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1. Provider Name 3. Patient Control Number 4. Type of Bill 6. Statement Covers Date - Begin 6. Statement Covers Date - End 7. Covered Days 8. Non-Covered Days 9. Coinsurance Days 10. Lifetime Reserve Days 12. Patient's Name - Last 12. Patient's Name - First 12. Patient's Name - Middle 13. Patient's Address - Street 13. Patient's Address - City 13. Patient's Address - State 13. Patient's Address - Zip 14. Patient's Date of Birth 15. Patient's Sex 17. Admission Date & Hour |
19. Type of Admission 20. Source of Admission 22. Patient Status 50. Payer Name 51. Provider Number 54. Prior Payments 54. Patient Prior Payments 55. Estimated Amount Due 55. Patient Estimated Amount Due 58. Insured's Name - Last 58. Insured's Name - First 58. Insured's Name - Middle 60. CERT. - SSN - HIC. - ID NO. 61. Group Name 62. Insurance Group Number 63. Treatment Authorization Codes 67. Principal Diagnosis Codes 76. Admitting Diagnosis Codes 77. E-Code |
80. Principal Procedure Code 80. Principal Procedure Date 82. Attending Physician ID 82. Attending Physician Name - Last 82. Attending Physician Name - First 82. Attending Physician Name - Middle 83. Operating Physician ID 83. Operating Physician Name - Last 83. Operating Physician Name - First 83. Operating Physician Name - Middle 83. Other Provider ID 83. Other Provider Name - Last 83. Other Provider Name - First 83. Other Provider Name - Middle 83. Referring Provider ID 83. Referring Provider Name - Last 83. Referring Provider Name - First 83. Referring Provider Name - Middle Clearinghouse Trace Number Original Reference Number |