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