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| Number |
Position |
Field Name |
Data Entry Screen |
| 01 |
1-3 |
Record Type |
(Auto Fill) |
| 02 |
4-19 |
Submitter ID |
Billing > Electronic Claims Receivers > Generator Options button > Submitter
tab > Submitter ID |
| 03 |
20-28 |
Reserved |
(Not Supported) |
| 04 |
29-34 |
Submission Type |
Billing > Electronic Claim Receivers > Generator Options button
> Submission tab > Submission Type |
| 05 |
35-40 |
Submission Number |
(Auto Fill) |
| 06 |
41-73 |
Submitter Name |
Billing > Electronic Claim Receivers > Generator Options button
> Submitter tab > Name |
| 07 |
74-103 |
Submitter Address Line 1 |
Billing > Electronic Claim Receivers > Generator Options button
> Submitter tab > Address 1 |
| 08 |
104-133 |
Submitter Address Line 2 |
Billing > Electronic Claim Receivers > Generator Options button
> Submitter tab > Address 2 |
| 09 |
134-153 |
Submitter City |
Billing > Electronic Claim Receivers > Generator Options button > Submitter tab > City |
| 10 |
154-155 |
Submitter State |
Billing > Electronic Claim Receivers > Generator Options button
> Submitter tab > State |
| 11 |
156-164 |
Submitter Zip Code |
Billing > Electronic Claim Receivers > Generator Options button
> Submitter tab > Zip Code |
| 12 |
165-169 |
Submitter Region |
Billing > Electronic Claim Receivers > Generator Options button
> Submitter tab > Region |
| 13 |
170-202 |
Submitter Contact Person |
Billing > Electronic Claim Receivers > Generator Options button
> Submitter tab > Contact |
| 14 |
202-212 |
Submitter Contact Area/Phone |
Billing > Electronic Claim Receivers > Generator Options button
> Submitter tab > Telephone |
| 15 |
213-220 |
Create Date |
Auto Fill |
| 16 |
221-226 |
Submission Time |
(Not Supported) |
| 17 |
227-242 |
Receiver ID |
Billing > Electronic Claims Receivers > Generator Options
button > Receiver ID |
| 18 |
243 |
Receiver Type |
Billing > Electronic Claims Receivers > Generator Options
button > Receiver Type |
| 19 |
244-248 |
National Version Code |
Billing > Electronic Claims Receivers > Generator Options
button > EDI Control tab > National Version |
| 20 |
249-253 |
Local Version Codwe |
Billing > Electronic Claims Receivers > Generator Options button > EDI
Control tab > Local Version |
| 21 |
254-257 |
Test/Production Indicator |
Billing > Electronic Claims Receivers > Generator Options
button > Submission tab > Radio button choose for Test or Production |
| 22 |
258-265 |
Password |
Billing > Electronic Claims Receivers > Generator Options
button > Password |
| 23 |
266 |
Retransmission Status |
Billing > Electronic Claims Receivers > Generator Options
button > Submission tab > Retransmission Status |
| 24 |
267-282 |
Original Submitter ID |
(Not Supported) |
| 25 |
283 |
Vendor Applications Category |
Billing > Electronic Claims Receivers > Generator Options
button > EDI Control tab > Software Category |
| 26 |
284-289 |
Vendor Software Version |
Billing > Electronic Claims Receivers > Generator Options
button > EDI Control tab > Software Version |
| 27 |
289-290 |
Vendor Software Updates |
Billing > Electronic Claims Receivers > Generator Options
button > EDI Control tab > Software Update |
| 28 |
291 |
COB File Indicator |
Billing > Electronic Claims Receivers > Generator Options
button > Submission tab > COB Billing |
| 29 |
292-299 |
Process From Date |
Billing > Electronic Claims Receivers > Generator Options
button > Receiver > Advanced Button |
| 30 |
300-307 |
Process Through Date |
(Not Supported) |
| 31 |
308 |
Acknowledgement Request |
Billing > Electronic Claims Receivers > Generator Options
button > Receiver tab > Advanced button |
| 32 |
309-316 |
Date of Receipt |
Billing > Electronic Claims Receivers > Generator Options
button > Receiver tab > Advanced button |
| 33 |
317-320 |
Filler - National |
(Not Supported) |
