Accident Fault AttributionAdjusted Repriced Claim Reference NumAdvanced Technology Operating AllowanceAffiliated Claim IndAllowed AmtAmount Applied to Benefit LimitAmount Applied to Out-of-pocket LimitApproved AmtAttachment TransmissionAttachment TypeAudit IndBill From DateBilling Form TypeBill To DateCapital Charge AmtClaim Data SourceClaim Filing TypeClaim NumClaim Pricing MethodClaim Recovery StrategyClaim Signature DateClaim Size CategoryClaim StatusClaim Status ReasonClaim Status TsClaim VersionClass Of ClaimClean Claim Receipt DateClearinghouse Trace NumCLIA NumCOB AmtContract AmtContract Code NumContract PctContract TypeContract Version NumCurrencyDecisionsDelay ReasonDemonstration Project NumDocument Control NumDRG WeightingDual Coverage IndEOB Requested IndEstimated Due AmtExtraordinary Capital AllowanceExtreme Care Capital AllowanceExtreme Care Days Covered CntExtreme Care Operating AllowanceFI Action TypeGovernment Reduction AmtHIPPSIncoming IndIncurred But Not Reported IndIndemnity PortionIn Plan Network IndInvestigational Device Exemption Identifier NumLast Worked DateLow Utilization AdjustmentMedical Education Capital AllowanceMedical Education Operating AllowanceMedicare A Covered Months CntMedicare B Covered Months CntMedicare Buyin Months Covered CntMedicare HMO Months Covered CntMember Authorization TypeMinimal Care Cost Capital ReductionMinimal Care Cost Operating ReductionNational Capital AllowanceNational Operating AllowanceOne Pass Process IndOperating Charge AmtOriginal Claim NumOut of Area Financial Administration Fee AmtOut of Area General Administration Fee AmtOut of Area Surcharge AmtOut-of-Network ReasonParticipation Agreement CodePatient Demographic Capital AllowancePatient Demographic Operating AllowancePatient Paid AmtPayer Paid AmtPPS Claim CodePre-Authorization Exception ReasonPrompt Payment Discount AmtProperty Casualty Claim NumProvider Assignment IndProvider Capital AllowanceProvider Operating AllowanceProvider Signature IndRepriced Allowed AmtRepriced Approved Ambulatory Patient Group AmtRepriced Approved Ambulatory Patient Group Code NumRepriced Claim Reference NumRepriced Saving AmtReprice Exception CodeReprice Policy ComplianceReprice Rejection Reason CodeRepricing Flat Rate AmtResponsible Party ReasonRetained Service AmtSecondary Payer Pass-through AmtSecondary Payment IndService Authorization Exception TypeSettlement CurrencySubmission Clarification TypeSubrogation IndSupporting Documentation IndTerm Discount PctTotal Adjustment Units of ServiceTotal Claim Charge AmtTotal CostTotal Member Liability AmtTotal Nonpayable Professional Fees AmtTotal Purchased Services AmtTotal Units of ServicesTotal Visits Rendered CntType 4081 Claim Ind
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