Adjustment Sequence Number
|
000
|
Adjustment/Denial Reason Code
|
N/D
|
Administrative CLIN
|
N/D
|
AGR Legal Authority Code
|
Z
|
Amount Interest Payment
|
Zeroes
|
Amount Network Provider Discount
|
Zeroes
|
Amount Paid By Other Health
Insurance
|
Zeroes
|
Amount Patient Cost-share
|
Zeroes
|
Begin Date Of Care
|
N/D
|
CA/NAS Exception Reason
|
N/D
|
CA/NAS Number
|
N/D
|
CA/NAS Reason For Issuance
|
N/D
|
Claim Form Type/EMC Indicator
|
N/D
|
Date Adjustment Identified
|
N/D
|
Date Ted Record Processed To
Completion
|
N/D
|
DEERS Identifier (Patient)
|
Zeroes
|
End Date Of Care
|
N/D
|
Enrollment/Health Plan Code
|
N/D
|
Health Care Coverage Copayment
Factor Code
|
Z
|
Health Care Coverage Member
Category Code
|
Z
|
Health Care Coverage Member
Relationship Code
|
Z
|
Health Care Delivery Program
Plan Coverage Code
|
000
|
Health Care Delivery Program
Special Entitlement Code
|
00
|
Occurrence/Line Item Number
|
N/D
|
Other Government Program Begin
Reason Code
|
W
|
Other Government Program Type
Code
|
N
|
Override Code
|
N/D
|
Patient Identifier (DoD)
|
Zeroes
|
Patient ZIP Code
|
N/D
|
Pay Grade Code (Sponsor)
|
00
|
Pay Plan Code (Sponsor)
|
ZZ
|
PCM Location DMIS-ID (Enrollment)
Code
|
N/D
|
Person Birth Calendar Date
(Patient)
|
19111111
|
Person Cadency Name (Patient)
|
Blanks
|
Person First Name (Patient)
|
Blanks
|
Person Identifier (Patient)
|
Zeroes
|
Person Identifier (Sponsor)
|
N/D
|
Person Identifier Type Code
(Patient)
|
Z
|
Person Identifier Type Code
(Sponsor)
|
Z
|
Person Last Name (Patient)
|
N/D
|
Person Middle Name (Patient)
|
Blanks
|
Person Sex (Patient)
|
Z
|
Pricing Rate Code
|
Blanks
|
Principal Treatment Diagnosis
|
7999*
R69**
|
Provider Group NPI Number (Reserved)
|
Reserved
|
Provider Individual NPI Number
(Reserved)
|
Reserved
|
Provider Network Status Indicator
|
N/D
|
Provider Participation Indicator
|
N/D
|
Provider State Or Country Code
|
N/D
|
Provider Sub-Identifier
|
N/D
|
Provider Taxpayer Number
|
N/D
|
Provider ZIP Code
|
N/D
|
Reason For Interest Payment
|
Blanks
|
Record Type Indicator
|
N/D
|
Region Indicator
|
N/D
|
Secondary Treatment Diagnosis
|
N/D
|
Service Branch Classification
Code (Sponsor)
|
Z
|
Special Processing Code
|
N/D
|
TED Record Indicator
|
N/D
|
Total Occurrence/Line Item
Count
|
N/D
|
Type Of Submission
|
D
|