1-001
|
RECORD TYPE
INDICATOR
|
X
|
1
|
1
|
1-005
|
TED RECORD INDICATOR
|
|
2
|
25
|
1-010
|
INTERNAL CONTROL
NUMBER (ICN)
|
|
2
|
18
|
1-015
|
FILING DATE
|
YYYYDDD
|
2
|
8
|
1-020
|
FILING STATE/COUNTRY
CODE
|
X(3)
|
9
|
11
|
1-025
|
SEQUENCE NUMBER
|
X(7)
|
12
|
18
|
1-030
|
TIME STAMP
|
X(6)
|
19
|
24
|
1-035
|
ADJUSTMENT KEY
|
X
|
25
|
25
|
1-040
|
DATE TED RECORD
PROCESSED TO COMPLETION
|
YYYYMMDD
|
26
|
33
|
1-045
|
DATE ADJUSTMENT
IDENTIFIED
|
YYYYMMDD
|
34
|
41
|
1-050
|
PERSON IDENTIFIER
(SPONSOR)
|
X(9)
|
42
|
50
|
1-051
|
PERSON IDENTIFIER
TYPE CODE (SPONSOR)
|
X
|
51
|
51
|
1-056
|
PAY GRADE CODE
(SPONSOR)
|
X(2)
|
52
|
53
|
1-057
|
PAY PLAN CODE
(SPONSOR)
|
X(5)
|
54
|
58
|
1-060
|
SERVICE BRANCH
CLASSIFICATION CODE (SPONSOR)
|
X
|
59
|
59
|
1-065
|
AGR SERVICE
LEGAL AUTHORITY CODE
|
X
|
60
|
60
|
1-066
|
HEALTH CARE
COVERAGE MEMBER CATEGORY CODE
|
X
|
61
|
61
|
1-070
|
HEALTH CARE
COVERAGE MEMBER RELATIONSHIP CODE
|
X
|
62
|
62
|
1-075
|
PERSON NAME
(PATIENT)
|
|
63
|
157
|
1-076
|
PERSON LAST
NAME (PATIENT)
|
X(35)
|
63
|
97
|
1-077
|
PERSON FIRST
NAME (PATIENT)
|
X(25)
|
98
|
122
|
1-078
|
PERSON MIDDLE
NAME (PATIENT)
|
X(25)
|
123
|
147
|
1-079
|
PERSON CADENCY
NAME (PATIENT)
|
X(10)
|
148
|
157
|
1-080
|
PERSON IDENTIFIER
(PATIENT)
|
X(9)
|
158
|
166
|
1-081
|
PERSON IDENTIFIER
TYPE CODE (PATIENT)
|
X
|
167
|
167
|
1-085
|
PERSON BIRTH
CALENDAR DATE (PATIENT)
|
YYYYMMDD
|
168
|
175
|
1-095
|
PATIENT IDENTIFIER
(DOD)
|
X(10)
|
176
|
185
|
1-097
|
DEERS IDENTIFIER
(PATIENT)
|
X(11)
|
186
|
196
|
1-100
|
PERSON SEX (PATIENT)
|
X
|
197
|
197
|
1-105
|
PATIENT ZIP
CODE
|
X(9)
|
198
|
206
|
1-110
|
ENROLLMENT/HEALTH
PLAN CODE
|
X(2)
|
207
|
208
|
1-111
|
HEALTH CARE
DELIVERY PROGRAM PLAN COVERAGE CODE
|
X(3)
|
209
|
211
|
1-112
|
REGION INDICATOR
|
X(2)
|
212
|
213
|
1-115
|
PCM LOCATION
DMIS-ID (ENROLLMENT) CODE
|
X(4)
|
214
|
217
|
1-120
|
AMOUNT BILLED
(TOTAL)
|
S9(7)V99
|
218
|
226
|
1-125
|
AMOUNT ALLOWED
(TOTAL)
|
S9(7)V99
|
227
|
235
|
1-130
|
AMOUNT PAID
BY OTHER HEALTH INSURANCE
|
S9(7)V99
|
236
|
244
|
1-131
|
OTHER GOVERNMENT
PROGRAM TYPE CODE
|
X
|
245
|
245
|
1-132
|
OTHER GOVERNMENT
PROGRAM BEGIN REASON CODE
|
X
|
246
|
246
|
1-135
|
AMOUNT PATIENT
COST-SHARE
|
S9(7)V99
|
247
|
255
|
1-136
|
HEALTH CARE
COVERAGE COPAYMENT FACTOR CODE
|
X
|
256
|
256
|
1-140
|
AMOUNT PAID
BY GOV’T CONTRACTOR (TOTAL)
|
S9(7)V99
|
257
|
265
|
1-145
|
AMOUNT INTEREST
PAYMENT
|
S9(7)V99
|
266
|
274
|
1-150
|
REASON FOR INTEREST
PAYMENT
|
X(2)
|
275
|
276
|
1-155
|
PROCESSING INFORMATION
|
|
277
|
313
|
1-160
|
OVERRIDE CODE
|
X(6)
|
277
|
282
|
1-165
|
TYPE OF SUBMISSION
|
X
|
283
|
283
|
1-170
|
CA/NAS NUMBER
|
X(15)
|
284
|
298
|
1-175
|
CA/NAS REASON
FOR ISSUANCE
|
X
|
299
|
299
|
1-180
|
CA/NAS EXCEPTION
REASON
|
X(2)
|
300
|
301
|
1-185
|
SPECIAL PROCESSING
CODE
|
X(8)
|
302
|
309
|
1-186
|
HEALTH CARE
DELIVERY PROGRAM SPECIAL ENTITLEMENT CODE
|
X(2)
|
310
|
311
|
1-190
|
PRICING RATE
CODE
|
X(2)
|
312
|
313
|
1-195
|
PROVIDER STATE
OR COUNTRY CODE
|
X(3)
|
314
|
316
|
1-200
|
PROVIDER TAXPAYER
NUMBER
|
X(9)
|
317
|
325
|
1-205
|
PROVIDER SUB-IDENTIFIER
|
X(4)
|
326
|
329
|
1-208
|
SCH DRG CALCULATION
|
S9(7)V99
|
330
|
338
|
|
FILLER
|
X
|
339
|
339
|
1-215
|
PROVIDER ORGANIZATIONAL
NPI NUMBER (TYPE 2)
|
X(10)
|
340
|
349
|
1-220
|
PROVIDER ZIP
CODE
|
X(9)
|
350
|
358
|
1-225
|
PROVIDER PARTICIPATION
INDICATOR
|
X
|
359
|
359
|
1-230
|
PROVIDER NETWORK
STATUS INDICATOR
|
X
|
360
|
360
|
1-235
|
TYPE OF INSTITUTION
|
X(2)
|
361
|
362
|
1-240
|
CLAIM FORM TYPE/EMC
INDICATOR
|
X
|
363
|
363
|
1-245
|
TYPE OF BILL
|
|
364
|
365
|
1-250
|
FREQUENCY CODE
|
X
|
364
|
364
|
1-255
|
TYPE OF ADMISSION
|
X
|
365
|
365
|
1-260
|
POINT OF ORIGIN
|
X
|
366
|
366
|
1-265
|
ADMISSION DATE
|
YYYYMMDD
|
367
|
374
|
1-270
|
PATIENT STATUS
|
X(2)
|
375
|
376
|
1-275
|
BEGIN DATE OF
CARE
|
YYYYMMDD
|
377
|
384
|
1-280
|
END DATE OF
CARE
|
YYYYMMDD
|
385
|
392
|
1-283
|
ADMINISTRATIVE
CLIN
|
X(18)
|
393
|
410
|
1-285
|
COVERED DAYS
|
S9(3)
|
411
|
413
|
1-290
|
DRG NUMBER
|
X(3)
|
414
|
416
|
1-292
|
HIPPS CODE
|
X(5)
|
417
|
421
|
1-293
|
ICD VERSION
|
X
|
422
|
422
|
1-295
|
ADMISSION DIAGNOSIS
|
X(7)
|
423
|
429
|
1-300
|
PRINCIPAL TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION
|
X(8)
|
430
|
437
|
1-305
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-1
|
X(8)
|
438
|
445
|
1-306
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-2
|
X(8)
|
446
|
453
|
1-307
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-3
|
X(8)
|
454
|
461
|
1-308
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-4
|
X(8)
|
462
|
469
|
1-309
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-5
|
X(8)
|
470
|
477
|
1-310
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-6
|
X(8)
|
478
|
485
|
1-311
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-7
|
X(8)
|
486
|
493
|
1-312
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-8
|
X(8)
|
494
|
501
|
1-313
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-9
|
X(8)
|
502
|
509
|
1-314
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-10
|
X(8)
|
510
|
517
|
1-315
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-11
|
X(8)
|
518
|
525
|
1-316
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-12
|
X(8)
|
526
|
533
|
1-317
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-13
|
X(8)
|
534
|
541
|
1-318
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-14
|
X(8)
|
542
|
549
|
1-319
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-15
|
X(8)
|
550
|
557
|
1-320
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-16
|
X(8)
|
558
|
565
|
1-321
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-17
|
X(8)
|
566
|
573
|
1-322
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-18
|
X(8)
|
574
|
581
|
1-323
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-19
|
X(8)
|
582
|
589
|
1-324
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-20
|
X(8)
|
590
|
597
|
1-325
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-21
|
X(8)
|
598
|
605
|
1-326
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-22
|
X(8)
|
606
|
613
|
1-327
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-23
|
X(8)
|
614
|
621
|
1-328
|
SECONDARY TREATMENT
DIAGNOSIS/PRESENT ON ADMISSION-24
|
X(8)
|
622
|
629
|
1-345
|
PRINCIPAL OPERATION/NON-SURGICAL
PROCEDURE CODE
|
X(7)
|
630
|
636
|
1-350
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-1
|
X(7)
|
637
|
643
|
1-351
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-2
|
X(7)
|
644
|
650
|
1-352
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-3
|
X(7)
|
651
|
657
|
1-353
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-4
|
X(7)
|
658
|
664
|
1-354
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-5
|
X(7)
|
665
|
671
|
1-355
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-6
|
X(7)
|
672
|
678
|
1-356
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-7
|
X(7)
|
679
|
685
|
1-357
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-8
|
X(7)
|
686
|
692
|
1-358
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-9
|
X(7)
|
693
|
699
|
1-359
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-10
|
X(7)
|
700
|
706
|
1-360
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-11
|
X(7)
|
707
|
713
|
1-361
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-12
|
X(7)
|
714
|
720
|
1-362
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-13
|
X(7)
|
721
|
727
|
1-363
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-14
|
X(7)
|
728
|
734
|
1-364
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-15
|
X(7)
|
735
|
741
|
1-365
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-16
|
X(7)
|
742
|
748
|
1-366
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-17
|
X(7)
|
749
|
755
|
1-367
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-18
|
X(7)
|
756
|
762
|
1-368
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-19
|
X(7)
|
763
|
769
|
1-369
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-20
|
X(7)
|
770
|
776
|
1-370
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-21
|
X(7)
|
777
|
783
|
1-371
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-22
|
X(7)
|
784
|
790
|
1-372
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-23
|
X(7)
|
791
|
797
|
1-373
|
SECONDARY OPERATION/NON-SURGICAL
PROCEDURE CODE-24
|
X(7)
|
798
|
804
|
1-374
|
TED RECORD CORRECTION
INDICATOR
|
X
|
805
|
805
|
1-375
|
TOTAL OCCURRENCE/LINE
ITEM COUNT
|
9(3)
|
806
|
808
|
1-377
|
AMOUNT NETWORK
PROVIDER DISCOUNT
|
S9(7)V99
|
809
|
817
|
1-378
|
ADJUSTMENT SEQUENCE
NUMBER
|
X(3)
|
818
|
820
|
1-379
|
SCH DRG NUMBER
|
X(3)
|
821
|
823
|
|
FILLER
|
X(17)
|
824
|
840
|
1-380
|
OCCURRENCE/LINE
ITEM NUMBER (OCCURS 1 TO 450 TIMES)
|
9(3)
|
841
|
843
|
1-385
|
REVENUE CODE
|
X(4)
|
844
|
847
|
1-390
|
UNITS OF SERVICE
BY REVENUE CODE
|
S9(10)
|
848
|
857
|
1-395
|
TOTAL CHARGE
BY REVENUE CODE
|
S9(7)V99
|
858
|
866
|
1-400
|
ADJUSTMENT/DENIAL
REASON CODE
|
X(5)
|
867
|
871
|
|
FILLER
|
X(30)
|
872
|
901
|