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Actuarial Value ME120 Utah Medical Eligibility File Submission
Admission Date/Hour 2300 DTP03 When DTP01=435 47 Utah Medical Claims File Submission 837I
Admission Date MC018 Utah Medical Claims File Submission
Admission Hour MC019 Utah Medical Claims File Submission
Admission Source MC021 Utah Medical Claims File Submission
Admission Type MC020 Utah Medical Claims File Submission
Admissio Date 2300 DTP03 When DTP01=435 47 Utah Medical Claims File Submission 837P
Admitting Diagnosis MC039 Utah Medical Claims File Submission
Allowed Amount 2400 AMT02 118 Utah Medical Claims File Submission 837P
APC MC073 Utah Medical Claims File Submission
APC Version MC074 Utah Medical Claims File Submission
Attending Physician FName 2310A NM104 103 Utah Medical Claims File Submission 837I
Attending Physician LName 2310A NM103 102 Utah Medical Claims File Submission 837I
Attending Physician Name Middle 2310A NM105 104 Utah Medical Claims File Submission 837I
Attending Physician Name Suffix 2310A NM107 105 Utah Medical Claims File Submission 837I
Attending Physician Primary Identifier 2310A NM109 106 Utah Medical Claims File Submission 837I
Attending Physician Secondary Identification 2310A REF02 107 Utah Medical Claims File Submission 837I
Attending Physician Specialty Information 2000A or 2310A PRV03 101 Utah Medical Claims File Submission 837I
Benefit Option Code 24 Utah Medical Eligibility File Submission
BHT01 Hierarchical Structure Code BHT06 1 Utah Medical Claims File Submission 837I
BHT Beginning of Hierarchical Transaction BHT06 1 Utah Medical Claims File Submission 837P
Billing Provider ID 2010AA NM109 10 Utah Medical Claims File Submission 837P
Billing Provider ID 2010AA NM109 10 Utah Medical Claims File Submission 837I
Billing Provider Last Name or Organization Name MC078 Utah Medical Claims File Submission
Billing Provider Name 2010AA NM103 9 Utah Medical Claims File Submission 837P
Billing Provider Name 2010AA NM103 9 Utah Medical Claims File Submission 837I
Billing Provider Number MC076 Utah Medical Claims File Submission
Billing Provider Secondary Identification 2010AA REF02 11 Utah Medical Claims File Submission 837P
Billing Provider Secondary Identification 2010AA REF02 11 Utah Medical Claims File Submission 837I
Birth date 16 Utah Medical Eligibility File Submission
Capitated Service Indicator MC206 Utah Medical Claims File Submission
Charge Amount MC062 Utah Medical Claims File Submission
Charge Amount PC035 Utah Pharmacy Claims File Submission
City 12 Utah Medical Eligibility File Submission
Claim Adjudication Date 2330B DTP03 WHEN DTP01=573 62 Utah Medical Claims File Submission 837P
Claim Adjudication Date 2330B DTP03 WHEN DTP01=573 62 Utah Medical Claims File Submission 837I
Claim Adjustment Group Code 2320 CAS01 64 Utah Medical Claims File Submission 837P
Claim Adjustment Group Code 2320 CAS01 64 Utah Medical Claims File Submission 837I
Claim Adjustment Reason Code 2320 CAS02 65 Utah Medical Claims File Submission 837P
Claim Adjustment Reason Code 2320 CAS02 65 Utah Medical Claims File Submission 837I
Claim Frequency Type Code (Type of Bill, Position 4) 2300 CLM05-3 44 Utah Medical Claims File Submission 837P
Claim Frequency Type Code (Type of Bill, Position 4) 2300 CLM05-3 45 Utah Medical Claims File Submission 837I
Claim Level Adjustment Amount 2320 CAS03 66 Utah Medical Claims File Submission 837P
Claim Level Adjustment Amount 2320 CAS03 66 Utah Medical Claims File Submission 837I
Claim Status MC038 Utah Medical Claims File Submission
Claim Status PC025 Utah Pharmacy Claims File Submission
Co-pay Amount MC065 Utah Medical Claims File Submission
Co-pay Amount PC040 Utah Pharmacy Claims File Submission
Coinsurance Amount MC066 Utah Medical Claims File Submission
Coinsurance Amount PC041 Utah Pharmacy Claims File Submission
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