Position

Element

Name

Type

Requirement

Min

Max

Repeat

TS301

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.

TS302

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.

TS303

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.

TS304

Quantity

Decimal number (R)

Mandatory

1

15

1

Numeric value of quantity

TS304 is the total number of claims.

TS305

Monetary Amount

Decimal number (R)

Mandatory

1

18

1

Monetary amount

TS305 is the total of reported charges.

TS306

Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS306 is the total of covered charges.

TS307

Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS307 is the total of noncovered charges.

TS308

Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS308 is the total of denied charges.

TS309

Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS309 is the total provider payment.

TS310

Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS310 is the total amount of interest paid.

TS311

Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS311 is the total contractual adjustment.

TS312

Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS312 is the total Gramm-Rudman Reduction.

TS313

Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

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

TS314

Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS314 is the total blood deductible amount in dollars.

TS315

Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS315 is the summary of non-lab charges.

TS316

Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS316 is the total coinsurance amount.

TS317

Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS317 is the Healthcare Common Procedure Coding System (HCPCS) reported charges.

TS318

Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS318 is the total Healthcare Common Procedure Coding System (HCPCS) payable amount.

TS319

Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS319 is the total deductible amount.

TS320

Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS320 is the total professional component amount.

TS321

Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

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

TS322

Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS322 is the total patient reimbursement.

TS323

Quantity

Decimal number (R)

Optional

1

15

1

Numeric value of quantity

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

TS324

Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

TS324 is total periodic interim payment (PIP) adjustment.