Acute Manifestation DtAdjusted Repriced Line Item Reference NumAdjustment AmtAdmin Cost AmtAllowed AmtAmbulatory Patient Group CdAmbulatory Patient Group Code DescrAmbulatory Patient Group Code SkAnnual Maximum Benefit AmtApproved AmtAttachment Report Type CdAttachment Report Type Code SkAttachment Report Type DescrAttachment Transmission CdAttachment Transmission Code SkAttachment Transmission DescrAWM Load Info SkBenefit Stage AmtBenefit Stage Qualifier CdBenefit Stage Qualifier Code DescrBenefit Stage Qualifier Code SkCertification Type CdCertification Type Code SkCertification Type DescrClaim Base Payment RtClaimed Days CntClaim Item NumClaim Line BkClaim Line DkClaim Line Item CdClaim Line Item Code DescrClaim Line Item Code SkClaim Line Item Code Type CdClaim Line Item Code Type Code DescrClaim Line Item Code Type Code SkClaim Line SkClaim Post Discount AmtClaim Pre Discount AmtCo-Insurance PctCompound Drug CdCompound Drug Code DescrCompound Drug Code SkCompound Drug IndCompound 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DescrLine Item Charge AmtLine Item Control NumLine Item Unit Charge AmtLine Note TxtLow Income Cost Sharing Level CdLow Income Cost Sharing Level Code DescrLow Income Cost Sharing Level Code SkMember Penalty AmtNational Drug Code NumNetwork Access Fee AmtNoncovered Charge AmtNon Covered Days CntNon-Covered Reason CdNon-Covered Reason Code DescrNon-Covered Reason Code SkNonpayable Professional Fees AmtNumber of Non Covered ServicesNumber of Services per Repetition PeriodOnset DtOther Coverage Exists IndOut Of Area Claim IndPaid AmtPaid Days CntPatient Group NumPatient Paid AmtPatient Payment AmtPatient Responsibility AmtPayer Paid AmtPharmacy Claim Line Item Status Reason CdPharmacy Claim Line Item Status Reason Code DescrPharmacy Claim Line Item Status Reason Code SkPharmacy Co-Payment Basis CdPharmacy Co-Payment Basis Code DescrPharmacy Co-Payment Basis Code SkPharmacy Dispensing Fee Basis CdPharmacy Dispensing Fee Basis Code DescrPharmacy Dispensing Fee Basis Code SkPharmacy Gross Amount SubmittedPharmacy Level Of Service CdPharmacy Level Of Service Code DescrPharmacy Level Of Service Code SkPharmacy Reimbursement Basis CdPharmacy Reimbursement Basis Code DescrPharmacy Reimbursement Basis Code SkPharmacy Service Reason CdPharmacy Service Reason Code DescrPharmacy Service Reason Code SkPharmacy Service Result CdPharmacy Service Result Code DescrPharmacy Service Result Code SkPhysician Assistant Discount CdPhysician Assistant Discount Code SkPhysician Assistant Discount DescrPlace Of Service CdPlace Of Service Code SkPlace Of Service DescrPolicy Compliance CdPolicy Compliance Code SkPolicy Compliance DescrPostage Claimed AmtPreference Incentive Co-Payment AmtPricing Methodology CdPricing Methodology Code SkPricing Methodology DescrPricing RtPrincipal Procedure IndPrior Authorization NumProfessional Pharmacy Service PPS CdProfessional Pharmacy Service PPS Code DescrProfessional Pharmacy Service PPS Code SkProfessional Service Fee SubmittedPrognosis CdPrognosis Code SkPrognosis DescrProvider Penalty AmtPurchased Service Charge AmtPurchase Price AmtReceived DtReimbursement DtReject Reason CdReject Reason Code SkReject Reason DescrRental Price AmtRepriced Allowed AmtRepriced Approved Ambulatory Patient Group AmtRepriced Approved Ambulatory Patient Group CdRepriced Approved Ambulatory Patient Group Code SkRepriced Approved Ambulatory Patient Group DescrRepriced Approved Service Unit CntRepriced Line Item Reference NumRepriced Saving AmtRepricing Flat Rate AmtResident in CMS Qualified Facility IndRevenue CdRevenue Code NumRevenue Code SkRevenue DescrSales Tax AmtSecondary Payment IndService Delivery CalendarService Delivery TimesService Duration CntService Duration PeriodService Duration Period CntService Repetition CntService Repetition PeriodService Unit CntService Unit Type CdService Unit Type Code SkSimilar Illness DtSource CdSource Code DescrSource Code SkSource DescrTenant SkTerm Discount PctTest Performed DtTherapeutic Class Code NumType CdType Code DescrType Code SkUnit Price AmtUniversal Product NumUsual And Customary Charge UCCValid From TsValid To Ts
