New Bill Pay Record Layout

Field Name Description Data 

Type/Size

Allowable Val

Case Number Unique Identifier for each case assigned by the responsible 

District Office. 

Char(9)

Payee Number Unique Identifier assigned to provider ( SSN or Tax ID) Char(9)Service From Date Beginning Date of Service Date(8) CCYYMMDDService To Date Ending Date of Service Date(8) CCYYMMDD

B=Normal Bill C= Cancel CheD=DebtM=Manual Che

Payee Number Payee ID number Char(9)Payee Name Claimant's Name Char(35)Payee Address Line 1 Payee's Address Char(35)Payee Address Line 2 Payee's Address Char(35)Payee Address Line 3 Payee's Address Char(30)Payee City Payee's City Char(20)Payee State Payee's State Char(2)Payee Zip Payee's Zip Char(5)Payee Zip 4 Payee's Zip +4 Char(4)

F= PharmacyP= PhysicianH= HospitalR=Claimant 

Reimbursement Code Indicates Payment Made to the Claimant Char(1) R= ReimbursePharmacy Number Pharmacy NABP Number Char(7)Pay Center Code Code Used to Identify a Central Payment Center for a Pharmacy 

Chain

Char(6) Availiable for b

Clearinghouse ID Clearinghouse ID Number Char(3) Availiable for bEmployee last Name Employee's Last name ( From CMF) Char(10)Employee First Initial Employee's First Initial (From CMF) Char(1)Area Code SMSA/MSA Identifier Char(4) FIPS Code tab

RX Numbers Prescribes Number Char(7) RX Appeals RX Appealed Char(1)RX Refills Char(2)Provider Type Char(1)

Redefine - UNIQUE TO Hospital Record Type= H

Redefine - UNIQUE TO Pharmacy Record Type= F 

Record Type Type of record Char(1)

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New Bill Pay Record Layout

Field Name Description Data 

Type/Size

Allowable Val

Diagnosed related group number Diagnosis Related Group for Inpatient Bills Char(3)Filler Char(4)Appeal Medical Bill Appealed Char(1) Y/N= WFiller Char(2)Procedure Code Billed procedure code Char(5) CPT-4, HCPC

OWCP ProcedProveded 

Modifier Code Indicates different level of service Char(2)Appeals Code Fee schedule appeal code Char(1) B, 1-7Filler Char(2)

Transfer Indicator Funds have been transferred Char(1) 0Adjustment Indicator Adjustment has been made Char(1) 0Filler Char(8)

A= Anesthesia

E= Evaluation/

M=MedicineP= Pathology/R= Radiology/UltrasoundS= Surgery

Work Unit Work Relative Unit Char(3) 000Practice Unit Practice Expenses Geographical Adjustment Factor Char(3) 000Malpractice Unit Malpractice Relative Value Char(3) 000Unit Cost Conversion Factor Char(3) 000Adjust Factor Expenses Geographic Adjustment factor Char(3) 000Practice Adjustment factor Practice Expenses Geographic Adjustment Factor Char(3) 000Malpractice Adjustment Factor Malpractice Expenses Geographic Adjustment Factor Char(3) 000Percent Modifier Adjustment factor for Procedure code Modifier Char(2) 00National Drug Code National Drug Code Char(11) 00000000000Two-Year High Price 2YR High, Wholesale Price Char(5) 00000Dispensing Fee Allowed Dispensing Fee For Prescription Char(2) 00

Redefine - UNIQUE TO Physician Record Type= P

Category Code Procedure Code Category Char(1)

Redefine - UNIQUE TO Fund Adjustment Data Prior to 09/04/03

Return from Redefine

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New Bill Pay Record Layout

Field Name Description Data 

Type/Size

Allowable Val

Allowed Fee Amount Allowable cost for prescription Char(5) 0

DRG Amount Actual Cost, Calculated by Diagnostic Related Group for 

Inpatient bills

Char(5)

00000

Servicing State Code State where Service was Performed Char(2)Servicing Zip Code Zip Code Where Service was Performed Char(5)Prompt Payment obligation Prompt Payment Flag Indicating contractual payment obligation Char(1)Bill Number Bill Number Char(12) 000000000000Invoice type Type of Invoice Char(1) 0Invoice number Invoice number Char(8) 00000000Invoice Date If Invoice type=D, Date provider created the bill If Invoice type = 

N, Providers Unique ID number for the bill

Date(8)

TCN Unique Transaction Control Number Char(17)Dispense Rate Dispensing rate Char(4) 0000Provider Charges Amount Amount Charged by provider Char(5) 00000Ineligible Amount Amount Not Covered Char(5) 00000Ineligible code Ineligible payment code Char(1) 0Fee Reduction Amount Fee Reduced Amount Char(5) 00000Amount paid Net Amount Paid Char(5) 00000Service Units Billed Service Units Billed Char(5) 00000Locator Code UB92 Loc 4; Code Indicates type of Institution Char(3)Prescriber’s Name Physician's name Char(10)Bill Received Date Date Bill was received Date(8) CCYYMMDDBill Date Key Date Bill was keyed for payment Date(8) CCYYMMDDBill Paid Date Check Date/Payment Date Date(8) CCYYMMDDAdjustment Date Date an adjustment transaction was entered against a bill Date(8) CCYYMMDDBill Authorizing Official Conditional ; System Generated ID Char(3) Three Charact

Redefine - UNIQUE TO Bills Paid Prior To 9/4/03

Redefine - UNIQUE TO Pharmacy Record Type= F

Return from Redefine

Redefine - UNIQUE TO Hospital Record Type= H

Redefine - UNIQUE TO Bills Paid After 9/4/03

Redefine - UNIQUE TO Invoice Type

Page 3 of 5 
New Bill Pay Record Layout

Field Name Description Data 

Type/Size

Allowable Val

Bypass Code Indicates Type of Payment or Adjustment Char(1)District Office Input Code District Office Code Char(2)District Office Control Code District Office Sequent Code Char(2)Error Code Internal Processor Only Char(1)Batch ID Number The Batch the Bill was keyed with Char(6)Operator Identifier System Generated Log-on ID Char(8)

TCN to Credit Original Case Number Char(17)Payee Case from Code Code Indicates if a change to a Case Number or Provider ID Char(1)Payee Case from ID Original Case Number or Provider ID Char(9)Payee Case to Code Code Indicates if a change to a Case Number or Provider ID Char(1)Payee Case to ID Corrected Case Number or Provider ID Char(9)Bill ID Number Sequential number of bill within a batch of bills Char(2)Bill Line Number Sequential Number of bill line item Char(3)Record Sequence Internal process Char(2)Resolver ID ID of Person who resolved the suspended bill Char(8)New TCN New transaction Control Number Char(17)

Work Unit Work Relative Unit Char(5) CPT4 & HFCA Practice Unit Practice Expenses Geographical Adjustment Factor Char(5) CPT4 & HFCA Malpractice Unit Malpractice Char(5) CPT4 & HFCA Unit Cost Conversion Factor Char(5)Adjust Factor Expenses Geographic Adjustment factor Char(4)Practice Adjustment factor Practice Expenses Geographic Adjustment Factor Char(4)Malpractice Adjustment Factor Malpractice Expenses Geographic Adjustment Factor Char(4)Percent Modifier Adjustment factor for Procedure code Modifier Char(3)Two-Year High Price 2YR High, Wholesale Price for RX Char(10) Modified ElemDispensing Fee Allowed Dispensing Fee For Prescription Char(7) Modified ElemAllowed Fee Amount Allowable cost for prescription Char(10) Modified ElemProvider Charged Amount Amount Charged by provider Char(10) Modified ElemIneligible Amount Amount Not Covered Char(10) Modified ElemFee Reduction Amount Fee Reduced Char(10) Modified Elem

Expanded Amount Fields

Redefine - UNIQUE TO Bills Paid Prior 9/4/03

Redefine - UNIQUE TO Bills Paid After 9/4/03

Return from Redefine

Page 4 of 5 
New Bill Pay Record Layout

Field Name Description Data 

Type/Size

Allowable Val

Amount paid Net Amount Paid Char(10) Modified ElemService Units Billed Service Units Billed Char(8)Bill ID Number Sequential number of bill within a batch of bills Char(3)Bill Line Number Sequential Number of bill line item Char(4)Record Sequence Internal process Char(3)

Page 5 of 5