# ID Source Entity Type Source

1 2001 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.SOURCE

2 2002 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.MEMID
3 2003 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.EMPID

4 2004 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.SUBSCRIBERFLAG

5 2005 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.RELFLAG

6 2006 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.MEMFIRSTNAME

7 2007 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.MEMLASTNAME

8 2008 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.GENDER
9 2009 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.DOB

10 2010 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.ADDR1

11 2011 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.ADDR2

12 2012 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.CITY
13 2013 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.STATE
14 2014 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.ZIP
15 2015 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.HOMEPHONE
16 2016 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.WORKPHONE
17 2017 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.EMPZIP
18 2018 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.LOCATION

HP-A1.HP_ELIGIBILITIES.OPCHEMEFFDATE

HP-A1.HP_ELIGIBILITIES.IPCHEMEFFDATE

HP-A1.HP_ELIGIBILITIES.OPMHEFFDATE

HP-A1.HP_ELIGIBILITIES.IPMHEFFDATE
HP-A1.HP_ELIGIBILITIES.VISEFFDATE
HP-A1.HP_ELIGIBILITIES.STDEFFDATE
HP-A1.HP_ELIGIBILITIES.DENEFFDATE

19 2019 DATA_ELEMENT
 HP-A1.HP_ELIGIBILITIES.RXEFFDATE
HP-A1.HP_ELIGIBILITIES.MEDEFFDATE
19 2019 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.EFFDATE

HP-
A1.HP_ELIGIBILITIES.OPCHEMTERMDATE

HP-
A1.HP_ELIGIBILITIES.IPCHEMTERMDATE

HP-A1.HP_ELIGIBILITIES.OPMHTERMDATE

HP-A1.HP_ELIGIBILITIES.IPMHTERMDATE

HP-A1.HP_ELIGIBILITIES.VISTERMDATE

HP-A1.HP_ELIGIBILITIES.STDTERMDATE

HP-A1.HP_ELIGIBILITIES.DENTERMDATE
HP-A1.HP_ELIGIBILITIES.RXTERMDATE

HP-A1.HP_ELIGIBILITIES.MEDTERMDATE
20 2020 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.TERMDATE

21 2021 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.LVL1ID

22 2022 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.LVL1DESC

23 2023 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.LVL2ID

24 2024 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.LVL2DESC

25 2025 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.LVL3ID

26 2026 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.LVL3DESC

27 2027 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.LVL4ID

28 2028 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.LVL4DESC

29 2029 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.LVL5ID

30 2030 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.LVL5DESC

31 2031 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.LVL6ID

32 2032 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.LVL6DESC
33 2033 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.CMSTATUS

34 2049 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.CATCODE

35 2050 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.CATDESC

36 2052 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.TEAMNAME

37 2053 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.PROVID
38 2054 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.PROVNAME
39 2055 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.SSN
40 2057 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.UDF1_MEM
41 2059 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.UDF2_MEM

42 2061 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.UDFC2

43 2063 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.UDFC16

44 2064 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.UDFC17

45 2065 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.UDFC6

46 2066 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.UDFC7

47 2067 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.RCVMTH

48 2068 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.SRCFILENAME

49 2069 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.BENCOVTYPE

50 2070 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.UDFC20

51 2071 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.SICCODE

52 2072 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.SICDESC

53 2073 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.PAYERTYPE

54 2082 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.ELIGCAT

55 2083 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.MCAID1

56 2084 DATA_ELEMENT HP-A1.HP_ELIGIBILITIES.OREC

57 2095 DATA_ELEMENT HP-A1.HP_CLAIMS.MODIFIERCODE

58 2096 DATA_ELEMENT HP-A1.HP_CLAIMS.PROVNPI
59 2097 DATA_ELEMENT HP-A1.HP_CLAIMS.SOURCE
60 2098 DATA_ELEMENT HP-A1.HP_CLAIMS.SN

61 2099 DATA_ELEMENT HP-A1.HP_CLAIMS.CLMNUM

62 2100 DATA_ELEMENT HP-A1.HP_CLAIMS.CLMTYPE

63 2101 DATA_ELEMENT HP-A1.HP_CLAIMS.CLMTYPEDESC

64 2102 DATA_ELEMENT HP-A1.HP_CLAIMS.CLMCAT
65 2103 DATA_ELEMENT HP-A1.HP_CLAIMS.MEMID
66 2104 DATA_ELEMENT HP-A1.HP_CLAIMS.EMPID
67 2105 DATA_ELEMENT HP-A1.HP_CLAIMS.SUBSCRIBERFLAG

68 2106 DATA_ELEMENT HP-A1.HP_CLAIMS.RELFLAG

69 2107 DATA_ELEMENT HP-A1.HP_CLAIMS.MEMFIRSTNAME
70 2108 DATA_ELEMENT HP-A1.HP_CLAIMS.MEMLASTNAME
71 2109 DATA_ELEMENT HP-A1.HP_CLAIMS.GENDER
72 2110 DATA_ELEMENT HP-A1.HP_CLAIMS.DOB
HP-A1.HP_CLAIMS.ADDR2
73 2111 DATA_ELEMENT HP-A1.HP_CLAIMS.ADDR1
74 2113 DATA_ELEMENT HP-A1.HP_CLAIMS.CITY
75 2114 DATA_ELEMENT HP-A1.HP_CLAIMS.STATE
76 2115 DATA_ELEMENT HP-A1.HP_CLAIMS.ZIP
77 2116 DATA_ELEMENT HP-A1.HP_CLAIMS.HOMEPHONE
78 2117 DATA_ELEMENT HP-A1.HP_CLAIMS.WORKPHONE

79 2118 DATA_ELEMENT HP-A1.HP_CLAIMS.LVL1ID

80 2119 DATA_ELEMENT HP-A1.HP_CLAIMS.LVL1DESC

81 2120 DATA_ELEMENT HP-A1.HP_CLAIMS.LVL2ID

82 2121 DATA_ELEMENT HP-A1.HP_CLAIMS.LVL2DESC

83 2122 DATA_ELEMENT HP-A1.HP_CLAIMS.LVL3ID

84 2123 DATA_ELEMENT HP-A1.HP_CLAIMS.LVL3DESC

 85 2124 DATA_ELEMENT HP-A1.HP_CLAIMS.LVL4ID

86 2125 DATA_ELEMENT HP-A1.HP_CLAIMS.LVL4DESC

87 2126 DATA_ELEMENT HP-A1.HP_CLAIMS.LVL4FIRSTNAME

88 2127 DATA_ELEMENT HP-A1.HP_CLAIMS.LVL4LASTNAME

89 2128 DATA_ELEMENT HP-A1.HP_CLAIMS.LVL5ID

90 2129 DATA_ELEMENT HP-A1.HP_CLAIMS.LVL5DESC

91 2130 DATA_ELEMENT HP-A1.HP_CLAIMS.LVL6ID

92 2131 DATA_ELEMENT HP-A1.HP_CLAIMS.LVL6DESC

93 2132 DATA_ELEMENT HP-A1.HP_CLAIMS.CMSTATUS

94 2133 DATA_ELEMENT HP-A1.HP_CLAIMS.FROMDATE
95 2134 DATA_ELEMENT HP-A1.HP_CLAIMS.TODATE
96 2135 DATA_ELEMENT HP-A1.HP_CLAIMS.RCVDATE
97 2136 DATA_ELEMENT HP-A1.HP_CLAIMS.PAIDDATE

98 2137 DATA_ELEMENT HP-A1.HP_CLAIMS.DIAGCODE

99 2138 DATA_ELEMENT HP-A1.HP_CLAIMS.DIAGDESC

100 2139 DATA_ELEMENT HP-A1.HP_CLAIMS.FIRSTDIAGCODE

101 2140 DATA_ELEMENT HP-A1.HP_CLAIMS.SECONDDIAGCODE

102 2141 DATA_ELEMENT HP-A1.HP_CLAIMS.THIRDDIAGCODE

103 2142 DATA_ELEMENT HP-A1.HP_CLAIMS.FOURTHDIAGCODE

104 2143 DATA_ELEMENT HP-A1.HP_CLAIMS.DRGCODE

105 2144 DATA_ELEMENT HP-A1.HP_CLAIMS.PROVID
106 2145 DATA_ELEMENT HP-A1.HP_CLAIMS.PROVNAME
107 2146 DATA_ELEMENT HP-A1.HP_CLAIMS.PROVCITY
108 2147 DATA_ELEMENT HP-A1.HP_CLAIMS.PROVSTATE
109 2148 DATA_ELEMENT HP-A1.HP_CLAIMS.INNWK

110 2149 DATA_ELEMENT HP-A1.HP_CLAIMS.OOA

111 2150 DATA_ELEMENT HP-A1.HP_CLAIMS.PREFERRED

112 2151 DATA_ELEMENT HP-A1.HP_CLAIMS.NWKID
113 2152 DATA_ELEMENT HP-A1.HP_CLAIMS.NWKNAME

114 2153 DATA_ELEMENT HP-A1.HP_CLAIMS.NWKCITY

115 2154 DATA_ELEMENT HP-A1.HP_CLAIMS.NWKSTATE

116 2155 DATA_ELEMENT HP-A1.HP_CLAIMS.PERSISTENCEFACTOR

117 2156 DATA_ELEMENT HP-A1.HP_CLAIMS.ADMITTYPE
118 2157 DATA_ELEMENT HP-A1.HP_CLAIMS.ADMITSOURCE

119 2158 DATA_ELEMENT HP-A1.HP_CLAIMS.IPDAYS

120 2159 DATA_ELEMENT HP-A1.HP_CLAIMS.DISCHRGIND

121 2160 DATA_ELEMENT HP-A1.HP_CLAIMS.SPECROLLUPCODE

122 2161 DATA_ELEMENT HP-A1.HP_CLAIMS.SPECROLLUPDESC

123 2162 DATA_ELEMENT HP-A1.HP_CLAIMS.TEAMCODE

124 2163 DATA_ELEMENT HP-A1.HP_CLAIMS.TEAMNAME

125 2164 DATA_ELEMENT HP-A1.HP_CLAIMS.SSN
126 2165 DATA_ELEMENT HP-A1.HP_CLAIMS.RCVMTH
127 2166 DATA_ELEMENT HP-A1.HP_CLAIMS.SRCFILENAME

128 2167 DATA_ELEMENT HP-A1.HP_CLAIMS.DUPCHECK

129 2168 DATA_ELEMENT HP-A1.HP_CLAIMS.PROVTYPECODE

130 2169 DATA_ELEMENT HP-A1.HP_CLAIMS.PROVTYPEDESC

131 2170 DATA_ELEMENT HP-A1.HP_CLAIMS.FIFTHDIAGCODE

132 2171 DATA_ELEMENT HP-A1.HP_CLAIMS.ICD9PROCCODE1

133 2172 DATA_ELEMENT HP-A1.HP_CLAIMS.ICD9PROCCODE2

134 2173 DATA_ELEMENT HP-A1.HP_CLAIMS.ICD9PROCCODE3

135 2174 DATA_ELEMENT HP-A1.HP_CLAIMS.ICD9PROCCODE4

136 2175 DATA_ELEMENT HP-A1.HP_CLAIMS.ICD9PROCCODE5

137 2176 DATA_ELEMENT HP-A1.HP_CLAIMS.SIXTHDIAGCODE

138 2177 DATA_ELEMENT HP-A1.HP_CLAIMS.SEVENTHDIAGCODE

139 2178 DATA_ELEMENT HP-A1.HP_CLAIMS.EIGHTHDIAGCODE

140 2179 DATA_ELEMENT HP-A1.HP_CLAIMS.NINTHDIAGCODE

141 2180 DATA_ELEMENT HP-A1.HP_CLAIMS.TENTHDIAGCODE

142 2181 DATA_ELEMENT HP-A1.HP_CLAIMS.ICD9PROCCODE6

143 2182 DATA_ELEMENT HP-A1.HP_CLAIMS.DRGIDENTIFIER

144 2183 DATA_ELEMENT HP-A1.HP_CLAIMS.DISCHSTATUS
145 2184 DATA_ELEMENT HP-A1.HP_CLAIMS.TYPEOFBILL
146 2185 DATA_ELEMENT HP-A1.HP_CLAIMS.CLAIMSTATUS

147 2186 DATA_ELEMENT HP-A1.HP_CLAIMS.NETWORKTYPE

148 2187 DATA_ELEMENT HP-A1.HP_CLAIMS.EMP_NBR

149 2188 DATA_ELEMENT HP-A1.HP_CLAIMS.MEDELIGCATID

150 2189 DATA_ELEMENT HP-A1.HP_CLAIMS.PRODUCTID

151 2190 DATA_ELEMENT HP-A1.HP_CLAIMS.CLAIM_ID

152 2191 DATA_ELEMENT HP-A1.HP_CLAIMS.ICDTYPE

153 2192 DATA_ELEMENT HP-A1.HP_CLAIMS.IUOU

154 2193 DATA_ELEMENT HP-A1.HP_CLAIMS.VHPAYORID

155 2194 DATA_ELEMENT HP-A1.HP_CLAIMS.VHLAYOUTID

156 2195 DATA_ELEMENT HP-A1.HP_CLAIMS.SN
157 2196 DATA_ELEMENT HP-A1.HP_CLAIMS.CLMNUM
158 2197 DATA_ELEMENT HP-A1.HP_CLAIMS.SERVICEDATE

159 2198 DATA_ELEMENT HP-A1.HP_CLAIMS.BILLTYPE

160 2199 DATA_ELEMENT HP-A1.HP_CLAIMS.FUNDCODE

161 2200 DATA_ELEMENT HP-A1.HP_CLAIMS.FUNDDESC

162 2201 DATA_ELEMENT HP-A1.HP_CLAIMS.POSCODE

163 2202 DATA_ELEMENT HP-A1.HP_CLAIMS.POSDESC

164 2203 DATA_ELEMENT HP-A1.HP_CLAIMS.SPECCODE
165 2204 DATA_ELEMENT HP-A1.HP_CLAIMS.SPECDESC

166 2205 DATA_ELEMENT HP-A1.HP_CLAIMS.PROCTYPE

167 2207 DATA_ELEMENT HP-A1.HP_CLAIMS.PROCDESC

168 2208 DATA_ELEMENT HP-A1.HP_CLAIMS.REVCODE

169 2209 DATA_ELEMENT HP-A1.HP_CLAIMS.MODIFIERCODE

170 2210 DATA_ELEMENT HP-A1.HP_CLAIMS.PROCCODE

171 2211 DATA_ELEMENT HP-A1.HP_CLAIMS.MODIFIERDESC

172 2212 DATA_ELEMENT HP-A1.HP_CLAIMS.PROVNAME
173 2213 DATA_ELEMENT HP-A1.HP_CLAIMS.SERVICEUNITS
174 2214 DATA_ELEMENT HP-A1.HP_CLAIMS.PAIDAMT

175 2215 DATA_ELEMENT HP-A1.HP_CLAIMS.GROSSCHARGE

176 2216 DATA_ELEMENT HP-A1.HP_CLAIMS.BILLEDAMT
177 2217 DATA_ELEMENT HP-A1.HP_CLAIMS.ALLOWEDAMT

178 2218 DATA_ELEMENT HP-A1.HP_CLAIMS.PPOSAVINGAMT

179 2219 DATA_ELEMENT HP-A1.HP_CLAIMS.EMPPAIDAMT

180 2220 DATA_ELEMENT HP-A1.HP_CLAIMS.COINSAMT

181 2221 DATA_ELEMENT HP-A1.HP_CLAIMS.COPAYAMT
182 2222 DATA_ELEMENT HP-A1.HP_CLAIMS.DEDUCTAMT
183 2223 DATA_ELEMENT HP-A1.HP_CLAIMS.NOTALLOWEDAMT
184 2224 DATA_ELEMENT HP-A1.HP_CLAIMS.COBAMT

185 2225 DATA_ELEMENT HP-A1.HP_CLAIMS.PLANEXCLAMT

186 2226 DATA_ELEMENT HP-A1.HP_CLAIMS.REINSAMT

187 2227 DATA_ELEMENT HP-A1.HP_CLAIMS.REPRICEDAMT

188 2228 DATA_ELEMENT HP-A1.HP_CLAIMS.ADJCODE

189 2229 DATA_ELEMENT HP-A1.HP_CLAIMS.ADJFLAG

190 2230 DATA_ELEMENT HP-A1.HP_CLAIMS.SERVICECODE

191 2231 DATA_ELEMENT HP-A1.HP_CLAIMS.LABTESTDATA

192 2232 DATA_ELEMENT HP-A1.HP_CLAIMS.SERVTYPECODE

193 2233 DATA_ELEMENT HP-A1.HP_CLAIMS.SERVTYPEDESC

194 2234 DATA_ELEMENT HP-A1.HP_CLAIMS.REVCODE1

195 2235 DATA_ELEMENT HP-A1.HP_CLAIMS.REVCODE2

196 2236 DATA_ELEMENT HP-A1.HP_CLAIMS.REVCODE4

197 2237 DATA_ELEMENT HP-A1.HP_CLAIMS.REVCODE3

198 2238 DATA_ELEMENT HP-A1.HP_CLAIMS.REVCODE5

 HP-A1.HP_CLAIMS.PROCCODE
HP-A1.HP_CLAIMS.PROCTYPE
HP-A1.HP_CLAIMS.HCPCS
199 2239 DATA_ELEMENT HP-A1.HP_CLAIMS.CPT4_1

200 2240 DATA_ELEMENT HP-A1.HP_CLAIMS.CPT4_2

201 2241 DATA_ELEMENT HP-A1.HP_CLAIMS.CPT4_3

202 2243 DATA_ELEMENT HP-A1.HP_CLAIMS.PROVIDERFIRSTNAME

203 2244 DATA_ELEMENT HP-A1.HP_CLAIMS.PROVIDERLASTNAME

204 2245 DATA_ELEMENT HP-A1.HP_CLAIMS.RBIND

205 2246 DATA_ELEMENT HP-A1.HP_CLAIMS.SICCODE

206 2247 DATA_ELEMENT HP-A1.HP_CLAIMS.SICDESC

207 2248 DATA_ELEMENT HP-A1.HP_CLAIMS.MODIFIERCODE2

208 2249 DATA_ELEMENT HP-A1.HP_CLAIMS.CPTII

209 2250 DATA_ELEMENT HP-A1.HP_CLAIMS.PCP_YN

210 2251 DATA_ELEMENT HP-A1.HP_CLAIMS.OBGYN_YN

211 2252 DATA_ELEMENT HP-A1.HP_CLAIMS.MHPROV_YN

212 2253 DATA_ELEMENT HP-A1.HP_CLAIMS.EYECAREPROV_YN

213 2254 DATA_ELEMENT HP-A1.HP_CLAIMS.DENTIST_YN

214 2255 DATA_ELEMENT HP-A1.HP_CLAIMS.NEPHROLOGIST_YN

215 2256 DATA_ELEMENT HP-A1.HP_CLAIMS.CDPROV_YN

216 2257 DATA_ELEMENT HP-A1.HP_CLAIMS.NPRPROV_YN

217 2258 DATA_ELEMENT HP-A1.HP_CLAIMS.PASPROV_YN

218 2259 DATA_ELEMENT HP-A1.HP_CLAIMS.PROVPRES_YN

219 2260 DATA_ELEMENT HP-A1.HP_CLAIMS.PAIDDAYS

220 2261 DATA_ELEMENT HP-A1.HP_CLAIMS.CLAIM_LINE_NBR
221 2262 DATA_ELEMENT HP-A1.HP_RXCLAIMS.SOURCE
222 2263 DATA_ELEMENT HP-A1.HP_RXCLAIMS.SN
223 2264 DATA_ELEMENT HP-A1.HP_RXCLAIMS.CLMNUM
224 2265 DATA_ELEMENT HP-A1.HP_RXCLAIMS.MEMID
225 2266 DATA_ELEMENT HP-A1.HP_RXCLAIMS.EMPID

226 2267 DATA_ELEMENT HP-A1.HP_RXCLAIMS.SUBSCRIBERFLAG

227 2268 DATA_ELEMENT HP-A1.HP_RXCLAIMS.RELFLAG

228 2269 DATA_ELEMENT HP-A1.HP_RXCLAIMS.MEMFIRSTNAME

229 2270 DATA_ELEMENT HP-A1.HP_RXCLAIMS.MEMLASTNAME
230 2271 DATA_ELEMENT HP-A1.HP_RXCLAIMS.GENDER
231 2272 DATA_ELEMENT HP-A1.HP_RXCLAIMS.DOB
HP-A1.HP_RXCLAIMS.ADDR2
232 2273 DATA_ELEMENT HP-A1.HP_RXCLAIMS.ADDR1
233 2275 DATA_ELEMENT HP-A1.HP_RXCLAIMS.CITY
234 2276 DATA_ELEMENT HP-A1.HP_RXCLAIMS.STATE
235 2277 DATA_ELEMENT HP-A1.HP_RXCLAIMS.ZIP
236 2278 DATA_ELEMENT HP-A1.HP_RXCLAIMS.HOMEPHONE
237 2279 DATA_ELEMENT HP-A1.HP_RXCLAIMS.WORKPHONE

238 2280 DATA_ELEMENT HP-A1.HP_RXCLAIMS.LVL1ID

239 2281 DATA_ELEMENT HP-A1.HP_RXCLAIMS.LVL1DESC

240 2282 DATA_ELEMENT HP-A1.HP_RXCLAIMS.LVL2ID

241 2283 DATA_ELEMENT HP-A1.HP_RXCLAIMS.LVL2DESC

242 2284 DATA_ELEMENT HP-A1.HP_RXCLAIMS.LVL3ID

243 2285 DATA_ELEMENT HP-A1.HP_RXCLAIMS.LVL3DESC

244 2286 DATA_ELEMENT HP-A1.HP_RXCLAIMS.LVL4ID

245 2287 DATA_ELEMENT HP-A1.HP_RXCLAIMS.LVL4DESC

246 2288 DATA_ELEMENT HP-A1.HP_RXCLAIMS.LVL4FIRSTNAME

247 2289 DATA_ELEMENT HP-A1.HP_RXCLAIMS.LVL4LASTNAME

248 2290 DATA_ELEMENT HP-A1.HP_RXCLAIMS.LVL5ID

249 2291 DATA_ELEMENT HP-A1.HP_RXCLAIMS.LVL5DESC

250 2292 DATA_ELEMENT HP-A1.HP_RXCLAIMS.LVL6ID

251 2293 DATA_ELEMENT HP-A1.HP_RXCLAIMS.LVL6DESC

252 2294 DATA_ELEMENT HP-A1.HP_RXCLAIMS.CMSTATUS
253 2295 DATA_ELEMENT HP-A1.HP_RXCLAIMS.PAIDDATE
254 2296 DATA_ELEMENT HP-A1.HP_RXCLAIMS.PHARMID

255 2297 DATA_ELEMENT HP-A1.HP_RXCLAIMS.PHARMNAME

256 2298 DATA_ELEMENT HP-A1.HP_RXCLAIMS.DEANO

257 2299 DATA_ELEMENT HP-A1.HP_RXCLAIMS.DEANAME

258 2300 DATA_ELEMENT HP-A1.HP_RXCLAIMS.PRESCRIBERTYPE

259 2301 DATA_ELEMENT HP-A1.HP_RXCLAIMS.TEAMCODE

260 2302 DATA_ELEMENT HP-A1.HP_RXCLAIMS.TEAMNAME

261 2303 DATA_ELEMENT HP-A1.HP_RXCLAIMS.SSN
262 2304 DATA_ELEMENT HP-A1.HP_RXCLAIMS.RCVMTH
263 2305 DATA_ELEMENT HP-A1.HP_RXCLAIMS.SRCFILENAME

264 2306 DATA_ELEMENT HP-A1.HP_RXCLAIMS.SICCODE

265 2307 DATA_ELEMENT HP-A1.HP_RXCLAIMS.SICDESC

266 2308 DATA_ELEMENT HP-A1.HP_RXCLAIMS.CLAIMSTATUS

267 2309 DATA_ELEMENT HP-A1.HP_RXCLAIMS.NETWORKTYPE

268 2310 DATA_ELEMENT HP-A1.HP_RXCLAIMS.EMP_NBR

269 2311 DATA_ELEMENT HP-A1.HP_RXCLAIMS.MEDELIGCATID

270 2312 DATA_ELEMENT HP-A1.HP_RXCLAIMS.PRODUCTID

271 2313 DATA_ELEMENT HP-A1.HP_RXCLAIMS.VHPAYORID

272 2314 DATA_ELEMENT HP-A1.HP_RXCLAIMS.VHLAYOUTID

273 2315 DATA_ELEMENT HP-A1.HP_RXCLAIMS.SN
274 2316 DATA_ELEMENT HP-A1.HP_RXCLAIMS.CLMNUM

275 2317 DATA_ELEMENT HP-A1.HP_RXCLAIMS.SERVICEDATE

276 2318 DATA_ELEMENT HP-A1.HP_RXCLAIMS.SERVICEUNITS
277 2319 DATA_ELEMENT HP-A1.HP_RXCLAIMS.DAYSSUPPLY

278 2320 DATA_ELEMENT HP-A1.HP_RXCLAIMS.DRUGCODE

279 2321 DATA_ELEMENT HP-A1.HP_RXCLAIMS.DRUGDESC
280 2322 DATA_ELEMENT HP-A1.HP_RXCLAIMS.DRUGSTRENGTH
281 2323 DATA_ELEMENT HP-A1.HP_RXCLAIMS.DRUGTYPECODE
282 2324 DATA_ELEMENT HP-A1.HP_RXCLAIMS.DRUGTYPEDESC
283 2325 DATA_ELEMENT HP-A1.HP_RXCLAIMS.FORMULARY_YN
284 2326 DATA_ELEMENT HP-A1.HP_RXCLAIMS.MOI
285 2327 DATA_ELEMENT HP-A1.HP_RXCLAIMS.GCN
286 2328 DATA_ELEMENT HP-A1.HP_RXCLAIMS.GI
287 2329 DATA_ELEMENT HP-A1.HP_RXCLAIMS.GPI
288 2330 DATA_ELEMENT HP-A1.HP_RXCLAIMS.RXCODE
289 2331 DATA_ELEMENT HP-A1.HP_RXCLAIMS.RXDESC
290 2332 DATA_ELEMENT HP-A1.HP_RXCLAIMS.PAIDAMT
291 2333 DATA_ELEMENT HP-A1.HP_RXCLAIMS.BILLEDAMT

292 2334 DATA_ELEMENT HP-A1.HP_RXCLAIMS.INGREDCOST

293 2335 DATA_ELEMENT HP-A1.HP_RXCLAIMS.DISPENSINGCOST

294 2336 DATA_ELEMENT HP-A1.HP_RXCLAIMS.SALESTAX
295 2337 DATA_ELEMENT HP-A1.HP_RXCLAIMS.ALLOWEDAMT

296 2338 DATA_ELEMENT HP-A1.HP_RXCLAIMS.EMPPAIDAMT

297 2339 DATA_ELEMENT HP-A1.HP_RXCLAIMS.COINSAMT

298 2340 DATA_ELEMENT HP-A1.HP_RXCLAIMS.COPAYAMT
299 2341 DATA_ELEMENT HP-A1.HP_RXCLAIMS.DEDUCTAMT

300 2342 DATA_ELEMENT HP-A1.HP_RXCLAIMS.NOTALLOWEDAMT

301 2343 DATA_ELEMENT HP-A1.HP_RXCLAIMS.ADMFEES

302 2344 DATA_ELEMENT HP-A1.HP_RXCLAIMS.AWP

303 2345 DATA_ELEMENT HP-A1.HP_RXCLAIMS.COBAMT

304 2346 DATA_ELEMENT HP-A1.HP_RXCLAIMS.REINSAMT

305 2347 DATA_ELEMENT HP-A1.HP_RXCLAIMS.REPRICEDAMT

HP-
306 2348 DATA_ELEMENT A1.HP_RXCLAIMS.PERSISTENCEFACTOR
307 2349 DATA_ELEMENT HP-A1.HP_RXCLAIMS.ADJCODE

308 2350 DATA_ELEMENT HP-A1.HP_RXCLAIMS.SUPPLYFLAG

309 2351 DATA_ELEMENT HP-A1.HP_RXCLAIMS.DISCOUNTAMT

310 2352 DATA_ELEMENT HP-A1.HP_RXCLAIMS.PRESCOUNT

311 2353 DATA_ELEMENT HP-A1.HP_RXCLAIMS.DRUGCODE

 Target Entity Type Target

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_1
DATA_ELEMENT CIF-L1.TX_800.MEMBER_NUM
DATA_ELEMENT CIF-L1.TX_800.SUB_NUM

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_18

CIF-
DATA_ELEMENT L1.TX_800.MEMBER_REL_TO_SUB_CD

DATA_ELEMENT CIF-L1.TX_800.MEMBER_FIRST_NM

DATA_ELEMENT CIF-L1.TX_800.MEMBER_LAST_NM
DATA_ELEMENT CIF-L1.TX_800.MEMBER_GENDER
DATA_ELEMENT CIF-L1.TX_800.MEMBER_DOB

DATA_ELEMENT CIF-L1.TX_800.MEMBER_ADDRESS_1

DATA_ELEMENT CIF-L1.TX_800.MEMBER_ADDRESS_2
DATA_ELEMENT CIF-L1.TX_800.MEMBER_CITY
DATA_ELEMENT CIF-L1.TX_800.MEMBER_STATE
DATA_ELEMENT CIF-L1.TX_800.MEMBER_ZIP
DATA_ELEMENT CIF-L1.TX_800.MEMBER_PHONE_1
DATA_ELEMENT CIF-L1.TX_800.MEMBER_PHONE_2
DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_5
DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_9

DATA_ELEMENT CIF-L1.TX_800.ELIGIBILITY_START_DT
DATA_ELEMENT CIF-L1.TX_800.ELIGIBILITY_START_DT

DATA_ELEMENT CIF-L1.TX_800.ELIGIBILITY_END_DT

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_10

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_11

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_12

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_13

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_14

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_15

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_16

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_17

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_21

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_22

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_23
DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_24
DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_8

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_19

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_20

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_25
DATA_ELEMENT CIF-L1.TX_800.PCP_NUM
DATA_ELEMENT CIF-L1.TX_800.PCP_FULL_NM
DATA_ELEMENT CIF-L1.TX_800.MEMBER_SSN
DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_6
DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_7

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_30

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_47

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_48

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_49

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_50
DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_4

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_3

DATA_ELEMENT CIF-L1.TX_800.SUB_CONTRACT_CLASS

DATA_ELEMENT CIF-L1.TX_800.SUB_COVERAGE_TYPE

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_26

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_27

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_28

DATA_ELEMENT CIF-L1.TX_800.EXTENSION_FIELD_29

DATA_ELEMENT CIF-L1.TX_800.MCD_ELIGIBILITY_CAT

DATA_ELEMENT CIF-L1.TX_800.ORIG_RSN_FOR_ENT_CD

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_10
DATA_ELEMENT CIF-L1.TX_120.BILL_PROV_NUM_NPI
DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_1
DATA_ELEMENT CIF-L1.TX_120.CLAIM_SEQ_NUM

DATA_ELEMENT CIF-L1.TX_120.CLAIM_NUM
DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_8

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_48
DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_9
DATA_ELEMENT CIF-L1.TX_120.PATIENT_NUM
DATA_ELEMENT CIF-L1.TX_120.SUB_NUM
DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_5

CIF-
DATA_ELEMENT L1.TX_120.PATIENT_REL_TO_SUB_CD
DATA_ELEMENT CIF-L1.TX_120.PATIENT_FIRST_NM
DATA_ELEMENT CIF-L1.TX_120.PATIENT_LAST_NM
DATA_ELEMENT CIF-L1.TX_120.PATIENT_GENDER
DATA_ELEMENT CIF-L1.TX_120.PATIENT_DOB

DATA_ELEMENT CIF-L1.TX_120.PATIENT_ADDRESS
DATA_ELEMENT CIF-L1.TX_120.PATIENT_CITY
DATA_ELEMENT CIF-L1.TX_120.PATIENT_STATE
DATA_ELEMENT CIF-L1.TX_120.PATIENT_ZIP
DATA_ELEMENT CIF-L1.TX_120.PATIENT_PHONE
DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_6

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_10

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_11

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_12

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_13

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_14

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_15
DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_16

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_17

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_18

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_19

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_21

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_22

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_23

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_24

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_49
DATA_ELEMENT CIF-L1.TX_120.ADMIT_DT
DATA_ELEMENT CIF-L1.TX_120.DISCHARGE_DT
DATA_ELEMENT CIF-L1.TX_120.RECEIVED_DT
DATA_ELEMENT CIF-L1.TX_120.PAID_DT

DATA_ELEMENT CIF-L1.TX_120.PRINCIPAL_DIAGNOSIS

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_25

DATA_ELEMENT CIF-L1.TX_120.OTHER_DIAGNOSIS_1

DATA_ELEMENT CIF-L1.TX_120.OTHER_DIAGNOSIS_2

DATA_ELEMENT CIF-L1.TX_120.OTHER_DIAGNOSIS_3

DATA_ELEMENT CIF-L1.TX_120.OTHER_DIAGNOSIS_4

DATA_ELEMENT CIF-L1.TX_120.DIAGNOSIS_RLTD_GRP
DATA_ELEMENT CIF-L1.TX_120.BILL_PROV_NUM
DATA_ELEMENT CIF-L1.TX_120.BILL_PROV_FULL_NM
DATA_ELEMENT CIF-L1.TX_120.BILL_PROV_CITY
DATA_ELEMENT CIF-L1.TX_120.BILL_PROV_STATE
DATA_ELEMENT CIF-L1.TX_120.IN_NETWORK_IND

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_26

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_27
DATA_ELEMENT CIF-L1.TX_120.NETWORK_ID
DATA_ELEMENT CIF-L1.TX_120.NETWORK_NM

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_28

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_29

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_30
DATA_ELEMENT CIF-L1.TX_120.ADMIT_TYPE
DATA_ELEMENT CIF-L1.TX_120.ADMIT_SOURCE

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_7

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_50

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_34

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_35

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_36

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_37
DATA_ELEMENT CIF-L1.TX_120.PATIENT_SSN
DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_4
DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_3

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_38

CIF-
L1.TX_120.BILL_PROV_PRIMARY_SPEC_
DATA_ELEMENT CD

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_39

DATA_ELEMENT CIF-L1.TX_120.OTHER_DIAGNOSIS_5

DATA_ELEMENT CIF-L1.TX_120.PRINCIPAL_PROC_CD

DATA_ELEMENT CIF-L1.TX_120.OTHER_PROC_CD_1

DATA_ELEMENT CIF-L1.TX_120.OTHER_PROC_CD_2

DATA_ELEMENT CIF-L1.TX_120.OTHER_PROC_CD_3

DATA_ELEMENT CIF-L1.TX_120.OTHER_PROC_CD_4
DATA_ELEMENT CIF-L1.TX_120.OTHER_DIAGNOSIS_6

DATA_ELEMENT CIF-L1.TX_120.OTHER_DIAGNOSIS_7

DATA_ELEMENT CIF-L1.TX_120.OTHER_DIAGNOSIS_8

DATA_ELEMENT CIF-L1.TX_120.OTHER_DIAGNOSIS_9

DATA_ELEMENT CIF-L1.TX_120.OTHER_DIAGNOSIS_10

DATA_ELEMENT CIF-L1.TX_120.OTHER_PROC_CD_5

CIF-
DATA_ELEMENT L1.TX_120.DIAGNOSIS_RLTD_GRP_SYS
DATA_ELEMENT CIF-L1.TX_120.DISCHARGE_STATUS
DATA_ELEMENT CIF-L1.TX_120.TYPE_OF_BILL
DATA_ELEMENT CIF-L1.TX_120.ENCOUNTER_IND

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_40

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_41

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_42

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_43

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_44

DATA_ELEMENT CIF-L1.TX_120.DIAGNOSIS_CD_QUAL

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_45

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_46

DATA_ELEMENT CIF-L1.TX_120.EXTENSION_FIELD_47
DATA_ELEMENT CIF-L1.TX_130.CLAIM_SEQ_NUM
DATA_ELEMENT CIF-L1.TX_130.CLAIM_NUM
DATA_ELEMENT CIF-L1.TX_130.SERVICE_DT

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_11

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_16

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_17
DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_7

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_18
DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_9
DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_6

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_12

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_14

DATA_ELEMENT CIF-L1.TX_130.REVENUE_CD

DATA_ELEMENT CIF-L1.TX_130.HCPCS_MODIFIER_CD_1

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_13

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_15
DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_8
DATA_ELEMENT CIF-L1.TX_130.SERVICE_UNITS
DATA_ELEMENT CIF-L1.TX_130.PAID_AMNT

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_19
DATA_ELEMENT CIF-L1.TX_130.CHARGE_AMNT
DATA_ELEMENT CIF-L1.TX_130.ALLOWED_AMNT

DATA_ELEMENT CIF-L1.TX_130.PPO_DISCOUNT_AMNT

DATA_ELEMENT CIF-L1.TX_130.MEMBER_PAID_AMNT

DATA_ELEMENT CIF-L1.TX_130.COINSURANCE_AMNT
DATA_ELEMENT CIF-L1.TX_130.COPAYMENT_AMNT
DATA_ELEMENT CIF-L1.TX_130.DEDUCTIBLE_AMNT
DATA_ELEMENT CIF-L1.TX_130.DISALLOWED_AMNT
DATA_ELEMENT CIF-L1.TX_130.COB_AMNT

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_28
DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_21

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_22

DATA_ELEMENT CIF-L1.TX_130.LINE_STATUS_CD

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_23

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_24

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_25

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_26

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_27

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_1

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_2

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_4

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_3

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_5
DATA_ELEMENT CIF-L1.TX_130.HCPCS_PROC_CD

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_29

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_30

DATA_ELEMENT CIF-L1.TX_120.BILL_PROV_FIRST_NM

DATA_ELEMENT CIF-L1.TX_120.BILL_PROV_LAST_NM

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_34

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_35

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_36
DATA_ELEMENT CIF-L1.TX_130.HCPCS_MODIFIER_CD_2

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_37

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_38

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_39

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_40

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_41

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_42

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_43

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_44

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_45

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_46

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_47

DATA_ELEMENT CIF-L1.TX_130.EXTENSION_FIELD_48
DATA_ELEMENT CIF-L1.TX_130.LINE_NUM
DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_1
DATA_ELEMENT CIF-L1.TX_160.CLAIM_SEQ_NUM
DATA_ELEMENT CIF-L1.TX_160.CLAIM_NUM
DATA_ELEMENT CIF-L1.TX_160.PATIENT_NUM
DATA_ELEMENT CIF-L1.TX_160.SUB_NUM

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_5

CIF-
DATA_ELEMENT L1.TX_160.PATIENT_REL_TO_SUB_CD

DATA_ELEMENT CIF-L1.TX_160.PATIENT_FIRST_NM
DATA_ELEMENT CIF-L1.TX_160.PATIENT_LAST_NM
DATA_ELEMENT CIF-L1.TX_160.PATIENT_GENDER
DATA_ELEMENT CIF-L1.TX_160.PATIENT_DOB

DATA_ELEMENT CIF-L1.TX_160.PATIENT_ADDRESS
DATA_ELEMENT CIF-L1.TX_160.PATIENT_CITY
DATA_ELEMENT CIF-L1.TX_160.PATIENT_STATE
DATA_ELEMENT CIF-L1.TX_160.PATIENT_ZIP
DATA_ELEMENT CIF-L1.TX_160.PATIENT_PHONE
DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_7

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_10

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_11

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_12

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_13

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_14

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_15

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_16

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_17

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_35

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_36

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_18

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_19

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_20

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_21
DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_8
DATA_ELEMENT CIF-L1.TX_160.PAID_DT
DATA_ELEMENT CIF-L1.TX_160.PHARMACY_NUM

DATA_ELEMENT CIF-L1.TX_160.PHARMACY_FULL_NM
 CIF-
DATA_ELEMENT L1.TX_160.PRESCRIB_PROV_DEA_NUM

CIF-
DATA_ELEMENT L1.TX_160.PRESCRIB_PROV_FULL_NM

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_9

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_37

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_38
DATA_ELEMENT CIF-L1.TX_160.PATIENT_SSN
DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_4
DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_3

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_39

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_40
DATA_ELEMENT CIF-L1.TX_160.ENCOUNTER_IND

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_22

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_23

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_24

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_25

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_26

DATA_ELEMENT CIF-L1.TX_160.EXTENSION_FIELD_27
DATA_ELEMENT CIF-L1.TX_170.CLAIM_SEQ_NUM
DATA_ELEMENT CIF-L1.TX_170.CLAIM_NUM

CIF-
DATA_ELEMENT L1.TX_170.PRESCRIPTION_FILLED_DT
DATA_ELEMENT CIF-L1.TX_170.PRESCRIBED_QTY
DATA_ELEMENT CIF-L1.TX_170.DAYS_SUPPLY

DATA_ELEMENT CIF-L1.TX_170.PRODUCT_SERVICE_CD
DATA_ELEMENT CIF-L1.TX_170.EXTENSION_FIELD_1
DATA_ELEMENT CIF-L1.TX_170.EXTENSION_FIELD_9
DATA_ELEMENT CIF-L1.TX_170.EXTENSION_FIELD_2
DATA_ELEMENT CIF-L1.TX_170.EXTENSION_FIELD_3
DATA_ELEMENT CIF-L1.TX_170.FORMULARY_IND
DATA_ELEMENT CIF-L1.TX_170.MAIL_ORDER_IND
DATA_ELEMENT CIF-L1.TX_170.EXTENSION_FIELD_4
DATA_ELEMENT CIF-L1.TX_170.EXTENSION_FIELD_5
DATA_ELEMENT CIF-L1.TX_170.EXTENSION_FIELD_6
DATA_ELEMENT CIF-L1.TX_170.EXTENSION_FIELD_7
DATA_ELEMENT CIF-L1.TX_170.EXTENSION_FIELD_8
DATA_ELEMENT CIF-L1.TX_170.PAID_AMNT
DATA_ELEMENT CIF-L1.TX_170.CHARGE_AMNT

CIF-
DATA_ELEMENT L1.TX_170.INGREDIENT_COST_AMNT

DATA_ELEMENT CIF-L1.TX_170.DISPENSING_FEE_AMNT
DATA_ELEMENT CIF-L1.TX_170.SALES_TAX_AMNT
DATA_ELEMENT CIF-L1.TX_170.ALLOWED_AMNT

DATA_ELEMENT CIF-L1.TX_170.MEMBER_PAID_AMNT

DATA_ELEMENT CIF-L1.TX_170.COINSURANCE_AMNT
DATA_ELEMENT CIF-L1.TX_170.COPAYMENT_AMNT
DATA_ELEMENT CIF-L1.TX_170.DEDUCTIBLE_AMNT

DATA_ELEMENT CIF-L1.TX_170.DISALLOWED_AMNT
DATA_ELEMENT CIF-L1.TX_170.ADMIN_FEE_AMNT

CIF-
L1.TX_170.AVG_WHOLESALE_PRICE_A
DATA_ELEMENT MNT
DATA_ELEMENT CIF-L1.TX_170.COB_AMNT

DATA_ELEMENT CIF-L1.TX_170.EXTENSION_FIELD_10

DATA_ELEMENT CIF-L1.TX_170.EXTENSION_FIELD_11

DATA_ELEMENT CIF-L1.TX_170.EXTENSION_FIELD_12
DATA_ELEMENT CIF-L1.TX_170.LINE_STATUS_CD

DATA_ELEMENT CIF-L1.TX_170.EXTENSION_FIELD_13
DATA_ELEMENT CIF-L1.TX_170.DISCOUNT_AMNT

DATA_ELEMENT CIF-L1.TX_170.PRESCRIPTION_NUM

DATA_ELEMENT CIF-L1.TX_170.NATIONAL_DRUG_CD
 Transformation

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/DERIVEDFIELD MEMBER_REL_TO_SUB_CD IF
__Condition_1_0ed4f7a99cbe4a16a7a1cc4bf8fde1fd
THEN '00' ELSE IF
__Condition_2_0ed4f7a99cbe4a16a7a1cc4bf8fde1fd
THEN '01' ELSE '02' /CONDITION
__Condition_1_0ed4f7a99cbe4a16a7a1cc4bf8fde1fd
RELFLAG = 'E' /CONDITION
__Condition_2_0ed4f7a99cbe4a16a7a1cc4bf8fde1fd
RELFLAG = 'S'

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/DERIVEDFIELD ELIGIBILITY_START_DT EFFDATE

/DERIVEDFIELD ELIGIBILITY_START_DT EFFDATE

/DERIVEDFIELD ELIGIBILITY_END_DT TERMDATE

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null
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null
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/DERIVEDFIELD CLAIM_NUMBER FUNCTIONCALL
REGEXREPLACE( CLMNUM, U'^Y_|^N_', U'' )
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/DERIVEDFIELD PATIENT_REL_TO_SBSCRBR_NUM IF
__Condition_1_d178a4f2c9f049eab16e4a6b348ec96b
THEN '00' ELSE IF
__Condition_2_d178a4f2c9f049eab16e4a6b348ec96b
THEN '01' ELSE '02' /CONDITION
__Condition_1_d178a4f2c9f049eab16e4a6b348ec96b
RELFLAG = 'E' /CONDITION
__Condition_2_d178a4f2c9f049eab16e4a6b348ec96b
RELFLAG = 'S'
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/DERIVEDFIELD PATIENT_ADDRESS ADDR1 + ADDR2

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/DERIVEDFIELD DIAG_RELATED_GROUP FUNCTIONCALL
REPLACE(DRGCODE, 'D', '' )
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/DERIVEDFIELD EXTENSION_FIELD_7 FUNCTIONCALL
TOTEXT( IPDAYS )

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/DERIVEDFIELD PRNCPL_PROCEDURE_CODE
FUNCTIONCALL REPLACE(ICD9PROCCODE1, 'I', '' )
/DERIVEDFIELD OTHER_PROCEDURE_CODE_1
FUNCTIONCALL REPLACE( ICD9PROCCODE2, 'I', '' )
/DERIVEDFIELD OTHER_PROCEDURE_CODE_2
FUNCTIONCALL REPLACE(ICD9PROCCODE3, 'I', '' )
/DERIVEDFIELD OTHER_PROCEDURE_CODE_3
FUNCTIONCALL REPLACE(ICD9PROCCODE4, 'I', '' )
/DERIVEDFIELD OTHER_PROCEDURE_CODE_4
FUNCTIONCALL REPLACE(ICD9PROCCODE5, 'I', '' )
null

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/DERIVEDFIELD OTHER_PROCEDURE_CODE_5
FUNCTIONCALL REPLACE(ICD9PROCCODE6, 'I', '' )

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/DERIVEDFIELD DIAGNOSIS_CD_QUAL IF
__Condition_5_faa3d992914e4aad88dc24b0b10c84dd
THEN '09' ELSE IF
__Condition_6_faa3d992914e4aad88dc24b0b10c84dd
THEN '10' ELSE ICDTYPE /CONDITION
__Condition_5_faa3d992914e4aad88dc24b0b10c84dd
ICDTYPE MT /[iI][cC][dD]9/ /CONDITION
__Condition_6_faa3d992914e4aad88dc24b0b10c84dd
ICDTYPE MT /[iI][cC][dD]10/

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/DERIVEDFIELD CLAIM_NUMBER FUNCTIONCALL
REGEXREPLACE( CLMNUM, U'^Y_|^N_', U'' )
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/DERIVEDFIELD REV_CODE FUNCTIONCALL
REPLACE( REVCODE, 'R','' )

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/DERIVEDFIELD LINE_STTS_CODE IF
__Condition_1_3ee9301b84084a9e8db6b99dae06f801
THEN '05' ELSE IF
__Condition_2_3ee9301b84084a9e8db6b99dae06f801
THEN '03' ELSE IF
__Condition_3_3ee9301b84084a9e8db6b99dae06f801
THEN '01' ELSE IF
__Condition_4_3ee9301b84084a9e8db6b99dae06f801
THEN '02' ELSE '00' /CONDITION
__Condition_1_3ee9301b84084a9e8db6b99dae06f801
ADJCODE = 'D' /CONDITION
__Condition_2_3ee9301b84084a9e8db6b99dae06f801
ADJCODE = 'R' /CONDITION
__Condition_3_3ee9301b84084a9e8db6b99dae06f801
ADJCODE = 'A' /CONDITION
__Condition_4_3ee9301b84084a9e8db6b99dae06f801
ADJCODE = 'E'

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/DERIVEDFIELD EXTENSION_FIELD_1 FUNCTIONCALL
REPLACE( REVCODE1, 'R', '' )
/DERIVEDFIELD EXTENSION_FIELD_2 FUNCTIONCALL
REPLACE( REVCODE2, 'R', '' )
/DERIVEDFIELD EXTENSION_FIELD_4 FUNCTIONCALL
REPLACE( REVCODE4, 'R', '' )
/DERIVEDFIELD EXTENSION_FIELD_3 FUNCTIONCALL
REPLACE( REVCODE3, 'R', '' )
/DERIVEDFIELD EXTENSION_FIELD_5 FUNCTIONCALL
REPLACE( REVCODE5, 'R', '' )
/DERIVEDFIELD HCPCS_PROC_CD IF
__Condition_5_6cc655702bee448496931bbf1f4955ae
THEN PROCCODE ELSE IF
__Condition_6_6cc655702bee448496931bbf1f4955ae
THEN CPT4_1 ELSE HCPCS /CONDITION
__Condition_5_6cc655702bee448496931bbf1f4955ae
PROCTYPE = 'CPT4' /CONDITION
__Condition_6_6cc655702bee448496931bbf1f4955ae
CPT4_1 != NULL

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/DERIVEDFIELD PATIENT_REL_TO_SUB_CD IF
__Condition_1_5ca74ff2b8ed4c1c80f5bac73f32566e
THEN '00' ELSE IF
__Condition_2_5ca74ff2b8ed4c1c80f5bac73f32566e
THEN '01' ELSE '02' /CONDITION
__Condition_1_5ca74ff2b8ed4c1c80f5bac73f32566e
RELFLAG = 'E' /CONDITION
__Condition_2_5ca74ff2b8ed4c1c80f5bac73f32566e
RELFLAG = 'S'

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/DERIVEDFIELD PATIENT_ADDRESS ADDR1 + ADDR2

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/DERIVEDFIELD LINE_STATUS_CD IF
__Condition_1_0b19b09cbaf54c368559206c1ba7dbf5
THEN '05' ELSE IF
__Condition_2_0b19b09cbaf54c368559206c1ba7dbf5
THEN '03' ELSE IF
__Condition_3_0b19b09cbaf54c368559206c1ba7dbf5
THEN '01' ELSE IF
__Condition_4_0b19b09cbaf54c368559206c1ba7dbf5
THEN '02' ELSE '00' /CONDITION
__Condition_1_0b19b09cbaf54c368559206c1ba7dbf5
ADJCODE = 'D' /CONDITION
__Condition_2_0b19b09cbaf54c368559206c1ba7dbf5
ADJCODE = 'R' /CONDITION
__Condition_3_0b19b09cbaf54c368559206c1ba7dbf5
ADJCODE = 'A' /CONDITION
__Condition_4_0b19b09cbaf54c368559206c1ba7dbf5
ADJCODE = 'E'

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/DERIVEDFIELD PRESCRIPTION_NUM FUNCTIONCALL
TOTEXT( PRESCOUNT )

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