ NM1*71*1*JONES*JOHN*J***XX*B99937~ PRV*AT*ZZ*363LP0200N~ SBR*S*01*351630*STATE TEACHERS*GP****CI~ DMG***F~ OI***Y***Y~ NM1*IL*1*DOE*JANE*S***MI*222004433~ N3*78781 CITY AVENUE~ N4*CENTERVILLE*PA*17111~ NM1*PR*2*STATE TEACHERS*****PI*1135~ LX*1~ SV2*309*HC:85025*13.39*UN*1~ DTP*472*D8*19960911~ LX*2~ SV2*722*HC:93005*76.54*UN*3~ DTP*472*D8*19960911~ CLM*111111111*181818.99***14:A:1**Y*Y*Y~ DTP*434*D8*19960911~ CL1*3*1~ HI*BK:366.9*BJ:361.32~ HI*BF:401.9*BF:794.31~ HI*BR:3612:D8:20080407~ HI*BQ:3722:D8:20080403~ HI*BH:A1:D8:19261111*BH:A2:D8:19911101~ BH:B1:D8:19261111*BH:B2:D8:19870101~ HI*BE:A2:::15.31~ HI*BG:09~ NM1*71*1*JONES*JOHN*J***XX*B99937~ PRV*AT*ZZ*363LP0200N~ LX*1~ SV2*1111*HC:11111*11.11*UN*1~ DTP*472*D8*19960911~ SE*44*987654~ GE*1*27211711~ IEA*1*002721171~
Basic Inline
Base Mapping for the 837I
********** Com1 Software Parser Map ********** Generated :04/10/15 11:16:30 ********** (c) 1992-2015 COM1 SOFTWARE DEVELOPMENT ************************************************** ********* File Name : 837I.cfg ********* 837I Claim Submission Configuration ************************************************** X12TRANSACTIONTYPE=837I KEYHEADERFIELD=HL,,,20 KEYFIELD=HL,,,22 KEYDOCFIELD=CLM KEYLINEFIELD=SV2 FIELD=SUBID,16,NM1,IL,2,9 FIELD=BILLINGPROVIDERID,16,NM1,85,2,9,,,,2 FIELD=BILLINGPROVIDERNAME,32,NM1,85,2,3,,,,2 FIELD=BILLINGPROVIDERADDR1,30,N3,,,1,,BILLINGPROVIDERNAME,,2 FIELD=BILLINGPROVIDERADDR2,30,N3,,,2,,BILLINGPROVIDERNAME,,2 FIELD=BILLINGPROVIDERCITY,30,N4,,,1,,BILLINGPROVIDERNAME,,2 FIELD=BILLINGPROVIDERST,2,N4,,,2,,BILLINGPROVIDERNAME,,2 FIELD=BILLINGPROVIDERZIP,10,N4,,,3,,BILLINGPROVIDERNAME,,2 FIELD=PAYTOPROVIDERID,16,NM1,87,2,9,,,,2 FIELD=PAYTOPROVIDERNAME,32,NM1,87,2,3,,,,2 FIELD=PAYTOPROVIDERADDR1,30,N3,,,1,,PAYTOPROVIDERNAME,,2 FIELD=PAYTOPROVIDERADDR2,30,N3,,,2,,PAYTOPROVIDERNAME,,2 FIELD=PAYTOPROVIDERCITY,30,N4,,,1,,PAYTOPROVIDERNAME,,2 FIELD=PAYTOPROVIDERST,2,N4,,,2,,PAYTOPROVIDERNAME,,2 FIELD=PAYTOPROVIDERZIP,10,N4,,,3,,PAYTOPROVIDERNAME,,2 FIELD=PRIMARYCOV,1,SBR,P,2,1 FIELD=SECONDARYCOV,1,SBR,S,2,1 FIELD=TERTIARYCOV,1,SBR,T,2,1 FIELD=SUBLNAME,32,NM1,IL,2,3,,SUBID FIELD=SUBFNAME,32,NM1,IL,2,4,,SUBID FIELD=SUBMI,1,NM1,IL,2,5,,SUBID FIELD=SUBADDR1,30,N3,,,1,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBADDR2,30,N3,,,2,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBCITY,30,N4,,,1,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBST,2,N4,,,2,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBZIP,10,N4,,,3,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBSEX,1,DMG,,,3,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBMSTATUS,1,DMG,,,4,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBDOB,10,DMG,,,2,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBREL,3,SBR,,,2,,SUBID FIELD=SUBORDER,3,SBR,,,1,,SUBID FIELD=PAYERID,16,NM1,PR,2,9,,SUBID FIELD=PAYERNAME,32,NM1,PR,2,3,,PAYERID FIELD=PAYERADDR1,30,N3,,,1,,PAYERID FIELD=PAYERADDR2,30,N3,,,2,,PAYERID FIELD=PAYERCITY,30,N4,,,1,,PAYERID FIELD=PAYERST,2,N4,,,2,,PAYERID FIELD=PAYERZIP,10,N4,,,3,,PAYERID FIELD=PRIMARYSUBID,16,NM1,IL,2,9,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBLNAME,32,NM1,IL,2,3,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBFNAME,32,NM1,IL,2,4,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBMI,1,NM1,IL,2,5,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBADDR1,30,N3,,,1,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBADDR2,30,N3,,,2,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBCITY,30,N4,,,1,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBST,2,N4,,,2,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBZIP,10,N4,,,3,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBSEX,1,DMG,,,3,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBMSTATUS,1,DMG,,,4,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBDOB,10,DMG,,,2,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBREL,3,SBR,,,2,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYGRPPOLNUM,24,SBR,,,3,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYGRPNAME,32,SBR,,,4,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYINSTYPE,4,SBR,,,5,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYCFI,24,SBR,,,9,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYPAYERID,16,NM1,PR,2,9,,PRIMARYCOV FIELD=PRIMARYPAYERNAME,32,NM1,PR,2,3,,PRIMARYCOV FIELD=PRIMARYPAYERADDR1,30,N3,,,1,,PRIMARYCOV FIELD=PRIMARYPAYERADDR2,30,N3,,,2,,PRIMARYCOV FIELD=PRIMARYPAYERCITY,30,N4,,,1,,PRIMARYCOV FIELD=PRIMARYPAYERST,2,N4,,,2,,PRIMARYCOV FIELD=PRIMARYPAYERZIP,10,N4,,,3,,PRIMARYCOV FIELD=SECONDARYSUBID,16,NM1,IL,2,9,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBLNAME,32,NM1,IL,2,3,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBFNAME,32,NM1,IL,2,4,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBMI,1,NM1,IL,2,5,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBADDR1,30,N3,,,1,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBADDR2,30,N3,,,2,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBCITY,30,N4,,,1,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBST,2,N4,,,2,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBZIP,10,N4,,,3,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBSEX,1,DMG,,,3,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBMSTATUS,1,DMG,,,4,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBDOB,10,DMG,,,2,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBREL,3,SBR,,,2,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYGRPPOLNUM,24,SBR,,,3,,SECONDARYCOV,,,,,,,,SBR,P,2,SECONDARYPAYERID FIELD=SECONDARYGRPNAME,32,SBR,,,4,,SECONDARYCOV,,,,,,,,SBR,P,2,SECONDARYPAYERID FIELD=SECONDARYINSTYPE,4,SBR,,,5,,SECONDARYCOV,,,,,,,,SBR,P,2,SECONDARYPAYERID FIELD=SECONDARYCFI,24,SBR,,,9,,SECONDARYCOV,,,,,,,,SBR,P,2,SECONDARYPAYERID FIELD=SECONDARYPAYERID,16,NM1,PR,2,9,,SECONDARYCOV FIELD=SECONDARYPAYERNAME,32,NM1,PR,2,3,,SECONDARYCOV FIELD=SECONDARYPAYERADDR1,30,N3,,,1,,SECONDARYCOV FIELD=SECONDARYPAYERADDR2,30,N3,,,2,,SECONDARYCOV FIELD=SECONDARYPAYERCITY,30,N4,,,1,,SECONDARYCOV FIELD=SECONDARYPAYERST,2,N4,,,2,,SECONDARYCOV FIELD=SECONDARYPAYERZIP,10,N4,,,3,,SECONDARYCOV FIELD=TERTIARYSUBID,16,NM1,IL,2,9,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBLNAME,32,NM1,IL,2,3,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBFNAME,32,NM1,IL,2,4,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBMI,1,NM1,IL,2,5,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBADDR1,30,N3,,,1,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBADDR2,30,N3,,,2,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBCITY,30,N4,,,1,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBST,2,N4,,,2,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBZIP,10,N4,,,3,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBSEX,1,DMG,,,3,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBMSTATUS,1,DMG,,,4,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBDOB,10,DMG,,,2,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBREL,3,SBR,,,2,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYGRPPOLNUM,24,SBR,,,3,,TERTIARYCOV,,,,,,,,SBR,P,2,TERTIARYPAYERID FIELD=TERTIARYGRPNAME,32,SBR,,,4,,TERTIARYCOV,,,,,,,,SBR,P,2,TERTIARYPAYERID FIELD=TERTIARYINSTYPE,4,SBR,,,5,,TERTIARYCOV,,,,,,,,SBR,P,2,TERTIARYPAYERID FIELD=TERTIARYCFI,24,SBR,,,9,,TERTIARYCOV,,,,,,,,SBR,P,2,TERTIARYPAYERID FIELD=TERTIARYPAYERID,16,NM1,PR,2,9,,TERTIARYCOV FIELD=TERTIARYPAYERNAME,32,NM1,PR,2,3,,TERTIARYCOV FIELD=TERTIARYPAYERADDR1,30,N3,,,1,,TERTIARYCOV FIELD=TERTIARYPAYERADDR2,30,N3,,,2,,TERTIARYCOV FIELD=TERTIARYPAYERCITY,30,N4,,,1,,TERTIARYCOV FIELD=TERTIARYPAYERST,2,N4,,,2,,TERTIARYCOV FIELD=TERTIARYPAYERZIP,10,N4,,,3,,TERTIARYCOV FIELD=PATID,16,NM1,QC,2,9 FIELD=PATLNAME,32,NM1,QC,2,3 FIELD=PATFNAME,32,NM1,QC,2,4 FIELD=PATMI,1,NM1,QC,2,5 FIELD=PATADDR1SUBADDR1,30,N3,,,1,,PATLNAME FIELD=PATADDR2SUBADDR2,30,N3,,,2,,PATLNAME FIELD=PATCITY,30,N4,,,1,,PATLNAME FIELD=PATST,2,N4,,,2,,PATLNAME FIELD=PATZIP,10,N4,,,3,,PATLNAME FIELD=PATSEX,1,DMG,,,3,,PATLNAME FIELD=PATMSTAT,1,DMG,,,4,,PATLNAME FIELD=PATDOB,10,DMG,,,2,,PATLNAME FIELD=PATREL,1,PAT,,,2,,PATLNAME FIELD=CLAIMID,20,CLM,,,1,,SUBID FIELD=CLAIMAMT,20,CLM,,,2,,SUBID FIELD=ADMISSIONDATETIME,16,DTP,435,2,3,,SUBID FIELD=ADMISSIONTYPE,3,CL1,,,1,,SUBID FIELD=ADMISSIONSOURCE,3,CL1,,,2,,SUBID FIELD=PATIENTSTATUS,3,CL1,,,3,,SUBID FIELD=NURSINGHOMECODE,3,CL1,,,4,,SUBID FIELD=REPORTTYPECODE,20,PWK,,,1,,SUBID FIELD=REPORTTRANCODE,20,PWK,,,2,,SUBID FIELD=REPORTDESC,20,PWK,,,6,,SUBID FIELD=CLAIMNUMBER,20,REF,D9,2,2,,SUBID FIELD=DISCHARGEDATE,10,CR6,,,5,,SUBID FIELD=DISCHARGEHOUR,10,DTP,096,2,3,,SUBID FIELD=STATEMENTDATE,20,DTP,434,2,3,,SUBID FIELD=MEDICALRECORDNUMBER,10,REF,EA,2,2,,SUBID FIELD=FACILITYCODEVALUE,3,CLM,,,5,1,SUBID FIELD=FACILITYCODEQUALIFIER,3,CLM,,,5,2,SUBID FIELD=FREQUENCYTYPECODE,3,CLM,,,5,3,SUBID FIELD=PRINCIPALDX,7,HI,ABK:BK,2,1,2,SUBID FIELD=PPOAIND,1,HI,ABK:BK,2,1,9,SUBID FIELD=ADMITDX,7,HI,ABJ:BJ,2,1,2,SUBID FIELD=PRIORAUTH,10,REF,G1,2,2,,SUBID FIELD=K3DATA,20,K3,,,1,,SUBID FIELD=NOTECODE,4,NTE,,,1,,SUBID FIELD=NOTEDESC,4,NTE,,,2,,SUBID FIELD=SUPPLEMENTALINFOTYPE,4,PWK,,,1,,SUBID FIELD=SUPPLEMENTALINFOTRANS,4,PWK,,,2,,SUBID FIELD=SUPPLEMENTALINFODESC,4,PWK,,,6,,SUBID FIELD=NDCCODE,16,LIN,N4,2,3,,SUBID FIELD=NDCUNITPRICE,16,CTP,,,3,,SUBID FIELD=NDCUNITS,16,CTP,,,4,,SUBID FIELD=ECODE,7,HI,BN,2,1,2,SUBID FIELD=PATIENTREASONFORVISIT,30,HI,PR,2,1,2,SUBID FIELD=ATTENDINGID,16,NM1,71,2,9,,SUBID FIELD=ATTENDINGLNAME,32,NM1,71,2,3,,SUBID FIELD=ATTENDINGFNAME,32,NM1,71,2,4,,SUBID FIELD=ATTENDINGMNAME,32,NM1,71,2,5,,SUBID FIELD=ATTENDINGPREFIX,32,NM1,71,2,6,,SUBID FIELD=ATTENDINGSUFFIX,32,NM1,71,2,7,,SUBID FIELD=ATTENDINGIDCODE,4,NM1,71,2,8,,SUBID FIELD=ATTENDINGTYPE,2,NM1,71,2,1,,SUBID FIELD=ATTENDINGTAXONOMY,2,PRV,AT,2,3,,ATTENDINGID FIELD=OPERATEINGID,16,NM1,72,2,9,,SUBID FIELD=OPERATEINGLNAME,32,NM1,72,2,3,,SUBID FIELD=OPERATEINGFNAME,32,NM1,72,2,4,,SUBID FIELD=OPERATINGMNAME,32,NM1,72,2,5,,SUBID FIELD=OPERATINGPREFIX,32,NM1,72,2,6,,SUBID FIELD=OPERATINGSUFFIX,32,NM1,72,2,7,,SUBID FIELD=OPERATINGIDCODE,4,NM1,72,2,8,,SUBID FIELD=OPERATINGTYPE,2,NM1,72,2,1,,SUBID FIELD=OPERATINGTAXONOMY,2,PRV,AT,2,3,,OPERATINGID FIELD=REFERRINGID,16,NM1,DN,2,9,,SUBID FIELD=REFERRINGLNAME,32,NM1,82,2,3,,SUBID FIELD=REFERRINGFNAME,32,NM1,82,2,4,,SUBID FIELD=REFERRINGMNAME,32,NM1,82,2,5,,SUBID FIELD=REFERRINGPREFIX,32,NM1,82,2,6,,SUBID FIELD=REFERRINGSUFFIX,32,NM1,82,2,7,,SUBID FIELD=REFERRINGIDCODE,4,NM1,82,2,8,,SUBID FIELD=REFERRINGTYPE,2,NM1,82,2,1,,SUBID FIELD=REFERRINGTAXONOMY,2,PRV,AT,2,3,,REFERRINGID FIELD=RENDERINGID,16,NM1,82,2,9,,SUBID FIELD=RENDERINGLNAME,32,NM1,82,2,3,,SUBID FIELD=RENDERINGFNAME,32,NM1,82,2,4,,SUBID FIELD=RENDERINGMNAME,32,NM1,82,2,5,,SUBID FIELD=RENDERINGPREFIX,32,NM1,82,2,6,,SUBID FIELD=RENDERINGSUFFIX,32,NM1,82,2,7,,SUBID FIELD=RENDERINGIDCODE,4,NM1,82,2,8,,SUBID FIELD=RENDERINGTYPE,2,NM1,82,2,1,,SUBID FIELD=RENDERINGTAXONOMY,2,PRV,AT,2,3,,RENDERINGID FIELD=SERVICEFACILITYNAME,32,NM1,77,2,3,,SUBID FIELD=SERVICEFACILIYID,16,NM1,77,2,9,,SUBID FIELD=OTHERDX01,7,HI,ABF:BF,2,1,2,SUBID FIELD=OPOAIND1,1,HI,ABF:BF,2,1,9,SUBID FIELD=OTHERDX02,7,HI,ABF:BF,2,2,2,SUBID FIELD=OPOAIND2,1,HI,ABF:BF,2,2,9,SUBID FIELD=OTHERDX03,7,HI,ABF:BF,2,3,2,SUBID FIELD=OPOAIND3,1,HI,ABF:BF,2,3,9,SUBID FIELD=OTHERDX04,7,HI,ABF:BF,2,4,2,SUBID FIELD=OPOAIND4,1,HI,ABF:BF,2,4,9,SUBID FIELD=OTHERDX05,7,HI,ABF:BF,2,5,2,SUBID FIELD=OPOAIND5,1,HI,ABF:BF,2,5,9,SUBID FIELD=OTHERDX06,7,HI,ABF:BF,2,6,2,SUBID FIELD=OPOAIND6,1,HI,ABF:BF,2,6,9,SUBID FIELD=OTHERDX07,7,HI,ABF:BF,2,7,2,SUBID FIELD=OPOAIND7,1,HI,ABF:BF,2,7,9,SUBID FIELD=OTHERDX08,7,HI,ABF:BF,2,8,2,SUBID FIELD=OPOAIND8,1,HI,ABF:BF,2,8,9,SUBID FIELD=OTHERDX09,7,HI,ABF:BF,2,9,2,SUBID FIELD=OPOAIND9,1,HI,ABF:BF,2,8,9,SUBID FIELD=OTHERDX10,7,HI,ABF:BF,2,10,2,SUBID FIELD=OPOAIND10,1,HI,ABF:BF,2,10,9,SUBID FIELD=OTHERDX11,7,HI,ABF:BF,2,11,2,SUBID FIELD=OPOAIND11,1,HI,ABF:BF,2,11,9,SUBID FIELD=OTHERDX12,7,HI,ABF:BF,2,12,2,SUBID FIELD=OPOAIND12,1,HI,ABF:BF,2,12,9,SUBID FIELD=PRINCIPLEPROCICD9,7,HI,BR,2,1,2,SUBID FIELD=PRINCIPLEPROCDATE,7,HI,BP,2,1,4,SUBID FIELD=PRINCIPLEPROCHCFA,7,HI,BP,2,1,2,SUBID FIELD=OTHERPROC01,7,HI,BBQ:BQ:BO,2,1,2,SUBID FIELD=OTHERPROC02,7,HI,BBQ:BQ:BO,2,2,2,SUBID FIELD=OTHERPROC03,7,HI,BBQ:BQ:BO,2,3,2,SUBID FIELD=OTHERPROC04,7,HI,BBQ:BQ:BO,2,4,2,SUBID FIELD=OTHERPROC05,7,HI,BBQ:BQ:BO,2,5,2,SUBID FIELD=OTHERPROC06,7,HI,BBQ:BQ:BO,2,6,2,SUBID FIELD=OTHERPROC07,7,HI,BBQ:BQ:BO,2,7,2,SUBID FIELD=OTHERPROC08,7,HI,BBQ:BQ:BO,2,8,2,SUBID FIELD=OTHERPROC09,7,HI,BBQ:BQ:BO,2,9,2,SUBID FIELD=OTHERPROC10,7,HI,BBQ:BQ:BO,2,10,2,SUBID FIELD=OTHERPROC11,7,HI,BBQ:BQ:BO,2,11,2,SUBID FIELD=OTHERPROC12,7,HI,BBQ:BQ:BO,2,12,2,SUBID FIELD=OCCURRENCESPAN01,12,HI,BI,2,1,2,SUBID FIELD=OCCURRENCESPAN02,12,HI,BI,2,2,2,SUBID FIELD=OCCURRENCESPAN03,12,HI,BI,2,3,2,SUBID FIELD=OCCURRENCESPAN04,12,HI,BI,2,4,2,SUBID FIELD=OCCURRENCESPAN05,12,HI,BI,2,5,2,SUBID FIELD=OCCURRENCESPAN06,12,HI,BI,2,6,2,SUBID FIELD=OCCURRENCESPAN07,12,HI,BI,2,7,2,SUBID FIELD=OCCURRENCESPAN08,12,HI,BI,2,8,2,SUBID FIELD=OCCURRENCESPAN09,12,HI,BI,2,9,2,SUBID FIELD=OCCURRENCESPAN10,12,HI,BI,2,10,2,SUBID FIELD=OCCURRENCESPAN11,12,HI,BI,2,11,2,SUBID FIELD=OCCURRENCESPAN12,12,HI,BI,2,12,2,SUBID FIELD=OCCURRENCECODE01,12,HI,BH,2,1,2,SUBID FIELD=OCCURRENCEDATE01,12,HI,BH,2,1,4,SUBID FIELD=OCCURRENCECODE02,12,HI,BH,2,2,2,SUBID FIELD=OCCURRENCEDATE02,12,HI,BH,2,2,4,SUBID FIELD=OCCURRENCECODE03,12,HI,BH,2,3,2,SUBID FIELD=OCCURRENCEDATE03,12,HI,BH,2,3,4,SUBID FIELD=OCCURRENCECODE04,12,HI,BH,2,4,2,SUBID FIELD=OCCURRENCEDATE04,12,HI,BH,2,4,4,SUBID FIELD=OCCURRENCECODE05,12,HI,BH,2,5,2,SUBID FIELD=OCCURRENCEDATE05,12,HI,BH,2,5,4,SUBID FIELD=OCCURRENCECODE06,12,HI,BH,2,6,2,SUBID FIELD=OCCURRENCEDATE06,12,HI,BH,2,6,4,SUBID FIELD=OCCURRENCECODE07,12,HI,BH,2,7,2,SUBID FIELD=OCCURRENCEDATE07,12,HI,BH,2,7,4,SUBID FIELD=OCCURRENCECODE08,12,HI,BH,2,8,2,SUBID FIELD=OCCURRENCEDATE08,12,HI,BH,2,8,4,SUBID FIELD=OCCURRENCECODE09,12,HI,BH,2,9,2,SUBID FIELD=OCCURRENCEDATE09,12,HI,BH,2,9,4,SUBID FIELD=OCCURRENCECODE10,12,HI,BH,2,10,2,SUBID FIELD=OCCURRENCEDATE10,12,HI,BH,2,10,4,SUBID FIELD=OCCURRENCECODE11,12,HI,BH,2,11,2,SUBID FIELD=OCCURRENCEDATE11,12,HI,BH,2,11,4,SUBID FIELD=OCCURRENCECODE12,12,HI,BH,2,12,2,SUBID FIELD=OCCURRENCEDATE12,12,HI,BH,2,12,4,SUBID FIELD=VALUECODE01,12,HI,BE,2,1,2,SUBID FIELD=VALUEAMOUNT01,12,HI,BE,2,1,5,SUBID FIELD=VALUEQTY01,12,HI,BE,2,1,6,SUBID FIELD=VALUECODE02,12,HI,BE,2,2,2,SUBID FIELD=VALUEAMOUNT02,12,HI,BE,2,2,5,SUBID FIELD=VALUEQTY02,12,HI,BE,2,2,6,SUBID FIELD=VALUECODE03,12,HI,BE,2,3,2,SUBID FIELD=VALUEAMOUNT03,12,HI,BE,2,3,5,SUBID FIELD=VALUEQTY03,12,HI,BE,2,3,6,SUBID FIELD=VALUECODE04,12,HI,BE,2,4,2,SUBID FIELD=VALUEAMOUNT04,12,HI,BE,2,4,5,SUBID FIELD=VALUEQTY04,12,HI,BE,2,4,6,SUBID FIELD=VALUECODE05,12,HI,BE,2,5,2,SUBID FIELD=VALUEAMOUNT05,12,HI,BE,2,5,5,SUBID FIELD=VALUEQTY05,12,HI,BE,2,5,6,SUBID FIELD=VALUECODE06,12,HI,BE,2,6,2,SUBID FIELD=VALUEAMOUNT06,12,HI,BE,2,6,5,SUBID FIELD=VALUEQTY06,12,HI,BE,2,6,6,SUBID FIELD=VALUECODE07,12,HI,BE,2,7,2,SUBID FIELD=VALUEAMOUNT07,12,HI,BE,2,7,5,SUBID FIELD=VALUEQTY07,12,HI,BE,2,7,6,SUBID FIELD=VALUECODE08,12,HI,BE,2,8,2,SUBID FIELD=VALUEAMOUNT08,12,HI,BE,2,8,5,SUBID FIELD=VALUEQTY08,12,HI,BE,2,8,6,SUBID FIELD=VALUECODE09,12,HI,BE,2,9,2,SUBID FIELD=VALUEAMOUNT09,12,HI,BE,2,9,5,SUBID FIELD=VALUEQTY09,12,HI,BE,2,9,6,SUBID FIELD=VALUECODE10,12,HI,BE,2,10,2,SUBID FIELD=VALUEAMOUNT10,12,HI,BE,2,10,5,SUBID FIELD=VALUEQTY10,12,HI,BE,2,10,6,SUBID FIELD=CONDITIONCODE01,12,HI,BG,2,1,2,SUBID FIELD=CONDITIONCODE02,12,HI,BG,2,2,2,SUBID FIELD=CONDITIONCODE03,12,HI,BG,2,3,2,SUBID FIELD=CONDITIONCODE04,12,HI,BG,2,4,2,SUBID FIELD=CONDITIONCODE05,12,HI,BG,2,5,2,SUBID FIELD=CONDITIONCODE06,12,HI,BG,2,6,2,SUBID FIELD=CONDITIONCODE07,12,HI,BG,2,7,2,SUBID FIELD=CONDITIONCODE08,12,HI,BG,2,8,2,SUBID FIELD=CONDITIONCODE09,12,HI,BG,2,9,2,SUBID FIELD=CONDITIONCODE10,12,HI,BG,2,10,2,SUBID FIELD=CONDITIONCODE11,12,HI,BG,2,11,2,SUBID FIELD=CONDITIONCODE12,12,HI,BG,2,12,2,SUBID FIELD=TREATMENTCODE01,12,HI,TC,2,1,2,SUBID FIELD=TREATMENTCODE02,12,HI,TC,2,2,2,SUBID FIELD=TREATMENTCODE03,12,HI,TC,2,3,2,SUBID FIELD=TREATMENTCODE04,12,HI,TC,2,4,2,SUBID FIELD=TREATMENTCODE05,12,HI,TC,2,5,2,SUBID FIELD=TREATMENTCODE06,12,HI,TC,2,6,2,SUBID FIELD=TREATMENTCODE07,12,HI,TC,2,7,2,SUBID FIELD=TREATMENTCODE08,12,HI,TC,2,8,2,SUBID FIELD=TREATMENTCODE09,12,HI,TC,2,9,2,SUBID FIELD=TREATMENTCODE10,12,HI,TC,2,10,2,SUBID FIELD=TREATMENTCODE11,12,HI,TC,2,11,2,SUBID FIELD=TREATMENTCODE12,12,HI,TC,2,12,2,SUBID FIELD=ADMITTINGDX01,7,HI,BJ,2,1,2,SUBID FIELD=ADMITTINGDX02,7,HI,BJ,2,2,2,SUBID FIELD=ADMITTINGDX03,7,HI,BJ,2,3,2,SUBID FIELD=ADMITTINGDX04,7,HI,BJ,2,4,2,SUBID FIELD=ADMITTINGDX05,7,HI,BJ,2,5,2,SUBID FIELD=ADMITTINGDX06,7,HI,BJ,2,6,2,SUBID FIELD=ADMITTINGDX07,7,HI,BJ,2,7,2,SUBID FIELD=ADMITTINGDX08,7,HI,BJ,2,8,2,SUBID FIELD=ADMITTINGDX09,7,HI,BJ,2,9,2,SUBID FIELD=ADMITTINGDX10,7,HI,BJ,2,10,2,SUBID FIELD=ADMITTINGDX11,7,HI,BJ,2,11,2,SUBID FIELD=ADMITTINGDX12,7,HI,BJ,2,12,2,SUBID FIELD=VISITREASONDX01,7,HI,PR,2,1,2,SUBID FIELD=VISITREASONDX02,7,HI,PR,2,2,2,SUBID FIELD=VISITREASONDX03,7,HI,PR,2,3,2,SUBID FIELD=VISITREASONDX04,7,HI,PR,2,4,2,SUBID FIELD=VISITREASONDX05,7,HI,PR,2,5,2,SUBID FIELD=VISITREASONDX06,7,HI,PR,2,6,2,SUBID FIELD=VISITREASONDX07,7,HI,PR,2,7,2,SUBID FIELD=VISITREASONDX08,7,HI,PR,2,8,2,SUBID FIELD=VISITREASONDX09,7,HI,PR,2,9,2,SUBID FIELD=VISITREASONDX10,7,HI,PR,2,10,2,SUBID FIELD=VISITREASONDX11,7,HI,PR,2,11,2,SUBID FIELD=VISITREASONDX12,7,HI,PR,2,12,2,SUBID FIELD=DRG,16,HI,DR,2,1,2,SUBID FIELD=DRGAMT,16,AMT,ZZ,2,2,,SUBID FIELD=IREVCODE1,10,SV2,,,1,,SUBID,,,1 FIELD=IPROC1,10,SV2,,,2,2,SUBID,,,1 FIELD=IPROCQUAL1,10,SV2,,,2,1,SUBID,,,1 FIELD=IMODA1,3,SV2,,,2,3,SUBID,,,1 FIELD=IMODB1,3,SV2,,,2,4,SUBID,,,1 FIELD=IMODC1,3,SV2,,,2,5,SUBID,,,1 FIELD=IMODD1,3,SV2,,,2,6,SUBID,,,1 FIELD=IAMT1,10,SV2,,,3,,SUBID,,,1 FIELD=IUNITS1,10,SV2,,,5,,SUBID,,,1 FIELD=IQTY1,10,SV2,,,6,,SUBID,,,1 FIELD=IRATE1,10,SV2,,,7,,SUBID,,,1 FIELD=IAMTNCC1,10,SV2,,,8,,SUBID,,,1 FIELD=IDOS1,10,DTP,472,2,3,,SUBID,,,1 FIELD=IADJGRPCODE1,10,CAS,,,1,,SUBID,,,1 FIELD=IADJREASONCODE1,10,CAS,,,2,,SUBID,,,1 FIELD=IADJAMOUNT1,10,CAS,,,3,,SUBID,,,1 FIELD=IADJQTY1,10,CAS,,,4,,SUBID,,,1 FIELD=IREVCODE2,10,SV2,,,1,,SUBID,,,2 FIELD=IPROC2,10,SV2,,,2,2,SUBID,,,2 FIELD=IPROCQUAL2,10,SV2,,,2,1,SUBID,,,2 FIELD=IMODA2,3,SV2,,,2,3,SUBID,,,2 FIELD=IMODB2,3,SV2,,,2,4,SUBID,,,2 FIELD=IMODC2,3,SV2,,,2,5,SUBID,,,2 FIELD=IMODD2,3,SV2,,,2,6,SUBID,,,2 FIELD=IAMT2,10,SV2,,,3,,SUBID,,,2 FIELD=IUNITS2,10,SV2,,,5,,SUBID,,,2 FIELD=IQTY2,10,SV2,,,6,,SUBID,,,2 FIELD=IRATE2,10,SV2,,,7,,SUBID,,,2 FIELD=IAMTNCC2,10,SV2,,,8,,SUBID,,,2 FIELD=IDOS2,10,DTP,472,2,3,,SUBID,,,2 FIELD=IADJGRPCODE2,10,CAS,,,1,,SUBID,,,2 FIELD=IADJREASONCODE2,10,CAS,,,2,,SUBID,,,2 FIELD=IADJAMOUNT2,10,CAS,,,3,,SUBID,,,2 FIELD=IADJQTY2,10,CAS,,,4,,SUBID,,,2 FIELD=IREVCODE3,10,SV2,,,1,,SUBID,,,3 FIELD=IPROC3,10,SV2,,,2,2,SUBID,,,3 FIELD=IPROCQUAL3,10,SV2,,,2,1,SUBID,,,3 FIELD=IMODA3,3,SV2,,,2,3,SUBID,,,3 FIELD=IMODB3,3,SV2,,,2,4,SUBID,,,3 FIELD=IMODC3,3,SV2,,,2,5,SUBID,,,3 FIELD=IMODD3,3,SV2,,,2,6,SUBID,,,3 FIELD=IAMT3,10,SV2,,,3,,SUBID,,,3 FIELD=IUNITS3,10,SV2,,,5,,SUBID,,,3 FIELD=IQTY3,10,SV2,,,6,,SUBID,,,3 FIELD=IRATE3,10,SV2,,,7,,SUBID,,,3 FIELD=IAMTNCC3,10,SV2,,,8,,SUBID,,,3 FIELD=IDOS3,10,DTP,472,2,3,,SUBID,,,3 FIELD=IADJGRPCODE3,10,CAS,,,1,,SUBID,,,3 FIELD=IADJREASONCODE3,10,CAS,,,2,,SUBID,,,3 FIELD=IADJAMOUNT3,10,CAS,,,3,,SUBID,,,3 FIELD=IADJQTY3,10,CAS,,,4,,SUBID,,,3 FIELD=IREVCODE4,10,SV2,,,1,,SUBID,,,4 FIELD=IPROC4,10,SV2,,,2,2,SUBID,,,4 FIELD=IPROCQUAL4,10,SV2,,,2,1,SUBID,,,4 FIELD=IMODA4,3,SV2,,,2,3,SUBID,,,4 FIELD=IMODB4,3,SV2,,,2,4,SUBID,,,4 FIELD=IMODC4,3,SV2,,,2,5,SUBID,,,4 FIELD=IMODD4,3,SV2,,,2,6,SUBID,,,4 FIELD=IAMT4,10,SV2,,,3,,SUBID,,,4 FIELD=IUNITS4,10,SV2,,,5,,SUBID,,,4 FIELD=IQTY4,10,SV2,,,6,,SUBID,,,4 FIELD=IRATE4,10,SV2,,,7,,SUBID,,,4 FIELD=IAMTNCC4,10,SV2,,,8,,SUBID,,,4 FIELD=IDOS4,10,DTP,472,2,3,,SUBID,,,4 FIELD=IADJGRPCODE4,10,CAS,,,1,,SUBID,,,4 FIELD=IADJREASONCODE4,10,CAS,,,2,,SUBID,,,4 FIELD=IADJAMOUNT4,10,CAS,,,3,,SUBID,,,4 FIELD=IADJQTY4,10,CAS,,,4,,SUBID,,,4 FIELD=IREVCODE5,10,SV2,,,1,,SUBID,,,5 FIELD=IPROC5,10,SV2,,,2,2,SUBID,,,5 FIELD=IPROCQUAL5,10,SV2,,,2,1,SUBID,,,5 FIELD=IMODA5,3,SV2,,,2,3,SUBID,,,5 FIELD=IMODB5,3,SV2,,,2,4,SUBID,,,5 FIELD=IMODC5,3,SV2,,,2,5,SUBID,,,5 FIELD=IMODD5,3,SV2,,,2,6,SUBID,,,5 FIELD=IAMT5,10,SV2,,,3,,SUBID,,,5 FIELD=IUNITS5,10,SV2,,,5,,SUBID,,,5 FIELD=IQTY5,10,SV2,,,6,,SUBID,,,5 FIELD=IRATE5,10,SV2,,,7,,SUBID,,,5 FIELD=IAMTNCC5,10,SV2,,,8,,SUBID,,,5 FIELD=IDOS5,10,DTP,472,2,3,,SUBID,,,5 FIELD=IADJGRPCODE5,10,CAS,,,1,,SUBID,,,5 FIELD=IADJREASONCODE5,10,CAS,,,2,,SUBID,,,5 FIELD=IADJAMOUNT5,10,CAS,,,3,,SUBID,,,5 FIELD=IADJQTY5,10,CAS,,,4,,SUBID,,,5 FIELD=IREVCODE6,10,SV2,,,1,,SUBID,,,6 FIELD=IPROC6,10,SV2,,,2,2,SUBID,,,6 FIELD=IPROCQUAL6,10,SV2,,,2,1,SUBID,,,6 FIELD=IMODA6,3,SV2,,,2,3,SUBID,,,6 FIELD=IMODB6,3,SV2,,,2,4,SUBID,,,6 FIELD=IMODC6,3,SV2,,,2,5,SUBID,,,6 FIELD=IMODD6,3,SV2,,,2,6,SUBID,,,6 FIELD=IAMT6,10,SV2,,,3,,SUBID,,,6 FIELD=IUNITS6,10,SV2,,,5,,SUBID,,,6 FIELD=IQTY6,10,SV2,,,6,,SUBID,,,6 FIELD=IRATE6,10,SV2,,,7,,SUBID,,,6 FIELD=IAMTNCC6,10,SV2,,,8,,SUBID,,,6 FIELD=IDOS6,10,DTP,472,2,3,,SUBID,,,6 FIELD=IADJGRPCODE6,10,CAS,,,1,,SUBID,,,6 FIELD=IADJREASONCODE6,10,CAS,,,2,,SUBID,,,6 FIELD=IADJAMOUNT6,10,CAS,,,3,,SUBID,,,6 FIELD=IADJQTY6,10,CAS,,,4,,SUBID,,,6 FIELD=IREVCODE7,10,SV2,,,1,,SUBID,,,7 FIELD=IPROC7,10,SV2,,,2,2,SUBID,,,7 FIELD=IPROCQUAL7,10,SV2,,,2,1,SUBID,,,7 FIELD=IMODA7,3,SV2,,,2,3,SUBID,,,7 FIELD=IMODB7,3,SV2,,,2,4,SUBID,,,7 FIELD=IMODC7,3,SV2,,,2,5,SUBID,,,7 FIELD=IMODD7,3,SV2,,,2,6,SUBID,,,7 FIELD=IAMT7,10,SV2,,,3,,SUBID,,,7 FIELD=IUNITS7,10,SV2,,,5,,SUBID,,,7 FIELD=IQTY7,10,SV2,,,6,,SUBID,,,7 FIELD=IRATE7,10,SV2,,,7,,SUBID,,,7 FIELD=IAMTNCC7,10,SV2,,,8,,SUBID,,,7 FIELD=IDOS7,10,DTP,472,2,3,,SUBID,,,7 FIELD=IADJGRPCODE7,10,CAS,,,1,,SUBID,,,7 FIELD=IADJREASONCODE7,10,CAS,,,2,,SUBID,,,7 FIELD=IADJAMOUNT7,10,CAS,,,3,,SUBID,,,7 FIELD=IADJQTY7,10,CAS,,,4,,SUBID,,,7 FIELD=IREVCODE8,10,SV2,,,1,,SUBID,,,8 FIELD=IPROC8,10,SV2,,,2,2,SUBID,,,8 FIELD=IPROCQUAL8,10,SV2,,,2,1,SUBID,,,8 FIELD=IMODA8,3,SV2,,,2,3,SUBID,,,8 FIELD=IMODB8,3,SV2,,,2,4,SUBID,,,8 FIELD=IMODC8,3,SV2,,,2,5,SUBID,,,8 FIELD=IMODD8,3,SV2,,,2,6,SUBID,,,8 FIELD=IAMT8,10,SV2,,,3,,SUBID,,,8 FIELD=IUNITS8,10,SV2,,,5,,SUBID,,,8 FIELD=IQTY8,10,SV2,,,6,,SUBID,,,8 FIELD=IRATE8,10,SV2,,,7,,SUBID,,,8 FIELD=IAMTNCC8,10,SV2,,,8,,SUBID,,,8 FIELD=IDOS8,10,DTP,472,2,3,,SUBID,,,8 FIELD=IADJGRPCODE8,10,CAS,,,1,,SUBID,,,8 FIELD=IADJREASONCODE8,10,CAS,,,2,,SUBID,,,8 FIELD=IADJAMOUNT8,10,CAS,,,3,,SUBID,,,8 FIELD=IADJQTY8,10,CAS,,,4,,SUBID,,,8 FIELD=IREVCODE9,10,SV2,,,1,,SUBID,,,9 FIELD=IPROC9,10,SV2,,,2,2,SUBID,,,9 FIELD=IPROCQUAL9,10,SV2,,,2,1,SUBID,,,9 FIELD=IMODA9,3,SV2,,,2,3,SUBID,,,9 FIELD=IMODB9,3,SV2,,,2,4,SUBID,,,9 FIELD=IMODC9,3,SV2,,,2,5,SUBID,,,9 FIELD=IMODD9,3,SV2,,,2,6,SUBID,,,9 FIELD=IAMT9,10,SV2,,,3,,SUBID,,,9 FIELD=IUNITS9,10,SV2,,,5,,SUBID,,,9 FIELD=IQTY9,10,SV2,,,6,,SUBID,,,9 FIELD=IRATE9,10,SV2,,,7,,SUBID,,,9 FIELD=IAMTNCC9,10,SV2,,,8,,SUBID,,,9 FIELD=IDOS9,10,DTP,472,2,3,,SUBID,,,9 FIELD=IADJGRPCODE9,10,CAS,,,1,,SUBID,,,9 FIELD=IADJREASONCODE9,10,CAS,,,2,,SUBID,,,9 FIELD=IADJAMOUNT9,10,CAS,,,3,,SUBID,,,9 FIELD=IADJQTY9,10,CAS,,,4,,SUBID,,,9 FIELD=IREVCODE10,10,SV2,,,1,,SUBID,,,10 FIELD=IPROC10,10,SV2,,,2,2,SUBID,,,10 FIELD=IPROCQUAL10,10,SV2,,,2,1,SUBID,,,10 FIELD=IMODA10,3,SV2,,,2,3,SUBID,,,10 FIELD=IMODB10,3,SV2,,,2,4,SUBID,,,10 FIELD=IMODC10,3,SV2,,,2,5,SUBID,,,10 FIELD=IMODD10,3,SV2,,,2,6,SUBID,,,10 FIELD=IAMT10,10,SV2,,,3,,SUBID,,,10 FIELD=IUNITS10,10,SV2,,,5,,SUBID,,,10 FIELD=IQTY10,10,SV2,,,6,,SUBID,,,10 FIELD=IRATE10,10,SV2,,,7,,SUBID,,,10 FIELD=IAMTNCC10,10,SV2,,,8,,SUBID,,,10 FIELD=IDOS10,10,DTP,472,2,3,,SUBID,,,10 FIELD=IADJGRPCODE10,10,CAS,,,1,,SUBID,,,10 FIELD=IADJREASONCODE10,10,CAS,,,2,,SUBID,,,10 FIELD=IADJAMOUNT10,10,CAS,,,3,,SUBID,,,10 FIELD=IADJQTY10,10,CAS,,,4,,SUBID,,,10 FIELD=PAYTOPLAID,16,NM1,PE,2,9,,SUBID FIELD=PAYTOPLANAME,32,NM1,PE,2,3,,SUBID FIELD=PAYTOPLAADDR1,30,N3,,,1,,PAYTOPLANAME FIELD=PAYTOPLAADDR2,30,N3,,,2,,PAYTOPLANAME FIELD=PAYTOPLACITY,30,N4,,,1,,PAYTOPLANAME FIELD=PAYTOPLAST,2,N4,,,2,,PAYTOPLANAME FIELD=PAYTOPLAZIP,10,N4,,,3,,PAYTOPLANAME FIELD=RECEIVERID,16,NM1,40,2,9,,,,1 FIELD=RECEIVERNAME,32,NM1,40,2,3,,,,1 FIELD=RECEIVERADDR1,30,N3,,,1,,RECEIVERNAME,,1 FIELD=RECEIVERADDR2,30,N3,,,2,,RECEIVERNAME,,1 FIELD=RECEIVERCITY,30,N4,,,1,,RECEIVERNAME,,1 FIELD=RECEIVERST,2,N4,,,2,,RECEIVERNAME,,1 FIELD=RECEIVERZIP,10,N4,,,3,,RECEIVERNAME,,1 FIELD=SUBMITTERID,16,NM1,41,2,9,,,,1 FIELD=SUBMITTERNAME,32,NM1,41,2,3,,,,1 FIELD=SUBMITTERADDR1,30,N3,,,1,,SUBMITTERNAME,,1 FIELD=SUBMITTERADDR2,30,N3,,,2,,SUBMITTERNAME,,1 FIELD=SUBMITTERCITY,30,N4,,,1,,SUBMITTERNAME,,1 FIELD=SUBMITTERST,2,N4,,,2,,SUBMITTERNAME,,1 FIELD=SUBMITTERZIP,10,N4,,,3,,SUBMITTERNAME,,1 FIELD=TRANSACTIONSETCODE,10,BHT,,,2,,,,1 FIELD=TRANSACTIONID,20,BHT,,,3,,,,1 FIELD=TRANSACTIONDATE,10,BHT,,,4,,,,1 FIELD=TRANSACTIONTIME,10,BHT,,,5,,,,1 FIELD=TRANSACTIONTYPE,10,BHT,,,6,,,,1 FIELD=SOURCEFILE,64,,,,,,,,5 FIELD=DESTINATIONFILE,64,,,,,,,,6 ************************************* X12 Out Mapping SEGMENT=1,BHT,0019,$TRANSACTIONSETCODE,$TRANSACTIONID,$TRANSACTIONDATE SEGMENT=1,REF,87,005010X223A1 SEGMENT=1,NM1,40,2,$RECEIVERNAME SEGMENT=1,NM1,41,$SUBMITTERNAME SEGMENT=1,N3:$SUBMITTERADDRESS1,$SUBMITTERADDRESS1,$SUBMITTERADDRESS2 SEGMENT=1,N4:$SUBMITTERCITY,$SUBMITTERCITY,$SUBMITTERERST,$SUBMITTERZIP SEGMENT=1,HL,&HL,,20,0 SEGMENT=1,PRV,BI,ZZ,0000000 SEGMENT=1,NM1,85,$BILLINGPROVIDERNAME SEGMENT=1,N3:$BILLINGPROVIDERADDRESS1,$BILLINGPROVIDERADDRESS1,$BILLINGPROVIDERADDRESS2 SEGMENT=1,N4:$BILLINGPROVIDERCITY,$BILLINGPROVIDERCITY,$BILLINGPROVIDERERST,$BILLINGPROVIDERZIP SEGMENT=1,NM1:$PAYTOPROVIDERNAME,87,$PAYTOPROVIDERNAME SEGMENT=1,N3:$PAYTOPROVIDERADDRESS1,$PAYTOPROVIDERADDRESS1,$PAYTOPROVIDERADDRESS2 SEGMENT=1,N4:$PAYTOPROVIDERCITY,$PAYTOPROVIDERCITY,$PAYTOPROVIDERERST,$PAYTOPROVIDERZIP SEGMENT=2,HL,&HL,1,22,0 SEGMENT=2,SBR,P,18,,,,,,,,MB SEGMENT=2,NM1,IL,1,$PRIMARYSUBLNAME,$PRIMARYSUBFNAME,$PRIMARYSUBMI,,,XX,$PRIMARYSUBID SEGMENT=2,N3,$PRIMARYSUBADDRESS1,$PRIMARYSUBADDRESS2 SEGMENT=2,N4,$PRIMARYSUBCITY,$PRIMARYSUBERST,$PRIMARYSUBZIP SEGMENT=2,PAT:$PATLNAME,01 SEGMENT=2,NM1:$PATLNAME,QC,1,$PATLNAME,$PATFNAME,$PATMI,,,XX,$PATID SEGMENT=2,N3:$PATADDRESS1,$PATADDRESS1,$PATADDRESS2 SEGMENT=2,N4:$PATCITY,$PATCITY,$PATST,$PATZIP SEGMENT=2,CLM,$CLAIMID,$CLAIMAMT,,,Y,A,Y,Y,C SEGMENT=2,DTP:$ADMISSIONDATETIME,435,$ADMISSIONDATETIME SEGMENT=2,CR1,$ADMISSIONTYPE,$ADMISSIONSOURCE,$PATIENTSTATUS,$NURSINGHOMECODE SEGMENT=2,PWK:$REPORTTYPECODE,$REPORTTYPECODE,$REPORTTRANCODE,,,$REPORTDESC SEGMENT=2,REF:$CLAIMNUMBER,D9,$CLAIMNUMBER SEGMENT=2,K3:$K3DATA,$K3DATA SEGMENT=2,NTE:$NOTECODE,$NOTECODE,$NOTEDESC SEGMENT=2,DTP:$DISCHARGEHOUR,096,$DISCHARGEHOUR SEGMENT=2,DTP:$STATEMENTDATE,434,$STATEMENTDATE SEGMENT=2,REF:$MEDICALRECORDNUMBER,EA,$MEDICALRECORDNUMBER SEGMENT=2,HI:$PRINCIPALDX,%ABK;$PRINCIPALDX SEGMENT=2,REF:$PRIORAUTH,G1,$PRIORAUTH SEGMENT=2,HI:$OTHERDX01,%ABF;$OTHERDX01;;;;;;$OPOAIND1 SEGMENT=2,HI:$OTHERDX02,%ABF;$OTHERDX02;;;;;;$OPOAIND2 SEGMENT=2,HI:$OTHERDX03,%ABF;OTHERDX03;;;;;;$OPOAIND3 SEGMENT=2,HI:$OTHERDX04,%ABF;$OTHERDX04;;;;;;$OPOAIND4 SEGMENT=2,HI:$OTHERDX05,%ABF;$OTHERDX05;;;;;;$OPOAIND5 SEGMENT=2,HI:$OTHERDX06,%ABF;$OTHERDX06;;;;;;$OPOAIND6 SEGMENT=2,HI:$OTHERDX07,%ABF;$OTHERDX07;;;;;;$OPOAIND7 SEGMENT=2,HI:$OTHERDX08,%ABF;$OTHERDX08;;;;;;$OPOAIND8 SEGMENT=2,HI:$OTHERDX09,%ABF;$OTHERDX09;;;;;;$OPOAIND9 SEGMENT=2,HI:$OTHERDX10,%ABF;$OTHERDX10;;;;;;$OPOAIND10 SEGMENT=2,HI:$OTHERDX11,%ABF;$OTHERDX11;;;;;;$OPOAIND11 SEGMENT=2,HI:$OTHERDX12,%ABF;$OTHERDX12;;;;;;$OPOAIND12 SEGMENT=2,HI:$PRINCIPLEPROCICD9,%BR;$PRINCIPLEPROCICD9;D8;$PRINCIPLEPROCDATE SEGMENT=2,HI:$OTHERPROC01,%BBQ;$OTHERPROC01 SEGMENT=2,HI:$OTHERPROC02,%BBQ;$OTHERPROC02 SEGMENT=2,HI:$OTHERPROC03,%BBQ;$OTHERPROC03 SEGMENT=2,HI:$OTHERPROC04,%BBQ;$OTHERPROC04 SEGMENT=2,HI:$OTHERPROC05,%BBQ;$OTHERPROC05 SEGMENT=2,HI:$OTHERPROC06,%BBQ;$OTHERPROC06 SEGMENT=2,HI:$OTHERPROC07,%BBQ;$OTHERPROC07 SEGMENT=2,HI:$OTHERPROC08,%BBQ;$OTHERPROC08 SEGMENT=2,HI:$OTHERPROC09,%BBQ;$OTHERPROC09 SEGMENT=2,HI:$OTHERPROC10,%BBQ;$OTHERPROC10 SEGMENT=2,HI:$OTHERPROC11,%BBQ;$OTHERPROC11 SEGMENT=2,HI:$OTHERPROC12,%BBQ;$OTHERPROC12 SEGMENT=2,HI:$OCCURRENCESPAN01,%BI;$OCCURRENCESPAN01 SEGMENT=2,HI:$OCCURRENCESPAN02,%BI;$OCCURRENCESPAN02 SEGMENT=2,HI:$OCCURRENCESPAN03,%BI;$OCCURRENCESPAN03 SEGMENT=2,HI:$OCCURRENCESPAN04,%BI;$OCCURRENCESPAN04 SEGMENT=2,HI:$OCCURRENCESPAN05,%BI;$OCCURRENCESPAN05 SEGMENT=2,HI:$OCCURRENCESPAN06,%BI;$OCCURRENCESPAN06 SEGMENT=2,HI:$OCCURRENCESPAN07,%BI;$OCCURRENCESPAN07 SEGMENT=2,HI:$OCCURRENCESPAN08,%BI;$OCCURRENCESPAN08 SEGMENT=2,HI:$OCCURRENCESPAN09,%BI;$OCCURRENCESPAN09 SEGMENT=2,HI:$OCCURRENCESPAN10,%BI;$OCCURRENCESPAN10 SEGMENT=2,HI:$OCCURRENCESPAN11,%BI;$OCCURRENCESPAN11 SEGMENT=2,HI:$OCCURRENCESPAN12,%BI;$OCCURRENCESPAN12 SEGMENT=2,HI:$OCCURRENCECODE01,%BH;$OCCURRENCECODE01;D8;$OCCURRENCEDATE01 SEGMENT=2,HI:$OCCURRENCECODE02,%BH;$OCCURRENCECODE02;D8;$OCCURRENCEDATE02 SEGMENT=2,HI:$OCCURRENCECODE03,%BH;$OCCURRENCECODE03;D8;$OCCURRENCEDATE03 SEGMENT=2,HI:$OCCURRENCECODE04,%BH;$OCCURRENCECODE04;D8;$OCCURRENCEDATE04 SEGMENT=2,HI:$OCCURRENCECODE05,%BH;$OCCURRENCECODE05;D8;$OCCURRENCEDATE05 SEGMENT=2,HI:$OCCURRENCECODE06,%BH;$OCCURRENCECODE06;D8;$OCCURRENCEDATE06 SEGMENT=2,HI:$OCCURRENCECODE07,%BH;$OCCURRENCECODE07;D8;$OCCURRENCEDATE07 SEGMENT=2,HI:$OCCURRENCECODE08,%BH;$OCCURRENCECODE08;D8;$OCCURRENCEDATE08 SEGMENT=2,HI:$OCCURRENCECODE09,%BH;$OCCURRENCECODE09;D8;$OCCURRENCEDATE09 SEGMENT=2,HI:$OCCURRENCECODE10,%BH;$OCCURRENCECODE10;D8;$OCCURRENCEDATE10 SEGMENT=2,HI:$OCCURRENCECODE11,%BH;$OCCURRENCECODE11;D8;$OCCURRENCEDATE11 SEGMENT=2,HI:$OCCURRENCECODE12,%BH;$OCCURRENCECODE12;D8;$OCCURRENCEDATE12 SEGMENT=2,HI:$VALUECODE01,%BE;$VALUECODE01;;$VALUEAMOUNT01;VALUEQTY01 SEGMENT=2,HI:$VALUECODE02,%BE;$VALUECODE02;;$VALUEAMOUNT02;VALUEQTY02 SEGMENT=2,HI:$VALUECODE03,%BE;$VALUECODE03;;$VALUEAMOUNT03;VALUEQTY03 SEGMENT=2,HI:$VALUECODE04,%BE;$VALUECODE04;;$VALUEAMOUNT04;VALUEQTY04 SEGMENT=2,HI:$VALUECODE05,%BE;$VALUECODE05;;$VALUEAMOUNT05;VALUEQTY05 SEGMENT=2,HI:$VALUECODE06,%BE;$VALUECODE06;;$VALUEAMOUNT06;VALUEQTY06 SEGMENT=2,HI:$VALUECODE07,%BE;$VALUECODE07;;$VALUEAMOUNT07;VALUEQTY07 SEGMENT=2,HI:$VALUECODE08,%BE;$VALUECODE08;;$VALUEAMOUNT08;VALUEQTY08 SEGMENT=2,HI:$VALUECODE09,%BE;$VALUECODE09;;$VALUEAMOUNT09;VALUEQTY09 SEGMENT=2,HI:$VALUECODE10,%BE;$VALUECODE10;;$VALUEAMOUNT10;VALUEQTY10 SEGMENT=2,HI:$VALUECODE11,%BE;$VALUECODE11;;$VALUEAMOUNT11;VALUEQTY11 SEGMENT=2,HI:$VALUECODE12,%BE;$VALUECODE12;;$VALUEAMOUNT12;VALUEQTY12 SEGMENT=2,HI:$CONDITIONCODE01,%BG;$CONDITIONCODE01 SEGMENT=2,HI:$CONDITIONCODE02,%BG;$CONDITIONCODE02 SEGMENT=2,HI:$CONDITIONCODE03,%BG;$CONDITIONCODE03 SEGMENT=2,HI:$CONDITIONCODE04,%BG;$CONDITIONCODE04 SEGMENT=2,HI:$CONDITIONCODE05,%BG;$CONDITIONCODE05 SEGMENT=2,HI:$CONDITIONCODE06,%BG;$CONDITIONCODE06 SEGMENT=2,HI:$CONDITIONCODE07,%BG;$CONDITIONCODE07 SEGMENT=2,HI:$CONDITIONCODE08,%BG;$CONDITIONCODE08 SEGMENT=2,HI:$CONDITIONCODE09,%BG;$CONDITIONCODE09 SEGMENT=2,HI:$CONDITIONCODE10,%BG;$CONDITIONCODE10 SEGMENT=2,HI:$CONDITIONCODE11,%BG;$CONDITIONCODE11 SEGMENT=2,HI:$CONDITIONCODE12,%BG;$CONDITIONCODE12 SEGMENT=2,HI:$TREATMENTCODE01,%TC;$TREATMENTCODE01 SEGMENT=2,HI:$TREATMENTCODE02,%TC;$TREATMENTCODE02 SEGMENT=2,HI:$TREATMENTCODE03,%TC;$TREATMENTCODE03 SEGMENT=2,HI:$TREATMENTCODE04,%TC;$TREATMENTCODE04 SEGMENT=2,HI:$TREATMENTCODE05,%TC;$TREATMENTCODE05 SEGMENT=2,HI:$TREATMENTCODE06,%TC;$TREATMENTCODE06 SEGMENT=2,HI:$TREATMENTCODE07,%TC;$TREATMENTCODE07 SEGMENT=2,HI:$TREATMENTCODE08,%TC;$TREATMENTCODE08 SEGMENT=2,HI:$TREATMENTCODE09,%TC;$TREATMENTCODE09 SEGMENT=2,HI:$TREATMENTCODE10,%TC;$TREATMENTCODE10 SEGMENT=2,HI:$TREATMENTCODE11,%TC;$TREATMENTCODE11 SEGMENT=2,HI:$TREATMENTCODE12,%TC;$TREATMENTCODE12 SEGMENT=2,HI:$ADMITTINGDX01,%ABJ;$ADMITTINGDX01 SEGMENT=2,HI:$ADMITTINGDX02,%ABJ;$ADMITTINGDX02 SEGMENT=2,HI:$ADMITTINGDX03,%ABJ;$ADMITTINGDX03 SEGMENT=2,HI:$ADMITTINGDX04,%ABJ;$ADMITTINGDX04 SEGMENT=2,HI:$ADMITTINGDX05,%ABJ;$ADMITTINGDX05 SEGMENT=2,HI:$ADMITTINGDX06,%ABJ;$ADMITTINGDX06 SEGMENT=2,HI:$ADMITTINGDX07,%ABJ;$ADMITTINGDX07 SEGMENT=2,HI:$ADMITTINGDX08,%ABJ;$ADMITTINGDX08 SEGMENT=2,HI:$ADMITTINGDX09,%ABJ;$ADMITTINGDX09 SEGMENT=2,HI:$ADMITTINGDX10,%ABJ;$ADMITTINGDX10 SEGMENT=2,HI:$ADMITTINGDX11,%ABJ;$ADMITTINGDX11 SEGMENT=2,HI:$ADMITTINGDX12,%ABJ;$ADMITTINGDX12 SEGMENT=2,HI:$VISITREASONDX01,%APR;$VISITREASONDX01 SEGMENT=2,HI:$VISITREASONDX02,%APR;$VISITREASONDX02 SEGMENT=2,HI:$VISITREASONDX03,%APR;$VISITREASONDX03 SEGMENT=2,HI:$VISITREASONDX04,%APR;$VISITREASONDX04 SEGMENT=2,HI:$VISITREASONDX05,%APR;$VISITREASONDX05 SEGMENT=2,HI:$VISITREASONDX06,%APR;$VISITREASONDX06 SEGMENT=2,HI:$VISITREASONDX07,%APR;$VISITREASONDX07 SEGMENT=2,HI:$VISITREASONDX08,%APR;$VISITREASONDX08 SEGMENT=2,HI:$VISITREASONDX09,%APR;$VISITREASONDX09 SEGMENT=2,HI:$VISITREASONDX10,%APR;$VISITREASONDX10 SEGMENT=2,HI:$VISITREASONDX11,%APR;$VISITREASONDX11 SEGMENT=2,HI:$VISITREASONDX12,%APR;$VISITREASONDX12 SEGMENT=2,HI:$DRG,DR,$DRG SEGMENT=2,AMT:$DRGAMT,ZZ,$DRGAMT SEGMENT=3,SV2,$IREVCODE,%HC;$IPROC,$IUNITS,UN,$IQTY SEGMENT=3,DTM,472,D8,$IDOS ISA06=test123