Acute Manifestation DtAdjusted Repriced Line Item Reference NumAdjustment AmtAdmin Cost AmtAllowed AmtAmbulatory Patient Group Code SkAmbulatory Payment Classification CdAnnual Maximum Benefit AmtApplied To Out Of Pocket Limit AmtApproved AmtAttachment Copies Needed CntAttachment Report Type Code SkAttachment Transmission Code SkBenefit Stage AmtBenefit Stage Qualifier Code SkCertification Type Code SkClaim Base Payment RtClaimed Days CntClaim Item NumClaim Line Item Code SkClaim Line Item Code Type Code SkClaim Line SkClaim Line Status Code SkClaim Line Status Reason Code SkClaim Line Status TsClaim Post Discount AmtClaim Pre Discount AmtCoinsurance AmtCo-Insurance PctCompound Drug Code SkCompound Drug IndCompound Ingredient Modifier Code SkContract AmtContract Id NumContract PctContract Type Code SkContract Version Id NumCopay Deductible AmtCopayment AmtCo-Pay Status Code SkCost Sharing IndCurrency Code SkDeductible AmtDisallowed AmtDiscount AmtDispensing Fee Paid AmtDispensing Fee Submitted AmtDosage Form Code SkEffective From DtEffective To DtEmployer Cost AmtEPSDT IndExpected CMS Payment AmtFamily Planning IndFee For Service Equivalent AmtForm Id NumIncentive AmtIngredient Cost Basis Code SkIngredient Cost Paid AmtIngredient Cost Submitted AmtIngredient IndInitial Treatment DtInterest AmtLast X-Ray DtLength Of Medical Necessity CntLevel Of Effort Code SkLifetime Maximum Benefit AmtLine Item 80_100 Code SkLine Item Charge AmtLine Item Control NumLine Item Unit Charge AmtLine Note TxtLoad Info SkLocal Sales Tax AmtLow Income Cost Sharing Level Code SkMember Penalty AmtNational Drug Code NumNetwork Access Fee AmtNoncovered Charge AmtNon Covered Days CntNon-Covered Reason Code SkNonpayable Professional Fees AmtNumber of Claimed ServicesNumber of Non Covered ServicesNumber of Services per Repetition PeriodOnset DtOther Coverage Exists IndOut Of Area Claim IndOut-of-Pocket Maximum AmtPackaging Status CdPaid AmtPaid Days CntPatient Group NumPatient Paid AmtPatient Payment AmtPatient Responsibility AmtPayer Paid AmtPayment Adjustment CdPayment Due Prior to COBPharmacy Claim Line Item Status Reason Code SkPharmacy Co-Payment Basis Code SkPharmacy Dispensing Fee Basis Code SkPharmacy Fund AmtPharmacy Gross Amount SubmittedPharmacy Level Of Service Code SkPharmacy Reimbursement Basis Code SkPharmacy Service Reason Code SkPharmacy Service Result Code SkPhysician Assistant Discount Code SkPlace Of Service Code SkPolicy Compliance Code SkPostage Claimed AmtPreference Incentive Co-Payment AmtPricing Methodology Code SkPricing RtPrincipal Procedure IndPrior Authorization NumProfessional Pharmacy Service PPS Code SkProfessional Service Fee PaidProfessional Service Fee SubmittedPrognosis Code SkProvider Penalty AmtPurchased Service Charge AmtPurchase Price AmtRebate AmtReceived DtReimbursement Action CdReimbursement DtReinsurance AmtReject Reason Code SkRental Price AmtRepriced Allowed AmtRepriced Approved Ambulatory Patient Group AmtRepriced Approved Ambulatory Patient Group Code SkRepriced Approved Service Unit CntRepriced Line Item Reference NumRepriced Saving AmtRepricing Flat Rate AmtResident in CMS Qualified Facility IndRevenue Code NumRevenue Code SkSales Tax Amount SubmittedSales Tax AmtService Delivery CalendarService Delivery TimesService Duration CntService Duration PeriodService Duration Period CntService Repetition CntService Repetition PeriodService State Code SkService Unit CntService Unit Type Code SkSimilar Illness DtSource Code SkTenant SkTerm Discount PctTest Performed DtTherapeutic Class Code NumType Code SkUnit Price AmtUniversal Product NumUsual And Customary Charge UCCValid From TsValid To TsWrite Off Amt
