Position

Element

Name

Type

Requirement

Min

Max

Repeat

TS3-01 Reference Identification

String (AN)

Mandatory

1

80

1

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

TS301 is the provider number.

TS3-02 Facility Code Value

String (AN)

Mandatory

1

3

1

Code identifying where services were, or may be, performed; the National Uniform Billing Committee (NUBC) Facility Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.

TS3-03 Date

Date (DT)

Mandatory

8

8

1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

TS303 is the last day of the provider's fiscal year.

TS3-04 Quantity

Decimal number (R)

Mandatory

1

15

1

Numeric value of quantity

TS304 is the total number of claims.

TS3-05 Monetary Amount

Decimal number (R)

Mandatory

1

18

1

Monetary amount

TS305 is the total of reported charges.

TS3-06 Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS306 is the total of covered charges.

TS3-07 Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS307 is the total of noncovered charges.

TS3-08 Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS308 is the total of denied charges.

TS3-09 Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS309 is the total provider payment.

TS3-10 Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS310 is the total amount of interest paid.

TS3-11 Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS311 is the total contractual adjustment.

TS3-12 Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS312 is the total Gramm-Rudman Reduction.

TS3-13 Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS313 is the total Medicare Secondary Payer (MSP) primary payer amount.

TS3-14 Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS314 is the total blood deductible amount in dollars.

TS3-15 Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS315 is the summary of non-lab charges.

TS3-16 Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS316 is the total coinsurance amount.

TS3-17 Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS317 is the Health Care Financing Administration Common Procedural Coding System (HCPCS) reported charges.

TS3-18 Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS318 is the total Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.

TS3-19 Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS319 is the total deductible amount.

TS3-20 Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS320 is the total professional component amount.

TS3-21 Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS321 is the total Medicare Secondary Payer (MSP) patient liability met.

TS3-22 Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS322 is the total patient reimbursement.

TS3-23 Quantity

Decimal number (R)

Optional

1

15

1

Numeric value of quantity

TS323 is the total periodic interim payment (PIP) number of claims.

TS3-24 Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS324 is total periodic interim payment (PIP) adjustment.