FeeSlipHcfa
The <FeeSlipHcfa> element contains data relative to the CMS-1500 insurance billing form. There is generally one <FeeSlipHcfa> element nested within a <FeeSlip> element.
| Element | Description | Type | Notes |
|---|---|---|---|
| hcfa_no | Claim number (key) | int | |
| feeslip_no | Fee slip number | int | |
| insurance_no | Insurance plan | int | |
| provider_no | Provider | int | |
| serv_date | Date of service | datetime | |
| co_name | Insurance company name | nvarchar | |
| co_add1 | Insurance address 1 | nvarchar | |
| co_add2 | Insurance address 2 | nvarchar | |
| co_city | Insurnace city | nvarchar | |
| co_state | Insurance state | nvarchar | |
| co_zip | Insurance ZIP | nvarchar | |
| pat_ssno | Patient's social security number | nvarchar | |
| pat_last | Patient's last name | nvarchar | |
| pat_first | Patient's first name | nvarchar | |
| pat_middle | Patient's middle name or initial | nvarchar | |
| pat_suffix | Patient's suffix | nvarchar | |
| pat_add | Patient's address 1 | nvarchar | |
| pat_add2 | Patient's address 2 | nvarchar | |
| pat_city | Patient's city | nvarchar | |
| pat_phone | Patient's telephone | nvarchar | |
| pat_dob | Patient's date of birth | nvarchar | mm/dd/yyyy |
| pat_sex | Patient's sex | nvarchar |
Male Female Unknown |
| pat_rel_ins | Patient's relationship to insured | nvarchar |
01 = Self 02 = Spouse 03 = Natural Child/Insured has Fin Resp 04 = Natural Child/Ins has no Fin Resp 05 = Step Child 06 = Foster Child 07 = Ward of Court 08 = Employee 09 = Unknown 10 = Handicapped Dependent 11 = Organ Donor 12 = Cadaver Donor 13 = Grandchild 14 = Niece/Nephew 15 = Injured Plaintiff 16 = Sponsored Dependent 17 = Minor Dependent of a Minor Dependent 18 = Parent 19 = Grandparent 20 = Life Partner 21 = Student |
| pat_employer | Patient's employer | nvarchar | May be empty |
| pat_student_ind | Patient student indicator | nvarchar |
Y = Yes N = No |
| pat_sig_Ind | Patient signature indicator | nvarchar |
Y = Yes N = No |
| pat_sig_date | Patient signature date | nvarchar | mm/dd/yyyy |
| pat_sig_source | Patient signature source | nvarchar | P = Patient |
| ins_ssn | Insured's social security number | nvarchar | |
| ins_last | Insured's last name | nvarchar | |
| ins_first | Insured's. first name | nvarchar | |
| ins_middle | Insured's middle name | nvarchar | |
| ins_Suffix | Insured's suffix | nvarchar | |
| ins_add | Insured's address | nvarchar | |
| ins_city | Insured's city | nvarchar | |
| ins_phone | Insured's telephone | nvarchar | |
| ins_dob | Insured's. date of birth | nvarchar | |
| ins_sex | Insured's sex | nvarchar | |
| ins_emp | Insured's employer | nvarchar | |
| ins_emp_status | Insured's employment status | nvarchar |
The following are provided, but additional custom options may exist: 1 = Employed full time F = Full time student P = Part time student N = Not a student 2 = Employed part time 3 = Not employed 4 = Self employed 5 = Retired 6 = On active military duty 9 = Unknown |
| ins_plan | Insurance plan | nvarchar | |
| ins_pat_no | Guarantor number | int | References the guarantor's patient system-generated patient number. |
| policy_type | Insurance policy type | nvarchar | Insurance policy type |
| ppo_hmo | PPO/HMO indicator | nvarchar | |
| ref_first | Referring provider first name | nvarchar | |
| ref_last | Referring provider last name | nvarchar | |
| prior_auth_no | Authorization number | nvarchar | |
| fed_tax | Provider's federal tax ID | nvarchar | |
| ssn_ein | Provider's federal tax ID type | nvarchar |
S = Social security number E = Employer identification number |
| prov_last | Provider's last name | nvarchar | |
| prov_Middle | Provider's middle name or initial | nvarchar | |
| prov_TPA_No | Provider's third-party administrator number | nvarchar | |
| prov_UPIN_No | Provider's Unique Physician Identification Number | nvarchar | |
| pat_no | Patient's system ID | int | This number identifies the patient. |
| pat_acct | Patient's account number | nvarchar | |
| serv_name | Servicer's name | nvarchar | Typically same as practice location |
| serv_add1 | Servicer's address 1 | nvarchar | Typically same as practice location |
| serv_city | Servicer's city | nvarchar | Typically same as practice location |
| serv_state | Servicer's state | nvarchar | Typically same as practice location |
| serv_zip | Servicer's ZIP | nvarchar | Typically same as practice location |
| off_phone | Practice phone | nvarchar | |
| off_name | Practice name | nvarchar | |
| off_add1 | Practice address 1 | nvarchar | |
| off_add2 | Practice address 2 | nvarchar | |
| off_city | Practice city | nvarchar | |
| off_state | Practice state | nvarchar | |
| off_zip | Practice ZIP | nvarchar | |
| grp | insurance payer group ID | nvarchar | |
| create_date | Claim create date | nvarchar | |
| updated_date | Claim update date | nvarchar | |
| source_of_pay | Payment source | nvarchar |
Z = PPO Z = VSP C = Medicare Part B D = Medicaid I = HMO Z = Other Vision Plan Z = Managed Care F = Commercial Insurance Company H = Champus H = ChampVA E = Group Health Plan E = FECA Black Lung G = Blue Cross G = Blue Shield MG = Medigap K = Central Certification 11 = Other Non-Federal Programs 12 = Preferred Provider Organization 13 = Point of Service 14 = Exclusive Provider Organization 15 = Indemnity Insurance AM = Automobile Medical DS = Disability LI = Liability LM = Liability Medical T = Title V B = Workers Compensation Health Claim Z = Mutually Defined Unknown 17 = Dental Maintenance Organization FI = Federal Employees Program MA = Medicare Part A |
| payor_id | Insurance payer ID | nvarchar | |
| paid_amt | Payment amount | money | |
| phd_sig | Provider signature | nvarchar | |
| phd_date | Provider signature date | nvarchar | |
| ins_oth_plan_no | . | int | |
| serv_add2 | Servicer's address 2 | nvarchar | |
| serv_phone | Servicer's telephone | nvarchar | |
| prov_first | Provider first name | nvarchar | |
| BillProv_NPI_NUM | Provider NPI | nvarchar | |
| BillProv_ID_Qualifier | Provider ID qualifier. | int |
1228 = Facility ID Number 1229 = State License Number 1230 = Blue Cross Provider Number 1231 = Blue Shield Provider Number 1232 = Medicare Provider Number 1233 = Medicaid Provider Number 1234 = Provider UPIN Number 1235 = CHAMPUS Identification Number 1236 = Provider Commercial Number 1237 = Location Number 1238 = State Industrial Accident Provider Num 1239 = Preferred Provider Organization Number 1240 = HMO Vode Number 1241 = Clinic Number 1242 = Provider Site Number 1243 = Unique Supplier Identification Number 1271 = Provider Taxonomy 1687 = Employer's Identification Number 1688 = Social Security Number |
| Ref_NPI_NUM | Refering provider NPI | nvarchar | |
| REF_ID_Qualifier | Refering provider ID qualifer | int | |
| Serv_NPI | Servicer's NPI | nvarchar | |
| ref_id | Same as Billing prov_other ID if populated | nvarchar | |
| insured_id | Insured's ID | nvarchar | |
| ins_state | Insurance company's state | nvarchar | |
| ins_zip | Insurance company's ZIP | nvarchar | |
| pat_state | Patient's state | nvarchar | |
| pat_zip | Patient's ZIP | nvarchar | |
| ins_oth_policy_no | Insurance other policy number | nvarchar | |
| BillProv_OtherID | Same as ref ID | nvarchar | |
| ins_type | Insurance type | nvarchar | |
| ins_policy_no | Insurance policy number | nvarchar |
C = Medicare Part B D = Medicaid E = Group health plan or FECA Black Lung F = Commercial insurance company G = Blue cross or Blue shield Z = PPO, VSP, Other Vision Plan or Managed Care |
| uni_diag1 | Diagnosis 1 | nvarchar | May be ICD-9 or ICD-10, depending on the date of service. |
| uni_diag2 | Diagnosis 2 | nvarchar | May be ICD-9 or ICD-10, depending on the date of service. |
| uni_diag3 | Diagnosis 3 | nvarchar | May be ICD-9 or ICD-10, depending on the date of service. |
| uni_diag4 | Diagnosis 4 | nvarchar | May be ICD-9 or ICD-10, depending on the date of service. |
| phd_sig_Location | Location of signed HCFA | nvarchar | |
| ins_oth_plan_id | Other insurance plan number | smallint | |
| Plan_No | Insurance plan number | int | |
| BOX17RefProv | Referring provider | bit | |
| HCFANotes | Manually endered notes on the ICD-10 | ntext | |
| uni_diag5 | Diagnosis 5 | nvarchar | ICD-10 |
| uni_diag6 | Diagnosis 6 | nvarchar | ICD-10 |
| uni_diag7 | Diagnosis 7 | nvarchar | ICD-10 |
| uni_diag8 | Diagnosis 8 | nvarchar | ICD-10 |
| uni_diag9 | Diagnosis 9 | nvarchar | ICD-10 |
| uni_diag10 | Diagnosis 10 | nvarchar | ICD-10 |
| uni_diag11 | Diagnosis 11 | nvarchar | ICD-10 |
| uni_diag12 | Diagnosis 12 | nvarchar | ICD-10 |
| box17RefProv_Qualifier | Referring provider qualifier | int |